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Even in cases of cardiac arrest caused by hemorrhagic shock, when reliable control of the bleeding source is possible, ECPR may be an effective treatment option if anticoagulant therapy is well‐managed and is withdrawn early.

Aims We investigated how do-not-attempt-resuscitation (DNAR) orders are currently used, and we examined the emergency medical team responses for out-of-hospital cardiac arrest (OHCA) cases in Japan. Methods The sample for this prospective study comprised all OHCA cases attended to by the Sagamihara Municipal Fire Department emergency medical services between May 30, 2019 and February 15, 2020. Data were recorded by the responding emergency medical team. Results There were 396 OHCA cases. The mean age was 75 ± 18 years, and individuals aged 65 years or older accounted for 80.6%. Approximately 70% of the patients had an underlying disease. A DNAR order was available in only 45 (11.4%) of the cases, of which 12 (26.7%) were written, 27 (60%) were verbally confirmed, and six (13.3%) were confirmed in some other way or both. The home physician was present and able to confirm the patient's death in only one of the DNAR cases. In 43 (95.6%) of the cases, the emergency medical team carried out cardiopulmonary resuscitation despite a DNAR order; of them, a total of 17 (37.8%) patients were transported to a tertiary emergency hospital. Conclusions Our analyses indicate the under-utilization of DNAR advance directives and advance care planning (which are important for better end-of-life care) in Japan. Currently, an emergency medical team could be required to attempt resuscitation against an individuals' clear DNAR order. In the future, legal arrangements regarding the handling of DNAR directives on site may be required to respect patients' wishes.

Aim Skin and soft tissue infections are classified into cellulitis and necrotizing fasciitis, which are difficult to distinguish. Necrotizing fasciitis has a poor prognosis and requires immediate intensive care. The diagnostic gold standard is to incise the lesion to determine whether necrosis has reached the fascia. We aimed to show that these infections can be differentiated using near‐infrared spectroscopy. Methods We describe two cases in an observational study about the utility of near‐infrared spectroscopy. Case 1 involved a 77‐year‐old man with a chief complaint of pain, redness, and swelling in the right lower leg for 1 week. Computed tomography of his legs showed no gas formation. Case 2 involved an 82‐year‐old man. He visited another hospital because of pain, redness, and swelling in the right thigh. Based on the X‐ray examination, necrotizing fasciitis was suspected, and he was transferred to our hospital. Results In Case 1, the regional oxygen saturation value was lower on the lesion side (41%) than on the healthy side (55%). We confirmed the depth of invasion by incision, leading to a diagnosis of necrotizing fasciitis. In Case 2, the thigh’s regional oxygen saturation was higher on the affected side (76%) than on the healthy side (61%). An incision was made for diagnosis, but the fascia was not necrotized. Thus, we diagnosed cellulitis and provided conservative treatment using antibiotics. Conclusion Near‐infrared spectroscopy can be utilized to measure tissue blood flow, and it could be useful as a non‐invasive diagnostic tool for skin and soft tissue infections., Currently, the diagnosis of necrotizing fasciitis is made by surgical incision. In this paper we report on a new diagnostic tool for Skin and soft tissue infections.

Aim This study examines the use of the medical risk/resource ratio (RRR) and need for medical resources (NMR) as new indicators of the imbalance in medical demand and supply in disasters. These indicators are used to quantify the medical demand-supply imbalance per disaster base hospital, examine the demand-supply imbalance in the region, and verify the need for medical support. Methods We calculated the RRR of each disaster base hospital by dividing the revised estimate of the number of patients with the number of empty beds. We calculated the required number of hospital beds as the NMR to restore the RRR of each disaster base hospital to two. The RRR and NMR were combined, and prioritization for medical support was classified into three levels. Results The median RRR was 23 (range, 1-101), and the median NMR was 943 (range, 0-2,124). Fifteen hospitals had a medical support priority of 1, five hospitals had a priority of 2, and 13 hospitals had a priority of 3. Conclusion The medical demand-supply imbalance and amount of medical support needed can be quantified using RRR and NMR, which allows examination of the priority level for medical support.

Case Alkaline ingestion frequently causes corrosive esophagitis but rarely causes lower digestive tract injury. In this case, a 79-year-old man accidentally drank kitchen detergent. After 3 h, lower abdominal pain occurred and gradually worsened. He was taking a proton pump inhibitor after proximal gastrectomy for gastric cancer. He had local tenderness in the left lower abdomen. Abdominal computed tomography showed expansion of the small intestine, thickening of the intestinal wall, and inflammatory changes. Upper gastrointestinal endoscopy showed no obvious injury to the esophagus or stomach. Outcome Conservative treatment with an ileus tube was undertaken for intestinal obstruction caused by alkaline ingestion. There were no complications, such as gastrointestinal perforation, and he was discharged on day 17. Conclusion Alkaline ingestion may cause injuries not only to the upper but also to the lower digestive tract in patients who are taking proton pump inhibitors or have had gastrectomy.

