State Of Cardiopulmonary Arrest Research Articles

Shaken adult syndrome due to ocean wave: an autopsy case.

Severe intracranial trauma during torture or assault is reportedly caused by shaken adult syndrome. However, intracranial traumas caused by natural forces, excluding human factors and collision impact, are extremely rare. We report an autopsy case of shaken adult syndrome caused by ocean wave forces. A man in his 40s without any medical history was washed away by a wave during recreational fishing. He was found approximately 500m away from the fishing point drifting on the ocean in a state of cardiopulmonary arrest and was confirmed dead, with no response to cardiopulmonary resuscitation, 3h after the accident. The autopsy revealed no mechanical trauma to the entire body surface, including the head. Both lungs were inflated, and pleural effusion was observed. The brain was swollen and congested, and subarachnoid hemorrhage was observed in the interhemispheric fissure and the convexity of the parietal occipital lobe. Macroscopic and microscopic hemorrhage spots were found in the brain, and the results of the blood alcohol test and urinary toxicological screening were negative. The cause of death was determined as drowning. This case demonstrates a rare but notable mechanism of injury observed in immersed bodies.

Acute benzyl alcohol intoxication: An autopsy case report.

The main mechanism of death and the pathological appearance of cases of benzyl alcohol intoxication has not been fully investigated. Autopsy reports of cases of benzyl alcohol intoxication have not been published. A 24-year-old man was found in the state of cardiopulmonary arrest at a construction site. He had been performing paint stripping. He was immediately transferred to the hospital, but he did not recover. An autopsy showed focal coloring of the skin without any major caustic injury. A histopathological investigation showed vacuolar degeneration in the epidermis and dermo-epidermal junction, and severe erosion of the tracheal and bronchial mucosa. No pathological changes in the kidney were evident. A neuropathological investigation showed central chromatolysis of neuronal cells in pontine nuclei and grumose degeneration in the cerebellar dentate nucleus. The blood content of benzyl alcohol was 780.0 μg/mL. Present case suggest that multiple pathways of exposure may be associated with more rapid progression in acute benzyl alcohol intoxication, and that early and/or severe involvement of the central nervous system rather than renal dysfunction may be associated with an early death.

心肺停止に至った遺伝性血管性浮腫（HAE）に対してドクターカー出動による気道確保を行った1例(Performing airway securement under Doctor–car system after cardiopulmonary arrest caused by hereditary angioedema: a case report)

要旨 症例は51歳の女性。救急搬送前日より口唇や口腔内の腫脹を自覚。当日は朝から顔面・頸部の腫脹が続き，窒息様の仕草の後に倒れたため救急要請となった。救急隊到着時，家族がCPR実施中であり，CPAを確認。波形はPEA，徐脈であった。当院ドクターカー医師が到着し，喉頭展開すると咽喉頭浮腫による気道閉塞を認めた。声帯は可視できなかったが急峻なJ型に挿管チューブを形成し，経口気管挿管を試みた。声門と思われる位置で抵抗を感じたが挿管に成功した。自己心拍再開し当院搬送となった。気管支鏡検査で喉頭蓋・声門周囲の浮腫は著明であったが感染を疑う所見は乏しく，以前から誘因なく顔が腫れることがあったという既往と同様の症状を肉親も有するという家族歴より遺伝性血管性浮腫（HAE）を疑い検査を行ったところ，C4 1.3mg/dL, C1–INH活性 25%以下と共に低値であった。血管浮腫情報センター（CREATE）に遺伝子解析を依頼したところ，遺伝子の変異を認めHAEと診断された。集中治療管理を継続したが残念ながら脳蘇生が得られず死亡退院となった。HAEは未だ一般の認知度が低く迅速診断法がないこと, C1–INH製剤を常備する医療機関が限られていることなど課題も多い。しかし，早期の診断と適切な気道管理がなされれば血縁家族の罹患発見にも繋がり，心停止は回避可能な疾患である。

Factors affecting survival of patients in the acute phase of upper cervical spine injuries.

