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Minor leak before rupture of an intracranial aneurysm and subarachnoid hemorrhage of unknown etiology
ABSTRACTS
48 hours, and seven days. Follow-up was successful in all but one patient (99.8%). Twenty-seven(5.4%) of the 503 infants enrolled in the study were identified as having serious bacterial infections. Nine (1.8%) patients had bacteremia,eight (1.6%) had urinary tract infections without bacteremia,and ten (2.0%) had bacterial gastroenteritis without bacteremia. Clinical screeningcriteria could not distinguish between infants with or without serious bacterial infections. However,all 27 infants with serious bacterial infections receivedappropriate antibiotic therapy and were well at follow-up. Twenty-six of 27 bacterial pathogens were susceptibleto ceftriaxone (one urinary Streptococcus faecalis isolate was resistant). No complications from ceftriaxone administration were documentedafter seven days of follow-up. After full septic evaluation with strict follow-up protocols and pending results of cultures, the authors concludedthat outpatient therapy with ceftriaxone is a safe alternative to hospital admission. Ted G Lawson, MD
cerebral aneurysm;subarachnoid hemorrhage
Minor leak before rupture of an intracranial aneurysm and subarachnoid hemorrhage of unknown etiology Juvela S Neurosurgery30:7-11 Jan 1992
studied. Two hundredseventy-three patients had a ruptured aneurysm; they did not differ from the 30 patients with nonaneurysmalsubarachnoidhemorrhagewith respect to epidemiologicdata but did have significantly worse outcome. Eighteen of 297 (6%) patients had a normal CT scan on admission. Patients and their families were questionedabout previoussymptoms consistent with minor leaks: generalizedor localizedheadacheof acute onset with or without nausea, vomiting, or oculomotorpalsy. One hundred of 273 patients (36.6%) with aneurysmalsubarachnoidhemorrhage had a history of symptoms suggestive of premonitory minor leaks, comparedwith four of 30 (13.3%) with subarachnoidhemorrhage of unknown etiology (P< .05). The time between minor leak and major rupture rangedfrom one day to four months; 50% were five to 18 days between episodes.The authors conclude that aneurysmalsubarachnoid hemorrhageis often preceded by a minor leak; if the symptoms are recognizedby the patient and physician, outcome may be improved significantly by elimination of the aneurysm before major rupture occurs. Normal CT scan does not exclude subarachnoidhemorrhage. [Editor's note: Although not a new concept, this article underscores the importance of evaluating patients for a minor premonitory leak in possible aneurysmal subarachnoidhemorrhage with CTscan and lumbar puncture if the CTscan is negative.] Patricia D Logan, MD
CPR
cardiac arrest
A study of chest compression rates during cardiopulmonary resuscitation in humans
Case and survival definitions in outof-hospital cardiac
Kern KB, SandersAn, Raife J, et al Arch Intern Med 152:145-149 Jan 1992 In this prospective,crossovertrial, the authors examinedthe effect on end-tidal carbon dioxide production of 80 and 120 compressionper minute CPR.In addition, the use of an audio tone to prompt compression at the appropriate rate also was examined.A total of 23 cardiac arrest patients were enrolled in the study. A mean end-tidal carbon dioxide of 15.0 + 1.8 mm Hg was obtained with 120 compressionsper minute. A compressionrate of 80 per minute yielded an end-tidal carbon dioxideof 13.0+1.8 mm Hg (P< .01). The use of audio tones produceda significant increasein end-tidal carbon dioxide from 8.7 +1.2 mm Hg to 14.0+1.3 mm Hg (P< .01). The authors concludethat a higher compression rate and the use of audio tone prompting may improve CPR performanceand, therefore, outcome. [Editor's note: The important finding of this study is not the rather stoat difference in end-tidal carbon dioxide producedby a faster compression rate, Which is of questionable clinical significance, but rather the more dramatic improvementin end-tidal carbon dioxide with audible tone rate guidance.]
