平川 昭彦

関西医科大学附属滝井病院では，2001年から精神科医が救命救急センターに常駐し，救急医と連携して自殺未遂者に対する身体的・精神的治療を行ってきた。また，2007年から自殺対策のための戦略研究の共同研究施設となり，PSWも協働して未遂者に対して心理・社会的支援を行うようになった。さらに，2010年からは大阪府自殺未遂者実態調査事業の委託を受け，PSWも救命救急センターに常駐する体制を整えた。その結果，搬送後早い時期から情報収集，家族への情緒的サポート，ソーシャルワーク介入が可能となった。救命救急センターにおけるPSWの重要な役割としては，以下の4点が考えられる。未遂者に寄り添うこと，危機的状況になったときの対処能力をエンパワメントすること，自殺企図の根底にある心理・社会的問題に対して社会資源を活用し解決を図っていくこと，さらに，身近な人や関係機関との連携体制を構築し，より長期的なサポートを保障することである。

Background. Hemorrhagic shock and resuscitation induce immunosuppression. CD4(+)CD25(+)Foxp3(+) regulatory T Cells (Foxp3(+) Tregs), iNOS and cytokines may affect these severe conditions such as acute respiratory distress syndrome and multiple organ failure after hemorrhagic shock and resuscitation. Foxp3+ Tregs have been described to be specific and play a key role in the control of the immune system. Immune condition may be restored by hypertonic saline resuscitation that inhibits pro-inflammatory effects of cytokine. Our aim was to investigate how hypertonic saline resuscitation affected Foxp3(+) Tregs after hemorrhagic shock and resuscitation in relation to iNOS and cytokines. Methods. Male C57BL6/J and B6.129P2-NOS2(tm1Lau)/J (iNOS gene knockout) mice were used in creating hemorrhagic shock model. Mice were divided into two groups, each according to the type of resuscitation. (1) Wild HS: resuscitation with hypertonic saline (4 mL/Kg of 7.5% NaCl) and the shed blood (SB); (2) wild 2LR: resuscitation with lactated Ringer's solution and the SB; (3) iNOS knockout HS: similarly resuscitated as wild HS; (4) iNOS knockout 2LR: similarly resuscitated as wild 2LR. Samples of thymus and spleen were harvested at 2, 6, 24, 48, and 72 h after resuscitation. CD4(+) T cells and Foxp3(+) Tregs were analyzed at 24, 48, and 72 h. At 2, 6, 24, and 48 h, plasma cytokines were assayed and expression of iNOS (NOS2) was also measured by immunofluorescence. Results. NOS2 of HS and 2LR wild groups at 2 and 6 h in spleen increased compared with the control group. At 6h, NOS2 in HS wild group was significantly lower than in 2LR wild group. Plasma levels of interleukin (IL)-6, TNF-alpha, MCP-1, and IL-10 increased at 2 h. Both in wild type and iNOS knockout mice, hypertonic saline resuscitation decreased plasma IL-6, TNF-alpha, and MCP-1 levels at 2 h; CD4(+) T cells in spleen and thymus decreased at 24, 48, and 72 h, and Foxp3(+) Tregs in spleen at 48 h increased, however, hypertonic saline resuscitation did not affect the Foxp3(+). Conclusions. These results show that in early phase, the inflammatory cytokines in plasma might affect iNOS expression and cytokines. Further, this study showed that hypertonic saline resuscitation and suppression of iNOS might improve immunosuppressive reaction after hemorrhagic shock. (C) 2012 Elsevier Inc. All rights reserved.

Objective: Impaired fibrinolysis is associated with a higher incidence of both multiple organ dysfunction and mortality in the intensive care unit (ICU). Plasminogen activator inhibitor (PAI)-1 is the chief inhibitor of fibrinolysis. We investigated the influence of the 4G/5G polymorphism (rs1799768) of the PAI-1 gene on the plasma PAI-1 level and the outcome of critically ill patients. Methods: In 41 consecutive patients admitted to the ICU, PAI-1 gene polymorphism was assessed, plasma PAI-1 and arterial lactate concentrations were measured and clinical severity scores were recorded. Results: Homozygotes for the 4G allele had higher plasma levels of PAI-1 antigen. The mean +/- SD PAI-1 antigen level was 193.31 +/- 167.93 ng/ml for the 4G/4G genotype, 100.67 +/- 114.16 ng/ml for the 4G/5G genotype and 0.43 +/- 0.53 ng/ml for the 5G/5G genotype. There was a significant correlation between plasma PAI-1 and arterial lactate concentrations, as well as between PAI-1 and severity scores. The mortality rate was 63, 33 and 0% for patients with the 4G/4G, 4G/5G and 5G/5G genotypes, respectively. Conclusions: These results demonstrate that the 4G/5G polymorphism of the PAI-1 gene affects the plasma PAI-1 concentration, which could impair fibrinolysis and cause organ failure, and thus the presence of the 4G allele increases the risk of death. Copyright (C) 2011 S. Karger AG, Basel

