The term brain death has several connotations. From the historical aspect, the original concept of brain death was possibly a vague idea that the central nervous system, including the spinal cord, had sustained irreversible functional loss. Then, the functional cessation of the entire brain in the cranial vault was regarded as brain death. This whole brain death means that the entire brain, including the brainstem and the cerebellum, is dead. Brainstem death, which was advocated soon after, means that the brainstem is dead whether the cerebrum is dead or alive. Throughout this synoptic history, the concept of brain death has been based only on considerations of clinical neurology. The main reason for brain death being exclusively clinical is that autopsy findings vary from almost normal tissue brain to the so-called “respirator brain”. However, from the pathological viewpoint focused on the early stage of autolysis, especially foamy changes in red blood cells, the cessation of blood flow occurs at least in the brainstem by the time the judgement of brain death is made and this event is considered to be the beginning of absolute irreversible changes. Therefore the concept of brain death proves to be pathophysiological as well as clinical and the concept of brainstem death is also essential. Solitary brainstem death, in which the cerebrum is still alive is induced on rare occasions in which supratentorial perfusion pressure is maintained, for instance, by ventricular drainage. The results of blood flow studies, electrophysiological examinations, and so on, performed on brain dead patients all correspond to the above definition of solitary brainstem death. The death of the brain results in that of the body biologically. The concept of brain death established on the basis of these pathophysiological criteria will contribute to the intimately related controversial proposition that a philosophy, with complex but conceptually distinguishable components, that is to say, the biological entity and the person as a human being, be established

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Computer-assisted instruction (CAI) is one of the new educational methods using modern computer technology that has been applied to medical education. Significant advantages of CAI are individualization of basic education of a particular area and reduction in the educational staff. Training of the general public in cardiopulmonary resuscitation (CPR) is an example of its use. We have created CAI courseware for CPR, and used it in CPR training for sports instructors (n=30) in the Tokyo Metropolitan Health Promotion Program. The courseware is designed to provide basic knowledge of physiology and procedures of CPR. The result of a paper test for basic knowledge of CPR which was performed before CAI education and improvement of results of the same test performed after courseware application were significantly correlated with time for courseware use (test result before CAI and time: y=-2.68x+305, r=0.55, p<0.05, improvement of the test result: y=1.9x+96, r=0.43, p<0.05). These results suggest basic education was individualized. Studying with CAI, the trainees could progress according to their own understanding. We believe that CAI fits in with CPR education for the general public and provides individualized learning with a limited staff.

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The subjects of this study were 24 cases of DOA brought to the emergency room. Autopsy was performed to determine the cause of cardiac arrest, and the pathological diagnosis was compared with the clinical diagnosis. The clinical diagnoses in the 24 cases were acute heart failure (14 cases), acute respiratory failure (4 cases), dissecting aneurysm (3 cases), melena (1 case), cerebral hemorrhage (1 case), and hypothyroidism (1 case). The pathological diagnoses of the cause of cardiac arrest were acute myocardial infarction (9 cases), dissecting aneurysm (4 cases), respiratory disorders (3 cases), aspiration pneumonia (2 cases), and other (6 cases). Comparison of the clinical and pathological diagnoses revealed 6 cases in which the clinical diagnosis was different from pathological diagnosis. The cause of cardiac arrest in 11 cases was revealed at autopsy, and the clinical diagnosis was the same as the pathological diagnosis in 7 cases. Although there was a high rate of consistency between the diagnoses in dissecting aneurysm and respiratory disorders, autopsy was found to be more useful for determining the cause of cardiac arrest in 17 cases (71% of all cases). In this study, 14 cases of acute cardiac failure were diagnosed without a clear certification. These cases apeared to require diagnosis taking into account autopsy findings, past history and clinical finding as a whole, since autopsies are limited as a means of determining the cause of cardiac arrest.

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A series of 14 patients with cerebral embolism were treated by superselective thrombolytic therapy. Our criteria for candidates for this treatment are: 1) within five hours after onset and 2) no abnormal high or low density area on the CT scan. A high recanalization (93%) rate and neurological improvement (57%) were achieved with either urokinase or tissue plasminogen activator (t-PA), but 3 patients had an unfavorable outcome due to hemorrhagic complications and reocclusion. All of these complications were related to poor collateral circulation and inadequate medical treatment after this therapy. Careful patient selection is necessary for distal occlusion of the MCA because of poorer clinical outcome than in proximal M1 occlusion.

