交通事故剖検例171例(男126例,女45例,平均年齢45.3±21.5歳)に対してAIS-85, ISSを用いて重症度評価を行った。対象例の約50%が現場死群,21%が受傷後6時間以内の短期生存群であった。死因別では,胸腹腔内臓器損傷が約半数を占め,頭蓋内損傷がこれに続いた。全対象例のISS平均値は43.9±19.8であり,生存時間とISSの関係では長期生存群ほどISSは低値であった。現場死群を除いた受療群のISS値は32.8±13.0であり,死因別では胸腹腔内臓器損傷が34.9±14.8と最も高く,以下頭蓋内損傷33.7±6.6,二次性感染症30.1±11.6であった。受療群を対象とした検討では,65歳以上の高齢者群でISS値は27.1±10.1と有意に低値を示した。そして事故様式別では,ISS,頭部AIS値ともに自転車群で最も高く,車両群にて有意に低値であった。また,四肢AISは歩行者群で最も高値を示した。医療行為とISSの関係は開腹手術施行群で50.4±12.1と最も高く,開胸手術,開頭手術,保存的療法群ではおおむね30～33の範囲であった。外来処置のみの医療が3例みられ,その原因として塞栓症等が含まれた。交通事故による多発外傷死の剖検による重症度判定は,救急医学の領域での重症度判定にも参考になると思われる。

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頭部外傷を伴った多発外傷患者のpriority,多発外傷の頭部外傷に与える影響,外科的治療の治療戦略について検討した。日本医科大学救急医学科関連施設の全入院患者22,828人のうち外傷患者は8,085人(35%),頭部を含む外傷患者は3,536人(16%),頭部を含む多発外傷は1,280人(6%)であった。なお多発外傷を伴う頭部外傷とは,頭部外傷のほかにAISが3以上の他部位の損傷を有する外傷である。1,280例の転帰として来院時心肺停止263例を除くと,救命は708例(70%),死亡は309例(30%)であった。緊急手術を要した患者220名の初診時の意識レベル(GCS),収縮期血圧(sBP)と手術部位を検討すると,GCS>8, sBP≦90mmHg (subset II)では頭部手術を要したのはわずか2%であり,GCS≦8, sBP>90mmHg (subset III)では頭部手術が91%必要となっていた。GCS≦8, sBP≦90mmHg (subset IV)では胸腹部手術が58%,頭部手術が33%であった。多発外傷を伴う頭部外傷と頭部単独外傷患者808名を比較検討すると,解剖学的重症度(ISS),生理学的重症度(RTS),輸血単位数,最低血小板数において多発外傷を伴う頭部外傷は有意に重症であったが,頭部AISが3以下の症例では多発外傷群で有意に転帰が不良であるが,頭部外傷が重症になるほど(頭部AIS≧4, CT分類(TCDB) D-III, IV,頭部手術が施行症例)多発外傷の影響は小さくなる傾向があった。多発外傷を伴った頭部外傷に対する治療戦略はearly definitive surgery, early ICP monitoringである。緊急開頭術が施行された211名の検討では,開頭血腫除去術の生存率(54%)に比べ穿頭血腫吸引術の生存率(17%)は不良であった。非占拠性病変に対し頭蓋内圧測定を64例に施行した。頭蓋内圧上昇により開頭血腫除去術を要した9例のうち8例(89%)は生存しており,頭蓋内病変の早期発見により予後改善が期待できる。多部位同時手術が43例に施行されており生存率は44%であり,優先すべき損傷が同時に複数存在する場合は有効である可能性がある。われわれの治療法の有効性を証明するためには,さらなるcontrol studyが不可欠である。

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平成8年3月から平成9年2月までの1年間に当院に搬送された院外心肺機能停止患者72例を対象に,来院直後の動脈血ガス値および血中乳酸値,心拍再開率ならびに現場での処置時間を指標として,特定行為としてのラリンジアルマスクの有用性について検討した。その結果,ラリンジアルマスク群(14.8±3.9min,平均±標準偏差)は従来のマスク群(8.2±3.4min)に比べて,約7分間の処置時間の延長(p<0.01)を認めた。一方,処置時間の延長にもかかわらず,心拍再開率に関しては,ラリンジアルマスク群が57%,従来のマスク群が52%で両群間に有意差を認めなかった(P=0.72)。また来院直後の動脈血pH,二酸化炭素分圧,酸素分圧,乳酸値のいずれに関しても,両群間に有意差を認めなかった(p>0.43)。したがって,ラリンジアルマスクの功罪両方を認め,その有用性については結論できなかった。すでに救急救命士制度が発足して5年が経過し,気管内挿管の代替処置として導入されたラリンジアルマスクの再検討が必要な時期にきている。早急にコントロールされた全国規模の調査が施行されるべきと考えられる。

