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Cardiopulmonary resuscitation system in the middle sized emergency hospital
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AMERICAN JOURNAL OF EMERGENCY MEDICINE n Volume 8, Number 6 n November 1990
on the classification of Kaku were the most common. Nine cases had independent mesenteric injuries, and five of them were accompanied by circulatory disturbances. The site of intestinal injury was jejunum in most cases of penetrating injury, and multiple perforations were noted. In the case of blunt injury, the ileum outnumbered the jejunum. Associated injuries were found in 24 cases and the colon and rectum were the most typical sites. In the cases complicated by head injury disturbance of consciousness or pelvic fracture, an early diagnosis of intestinal and mesenteric injuries tends to be difficult, and it seems that particular care is necessary in such patients. As for the surgical management, simple closure of the perforation was employed for type I injuries, intestinal resection for type II injuries, and suitable techniques were selected for type III and type IV injuries depending on the local findings. Cardiopulmonary resuscitation system in the middle sized emergency hospital. Meguro K, Oohashi N, Fukuda I, et al. Jpn J Acute Med 1989;13:1839-1843. In order to perform cardiopulmonary resuscitation (CPR) more effectively, the authors adopted a system in which available physicians are mobilized to the scene of cardiac arrest by using a loud speaker. Ninety-six CPR attempts were carried out, 79 in the emergency department (ED) and 17 in the ward. Thirty-two percent and 88% of each group of the patients were resuscitated successfully, at least reaching intensive care unit. Five of 79 patients resuscitated in the ED and 7 of 17 patients in the ward survived a long period of time. Taking account of the fact that most of the patients resuscitated in the ED were dead on arrival, our system appeared to have functioned well. The authors have encountered several problems with this system, namely (1) lack of leadership, (2) too many physicians at the scene, (3) resuscitating ability during night, (4) unnecessary or unjustifiable resuscitation, (5) noise caused by loud speaker and mobilization of physicians. However, the authors were able to solve majority of the problems with minor adjustments of the system. The authors found that in the middle sized hospital our general alert system works well, although in the larger hospital CPR team is desirable. Predicting the site of coronary artery occlusion based on admission electrocardiogram In the early stage of acute myocardial infarction: Pit-falls in the diagnosis in the emergency department. Morita H, Kaneda Y, Sakai Y, et al. Jpn J Acute Med 1990;14:61-64. The admission electrocardiographic (ECG) abnormalities of 54 patients, who were admitted within 6 hours of the onset of acute myocardial infarction (AMI) and showed Q wave AM1 by later serial ECG, were retrospectively correlated with the infarct-related artery as determined by emergency or elective coronary cineangiogram. Acute ST segment elevation was present in all of 18 patients with infarction due to the right coronary artery (RCA) in the leads of III and aV,, and in 93% of 29 patients with infarction due to left anterodescending artery (LAD) in the lead of V,, and in 43% of 7 patients with infarction due to left circumflex artery (LCX) in the leads of III and aV,. Fifty-seven percent of patients with LCX as the infarct-related artery, however, presented
with atypical ECG abnormalities or normal findings. Thus, the ECG obtained in the first few hours of AMI was reliable in localizing the LAD or RCA as the infarct-related artery. Presentation with signs and symptoms of AM1 and an atypical ECG was suggestive of LCX occlusion. The infarctrelated artery in patients with inferior wall AM1 must be distinguished whether it is RCA or LCX. Cllnicopathological studies of brain death. Maenosono A, Suzuki K, Takasu N, et al. Jpn J Acute Med 1990;14:65-73. Thirty-live autopsy cases with brain death were studied to determine damage to organs, particularly to the heart, lung, kidney, and liver. A pathological examination showed variable damage in many patients with 82.8% exhibiting damage to the heart, 88.6% to the lung, 65.7% to the kidney, and 74.3% to the liver. Renal damage was more frequently noted in the aged patients, and the incidence of cardiac damage was aggravated by the period after brain death. Then, the authors examined whether pathological abnormalities of the organs could be predicted by routine laboratory examination. It was found that organ damage could not be easily diagnosed by such routine examination. Therefore, these findings suggest that patients with brain death may not be suitable donors for organ transplantation because of the high incidence of organ damage. With regard to this, further studies should be done. A clinical study of small bowel perforation. Nakamura E, Mochizuki H, Kikuchi S, et al. Jpn J Acute Med 1990;14:75-79. Of 106 cases of digestive tract perforation, 24 (22.6%) were perforations of the small bowel. These 24 cases were studied in terms of clinical features. The age of the patients ranged from 20 to 89 years (mean, 50.6 yrs). The causes of the perforation were ileus in six, inflammatory bowel disease in five, iatrogenic factor in five, trauma in three, malignant tumor invasion in two, and other causes in three. The most common site of perforation was distal 100 cm segment of the ileum. The time from the onset of perforation to surgery was long (43 2 10.5 hrs). It was apparently longer in dead patients compared with survived ones. Seven of nine dead patients died of multiple organ failure resulting from uncontrolled intraabdominal sepsis. It was concluded, in order to improve the surgical outcome of small bowel perforation, an early accurate diagnosis and immediate operation were mandatory. Evaluation of 45 cases dying of multiple injuries associated with a head injury. Horimoto C, Taxamiya K, Tsutsumi K, et al. Jpn J Acute Med 1990;14:81-85. Of 45 deaths caused by multiple injuries associated with brain damages, serious systemic insults to the already injured brains were present in all cases. Hypoxia was seen in all cases, in particular, severe hypoxia was associated with death due to a shock. Arterial hypotensions were seen in 38 cases, and severe hypotensions were caused by shocks and severe brain damages including injured medulla oblongata. Systemic insults such as hypoxia and hypotension were associated with progression of secondary brain damages. We believe that unless these systemic insults are rapidly cor-
