The strongest prognostic factor for acute coronary syndrome (ACS) is early reperfusion therapy. American Heart Association Guideline 2005 (G2005) recommends pre-hospital electrocardiographic diagnosis for early triage. The authors installed a 12-lead electrocardiogram on a Funabashi Doctor Car (FDC) and made pre-hospital diagnoses based on on-site electrocardiography for patients with suspected ACS. Such diagnosis were made for a total of 226 patients for whom FDC was sent out during the two-year period from February 1, 2005 to January 31, 2007 with descriptions by civilians that included the following key profile: “chest pain, cold sweat, ≥ 40 years old”. Patients included 160 men and 66 women, and had a mean age of 66.9 ± 13.0 years. A total of 146 of 226 patients were diagnosed with ACS by the on-board doctor before reaching the hospital, but a definitive diagnosis of ACS was made for 100 (68.5%) of these patients. In addition, among the 80 patients who were diagnosed as not having ACS before reaching the hospital, 5 were given a definitive diagnosis of ACS. The sensitivity and specificity of prehospita diagnosis were 95.2% and 62.0%, respectively. The ST elevation group, ST depression group, and non-ST change group had a sensitivity of 96.3%, 100%, and 92.9%, respectively, and a specificity of 18.1%, 40.0%, and 69.0%, respectively. Among the 105 patients given a definitive diagnosis of ACS, 92 (87.6%) were directly transferred to facilities capable of performing percutaneous coronary intervention (PCI). However, in a follow-up study conducted in 2002 on cases of transfer by Funabashi emergency personnel, 281 of 386 (72.8%) patients with ACS were directly transferred to facilities capable of performing PCI, indicating a significant difference in the rate of transfer to facilities capable of performing PCI (p<0.01). Prehospital diagnosis of ACS using a 12-lead electrocardiogram is highly sensitive and may be useful for screening. However, its specificity is insufficient and the accuracy of electrocardiographic diagnosis must be improved without lowering sensitivity. The present findings also indicate the limitations of pre-hospital ACS diagnosis based on electrocardiographic findings.

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Objectives: Reducing the door-to-balloon time (DTBT) when treating patients with ST-segment elevation myocardial infarction (STEMI) is very important. The aim of this study is to evaluate DTBT at a single local hospital and discuss strategies for reducing the DTBT.
Method: We evalutated the door-to-balloon time in 18 patients with STEMI who underwent precutaneous coronary intervention (PCI) in the Emergency Department (ED) of a single hospital in Japan during in the course of one year. We also compared the DTBT of the cases that were admitted in the day-time with those admitted in the night-time, cases that were complicated with heart failure with those without, and cases who underwent PCI by a radial approach with those who underwent a femoral approach.
Result: The mean door-to-balloon time was 76 ± 13 minutes, and the ratio of cases in which the DTBT was less than 90 minutes was 89%. There was no differences between the DTBT of the cases that were admitted in the day-time (71 ± 11minutes) with those admitted in the night-time (79 ± 13minutes), cases that were complicated without heart failure (Killip I) (79 ± 13minutes) with those with heart failure (Killip≥II) (69 ± 13minutes), and cases who underwent PCI from a radial approach (76 ± 14minutes) with a femoral approach (77 ± 10minutes).
Conclusion: The results of DTBT in patients with STEMI at our hospital were found to be acceptable. It therefore seems important that not only a rapid diagnosis, but also simplifying the system to call the catheter-labo staff and providing feedback to the ED staff regarding the cilinical course of the patients.

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We report a case of refractory status epilepticus in a 50-year-old man who suffered from fever and general fatigue. Four days after symptom onset, disturbance of consciousness and a stiff neck were noted, and he was hospitalized for treatment of cerebromeningitis. Convulsive seizures of various duration, lasting from several seconds to about 30 minutes, occurred after admission. On the 9th day of illness, the patient was transferred to our hospital for further examination and treatment. Although we tried to control the convulsions with an antiepileptic drug combined with midazolam and intravenous anesthetics such as thiamylal and propofol, the convulsions continued. Because autoantibodies against glutamate receptor subunit ε-2 were detected in the patient's serum, autoimmune encephalitis was strongly suspected. Over his clinical course, methylprednisolone pulse therapy was not effective, so we administered very-high-dose phenobarbital at daily doses of up to 1,200 mg. When the serum level of phenobarbital rose to > 60μg/ml, the convulsions disappeared. Although very-high-dose phenobarbital treatment is not a first-choice therapy against convulsions, we suggest that such therapy can be useful for the treatment of refractory status epilepticus.

