Blood transfusion therapy for traumatic cardiopulmonary arrest.

BACKGROUND: Blood transfusion therapy (BTT), which represents transplantation of living cells, poses several risks. Although BTT is necessary for trauma victims with hemorrhagic shock, it may be futile for patients with blunt traumatic cardiopulmonary arrest (BT-CPA). MATERIALS AND METHODS: We retrospectively examined the medical records of consecutive patients with T-CPA. The study period was divided into two periods: The first from 1995-1998, when we used packed red cells (PRC) regardless of the return of spontaneous circulation (ROSC), and the second from 1999-2004, when we did not use PRC before ROSC. The rates of ROSC, admission to the ICU, and survival-to-discharge were compared between these two periods. RESULTS: We studied the records of 464 patients with BT-CPA (175 in the first period and 289 in the second period). Although the rates of ROSC and admission to the ICU were statistically higher in the first period, there was no statistical difference in the rate of survival-to-discharge between these two periods. In the first period, the rate of ROSC was statistically higher in the non-BTT group than the BTT group. However, for cases in which ROSC was performed and was successful, there were no statistical differences in the rate of admission and survival-to-discharge between the first and second group, and between the BTT and non-BTT group. CONCLUSION: Our retrospective consecutive study shows the possibility that BTT before ROSC for BT-CPA and a treatment strategy that includes this treatment improves the success rate of ROSC, but not the survival rate. BTT is thought to be futile as a treatment for BT-CPA before ROSC.

Complications of bystander cardiopulmonary resuscitation for unconscious patients without cardiopulmonary arrest.

BACKGROUND: Insufficient knowledge of the risks and complications of cardiopulmonary resuscitation (CPR) may be an obstructive factor for CPR, however, particularly for patients who are not clearly suffering out of hospital cardiopulmonary arrest (OH-CPA). The object of this study was to clarify the potential complication, the safety of bystander CPR in such cases. MATERIALS AND METHODS: This study was a population-based observational case series. To be enrolled, patients had to have undergone CPR with chest compressions performed by lay persons, had to be confirmed not to have suffered OHCPA. Complications of bystander CPR were identified from the patients' medical records and included rib fracture, lung injury, abdominal organ injury, and chest and/or abdominal pain requiring analgesics. In our emergency department, one doctor gathered information while others performed X-ray and blood examinations, electrocardiograms, and chest and abdominal ultrasonography. RESULTS: A total of 26 cases were the subjects. The mean duration of bystander CPR was 6.5 minutes (ranging from 1 to 26). Nine patients died of a causative pathological condition and pneumonia, and the remaining 17 survived to discharge. Three patients suffered from complications (tracheal bleeding, minor gastric mucosal laceration, and chest pain), all of which were minimal and easily treated. No case required special examination or treatment for the complication itself. CONCLUSION: The risk and frequency of complications due to bystander CPR is thought to be very low. It is reasonable to perform immediate CPR for unconscious victims with inadequate respiration, and to help bystanders perform CPR using the T-CPR system.

Characteristics of high-echoic objects in the hepatic vessels of patients with cardiopulmonary arrest: a prospective cohort study.

BACKGROUND: High-echoic objects in the hepatic vessels of patients with cardiopulmonary arrest (CPA) are frequently detected by ultrasonography. OBJECTIVE: To demonstrate this phenomenon and clarify its clinical characteristics. METHODS: In a tertiary care academic medical centre, 203 CPA patients were evaluated by ultrasonography. CT determined the origin and location of high-echoic objects detected in the liver. The frequency and characteristics of this phenomenon were investigated. The background, laboratory data and survival rate were compared between patients with and without high-echoic objects. RESULTS: High-echoic objects were seen in 73 (36.0%) patients and could clearly be detected in the hepatic veins of 41 (56.2%) patients. CT confirmed that these were gas in 27 of 53 patients, and were clearly visible in the hepatic veins in 12 (44.4%) patients. Hepatic portal venous gas was not identified. Compared to patients without high-echoic objects, witnessed arrest (p<0.001), bystander cardiopulmonary resuscitation (p=0.005), ventricular fibrillation or pulseless electrical activity (p=0.012) and return of spontaneous circulation (p=0.018) were significantly less frequent in patients with high-echoic objects. These patients had a lower incidence of survival to discharge (1.4% vs 7.7%, p=0.100). Multivariate analysis showed that absence of high-echoic objects was a marginally significant factor in association with return of spontaneous circulation (p=0.052). CONCLUSIONS: High-echoic objects were often observed on ultrasonography in CPA patients; these objects were considered hepatic venous gas. The presence of high-echoic objects may be a poor prognostic sign in patients with CPA.

