This prospective study was designed to evaluate postmortem computed tomography (CT) examination of motor vehicle accident fatalities as a possible means of compensating for the limited availability of forensic autopsy material in Japan. During a one-year research period, postmortem plain X-ray and whole-body CT were performed in eleven subjects who died before or immediately after medical intervention in the hospital. Five of the patients were in cardio-pulmonary arrest when they arrived at the hospital by ambulance 11 to 28 minutes after the accidents. In ten of the eleven subjects postmortem CT provided reliable evidence of twenty critical or lethal conditions consisting of brain injury (n=7), cervical spinal cord injury (n=1), respiratory failure caused by injuries to the respiratory system (n=4), massive peritoneal hemorrhage (n=1), and air embolism (n=7). Physical examination revealed only six of twenty critical conditions diagnosed by CT, all of which were brain injuries, and postmortem plain X-ray revealed five additional critical conditions, while the remaining nine were revealed by postmortem CT. Although further should be conducted to compare CT findings with the definitive standard, autopsy, the results indicate that postmortem whole-body CT is extremely effective in detecting fatal injuries when forensic autopsy is not available, and probably useful when it is combined with autopsy.

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The present study was performed to determine predictive factors for restoration of heart beat in cardiopulmonary arrest cases. The subjects were 239 patients with endogenous cardiopulmonary arrest, who were brought to the Critical Care Center of our hospital for resuscitation between March 1991 and December 1992. They were divided into 2 groups; group I, 193 patients, who died without successful restoration of the heart beat, and group II, 46 patients with successful restoration of the heart beat. The clinical backgrounds, causative disease, and various blood gas parameters, electrolytes, and lactate in the arterial blood and also in the central venous blood of the 2 groups were compared. Although there were no differences in age, sex, response time, or CPR time between the 2 groups, there were significantly more patients with a witness (p<0.01), ventricular fibrilation (Vf) or electromechanical dissociation (EMD) on ECG at arrival (p<0.01), and/or a bystander of CPR (p<0.05) observed in group II. Cardiac arrest time was significantly longer in group I (9.3±7.9min) than in group II (6.7±2.9min) (p<0.01). Among causative disease, cerebrovascular diseases showed the highest rate of restoration of the heart beat. Blood gas parameters in the central venous blood at arrival were found to more precisely reflect tissue perfusion associated with cardiac arrest than those in the arterial blood. Group II showed significantly higher pH (7.01±0.16 vs 6.87±0.19; p<0.01) and significantly lower PvCO₂ (76.4±22.5mmHg vs 98.2±37.0mmHg; p<0.01) and base excess (BE) (14.2±7.1mmol/l vs 17.7±8.6mmol/l; p<0.01) than did group I. Serum potassium was significantly lower in group II (5.5±1.5mEq/l) than in group I (6.6±2.4mEq/l) (p<0.01). Cardiac arrest time showed a negative correlation with pH (r=-0.39), a positive correlation with PvCO₂ (r=0.52), and a positive correlation with serum potassium (r=0.49), but was not correlated with lactate. PvCO₂ and serum potassium were significantly low in patients with a witness and those with Vf or EMD on ECG at arrival. Heart beat could not be restored in patients whose lactate level was altered by+2.0mmol/l or more at 10min after the start of advanced life support (ALS) (ΔLA). From these results, PvCO₂ and especially serum potassium in the central venous blood were thought to be useful predictive factors for restoration of heart beat. ΔLA seemed to be useful for determining whether or not resuscitation should be continued, but further examination is needed.

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This is a report of a case of intramural hematoma and necrosis of the sigmoid colon in a patient with myelodysplastic syndrome (MDS). The patient is a 77-year-old man diagnosed with MDS ten months prior to the development of this condition. He consulted a physician because of left lower abdominal pain and was referred to us with a tentative diagnosis of impending rupture of an abdominal aortic aneurysm. He had anemia, leukocytosis and thrombocytopenia. CT scan showed an abdominal aortic aneurysm and an enlarged sigmoid colon. The patient received platelet transfusions and was operated on 30 hours after the onset of symptoms. A 20-cm length of sigmoid colon was found to be was necrotic, and the affected segment of bowel was resected with sufficient margins and end-to-end anastomosis was performed. A submucosal hematoma was discovered, and a diagnosis of non-traumatic intramural hematoma and necrosis of the sigmoid colon was made. The patient resumed oral food intake uneventfully and was discharged 155 days after the operation. CT scanning was helpful in establishing the diagnosis of a rare intramural hematoma of the colon in our patient. MDS was suspected to have played a major role in the pathogenesis.

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Hepatic portal venous gas is a rare condition that may be encountered in bowel necrosis. We report two successfully treated cases of hepatic portal venous gas associated with superior mesenteric artery (SMA) syndrome and ischemic colitis, respectively. In first case, a 28-year-old woman with progressive myoclonic seizures presented with complaints of vomiting and fever. Computed tomography showed a characteristic gas pattern in the liver and marked dilatation of the duodenum proximal to the superior mesenteric artery with a collapsed distal intestine, confirming the diagnosis of SMA syndrome with portal hepatic venous gas. Emergency laparotomy revealed an edematous stomach with phlegmon of the fundus. Fundectomy and gastrojejunostomy were performed. The second case involved a 78-year-old man who was admitted in shock. Colonofberscopy revealed mucosal necrosis and hemorrhage from the dentate line to the sigmoid colon, indicating ischemic colitis. Computed tomography showed hepatic portal venous gas and retroperitoneal emphysema around the rectum. Rectal amputation was performed. Hepatic portal venous gas is considered a serious condition with an overall mortality rate 75%, which actually reflects the outcome of coexisting septicemia. Diagnosis and treatment of the primary disease in the early stage may improve the outcome.

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A rare case of central retinal artery occlusion associated with internal carotid artery stenosis due to closed head and neck injuries is reported. A five-year-old boy was hit over the head and neck in an automobile accident. On admission, he was semicomatose and had sustained a subcutaneous hematoma in the right occipital region, face and the right side of the neck. Craniograms revealed a linear skull fracture in the occipital bone. Computed tomography did not show intracranial mass lesions but mild brain swelling. Three weeks after the injury, he complained of blurred vision in the right eye. An angiogram of the right common carotid artery disclosed right internal carotid artery stenosis. It is suggested that the central retinal artery occlusion resulted from an embolism due to thrombosis of the internal carotid artery. Traumatic thrombosis of the internal carotid artery should be considered whenever a patient who has suffered a head or neck injury exhibits progressive neurological deterioration without an intracranial hematoma.

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