Japanese consultation-liaison (C-L) activities were expanded along with the critical care medical center projects. This might be different from other countries. After the development of critical care centers system, C-L psychiatrists applied “psychiatrists as gatekeepers” for the further development of C-L psychiatry. Two styles became common: liaison settings including a make-rounds style and in-house staff style. Make-rounds style means that C-L team makes rounds on the unit on a regular basis. They see all patients on the unit and play a key role in the total decision-making process which may incorporate psychiatric intervention. In some facilities, the psychiatrists or the C-L team is assigned as in-house staff in the critical care center. In some facilities, 10-15% of patients are due to suicide attempts. Therefore, concurrent psychiatric treatment of the suicidal patients in these units became essential. Furthermore, since all patients admitted to this center have serious illness, many patients become delirious or show mental/behavioral problems. Therefore, effective psychiatric treatment has become very important. For further development of C-L in this field, multidisciplinary team approach with co-medical staffs is necessary to supply efficient and effective care in critically ill patients and suicidal patients. Systematic clinical work and research of the efficient and effective role of C-L psychiatrists is necessary. Presenting the outcome of the work/research would be our next challenge to fully integrate ourselves into the practice of emergency medicine and catch up with the ongoing medical reform in Japan.

View full abstract

Background: The appearance of extensive early computed tomography (CT) signs is considered as a contraindication for thrombolytic therapy. However, to date, no report has been published on the timing of the appearance of CT signs. We therefore investigated the time after onset until the appearance of early CT signs in patients with middle cerebral artery (MCA) trunk or common carotid artery (CCA)/internal carotid artery (ICA) embolisms. Methods: The time from onset until an initial CT scan, the subtypes of ischemic stroke and the appearance of early CT signs were investigated in early ischemic stroke patients with lesions of the CCA/ICA or MCA trunk who had been transported to our emergency and critical care center between 2002 and 2007. Results: A total of 104 patients (CCA/ICA, n=23; MCA trunk, n=81) were examined. The results indicated that the rate of the appearance of early CT signs was 0% at less than 0.5 hours after onset; on the other hand, the rate was 100% at 1.5-2 h and 2-3 h after outset. A significant difference in the timing of the initial CT brain scan (p<0.0001 Wilcoxon test) was seen between the group without early CT signs (n=37) and the group with early CT signs (n=67). The boundary line between the two groups apparently occurred 0.5-1.0 hours after the onset period. Thus, most early CT signs appeared 0.5-1.0 hours after onset (p<0.0001 Wilcoxon test). Conclusions: The present results could be useful when making decisions regarding the timing of thrombolytic therapy.

View full abstract

Introduction: Early death after blunt trauma is caused by massive bleeding. Our previous report demonstrated that disseminated intravascular coagulation with a fibrinolytic phenotype from the time of admission to the emergency department until 4 hours thereafter contributes to a poor prognosis due to massive bleeding.
Objective: Fibrinolysis at admission to the emergency department immediately after blunt trauma may predict massive bleeding. This study retrospectively investigated the relationship between coagulation and fibrinolysis, and massive bleeding at an early phase in patients presenting with blunt trauma.
Methods: All patients with blunt trauma admitted to the emergency department, associated with, at least, one of the abbreviated injury scales _3 from January 2005 to December 2006 were enrolled in the study. The clinical backgrounds of the patients and the measured variables were retrospectively collected.
Results: Eighty-three patients; 17 patients with massive bleeding and 66 patients without massive bleeding, were included in this study. Fibrin/fibrinogen degradation products (FDP) and D-dimer levels markedly increased in both groups. FDP and D-dimer in the massive bleeding group were statistically higher than those in the non-massive bleeding group. A stepwise logistic regression analysis showed FDP to be an independent predictor of massive bleeding. The receiver operating characteristic curve analysis for massive bleeding showed FDP to have the largest area under the curve and that the optimal cutoff point of FDP in order to predict massive bleeding was >64.1 μg/ml.
Conclusion: Increased fibrin/fibrinogen degradation resulting in high FDP levels at an early phase of trauma is therefore considered to predict massive bleeding. The optimal cutoff point of FDP to predict massive bleeding was >64.1 μg/ml.

View full abstract

A 22-year-old healthy man developed cardiac arrest when playing basketball. Despite of cardiopulmonary resuscitation, he died in our hospital on the 2nd day. A autopsy revealed aberrant right coronary artery as the cause of death. This present had 2 episodes of syncope during drinking and exercise before. Sudden death of young athletes during exercise can be caused by aberrant right coronary artery from the left sinus of Valsalva. However, this disease is rarely diagnosed before cardiac arrest, though just 30% of such case has been reported to have episodes of syncope only during exercise. Few consult physicians because they have no symptoms after exercise. Additionally, if they had medical examinations, there is usually no significant finding on routine examination such as an electrocardiogram and echocardiograms at rest. Therefore, it is difficult to diagnose aberrant coronary artery before a major episode. Syncope is a relatively common symptom, however, in order to prevent sudden death due to this disease, we should more carefully examine young athletes with syncope, especially during exercise. We should aggressively consider using multi-slice computed tomography (CT) for the prevention of sudden death caused by this disease.

