First-aid drugs during cardiopulmonary resuscitation remain controversial even though they have been reevaluated. We conducted a clinical investigation in order to determine whether the regimen and deses of sodium bicarbonate and epinephrine hydrochloride causes differences in cardiac resuscitation rate. The subjects were 808 of DOA patients of medical causes admitted to this center. They were divided into the following 3 stages according to the regimen and doses of sodium bicarbonate and epinephrine hydrochloride. Stage I: Epinephrine hydrochloride, 1mg/dose/5min, sodium bicarbonate, immediate administration after ensuring an intravenous route, 228 cases. Stage II: Epinephrine hydrochloride, the same as in stage I; sodum bicarbonate, administration according to the results of arterial blood gas analysis after adequate artificial respiration, 247 cases. Stage III: Epinephrine hydrochloride, 5mg/dose/5min, sodium bicarbonate, the same as in stage II, 333 cases. Cardiac resuscitation rates were compared with respect to the ECG findings on admission in all cases in all 3 stages. There were no significant differences among stages I, II, and III. The cases were then limited to those not subjected to bystander CPR, although there was an observer. In these cases, the defibrillation effect of sodium bicarbonate was investigated by comparing ventricular fibrillation cases in stage I and stage II. The effect of epinephrine hydrochloride on the cardiac resuscitation was investigated by comparing cardiac arrest and ventricular fibrillation cases in stage II and stage III. The results suggest that immediate administration of sodium bicarbonate on admission did not improve the defibrillation rate (25.5% in stage I vs 24.6% in stage II) and that the increase in dose of epinephrine hydrochloride (1mg/dose to 5mg/dose) did not significantly affect the cardiac resuscitation rates [rate among cases of cardiac arrest with measurement of blood pressure possible (14.7% in stage II vs 17.6% in stage III); defibrillation rates in cases of ventricular fibrillation (24.6% in stage II vs 31.2% in stage III)]. Based on the above results concerning cardiac resuscitation, immediate administration of sodium bicarbonate on admission did not affect the defibrillation rate, but the size of the individual doses of epinephrine hydrochloride appear to require further investigation.

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There have been enormous advances in our understanding of the role of the spleen in the immunological response. As a consequence, traumatologists now try to preserve splenic function in splenic injuries. Surgical procedures such as partial splenectomy and splenorrhaphy have been employed to achieve splenic salvage. However, one of the crucial things to manage is hemorrhage from the injured spleen. Many patients with blunt splenic injury can be managed nonoperatively if continued bleeding from the injured spleen can be controlled. Transcatheter arterial embolization (TAE) is a less invasive technique to control splenic bleeding. In the past 12 years 3 months, 173 patients with blunt splenic injury have been treated at Kitasato University Hospital. Of these patients, 128 (74.0%) underwent surgery, and 45 (26.0%) were treated nonoperatively, including by TAE. Since April 1986, when we started to actively introduce nonoperative management of splenic injuries, the number of patients treated nonsurgically has increased to 41 out of 94 (43.6%). According to the classification of splenic injuries proposed by the Japanese Association for the Surgery of Trauma, type I included 3 patients, type II 30 patients, type III a 41 patients, type III b 22 patients, type III c 31 patients, type III d 41 patients, and type IV 5 patients. Most of the hemodynamically stable type I and type II patients without associated injuries requiring surgical intervention were managed by observation or underwent possibly unnecessary surgery, such as exploratory laparotomy with manual compression. Thirty-three of the 173 patients with blunt splenic injury underwent abdominal angiography. Twenty-one patients showed extravasation of the contrast material on arteriograms, and all were type III. Subsequently, TAE was performed on 18 of these 21 patients, using particles of gelatin sponge or autogenous clot infused into the splenic artery or a main branch of the splenic artery. TAE was successfully completed in 16 patients. The 2 patients in which TAE was unsuccessful were hemodynamically unstable and required cathecholamine support to maintain blood pressure, and showed marked vascular spasm on arteriograms. No severe complications were observed in the 16 patients who underwent successful TAE. Fourteen of the patients in which TAE was completed were successfully managed without any further surgical intervention for their splenic injuries. We conclude that TAE is a safe and useful technique to manage blunt splenic injuries nonoperatively in hemodynamically stable type III patients with continued hemorrhage, as indicated by extravasation of contrast material on arteriograms.