Outcomes from prehospital cardiac arrest in blunt trauma patients.

BACKGROUND: There are few strategies for treating patients who have suffered cardiopulmonary arrest due to blunt trauma (BT-CPA). The aim of this population-based case series observational study was to clarify the outcome of BT-CPA patients treated with a standardized strategy that included an emergency department thoracotomy (EDT) under an emergency medical service (EMS) system with a rapid transportation system. METHODS: The 477 BT-CPA registry data were augmented by a review of the detailed medical records in our emergency department (ED) and action reports in the prehospital EMS records. RESULTS: Of those, 76% were witnessed and 20% were CPA after leaving the scene. In all, 18% of the patients went to the intensive care unit (ICU), the transcatheter arterial embolization (TAE) room, or the operating room (OR). Only 3% survived to be discharged. Among the 363 witnessed patients-11 of whom had ventricular fibrillation (VF) as the initial rhythm, 134 exhibiting pulseless electrical activity (PEA), and 221 with asystole-13, 1, and 3%, respectively, survived to discharge. The most common initial rhythm just after collapse was not VF but PEA, and asystole increased over the 7 min after collapse. There were no differences in the interval between arrival at the hospital and the return of spontaneous circulation between the patients that survived to discharge and deceased patients in the ED, OR, TAE room, or ICU. The longest interval was 17 min. CONCLUSIONS: In BT-CPA patients, a 20-min resuscitation effort and termination of the effort are thought to be relevant. The initial rhythm is not a prognostic indicator. We believe that the decision on whether to undertake aggressive resuscitation efforts should be made on a case-by-case basis.

Usefulness and safety of open tracheostomy by a paramedian approach for cervical infection: esophageal and tracheal injury and necrotizing fascitis.

Tracheostomy is hardly performed in patients with cervical infection close to the site of the tracheostomy. This study aimed to present and clarify the usefulness and safety of open tracheostomy performed by the paramedian approach technique. The procedure is as follows. A 2.5-cm paramedian incision is made for the tracheostomy on the opposite side of infectious focus; the anterior neck muscles are dissected and split; the trachea is fenestrated by a reverse U-shaped incision; and the fenestral flap of the trachea is fixed to the skin. We used this technique in five patients. There were no complications such as bleeding, desaturation, and displacement of the tube; and there were no postoperative complications such as severe contamination or infection of the tracheostomy site from the nearby cervical wound, difficulty in securing the tracheostomy tube and connecting device to the ventilator, difficulties in daily management and care, or dislocation of the tracheostomy tube. All wounds resulting from the tracheostomy were kept separate from and not contaminated by the nearby dirty wounds. Open tracheostomy by the paramedian approach technique is useful and safe for patients with severe cervical infection requiring open drainage and long ventilatory management.

Treatment of hepatic encephalopathy by on-line hemodiafiltration: a case series study.

BACKGROUND: It is thought that a good survival rate of patients with acute liver failure can be achieved by establishing an artificial liver support system that reliably compensates liver function until the liver regenerates or a patient undergoes transplantation. We introduced a new artificial liver support system, on-line hemodiafiltration, in patients with acute liver failure. METHODS: This case series study was conducted from May 2001 to October 2008 at the medical intensive care unit of a tertiary care academic medical center. Seventeen consecutive patients who admitted to our hospital presenting with acute liver failure were treated with artificial liver support including daily on-line hemodiafiltration and plasma exchange. RESULTS: After 4.9 +/- 0.7 (mean +/- SD) on-line hemodiafiltration sessions, 16 of 17 (94.1%) patients completely recovered from hepatic encephalopathy and maintained consciousness for 16.4 +/- 3.4 (7-55) days until discontinuation of artificial liver support (a total of 14.4 +/- 2.6 [6-47] on-line hemodiafiltration sessions). Significant correlation was observed between the degree of encephalopathy and number of sessions of on-line HDF required for recovery of consciousness. Of the 16 patients who recovered consciousness, 7 fully recovered and returned to society with no cognitive sequelae, 3 died of complications of acute liver failure except brain edema, and the remaining 6 were candidates for liver transplantation; 2 of them received living-related liver transplantation but 4 died without transplantation after discontinuation of therapy. CONCLUSIONS: On-line hemodiafiltration was effective in patients with acute liver failure, and consciousness was maintained for the duration of artificial liver support, even in those in whom it was considered that hepatic function was completely abolished.