パラコート中毒患者来院時,救命可能かどうかを判定する簡便な重症度の指標を作成した。パラコート中毒患者の上部消化管内視鏡検査の所見をスコア化し,これらの変数から死亡確率を求める予測モデルを線形ロジスティック回帰分析により求めた。対象は過去9年間に当院を受診したパラコート中毒44例中,来院より72時間以内に内視鏡検査を施行した23例である。生存群5例と死亡群18例について性別,年齢,治療法,推定摂取量,初療までの時間について検討したが2群間に有意差はなかった。内視鏡所見を食道,胃,十二指腸の各部位について3段階に分けスコア化した。食道:所見なし(0点),食道炎(1点),食道潰瘍(2点),胃:所見なし(0点),発赤,浮腫,小さな比較的限局した軽度びらんをAGML(+)(1点),びらん,潰瘍形成をAGML(++)(2点),十二指腸:所見なし(0点),発赤,浮腫,軽度びらんをADML(+)(1点),びらん,潰瘍形成をADML(++)(2点)とした。以上の内視鏡所見から,ロジスティック回帰分析にて予測死亡確率(Pr)を求めたところ,Pr=1/{1+exp(17-4.14eso-8.85stom-4.14duod)}となった(exp:自然対数,eso, stom, duodはそれぞれ食道,胃,十二指腸の内視鏡所見のスコア)。実際のスコアを代入しPrを求めたところ,生存群は0.20±0.12,死亡群は0.89±0.05となり2群間に有意差を認めた(p 0.5であった14例では全例死亡し,Pr=0.5であった6例では,そのうち33.3%が生存,66.7%が死亡した。以上よりPr 0.5では現在の治療法では救命困難と推定され,Prは予後の推定に有用であると考えられた。

A case of spontaneous rupture of the esophageal diverticulum of the lower esophagus is presented. A 47-year-old man was referred to our emergency center with the chief complaint of chest pain which occurred suddenly at midnight without vomiting. Chest X-ray films and CT scan showed pleural effusion, pneumomediastinum and subcutaneous emphysema of the neck. Gastrografin study showed a perforation of the lower esophagus into the left thoracic cavity. Endoscopic examination revealed a diverticulum of the lower esophagus, a perforation at the top of this diverticulum and white exudate into diverticulum. We performed primary closure through thracotomy 43 hours after the onset of pain. After surgery, mediastinal abscess and pyothorax developed; therefore, we performed open chest drainage followed by esophagostomy. In addition, we performed esophagectomy and esophagogastrostomy through the anterior-thoracic wall route about 7 months after the first operation. His course was uneventful after the final operation. Perforation of the esophageal diverticulum has been reported in only 10 cases in Japan. Perforation of the esophagus without vomiting should be taken into consideration in esophageal diverticulum.

ベンゾジアゼピン系薬剤による急性中毒の治療に,輸液による利尿法は有効でないとされる。しかし尿中のベンゾジアゼピン活性型代謝物排泄量を測定し,輸液の効果を検討した報告はない。われわれはラジオレセプター法を用い,輸液によるジアゼパム活性型代謝物の尿排泄動態をウサギのジアゼパムによる急性中毒モデルで検討した。体重3.1kg前後のウサギにジアゼパム15mg/kgの量を10分間かけて静脈内投与し,1時間後より生理食塩水を50ml/kg/hrの速度で3時間投与した。1時間ごとに採尿,採血し輸液終了3時間後まで続けた。血清中ジアゼパム濃度はHPLC法で,尿中ジアゼパム活性型代謝物はラジオレセプター法で測定した。輸液開始前のジアゼパム血清中濃度は非輸液群で1,339.5±152.5ng/ml,輸液群で1,519.2±542.7ng/mlであった。ジアゼパムの血中消失速度定数は,非輸液群では0.200±0.031/hr,輸液群では0.452±0.090/hrであり,血中半減期は非輸液群では3.55±0.43hr,輸液群では1.54±0.43hrでいずれも両群間に有意な差が認められた。静脈内投与後6時間までの尿量は非輸液群で70.7±32.7ml,輸液群で270.6±117.4mlであった。尿中ジアゼパム活性型代謝物総排泄量は,ジアゼパム当量で非輸液群では51.6±33.3μg,輸液群では528.9±404.7μgであり,両群間のこの値に有意な差が認められ,輸液により尿量以上の排泄増加をみた。輸液中のジアゼパム活性型代謝物分画排泄率は輸液前に比し有意に増加し,また尿中ジアゼパム活性型代謝物排泄量と尿量,尿Na排泄量にも有意の正相関が認められた。ウサギのジアゼパム急性中毒モデルでは,ジアゼパム活性型代謝物の尿中排泄が輸液により促進された。その機序に輸液によるジアゼパム活性型代謝物の尿細管での再吸収抑制が示唆された。