並木 淳

A considerable number of patients with mild traumatic brain injury have been known to “talk and die.” Serial neurological examinations, however, have been the only method of determining the necessity of repeat computed tomography (CT), and no validated method has been available to predict early deterioration of minor head injury. This study aimed to evaluate the association between hypertension and bradycardia, a classic sign of raised intracranial pressure (Cushing reflex) on hospital arrival and determine the clinical consequences of minor head injury after blunt trauma. We created a new Cushing Index (CI) by dividing the systolic blood pressure by the heart rate (equaling the inverse number of the Shock Index, a score for hemodynamic stability) and hypothesized that a high CI would predict surgical intervention for deterioration and in-hospital death among patients with minor head injury. To test our hypothesis, a retrospective observational study was conducted using a nationwide trauma database. Accordingly, adult blunt trauma with minor head injury (defined as a Glasgow Coma Scale of 13–15 and Abbreviated Injury Scale score of ≥2 in the head) who were transported directly from the scene by ambulances were included. Among the 338,744 trauma patients identified in the database, 38,844 were eligible for inclusion. A restricted cubic spline regression curve for risks of in-hospital death was created using the CI. Thereafter, the thresholds were determined based on inflection points of the curve, and patients were divided into low-, intermediate-, and high-CI groups. Patients with high CI showed significantly higher in-hospital mortality rates compared with those with intermediate CI (351 [3.0%] vs. 373 [2.3%]; odds ratio [OR] = 1.32 [1.14–1.53]; p  < 0.001). Patients with high index also had a higher incidence of emergency cranial surgery within 24h after arrival than those with an intermediate CI (746 [6.4%] vs. 879 [5.4%]; OR = 1.20 [1.08–1.33]; p  < 0.001). In addition, patients with low CI (equal to high Shock Index, meaning hemodynamically unstable) showed higher in-hospital death compared with those with intermediate CI (360 [3.3%] vs. 373 [2.3%]; p  < 0.001). In conclusion, a high CI (high systolic blood pressure and low heart rate) on hospital arrival would be helpful in identifying patients with minor head injury who might experience deterioration and need close observation.

Case An 89‐year‐old man fell from stairs and sustained head trauma. He was taking warfarin and aspirin. Upon arrival at our hospital, his Glasgow Coma Scale score was 14. Initial head computed tomography showed small acute subdural hematoma. We immediately administered vitamin K and ordered fresh‐frozen plasma. Repeat computed tomography 3 and 6 h after trauma revealed the acute subdural hematoma had increased to 14 and 20 mm, respectively, and there were several new intracranial hemorrhages. Fresh‐frozen plasma and platelet transfusion were initiated. Outcome Follow‐up computed tomography revealed no further progression of intracranial hemorrhages, and the patient's consciousness did not deteriorate further. Conclusion Appropriate administration of vitamin K, fresh‐frozen plasma, and platelets successfully arrested progression of traumatic intracranial hemorrhages in this patient taking anticoagulant/antiplatelet agents and may have averted brain surgery.

Background. Images of head CT for the supratentorial compartment are sometimes recommended to be reconstructed with a thickness of 8–10 mm to achieve lesion conspicuity. However, additional images of a thin slice may not be routinely provided for patients with trauma in the emergency room (ER). We investigated the diagnostic sensitivity of a head CT, where axial images were 10 mm thick slices, in cases of linear skull fractures.Methods. Two trauma surgeons retrospectively reviewed head CT with 10 mm slices and skull X-rays of patients admitted to the ER that were diagnosed with a linear skull fracture. All patients had undergone both head CT and skull X-rays ().Result. The diagnostic sensitivity of head CT with a thickness of sequential 10 mm was 89% for all linear skull fractures but only 56% for horizontal fractures. This CT technique with 10 mm slices missed 6% of patients with linear skull fractures. False-negative diagnoses were significantly more frequent for older (≥55 years) than for young (<15 years) individuals ().Conclusions. A routine head CT of the supratentorial region for patients in the ER with head injuries requires both thick-slice images to visualize cerebral hemispheres and thin-slice images to detect skull fractures of the cranial vault.

57歳女。高血圧症・大動脈二尖弁の既往が有り、突然発症した右後頭部痛を主訴に救急搬送された。意識清明、心拍数58/分、両側橈骨動脈は触知可能で左右差はなかった。来院時には頭痛は軽快し、胸背部痛・神経学的異常・頭部CT上の異常も認めなかったが、2時間後に左上肢Barre徴候が陽性となり、頭部MRIでは両側大脳半球と右小脳半球に拡散強調像で高信号域を認め、急性期脳梗塞と診断した。両上腕とも収縮期血圧普段より低く測定が不安定であり、CTにて偽腔開存型大動脈解離を認めた。緊急に上行大動脈および部分弓部人工血管置換術を施行した結果、明らかな運動麻痺を残さず第28病日にリハビリテーション目的に転院した。

24歳男。左頬のひきつれ感を主訴に自分で救急要請した。明らかな異常所見を認めず、救急外来で経過観察中に左頬の自発痛の訴えは消失し、続いて右頬の同様の自発痛を訴え、その直後疼痛の訴えは左に戻った。身体表現性障害の判断で処方は行わず、神経内科か精神科への受診を勧め紹介状を渡したが、同日帰宅途中に電車に飛び込み死亡した。口腔心身症は医科の世界ではあまり知られていないが、精神科や歯科の両面での治療を考える必要があると思われた。

【目的】救急患者の意識レベル評価に際し，わが国で広く用いられているJapan Coma Scale（以下JCS）による誤判定の要因を明らかにする。【方法】当救急部で3年間に取り扱った救急車搬入の患者データベースから，頻度の高い8通りの意識レベルをGlasgow Coma Scaleのeye, verbal, motor（以下EVM）スコアに基づいて選択し，模擬患者が演ずる意識レベルを標準的な手順で診察するシミュレーションビデオを作製した。経験の少ない医療従事者として 1 年目初期臨床研修医94人を対象に，ビデオを用いたJCSによる意識レベルの判定テストを行い，その解答結果を解析した。【結果】JCSの誤判定率は， 8 つの設問の平均で19 ± 15%（平均±標準偏差）。JCS 0, 300の誤判定は稀だったが，JCS 2, 10, 200は20%以上の誤判定率であった。設問のJCSスコアと誤判定されたJCSスコアを対比すると，意識レベルを良い方に誤判定する傾向が示され，とくに軽度～中等度の意識障害でその傾向が強かった。設問でシミュレーションされたEVMスコアと誤判定されたJCSスコアを比較した結果，JCS誤判定の主な要因は次の3点であった。1）最良運動反応の「M4：逃避（正常屈曲）」を 「JCS 100：はらいのけるような動作」とする誤り。2）発語反応の「V4：会話混乱（見当識障害）」を「JCS 0：意識清明」とする誤り。とくに最良運動反応が「M6：命令に従う」の場合に「JCS 0：意識清明」と誤判定される。3）開眼反応における「E3：呼びかけによる」をJCS 1 桁とする誤り。とくに発語反応が「V4, 5：会話可能」な場合にJCS 1 桁と誤判定される。【結論】JCSによる救急患者の意識レベル誤判定の主な要因は，逃避と疼痛部位認識の運動反応の区別，見当識障害と意識清明の区別，呼びかけによる開眼反応の判定である。