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Three patients with acute subdural hematoma (SDH) caused by a ruptured intracranial aneurysm were admitted in a comatose state with signs of cerebral herniation. In one patient, while the SDH was evacuated by an emergency craniotomy, cerebral angiography was performed. Aneurysmal neck clipping was performed during the same operation. The man made a good recovery. In the other patients, while the SDH was irrigated by emergency trepanation, cerebral angiography was performed. These hepatomas were inoperable and the 2 patients died the day after admission. Several recent reports have suggested that SDH evacuation with craniotomy and aneurysmal neck clipping should be conducted simultaneously. However, the start of a one-stage operation for SDH and ruptured aneurysm is usually delayed several hours due to the need for preoperative examinations including angiography. A portable digital imaging system (PDIS) showing real time subtraction images is useful for finding critical vascular anomalies. The authors emphasize that a one-stage operation can be started within 50 minutes after admission by using a PDIS.

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This is the first report of an aorto-caval fistula resulting from an inflammatory abdominal aortic aneurysm (IAAA) in Japan. A 78-year-old man was admitted to a local hospital with dyspnea and leg pains. Angiography revealed an aorto-caval fistula adjacent to the aortic bifurcation. He was transferred to our institute for surgical repair on the 19th day after the onset. On admission he was in shock due to “high output cardiac failure”. His cardiac index was 6.20l/min/m² and his systemic vascular resistance index was 606dyn·sec/cm⁵/m². The IAAA was exposed at the operation. The fistula was closed by using the anterior wall of the aneurysm as a patch. The aneurysm was replaced with an aorto-iliac graft. Most aorto-caval fistulas result from rupture of an atherosclerotic abdominal aortic aneurysm. Only six cases of aorto-caval fistulas resulting from an IAAA have been reported. None of the patients had symptoms of cardiac failure. Ours is the first case of an aorto-caval fistula resulting from an IAAA with symptoms of cardiac failure.

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A 54-year-old man developed transient cardiac arrest due to malignant hyperthermia (MH) during clipping of a cerebral aneurysm. He was found to have unruptured middle cerebral artery aneurysms on both sides. At the first operation, on the left aneurysm, anesthesia was induced by thiopental and vecronium and maintained by isoflurane, nitrous oxide and oxygen. He suddenly developed cardiac arrest soon after an arrythmia of grade 3 A-V block which occurred 6.5 hours after the operation had started. Fortunately the heart recovered after 20 minutes of cardiopulmonary resuscitation. After this accident, the rectal temperature rose to 41.5°C with the manifestation of macro hematuria, metabolic acidosis, and elevation of the levels of serum enzymes GOT, LDH, and CPK. At this point, we suspected MH. Five weeks after the first operation, the second operation, on the right aneurysm was performed. Before anesthesia, dantrolene sodium was administered and a percutaneous pacemaker was inserted intravenously. Balance anesthesia was induced and the second operation was completed uneventfully. We should keep in mind that dantrolene should always be prepared and injected immediately under general anesthesia whenever MH is suspected.

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Patients with traumatic transection of the thoracic aorta are now more frequently seen in the Emergency Department due to an increase in the number of high-speed motor vehicle collisions and improvements in the Emergency Medical System. Although transection of the aorta is usually fatal, patients who survive long enough to undergo surgery have a good prognosis. In this report, two cases of complete thoracic aortic transection are described. Both patients were involved in motor vehicle collisions. The first, a 52-year-old woman, underwent emergent angiography and aortic repair within 3 hours of admission. The second patient, a 39-year-old man, underwent hepatic lobectomy immediately after admission, and aortic repair the following day. In the setting of complete thoracic aortic transection with multisystem trauma, a flexible strategy is probably the most important measure impacting survival.

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