AMERICAN JOURNAL OF EMERGENCY MEDICINE n Volume 8, Number 6 n November 1990
on the classification of Kaku were the most common. Nine cases had independent mesenteric injuries, and five of them were accompanied by circulatory disturbances. The site of intestinal injury was jejunum in most cases of penetrating injury, and multiple perforations were noted. In the case of blunt injury, the ileum outnumbered the jejunum. Associated injuries were found in 24 cases and the colon and rectum were the most typical sites. In the cases complicated by head injury disturbance of consciousness or pelvic fracture, an early diagnosis of intestinal and mesenteric injuries tends to be difficult, and it seems that particular care is necessary in such patients. As for the surgical management, simple closure of the perforation was employed for type I injuries, intestinal resection for type II injuries, and suitable techniques were selected for type III and type IV injuries depending on the local findings. Cardiopulmonary resuscitation system in the middle sized emergency hospital. Meguro K, Oohashi N, Fukuda I, et al. Jpn J Acute Med 1989;13:1839-1843. In order to perform cardiopulmonary resuscitation (CPR) more effectively, the authors adopted a system in which available physicians are mobilized to the scene of cardiac arrest by using a loud speaker. Ninety-six CPR attempts were carried out, 79 in the emergency department (ED) and 17 in the ward. Thirty-two percent and 88% of each group of the patients were resuscitated successfully, at least reaching intensive care unit. Five of 79 patients resuscitated in the ED and 7 of 17 patients in the ward survived a long period of time. Taking account of the fact that most of the patients resuscitated in the ED were dead on arrival, our system appeared to have functioned well. The authors have encountered several problems with this system, namely (1) lack of leadership, (2) too many physicians at the scene, (3) resuscitating ability during night, (4) unnecessary or unjustifiable resuscitation, (5) noise caused by loud speaker and mobilization of physicians. However, the authors were able to solve majority of the problems with minor adjustments of the system. The authors found that in the middle sized hospital our general alert system works well, although in the larger hospital CPR team is desirable. Predicting the site of coronary artery occlusion based on admission electrocardiogram In the early stage of acute myocardial infarction: Pit-falls in the diagnosis in the emergency department. Morita H, Kaneda Y, Sakai Y, et al. Jpn J Acute Med 1990;14:61-64. The admission electrocardiographic (ECG) abnormalities of 54 patients, who were admitted within 6 hours of the onset of acute myocardial infarction (AMI) and showed Q wave AM1 by later serial ECG, were retrospectively correlated with the infarct-related artery as determined by emergency or elective coronary cineangiogram. Acute ST segment elevation was present in all of 18 patients with infarction due to the right coronary artery (RCA) in the leads of III and aV,, and in 93% of 29 patients with infarction due to left anterodescending artery (LAD) in the lead of V,, and in 43% of 7 patients with infarction due to left circumflex artery (LCX) in the leads of III and aV,. Fifty-seven percent of patients with LCX as the infarct-related artery, however, presented
with atypical ECG abnormalities or normal findings. Thus, the ECG obtained in the first few hours of AMI was reliable in localizing the LAD or RCA as the infarct-related artery. Presentation with signs and symptoms of AM1 and an atypical ECG was suggestive of LCX occlusion. The infarctrelated artery in patients with inferior wall AM1 must be distinguished whether it is RCA or LCX. Cllnicopathological studies of brain death. Maenosono A, Suzuki K, Takasu N, et al. Jpn J Acute Med 1990;14:65-73. Thirty-live autopsy cases with brain death were studied to determine damage to organs, particularly to the heart, lung, kidney, and liver. A pathological examination showed variable damage in many patients with 82.8% exhibiting damage to the heart, 88.6% to the lung, 65.7% to the kidney, and 74.3% to the liver. Renal damage was more frequently noted in the aged patients, and the incidence of cardiac damage was aggravated by the period after brain death. Then, the authors examined whether pathological abnormalities of the organs could be predicted by routine laboratory examination. It was found that organ damage could not be easily diagnosed by such routine examination. Therefore, these findings suggest that patients with brain death may not be suitable donors for organ transplantation because of the high incidence of organ damage. With regard to this, further studies should be done. A clinical study of small bowel perforation. Nakamura E, Mochizuki H, Kikuchi S, et al. Jpn J Acute Med 1990;14:75-79. Of 106 cases of digestive tract perforation, 24 (22.6%) were perforations of the small bowel. These 24 cases were studied in terms of clinical features. The age of the patients ranged from 20 to 89 years (mean, 50.6 yrs). The causes of the perforation were ileus in six, inflammatory bowel disease in five, iatrogenic factor in five, trauma in three, malignant tumor invasion in two, and other causes in three. The most common site of perforation was distal 100 cm segment of the ileum. The time from the onset of perforation to surgery was long (43 2 10.5 hrs). It was apparently longer in dead patients compared with survived ones. Seven of nine dead patients died of multiple organ failure resulting from uncontrolled intraabdominal sepsis. It was concluded, in order to improve the surgical outcome of small bowel perforation, an early accurate diagnosis and immediate operation were mandatory. Evaluation of 45 cases dying of multiple injuries associated with a head injury. Horimoto C, Taxamiya K, Tsutsumi K, et al. Jpn J Acute Med 1990;14:81-85. Of 45 deaths caused by multiple injuries associated with brain damages, serious systemic insults to the already injured brains were present in all cases. Hypoxia was seen in all cases, in particular, severe hypoxia was associated with death due to a shock. Arterial hypotensions were seen in 38 cases, and severe hypotensions were caused by shocks and severe brain damages including injured medulla oblongata. Systemic insults such as hypoxia and hypotension were associated with progression of secondary brain damages. We believe that unless these systemic insults are rapidly cor-