In this year of 1991, modern cardiopulmonary resuscitation (CPR) is only 31 years old. There were few immediately applicable effective CPR techniques available before the 1950s. Modern respiratory resuscitation was pioneered in the 1950s, external cardiac resuscitation in the 1960s, and post-resuscitation brain-oriented intensive therapy since the 1970s when CPR was extended to cardiopulmonary cerebral resuscitation (CPCR). From a medical standpoint, CPR shound be rediscovered, re-explored, and put together into an effective resuscitation system, out of a greater appreciation of its life-saving potential. Fortunately, the recent history of modern CPR shows a series of landmark developments during the past 31 years, and resuscitation continues to be enjoying a renaissance of interest worldwide.

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To evaluate the clinical significance of a tall T wave without ST elevation, 85 patients with anterior myocardial infarction who were brought to the CCU less than six hours from the onset of chest pain were reviewed. These patients were divided into three types, namely, type A (n=12) had a T wave more than 10mm in height without ST elevation; type B (n=21) had ST elevation of more than 2mm; type C (n=52) had a dome shaped or plateau ST segment. 25% of type A, 33% of type B and 50% of type C patients had a history of angina pectoris. In type A, the degree of chest pain at onset of myocardial infarction (MI) was greater than in the other types. The first ECG tracing was made 1.6hr (type A), 2.4hr (type B) and 2.6hr (type C) after onset of MI, and the first CPK concentration was 112IU/l (type A), 347IU/l (type B) and 522IU/l (type C). There was a significant difference between type A and the other types. The peak CPK concentration was similar in the 3 types and the time of the peak CPK was 12.6hr (type A), 17.6hr (type B) and 18.0hr (type C). There was a significant difference between type A and the other types. In type A, the mortality rate was 41.7%, but the clinical course of the survivors was better than in the other types. Angiographic findings one month later revealed no total occlusion and no collaterals to the LAD lesion. As a consequence it follows that the shorter the time to peak CPK, the better was the clinical course of the survivors. Angiographically there was no total occlusion, and the culprit lesion of type A was reperfused by internal treatment. We believe type A has a smaller degree of myocardial ischemia before MI for the reason that the rate of a history of angina pectoris was lower, the symptom at onset of MI was more severe and angiographically there was no collateral.

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To obtain prognostic indicators for survival of dead on arrival (DOA) patients, the records of 643 consecutive DOA patients brought to our emergency department from November 1985 to October 1989 were analyzed. Of the 643 patients, 509 could not be resuscitated (group I). One hundred and sixteen patients (18.0%) were successfully resuscitated, but subsequently died in our hospital (group II). Eighteen patients (2.8%) survived more than 30 days and were discharged (group III). The relationship between their outcome and 10 factors was examined. The factors were cause of cardiac arrest, sex, age, initial ECG, witness, bystander CPR, arrest after arrival of ambulance personnel, interval from cardiac arrest to basic life support (BLS), duration of BLS, and interval from cardiac arrest to advanced life support (ALS). Of these factors, cause of cardiac arrest, witness, arrest after arrival of ambulance personnel, duration of BLS and interval from cardiac arrest to ALS influenced the outcome of DOA patients significantly. Drowning and asphyxia were the most favorable causes. The survival rate (III/I+II+III) was highest for drowning and asphyxia (p<0.05). The presence of a witness was of critical importance to the outcome of DOA patients in whom the cause was disease. The resuscitation rate (II+III/I+II+III) for patients with a witness was higher than for those without a witness (p<0.01). There was no group III patient without a witness. Especially in trauma cases whether they experienced cardiac arrest after arrival of ambulance personnel was important. Patients whose arrest occurred after arrival of the ambulance had a better chance of survival (p<0.05). All patients who had no vital signs when the ambulance arrived died. Duration of BLS was 22.6±7.5min in group I and 14.4±10.3min in group III, a singificant difference (p<0.01). The intervals from cardiac arrest to ALS were 27.5±8.5min (group I), 25.0±9.8min (group II) and 17.3±11.3min (group III). Group III had a shorter interval than group I (p<0.01) and group II (p<0.05). Under the present emergency system these five factors will be important for predicting the outcome of DOA patients. Considering this, we should treat DOA patients and improve the system.

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Six patients with intracranial hematomas developed new hematomas on the contralateral side following decompressive surgery for the initial lesion. This entity was named “traumatic delayed contralateral hematoma” (TDCH). In a typical case the patient displays an ipsilateral linear fracture after striking the side of the head, with development of a hematoma on the contralateral side. In the present series most patients were struck near the midline and plain skull films revealed fractures across the cranium, involving a dissociation fracture or linear fracture along the midline. In the reported cases, the first CT scan was taken within about 3 hours after the injury. The initial hematomas were acute epidural hematoma and acute subdural hematomas in almost equal numbars. In our series, cerebral edema, traumatic subarachnoid hemorrhage and cerebral contusion were seen on the side contralateral to the primary lesion. Most TDCH patients reported in the literature showed severe disturbance of consciousness. All 6 patients in the present series were comatose and 3 had no lucid intervals. The first surgical procedure was generally performed within 4 hours after the trauma and cerebral edema was generally seen during the procedure. In cases reported in the literature, findings according to the Grasgow outcome scale were severe disability or less in approximately 50%. The outcome of TDCH is naturally related to the complicating brain damage, progression of neurological deficit, and time until the secondary operation, so to improve the outcome of TDCH, it is necessary to anticipate the development of a secondary hematoma at the time of the first operation, and rapid and adequate countermeasures should be taken if a TDCH has formed.

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The innovation of transporting critically ill patients by ambulance is one of the most important developments for reducing the death rate in emergency medicine. The role of the ambulance personnel has also become more important than ever. The new system for transtelephonic electrocardiographic recording might improve emergency medicine in this system, consists of a mobile telephone and acoustic coupler. Ambulance personnel can send electrocardiograms directly to the coronary care unit, where a cardiologist can immediately interprete electrocardiographic recordings and give suggestions for management. This system is easy to handle, without any regulations, can send real time electrogram, and may be useful for reducing the death rate ambulances because each critical patient can receive proper therapeutic support ordered directly by the cardiologist. From June, 1989 to August, 1990, this system was used for 43 patients including 12 patients with cardiac diseases and 31 patients with non-cardiac diseases. In patients with cardiac emergencies, there were 2 patients with acute myocardial infarction, 4 patients with unstable angina, 4 patients with arrhythmia, and 2 patients with congestive heart failure. The electrocardiograms, which were transferred from an ambulance to the coronary care unit, showed normal sinus rhythm in 24 patients, sinus tachycardia in 5 patients, sinus bradycardia in 1 patient, atrial fibrillation in 2 patients, complete left bundle branch block in 1 patient, and cardiac asystole in 5 patients. Elevation of the ST segment occurred in 5 patients including 2 patients with a QS pattern. In each case, the ambulance personnel reported the patient's symptoms and status at the same time, and received a brief diagnosis and proper suggestion from the cardiologist in the coronary care unit. In addition, staff personnel in the coronary care unit could prepare all of the emergency equipment that would be needed in the emergency room, before the ambulance arrived at the hospital. In conclusion, this transtelephonic electrocardiographic recording system is useful not only for screening emergency patients whether with or without cardiac problems, but also for preparing equipment for emergency care before patients are transferred to the hospital.

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