Cardiopulmonary arrest on arrival due to penetrating trauma.

INTRODUCTION: The aim of this study was to clarify the outcome of patients with cardiopulmonary arrest on arrival due to penetrating trauma (PT-CPA) and to establish the treatment strategy. PATIENTS AND METHODS: The clinical course of 29 patients with PT-CPA over the past 10 years was examined. We have taken three approaches to these patients: (i) an aggressive treatment strategy; (ii) an in-hospital system supporting this aggressive resuscitation; and (iii) the pre-hospital emergency medical service (EMS) system in our city. RESULTS: Although the return of spontaneous circulation (ROSC) was established in 59% of patients, only 17% survived for 7 days, 14% were discharged, and 7% were neurologically intact. Of 10 patients showing pulseless electrical activity (PEA) on the scene, ROSC was established in 100% and 30% were discharged; however, of 12 patients showing asystole, ROSC was established in 33% and no patient could be discharged. There was no difference in the time interval from the arrival at the emergency department to ROSC between discharged patients and patients who died. The time interval from collapse to arrival at the emergency department in discharged patients and patients who went to the intensive care unit was shorter than that of patients who died in the emergency department with and without ROSC. CONCLUSIONS: We cannot decide to give up and terminate resuscitation in any PT-CPA patients and cannot define salvageable patients. However, our data show that 30-min resuscitation is thought to be relevant and that we should not give up on resuscitation because of the time interval without ROSC after arrival at the hospital.

Effect of fasting on coagulation factors in patients who undergo major abdominal surgery.

Major abdominal surgery without preoperative adequate oral intake with some cephalosporins may result in vitamin K deficiency and bleeding tendency. The aim of this study is to clarify the effect of preoperative fasting on postoperative coagulation factors. We prospectively examined 16 patients who underwent major abdominal surgery. Patients were divided into a preoperative fast group (Group F, n = 7, mean period of preoperative fasting 8.7 days) and a control group (Group C, n = 9). We did not administer vitamin K and initiated feeding after the seventh postoperative day. In Group C, prothrombin time (PT) and Factors II, VII, IX, and X levels were decreased after the surgery to within normal limits. In Group F, the PT and Factors II, VII, and X levels were decreased after the surgery. Abnormal lower levels of PT and Factors II, VII, and X were seen in 67, 33, 67, and 67 per cent of patients after the surgery, respectively. Factors VII and X levels were higher than in Group C by the third postoperative day. The protein induced by vitamin K absence or antagonist-II levels in Group F were increased at all postoperative points. Clinicians should realize that preoperative fasting for as little as 1 week can induce precoagulopathy, resulting in postoperative coagulopathy after major surgery.

A new concept for stage grouping of gastric cancer according to dynamic stage migration with time: a survival-period perspective.

The aim of this study was to clarify the mechanism of "dynamic stage migration with time". Nine hundred thirty-nine patients with gastric cancer were evaluated in the study. Patients who survived for more than 1, 2, 3, 4, and 5 years after the initial operation were selected. The 6-, 7-, 8-, 9-, and 10-year survival rates from the time of surgery were evaluated for every tumor depth (t)/nodular status (n) group in every stage. The longer the patients survived after the initial operation, the closer the next 5 year survival of patients in the t2n0 group came to that of patients in the t1n0 group; the closer that of t2n1 patients came to that of t1n1; and the closer those of t3n2, t2n2, t2n3, and t3n1 patients came to that of t3n0 patients. A stage grouping at some years after the initial operation is expected to differ from that estimated just after surgery because of the heterogeneity of the disease.

Lethal obstructive colitis: how and when patients with colonic obstruction should be prevented from falling into a lethal condition.

