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The role of concentrated sodium solutions in the resuscitation of patients with severe burns
The Journal of Emergency Medicine
is unable to remain immobile during scanning. Patients on mechanical life support cannot be scanned because the technique prohibits the presence of metallic and electrical devices in the scanning area. Furthermore, NMR scanners cannot visualize compact bone and therefore may not detect bony fragments lodged in the brain. The authors conclude that the superb sensitivity of NMR imaging makes it a useful adjunct to CT scanning in selected patients with head trauma. [Richard J. Pawl, MD]
[] HYPEREXTENSION T R A U M A IN THE ELDERLY: A N E A S I L Y O V E R L O O K E D SPINAL INJURY. Scher AT. J Trauma 1984; 23:1066-1068; This article reports the case of a middle-aged man who developed upper extremity weakness and patchy sensory loss after falling and striking his head. Because of the "bizarre" neurolog• ic findings, hysteria was considered in the initial diagnosis. Subsequently, central cord syndrome secondary to hyperextension injury of the cervical spine was made. Cervical spondylosis in middle-aged and elderly patients causes degeneration of intervertebral discs and weakening of the anterior longitudina ! ligament. Weakening and rupture of the ligamentous-supporting structures allows posterior displacement of the vertebral bodies (with or without facture) after apparently minor injury, usually hyperextension. Hemorrhage into the central grey matter of the cord affects predominantly the centrally located arm tracts and to a lesser extent the leg tracts. Loss of voluntary bladder control, urinary retention, and patchy sensory loss are common. Cervical spine x-rays may show spondylosis, osteophytes, hemorrhage into the prevertebral soft-tissue, space or abnormal widening of an intervertebral disc space. Because of the nonradicular neurologic findings and x-rays that may not show bony damage, this condition is often erroneously diagnosed as malingering or hysteria. The possibility of soft-tissue injury with ligamentous instability must be remembered, particularly in elderly patients with cervical spondylosis and a history of hyperextension injury. The author suggests that a cross table lateral view of the cervical spine is a safe, quick, and inexpensive screening exam for victims of head injury. [G. D. Innes, MD] Editor's Note: Nevertheless, lateral C-spine studies in this condition may be hard to inter-
pret. It is safest to assume neurologic lesions in the context of trauma whatever the interpretation of the x-rays.
[] THE ROLE OF CONCENTRATED SODIUM SOLUTIONS IN THE RESUSCITATION OF PATIENTS W I T H SEVERE BURNS. Monafo WW, Halverson J, Schechtman K. Surgery 1984; 95:129-134. A prospective study was done to determine the relationship between sodium and water loads required for resuscitation of severely burned patients. Seventy-four patients who had sustained thermal burns of at least 40°70 body surface area within the previous six hours were included in the study. Solutions of either hypertonic lactated saline (HLS) or lactated Ringer's (LR) were used. No colloid solution was used. Fluids were adjusted to maintain a urine output of 0.5 to 1.0 m L / k g / h r . The volume and average sodium concentration of all fluids administered during each of the first two days were calculated. Patients were then divided into three groups based on the average sodium concentration of fluids administered during the first 24 hours. The sodium concentrations ranged from 116 to 250 mEq/L. During the first 24 hours, 21 patients received fluids containing less than 150 mEq sodium/L, mostly lactated Ringer's solution; 31 patients received fluid containing greater than 199 mEq sodium/L. Twenty-two patients received solutions of intermediate saline concentration ( 150-199 mEq/L). Patients receiving primarily LR solution required 4407o more fluid during the first 24 hours than those receiving primarily HLS. During the second day, no intergroup differences in sodium or water load existed. Water and sodium requirements increased with age and extent of burn. Thirty-one patients died. At both 24 and 48 hours survivors had received significantly smaller loads of sodium and water than nonsurvivors. The use of concentrated sodium solutions did not increase the sodium requirement. Water loads, however, were much lower in patients receiving more concentrated solutions. The authors conclude that increasing the sodium content of administered fluid might enhance survival of severely burned patients. [Karen Curran, X~D] Editor's Note: This work supports that of Jelenko who combined hypertonic solutions with albumin as a colloid. Proponents in the past lost enthusiasm for the hypertonic solutions
Abstracts
because of a higher incidence of renal shut down but it would appear that this was not a problem in the preceding nor in Jelenko's series.
