Host response to a variety of severe clinical insults is the main pathogenetic factor causing shock and organ dysfunction seen in critically ill patients, and cytokines are known to play a central role in the pathogenetic mechanisms. Of various cytokines, tumor necrosis factor (TNF)-alpha and interleukin-1 (IL-1) are the primary proinflammatory cytokines inducing the systemic inflammatory response syndrome, shock and organ dysfunction. TNF-alpha and IL-1 induce the production of themselves, IL-6, IL-8, and other endogenous mediators including platelet activating factor and nitric oxide. Infusion of recombinant TNF-alpha and/or IL-1-beta into rabbits results in the development of hypotension and an increase in cardiac output. The animals also develop pathological changes in the lungs similar to ARDS after the cytokine administration. Ibuprofen blocks these changes. These are the direct evidences supporting the hypothesis that the host response to insults, rather than an insult itself, causes shock and organ dysfunction. IL-6 acts as an alarm hormone inducing systemic acute phase responses, and IL-8 is a primary chemotactic and activating factor for granulocytes which subsequently produces various mediators including cytokines. In critically ill patients, elevated blood levels of cytokines, particularly of IL-6, have been observed. Under overwhelming insults such as sepsis, the systemic cytokine production is dysregulated resulting in the development of autodestructive systemic inflammation associated with high blood levels of various proinflammatory and anti-inflammatory cytokines. This condition is called “cytokine storm”. The improved understanding of the pathogenetic role of cytokines in acute phase response provide a rationale for the anticytokine therapies. In human trial, Anti-TNF antibody, soluble TNF receptor, or interleukin-1 receptor antagonist have shown favourable results when used in extremely severe patients. Further understanding of the mechanisms will suggest new therapeutic strategies for interrupting the cytokine storm.

View full abstract

There have been no studies on mental stress, following natural disasters, from the psychological viewpoint. We observed 5 cases, physically injured in the Hokkaido Nansei-Oki Earthquake and Tsunami, and evaluated their stress in the recoil phase one week after injury. We rated their responses on the psychological stress response scale (PSRS) and examined coping behavior and adaptability. The mean value of the total PSRS was quite high, 94. In general, the PSRS showed high scores in depression, anxiety and anger within the emotional response, and in worry, spiritlessness, withdrawal and irritation within the cognitive-behavior response. However, the scores in loss of self-confidence and distruct were rather low, such that stress had little impact on human relations or perceived individual capabilities. In disaster medicine, it is essential for the emergency and disaster physician to attend to a patient's mental and psychological state as well as to their physical condition.

View full abstract

We present 5 spontaneous esophageal ruptures experienced in our institute during past 10 years. All patients were males, with a mean age of 44.8 (range, 38-52) years. Epigastralgia without peritoneal signs was the chief complaint in 4 of 5 patients. Three of the 5 spontaneous esophageal ruptures were diagnosed or suspected at prior institutes, and the patients were transferred to our institute within 9.0 hours (mean) of the onset. The remaining 2, who were diagnosed as having pneumonia or Mallory-Weiss syndrome at prior institutes, required from 3 to 6 days before arrival. Plain chest roentgenograms showed pneumomediastinum in 4, pleural effusion in all, and pneumothorax in 3 of the 5 patients. Esophagography using water soluble contrast media and endoscopic examinations was diagnostic in all patients on whom it was performed. All patients underwent surgery. Primary closure with suturing was performed in 4 patients and a cervical esophagostomy (salivary diversion) was constructed in 1 case. One patient underwent esophageal resection, because esophageal necrosis had been obvious endoscopically before surgery. The number of bacterial species in the cultured pleural effusion tended to correlate with the time elapsed from rupture to bacterial examination (monomicrobial 10.3 hours versus polymicrobial 83.3 hours, mean). Among 3 patients whose ruptures were sutured primarily without esophagostomy, 2 had complications of leakage from the sutured site. No patient died. In conclusion, we emphasize that it is important to suspect spontaneous esophageal rupture if a patient complains of epigastralgia without peritoneal signs occurring after vomiting. In such cases, immediate diagnosis and initiation of therapy are advocated to reduce the morbidity and mortality of this disease.

