Although the rate of survival after an out-of-hospital Cardiac Arrest (CA) has been increasing due to improvement of quality of resuscitation and developments in medical technology, it is still low. This paper describes on a study conducted with the cooperation of the Kobe City Fire Department, the use of Public-Access Defibrillation (PAD) in out-of-hospital CA cases, which occurred in Kobe, a government-ordinance-designated-city with a population of approximately 1.53 million people, and the outcomes of use of PAD. We analyzed the actual status of automated external defibrillator (AED) kits located within Kobe City and the current situation regarding use of PAD in 5,700 CA cases transported to hospital by emergency services, which occurred in Kobe City during the five years between April 2005 and March 2010. In April 2005, there were 90 AED kits installed across Kobe City, the AED installed-base expanded, and as at March 2010, the installation-base was 1,299 kits (according to data by the Kobe City Fire Depatment). During this period, the AED was applied by bystanders in 136 cases (2.6%). AED was applied to witnessed CA in 90 cardiogenic cases and 42 cases (46.7%) were indicated for defibrillation, of which return of spontaneous circulation was recognized in 26 cases (61.9%) and one month survival was obtained in 23 cases (54.8%). AED was also applied to 44 cardiogenic cases without witness, and 6 cases (13.6%) were indicated for defibrillation of which return of spontaneous circulation was recognized in 2 cases (33.3%), and one month survival was seen in 1 case (16.7%). In 2010, Kitamura et al compiled a report on all of the CA cases across Japan using data from the Fire and Disaster Management Agency under the Ministry of Internal Affairs and Communications, which showed the usefulness of PAD. A comparison of the results of our study from Kobe City and the national results for Japan showed that PAD cases in Kobe City have a better prognosis. However, given the low levels of application of AED at 2.3% of all CA cases and only 4.2% for cardiogenic cases alone, further AED promotion initiatives are required.

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Background: The availability of primary trauma care is well known to have a considerable impact on the prognosis of severe trauma patients. It is more difficult to assess and treat pediatric patients than adult patients, because of the differences in the physical size and vital signs between adult and pediatric patients. A medical care system for children was established in 2005 to improve the treatment levels for children with severe trauma at emergency medical care centers.
Objectives: This study was conducted to evaluate the effectiveness of the improved medical care system for pediatric patients with severe trauma at an emergency medical care center.
Methods: We enrolled all patients with severe trauma admitted to the hospital from 2000 to 2008. The therapeutic process and outcome of trauma care before and after the establishment of medical care system were retrospectively compared by reviewing the patients' medical records.
Results: A comparison of the therapeutic process in the pediatric population between the two time-periods (before and after the establishment of the improved medical care system; pre-group and post-group, respectively) revealed that the times spent in establishing an intravenous line (pediatric pre-group vs. post-group: 7 vs. 2 minutes), in accomplishing tracheal intubation (15 vs. 10 minutes), and until entering the CT room (31 vs. 23 minutes) were significantly decreased after the establishment of the improved medical care system. However, no significant differences in the time until the beginning of craniotomy / trepanation (pediatric pre-group vs. post-group: 58 vs. 59 minutes) or time spent in performing hemostatic procedures (60 vs. 48 minutes) were found between the two time-periods. A comparison of the therapeutic process between the pediatric and adult groups revealed that there were no significant differences in the time spent in establishing an intravenous line (pediatric post-group vs. adult group: 2 vs. 2 minutes), in accomplishing tracheal intubation (10 vs. 9 minutes), until entering the CT room (23 vs. 29 minutes), until the beginning of craniotomy/trepanation (pediatric post-group vs. adult group: 59 vs. 52 minutes), or in performing hemostatic procedures (48 vs. 50 minutes). The craniotomy/trepanation and hemostatic procedures could be started within 60 minutes. There were no cases of preventable death in the pediatric post-group.
Conclusion: Establishment of the improved medical care system for pediatric patients allowed provision of trauma care for children at a level equivalent to that for adult patients.

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This is a case report of a 43-year-old female who had been repeatedly admitted and discharged from the hospital's psychiatric department since being diagnosed with anorexia nervosa at 30 years of age. She was admitted to a different hospital after slipping into a coma at home. She was diagnosed as having shock and hypoglycemia due to dehydration and malnutrition. Total parenteral nutrition was administered, while ensuring adequate fluid replacement. However, she was subsequently transported to the ICU of our hospital on Day 13 of treatment with evidence of multiple organ failure. She was diagnosed as having the refeeding syndrome, because the parenteral nutrition had been administered without correcting the hypophosphatemia. She was found to have significant hypophosphatemia (IP 0.5 mg/dl), and was administered a low-calorie infusion solution, which resulted in improvementof the serum phosphorus level. The patient recovered from the shock and her organ functions improved, followed by recovery of the serum phosphorous level. The importance of nutritional management has been recognized; however, refeeding syndrome is difficult to recognize in the emergency and intensive care settings. It is therefore important to bear the possibility of refeeding syndrome in mind when providing nutritional management to patients with anorexia nervosa. In addition, it is important to administer nutritional support starting with a low-calorie diet containing microelements to avoid the onset of organ failure.