[] PROSPECTIVE ASSESSMENT OF RECURRENCE RISK IN S U D D E N INFANT DEATH SYNDROME SIBLINGS. Irgens LM, Skjaerven R, Peterson DR. JPediatr 1984; 104: 349-351. This prospective Norwegian study attempts to estimate the risk of recurrence of sudden infant death syndrome (SIDS) in siblings. Records of 826,162 Norwegian babies born from 1967 through 1980 who survived the first week of life form the data base of this report. Of these infants, 3,582 died during the postperinatal period; 1,062 were deemed SIDS victims. The incidence of SIDS in this group was 1.3 per 1,000. The first SIDS victim in each family was then defined as the index case. Children born to the same mother subsequent to the index case were considered to be at risk for SIDS. Of the 712 children born immediately following the index case (next subsequent sibling), eight died. SIDS was determined to be the cause of death in four, an incidence of 5.6 per 1,000. Altogether 1,043 children were born after the index case, 5 of which died from SIDS (4.8 per 1,000). The authors conclude that although the occurrence of SIDS is greater in siblings of SIDS victims, the rate is lower than that previously reported. The incidence of SIDS in Norway is lower than that reported in other countries. Although the relative risk is valid, the extent that these findings apply to other countries is difficult to assess and further studies are warranted. [Esequiel C. Guevara, rao]
[] C H L O R A M P H E N I C O L TOXICITY IN NEONATES: ITS INCIDENCE AND PREVENTION. Mulhall A, deLouvois J, Hurley R. Br Med J 1983; 287:1424-1427. Chloramphenicol toxicity may be manifested as grey baby syndrome, hemopoietic disturbances, or idiopathic marrow aplasia. Its use is still indicated for the treatment of life-threatening infections, however, particularly neonatal meningitis. The authors investigated the incidence of chloramphenicol toxicity in 64 neonates, 10% of whom had clinical signs of toxicity (six with grey baby syndrome and four with hematologic reactions). All 10 infants had
serum concentrations above the therapeutic range (15-25 mg/L). An additional 27 neonates were also found to have levels in the toxic range but were without clinical evidence of toxicity. No patient in the therapeutic range was clinically toxic. There were no patients with idiopathic marrow aplasia, a form of chloramphenicol toxicity that is not dose related and is unpredictable, irreversible, and often fatal. The authors emphasize careful prescribing and monitoring of serum concentrations to assure therapeutic goals without toxicity. [Elizabeth Mueller, MD] Editor's Note: This paper provides helpful dosage and monitoring guidelines for use of an effective, but potentially toxic antibiotic.
[] THE EFFECT OF PENICILLIN THERAPY ON THE SYMPTOMS A N D SIGNS OF STREPTOCOCCAL PHARYNGITIS. Nelson JD. Pediatr Infect Dis 1984; 3:10-13. The effect of penicillin to ameliorate the symptoms of streptococcal pharyngitis has long been debated. This controlled randomized study measures the effect of penicillin and placebo on the resolution of symptoms of pharyngitis caused by Group A streptococcus. Fifty children aged 5 years or older with an acute illness characterized by at least four of six features (sore throat, fever, pharyngeal injection, tonsillar exudate, dysphonia, enlarged and tender cervical lymph nodes) were studied. A throat culture was obtained from each patient. Patients then received either intramuscular penicillin (n = 25) or oral placebo (n = 26) and were evaluated during a return visit at 48 hours. Throat cultures grew Group A streptococcus in 17 treated children and 18 control patients. The remaining 16 patients with negative throat cultures were excluded from analysis. At the 48-hour return visit, significantly more children in the treated group had resolution of pharyngeal injection and cervical adenopathy than control patients. The speed of resolution of pharyngeal exudate and cessation of fever were not significantly different in the two groups. Subjectively, parents considered their children to be improved and completely well significantly sooner in the penicillin-treated group. The authors conclude that their data suggest a favorable and prompt improvement in the symptoms of streptococcal pharyngitis in penicillin-treated children. The common practice of withholding antibiotic therapy for 24 to 48 hours
