船橋市では1993年4月から現場出動型のドクターカーを24時間365日体制で運用している。本報告の目的は4年間にドクターカーが出動した院外心肺停止(OHCPA) 986例の転帰をUtstein styleに則って分析することによりOHCPAの治療におけるドクターカーの有用性を検証し,あわせてプレホスピタルケアの問題点を明らかにすることにある。986例のうち発作を目撃された心疾患によるCPAは247例であった。247例の現場での心電図所見はAsystoleが154例,VF, VTが58例,その他が33例,不明2例であった。現場での二次救命処置によって45.7%に心拍再開が得られ,23.1%が入院,8.5%が退院,6.9%が1年生存し,6.5%が社会復帰または家庭内自立となった。社会復帰または家庭内自立にまで回復したOHCPAのうち72.7%は心疾患によるものであり,witnessed VF, VTがそのうち68.8%を占めた。したがってwitnessed VF, VTはOHCPA中最大のターゲットであることが明らかになった。witnessed VF, VTの1年生存率,社会復帰率はそれぞれ20.1%, 17.2%であった。この成績は米国中都市での成績と比肩しうるものであり,ドクターカーがOHCPAの治療に有用であることが明らかとなった。さらに救命率,社会復帰率を向上させるには,先着する救急隊全隊に救急救命士を配備すること,市民によるbystander CPRの実施率を高める努力をすることが必要である。一方現場で遭遇するVF, VTの頻度は米国のそれと比べ著しく低く,両国間での疾病構造の違いが示唆された。この点を明らかにするために,多地域における疫学的調査を行う必要があると考えられた。

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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.

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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.

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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.

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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.

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