In recent years, on the one hand, the mortality rates of upper cervical spine injuries, such as odontoid fractures, were suggested to be not so high, but on the other hand reported to be significantly high. Furthermore, it has not been well documented the relationship between survival rates and various clinical features in those patients during the acute phase of injury because of few reports. This study aimed to evaluate survival rates and acute-phase clinical features of upper cervical spine injuries. We conducted a retrospective review of all patients who were transported to the advanced emergency medical center and underwent computed tomography of the cervical spine at our hospital between January 2006 and December 2015. We excluded the patients who were discovered in a state of cardiopulmonary arrest (CPA) and could not be resuscitated after transportation. Of the 215 consecutive patients with cervical spine injuries, we examined 40 patients (18.6%) diagnosed with upper cervical spine injury (males, 28; females, 12; median age, 58.5years). Age, sex, mechanism of injury, degree of paralysis, the level of cervical injury, injury severity score (ISS), and incidence of CPA at discovery were evaluated and compared among patients classified into the survival and mortality groups. The survival rate was 77.5% (31/40 patients). In addition, complete paralysis was observed in 32.5% of patients. The median of ISS was 34.0 points, and 14 patients (35.0%) presented with CPA at discovery. Age, the proportion of patients with complete paralysis, a high ISS, and incidence of CPA at discovery were significantly higher in the mortality group (p = 0.038, p = 0.038, p < 0.001, and p < 0.001, respectively). Elderly people were more likely to experience upper cervical spine injuries, and their mortality rate was significantly higher than that in injured younger people. In addition, complete paralysis, high ISS, a state of CPA at discovery, was significantly higher in the mortality group.

Fatal broncho-pneumonia of an infant with arthrogryposis multiplex congenita (AMC)

Arthrogryposis multiplex congenita (AMC) is a heterogenous group of disorders characterized by multiple joint contractures with an estimated frequency of 1 in 3000-5100 livebirths. The authors present a case of an 11-month-old infant with AMC who died due to severe pneumonia. The deceased had no significant anomaly except for the stated orthpaediatric deformities, and the long-term outcome was expected to be positive. The only remarkable past medical history was respiratory syncytial virus (RS) infection at 6-months old which had taken a few days for a complete recovery. Onset of high fever was observed 3 days prior to her death and she was found in a state of cardiopulmonary arrest in bed by her father in an early morning. Forensic autopsy confirmed the pathohistological diagnosis of severe broncho-pneumonia. The presence of scoliosis and funnel chest was considered to be attributable to the disability to turn herself over and excrete sputum sufficiently, leading to a fatal respiratory complication. This paper stresses the possibility of distal arthrogryposis type of AMC becoming contributory to death despite the initial optimistic prognosis, as well as the importance of postmortem investigation in unexpected fatal cases.

Temporal evolution in peritoneal hemorrhage as depicted by postmortem CT

BackgroundComputed Tomography (CT) is now utilized as an effective tool for postmortem diagnoses. However, reports on the temporal evolution in imaging findings of these postmortem CT is limited. Case presentationOne night, a 66 year old male following drinking at a bar on his way home slept in the road. He was ran over by a taxi at 01:28 and immediately transferred to a nearby hospital. During his transfer to the hospital, he lost consciousness and fell into a state of cardiopulmonary arrest, and died despite resuscitation attempts. CT images were taken at 02:30. Following this, CT images were re-taken 54 h after death, just prior to a medicolegal autopsy. Result & discussionSmall amount of intra-abdominal hemorrhage was found during the initial CT examination. However, the extent of intra-abdominal bleeding observed during the second CT examination performed 54 h later had substantially increased. During the autopsy, the amount of intra-abdominal hemorrhage was 1700 mL. Injury to the mesentery, liver and pancreas was also observed. Additional major injuries discovered during the autopsy were, skin abrasions and lacerations of the scalp, subarachnoid hemorrhage, fractures of the ribs, right humerus, and pelvic bones. The deceased postmortem blood alcohol level was 2.4 mg/mL. The cause of death was determined as exanguination due to systemic injury. The mechanism of the postmortem increase in the intra-abdominal hemorrhage remained unknown. However, the amount of bleeding found during autopsies may not be the same as that at the time of death. As a result, the criteria for the diagnosis of the cause of death in autopsies should be carefully reconsidered. In addition, accompanying CT imaging at the time of death and possible postmortem changes should be carefully considered in postmortem CT imaging, so that there will not be incorrect assignment of the causes of death.

