臨床検査が不十分のまま急死した交通外傷例の損傷診断や死因分析に関し,法医学的剖検が不足しているわが国の現状を補完する手段として,死後CT撮影の有用性を検討した。1年の研究期間中に,病院搬入時に心肺機能停止であった5例を含む11例(搬送時間11～28分)の死亡後,単純X線撮影と全身CT撮影を計画的に行った。11例中10例には,致死的病態を示す所見が死後CTから得られた。その内訳は,脳損傷7例,高位頸髄損傷1例,呼吸器官損傷による呼吸不全4例,腹腔内大量出血1例,空気塞栓7例の合計20件である。このうち,体表からの理学的検査のみでも推定できた病態は6件(すべて脳損傷)にすぎず,死後の単純X線が5件を追加したが,9病態はCTによって初めて診断された。今後さらに,gold standardである剖検所見との比較研究が必要だが,剖検を実施できない場合には死後の全身CT撮影が致死的病態の診断にきわめて有効であることが確認された。また,剖検と組み合わせた利用法の可能性も示唆された。

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来院時心肺停止例(cardiopulmonary arrest on arrival; CPAOA)において心拍再開の予測因子について検討した。1991年3月より1992年12月までに東邦大学付属大森病院救命救急センターに搬送された内因性心肺停止239例について,心拍非再開群193例(I群)と再開群46例(II群)に分け,臨床的背景,原因疾患,動脈血および中心静脈血の血液ガス分析値,電解質,乳酸(LA)について比較した。心拍再開群は非再開群に比し年齢差,性差,response time, CPR時間に有意差はなかったが,心停止目撃者あり(p<0.01),到着時心電図が心室細動(ventricular fibrilation; Vf)や電導収縮解離(electromechanical dissociation; EMD) (p<0.01), bystander CPRあり(p<0.05)の例ではII群で有意に多かった。心停止からCPR開始までの心停止時間はI群9.3±7.9min, II群6.7±2.9minとII群で有意に短かった(p<0.01)。原因疾患では脳血管障害が最も再開率が高かった。中心静脈血は心停止に伴う末梢循環をより反映しており,II群の方がpH, PvCO₂, PvO₂, BE, SatO₂でI群との間に有意差を認めた。血清カリウム(K)もI群6.6±2.4mEq/lに対してII群で5.5±1.5mEq/lと有意に低値であった。心停止時間と中心静脈のPvCO₂とはr=0.52, Kとはr=0.49と正の相関が認められたが,PvCO₂は心停止時間が比較的短くても高値で心拍再開例があった。LAとは相関がなかった。心停止目撃者ありの例,到着時の心電図がVf, EMDの例でPvCO₂, Kは有意に低かった。LAは二次救命処置(advanced life support; ALS)開始10分後のLAの変化値(ΔLA)が2.0mmol/l以上の上昇例に心拍再開例はなかった。以上より中心静脈のPvCO₂, Kは心停止時間と相関があったが,心拍再開の予測因子としてはとくにKが有用と思われた。また,ΔLAは到着後の蘇生術の効果判定の指標として有用と思われたが,今後十分な検討が必要と考えられた。

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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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