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A complication of lower thoracic oesophagectomy for oesophageal carcinoma is reported. Extrapericardial tamponade was caused by a dilated retrosternal gastric roll. Echocardiography was useful for diagnosis. Diagnosis, investigation and management of this unusual but life-threatening complication are discussed. Transthoracic echocardiography is a useful and practical investigation for the evaluation of complications of oesophagectomy.

1986年1月から1995年12月の間に,6症例の中毒性表皮壊死症(TEN)の治療を経験した。3症例において疑わしき原因薬物が認められたが,残り3症例は不明であった。全例,個室隔離を行い,空気循環式ベッドを使用した。初期の2症例はステロイドの投与を継続したが,2症例は入室時に中止した。皮膚に対する局所治療は行わなかったが,全症例,皮膚と粘膜の治癒が得られた。われわれの臓器障害スコアを用いた評価では,皮膚症状の発現から14日以後に感染によると考えられる臓器障害の悪化が2症例でみられ,そのうち1症例が緑膿菌による敗血症で死亡した。以上より,TENは自然治癒疾患であり,感染などの合併症を予防することが重要であると考えられた。また,ステロイドの使用は,臨床症状を好転させないばかりか,むしろ易感染性を招来する可能性が示唆された。

Clonidine has both analgesic and sedative actions, and it has been used in a variety of settings as an analgesic, as a sedative, or both. We administered oral clonidine with intravenous ketamine to a burn patient to control severe pain. Clonidine produced good analgesia and sedation. In addition, clonidine counterbalanced the sympathetic stimulation of ketamine by virtue of its action in reducing sympathetic outflow. The combination of these two drugs may be useful for burn patients with hypertension or myocardial ischemia.

1992年12月1日から1996年6月30日までの3年7ヵ月間に,大阪市立大学医学部附属病院で救急救命士から電話による交信を受けた院外心肺機能停止(out-of-hospital cardiopulmonary arrest; OHCPA)症例は418例であった。このうち救急救命士が心電図を装着した時点で,心室細動を呈した症例は64例(15.3%)を占めた。本研究ではUtstein styleに従って早期除細動によるOHCPA症例の予後について検討した。目撃者のある心原性CPAは418症例のうち127例で,心静止64例(50.4%),心室細動49例(38.6%), EMD 14例(11.0%)であった。目撃者のある心原性心室細動症例49例(全心室細動症例の77%)に対して41例(84%)で除細動が施行され,10例で病院前心拍再開が得られた(病院前心拍再開率24.4%)。その10例中8例では200ジュール1回の除細動で心拍が再開し,2例(4.1%)が社会復帰した。しかし除細動までに要した時間は,除細動のみの施行群でさえ16.8±7.7minと長時間を要しており,ラリンゲアルマスクなどの挿入例ではさらに時間を要した。目撃者のある心原性以外の心室細動15例では1例が生存したが社会復帰例はなかった。一方bystander CPRは64症例中7例(10.9%)に施行されているにすぎず,目撃者のある心原性心室細動49例に対しては5例(10.2%)で施行されていた。社会復帰が可能となった2症例では,bystander CPRは施行されていなかったが,救急救命士によるCPRが4分前後に開始され除細動までの時間も短かった。bystander CPRが普及していない現状では,救急救命士による除細動は状況に恵まれた場合に限り蘇生の質の向上に対して有効であると思われた。救急医療システムとしてさらなる救命率の向上を目指すには,bystander CPRの普及,除細動施行までの時間短縮が急務である。

