Radiological emergencies vary from an isolated incident such as mishandling of radiation devices to a major accident such as criticality in nuclear power plants or a terrorist attack using dirty bombs or nuclear device detonation. The physiological effects range from irradiation to trauma or blast injuries with radiological contamination, or flash burn in the event of nuclear device detonation. Because irradiation itself does not cause any immediate death of the victims, and there is a minimum risk of secondary irradiation to medical personnel during decontamination procedures, lifesaving treatments should be prioritized while observing the rules of handling radiological substances for decontamination. When a major radiological accident occurs, information is scarce and/or becomes intricate. We might face with significant difficulties in determining the exact culprits of the event, i.e. radiological or chemical or others. Therefore, it is strongly recommended for the national and local governments, related organizations and hospitals to develop comprehensive systems to cope with all hazards (Chemical, Biological, Radiation, Nuclear, and Explosion) under the common Incident Command System. Following the subway Sarin attack in 1995, the national government had subsidized the designated disaster medical centers to prepare for chemical terrorisms or chemical disasters. As for the radiological emergency medical system, a major focus has been on designating hospitals and developing local networks in close proximities to the nuclear facilities. In order to apply the primary principles of emergency medicine to the radiological emergency medical system, that is “the best emergency medical services are available anywhere, and at any time”, it is imperative to reinforce the functions of the designated disaster medical centers or critical care centers in line with the Hospital All-Hazard Emergency Preparedness.

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We reviewed the incidence and analyzed the life threatening “fatal illnesses” encountered at the walk-in clinic in the nighttime of a university hospital. A retrospective cohort study was performed from September 2005 to January 2008 at the walk-in clinic of a university hospital. Patients were managed mostly by 2 nd year residents who were supervised by attending emergency physicians. A total of 17,564 visits were reviewed. Sixty (0.3%) fatal illnesses were identified during this period and 53% (32/60) of these cases presented with normal vital signs. Five cases deceased and two cases out of the five cases deceased within 24 hours from their visit. It is essential to take care of patients according to their urgency and severity of illness, as there are some portions of walk-in patients with fatal illnesses.

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Purpose: The goal of this study was to examine the effects of early sivelestat Na hydrate (sivelestat) administration in Acute lung injury/Acute respiratory distress syndrome (ALI/ARDS) patients.
Methods: This study altered the therapeutic strategies for patients with ALI/ARDS caused by various primary diseases in order to administer sivelestat therapy as soon as possible. We compared the results before and after changing the initiation of sivelestat treatment (before changing: late administration group 31 patients, after changing: early administration group 54 patients).
Parameters: The following parameters were examined: patient backgrounds (age, gender, primary disease, acute physiology and chronic health evaluation (APACHE) II score, time from diagnosis to administration, PaO₂/FiO₂ (P/F) ratio at the start and end of treatment, administration period, and outcome (survival rate at discharge).
Results: Although there was a significant difference in gender, there were no differences in other patient background parameters between the late administration group and early administration group. As targeted, the median interval until sivelestat administration was significantly shortened (late administration group: 46 hours, early administration group: 1 hour). The P/F ratio was significantly higher in the early administration group than the late administration group, both at the start of administration (Base line) and end (After administration) of treatment. A covariance analysis, in which the values at the start of administration were regarded as covariant, showed a significant increase in the P/F ratio in the early administration group (late administration group: from 115.4 ± 49.7mmHg to 213.6 ± 113.9mmHg, early administration group: from 164.8 ± 67.2mmHg to 305.3 ± 119.2mmHg). There was no significant difference in the duration of sivelestat administration between the late administration group and early administration group. The survival rates were statistically different with 58.1% and 77.8% in the late and early administration group, respectively.
Conclusion: These results suggest that early administration of sivelestat is therapeutically beneficial.