Introduction: It is important to have a venous line in cardiopulmonary arrest (CPA) patients as an emergency treatment measure in prehospital settings, but establishment of a peripheral venous line is difficult in such patients. This study aimed to investigate the current status of intravenous infusion (IVI) in CPA patients by Emergency Life-Saving Technicians (ELSTs) in Japan. We also considered alternative measures in case IVI was difficult or impossible. Methods: We investigated a nationwide database between 1 January 2005 and 31 December 2008. From a total of 431, 968 CPA cases, we calculated the IVI success rate and related parameters. The Bone Injection Gun (BIG) and simulator legs (adult, pediatric, and infant) were used by 100 ELSTs selected for the study to measure the time required and the success rate for intraosseous infusion (IOI). Results: The number of CPA patients, IVI, adrenaline administration, and the IVI success rate in adult CPA patients increased every year. However, the IVI success rate in pediatric CPA patients did not increase. Although adrenaline administration elevated the ROSC rate, there was no improvement in the 1-month survival rate. The time required for IOI with BIG was not different among the leg models. The success rates of IOI with BIG were 93%, 94%, and 84% (p &lt 0.05 vs. adult and pediatric) in adult, pediatric, and infant models, respectively. Conclusions: The rate of success of IVI in adult CPA patients has been increased yearly in Japan. However, as establishing a peripheral venous line in pediatric patients (1-7 years old) by ELSTs is extremely difficult in prehospital settings, there was no increase in the IVI success rate in such patients. As the study findings indicated IOI with BIG was easy and rapid, it may be necessary to consider IOI with BIG as an alternative option in case IVI is difficult or impossible in adult and pediatric patients. © 2012 Isayama et al.

Background. Hemorrhagic shock and resuscitation induce immunosuppression. CD4(+)CD25(+)Foxp3(+) regulatory T Cells (Foxp3(+) Tregs), iNOS and cytokines may affect these severe conditions such as acute respiratory distress syndrome and multiple organ failure after hemorrhagic shock and resuscitation. Foxp3+ Tregs have been described to be specific and play a key role in the control of the immune system. Immune condition may be restored by hypertonic saline resuscitation that inhibits pro-inflammatory effects of cytokine. Our aim was to investigate how hypertonic saline resuscitation affected Foxp3(+) Tregs after hemorrhagic shock and resuscitation in relation to iNOS and cytokines. Methods. Male C57BL6/J and B6.129P2-NOS2(tm1Lau)/J (iNOS gene knockout) mice were used in creating hemorrhagic shock model. Mice were divided into two groups, each according to the type of resuscitation. (1) Wild HS: resuscitation with hypertonic saline (4 mL/Kg of 7.5% NaCl) and the shed blood (SB); (2) wild 2LR: resuscitation with lactated Ringer's solution and the SB; (3) iNOS knockout HS: similarly resuscitated as wild HS; (4) iNOS knockout 2LR: similarly resuscitated as wild 2LR. Samples of thymus and spleen were harvested at 2, 6, 24, 48, and 72 h after resuscitation. CD4(+) T cells and Foxp3(+) Tregs were analyzed at 24, 48, and 72 h. At 2, 6, 24, and 48 h, plasma cytokines were assayed and expression of iNOS (NOS2) was also measured by immunofluorescence. Results. NOS2 of HS and 2LR wild groups at 2 and 6 h in spleen increased compared with the control group. At 6h, NOS2 in HS wild group was significantly lower than in 2LR wild group. Plasma levels of interleukin (IL)-6, TNF-alpha, MCP-1, and IL-10 increased at 2 h. Both in wild type and iNOS knockout mice, hypertonic saline resuscitation decreased plasma IL-6, TNF-alpha, and MCP-1 levels at 2 h; CD4(+) T cells in spleen and thymus decreased at 24, 48, and 72 h, and Foxp3(+) Tregs in spleen at 48 h increased, however, hypertonic saline resuscitation did not affect the Foxp3(+). Conclusions. These results show that in early phase, the inflammatory cytokines in plasma might affect iNOS expression and cytokines. Further, this study showed that hypertonic saline resuscitation and suppression of iNOS might improve immunosuppressive reaction after hemorrhagic shock. (C) 2012 Elsevier Inc. All rights reserved.