Study objective: To assess the treatment and outcome of patients with crush syndrome sustained in an earthquake disaster. Methods: We conducted a retrospective analysis of eight patients with crush syndrome and subsequent acute kidney failure who were treated in the ICU of a university hospital. All eight patients had been extricated from buildings that collapsed in the 1995 Kobe, Japan, earthquake. Crush injury involved the upper extremities in one patient and the lower extremities in seven. Each patient received intravenous fluid infusion and diuretic drugs and underwent hemodialysis. Emergency fasciotomy was performed in some patients, 17 to 100 hours after extrication. Results: All patients were conscious and lucid on admission, and blood pressure and heart rate were normal. All the patients demonstrated kidney failure with increased concentrations of serum creatinine (1.9 to 9.6 mg/dL [169 to 852 μmol/L]). Six patients were oliguric. Hyperkalemia (5.6 to 8.8 mEq/L) was present in six patients. We found close correlations between the serum potassium and creatine kinase concentrations, between the serum myoglobin and potassium concentrations, and between the serum myoglobin and creatine kinase concentrations. All the patients were weaned from hemodialysis. The serum creatinine concentration decreased to a normal level within 20 to 52 days of admission in all patients. No patients underwent amputation. Muscle weakness and sensory deficits persisted in all patients 6 months after the earthquake. Conclusion: Our findings support current therapeutic strategies for crush syndrome, despite the long delay to initiation of intensive therapy. All the patients recovered kidney function and were weaned from hemodialysis; none required amputation. [Oda Y, Shindoh M, Yukioka H, Nishi S, Fujimori M, Asada A: Crush syndrome sustained in the 1995 Kobe, Japan, earthquake: Treatment and outcome. Ann Emerg Med October 1997;30:507-512.]

Sir: Crush syndrome may be caused by compression of the extremities during transient unconsciousness induced by alcohol and other agents [1, 2]. However, rhabdomyolysis is also induced by alcohol withdrawal or alcoholic myopathy. We present a patient with crush syndrome occurring during alcohol withdrawal who remained unconscious for an extended period of time and developed persistent Korsakoff's psychosis. A 36-year-old man with a history of alcohol dependence was found lying on the floor at home with general convulsions. When he was transported to our intensive care unit, he was intubated, responsive only to painful stimuli, and horizontal nystagmus was noted. Convulsion was noted in his right arm and his left forearm was markedly swollen. Sinus tachycardia was noted by electrocardiogram, while no abnormalities were detected by echocardiogram. Urine color was brown and the laboratory data were remarkable for serum creatinine of 204 mmol/1, creatine kinase of 53009 IU/I and myoglobin of 61000 mg/l. Alcohol was not detected in the blood. No abnormal findings were noted on blood gas data, brain CT or cerebrospinal fluid examination. Administration of bicarbonate, total parenteral nutrition with thiamine 100 mg daily and hemodialysis were started, based on the diagnosis of crush syndrome induced during alcohol withdrawal. Fasciotomies of the right forearm compartments were performed for the marked swelling of the right hand and forearm on the day after admission. His level of consciousness gradually improved and the tracheal tube was removed on the 10th hospital day. No abnormal findings were detected on brain MRI. His renal function fully recovered and, approximately 5 weeks after admission, he became able to communicate with the medical staff, although disorientation persisted. A diagnosis of Korsakoff's psychosis was made by a psychiatrist, based on the presence of confabulation and anterograde and retrograde memory disorder. His mental state has not changed markedly since. The disturbance of consciousness associated with alcohol withdrawal usually lasts for only several days [3]. The duration of unconsciousness in our patient was remarkably long and the reason is unclear. Korsakoff's psychosis develops secondarily to Wernicke's encephalopathy in many patients and the horizontal nystagmus in our patient is commonly observed in Wernicke's encephalopathy [4]. However the absence of past history or classical signs of Wernicke's encephalopathy, such as hypothermia, hypotension and ataxia, prevents us from making the diagnosis of Wernicke's encephalopathy. Rhabdomyolysis in this patient may have been induced by alcohol withdrawal, as well as by compression of the arms during unconsciousness. Rhabdomyolysis may also be caused by alcoholic myopathy. However, the manifestations of alcoholic myopathy are typically more prominent in the legs, usually located in the proximal areas [5]. In this patient, the affected muscle was in the forearms and hand, which is common in rhabdomyolysis caused by compression [1, 2]. Alcohol withdrawal induces various conditions such as consciousness disturbance, convulsion and myopathy. In this patient, the prolonged unconsciousness might have been caused by alcohol withdrawal and subsequent Korsakoff's psychosis. Since crush syndrome may occur during unconsciousness, it is a rare, but important, complication during alcohol withdrawal.