is unable to remain immobile during scanning. Patients on mechanical life support cannot be scanned because the technique prohibits the presence of metallic and electrical devices in the scanning area. Furthermore, NMR scanners cannot visualize compact bone and therefore may not detect bony fragments lodged in the brain. The authors conclude that the superb sensitivity of NMR imaging makes it a useful adjunct to CT scanning in selected patients with head trauma. [Richard J. Pawl, MD]
[] HYPEREXTENSION T R A U M A IN THE ELDERLY: A N E A S I L Y O V E R L O O K E D SPINAL INJURY. Scher AT. J Trauma 1984; 23:1066-1068; This article reports the case of a middle-aged man who developed upper extremity weakness and patchy sensory loss after falling and striking his head. Because of the "bizarre" neurolog• ic findings, hysteria was considered in the initial diagnosis. Subsequently, central cord syndrome secondary to hyperextension injury of the cervical spine was made. Cervical spondylosis in middle-aged and elderly patients causes degeneration of intervertebral discs and weakening of the anterior longitudina ! ligament. Weakening and rupture of the ligamentous-supporting structures allows posterior displacement of the vertebral bodies (with or without facture) after apparently minor injury, usually hyperextension. Hemorrhage into the central grey matter of the cord affects predominantly the centrally located arm tracts and to a lesser extent the leg tracts. Loss of voluntary bladder control, urinary retention, and patchy sensory loss are common. Cervical spine x-rays may show spondylosis, osteophytes, hemorrhage into the prevertebral soft-tissue, space or abnormal widening of an intervertebral disc space. Because of the nonradicular neurologic findings and x-rays that may not show bony damage, this condition is often erroneously diagnosed as malingering or hysteria. The possibility of soft-tissue injury with ligamentous instability must be remembered, particularly in elderly patients with cervical spondylosis and a history of hyperextension injury. The author suggests that a cross table lateral view of the cervical spine is a safe, quick, and inexpensive screening exam for victims of head injury. [G. D. Innes, MD] Editor's Note: Nevertheless, lateral C-spine studies in this condition may be hard to inter-
pret. It is safest to assume neurologic lesions in the context of trauma whatever the interpretation of the x-rays.
[] THE ROLE OF CONCENTRATED SODIUM SOLUTIONS IN THE RESUSCITATION OF PATIENTS W I T H SEVERE BURNS. Monafo WW, Halverson J, Schechtman K. Surgery 1984; 95:129-134. A prospective study was done to determine the relationship between sodium and water loads required for resuscitation of severely burned patients. Seventy-four patients who had sustained thermal burns of at least 40°70 body surface area within the previous six hours were included in the study. Solutions of either hypertonic lactated saline (HLS) or lactated Ringer's (LR) were used. No colloid solution was used. Fluids were adjusted to maintain a urine output of 0.5 to 1.0 m L / k g / h r . The volume and average sodium concentration of all fluids administered during each of the first two days were calculated. Patients were then divided into three groups based on the average sodium concentration of fluids administered during the first 24 hours. The sodium concentrations ranged from 116 to 250 mEq/L. During the first 24 hours, 21 patients received fluids containing less than 150 mEq sodium/L, mostly lactated Ringer's solution; 31 patients received fluid containing greater than 199 mEq sodium/L. Twenty-two patients received solutions of intermediate saline concentration ( 150-199 mEq/L). Patients receiving primarily LR solution required 4407o more fluid during the first 24 hours than those receiving primarily HLS. During the second day, no intergroup differences in sodium or water load existed. Water and sodium requirements increased with age and extent of burn. Thirty-one patients died. At both 24 and 48 hours survivors had received significantly smaller loads of sodium and water than nonsurvivors. The use of concentrated sodium solutions did not increase the sodium requirement. Water loads, however, were much lower in patients receiving more concentrated solutions. The authors conclude that increasing the sodium content of administered fluid might enhance survival of severely burned patients. [Karen Curran, X~D] Editor's Note: This work supports that of Jelenko who combined hypertonic solutions with albumin as a colloid. Proponents in the past lost enthusiasm for the hypertonic solutions
Abstracts
because of a higher incidence of renal shut down but it would appear that this was not a problem in the preceding nor in Jelenko's series.