Immediate non-traumatic postmortem computed tomographic demonstration of myocardial intravascular gas of the left ventricle: effects from cardiopulmonary resuscitation

SummaryAn 87-year-old man was found in a state of cardiopulmonary arrest. Despite cardiopulmonary resuscitation (CPR) for over 1 hour by emergency technicians and physicians, the patient died. Immediate postmortem computed tomography showed cardiovascular gas in the right atrium, right ventricle, and left ventricle. Cardiovascular gas in the left ventricle was located in the myocardium and appeared as linear or branch-shaped suggesting the presence of myocardial intravascular gas. This is the first report describing the appearance and significance of myocardial intravascular gas of the left ventricle as a CPR-related change.

An Autopsy Case of Acute Carbon Monoxide Poisoning After a Long-Term Vegetative State

A 23-year-old woman was rescued from an accidental fire in a state of cardiopulmonary arrest. Based on the diagnosis of carbon monoxide (CO) poisoning, she received hyperbaric oxygen therapy and survived in a vegetative state. After 1 and a half years, she died without recovering from the vegetative state. At autopsy, the brain was observed to be moderately softened with a severely atrophied appearance and ventricular enlargement. In addition, a characteristic damage of hypoxic-ischemic leukoencephalopathy was also observed clearly in both the bilateral globus pallidus and cerebral white matter, which are typical findings of past acute CO poisoning. A long-term vegetative state causes the brain to soften and liquefy because of reactive gliosis and autolytic change. The cause of death becomes difficult to diagnose only from the autopsy findings in general. This case is rare in that the past acute CO poisoning could be diagnosed from the remaining typical cerebral findings even after a long-term vegetative state.

501 Analysis of the contractility of prostatic cancer-associated fibroblasts in a 3D collagen gel contraction assay

A 41-year-old man was accidentally exposed to carbon monoxide (CO) gas and found in a state of cardiopulmonary arrest while he took bath. After admission, he was resuscitated and underwent artificial ventilation in a comatose state and died about 19 h later. Computed tomography (CT) examination disclosed bilateral low density area in the basal ganglia and the thalamus, a well-known finding in the CO intoxication. Necropsy, histological examination, DNA ladder assay gave the first line of evidence for the presence of apoptosis as well as necrosis in the human case of CO intoxication. TdT-mediated dUTP-biotin nick-end labeling (TUNEL) positive apoptotic cells were more predominant in the CA2 area than in CA1 area. There is general co-relation between the ratio of TUNEL-positive cells and the DNA laddering on the agarose gel. Basal ganglia and thalamus, which showed bilateral low density area in CT, were revealed to be severe edema. The two types of cell death occurred in the cortex, basal ganglia, hippocampus, thalamus, and cerebellum. Hypoxia caused by CO–hemoglobin formation alone cannot explain the phenomena.

A fatal case of potential chronic overdoses of prescribed and proprietary remedies

