目的:内因性突然死の半数以上が,虚血性心疾患によるといわれている。そこで,虚血性心疾患に由来するdead on arrival(以下DOAと略す),突然死の症例を予防できないか検討した。対象:1986年1月から1992年3月までに当院救命救急センターに搬入された215例(内因性DOA109例,突然死106例)。方法:データはすべて当院および他院(前医,かかりつけ医)のカルテ,および患者本人,家族,他院の医師からのインタビューによる後向き調査により収集した。死因を,諸データより特定し得たdefinite群119例,病歴および発症時の状況より強く推定し得たprobable群49例,まったく不明のunknown群47例に分類し,このうちdefinite群とprobable群の計168例を検討した。結果:心血管系死因が54例(32%)を占め,そのうち急性心筋梗塞(以下AMIと略す)は30例(56%)であった。AMI 30例中23例(77%)に梗塞前狭心症の既往を認め,そのうち22例が新規狭心症,1例が増悪型狭心症であった。梗塞前狭心症の初発からAMI発症までの期間と医療機関受診の有無との関係の検討では,1日以内の症例12例中医療機関を受診したものは2例のみであり,2日以上の症例11例中10例が医療機関を利用していた。医療機関を受診した12例中6例は狭心症との診断を受けることなく放置され,6例は狭心症の診断のもとに投薬が開始されたが,入院のうえ冠動脈造影を受けた例は1例もなかった。結語:患者側に対しては狭心症,とくに新規狭心症の重大性につき認識を深め,速やかに医療機関を受診するよう啓蒙する一方,医療機関に対しては薬物療法のみで安心することなく速やかに冠動脈造影を施行し,最も適した治療法を選択することが重要であることを認識してもらう必要がある。これらのことにより,虚血性心疾患に由来するDOA,突然死を減少させることが可能である。
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.
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.
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.
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.
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.
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.