Disseminated intravascular coagulation (DIC) is first recognized as“the syndrome which associates with various basal diseases, and characterized by the intravascular activation of coagulation with loss of localization. It is initially detected only as a hematological disorder, but if it turns out sufficiently severe, can produce organ dysfunction and/or bleeding tendency caused by disseminated thrombus formation and consumptive coagulopathy”. In other words, the significance of DIC is the common category characterized by hematological disorder independent from the basal diseases. Numbers of researches have been performed and the detail of pathophysiology of DIC has been revealed that the pathological and clinical courses of DIC are different depending on the basal disease. Recent studies have demonstrated that the comprehensive diagnosis or treatment is not adequate. Even the importance of the individual measures depending on the individual backgrounds is emphasized. Especially, the treatment for septic DIC attracts much attention because of its high incidence, emergency and severity. With regard to the concept of DIC, it changes from the passive meaning“DIC is only a complication of sepsis”to positive meaning that“DIC is a protective reaction for the infection”. As for the diagnosis, it is generally accepted that early initiation by early diagnosis is preferable. Physiological anticoagulants including antithrombin, thrombomodulin and activated protein C are especially important as pharmaceuticals since they are expected to have not only the anti-coagulant effect but also the anti-inflammatory effect.

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Background: In pediatric patients, the optimum medical instruments and drug dosage vary depending on their age and physical frame. In initial medical care for pediatric emergencies in which it is difficult to obtain sufficient patient information in advance, it is recommended to use Broselow^TM Pediatric Emergency Tape for the purpose of preventing errors and promptly proceeding with medical care. From our experience in using BT, we prepared a pediatric resuscitation guide and equipment set for pediatric instruments and introduced them as a Senshu version of the pediatric resuscitation set.
Objective: To reveal the usefulness of the pediatric resuscitation set in the initial medical care for pediatric emergency patients.
Verification 1: Examination of accuracy. ‹Methods›At the emergency care center of our institution, patients were classified into two groups before and after introducing the pediatric resuscitation set, and the size and insertion length of a tracheal tube, complications due to tracheal intubation, and drug dosage were retrospectively examined from the medical records. ‹Results›In the post-introduction group, the proper size and insertion length of the tracheal tube were selected and there were no complications due to intubation. Moreover, a significantly accurate drug dosage was selected.
Verification 2: Examination of promptness. ‹Methods›A simulation was run on physicians in specialized pediatric healthcare facilities with three patterns: not using BT, using BT only, and using the pediatric resuscitation set. The promptness of selecting pediatric instruments and a drug dosage was compared among the three groups. ‹Results›In the group using the pediatric resuscitation set, the pediatric instruments and the drug dosage were selected in a significantly prompt manner in comparison to the other two groups.
Conclusions: The introduction of the pediatric resuscitation set has made it possible to promptly and safely select medical instruments and determine drug dosages. In initial medical care for pediatric emergency patients, it is important to attempt to standardize and simplify the initial medical care by introducing such a set.

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Background: Emergency surgery is usually selected for patients with Stanford A aortic dissection. However, operative indication is still controversial in thrombosed-type Stanford A aortic dissection especially in highly-aged patients or in patients with multiple complications.
Material and Method: Ischemic changes in electrocardiogram (ECG) just after the onset of type A dissection were retrospectively evaluated. Twenty-four patients with the mean age of 67 years were included. The mean maximum short-axis diameter of ascending aorta was 45±21 (30-53) mm.
Results: Ischemic ECG changes were observed in 13 (54%) patients. A ST-elevation on the chest leads was detected in five patients and that on the limb leads in three patients. A ST-depression was observed in a case and inverted T in four. Eleven patients underwent emergency operation and 13 patients were treated medically. Out of 11 patients who were absent from ischemic ECG changes, five patients with aortic dilatation of 45 mm or larger underwent surgery and six patients received conservative treatments. In 13 patients with ischemic ECG changes, six patients underwent surgery and residual seven patients received conservative treatments. The entry of aortic dissection was intraoperatively detected at ascending or arch aorta in four patients including three patients with a ST-elevation on the chest leads. In these three patients with a ST-elevation on the chest leads, extensive dissection including bilateral coronary artery orifices was detected. Twenty three patients survived and a patient with a ST-elevation on the chest leads died of bowel ischemia during conservative treatment. Creatinine phosphokinase (CPK) values on the hospital arrival were 2,425±1,576 IU/l in patients with ST elevation on chest leads, which was significantly (p<0.05) higher than 109±18 IU/l in patients without ischemic ECG change. ST-elevation on chest leads disappeared on the day of onset or after surgery, however, old myocardial infarction occurred in two patients even in late periods.
Discussion: In thrombosed-type Stanford A aortic dissection, a ST-elevation was transient probably because the compression on the coronary artery decreased by the progression of thrombosis in the false lumen. However, a ST-elevation on the chest leads indicates the compression on the left main trunk.
Conclusion: Patients with ST-elevation on chest leads should be operated urgently. Patients with other ischemic ECG changes may be observed conservatively except for large ascending aortic dilatation.