A 33-year-old man was found in a state of cardiopulmonary arrest. He was transported to an emergency hospital but was pronounced dead. He had suffered from depression for about 8 years and had attempted suicide repeatedly. A search by the police found 645 empty Press Through Package (PTP) sheets. They had included neuroleptics, antidepressants, hypnotics, proprietary antitussives containing caffeine, proprietary cold remedies containing caffeine, and other unidentified drugs. An autopsy showed higher rectal temperature (38 degrees C), severe pulmonary edema (left: 681 g, right: 821 g), and a large amount of urine in the bladder (about 760 mL). Toxicological analyses using gas chromatography-mass spectrometry (GC/MS) and high performance liquid chromatography (HPLC) demonstrated that doses of clomipramine hydrochloride (a tricyclic antidepressant), chlorpromazine (a phenothiazine), and caffeine (a methylxanthine derivative) were within the toxic range (0.68, 0.64, and 34.24 [microg/mL], respectively). Histological examination showed centrilobular necrosis of the liver with small fat droplets. We concluded that he had died of pulmonary edema due to combined drug intoxication including proprietary antitussives and cold remedies. Furthermore, there was a strong possibility that he had habitually taken overdoses of those drugs. Herein, the risk of misuse of prescribed and proprietary drugs, especially for people with psychological problems, should be reemphasized.

Nontraumatic postmortem computed tomographic demonstration of cerebral gas embolism following cardiopulmonary resuscitation

The aim of this study was to investigate cerebral gas embolism (GE) on nontraumatic postmortem CT (PMCT), regarding its frequency, location (arterial or venous), and causes. Our subjects were 404 nontraumatically deceased patients who had been in a state of cardiopulmonary arrest on arrival at our emergency room. PMCT was performed within 2 h of the confirmation of death. Cardiopulmonary resuscitation (CPR) was performed on 387 of the 404 subjects; and of these, cerebral GE was detected in 29 (7.5%) subjects (3 arterial, 25 venous, 1 undeterminable). Cerebral GE was not noted in the other 17 of the 404 subjects who did not undergo CPR. However, there was no significant difference in the incidence of cerebral GE between the subjects who underwent CPR and those who did not. The mechanism of cerebral arterial GE was presumed due to pulmonary barotrauma and/or paradoxical embolism, while the thoracic pump theory was suggested to explain the cerebral venous GE. Cerebral arterial/venous GE is found in CPR cases on nontraumatic PMCT.

Determination of methamphetamine in sudden death of a traffic accident inpatient by blood and hair analyses

A female in her late thirties, who was hospitalized for 13 days with rib fractures suffered in a traffic accident, was found in supine position on the patient’s bed in a state of cardiopulmonary arrest. The resuscitation failed to recover consciousness and her death was confirmed 1.75 h later. The autopsy revealed neither severe injuries nor lesion as a cause of death. Histological examinations revealed contraction band necrosis (CBN) in the cardiac muscle of the left and right ventricles, as well as congestion and edema in both lungs. Toxicological screening of urine using Triage™ revealed the presence of methamphetamine (MA). By gas chromatography-mass spectrometry (GC/MS), the concentrations of MA and its metabolite amphetamine (AP) in the heart blood were shown to be 0.178 and 0.051 μg/ml, respectively. From these findings, we conclude that the cause of her death was circulatory failure due to MA poisoning. Further, the stored scalp hair analysis demonstrated both MA and AP in 0–3 cm segments from the scalp. The results suggested that she was a MA abuser at least about 3 months before her death. In this case, preservation of hair samples collected during an autopsy was useful for providing evidence of MA abuse.

Pyogenic liver abscess caused by Klebsiella pneumoniae genetic serotype K1 in Japan

Pyogenic liver abscess caused by Klebsiella pneumoniae is an emerging disease worldwide, and we know the serotype K1 strain to be the most virulent strain. We report a Japanese case of septic pyogenic liver abscess caused by K. pneumoniae genetic serotype K1. A 60-year old man presented at our hospital in a state of cardiopulmonary arrest. From the patient's chief complaint of chest pain, we suspected acute coronary syndrome, i.e., acute myocardial infarction. We used extracorporeal circulation and checked coronary angiography, but the 75% stenosis by itself could not adequately account for the patient's critical condition. The patient's laboratory data indicated multiple organ failure. The patient's condition did not improve while in intensive care and he died 20 h after the onset of the cardiopulmonary arrest. Pathological autopsy later showed colliquative necrosis in the deltoid and left greater pectoral muscles, as well as liver abscesses. The patient's blood, gastric juice, and stool cultures all grew a Gram-negative bacillus identified as Klebsiella pneumoniae. We also performed capsular polysaccharide synthesis (cps) genotyping by polymerase chain reaction for the detection of K serotype-specific alleles at the wzx and wzy loci. The result indicated that wzx_K1 and wzy_K1 were positive. This is the first reported Japanese case of septic pyogenic liver abscess caused by K. pneumoniae genetic serotype K1.