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Thirty-three patients treated at the Critical Care and Emergency Center of Iwate Medical University between January 1, 1983 and March 31, 1994 had blood alcohol levels of at least 400mg/dl and no major complications on admission. We investigated the consciousness level, vital signs, hematological parameters and blood alcohol elimination rate in these patients as well as the procedures used in treating them to assess the pathological condition in which blood alcohol level is dangerously high and to define the necessary treatment and considerations. The subjects comprised 29 men and 4 women, with a mean age of 42.1±12.1 years. Nine patients whose blood alcohol level was at least 500mg/dl had a consciousness level of 100 or more as determined on the Japan coma scale (JCS); 4 of these showed JCS300. Of these 9 patients, 3 were found to have mydriasis and 2 to have pupillary inequality. The light reflex was absent in 2 and delayed in 4 of these 9 patients. All patients with blood alcohol levels of under 500mg/dl showed a quick light reflex, with the consciousness level varying according to the case. No life-threatening signs were seen in systolic blood pressure, mean heart rate or respiratory rate. Slight hypothermia was found in 20 patients, hypoxemia in 16 and increased PaCO₂ in 6. The blood alcohol elimination rate was -22.5mg/dl/hr. All patients were improved enough to leave the hospital through fluid therapy and respiratory care alone. Although respiratory failure and hypothermia are considered life-threatening conditions in heavy drinkers, they seem unlikely to be fatal if proper respiratory care is given in a medical facility.

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We report a case of spinal arteriovenous malformation. A 34-year-old man with abrupt onset of neck pain, nausea and vomiting came to our hospital. Computed tomography showed subarachnoid hemorrhage (SAH) mainly located in the posterior cranial fossa. Conventional 4-vessel angiography was performed, but abnormal vessels were not pointed out. Digital subtraction angiography (DSA) revealed arteriovenous malformation (AVM) fed by the anterior spinal artery and anterior radicular artery. Feeder ligation against the anterior radicular artery was carried out 39 days after the onset. Spinal AVM is an uncommon disease and its onset as SAH is rare. We consider it important to examine the upper cervical region by DSA, especially in cases of unkown SAH mainly located in the posterior cranial fossa.

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We report the successful repair of a ruptured abdominal aortic aneurysm in a 66-year-old man. He was admitted with cardiopulmonary arrest. Emergency surgery was successfully performed after cardiopulmonary resuscitation. Although postoperative MRSA infection developed in the retroperitoneal cavity, it was treated by continuous irrigation with 1% povidone iodine solution. He was discharged without any neurological difficulty and returned to his usual life.

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Intestinal injuries are usually diagnosed by abdominal findings or radiographically. It is difficult to diagnose intestinal injuries in multiple injury patients particularly if combined with severe head injury. We used laparoscopy for the definite diagnosis of three patients who were suspected to have intestinal injuries. These three patients had severe thoracic injury, severe head injury, and only abdominal injury, respectively. The first and third patients had intestinal rupture. Under general anesthesia, a laparoscope was inserted through a left lower abdominal port. We lifted the small intestine with two Debakey forceps (Jarit) through a left upper abdominal port and a right lower port, and examined all areas of the small intestine. Laparoscopic examination is thought to be a useful method for the definite diagnosis of intestinal injuries.

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Recently, toxic shock syndrome (TSS) has been described following Staphylococcus aureus infections in various clinical settings, e.g., surgical wound infections, skin lesions and respiratory tract infections. In 1987, Sperber and MacDonald reported TSS during an influenza outbreak. We report a 42-year-old man who presented with a high fever, watery diarrhea, sore throat, cough, and diffuse erythroderma during an outbreak of influenza in 1993. On the tenth hospital day, the patient developed profound shock with severe metabolic acidosis and loss of consciousness. He fulfilled the Centers for Disease Control confirmed case definition for toxic shock syndrome. Though neither TSST-1 nor enterotoxin was detected, his feces grew out Staphylococcus aureus. The patient required massive infusion of half saline and administration of catecholamines to recover from shock. Staphylococcal pneumonia is a well-recognized complication of influenza. This patient showed no evidence of pneumonia. However, MacDonald noted that TSS may occur during influenza without overt clinical evidence of suppurative bacterial respiratory tract infection. We must recognize TSS as a rare but severe complication of influenza.

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