In Japan, children less than 6 years old are excluded from brain death criteria, but our university have rendered the determination of brain death for 11 children less than 6 years of age. Six of the brain death determinations were based on the Japanese Health & Welfare Ministry's criteria and five of them were determined by our own criteria which demand cerebral blood flow (CBF) studies by angiography, single photon emission computed tomography (SPECT), or transcranial Doppler sonography (TCD) in addition to ordinary examinations. All except one of the children died without recovering consciousness or neuronal functions. The authors experienced a case of a 3-month old infant whose CBF and auditory brainstem activity-evoked responses (ABR) reappeared after determination of brain death. This infant was resuscitated following cardiac arrest at a local hospital. Computed tomography (CT) performed after cardiovascular stabilization revealed both bilateral frontotemporal chronic subdural hematomas and a thin acute subdural hematoma. An immediate burr hole irrigation was performed bilaterally at our hospital, but neurological examinations, electroencephalographic, the ABR and TCD performed on the 5th and 6th days of his hospitalization revealed brain death. However, on the 9th hospital day SPECT revealed appreciable accumulation. A subsequent TCD study demonstrated sufficient diastolic flow velocity. ABR performed on the 12th and 21st hospital days revealed the existence of each wave component. The patient's heart stopped beating on day 27. Our experience with 11 cases of infant brain death suggest that our criteria may be applicable for children more than 12 month of age. But for the infants less than 12 months of age, the feature of the diffculties in neuronal function assessment, plasticity of brain, and the expandible cranium cause difficult in determinating brain death. Therefore extreme caution should be exercised in the determination of brain death in very young infants, and the existing criteria for brain death in infants should be reinvestigated by accumulating many cases.

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To clarify the clinical characteristics of severe asthmatic patients requiring endotracheal intubation and mechanical ventilation, 2, 893 asthmatic patients admitted to the emergency clinic of the Kawasaki Medical School Hospital between 1988 and 1992 were studied. Eighty-six (3.0%) of these asthmatic patients were hospitalized during the aforementioned five-year period. Thirty patients (severe illness group) were mechanically ventilated, but the remaining 56 patients (moderate illness group) were not. Intubation of the trachea was necessitated for emergencies of CPAOA and pulmonary arrest and acute loss of consciousness during medication including steroids (46.7%), and for deterioration of the patients' conditions despite medication (46.7%). There were significant differences in initial physical findings between the severe and moderate illness groups; the incidence of profuse sweating, orthopnea and cyanosis in the former was significantly higher than that in the latter. As for initial blood gases, significant decreases in pH, PaO₂ and base excess and a significant increase in PaCO₂ were recognized in the severe group as compared with findings in the moderate group. To determine which factors were significantly associated with endotracheal intubation performed in the emergency clinic, we analyzed data sets of vital signs, physical findings and blood gases using multiple logistic regression. As a result, three factors; that is, profuse sweating, cyanosis and base excess, were found to be significantly associated with the decision to proceed with endotracheal intubation. Ten of the severe illness patients were treated with halothane or isoflurane, but the remaining 15 were not. There were no significant differences between the two groups with regard to hospitalization and the severity of symptoms and physical findings on admission. However, in blood gases on admission, a lower pH and higher PaCO₂ were noted in patients treated with inhaled anesthetic, indicating that the anesthetic group had worse ventilation than did the other group. Therefore, we conclude that asthmatic patients who show two or more abnormal physical findings; e.g. profuse sweating, cyanosis or dangerous blood gases despite medication, are potential candidates for endotracheal intubation and artificial ventilation. In addition, mechanical ventilation is crucial for CPAOA, pulmonary arrest, and acute deterioration of consciousness during medication. Inhaled anesthetic may be indicated in the emergency clinic in patients who have more severe airway obstruction.

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We investigated the trip sheets of out-of-hospital cardiac arrest patients in Pittsburgh, Matsuyama, Toon Area and Yonago to compare the efficiency of the emergency medical services (EMS) in the US and Japan. The ratio of patients who received basic life support (BLS) from bystanders was 35.2% in Pittsburgh, 8.4% in Matsuyama, 2.6% in Toon Area and 8.9% in Yonago. The percentage of patients who received BLS within 4 minutes after the call to an EMS was 57.4% in Pittsburgh, 15.3% in Matsuyama, 7.9% in Toon Area and 17.9% in Yonago. The percentage of patients who received advanced life support (ALS) within 10 minutes after the call to an EMS was 83.1% in Pittsburgh, 27.7% in Matsuyama, 2.6% in Toon Area and 39.3% in Yonago. The percentage of patients who underwent intubation or some alternative means of airway management was 86.9% in Pittsburgh, 16.4% in Matsuyama, 0.0% in Toon Area and 91.1% in Yonago. We conclude that the EMS in small cities in Japan is quite undeveloped as compared to that in Pittsburgh, and that the difference in the efficiency of EMS among the cities in Japan is another significant problem.

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A 68-year-old previously healthy man noticed swelling of his left leg after he had been playing golf. Two days after the onset of the symptom, he was admitted to our department with the diagnosis of deep venous thrombosis in his left leg. Decreased oxygenation and a mild CRP increase in laboratory data on admission. Since fibrinolytic and anticoagulant therapy with systemic administration of urokinase and heparin failed to reduce the local symptom, thrombectomy using a Fogarty balloon catheter was performed. On the 8th post-operative day, recurrence of deep venous thrombosis was detected by sonography. In addition, pulmonary embolism was detected by computed tomography following pulmonary angiography. A hereditary thrombotic background was suspected from the clinical feature of resistance to fibrinolytic and anticoagulant therapy and the complication of pulmonary embolism. The patient was found to be the heterozygote of familial deficiency of protein S. Protein S deficiency must be looked for in such a case in addition to AT-III deficiency and protein C deficiency, as an important hereditary thrombotic background.

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A case of atypical neuroleptic malignant syndrome following discontinuation of many different neuroleptics and antidepressant agents is described. A 33-year-old woman with a 6-year history of depression and alcoholism had been treated with daily oral doses of 2mg of haloperidol, 75mg of clomipramine, 150mg of sulpiride, 150mg of trazodone, 3mg of etizolam, 3mg of biperidene, and 0.5g of disulfiram. She was admitted to a local hospital because of agitation and confusion. The patient refused all medication and her ingestion had markedly decreased. Six days after discontinuing her medication, she developed hypotension and was transferred to our institution. When brought to our emergency room, she was in shock with cold sweats, tachycardia, and consciousness disturbance. She became pyrexic, and 3 days after admission developed systemic tremor and oral dyskinesia. Her serum creatine phosphokinase levels gradually increased in spite of the improvement of her hemodynamic state. A diagnosis of atypical neuroleptic malignant syndrome was made, and treatment with dantrolene and bromocriptine was instituted. Her symptoms gradually subsided. This case suggests that development of neuroleptic malignant syndrome should be borne in mind whenever antipsychotic drugs are abruptly discontinued.

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