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Long QT syndrome is not rare syndrome, but it is necessary to pay attention to ventricular fibrillation in order to avoid adverse outcomes. We herein report the case of a 12-year-old female who developed ventricular fibrillation while swimming in her elementary school's pool. The fibrillation resulted in sudden onset cardiac arrest. Her teacher immediately performed cardiac resuscitation with an automated external defibrillator. She soon had a return of spontaneous circulation, however, she did not recover consciousness, and was transferred to our hospital after intratracheal intubation by doctor. Upon arrival at the hospital, her consciousness level was deep coma, her bilateral pupils were 3 mm in diameter, and her blood pressure was 136/74mmHg, her pulse rate was 84/minute, and her respiratory rate was 19/ minute. An electrocardiogram displayed an extended QT time after correction. She recovered with no neurological deficits after brain hypothermia therapy at 33°C for 24 hours. She was diagnosed to have long QT syndrome, and was therefore suspected to have Romano-Ward syndrome because of her family history. As a result, she received an implantable cardioverter defibrillator on the seventh hospital day. She was uneventfully discharged on the 14 hospital day. The presence of long QT syndrome in a young subject is generally suspected to be due to a congenital disease such as Romano-Ward syndrome. Romano-Ward syndrome is an autosomal dominant disease, therefore it is necessary to perform genetic diagnosis to confirm the presence of the defective gene. Implantable cardioverter defibrillator insertion is indispensable in the high risk patients for ventricular fibrillation.

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We report a case of a 49-year-old man with acquired renal arteriovenous fistula (RAVF) caused by blunt renal injury. The patient fell down stairs and hit his right lower back, his lower back pain worsened, and therefore he consulted a local hospital 5 days after injury. The doctor diagnosed renal injury, and the patient was transferred to our hospital. Contrast-enhanced computed tomography (CT) revealed subcapsular hematoma and small renal parenchyma hematoma, corresponding to type Ib renal injury according to the Japanese Association for the Surgery of Trauma 2008 classification. His pain and hematuria improved and he was discharged from hospital 13 -days after injury. However, 29 days after injury his hematuria reappeared. Contrast-enhanced CT imaging findings suggested RAVF. However, because his vital signs were stable , he returned home. After another 4 days, his hematuria worsened, and therefore we performed angiography. Selective renal arteriography revealed RAVF and a pseudoaneurysm in the upper part of his right kidney. Transcatheter arterial embolization (TAE) was performed for the fistula with a coil and his hematuria improved. In mild renal injury as in the present case, it is routine to observe and not perform surgery. However, if hematuria caused by blunt renal injury remains, we must consider the possibility of RAVF or a pseudoaneurysm. TAE was useful in the present case.

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There have been an increasing number of bear sightings in recent years, and it is expected that there will be an increased need to treat bear-inflicted injuries at hospitals near mountains with bear habitat. Here, we report 4 patients with injuries caused by bears, who were treated at our hospital over the past 2 years. We also discuss the issues important in the initial treatment of these injuries. Most bear-inflicted injuries involve the craniofacial region. Facial soft tissue injuries include injuries to the eyes, nasolacrimal ducts, parotid ducts, and facial nerves. It may be necessary to consult a specialist based on the sites and severity of the injuries. The prevention of tetanus and other bacterial infections is also important. Serious infections were avoided in our 4 cases and in other patients reported in the literature by thorough irrigation of wounds and administration of antibiotics, tetanus toxoid, and human antitetanus immunoglobulin. Wounds in the limbs required more time to heal compared to craniofacial wounds. It is important to know about facial soft tissue injuries and prevention of infection for the treatment of bear-inflicted injuries.

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A 30-year-old woman and a 37-year-old man were admitted to the emergency department because of shock and altered consciousness of unknown cause. They complained of general fatigue and presented with a symptom similar to hypotension. Both patients showed severe bradycardia, atrioventricular block, acute renal failure with oliguria and increased serum creatinine, and poor response to catecholamines. The next day, many empty press-through packages of medicine, including diltiazem and nicorandil, were found in the patients' room. They were primarily diagnosed with calcium channel blocker poisoning due to an overdose of diltiazem. The patients failed to respond to treatment with intravenous calcium gluconate. However, they showed a significant response to treatment with calcium chloride, which led to an immediate increase in blood pressure and the recovery of sinus rhythm. The patients resumed the general conditions and were discharged without any complaints. Later, high concentration of diltiazem, desacetyl-diltiazem, and nicorandil were detected in their serum samples. Some reports recommend the use of calcium chloride rather than calcium gluconate for the treatment of calcium channel blocker poisoning. Therefore, the present findings suggest that intravenous administration of calcium chloride is an alternative treatment for patients who do not respond to calcium gluconate.

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