A total of 353 dead on arrival (DOA) cases (disease group: 222, trauma group: 131) were classified into 5 types according to ECG data upon arrival at the emergency room, and the resuscitation rate, prognosis, circumstances and cause of each type of DOA were examined. The mean interval from cardiac arrest to arrival at the emergency room was 32.3 min over all, the shortest interval being in the type II disease group, 16.1 min, while the interval was 26.5 min in the type I trauma group. The mean resuscitation rate was 20% over all, though the resuscitation rates in type N and type I were over 50%. As to the prognoses of surviving cases, prognosis was better with a shorter interval from cardiac arrest to arrival at the emergency room. The cardiac arrests of most DOA cases occurred during rest or exercise due to cardiac or cerebro vascular disease in the disease group. In the trauma group, most DOA cases were due to traffic accidents, and neither the resuscitation rate nor prognosis were found to be related with either the type of DOA or with the mean interval of each type. To improve the resuscitation rate, it is concluded that immediate initiation of optimal CPR is required in the disease group and that prehospital care including fluid infusion and aggressive hospital care are essential. Therefore, an early identification system, CPR education for citizen and aggressive prehospital and hospital care are expected to improve the resuscitation rate.

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From 1978 to 1990, fifty patients were operated on for pancreatic trauma at the National Mito Hospital Emergency Center. The injury classification we favor is described. Three types ( I, II, III) of injury were classified in view of the presence of absence of major pancreatic duct and combined duodenal injury. Types II and III were further classified into two subtypes (IIa, IIb and IIIa, IIIb) based on the point of peripancreatic devascularization. This classification system is simple and determines the operative treatment. Type I is best treated by simple repair and drainage, Type II by distal pancreatectomy, and Type III by duodenal repair or resection in addition to treatment of the pancreas. This system represents prognosis based on mortality rate. Simple repair and drainage were performed in 30 patients (60%), distal pancreatectomy in 11 (22%), the Letton-Wilson method in 1 (2%), head partial resection in 1 (2%), pancreaticoduodenectomy in 1 (2%), and Roux-en-Y duodenal jejunostomy in 7 (14%). In pancreatic trauma we have preferred distal pancreatectomy to the reconstructive procedure for the safety of operation. Even so there is slight possibility that distal pancreatectomy may eliminate pacreatic function. Thus there has been a tendency toward more frequent use of distal pancreatectomy (22%). Eleven patients treated by under 80% distal pancreatectomy were well managed, since only one patient developed postoperative diabetes and no exocrine pancreatic insufficiency was found. The postoperative morbidity rate (36%) after distal pancreatectomy was almost equal to that of simple repair and drainage. We recommend distal pancreatectomy as the standard procedure, since it is simple, safe, and the risk of endocrine or exocrine pancreatic insufficiency afterward is very small. The overall mortality rate was 16%, and the postoperative morbidity was 42%. Our experience suggests that postoperative morbidity and mortality after pancreatic trauma are minimized by early control of massive hemorrhaging from major peripancreatic vessels and by taking reasonable procedural measures based on recognition of the injury type.

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This study was designed to evaluate the efficacy of original percutaneous left heart bypass (left atrial-aortic bypass: AAB) on 5 patients (three with cardiac arrest, two with cardiogenic shock) with heart failure caused by acute myocardial infarction. First, the insertion procedure for the dehemaize tube into the left atrium was performed easily and safely under transesophageal echo monitoring. All patients had already been treated with intra-aortic balloon pumping (IABP) and percutaneous veno-arterial bypass (VAB), but without effect. Two of three patients with cardiac arrest were also treated with AAB, producing prompt hemodynamic improvement. One recovered secondary to this hemodynamic improvement. Two patients with cardiogenic shock were treated with AAB, and hemodynamics also improved. In particularly, a patient who had been dependent on IABP for 1 month, recovered from cardiogenic shock in response to AAB treatment within 3 days and subsequently underwent arteriocoronary bypass. In conclusion, VAB is useful for prompt treatment of cardiac arrest, while AAB is very useful for IABP and VAB is ineffective for heart failure.

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Peripheral nerve ischemia and reperfusion injury have not been well studied. We examined nerve blood flow and limb function during ischemia and reperfusion using occlusion of the abdominal aorta or ipsilateral common iliac and femoral arteries in rats. The ¹⁴C-butanol distribution method was used to measure regional blood flow in both sciatic and tibial nerves (NBF) and in both biceps femoris muscles (MBF). Clinical limb function was graded by the hind limb scoring system (HLFS). During occlusion of the aorta NBF was reduced to about half of the normal value, but HLFS showed a normal score in four of five rats, and the other one showed minimal impairment. In reperfusion after occlusion of the aorta for two hours, NBF increased in the bilateral distal part of the sciatic and tibial nerves. HLFS recovered completely normal in all rats including the rat which showed score 4 during occlusion. During occlusion of the ipsilateral common iliac and femoral arteries, NBF was reduced throughout and was only 20% of the control side in the tibial nerve. HLFS was 6.5 on average. In reperfusion after occlusion of the ipsilateral common iliac and femoral arteries for three hours, NBF increased to about double that of the control side in the tibial nerve and also increased in the sciatic nerve. HLFS showed 7 on average during occlusion and recovered to 4.6 one hour after reperfusion. Nerve ischemia is attended by a relatively hyperemic flow response during reperfusion after the arterial occlusion.