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An angiographically occult arteriovenous malformations (AOAVM) are cerebrovascular malformations that are not demonstrable on cerebral angiography. This report presents a case of a putaminal hemorrhage associated with severe multiple injuries caused by a traffic accident. A 24-year-old female was transferred to the nearest emergency hospital by ambulance. She was thereafter transferred to our department because of multiple high-energy injuries. A brain CT scan showed the existence of a putaminal hemorrhage without a cerebral contusion. The injury severity score was 48 on admission. Transcatheter arterial embolization was performed for the left renal injury. The traction of the right femoral bone with Kirschner wire was performed. In addition, disseminated intravascular coagulation was treated with massive blood transfusions including the fresh frozen plasma. A follow-up CT scan revealed a mild regrowth hematoma three hours after admission. Therefore, the patient further underwent emergency cerebral angiography which suggested an arteriovenous malformation. However, no vessel abnormalities were found. A cerebral herniation was demonstrated by CT scan six hours after admission. An emergency operation was therefore immediately performed. A hard mass was found in the hemorrhage during surgery. An AOAVM was thus revealed in the pathological examination. Regarding the differential diagnosis of an intracerebral hemorrhage in a young age patient or a patient without hypertension, this was considered to be an AOAVM.

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We report the primary care requirements and method for managing toxic shock syndrome (TSS) in areas where community-acquired infections with methicillin-resistant Staphylococcus aureus (CA-MRSA) infection is rare, such as Japan. A 31-year-old male was visited a hospital because of a deep dermal burn of leg, partially deteriorated into deep burn. After eight days of treatment he was admitted to the hospital with the positive diagnostic criteria for TSS. A few days later, MRSA was cultured from the burned necrotic tissue. Analysis of the antibiotic susceptibility of the cultured MRSA indicated a susceptibility to sulfamethoxazole · trimethoprim or clindamycin. Genotyping of the MRSA, however, identified SCCmec type IV, thus comfirming CA-MRSA as the causal organism. TSS in Japan is much more frequently caused by the methicillin-susceptible Staphylococcus aureus infection than by CA-MRSA. Penicillin or cephalosporin with clindamycin is therefore considered the first-line therapy for TSS. The routine use of anti MRSA-agents should be avoided in an area such as Japan, where CA-MRSA infection is rare; however, we have to consider treatment with the anti-MRSA agents on the assumption of CA-MRSA infection. To prepare for the probable increase in the ratios of CA-MRSA infection, we must also carefully observe the epidemiological alteration of the CA-MRSA infection in Japan.

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We report a case in which a patient with pneumatosis intestinalis (PI) affecting almost the entire length of the small bowel wall was successfully treated with conservative management. An 82-year-old man was brought to hospital with a 1-month history of abdominal distention and bloody stools. He had called emergency services because of fever (37°C), dyspnea, and cyanosis. Vital signs on admission were as follows: Glasgow Coma Score, E4, V2, M6; blood pressure, 120/64 mmHg; heart rate, 116 beats/min; respiratory rate, 18 breaths/min; and body temperature, 40°C. He complained of abdominal distension, but showed no signs of peritoneal irritation. Contrast-enhanced computed tomography (CT) showed paralytic ileus and abnormal gas patterns in the wall of the small bowel. We suspected the abnormal gas was caused by bowel wall necrosis. However, we were hesitant to perform emergency laparotomy because his clinical conditions improved with administration of antibiotics and fluid replacement. Abdominal distension gradually improved. CT on day 13 did not show any abnormal gas findings. Small bowel capsule endoscopy performed on day 19 showed only a small erosive lesion in the mucosa of the small bowel. The patient was discharged uneventfully on day 29. We believe that the abnormal gas patterns in the small bowel wall indicated PI. Increased intraluminal pressure will cause PI.

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