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We developed a simple severity index for patients with paraquat poisoning to determine in the initial stages of admission how likely a favorable outcome is. Upper gastrointestinal endoscopic examination was performed in 23 patients with paraquat poisoning over a 9-year period, and the severity of the findings were rated. Using these seventies, we compared survivors and non-survivors of paraquat poisoning. There were no significant differences between the two groups in age, sex, initial management or estimated volume of ingested paraquat. Endoscopic findings were rated on a scale of 0 to 3 as follows: normal esophageal findings 0, esophagitis 1, esophageal ulcer 2; normal gastric and duodenal findings 0, redness, swelling and slight erosion 1, and erosion and ulceration 2. The estimated probability of death (Pr) calculated by logistic regression from these endoscopic scores was 1/{1+exp(17-4.14eso-8.85stom-4.14duod)}. The value of Pr in survivors and non-survivors wan 0.20±0.12 and 0.89±0.05, respectively (P<0.01). At the cutoff value of Pr (0.5), sensitivity and specificity were 100% and 60%, respectively. The 3 patients whose Pr was less than 0.5 survived, and the 14 cases whose Pr was more than 0.5 died. Of the 6 patients whose Pr was 0.5, 2 patients (33.3%) survived and 4 patients (66.7%) had poor outcomes. Those results suggest that the Pr is a reliable and valuable prognostic index in the initial stage of paraquat poisoning.

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Acute intracranial hemorrhage is one of the most important disorders in the field of acute medicine. The main causes of acute intracranial hemorrhage are head injury and cerebrovascular disease. The clinico-pathological state is, of course, different between these two disorders, but their clinical signs and symptoms, and diagnostic imaging are sometimes quite similar. Therefore, it can be difficult to make an accurate diagnosis in the acute stage. However, in such cases, appropriate treatment is required as soon as possible for good prognosis. In this paper, the authors present 9 cases of acute intracranial hemorrhage in which it was difficult to judge whether the hemorrhage originated from head injury or cerebrovascular disease, and discuss the problems in diagnosing and treating these cases. The authors also stress the medico-legal problems of these cases.

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Retropharyngeal abscess was a fetal disease before the development of antibiotics, but today we rerely encounter severe cases. This report is just such a rare case. A 49-year-old Japanese man was admitted to our hospital because of sepsis due to retropharyngeal abscess. Computed tomographic scans demonstrated thrombosis extending into the right transverse sinus from the right jugular vein. The next day angiography revealed an aneurysm of the right internal carotid artery at the same level as the jugular vein thrombosis. Invasion of the bacterial infection from the retropharyngeal abscess into the internal carotid artery and jugular vein caused an aneurysm on thrombosis and one side on the other. The reason why these different lesions developed is the difference between the structure of arterial walls and venous walls. Generally speaking, arteries have thicker walls, and are exposed to higher pressure and faster blood flow than veins. Thus, when the bacterial infection invaded the vessels, an aneurysm developed in the artery and thrombosis developed in the vein.

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We encountered three cases of cervical spinal cord injury with development of clinical evidence of coagulopathy. Hemorrhagic diathesis was diagnosed 2-3 days after the spinal cord injury. Laboratory studies showed decreased fibrinogen and platelet levels, and increases in fibrin degradation products. Although treatment was symptomatic, the laboratory data returned to the normal range after a few days, and no organic dysfunction was observed. We were unable to detect any marked differences between these three cases and other spinal cord injuries with respect to onset, severity or methods of treatment.