View full abstract

There have been a few studies on the usefulness of multidetector-row CT (MDCT) for the diagnosis of blunt renal vascular injuries. We describe 4 cases of blunt renal vascular injuries depicted on MDCT. Case 1: A 20-year-old man sustained left IIIa renal injury, splenic injury and left lung contusion. On angiography, extravasation and pseudoaneurysm were depicted, but pseudoaneurysm was not depicted on MDCT. Case 2: A 58-year-old man sustained left IIIa renal injury. On angiography and MDCT, the injured segmental artery with extravasation was demonstrated. Case 3: A 75-year-old woman sustained left IIIb renal injury, thoracic aortic injury. On angiography and MDCT, injured posterior branch of the renal artery with extravasation was demonstrated. Case 4: A 67-year-old man sustained right IIIb renal injury. On angiography and MDCT, injured segmental artery with pseudoaneurysm and extravasation was demonstrated. Six blunt renal vascular injuries (four extravasations and two pseudoaneurysms) were confirmed on angiography in 4 cases. Except for one pseudoaneurysm, five vascular injuries were also depicted by the initial MDCT. We performed transcatheter arterial embolization (TAE) for renal injury in all cases and then nephrectomy was performed after TAE in case 3 and case 4. In our cases, MDCT successfully depicted blunt renal vascular injuries.

View full abstract

This is the report of a case that required clinical ethical evaluation due to family relations that became strained when a donor candidate was selected for adult-to-adult living donor liver transplantation (LDLT). A 40-year-old woman was transferred to our hospital because of drug-induced severe hepatitis. She suffered from hepatic encephalopathy grade III. On admission, her prothrombin time was 19%, and her total bilirubin was 26.6 mg/dl. Her condition deteriorated, and adult-to-adult LDLT was explained to her family members as the ultimate treatment of choice. The only donor candidate was her father who was divorced from her mother. He opted for the operation, but his common-law wife opposed his decision. After consulting a lawyer through the ethics committee, the operation was performed in respect for his will and interpersonal relationships among the family members deteriorated. The patient died from liver failure after several months. In cases of intractable severe acute liver failure involving conscious disorders, it is better for donor candidates to freely decide their will. At the same time, however, time limitations create psychological pressure when means of treatment and transplantation are explained to the donor's family as final medical measures because LDLT may offer the only chance of patient survival. It must be understood that these psychological pressures extend beyond the donor to his or her family members and all concerned should be offered psychosocial support, regardless of the decision of the donor candidate.

View full abstract

We report a case of cerebral infarction during pregnancy which was treated using thrombolytic therapy with urokinase during a therapeutic window. A 34-year-old woman (at 39 weeks gestation) developed sudden onset of left side semi-paralysis and articulation disorder, and was admitted into our Emergency room 90 minutes later. Her National Institute of Health Stroke Scale (NIHSS) score was 8 prior to thrombolytic treatment. computed tomography (CT) demonstrated an attenuated cortico-medullary border in the middle cerebral artery (MCA) scans 2 hours after onset. Diffusion-weighted imaging by magnetic resonance imaging (MRI) revealed a high intensity area 2.5 hours after onset, which confirmed the CT findings. We indicated thrombolytic therapy with urokinase to the patient from several methods since we considered the potential benefits of this therapy to outweigh the risks to her and her fetus. After treatment, her NIHSS score improved. She delivered on Day 3, recovered, and was discharged on Day 17 without sequelae. In this rare case with such a limited time period, a clinical decision was difficult to make in considering the treatment effects on both the patient and her fetus. The indication of thrombolytic therapy to the cerebral infarction patient during pregnancy should be carefully considered.

View full abstract

A 56-year-old man suddenly collapsed at the eighth station of Mt. Fuji. A foreign doctor happened to be on the scene and diagnosed cardiopulmonary arrest (CPA) and began cardiopulmonary resuscitation (CPR). During this time, another person on the scene notified the 8th Station First Aid Station and a doctor was dispatched with an automated external defibrillator (AED). The AED was successfully administered about 30 minutes after the patient collapsed. Shortly after the patient's breathing and pulse were restored. Once able to be safely transported, he was taken by an off-road (crawler caterpillar) vehicle down to the fifth station, where an ambulance was prepared to take him to the Yamanashi Red Cross Hospital. He arrived at the hospital about two hours after defibrillation was performed. By the next day, his consciousness was restored without hypothermia. A coronary arteriogram showed the perfect occlusion of the left anterior descending artery and that collateral circulation had developed. He was discharged four days later without any after effects of this occurrence. Along with the importance of having first aid stations at the 7th and 8th Stations, the success of this event reconfirms the importance of the 2007 initiative to make AED devices available at all mountain huts as well as training employees basic life support (BLS) skills.

View full abstract