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Gastric mucosal lacerations: A complication of cardiopulmonary resuscitation
ment of an early functional left-ventricular aneurysm after an initial anterior MI is fairly common and carries a high risk of death after 1 year that is independent of ejection fraction. Monica Hauptman, MD
CPR, COMPLICATION, ESOPHAGEALTRAUMA; TRAUMA, ESOPHAGEAL
Gastric muco sal lacerations: A c o m p l i c a t i o n of c a r d i o p u l m o n a r y resuscitation Register SD, Downs JB, Tabeling BB Anesthesiology 62:513-514 Apr 1985
The authors present a case in which a 64-year-old man who underwent external cardiac Compressions for ventricular fibrillation was found ultimately to have sustained a mucosal gastric tear. They state that gastroesophageal trauma is an increasingly recognized complication of CPR. In its first 4 years of clinical use, external cardiac massage was reported to have caused gastric rupture in 3 patients. In 1981, 16 cases of gastric trauma were reported. Only 3 of these patients survived the injury. Since then 5 additional cases have bee n reported. Autopsy series have reported that gastroesophageal trauma occurs in 9% to 12% of patients receiving CPR. Even in the absence of rupture, gastric mucosal lacerations can cause fatal hemorrhage. The mechanism of injury is not clear, but it may relate to pressure gradients between the stomach and the thoracic or abdominal cavities. This could be exacerbated by distention of the stomach w i t h air, as often occurs during ventilation in the acute setting. The authors recommend early skillful intubation, low-pressure ventilation, and immediate gastric decompression to decrease the incidence of gastroesophageal trauma. Postresuscitation gastric suctioning may facilitate diagnosis of any lacerations that m a y have occurred. [Editor's Note: A case report does not a disease make.] Marcus L Denson, MD
TRAUMA, PENETRATING, NECK
Routine versus s e l e c t i v e exploration of penetrating n eck injuries: A ran d om i z ed prospective study Golueke PJ, Gotdstein AS, Sclafani SJA, et al J Trauma 24:1010-1014 Dec 1984
A prospective, randomized study was performed on t60 patients with neck injuries penetrating the platysma muscle. Patients were randomized according to physician preference into either Group A (routine exploration) or Group B 14:10October 1985
[selective management). Clinical indications for exploration included expanding hematoma, active bleeding, pulse deficit , moderate or increasing subcutaneous emphysema, hematemesis, hemoptysis, or hoarseness. Of the 74 patients in Group A, 36 had clinical indications for exploration, 63 were eXplored, and 29 (46%) had negative explorations. Group A patients had an average hospital stay of 7.5 days, a morbidity of 18.9%, and a mortality of 4.0%. Of the 86 patients in Group B, 45 had clinical indications for exploration, 38 were explored, and 8 (21%) had negative explorations. Group B patients had an average hospital stay of 6.4 days, morbidity of 22.0%, and a mortality of 4.6%. Differences in hospital stay, morbidity, and mortality were not statistically significant. There were no delayed operations of missed injuries in the observed patients. The authors conclude that there is no clear advantage to either routine or selective exploration in the management of penetrating neck wounds, and thus treatment should be based on individual surgeon experience, ancillary support service, and operating room availabilitY. Richard E Grazer, MD
ASTHMA, ORAL AGENTS
Comparison of the a c u t e c a r d i o p u l m o n a r y effects of oral albuterol, m e t a p r o t e r e n o l , and t e r b u t a l i n e in a s t h m a t i c s Wolfe JD, Yamate M, Biedermann AA JAMA 253:2068-2072 Apt 12, 1985
The authors compared the acute cardiopulmonary effects of oral albuterol, metaproterenol, and terbutaline in asthmatics. The study was limited to 20 nonsmoking asthmatics who had exhibited reversible airway disease. A randomized, double-blind, three-way crossover design was used. A1! patients were asked to stop medications prior to participation, and they were studied on three different days separated by one-week intervals. Dosages used were albuterol, 4 rag; metaproterenol, 20 rag; and terbutaline, 5 rag. The blood pressure, heart rate, and FEV-1 were recorded at 15 minutes, 30 minutes, and hourly up to 8 hours. The maximal degree of bronchodilation was comparable for all three drugs. Metaproteren01 produced greater improvement in FEV-1 at 30 minutes, indicating a more rapid onset of action. Albuterol and terbutaline significantly produced greater improvement between 6 and 8 hours. There were no significant differences between drugs in heart rate response, but only albuterol and terbutaline lowered diastolic blood pressure from baseline. Although all three drugs exhibited mild side effects, albuterol induced the least. The authors conclude that the likelihood of breakthrough bronchospasm is less with albuterol or terbutaline, especially during 8 hours of sleep. Dosing of these drugs als0 is more convenient than metaproterenol, which requires a mQre frequent schedule. Metaproterenol might be invOked more rationally