Background: We investigated whether early initiation of hemoperfusion with a polymyxin B cartridge (PMX) after the diagnosis of septic shock could improve the clinical outcome. Methods: A prospective, open-labeled, multicenter cohort study was performed at intensive care units in Japan. 41 patients received PMX within 6 h after the diagnosis of septic shock (early group) and 51 patients were treated after 6 h (late group). Results: The early group had a significantly shorter duration of ventilator support and also had a lower catecholamine requirement. PMX was effective for improvement of hypotension, hypoperfusion, the sequential organ failure assessment score, and pulmonary oxygenation regardless of the timing of its initiation. The 28-day mortality rate did not differ between the two groups. Conclusions: Early initiation of PMX shortened the duration of ventilator support and also reduced the catecholamine requirement, so early treatment of septic shock should achieve a better outcome. Copyright (C) 2012 S. Karger AG, Basel

鈍的外傷による総胆管断裂、十二指腸全層性損傷合併は稀であり、再建法は損傷に応じた対応を迫られる。本症例では、総胆管断裂、十二指腸2部前側壁に広範な全層性損傷を認めたが、膵実質、Vater乳頭に損傷を認めなかった。胆管空腸吻合に用いた空腸と十二指腸を側々吻合してdouble tractを形成する事で、広範囲の十二指腸破裂にも適応し吻合部の減圧を容易にする再建法を行い、良好な結果を得た。(著者抄録)

A 19-year-old male was admitted because of the trauma due to sepsis-induced disseminated intravascular coagulation (DIC) and multiple organ failure (MOF). We treated with antibiotics, danaparoid, and continuous hemodiafiltration (CHDF). Once he recovered, but after several days, he had septic shock and MOF again. With treatment, the inflammation and MOF improved but the platelet count was less than 1.0 x 10(4)/mu L. Because of the usage of heparin, we suspected heparin-induced thrombocytopenia (HIT) and measured the HIT antibody and a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13). Heparin-induced thrombocytopenia antibody was positive in the second sepsis but negative in the first sepsis. ADAMTS13 activity was low in both sepses. After stopping CHDF and the usage of heparin, his platelet count improved. Thrombocytopenia is the common and occasional condition for DIC. Heparin-induced thrombocytopenia and thrombotic thrombocytopenic purpura is rare but they must be ruled out in thrombocytopenia with nontypical clinical course, and the assays for HIT antibody and ADAMTS13 activity are useful tools.

症例は43歳女と48歳男で、いずれも抗うつ薬による治療中に躁状態となり、自殺企図に至った。両例とも抗うつ薬の使用が躁転と長引く病像に関与していた可能性が示唆された。抗うつ薬を使用する際にはBipolar spectrumに留意し、躁転した場合には抗うつ薬の中止と気分安定薬の投与が必要であると思われた。今回の2例ではいずれもバルプロ酸が有効であった。

はじめに:救急救命士が心肺機能停止傷病者に静脈路を確保することは、さまざまな要因により困難な場合がある。目的:静脈路確保困難症例の対策として、従来の骨髄穿刺針に比べ簡便に骨髄内へ輸液路確保できる骨髄穿刺器具の1つであるBone Injection Gun(BIG)の有用性について検討した。方法:2008年中の救急活動検証票から救急救命士による静脈路確保の実施状況を調査した。また、救急救命士と救急隊員を対象(n=30)に訓練用BIGと訓練用下肢を用い、(1)広く明るい平地、(2)暗い環境、(3)狭い環境で、BIGによる骨髄内輸液の所要時間と成功率を測定した。結果:心肺機能停止傷病者全搬送人員(n=434)の90.8%に静脈路が確保されていなかった。BIGによる骨髄内輸液の所要時間は(1)16秒、(2)16秒、(3)15秒で、成功率は(1)96%、(2)93%、(3)100%であった。考察:BIGによる骨髄内輸液は、さまざまな穿刺困難因子にも影響されにくく、迅速かつ確実に実施できるため静脈路確保困難傷病者への薬剤・輸液投与時に有用な手段であると考えられる。(著者抄録)

We have experienced 5 cases of clinical trial with administration of incubated autologous bone marrow stromal cells (BMSC) into cerebrospinal fluid for acute Spinal cord injury. Our results were as follows, in 2 patients recovered lower limb function, but in 3 patients no change in the impairment scale. Here is the second case of our clinical trial. A 59-year-old male admitted due to cervical spinal cord injury (SCI) with no motor function at C6 and lower. On day 11 following no motor functional improvement observed, 2.1x10(6) BMSC were administered into the cerebrospinal fluid (CSF) through lumbar puncture. Motor function began to improve one week after the transplantation, and he was able to walk at 3 months. We would like to report this case because the clinical improvement and its timing after treatment were remarkable, even though they are not confirmed as the effect of the treatment.