View full abstract

Over the past 5 years, 1986-1990, 215 patients with ruptured intracranial aneurysm were admitted to our critical care center and the department of neurosurgery. Forty-seven of these patients (21.9%) [47/215=21.9%] had shown clear warning signs in the form of minor leakage episodes. The following factors were evaluated in these 47 patients and in the 168 patients in which no rebleeding attacks were observed: whether or not they had sought medical advice, time of rebleeding attack, grade according to Hunt & Kosnik's grading, percentage undergoing operation, outcome. Twenty-eight patients (59.6%) had sought medical advice. Twenty-four cases (51.1%) occurred within 72 hours of the first attack, and 44 patients (93.6%) had a rebleeding attack within 2 weeks. Rebleeding attacks therefore occur within a short time after minor leakage. Nine cases (19.1%) with minor leakage and 60 cases (35.8%) without rebleeding attacks were Hunt & Kosnik grade I or II. There were more severe cases in the minor leakage group, and so the percentage of those who required an operation, 20 cases (42.5%), was low. The prognosis was worse for those with minor leakage. Nearly all patients can be assumed to be Hunt & Kosnik grade I or II at the time of a minor leakage. Thus, at that time they are in good condition to undergo treatment. It follows that it is extremely important for primary care physicians and others to be aware of the frequency and significance of minor leakage. Its detection can improve the prognosis of ruptured intracranial aneurysm.

View full abstract

More than half of the cases of sudden death are known to be caused by ischemic heart disease. Among the 215 cases of dead on arrival and sudden death referred to us, we analyzed 119 cases in which the cause of death was identified and 49 cases in which the cause of death was strongly suspected. Cardiovascular diseases were the cause of death in 54 cases (32%), and acute myocardial infarction (AMI) was the cause in 30 (56%) of them. Twenty-three (77%) of the AMI patients had experienced pre-myocardial infarctional (pre-MI) angina, the de novo type in 22 of them and the worsening type in one of them. Only 2 of the 12 patients who suffered AMI within 24 hours of the first attack of pre-MI angina had consulted doctors, whereas 10 of the 11 patients who suffered AMI over 24 hours after pre-MI angina had. Among the 12 patients who were examined, 6 were diagnosed as having angina and were treated with medication. In the remaining 6 cases, not even a diagnoses of angina had been made. None of the patients were advised to undergo any further examinations, including coronary angiography. It is important to educate the public to recognize that angina, especially de novo type angina, can be life threatening, and to consult a doctor immediately. It is also necessary to educate physicians that administration of drugs to treat patients with de novo type angina is inadequate. By consulting the doctor as soon as possible after the first attack of angina, and by undergoing coronary angiography to determine which treatment is most appropriate, sudden deaths caused by ischemic heart disease can be reduced.

View full abstract

A 67-year-old female was taken to the emergency room for anemia related to rectal carcinoma. Following condensed red blood cell (CRC) transfusion, she had a high fever and petechiae for 11 days. Diarrhea, melena and liver dysfunction were subsequently recognized, and she ultimately died of pancytopenia and multiple organ failure. Regarding the clinical course and HLA typing, a diagnosis of GVHD was made. Her immunological disorder was not particularly severe, and CRC had been made 14 days before. This kind of GVH reaction is very rare, but suggests that we should consider GVHD as a side effect CRC transfusion even in an emergency situation.

View full abstract

Two patients with intracranial carotid injury, intracranial carotid occlusion (ICO) in one case and carotid-cavernous sinus fistula (CCF) in the other, diagnosed by transcranial Doppler sonography (TCD) are reported. The left ICO was diagnosed by TCD findings, showing a marked decrease in the flow velocity of the left middle cerebral artery (MCA) as compared to that of the right MCA and a normal flow velocity of the left ophthalmic artery. On the other hand, left CCF accompanied by significant steal was diagnosed by abnormal TCD flow patterns, i.e. an increased flow velocity in the left superior ophthalmic vein with an anterior direction, high flow velocity in the left cervical carotid artery, and decreased flow velocity in the left MCA. Both ICO and CCF were confirmed by angiography. Since TCD is non invasive and can be easily repeated at the bedside in critically ill patients, cerebral hemodynamics can be effectively evaluated. TCD is now commonly used to evaluate cerebral hemodynamics. Furthermore, in order to diagnose the acute phase of traumatic cerebral arterial injury by TCD, it is important to assess flow velocity information from many cerebral arteries using insonations.