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Object and Methods: This study was performed to make guidelines for optimal treatment selection in patients with blunt hepatic trauma using ultrasonography (US). For this purpose, the ultrasonographic findings of hepatic parenchyma obtained at the emergency room were classified as follows: hyperechoic (Hyper) type (with diffuse homogeneous hyperechoic area), mixed (M)type (with diffuse heterogeneous area), hypoechoic local (Hypolo) type (with vague hypoechoic area), hypoechoic lacerated (Hypola) type (with hypoechoic lacerated area). In 63 patients, US findings were evaluated and clinical result such as the number of operated cases, blood pressure on admission and blood transfusion volume were analyzed. Result: There were 18 false negative cases, but none of them required specific treatment for blunt hepatic injury. There were 23 cases with Hyper type findings and 11 cases with M type, 6 cases with Hypolo type and 5 cases with hypola type. Four of 5 cases with Hypola type required massive blood transfusion (more than 1, 000ml), and 4 of 5 were hypotensive on admission. There were 3 cases with IVC injury in this group. Three of 63 patients in this study died, and all three had hypola type findings on US and IVC injury. Five cases of the M type required massive blood transfusion and were hypotensive on admission. In the M type, 6 of 11 patients underwent surgery (3 for hepatic suture, 3 for hepatic partial resection) and 2 received interventional angiography (embolization). In patients with Hyper and Hypolo types, hepatic injury was treated conservatively and no surgical treatment or embolization was required. Conclusions: A patient with blunt hepatic injury presenting hyperechoic type or hypoechoic local type findings by US on admission would not be required to undergo specific treatment for hepatic injury and would be a good candidate for conservative treatment. A patient with mixed type may require a surgical procedure or interventional angiography and further detailed imaging diagnosis would be necessary. A hypoechoic laceration pattern on US is the most serious sign of blunt hepatic injury, and there is a high incidence of IVC injury. An urgent operation should be performed when a patient has this pattern on US and shock status on admission.

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Appropriate surgical management, selected from various options, is still controversial as the number of accumulated cases of bile duct injury due to blunt abdominal trauma is small. Furthermore, is seems that no single surgical intervention can be justified as the best management for delayed stricture of the common bile duct (CBD). This report describes an illustrative case of blunt trauma leading to delayed stricture of the CBD after immediate celiotomy for liver trauma and minor CBD injury at the intra-pancreatic portion, treated by left lateral segmentectomy and cholecystostomy. An initial postoperative cholangiogram through the cholecystostomy revealed no leakage and good passage of bile into the duodenum. However, follow-up cholangiography demonstrated stricture of the CBD and subsequent complete obstruction on the 31st postoperative day. In this case, the patient was managed conservatively with external bile drainage through the cholecystostomy. Spontaneous reopening of the CBD was evident by the 94th postoperative day. A review of 36 cases of blunt bile duct injury reported in the Japanese literature and our case suggested the possibility that conservative management for delayed stricture of the CBD may result in spontaneous reopening, especially when the stricture developed within 1 month after blunt trauma.

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A 69-year-old man who had been taking glycyrrhizin for chronic hepatitis had been suffering from watery diarrhea for several weeks. After retrograde urethrography for dysuria, he developed shock and was transferred to our hospital. His blood pressure was 72/44 mmHg and his ECG showed atrial fibrillation, ventricular extrasystoles and non-sustained and then sustained polymorphic ventricular tachycardia(torsade de pointes: TdP). Electrical cardioversion restored sinus rhythm, and the QTc interval was prolonged to 0.62 with a change in T and U waves (slow wave). The serum potassium level was 2.9mEq/l and the serum free calcium level was 0.7mEq/l, but other electrolyte levels were normal. He was diagnosed with TdP occurring in hypopotassemia-induced QT prolongation. He was treated with KCl, dobutamine and dopamine. The TdP attack was diminished within a few days, but the QTc interval returned to 0.42 0n the 20th day. He had no organic heart disease. TdP occurred in the manner of the pause-dependent type, and was accompanied with the prolongation of QTc interval and the fusion of T and U waves. This QT prolongation was produced by hypopotassemia induced by glycyrrhizin-related pseudoaldosteronism and probably hypomagnesemia accompanied by chronic diarrhea. This is the first case, to our knowledge, in which TdP occurred after retrograde urethrography.

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We report the case of a 17-year-old young woman who developed acute myocardial infarction with myocardial contusion following a blunt chest trauma sustained in a motorcycle accident. The chest roentgenogram on admission was normal. Electrocardiogram showed complete right bundle branch block and pathologic Q waves with ST elevation in leads I, aVL and V₁ to V₅. Two-dimensional echocardiogram revealed akinesis of the anterior wall and hypokinesis of the posterior wall of the left ventricle, consistent with extensive anterior myocardial infarction with myocardial contusion of the posterior wall. Coronary angiography revealed an abrupt, severe stenosis with delayed antegrade filling in the proximal left anterior descending artery, suggesting an intimal flap in the vessel wall. Technetium-99m pyrophosphate myocardial scintigraphy demonstrated diffuse tracer uptake in the left ventricular wall. Follow-up coronary angiography performed one year after the accident showed only minor stenosis without any filling defects of contrast medium at the site of the initial lesion. In this report, we discuss the spontaneous resolution of coronary artery dissection due to a blunt chest trauma together with its management and treatment.

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Flumazenil, a potent benzodiazepine antagonist, was administered to a patient who showed prolonged coma after sedation with diazepam. In this study, flumazenil was considered to be useful for differentiating sedation from anoxic encephalopathy. We recommend the use of flumazenil in evaluating the cause of prolonged coma in patients in the Intensive Care Unit who were sedated with benzodiazepine to control conditions such an status asthmaticus or brain injury.

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