Since 1992, authorized emergency life saving technicians (ELST) in Japan have provided prehospital advanced life support, including defibrillation, intravenous fluid administration and laryngeal mask airway or esophageal obturator airway insertion. In this study, we examined the effect of prehospital defibrillation on the prognosis for 57 patients with out-of-hospital cardiopulmonary arrest (CPA) probably of cardiac etiology, and ventricular fibrillation (VF) present at the scene of collapse out of 418 CPA patients treated by ELSTs between December 1992 and June 1996 in a southwestern district of Osaka City. Forty-nine episodes of collapse were witnessed, and defibrillation was performed for 41 of them (84%). Prehospital return of spontaneous circulation was observed in 24.4% of the defibrillation patients, but in none of the patients without defibrillation. Of patients with witnessed collapse, 5 (10.2%) survived for more than 1 week, and 2 of these 5 (4.1%), who underwent early defibrillation and had prehospital return of spontaneous circulation, fully recovered, although the average time before defibrillation in the 49 witnessed episodes of collapse was relatively long (about 20 minutes). Of the 8 patients with nonwitnessed collapse, 1 survived in a persistent vegetative state. Bystander cardiopulmonary resuscitation (CPR) was performed for only 28 of the 418 patients with CPA (6.7%) and 5 of the 49 witnessed cases of VF of cardiac etiology (10.2%). This relatively poor outcome reflects the low percentage of patients for whom bystander CPR was performed at the scene of collapse, and delayed defibrillation. Without correction of these problems, defibrillation by ELSTs will have little positive effect on the outcome of patients with out-of-hospital CPA.

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[Objective] To validate the determination of plasma volume (PV) and hepatic perfusion as assessed by the indicator dilution technique with indocyanine green (ICG) during hemorrhagic shock. [Subjects] Fourteen patients with hemorrhagic shock. The cause of hemorrhagic shock was trauma in 12 patients and a gastric ulcer in 2. Twelve patients were successfully resuscitated from shock (resuscitated cases) and 2 patients died from uncontrollable shock (non-resuscitated cases). [Methods] The volume of distribution of ICG as PV and the elimination rate constant (KICG) as hepatic perfusion were sequentially evaluated in each case during the period from 2 to 72 hours after the onset of hypotension. The curve of disappearance of ICG from plasma at 3, 5, 7, and 9 minutes after a single injection was extrapolated to the time of injection (zero time) and thereby the concentration at zero time (C0) was determined. PV (ml/kg) was calculated as 25/C0/body weight. KICG equals the slope of the ln-concentration versus the time curve. [Results] For 9 of the resuscitated cases, PV was maintained at higer than 40ml/kg and KICG remained normal throughout the study period. For the other 3 resuscitated cases, both values were decreased at 6 hours and were concomitantly improved within 12 to 48 hours. The changes in PV did not parallel those in blood pressure or urinary output. For the non-resuscitated cases, the decrease in KICG was more pronounced and separate from the change in PV. PVs were significantly correlated with KICG (r=0.445, p<0.05). [Conclusion] 1) This study indicates a correlation between KICG and PV in hemorrhagic shock. 2) The concomitant decrease in KICG and PV suggests hepatic hypoperfusion, which can require prompt improvement. 3) When the decrease in KICG is more pronounced than that in PV, those changes are probably due to hepatocellular damage, which may lead to a poor outcome.

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The advanced resuscitation procedures performed by emergency life saving technicians (ELSTs), i.e. IV placement, defibrillation and advanced airway management for cardiac arrest victims, are an important part of prehospital care in Japan. This survey was developed to determine how the resuscitation skills training and education for ELSTs have been implemented during/immediately after the initial training programs and as continuing education. Surveys consisting of 24 questions on education and training were distributed to 1, 087 ELSTs and 99.8% were returned. Overall, 97.6% of the respondents received skill training using mannequins/simulators and 84.7% had in-hospital clinical training during the initial programs. Among the resuscitation procedures, the training for IV placement was most commonly included (70.3%), followed by advanced airway management (39.7%) and defibrillation (38.3%). Overall, 38.1% of the respondents received training for all procedures. The same trend was found in the postprogram clinical training immediately after the initial programs. Regarding continuing education, 86.1% had clinical training periodically. The fire departments were responsible for continuing education in 59.8%, but of the remaining there was no requirement as a policy. Most of the respondents indicated that the fire departments should assume responsibility for continuing education and clinical training should be included as part of it (89% respondents). It was also revealed that most of the educational materials, such as mannequins/trainers, were allocated at the fire departments, whereas most of the respondents required them at each ambulance station. In conclusion, this study demonstrated that clinical education, particularly for advanced airway management and electrical therapy during/following the initial training programs, did not meet the demand required by ELSTs and that we should modify and develop the current education and training programs accordingly. In addition, easier access to educational materials needs to be provided.