Annals of EmergencyMedicine
1028/143
CPR, COMPLICATION, ESOPHAGEALTRAUMA; TRAUMA, ESOPHAGEAL
Gastric muco sal lacerations: A c o m p l i c a t i o n of c a r d i o p u l m o n a r y resuscitation Register SD, Downs JB, Tabeling BB Anesthesiology 62:513-514 Apr 1985
The authors present a case in which a 64-year-old man who underwent external cardiac Compressions for ventricular fibrillation was found ultimately to have sustained a mucosal gastric tear. They state that gastroesophageal trauma is an increasingly recognized complication of CPR. In its first 4 years of clinical use, external cardiac massage was reported to have caused gastric rupture in 3 patients. In 1981, 16 cases of gastric trauma were reported. Only 3 of these patients survived the injury. Since then 5 additional cases have bee n reported. Autopsy series have reported that gastroesophageal trauma occurs in 9% to 12% of patients receiving CPR. Even in the absence of rupture, gastric mucosal lacerations can cause fatal hemorrhage. The mechanism of injury is not clear, but it may relate to pressure gradients between the stomach and the thoracic or abdominal cavities. This could be exacerbated by distention of the stomach w i t h air, as often occurs during ventilation in the acute setting. The authors recommend early skillful intubation, low-pressure ventilation, and immediate gastric decompression to decrease the incidence of gastroesophageal trauma. Postresuscitation gastric suctioning may facilitate diagnosis of any lacerations that m a y have occurred. [Editor's Note: A case report does not a disease make.] Marcus L Denson, MD
TRAUMA, PENETRATING, NECK
Routine versus s e l e c t i v e exploration of penetrating n eck injuries: A ran d om i z ed prospective study Golueke PJ, Gotdstein AS, Sclafani SJA, et al J Trauma 24:1010-1014 Dec 1984
A prospective, randomized study was performed on t60 patients with neck injuries penetrating the platysma muscle. Patients were randomized according to physician preference into either Group A (routine exploration) or Group B 14:10October 1985
[selective management). Clinical indications for exploration included expanding hematoma, active bleeding, pulse deficit , moderate or increasing subcutaneous emphysema, hematemesis, hemoptysis, or hoarseness. Of the 74 patients in Group A, 36 had clinical indications for exploration, 63 were eXplored, and 29 (46%) had negative explorations. Group A patients had an average hospital stay of 7.5 days, a morbidity of 18.9%, and a mortality of 4.0%. Of the 86 patients in Group B, 45 had clinical indications for exploration, 38 were explored, and 8 (21%) had negative explorations. Group B patients had an average hospital stay of 6.4 days, morbidity of 22.0%, and a mortality of 4.6%. Differences in hospital stay, morbidity, and mortality were not statistically significant. There were no delayed operations of missed injuries in the observed patients. The authors conclude that there is no clear advantage to either routine or selective exploration in the management of penetrating neck wounds, and thus treatment should be based on individual surgeon experience, ancillary support service, and operating room availabilitY. Richard E Grazer, MD
ASTHMA, ORAL AGENTS
Comparison of the a c u t e c a r d i o p u l m o n a r y effects of oral albuterol, m e t a p r o t e r e n o l , and t e r b u t a l i n e in a s t h m a t i c s Wolfe JD, Yamate M, Biedermann AA JAMA 253:2068-2072 Apt 12, 1985
The authors compared the acute cardiopulmonary effects of oral albuterol, metaproterenol, and terbutaline in asthmatics. The study was limited to 20 nonsmoking asthmatics who had exhibited reversible airway disease. A randomized, double-blind, three-way crossover design was used. A1! patients were asked to stop medications prior to participation, and they were studied on three different days separated by one-week intervals. Dosages used were albuterol, 4 rag; metaproterenol, 20 rag; and terbutaline, 5 rag. The blood pressure, heart rate, and FEV-1 were recorded at 15 minutes, 30 minutes, and hourly up to 8 hours. The maximal degree of bronchodilation was comparable for all three drugs. Metaproteren01 produced greater improvement in FEV-1 at 30 minutes, indicating a more rapid onset of action. Albuterol and terbutaline significantly produced greater improvement between 6 and 8 hours. There were no significant differences between drugs in heart rate response, but only albuterol and terbutaline lowered diastolic blood pressure from baseline. Although all three drugs exhibited mild side effects, albuterol induced the least. The authors conclude that the likelihood of breakthrough bronchospasm is less with albuterol or terbutaline, especially during 8 hours of sleep. Dosing of these drugs als0 is more convenient than metaproterenol, which requires a mQre frequent schedule. Metaproterenol might be invOked more rationally
Annals of EmergencyMedicine
1028/143