View full abstract

The mechanism underlying the ocular signs associated with severe cases of bothrop bite is unknown. We subjected one case to various examinations including MRI of the brain, electrooculography and the tensilon test. The patient, a healthy 20-year-old male, had been bitten in the right index finger. Eight hours after the injury, he showed swelling over the right shoulder and ocular signs including double vision and ptosis. He was diagnosed as having a severe grade of bothrop bite associated with oculomotor and abducens palsies. No other neurological signs, including synergestic divergence, were detected and the brain MRI revealed no abnormal intensities in the midbrain. The tensilon test was negative. The electroculogram showed paralysis in the bilateral inferior oblique muscles, the left inferior rectus muscle, the left median rectus muscle and the left lateral rectus muscle. Administration of antiserum improved the swelling and the ocular signs. On the 39th hospital day, he was discharged with no neurological deficits. It is assumed that the mechanism of ocular signs in cases of bothrop bite is neuromuscular blockade by a neurotoxin.

View full abstract

A case of liver injury following blunt trauma treated by hepatic vascular exclusion using a Bio-pump^® is presented. A 49-year-old man was struck in the upper abdomen in a traffic accident. After admission, CT and ultrasound demonstrated intraabdominal hemorrhage and liver injury. Angiography of the inferior vena cava showed extravasation from the middle hepatic vein. He was diagnosed as type III b according to the classification of the Japanese Injury Association for the Surgery of Trauma. Laparotomy was carried out about 7 hours after injury, revealing massive hemorrhage, severe injury in the middle and anterior segments of the liver, and injury of the middle hepatic vein and inferior vena cava. Resectional debridement and repair of the inferior vena cava were safely carried out by hepatic vascular exclusion using a Bio-pump^®. His condition was stablized at 2 days after the operation, but he died of multiple organ failure 56 days postoperatively.

View full abstract

We report a 6-year-old boy with acute stress reaction and dissociative disorders, who suffered multiple injury in a traffic accident without cerebral contusion. He was still crying, suffered sleep disorders, was unable to communicate and showed hemiplegia a week after the injury. Brain CT showed no high or low attenuation areas. Cervical X-ray revealed neither fractures nor dislocation and cervical MRI showed no high or low intensities. His psychogenic symptoms improved temporarily both times 2.5mg of midazolam was intramusculary administered for CT scans and MRI. His psychogenic symptoms and hemiplegia remarkably and permanently disappeared after an intramuscular administration of 5mg of midazolam. The clinical course suggested acute stress reaction and dissociative disorders. Like adults, children may exhibit psychogenic symptoms despite the absence of cerebral contusions on CT scan and MRI, as a result of acute stress reaction following extremely frightening experiences. Focal neurological signs which are inexplicable by X-ray, CT or MRI may indicate dissociative disorders.

View full abstract

A rare case of Wallenberg's syndrome associated with a depressed facture in the posterior cranial fossa is reported. A 37-year-old male was admitted to our hospital because of a consciousness disturbance, immediately after falling from a height. On admission he was found to be in a state of drowsiness. Initial CT scans showed a depressed fracture with disappearance of the fourth ventricle and the cisterns, and his condition gradually deteriorated. Suboccipital decompressive craniectomy was then performed, and his condition improved. Neurological examination on day 5, however, disclosed signs of a typical right Wallenberg's syndrome. The right posterior inferior cerebellar artery (PICA) could not be identified on vertebral angiography. Magnetic resonance imaging (MRI) showed a small infarct in the right dorsolateral medulla. Occlusion of the vertebral artery territory due to a nonpenetrating injury is discussed, and comments are made on the mechanisms involved in our patient, with a selective review of the literature.

View full abstract