The city of Funabashi has operated a doctor car that can be dispatched to the scene on a 24-hours-a-day, 365-days-a-year basis since April 1993. The purpose of this report is to verify the usefulness of the doctor car in the treatment of out-of-hospital cardiopulmonary arrest (OHCPA). To elucidate problems in pre-hospital care, an Utstein style analysis was conducted of the outcome of 986 cases of OHCPA over a 4-year period in which the doctor car was dispatched, CPA was due to a witnessed heart disease in 247 of the 986 cases. On-scene ECGs in these 247 cases showed asystole in 154, VF/VT in 58, other findings in 33, and findings in 2 cases being unknown. As the result of advanced cardiac life support at the scene, a pulse returned in 45.7% of the cases, and 23.1% were admitted, 8.5% discharged, 6.9% survived 1 year, and 6.5% returned to a normal life or became independent within their households. In the cases of OHCPA in which the patients recovered to the point of returning to a normal life or independence, 72.7% were due to heart disease, and witnessed VF/VT accounted for 68.8% of them. Thus, witnessed VF/VT was found to be the largest target in OHCPA. The 1-year survival rate and rate of return to a normal life of witnessed VF/VT were 20.1% and 17.2%, respectively. These results compare favorably with the results in medium sized cities in the United States, and the doctor car has been found to be useful in the treatment of OHCPA. Stationing of emergency life-saving technicians in all rescue squads that arrive first, and efforts to increase bystander CPR by ordinary citizens are needed to further increase the resuscitation rate and rate of return to a normal life. The incidence of VF/VT encountered at the scene, however, is much lower than in the United States, suggesting a difference in disease structure in the two countries. It seems that a multi-regional epidemiological survey will be needed to resolve this point.

View full abstract

The emergency transport in an ambulance can be a considerable physical and psychical stress for the patient. In this report we prove by means of a test with volunteers and upto-date literature that stress during transport is an important, not to be neglected factor for the prognosis of the patient. We determined the hemodynamic and endocrinological values of 54 volunteers to verify this statement. Each volunteer was subject to one high speed emergency transport and one smooth transport. Significant differences of all measurements [heart rate (p≤0.001)], blood pressure, cortisol (p≤0.01), prolactin, somatotropine and ACTH between the two modes of transportation (emergency transport and smooth run) confirmed our presumption that, especially in the case of cardiac diseases, particularly fast transportation represents an additional danger. Especially in the case of cardiac diseases a very fast transport should not have absolute priority, it can do more harm than good.

View full abstract

A 31-year-old woman with blood type AB (-) suffered from a massive postpartum hemorrhage at private practice. She fell into severe hypotension and anemia (hemoglobin concentration of 5.5g/dl). She was immediately brought to the ICU in our hospital. Blood pressure increased following rapid infusion of a massive volume of crystalloid and colloid, but severe hemodilution (hematocrit 5.3%) occurred. Then she lost consciousness and her ventilation was impaired. We were able to start blood transfusion 2 hours after her arrival at the ICU, and she received a probe laparotomy and hemostatic operation. She recovered consciousness one hour after the operation with no neur-ological complications. It is suggested that a safe threshold of hemodilution for a conscious state would be similar to that under anesthesia.

View full abstract

We report a case of a ruptured splenic artery aneurysm. A 69-year-old man complained of sudden upper abdominal pain and his consciousness diminished transiently. He was transferred to our hospital by ambulance. In our emergency room, he was alert and complained of continuous abdominal pain. During our medical examination, he showed syncope and fell into shock. Enhanced computed tomography showed an intra-abdominal hemorrhage and a splenic artery aneurysm. Transcatheter arterial embolization (TAE) to the splenic artery was performed using platinum microcoils, and his hemodynamics stabilized immediately. However, his urine output decreased and metabolic acidosis appeared gradually. An exploratory laparotomy seven hours after TAE showed a huge intraperitoneal hematoma and paleness of the visceral organs. The hematoma was removed and the color of the organs improved. Splenectomy and resection of the splenic artery aneurysm were performed. His postoperative course was uneventful. Recently, the efficacy of TAE for splenic artery aneurysms has been reported. In our case, the hemostasis of the ruptured aneurysm was achieved by TAE, but laparotomy was required because of a huge intra-abdominal hematoma. We emphasize that close observation is needed after a hemostasis is performed by TAE in the case of a ruptured splenic artery aneurysm.

View full abstract

We report a case of hepatic infarction caused by the occlusion of both the hepatic artery and the superior mesenteric artery (SMA). In this case, we detected a thrombus at the left atrium as the embolic source by transesophageal echocardiography (TEE). A 53-year-old man was admitted to a local hospital with a diagnosis of renal infarction and atrial fibrillation. Seven days later he was transferred to our hospital because of complications from cerebral infarction. On the 2nd hospital day, a floating thrombus at the left atrial appendage was detected by TEE. On the 11th hospital day, he failed into shock and abdominal distension developed. Serum transaminase levels were markedly elevated. Computed tomography with a contrast agent showed a segmental non-enhancing lesion of the liver. At that time, TEE showed the disappearance of the left atrial thrombus. His condition worsened rapidly, and he died of multiple organ failure. Autopsy findings showed the thromboembolism of both the hepatic artery and the SMA, extensive liver infarction and massive intestinal necrosis. In this case, it is suggested that the obstruction of the hepatic artery and the SMA brought about a decrease in blood flow through the hepatic artery and the portal vein, and caused liver infarction.

View full abstract