BACKGROUND/AIMS: The objective of this study is to clarify the pathological condition and treatment strategy of lethal obstructive colitis (LOC), which is defined as obstructive colitis with severe shock or septic shock. METHODOLOGY: We examined 5 patients with LOC (colorectal cancer or suspected in 2, fecal impaction in 2, and volvulus in 1) and evaluated their pathophysiology and management strategy from their medical records. RESULTS: Emergency operations were performed within 150 minutes from arrival in all cases. Three were saved by repeat operations and 2 died. The systolic pressure of both survived and deceased patients were under 62 or palpable only on the common carotid artery, and there was no difference between survived and deceased patients. The mean pulse rate of the deceased patients was 76.5 while survived 117.7. Two deceased patients presented unconsciousness or conscious disorder while survived patients showed clear consciousness. The 2 deceased patients fell into VT just after arrival or during the operation. CONCLUSIONS: In managing colonic obstruction, we should be aware of this potentially lethal disease and surgical treatment should be performed as soon as possible before the patients fall into LOC. Early diagnosis and early aggressive surgery is essential for managing LOC.

Ultrasonography for the diagnosis of intraperitoneal free air in chest-abdominal-pelvic blunt trauma and critical acute abdominal pain.

OBJECTIVE: To clarify the usefulness of ultrasonography (US) as a diagnostic instrument for intraperitoneal free air (IPFA), which is thought to be useful in the fields of emergency medicine and traumatology. DESIGN: Prospective observational study. SETTING: Tertiary critical care and emergency center. PATIENTS: A total of 484 patients with severe chest-abdominal-pelvic blunt trauma or, in the absence of such trauma, severe acute abdominal pain were examined using US to detect IPFA. The exclusion criteria consisted of hemorrhagic shock with massive intraperitoneal fluid, penetrating or open abdominal trauma, and transfer to our center when general surgeons were absent. MAIN OUTCOME MEASURES: The primary outcome measure was the sensitivity and specificity of US for the diagnosis of gastrointestinal perforation performed by gastroenterologic or general surgeons with more than 5 years of experience with US. A US diagnosis of IPFA was made if high-echoic spots in the ventral space of the liver were detected. Conclusive diagnosis of gastrointestinal perforation was made based on the operative findings or on radiologic and clinical observation for more than 4 days. RESULTS: Fifty-four patients were diagnosed as having gastrointestinal perforation. In patients with blunt abdominal trauma, sensitivity for the diagnosis of gastrointestinal perforation by US was 85.7% and specificity was 99.6%; in patients with severe acute abdominal pain, sensitivity was 85.0% and specificity was 100.0%. CONCLUSION: Ultrasonography is useful for the diagnosis of IPFA with acute abdominal pain or blunt trauma, except in patients with gastrointestinal perforation without IPFA.

Severe anemia inducing preshock caused by sarcomatoid carcinoma of the small intestine.

A 55-year-old man consulted the outpatient department because of shortness of breath on effort and palpitation. Clinical examination showed severe anemia, a tumor with an ulcer on jejunography, with isodensity in contrast enhancement computed tomography, and a tumor stain on angiography, with middle intensity in T1- and T2-weighted images on magnetic resonance imaging. During laparotomy, we found jejunal tumors and lymph node swelling (TMN stage T3 N4 M1), and we performed a partial resection of the jejunum. Pathological examination showed a sarcomatoid carcinoma extending to the subserosal layer with multiple nodal metastases. The tumor was composed mainly of sheets of spindle cells and partially anaplastic cells appearing to be of epithelial cell origin. Histochemical staining showed a negative reaction for leukocyte common antigen and UCHL-1 and a weakly positive reaction for cytokeratin and epithelial membrane antigen. The patient died on postoperative day 283.

Lethal perianal infection with septic shock: how should we manage this critical condition?

Some patients with perianal infection fall into a critical condition with severe sepsis and septic shock (lethal perianal infection). The objective of this study is to clarify the clinicopathological characteristics of, and treatment strategies for, lethal perianal infection. The clinical records of 7 patients with lethal perianal infection were examined. For two rapidly dying cases (within 3 days), we performed resection of the rectum or local anal drainage as a primary management of damage control. These patients were transferred to our center because of septic shock and multiple organ dysfunction syndrome (MODS) and had received insufficient fluid resuscitation in the previous hospital. Another nonsurviving case who died on the 16th day was transferred without MODS and underwent perianal drainage but could not recover from shock, even after repeated surgical procedures were performed. To prevent a perianal infection from becoming lethal, it should be managed as early as possible with sufficient fluid resuscitation with adequate drainage.

Trans-abdominal-mediastinal approach with median phrenotomy for esophageal disruption.