[] PROSPECTIVE ASSESSMENT OF RECURRENCE RISK IN S U D D E N INFANT DEATH SYNDROME SIBLINGS. Irgens LM, Skjaerven R, Peterson DR. JPediatr 1984; 104: 349-351. This prospective Norwegian study attempts to estimate the risk of recurrence of sudden infant death syndrome (SIDS) in siblings. Records of 826,162 Norwegian babies born from 1967 through 1980 who survived the first week of life form the data base of this report. Of these infants, 3,582 died during the postperinatal period; 1,062 were deemed SIDS victims. The incidence of SIDS in this group was 1.3 per 1,000. The first SIDS victim in each family was then defined as the index case. Children born to the same mother subsequent to the index case were considered to be at risk for SIDS. Of the 712 children born immediately following the index case (next subsequent sibling), eight died. SIDS was determined to be the cause of death in four, an incidence of 5.6 per 1,000. Altogether 1,043 children were born after the index case, 5 of which died from SIDS (4.8 per 1,000). The authors conclude that although the occurrence of SIDS is greater in siblings of SIDS victims, the rate is lower than that previously reported. The incidence of SIDS in Norway is lower than that reported in other countries. Although the relative risk is valid, the extent that these findings apply to other countries is difficult to assess and further studies are warranted. [Esequiel C. Guevara, rao]
[] C H L O R A M P H E N I C O L TOXICITY IN NEONATES: ITS INCIDENCE AND PREVENTION. Mulhall A, deLouvois J, Hurley R. Br Med J 1983; 287:1424-1427. Chloramphenicol toxicity may be manifested as grey baby syndrome, hemopoietic disturbances, or idiopathic marrow aplasia. Its use is still indicated for the treatment of life-threatening infections, however, particularly neonatal meningitis. The authors investigated the incidence of chloramphenicol toxicity in 64 neonates, 10% of whom had clinical signs of toxicity (six with grey baby syndrome and four with hematologic reactions). All 10 infants had
serum concentrations above the therapeutic range (15-25 mg/L). An additional 27 neonates were also found to have levels in the toxic range but were without clinical evidence of toxicity. No patient in the therapeutic range was clinically toxic. There were no patients with idiopathic marrow aplasia, a form of chloramphenicol toxicity that is not dose related and is unpredictable, irreversible, and often fatal. The authors emphasize careful prescribing and monitoring of serum concentrations to assure therapeutic goals without toxicity. [Elizabeth Mueller, MD] Editor's Note: This paper provides helpful dosage and monitoring guidelines for use of an effective, but potentially toxic antibiotic.
[] THE EFFECT OF PENICILLIN THERAPY ON THE SYMPTOMS A N D SIGNS OF STREPTOCOCCAL PHARYNGITIS. Nelson JD. Pediatr Infect Dis 1984; 3:10-13. The effect of penicillin to ameliorate the symptoms of streptococcal pharyngitis has long been debated. This controlled randomized study measures the effect of penicillin and placebo on the resolution of symptoms of pharyngitis caused by Group A streptococcus. Fifty children aged 5 years or older with an acute illness characterized by at least four of six features (sore throat, fever, pharyngeal injection, tonsillar exudate, dysphonia, enlarged and tender cervical lymph nodes) were studied. A throat culture was obtained from each patient. Patients then received either intramuscular penicillin (n = 25) or oral placebo (n = 26) and were evaluated during a return visit at 48 hours. Throat cultures grew Group A streptococcus in 17 treated children and 18 control patients. The remaining 16 patients with negative throat cultures were excluded from analysis. At the 48-hour return visit, significantly more children in the treated group had resolution of pharyngeal injection and cervical adenopathy than control patients. The speed of resolution of pharyngeal exudate and cessation of fever were not significantly different in the two groups. Subjectively, parents considered their children to be improved and completely well significantly sooner in the penicillin-treated group. The authors conclude that their data suggest a favorable and prompt improvement in the symptoms of streptococcal pharyngitis in penicillin-treated children. The common practice of withholding antibiotic therapy for 24 to 48 hours