The results of toxicology screening of samples from 507 patients admitted to the Critical Care Medical Center (CCMC) of Nippon Medical School during a 10-month period (from Oct. 1992 to Jan. 1993 and from Jun. 1993 to Dec. 1993) were discussed. We investigated the actual condition of drug-use in patients by using an immunoassay, EMIT, and the results were confirmed by gas chromatography/mass spectrometry. Blood samples were analyzed for ethylalcohol (EtOH) by head space gas chromatography. Of the 507 patients, 42.7% (53) were positive for EtOH. Twenty-four point five percent (124) were positive for one or more drugs by EMIT: amphetamines (29), opiates (6), cannabinoids (2), barbiturates (18), benzodiazepines (65), tricyclic antidepressants (4). False-positive reactions caused by cross-reactivity with the analog were found in both the amphetamine and opiate assays. There were no falsenegative reactions in any of the assays. Rapid, random toxicology screening can provide useful clinical information for the patients admitted to a CCMC, especially for patients who were injured and sustained unknown-etiology disturbances. It is concluded that EMIT is suitable for toxicology screening for use in an emergency room.

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The Great Hanshin Earthquake caused many casualities and created enormous surgical and medical needs within 48 hours after impact. However a slow response and time lag by the government created a shortage of emergency medical services. In this situation, emergency medical services were expected from the resident medical staff members in the affected area and functioning hospitals in the neighboring area. We inquired about the behavior of the surgeons living in the affected area and neighboring area after the impact of the earthquake. Sixty percent of them went to their working hospitals and only 19% provided emergency medical care in the affected area. Seventy-eight percent of them had no opportunity to give medical care because they had regular work in their hospitals, and 49% because they waited in their hospital for transportation to the affected area in vain. Fifty-eight percent of them thought back-up support to be the most important role of the neighboring hospitals, but 24% insisted that staff members of neighboring hospitals shouId enter the affected area immediately to perform medical care (triage, treatment, and transportation) there. Thirty-four percent said they would enter the affected area for emergency medical care if a disaster occurs again in the neighboring area, and 41% said they would give emergency medical care in the affected hospital if a disaster occurs again in the living area. It is the affected people who bear the primary brunt of the emergency and who will have to take care of their dead and wounded. The medical staff members living in the affeected area should immediately give emergency medical care in the affected hospital, and neighboring functioning hospitals should not only wait for transportation only as back-up hospitals, but immediately send out specialized medical staffs to perform emergency care and management. It is necessary for general medical staffs and the population to be trained in disaster medicine.

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Neuroleptic malignant syndrome is an uncommon but potentially life-threatening complication that can occur in association with neuroleptic therapy. We report a 35-year-old male patient with schizophrenia who developed neuroleptic malignant syndrome following psychogenic polydipsia. The patient was in a deep coma on admission and his serum sodium concentration was decreased to 113mEq/l due to water intoxication. Although hyponatremia was spontaneously corrected by 9, 300ml of diuresis during the following eight hours, he developed muscular rigidity and hyperthermia with a marked elevation of serum creatine phosphokinase (42, 524IU/l). His condition was diagnosed as neuroleptic malignant syndrome and successfully treated by combination therapy with bromocriptine and intravenous dantrolene in addition to strict management of body water balance. It was assumed that the rapid increase in free water volume had provoked neuroleptic malignant syndrome by changing the concentrations of neuroleptic drugs in brain tissue and by increasing the osmolality gap across the muscular cell membranes in this patient.

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An increasing tendency for the occurrence of traumatic diaphragmatic injury has been noted with a recent increase in traffic accidents. Herein, a case of diaphragmatic rupture associated with a 3-point seatbelt is described. An 82-year-old female was seen at our hospital because of a traffic accident on May 29, 1994. She was a front seat passenger wearing a seatbelt. Physical examination showed dyspnea, abdominal distention and Blumberg's sign. Laboratory data showed her white blood cell count to be as high as 15, 600/μl. An X-ray examination revealed bowel gas in the pleural cavity. Emergency operation was undertaken under a preoperative diagnosis of left diaphragmatic rupture and panperitonitis. At laparotomy, pus-like ascites and a left diaphragmatic rupture measuring 10cm in diameter were revealed. Moreover, the perforation was confirmed to be located in the cecum. Closure of the diaphragmatic rupture and ileocecal resection were performed but she died of cardiac failure one day after the operation. A diaphragmatic rupture associated with an elevation of intraperitoneal pressure, caused by a seatbelt, should be considered in patients with seatbelt injuries.

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