BACKGROUND/AIMS: The prognosis for esophageal disruption is still poor. The aim of this study is to clarify the usefulness and safety of the transabdominal-mediastinal approach for spontaneous esophageal disruption. METHODOLOGY: The surgical procedure is as follows: upper median laparotomy with resection of the xyphoid process, folding up of the lateral segment of the left liver, median phrenotomy from the root of the xyphoid process to the esophageal hiatus, trans-mediastinal left thoracotomy by blunt dissection, blind lavage of the thoracic cavity, and simple interrupted suture and fundic patch of this suture line, if necessary. RESULTS: We managed 3 cases using this technique. Two cases had severe prior chronic diseases (poorly controlled diabetes and liver cirrhosis, and hemodialysis). In all cases, the lesions were completely exposed in the abdomen by and the ruptured sites were safely and completely sutured under a good field of view. The left thoracic cavity was adequately washed. All cases were saved without lethal complication. One case showed minor leakage, which was easily managed by continuous high pressure aspiration using double luminal drainage system (CHPA-DLD). CONCLUSIONS: We concluded that our technique is useful for esophageal disruption long after the onset, with severe prior chronic diseases, or with pleuritis.

Psychiatric assessment of suicide attempters in Japan: a pilot study at a critical emergency unit in an urban area.

BACKGROUND: The incidence of suicide has increased markedly in Japan since 1998. As psychological autopsy is not generally accepted in Japan, surveys of suicide attempts, an established risk factor of suicide, are highly regarded. We have carried out this study to gain insight into the psychiatric aspects of those attempting suicide in Japan. METHODS: Three hundred and twenty consecutive cases of attempted suicide who were admitted to an urban emergency department were interviewed, with the focus on psychosocial background and DSM-IV diagnosis. Moreover, they were divided into two groups according to the method of attempted suicide in terms of lethality, and the two groups were compared. RESULTS: Ninety-five percent of patients received a psychiatric diagnosis: 81% of subjects met the criteria for an axis I disorder. The most frequent diagnosis was mood disorder. The mean age was higher and living alone more common in the high-lethality group. Middle-aged men tended to have a higher prevalence of mood disorders. CONCLUSION: This is the first large-scale study of cases of attempted suicide since the dramatic increase in suicides began in Japan. The identification and introduction of treatments for psychiatric disorders at emergency departments has been indicated to be important in suicide prevention.

Gastrointestinal fiberscopic findings after simple closure for perforated duodenal ulcer in the early postoperative phase: from experience to evidence by evaluation of the healing process.

BACKGROUND/AIMS: Today, in light of widespread adoption of H2-RA and PPI, the standard surgical procedure for perforated duodenal ulcer (PDU) is simple closure and/or omental patch (SC). However, the healing process after these techniques has not been fully examined. We have not yet confirmed the propriety of simple suture of the bottom of the ulcer. This technique has been performed based only on experience, and there is insufficient evidence to conclude that this procedure can be definitively considered a safe therapeutic technique for the majority of patients with PDU. The aim of this study is to clarify the macroscopic findings of the healing process after SC for PDU. METHODOLOGY: Thirteen patients with PDU who were treated with SC underwent postoperative gastroduodenal fiberscopy (GF) at the 7th-16th postoperative day and the healing process was monitored under sufficient informed consent. Patients with severe preoperative disease were excluded from the study. Healing condition of the ulcer and stitches, deformity, and stenosis were evaluated by postoperative endoscopy. Possible adverse effects that were evaluated included: perforation, rise in fever, worsening of inflammation on laboratory data, gastrointestinal symptoms such as abdominal pain, sense of fullness, and vomiting. The indications for SC were as follows: PDU with 1) no stenosis and 2) no prominent ulcer ridge. The surgical technique was as follows: 1) interrupted simple closure with no trimming and debridement of wound (4-5 stitches) with absorbable monofilament suture, and/or 2) omental patch, 3) administration of H2-RA (or PPI) just after operation, and 4) oral feeding 4-5 days after operation independent of postoperative GF. RESULTS: GF findings in 2 patients showed active and healing stage, in whom surgical technique was thought to be insufficient; the ulcer had been large and included a descending portion, or a small perforation had occurred in the large ulcer bottom (the distance between the stitches and the edge of the ulcer was insufficient). In the other 11 patients, GF findings showed scar phase. There was no morbidity related to endoscopic procedure. CONCLUSIONS: Sutured PDU with SC will be in the scar phase in 1 or 2 weeks. Postoperative GF 1 week after SC for PDU is thought to be a safe examination. This study is a primitive study of a small group, and more cases that can adequately show the frequency of complications and indicate the overall safety of the procedure are needed.