arrest Valenzuela TD, Spaite DW, Meisfin HW, et al JAMA 267.272-274 Jan 1992 The authors' objective was to determine how survival rates were affected by using various definitions of arrest type and survival. Three hundred seventy-two adult patients suffering out-of-hospital cardiac arrest were included.Calculated survival rates were based on three definitions of arrest and two definitions of survival. Arrest definitions were cardiac arrest, witnessed cardiac arrest, and witnessed cardiac arrest with initial rhythm of ventricular fibrillation. Survival categories were survival to hospital admission and survival to hospital discharge. Survival rates varied from 6% for undifferentiated arrest victims alive at dischargeto 38% for witnessed arrest victims in ventricular fibrillation who were alive at admission. The authors assert that uniform definitions of arrest and survival must be adoptedto allow comparison between different studies. They recommendadoption of the uniform definitions presentedby the 1990 Utstein ConsensusConference. Michael J Nelson, MD
Scott McCufloch, MD
Subarachnoidhemorrhagefrom aneurysm carries high morbidity and mortality. Warning signs suggestive of a minor premonitory leak, if recognized, may allow diagnosis of aneurysm and operative repair before a major bleeding episode. Three hundredthree cases of subarachnoidhemorrhagediagnosedby computed tomography(CT)scan, lumbar puncture, or at autopsywere
158/766
ANNALS OF EMERGENCY MEDICINE 2 1 : 6 JUNE1992
48 hours, and seven days. Follow-up was successful in all but one patient (99.8%). Twenty-seven(5.4%) of the 503 infants enrolled in the study were identified as having serious bacterial infections. Nine (1.8%) patients had bacteremia,eight (1.6%) had urinary tract infections without bacteremia,and ten (2.0%) had bacterial gastroenteritis without bacteremia. Clinical screeningcriteria could not distinguish between infants with or without serious bacterial infections. However,all 27 infants with serious bacterial infections receivedappropriate antibiotic therapy and were well at follow-up. Twenty-six of 27 bacterial pathogens were susceptibleto ceftriaxone (one urinary Streptococcus faecalis isolate was resistant). No complications from ceftriaxone administration were documentedafter seven days of follow-up. After full septic evaluation with strict follow-up protocols and pending results of cultures, the authors concludedthat outpatient therapy with ceftriaxone is a safe alternative to hospital admission. Ted G Lawson, MD
cerebral aneurysm;subarachnoid hemorrhage
Minor leak before rupture of an intracranial aneurysm and subarachnoid hemorrhage of unknown etiology Juvela S Neurosurgery30:7-11 Jan 1992
studied. Two hundredseventy-three patients had a ruptured aneurysm; they did not differ from the 30 patients with nonaneurysmalsubarachnoidhemorrhagewith respect to epidemiologicdata but did have significantly worse outcome. Eighteen of 297 (6%) patients had a normal CT scan on admission. Patients and their families were questionedabout previoussymptoms consistent with minor leaks: generalizedor localizedheadacheof acute onset with or without nausea, vomiting, or oculomotorpalsy. One hundred of 273 patients (36.6%) with aneurysmalsubarachnoidhemorrhage had a history of symptoms suggestive of premonitory minor leaks, comparedwith four of 30 (13.3%) with subarachnoidhemorrhage of unknown etiology (P< .05). The time between minor leak and major rupture rangedfrom one day to four months; 50% were five to 18 days between episodes.The authors conclude that aneurysmalsubarachnoid hemorrhageis often preceded by a minor leak; if the symptoms are recognizedby the patient and physician, outcome may be improved significantly by elimination of the aneurysm before major rupture occurs. Normal CT scan does not exclude subarachnoidhemorrhage. [Editor's note: Although not a new concept, this article underscores the importance of evaluating patients for a minor premonitory leak in possible aneurysmal subarachnoidhemorrhage with CTscan and lumbar puncture if the CTscan is negative.] Patricia D Logan, MD
CPR
cardiac arrest
A study of chest compression rates during cardiopulmonary resuscitation in humans
Case and survival definitions in outof-hospital cardiac
Kern KB, SandersAn, Raife J, et al Arch Intern Med 152:145-149 Jan 1992 In this prospective,crossovertrial, the authors examinedthe effect on end-tidal carbon dioxide production of 80 and 120 compressionper minute CPR.In addition, the use of an audio tone to prompt compression at the appropriate rate also was examined.A total of 23 cardiac arrest patients were enrolled in the study. A mean end-tidal carbon dioxide of 15.0 + 1.8 mm Hg was obtained with 120 compressionsper minute. A compressionrate of 80 per minute yielded an end-tidal carbon dioxideof 13.0+1.8 mm Hg (P< .01). The use of audio tones produceda significant increasein end-tidal carbon dioxide from 8.7 +1.2 mm Hg to 14.0+1.3 mm Hg (P< .01). The authors concludethat a higher compression rate and the use of audio tone prompting may improve CPR performanceand, therefore, outcome. [Editor's note: The important finding of this study is not the rather stoat difference in end-tidal carbon dioxide producedby a faster compression rate, Which is of questionable clinical significance, but rather the more dramatic improvementin end-tidal carbon dioxide with audible tone rate guidance.]
arrest Valenzuela TD, Spaite DW, Meisfin HW, et al JAMA 267.272-274 Jan 1992 The authors' objective was to determine how survival rates were affected by using various definitions of arrest type and survival. Three hundred seventy-two adult patients suffering out-of-hospital cardiac arrest were included.Calculated survival rates were based on three definitions of arrest and two definitions of survival. Arrest definitions were cardiac arrest, witnessed cardiac arrest, and witnessed cardiac arrest with initial rhythm of ventricular fibrillation. Survival categories were survival to hospital admission and survival to hospital discharge. Survival rates varied from 6% for undifferentiated arrest victims alive at dischargeto 38% for witnessed arrest victims in ventricular fibrillation who were alive at admission. The authors assert that uniform definitions of arrest and survival must be adoptedto allow comparison between different studies. They recommendadoption of the uniform definitions presentedby the 1990 Utstein ConsensusConference. Michael J Nelson, MD
Scott McCufloch, MD
Subarachnoidhemorrhagefrom aneurysm carries high morbidity and mortality. Warning signs suggestive of a minor premonitory leak, if recognized, may allow diagnosis of aneurysm and operative repair before a major bleeding episode. Three hundredthree cases of subarachnoidhemorrhagediagnosedby computed tomography(CT)scan, lumbar puncture, or at autopsywere
158/766
ANNALS OF EMERGENCY MEDICINE 2 1 : 6 JUNE1992