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Streaky soft tissue infiltration appearance (“Streaky appearance”) of the mesentery by enhanced CT scan is reported in two patients with small intestinal perforation following blunt abdominal trauma. The first patient was a 33-year-old man with severe pelvic fracture. An enhanced CT scan was performed about two hours after the injury. Streaky appearance of the mesentery and ectopic intraperitoneal gas were revealed. Laparotomy was performed and small intestinal perforation repair with jejunectomy (60cm) was performed. The mesentery with the streaky appearance was identical to the area of perforated intestine. Pathological findings in the area of the mesentery were interstitial edema with inflammatory cellular infiltration. The second patient was an 18-year-old woman. Two hours after a traffic accident, she had only minor abdominal tenderness. A CT scan was performed and no ectopic gas, but streaky appearance of the mesentery was revealed. Gradually her abdominal physical findings deteriorated. Laparotomy was performed and jejunal perforation was repaired by suturing. The streaky appearance in this patient was also identical to the mesenteric area of the injured intestine. The streaky appearance of the mesentery by enhanced CT scan appears to be a valuable sign of intestinal perforation in the early phase of trauma.

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A 65-year-old male was transferred to our medical center because of circulatory shock from suspected acute myocardial infarction. The coronary angiogram findings, however, were normal. Subsequently, cyanosis and hypotension became worse despite inhalation of enriched oxygen and injection of high doses of dopamine. The pulmonary arterial pressure (68/38mmHg) was almost the same as the systemic blood pressure. Using a percutaneous cardiopulmonary support system (PCPS) and artificial ventilation, pulmonary angiography was performed, and showed vascular cutoff and filling defects in more than 4 lobar arteries due to thromboemboli. Tissuetype plasminogen activator (t-PA) was administered intravenously 6 and a half hours after the onset of symptoms at a dose of 1.6 million IU over one hour, followed by 3.2 million IU/day into the pulmonary artery for 3 consecutive days. After 8 hours of t-PA therapy, a rapid reduction in the abnormally elevated right heart pressure was observed, and we were able to wean the patient off medication. The patient subsequently recovered without any complications from the PCPS. Thus temporary emergency use of PCPS until thrombolysis and recanalization of the obstructed pulmonary vascular beds could be achieved was helpful in preserving both systemic circulation and oxygenation of vital organs, and may increase the likelihood of survival in patients with acute massive pulmonary embolism.

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A 47-year-old male was admitted because of severe chest pain after repeated vomiting. A little amount of coffeegrounds was seen in the vomitus, and emergency endoscopic examination was performed 1 hour after the onset of symptoms. Endoscopy demonstrated a lacerated wound about 3cm long on each side of the terminal esophagus. With a diagnosis of spontaneous rupture of the esophagus, a primary closure of the rupture was performed 4 hours after the onset, and a pedicled omental graft was applied over the suture site. The patient was discharged in improved condition on the 99th day. In Japan, more than 250 cases of spontaneous rupture of the esophagus have been reported, and 59 cases (including ours) have been observed endoscopically. Many authors have said that emergency endoscopy is useful for definitive diagnosis and for selection of the appropriate surgical procedure. The diagnostic accuracy with emergency endoscopy is 58 percent, so it has been suggested that emergency endoscopy is a valuable initial examination, but systematic diagnosis is necessary for early establishment of correct diagnosis.

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Internal herniae are mainly detected when they cause bowel obstruction but are responsible for less than one percent of bowel obstruction. Among these, approximately fifty percent are paraduodenal herniae. Although the preoperative diagnosis can be made radiographically, the findings can be subtle or even absent due to transition of the intestinal hernia. We experienced a 45-year-old man with paraduodenal internal hernia occurring on the left side of the duodenum, which was diagnosed by radiographic imaging including US, CT, angiography and barium study. He complained of severe epigastralgia with vomiting following a large meal on the previous night. CT showed the well-circumscribed bowel loops between the stomach and pancreas. Angiography revealed the jejunal arteries displaced to the left, crossing the inferior mesenteric vein, which seemed to outline the hernial ring. Immediately after angiography, the patient's symptoms disappeared, and CT after angiography revealed reduction of the intestinal loops. PGE₁ and/or high-osmolarity contrast medium used during the study might have reduced tissue edema and been responsible for the relief of symptoms, unless the incarceration was reduced spontaneously.

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