Application of ultrasonography for blunt laryngo-cervical-tracheal injury.

BACKGROUND: Bronchoscopy has been the gold standard for diagnosing blunt laryngo-cervical-tracheal injury (BLCTI); however, BLCTI is often undetected. Ultrasonography (US) is an indispensable tool in the field of critical care and traumatology, but has not been considered useful for evaluation of the airway. The aim of this study was to determine the usefulness of US in the diagnosis of BLCTI. METHODS: To determine the detectability of BLCTI by US, we use a model of cylindrical plastic with a protruding mass made of paste. The model was placed in a water bath and US (3.5-MHz probe) was used to try to detect the mass. RESULTS: We could detect the existence of the mass as a high echoic mass with strongly high echoic tail. We used four patients with BLCTIs whose sites of injury were confirmed by computed tomography (CT) and bronchoscopy. We evaluated the larynx and the cervical trachea as their outline of air in the cranial section near the sternal notch using a 3.5-MHz convex probe. The following US findings were compared with CT and bronchoscopic images as specific findings of BLCTI: discontinuity of the laryngo-cervical-tracheal wall and an abnormal mass protruding into the laryngo-cervical-tracheal lumen. Specific findings of BLCTI were detected in three of the four patients, whose sites of injury were the anterior or lateral side of the larynx or the cervical trachea. The site of injury of the remaining patient, where we detected no specific BLCTI findings, was the posterior wall of the larynx. CONCLUSIONS: US is useful for the diagnosis of BLCTI because it is capable of presenting specific images showing BLCTI features such as discontinuity of the laryngo-cervical-tracheal wall and abnormal masses protruding into the lumen; not only as a single diagnostic tool but one tool with many uses.

Changes in level of consciousness and association with hyperglycemia as tool for predicting and preventing re-bleeding after spontaneous subarachnoid hemorrhage.

INTRODUCTION: It is crucial to predict and prevent re-bleeding from ruptured intracranial aneurysms in patients with subarachnoid hemorrhage (SAH). During the prehospital period and on arrival to the hospital, blood glucose and serum potassium levels, as well as changes in levels of consciousness were assessed in patients in the acute stage of spontaneous subarachnoid hemorrhage. These assessments were analyzed as possible risk factors for re-bleeding and as potential contributors to the prevention of re-bleeding, both in prehospital care and after hospital admission. METHODS: Upon the arrival of 202 patients with spontaneous subarachnoid hemorrhage, the following indications were examined retrospectively: (1) presence/absence of re-bleeding; (2) time interval between the onset of SAH and re-bleeding; (3) level of consciousness using the Glasgow Coma Scale (GCS) score before and on arrival; (4) amount and distribution of subarachnoid blood using Fisher's Computerized Tomography Classification; (5) blood pressure; (6) blood glucose concentration; and (7) serum potassium concentration. The patients were hospitalized in the Yokohama City University Critical Care and Emergency Center (Yokohama, Japan) between January 1991 and December 2000. The re-bleeding rate was analyzed using the chi-square (chi2 test, and the averages and standard deviations of hematological data were compared using the Mann-Whitney U-test. The level of statistical significance was set at p < 0.05. RESULTS: The overall re-bleeding rate was 20.8%. Among 119 patients with a GCS score of 3-7 before arrival, 42 (35.3%) had re-bleeding, but none of the 83 patients with a GCS score of 8-15 before arrival had re-bleeding. Of 105 patients with a GCS score of 13-15 on arrival, 14 (51.8%) of 27 patients whose consciousness level was a GCS score of 3-7 before arrival experienced re-bleeding. The re-bleeding rate of this group was high. Moreover, this rebleeding group had a significantly higher blood glucose concentration than did the patients whose GCS score was 13-15 both before and on arrival. Between the patients with or without re-bleeding, there was no significant difference in the blood pressure on arrival or in distribution according to Fisher's Computerized Tomography Classification CONCLUSION: Since the re-bleeding rate is high in patients who have hyperglycemia and a history of a level of consciousness as low as a GCS score of 3-7, a detailed assessment of level of consciousness and blood glucose tests performed on arrival provide important information that will contribute to predicting and preventing re-bleeding. This may be extended to the prehospital phase, because blood glucose tests are simple and safe when performed by paramedics.