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Treatment of severe accidental hypothermia is still controversial. We had a 41-year-old-male patient whose tympanic temperature was 25°C. On arrival in our department, neurological findings showed a total of seven points at Glasgow Coma Scale, and bilateral fixed and dilated pupils. An electrocardiogram revealed sinus bradycardia with multifocal ventricular prematube beats. Rewarming trials by standard techniques neither increased the core temperature nor stabilized the circulation. A percutaneous cardiopulmonary support system (PCPS) was initiated with a femoral bypass two hours after his arrival. Both arterial and venous lines were immersed in warmed fluids. PCPS was controlled at a three-liters per minute flow rate for four hours until the core temperature rose to 33.1°C. After termination of PCPS, dopamine was easily removed. The patient was discharged 10 days after admission without any neurological deficits. In severe hypothermia, ventricular dysrhythmia is one of the most life-threatening complications. Cardiopulmonary bypass (CPB) is characterized as the fastest method on rewarming and as the best choice in cardiac-arrested patients with severe hypothermia. In comparison with CPB, PCPS can shorten preparatory time as well as decrease the number of staff members and medical expense. PCPS should be applied not only for arrested patients but also for non-arrested patients with severe hypothermia, who have a high risk of circulatory collapse.

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A 49-year-old woman was referred to our hospital with a complaint of subacute dyspnea with no other symptoms. Pulmonary hypertension was revealed by physical and laboratory findings. Lung scan suggested the possibility of diffuse pulmonary embolism although pulmonary arteriography showed no specific occlusion. Therapy with nitrates and heparin was started, but the effect was transient and hypoxemia was progressve. She died of hypoxemia and cardiac insufficiency despite mechanical ventilation and intensive management. A section of the lung obtained at autopsy showed a blood vessel with tumor embolus. The thrombus showed organization as well. The primary site of the tumor was the stomach. Recently, cytology obtained by pulmonary artery wedged specimen was reported to be useful for diagnosing this entity. This new type of diagnostic method should have been applied in our case. We report a case of rapidly progressive fatal pulmonary hypertension due to diffuse intravascular metastatic tumor emboli, which was difficult to diagnose prospectively. Malignant disease should be taken into consideration in the differential diagnosis of subacute pulmonary hypertension. Not only microtumor embolism but also diffuse intravascular fibrin formation due to DIC are considered to be related to the cause of pulmonary hypertension. Early diagnosis followed by prompt effective therapy for the underlying primary neoplasm might have prolonged survival.

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An isolated ACTH deficiency is a rare cause of pituitary coma, which is a life-threatening complication of hypopituitarism. We report a 77-year-old woman with an unrecognized isolated ACTH deficiency who had a hypopituitary crisis with coma and severe hypotension provoked by pneumonia. In October 1996, the patient complained of anorexia and fatigue, which could not be improved except by specific treatment. On 11 November, she was admitted to our ICU with coma, severe hypotension, respiratory insufficiency and anuria. Initially we suspected septic shock and septic encephalopathy, but endocrinological examinations which were performed for differential diagnosis revealed that she had an unrecognized isolated ACTH deficiency. She regained consciousness within 48 hours after intravenous replacement of hydrocortisone. These findings suggest that glucocorticoid may be directly involved in the control of consciousness, and that waiting for laboratory confirmation of a diagnosis must not delay immediate life-saving hydrocortisone replacement.

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