心肺蘇生後に発症した無石胆嚢炎の一例

A 47-year-old man was found at his home in a state of cardiopulmonary arrest. His family performed cardiopulmonary resuscitation on him. He was brought to our hospital by ambulance. On arrival, his pupils were dilated and his heart was in a state of ventricular fibrillation. After returning to spontaneous circulation by the cardiopulmonary resuscitation, the electrocardiogram revealed ST elevation at V2-V5. Cardiac catheterizatin revealed a left anterior descending coronary obstruction. Percutaneous coronary angioplasty was performed. On the 26th day after admission, acalculous cholecystitis was found. It was difficult to perform emergent surgery, because the patient was taking an anticoagulant drug. We performed PTGBA (percutaneous transhepatic gallbladder aspiration) on the same day, and the gallbladder inflammation was improved. We consider that PTGBA is an effective treatment for difficult cases of acalcuous cholecystitis.

Postmortem computed tomography for detecting causes of sudden death in infants and children: retrospective review of cases

The aim of this study was to investigate the usefulness of postmortem computed tomography (PMCT) in detecting causes of sudden death in infants and children. Our subjects were 15 nontraumatically deceased patients (nine boys and six girls, ranging in age from 20 days after birth to 12 years old, mean age 1.6 years), who had been in a state of cardiopulmonary arrest on arrival at our hospital. PMCT was performed within 2 h after certification of death: head (15 cases), chest (11 cases), and abdomen (12 cases). Blood was collected from 11 of the patients at the time of cardiopulmonary resuscitation. An autopsy was conducted on two. PMCT did not show any traumatic changes indicating child abuse. It was difficult to presume the cause of death with PMCT alone, but the cause of death in 14 of 15 cases could be presumed by combining information from their medical history, clinical course before death, PMCT findings, laboratory data, and bacterial culture. The remaining subject was classified as cause unknown. The causes of sudden death in infants and children were detected at a high rate when we comprehensively investigated the PMCT and other examination findings.

2. An Unusual Death due to the Impalement of a Gear Stick into the Brain Stem through the Nasal Cavity

A 59-year-old male was driving a car on the road and was involved in a traffic accident, colliding with a tanker and a big lorry. When an ambulance arrived at the scene, he was in a state of cardiopulmonary arrest and was bleeding profusely from his right nostril. He was confirmed dead at hospital. The autopsy showed a laceration of the right upper lip extending to the right nostril. In the basal skull there was a notable perforation at the ethmoid bone together with the central part of the sphenoid bone including the sella turcica. In accordance with the basal skull bone fractures, there were pronounced contusion injuries at the brain stem and a contusion injury was also observed in the right part of the cerebellum. After careful investigation of a causative stick-like item that was present inside the car, it was concluded that a severe movement of the man's body, as a result of the traffic collision, caused the gear stick which was fixed to the steering wheel to become impaled in the man's right nostril. The gear stick passed through the nasal cavity and into the basal skull bones, resulting in fatal brain stem injuries.