Background: Hemorrhagic shock and resuscitation induce immunosuppression. CD4(+)CD25(+) regulatory T cells and gamma delta T cells may affect these immunosuppressive conditions. Hypertonic saline resuscitation reduces damage to organs and apoptosis and also restores immunosuppressive condition. We investigated how hypertonic saline resuscitation affected the induction of CD4(+)CD25(+) regulatory T cells and gamma delta T cells, and their apoptosis after hemorrhagic shock and resuscitation, and its relationship to inducible nitric oxide synthase (NOS) (nitric oxide production). Methods: Male inbred C57BL6/J mice 8-week to 12-week-old as wild type and iNOS gene knock out (iNOS-/-), weighing 20 g to 35 g, were used. Hemorrhagic shock model of +/- 40 mm Hg for 60 minutes was setup. Animals were randomly assigned to the following four resuscitation group: (1) wild HS: resuscitation with hypertonic saline (4 mL/Kg of 7.5% NaCl) and shed blood (SB), (2) wild 2LR: resuscitation with lactated Ringer's solution (two times the volume of the SB) and SB, (3) iNOS knockout HS, and (4) iNOS knockout 2LR. Untreated groups for wild and iNOS knockout mice were designated as control groups. Samples of thymus and spleen were harvested at 2 hours, 6 hours, 24 hours, and 48 hours after resuscitation. CD4(+)CD25(+) regulatory T cells and gamma delta T cells were analyzed using three-color flow cytometry. Results: (1) gamma delta T cells increased earlier at 24 hours and CD4(+)CD25(+) regulatory T cells increased later at 48 hours compared with controls in spleen of wild type (p < 0.01). (2) Hypertonic saline resuscitation suppressed gamma delta T cells compared with 2LR at 24 hours in iNOS knockout mice in spleen (p < 0.05). Hypertonic saline resuscitation increased apoptosis of CD4(+)CD25(+) regulatory T cells at 48 hours in iNOS knockout mice in spleen (p < 0.01). (3) CD4(+)CD25(+) regulatory T cells of NOS knockout both in HS and 2LR groups at 48 hours decreased compared with wild type both in HS and 2LR groups in spleen (p < 0.01). (4) Apoptotic gamma delta T cells both in spleen and thymus in iNOS knockout mice at 48 hours increased compared with those in wild type (p < 0.05, respectively, except gamma delta T cells 2LR in spleen: p = 0.058). Conclusion: gamma delta T cells increased earlier at 24 hours, whereas CD4(+)CD25(+) regulatory T cells increased later at 48 hours in spleen of wild type. Hypertonic saline was effective without the presence of NOS, i.e., decreased gamma delta T cells at 24 hours and increased apoptosis of CD4(+)CD25(+) regulatory T cells at 48 hours. CD4(+)CD25(+) regulatory T cells at 48 hours without iNOS decreased compared with those of wild type. gamma delta T cells at 48 hours induced apoptosis under the condition without NOS in spleen and thymus. iNOS worked as an accelerating factor for immunosuppressive condition, affected apoptosis, and immunoenhancing effect by hypertonic saline.

症例は53歳の男性。草刈中に約3mの高さの土手より転落しフェンスで左側腹部を殴打し,その直後から同部に手拳大の膨隆を認めた。来院時,膨隆部に限局した圧痛を認めるのみで,腹膜刺激症状はなかった。腹部CTでは内腹斜筋の損傷と小腸の脱出を指摘されたが,腹水や後腹膜血腫,他臓器の損傷はなかった。以上より外傷性腹壁ヘルニアと診断し緊急手術を施行した。膨隆部直上で皮膚切開したところ,腹膜,横筋筋膜,内腹斜筋,外腹斜筋腱膜と断裂し腸管が脱出していた。腸管を精査したところ,色調には異常なく,浮腫もなかったので,腹腔内に還納した。ヘルニア門の修復には人工物は使わず結節縫合のみとした。術後経過は良好で術後7日目に退院となった。外傷性腹壁ヘルニアは,本邦において文献報告が19例と少なくまれな疾患である。自験例に加え19例の文献的考察もまとめて報告する。(著者抄録)