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Segmental arterial mediolysis (SAM) established as a cause of visceral aneurysms only recently. SAM mainly manifests as acute abdomen, hemorrhagic shock, and multiple beads-shaped aneurysms that occur frequently in visceral arteries in addition to coronary and intracranial arteries. An 83-year-old male presented with sudden deep coma and symptoms of shock. He developed cardiopulmonary arrest while being transferred to our hospital in helicopter ambulance. He recovered from the cardiopulmonary arrest in 4 minutes. Computed tomography, which was performed in our hospital, revealed massive intraperitoneal fluid collection with an extravasation of contrast media. Emergency angiography revealed an extravasation of contrast media at the splenic flexure of the mesenteric artery, and multiple beads-like dilatations of the splenic artery. Considering the risk of colon ischemia, emergency laparotomy (resection of the aneurysm) was performed. Histopathological analysis revealed fusion of the tunica media and medial island, and the condition was diagnosed as SAM. The postoperative course was uneventful, he was transferred to another hospital on the 33rd day. Computed tomography performed 2 years after the operation revealed that the multiple untreated aneurysms had almost disappeared. In case of abdominal visceral aneurysm with an indistinct cause, a treatment and a follow-up strategies must be planned after considering SAM.

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Gastric rupture is a rare complication of cardiopulmonary resuscitation (CPR). We report a case of bystander CPR that resulted in gastric rupture. A 77-year-old man suffered from choking during a meal; chest compression and bag valve mask ventilation were started after removal of the foreign body. After three minutes of CPR, spontaneous circulation and breathing resumed; he was transported to a nearby hospital. On admission, his abdomen was markedly distended, and a chest radiograph showed a large amount of subdiaphragmatic free air. He was transferred to our hospital on suspicion of a spontaneous esophageal rupture. An abdominal CT scan revealed free air in the lesser curvature of the gastric cardia, which was diagnosed as a gastric rupture. The patient underwent laparotomy, and a 7-cm tear along the lesser curvature of the gastric cardia was detected and repaired. There were no postoperative complications. Although massive gastric dilatation due to inadequate ventilation may itself result in gastric rupture with CPR, the combination of increased gastric volume and vigorous chest compression can elevate intragastric pressures and result in rupture. Prompt diagnosis and emergency surgery of gastric rupture may contribute to decreased mortality.

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We report a rare case of traumatic carotid-cavernous fistula (CCF) associated with transorbital penetration. A 58-year-old male was transferred to our emergency department after being stabbed in his face and chest with a knife. The injuries identified were right eyeball rupture, an incised wound on the right forehead and both hands, and a stab wound on the right chest wall. Brain computed tomography (CT) revealed subarachnoid hemorrhage. Therefore, the patient was admitted to the intensive care unit (ICU) after suture of the stab and incised wounds. On day 5, the patient developed unsteady gait, left hemiparesis, and an ocular bruit. Brain CT showed cerebral infarction on the right side, and cerebral angiography revealed a right CCF. We attempted to treat the CCF twice by endovascular embolization, however, the procedure failed. The fistula was then occluded on day 26 by trapping of the carotid artery. The postoperative course was uneventful and the ocular bruit disappeared. The patient was transferred to another hospital with left hemiparesis on day 75. CCF is a rare, but extremely serious complication of transorbital penetration. CCF should be put on our mind to treat patients with transorbital penetration.

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Although traumatic vertebral artery occlusion is primarily caused by traffic accidents, it has been reported to occur in sports in recent years. Herein, we present two cases that occurred during sumo practice. The first case was a 17-year-old boy who visited our hospital with chief complaints of headache and vomiting after knocking his forehead against his opponent's chest. Magnetic resonance imaging (MRI) showed multiple cerebral infarctions in the right posterior inferior cerebellar artery (PICA) territory, while magnetic resonance angiography (MRA) and cerebral angiography revealed right vertebral artery occlusion. The second case was a 16-year-old boy who presented with posterior cervical pain, vertigo, and numbness in the left arm and leg after being slapped in the face. MRI showed a cerebral infarction in the right lateral medulla oblongata, while MRA and cerebral angiography revealed right vertebral artery occlusion. Both patients were diagnosed with cerebral infarction associated with traumatic vertebral artery occlusion and discharged with no neurological deficit following intravenous edaravone treatment. As traumatic vertebral artery occlusions caused by rotation or hyperextension of the head and neck in sports are a cause of occlusive vascular disease among youths, we report the present study with the purpose of promoting awareness among emergency physician from the perspective of sports medicine.

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Awareness of the importance of clinical research has definitely increased in Japan, but, quantitatively, the amount of clinical research that is conducted centered on regional core hospitals is still small, and, qualitatively, hardly any of research is encountered that could tolerate conversion into English-language papers. This phenomenon has occurred because clinicians attach so much importance to statistical knowledge that their epidemiological viewpoint is inadequate. Good examples of this are the tendency to attach great importance to statistical tests and p values without having given sufficient consideration to bias, and not quantitatively estimating the influence of treatment or exposure. While from the standpoint of conducting clinical research it is much better to have the statistical knowledge that is used for population and samples, for calculating sample size, comparing basic attributes, and adjusting for confounding factors by multivariate analysis, not many clinicians understand the need for a considerable degree of epidemiologic knowledge when carrying out clinical research. More specifically, if there is no epidemiological viewpoint when clarifying research hypotheses, setting up control groups, preparing analysis models, or considering research results and biases, it is impossible to perform high quality clinical research.

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