The first edition and the second edition of clinical guideline for the management of acute pancreatitis had been published on July, 2003 and on July 2007 as the planned-renewal publishment. Otherwise, the diagnostic criteria and the assessment of severity of acute pancreatitis had been discussed on the base of past database of the cases experienced in Japan, and the minor and major changes of the assessment were proposed by the Japanese Ministry of Health, Labour and Welfare. Therefore, the descriptions of them and of the concerns in guideline should be renewal. Present introduction, and fundamental strategy for the management of acute pancreatitis are summerized.

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If patients with lower-extremity long bone fractures and severe head injury are treated with lower-extremity traction, they must remain in the supine position for long periods, and their oxygenation may worsen due to atelectasis, pneumonia, or other conditions. We studied whether early fixation of lower-extremity long bone fractures in patients with severe head injury prevents progressive oxygenation deterioration. The study comprised 228 patients requiring traction for lower-extremity long bone fracture fixation who were admitted to our center from April, 1991 through March, 2007. Of these patients, 34 had severe head injury (Abbreviated Injury Scale (AIS) ≥ 3) but did not suffer additional severe injury (AIS ≥ 3) to the thorax or abdomen. Patients who underwent fracture fixation from 24 hours to 5 days after their accident, patients in whom an arterial blood gas measurement was not obtained at day 5, and patients who were treated with hypothermia were excluded, leaving 18 patients for review. Patients were divided into two groups according to time of fracture fixation: early fracture fixation (EFF), occurring within the first 24 hours after the patient's accident (n = 8), and late fracture fixation (LFF), occurring after day 6 following the accident (n = 10). We compared PaO₂/F_IO₂ ratio (P/F ratio) at days 1 and 5 between the two groups and within each group. No differences were found between groups in regard to age, Injury Severity Score, and head AIS and lower-extremity AIS. The average P/F ratio of the EFF group was 453.3 ± 56.6 mmHg at day 1 and 405.9 ± 52.7 mmHg at day 5. The average P/F ratio of the LFF group was 408.4 ± 71.9 mmHg at day 1 and 305.1 ± 104.6 mmHg at day 5. Although the difference in P/F ratio between groups at day 1 was not statistically significant, the difference in P/F ratio at day 5 was statistically significant (p<0.05). In addition, although there was no significant difference in P/F ratio at days 1 and 5 in the EFF group, the difference in P/F ratio at days 1 and 5 in the LFF group was statistically significant (p<0.05). No deaths occurred in either group. We concluded that early fixation of lower-extremity long bone fractures in patients with severe head injury may prevent progressive oxygenation deterioration.

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We report a case of child abuse suspected by postmortem computed tomography (PMCT) and revealed by following legal autopsy. A 2-year-old boy with cardiopulmonary arrest was transferred to our hospital. Mother asserted that he bumped his occipital head against the wall and then fainted. The initial hospital electrocardiogram showed asystole. The cause of injury explained by her mother seemed minor, however, cardiac rhythm remained asystole even after 30 minutes of standard cardiopulmonary resuscitation. Although the external investigation of his body indicated no obvious trauma, echocardiogram showed the pericardial fluid collection, which is inexplicable for his mechanism of injury. PMCT was performed and it showed abnormalities in his heart, liver, and spleen. As a consequence of these CT findings, police decided to order a legal autopsy. The autopsy further revealed that he died of bleeding due to pancreatic injury. It also revealed many old subcutaneous hematomas which suggested that the child had suffered from regular abuse. In this case, PMCT was useful as a screening tool which led to legal autopsy.

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This is a report of a case of successful use of percutaneous cardiopulmonary support (PCPS) for salvage treatment of a patient with severe bronchospasm. A 46-year-old female injured in a traffic accident was brought to our hospital. We diagnosed diffuse axonal injury and a right pneumothorax. She was admitted to the ICU, after intubation and insertion of a chest tube. Suction was turned off, but was re-started on the 3rd day of admission after worsening of the pneumothorax. After a few hours, she suddenly developed a bronchospasm. She was treated with conventional measures and deep sedation, but the tidal volume was less than 100ml. We applied venovenous extracorporeal life support (ECLA) for a deteriorated respiratory status. Due to the presence of relative hypotention and bradycardia after one and half hours, we changed from ECLA to PCPS. Following this, the respiratory and hemodynamic states became stable and her respiratory mechanics improved. The PCPS was discontinued on the 4th day of admission. Afterwards, bronchospasm didn't occur. The cause of the bronchospasm might have been insufficient sedation and bronchial stimulation due to the suction of the chest tube. We believe PCPS has the potential to be a technique of value for severe bronchospasm.

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A 26-year-old male suffered a right femoral fracture and a blunt injury of the descending aorta in a traffic accident. On admission, he was mostly alert. External fixation of the femoral fracture was followed by a surgical graft replacement of the descending aorta for the treatment of blunt aortic injury. After starting percutaneus cardiopulmonary support, light-bloody bubbling secretions from the trachea were observed and his oxygenation suddenly deteriorated. Thereafter, hypoxemia, high fever, tachycardia, and a disturbance of consciousness continued for several postoperative days. We detected some petechiae on his chest wall on the 5th day after the admission. We diagnosed fat embolism syndrome based on the presence of the petechiae and other clinical symptoms of the patients. The physical condition of the patient gradually improved after the administration of corticosteroids, however, the disturbance of consciousness continued to deteriorate. Magnetic resonance imaging of the brain on the 21st day after the admission showed the typical findings of fat embolism syndrome. In the present case, it was difficult to diagnose fat embolism syndrome because of the sudden onset of the syndrome during surgical graft replacement of the descending aorta for the treatment of blunt aortic injury.

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