Background: In a previous study, we clarified the accuracy of screening for blunt cerebrovascular injury (BCVI) by 4 multidetector-row CT angiography (MDCTA). The purpose of this study was to evaluate the accuracy of diagnosis of BCVI by 64 MDCTA.
Patients and Methods: The study comprised 163 patients admitted from 2007 through 2010 with blunt cervical/facial/head trauma who met predefined screening criteria for CTA. Patients with negative MDCTA results underwent no further radiologic evaluation. Patients with positive findings and whose diagnosis was not definitive underwent conventional angiography (CA). Positive predictive value (PPV) was determined, and the detection rate of vascular injuries was compared with that in the previous study.
Results: MDCTA results were positive in 22 of 163 (13.5%) patients. Vascular injuries were diagnosed definitively by MDCTA in 11(14 injuries) of the 22 patients. The other 11 patients had positive MDCTA findings but their diagnosis was not definitive. CA was not performed in 2 of these 11 patients because of brain death. Among the 12 injuries in these 9 patients, 9 injuries (PPV: 75%) were confirmed to be BCVI. The detection rate of vascular injuries was increased to 11.0% from 7.7% in the previous study, although the difference was not statistically significant. Four injuries were detected by conventional angiography but not by MDCTA (mild internal carotid injury at skull base: 1; arteriovenous fistula: 3).
Conclusions: Sixty-four MDCTA is an excellent screening tool for BCVI. However, accuracy of diagnosis for injuries adjacent to bone or for arteriovenous fistula requires improvement in the future.

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Early use of polymyxin B hemoperfusion to treat septic shock patients has become widespread in Japan. However, it remains controversial whether this treatment is beneficial. Polymyxin B hemoperfusion was not performed for septic shock patients in our ICU, but rather hemodynamics were maintained with noradrenaline, a small amount of vasopressin and left ventricular preloading as appropriate based on assessment by echocardiography. We retrospectively analyzed the outcomes of 28 septic shock patients undergoing emergency laparotomy for lower intestinal diseases. The mean mortality rate was 17.9%, which was lower than the predicted mortality rate of 63.3% based on APACHE II scores. The mortality rate of 15 patients with perforation of the large intestine was 0% compared with the predicted mortality rate of 57.7%. The significantly lower mortality rate in our ICU suggests that polymyxin B hemoperfusion is not an optimal choice for first line therapy in septic shock patients.

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Objectives: In Japan, legislations for terminal care have not been fully developed, and various terminal-care guidelines have been presented by various institutions. However, these guidelines are markedly vague, and their contents are insufficient. During resuscitation procedures for out-of-hospital cardiopulmonary arrests, it is sometimes possible to confirm a clear living will for “do-not-attempt-resuscitation” (DNAR) at the end of life. Currently, however, there are no well-defined criteria regarding the appropriate timing for considering treatment discontinuation or abstention; resuscitation is often followed by intensive care. We aimed to determine the current situation and problematic issues related to DNAR in out-of-hospital cardiopulmonary arrest patients.
Subjects and Methods: A retrospective study was conducted on the basis of the medical records of out-of-hospital cardiopulmonary arrest patients who were transported to St. Luke's International Hospital's Emergency and Critical Care Center between April 2009 and March 2010.
Results: The presence or absence of a living will for DNAR was confirmed in 126 of the 304 patients studied. Twenty-nine (23.0%) patients had left a living will for DNAR, but 8 of these patients (approximately one-fourth) showed a return of spontaneous circulation (ROSC) and ended up receiving resuscitation treatment and intensive care against their will. One patient was discharged from the hospital without any neurological sequelae and with cerebral performance category 1 (CPC1), whereas another patient, who was stabilized in a vegetative state after overcoming the acute phase, was transferred to another hospital with CPC4.
Conclusion: With the current insufficiency of laws and guidelines regarding end-of-life care, cardiopulmonary arrest patients with a living will for DNAR at the end of life are still likely to receive treatment. Receiving unwanted treatment may result in the patient's survival with a loss of dignity. To avoid such an unfortunate situation, accurate prognostic methods for patients with cardiopulmonary arrest are desired, and the entire nation needs to consider whether cardiopulmonary arrest itself should be conceived of as the end of life. On the basis of the consensus from this debate, laws and guidelines pertaining to terminal care should be developed as soon as possible.

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We report a case of a teenage male with penetrating cardiac injury (IIIb) . He injured himself when he slipped and fell down the stairs into a display case. The glass shards pierced the region around his sternum, and he was transported to the Emergency and Critical Care Center of this hospital. Upon arrival at the hospital, the patient's level of consciousness was 10 on the Japan Coma Scale. His blood pressure was 80 mmHg; he had a heart rate of 130 bpm and decreased breath sounds in his right lung. He was given a rapid fluid infusion intravenously. Echocardiography did not reveal any accumulation of pericardial effusion. Chest drainage was performed because a portable chest X-ray revealed a massive right hemothorax. Tracheal intubation was also carried out simultaneously. The chest tube drained 1700 ml of blood when inserted. As the patient responded to infusion and blood transfusion, contrast-enhanced computed tomography scans of the chest and abdomen were taken. The patient went into shock again upon returning to the emergency room, and a decision to perform thoracotomy for hemostasis was made. Through a right anterolateral thoracotomy from the site of incision, pericardial bleeding was ascertained and diagnosed as Type IIIa right atrial damage (The Japanese Association for The Surgery of Trauma, Organ Injury Classification 2008). Transverse sternotomy was performed successively making this a clamshell thoracotomy. Insertion of the index finger into the damaged area of the right atrium stopped the bleeding, and the wound area was then clamped with Satinsky forceps. The damaged site and pericardium were sutured before the chest incision was closed up. The patient progressed favorably and was ambulant at discharge on postoperative day 15. The present case was complicated by mild pericardial damage but it happened to progress without developing into cardiac tamponade, and the hemothorax was of the type that bled slowly into the thoracic cavity; hence, the patient did not experience cardiopulmonary arrest. The key to saving the lives of patients with penetrating trauma is the execution of uninterrupted rapid emergency care and hemostasis by a trauma team.

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