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Background: Cases of drug overdoses are common in emergency departments. There are specific treatments such as a gastric lavage or activated charcoal. A Position Statement was presented in 1997, and a standard treatment was presented by the Japanese Society for Clinical Toxicology. Standardization of medical treatments for poisonings is a global goal.
Purpose: We reviewed whether activated charcoal improved clinical outcomes in drug overdose patients who did not require intubation.
Object and Methods: We conducted a retrospective review of drug overdose patients transported by ambulance to the Emergency Department of the International Medical Center of Japan between January 1, 2005 and December 31, 2007. 572 drug overdose patients were admitted, 484 (activated charcoal; 121 patients, control 363 patients) did not require intubation. We compared the number of hospital days of the activated charcoal group with that of the control group. We also investigated complications after activated charcoal treatment.
Results: No deaths were recorded. The number of hospital days for the activated charcoal group was 1.92 ± 0.95 days and the control group was 1.94 ± 0.95 days. There was no significant difference (p= 0.81), with the difference being just -0.02 days; 95% confidence interval, -0.22∼0.17. To control for corresponding factors, patients were assigned to one of two groups and matched using propensity scores. There were 89 patients-pairs (178 patients). The number of hospital days for these two groups were 1.80 ± 0.91 (activated charcoal) and 1.85 ± 0.95 (control), respectively. Similarly, there was no significant difference (p= 0.69), and the difference of the number of hospital days was -0.06 days; 95% confidence interval was -0.33∼0.22. Although vomiting after activated charcoal treatment was seen in 14 (11.6%) of the 121 patients, no aspiration pneumonia was considered to have been caused by activated charcoal.
Conclusion: It was suggested that activated charcoal is unnecessary as a routine treatment for drug overdose patients who do not require intubation.

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Background: Screening for blunt cerebrovascular injury (BCVI) is important because this injury occasionally results in serious compilations. The ability to diagnose cerebrovascular disease with multidetector computed tomographic angiography (CTA) has recently been improved, but diagnostic value for BCVI has not been clarified yet. This study evaluated the accuracy of diagnosis of BCVI by CTA.
Patients and methods: The study comprised 233 patients admitted from 2001 through 2007with cervical/facial/head trauma who met predefined screening criteria for CTA. Screening criteria were severe head injury (SHI), basilar skull fracture (BFX), facial fracture (FFX), cervical injury (CI), neurologic exam inconsistent with head CT scan findings, skull fracture crossing or extending into the dural sinus, and subarachnoid hemorrhage on suspicion of rupture of aneurysm or arteriovenous malformation. Patients with a negative CTA test underwent no further radiologic evaluation and were followed for 6 months or more if ischemic or hemorrhagic events occurred due to BCVI. Patients with positive CTA results underwent cerebral arteriography to confirm CTA findings and were treated according to the injury.
Results: Twenty-three patients (27 injuries) had positive CTA results, and 18 patients (21 injuries) were confirmed to have BCVI (positive predictive value: 77.8% (21/27)). Twenty-five injuries were detected by cerebral arteriography in these 18 patients; thus, 4 injuries were not detected by CTA (arteriovenous fistula [AVF]: 3, intimal injury in vertebral artery: 1). Screening criteria with high incidence in BCVI were FFX: 14.0% (7/50), SHI: 11.9% (8/67), CI: 11.8% (6/51), and BFX: 10.2% (9/88). CTA results were negative in 210 patients, and cerebrovascular event due to BCVI was not observed in the 132 patients who could be followed.
Conclusions: CTA is an excellent screening tool for BCVI. However, accuracy of diagnosis for mild intimal injury or AVF requires improvement in the future.

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Eight medical staff members were contaminated by the treatment agents while treating patients for organophosphate (OP) poisoning. One medical staff member who cared other emergency patients after transfer of this OP poisoning patient in the same room complained of weakness of the limbs and difficulty in walking, along with other common complaints (headache, generalized fatigue, and bleary eyesight). Serum butyrylcholine esterase (BCHE) activity was 27 IU/l (normal = 174-400 IU/l). Other laboratory data were normal. Although the level of BCHE remained under 40 IU/l, the staff member recovered fully in 5 days and returned to work. Under the suspicion of a congenital defect in BCHE synthesis, conventional genetic analysis was performed and a missense mutation at G365R (heterozygous) was confirmed. Because the abnormality was phenotypically different from that of a solitary missense mutation at G365R, another concomitant genetic mutation was thought to exist. A reduction in binding activity was thought to account for the hypersensitivity to OP by individuals with this congenital BCHE defect, and a relative increase in the concentration of OP at the neuromuscular junction was thought to account for the more severe subjective complaints by these individuals compared with personnel having normal BCHE activity. The low BCHE activity attributable to this congenital defect has been observed at our hospital. Maximal precautions are necessary to protect both medical staff members and visiting patients from secondary exposure to choline esterase inhibitors.

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