Response to Smallpox Vaccine in Persons Immunized in the Distant Past—Correction

To the Editor: The process of commercial coffee roasting releases large amounts of carbon monoxide (CO), which sometimes reach life-threatening levels. We report a case of a death due to CO poisoning sustained during commercial coffee roasting. Report of a Case. A 23-year-old employee of a roasting plant collapsed and lost consciousness soon after entering a storage tank (approximately 2 m in diameter and 2.7 m in height) to retrieve a tool that he had dropped into the tank. When removed from the tank 40 minutes later, he was found to be in a state of cardiopulmonary arrest and was transported to the hospital. Resuscitation attempts, including cardiac compression and administration of 100% oxygen, were unsuccessful. Five coworkers also were transported to nearby hospitals. Three of these had collapsed and lost consciousness when they went inside or approached the tank, while 2 others reported presyncopal symptoms. All 5 recovered soon or within a few hours, although 1 was hospitalized and given oxygen. The medicolegal autopsy of the deceased worker was performed in our department 17 hours after the death. A cherryred discoloration was seen on the back. Slight bruises were found on the left temporal area and the left forearm. Multiple petechial hemorrhages were observed in the pericardium and on lung surfaces. Both lungs showed severe edema and congestion. The concentration of CO hemoglobin (COHb) was 26% in the heart blood. No other toxic gases or drugs were detected. The cause of death was determined to be acute CO poisoning. According to the result of the subsequent forensic inspection, the company involved in this incident uses an extracting process on coffee beans that have already been roasted and ground. This process, which is widely used in the industry, involves adding water to ground beans in an extracting tank to produce a coffee extract that is then transferred to a storage tank. Air samples from storage tanks were collected throughout the roasting process for the determination of CO levels. In this case, the maximum levels of CO in the storage tank were found to be 10000 to 100000 ppm. An ambient CO concentration of 5000 to 10000 ppm can lead to a COHb saturation of as high as 75% (a lethal level) within a few minutes. Comment. Industrial coffee extraction may place workers at risk of CO poisoning. Workplace standards, improved industrial systems, and better worker education may help to reduce this risk.

Apoptotic and necrotic brain lesions in a fatal case of carbon monoxide poisoning

A 41-year-old man was accidentally exposed to carbon monoxide (CO) gas and found in a state of cardiopulmonary arrest while he took bath. After admission, he was resuscitated and underwent artificial ventilation in a comatose state and died about 19 h later. Computed tomography (CT) examination disclosed bilateral low density area in the basal ganglia and the thalamus, a well-known finding in the CO intoxication. Necropsy, histological examination, DNA ladder assay gave the first line of evidence for the presence of apoptosis as well as necrosis in the human case of CO intoxication. TdT-mediated dUTP-biotin nick-end labeling (TUNEL) positive apoptotic cells were more predominant in the CA2 area than in CA1 area. There is general co-relation between the ratio of TUNEL-positive cells and the DNA laddering on the agarose gel. Basal ganglia and thalamus, which showed bilateral low density area in CT, were revealed to be severe edema. The two types of cell death occurred in the cortex, basal ganglia, hippocampus, thalamus, and cerebellum. Hypoxia caused by CO–hemoglobin formation alone cannot explain the phenomena.

POSTOPERATIVE ACUTE PULMONARY EMBOLISM-A REPORT OF TWO PATIENTS COMPLAINING OF AN ABDOMINAL PAIN-

Postoperative pulmonary embolism (PPE) is a rare but extremely important complication because it is often lethal. We here report on two patients with PPE, both of who complained of an abdominal pain. Patient 1: A 60-year-old man who underwent a distal gastrectomy for an advanced gastric cancer complained of an abdominal pain and dyspnea and then fell into a state of cardiopulmonary arrest when he was walking on the second postoperative day. He was successfully resuscitated and the cause was diagnosed as PPE after examination. He eventually developed multiple organ failure and expired on the 23rd postoperative day notwithstanding full intensive care including anticoagulant therapy. Patinet 2: A 59-year-old man who underwent a distal gastrectomy for an early gastric cancer suddenly had an abdominal pain and collapsed on the first day after the operation. PPE was suspected by clinical symptoms and findings of some examinations. After the diagnosis of PPE was confirmed by a perfusion lung scintigraphy, the patient received an anticoagulant therapy and successfully recovered. We have fully realized that the prophylaxis of PPE is indispensable, and are now utilizing intermittent sequential pneumatic compression to prevent PPE.