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9: A Comparison of the USCOM Cardiac Output Monitor With Base Excess for Detecting Occult Hypoperfusion in Emergency Department Trauma Patients
ICEM 2008 Scientific Abstract Program
7
Serum S-100b Protein and Neuron-specific Enolase Concentrations in Patients With Carbon Monoxide Poisoning
Yardan T, Cevik Y, Donderici O, Kavalci C, Yilmaz FM, Yilmaz G, Vural K, Yuzbasioglu Y, Gunaydin YK, Sezer AA/Ondokuzmayis University, Samsun, Turkey; Ankara Education and Research Hospital, Ankara, Turkey
Study Objectives: Carbon monoxide poisoning occurs in cerebral and generalized hypoxia. The aim of the study was to assess the possible use of serum glial markers S-100B protein and neuron-specific enolase as a biochemical marker of ischemic brain injury in acute carbon monoxide poisoning. Methods: Patients with acute carbon monoxide poisoning admitted to Emergency Services of two Education and Research Hospitals (Ankara, Turkey) were included in this prospective study. Serum levels of S-100B protein and neuronspecific enolase were measured on admission. As a control group, twenty healthy adult were included the study. The patients were divided into two groups (unconscious and not unconscious) on admission. Results: Seventy patients diagnosed as carbon monoxide poisoning (mean age, 36.6⫾16.3 years; 64.3% women) were enrolled in this study. S-100B concentrations in the patient group were significantly higher than the control group (p⫽0.018). Serum neuron-specific enolase concentrations were not statistically different in between the patient group and the control group (p⫽0.0.801). There was a positive correlation between levels of S-100B and neuron-specific enolase (r⫽0.388, p⫽0.001). There were thirteen unconscious patients on admission. Values of S-100B and neuron-specific enolase were significantly higher in patients who had been unconscious than not unconscious, respectively (p⫽0.047 and p⫽0.005). In the unconscious patients, there was no significant difference levels of S-100B protein and neuron-specific enolase between who were treated with normobaric oxygen and hyperbaric oxygen, respectively (p⫽0.106 and p⫽0.825). Conclusion: Increased S-100B protein and neuron-specific enolase concentrations are related with consciousness in patients with carbon monoxide poisoning. Serum S-100B and neuron-specific enolase may be useful markers in assessment of carbon monoxide induced acute brain damage in emergency clinical practice.
8
Flumazenil Revisited
Williams JS, Lee MA, Schauben J, Nasca L, Kalynynch C/University of Florida, Jacksonville, FL
Study Objectives: Flumazenil is a benzodiazepine antagonist that carries a perceived seizure risk which often limits its use by practitioners. We analyzed cases from three poison centers comprising the Florida Poison Information Center Network (FPICN) for flumazenil use in managing patients with altered mental status from a suspected overdose of benzodiazepines. Methods: This IRB approved, retrospective review was performed on cases obtained from the FPICN statewide database between 2000 and 2006 involving flumazenil use. Cases were identified by querying the database of closed/completed cases utilizing search filters for flumazenil, seizure (single, multiple, discrete, or status), muscle rigidity, dystonia, and tremor. The poison center data was collected by Specialists in Poison Information (SPIs) and toxicologists at each of the American Association of Poison Control Center (AAPCC) certified Florida centers. The study was approved by the institutional review board and the FPICN administration (centers located in Jacksonville, Miami, and Tampa). Results: During the years 2000-2006, there were 837 recorded uses of flumazenil in patients with suspected overdose reported to the FPICN. Of those, 25 cases were identified as having either seizure, muscle rigidity, dystonia, or tremor associated with the use of the antagonist. These included 4 patients who had a seizure after flumazenil use, 1 patient with seizure activity before and after flumazenil use, 1 patient with dystonia after flumazenil use (relieved by benadryl alone), 3 patients that had seizure activity greater than 3 hours after flumazenil was administered, and 6 patients that had seizures before, but not after flumazenil use. Further, there were 10 cases where flumazenil-associated seizure risk was discussed with the providers, but no adverse event including seizure reported by the SPIs. Of note, co-ingestion with tricyclic antidepressants (TCAs) was reported in 32 cases (out of the 837 total cases). Of these, there was 1 documented case of seizure; however, this occurred greater than 10 hours after flumazenil was given. Given the short duration of action of flumazenil (30-45
Volume , . : April
minutes), it would be unlikely that the flumazenil induced the seizure. All of the reported seizures were either controlled with conventional therapy or resolved spontaneously. There were no reported status epilepticus or uncontrolled seizure events. In summary, this retrospective review revealed a small incidence of flumazenilassociated seizures or dystonia in 0.6% (5/837) of patients. Removing the dystonic reaction would make the occurrence even lower (0.5% 4/837). There were no deaths reported from flumazenil use. Conclusion: Despite the reputation of flumazenil use being associated with seizures, this phenomenon remains rare in our review. In fact, seizures, muscle rigidity, dystonia, and tremors were infrequent events associated with flumazenil use in patients with suspected overdose from benzodiazepines.
9
A Comparison of the USCOM Cardiac Output Monitor With Base Excess for Detecting Occult Hypoperfusion in Emergency Department Trauma Patients
Thom O, Taylor DM, Wolfe R, Judson RT, Myles P, Krum H, Wolfe R/Box Hill Hospital, Melbourne, Australia; Austin Hospital, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia; Monash University, Melbourne, Australia
Background: Occult hypoperfusion (OH) (as indicated by a low base excess in the presence of normal vital signs) is a significant problem in trauma patients admitted to the Intensive Care Unit. It is associated with increased length of stay (LOS) and increased mortality. We do not know the prevalence of this problem in the Emergency Department (ED) setting nor its impact on patient outcome. Study Objectives: To establish the proportion of adult trauma patients presenting to a level 1 trauma center (Royal Melbourne Hospital [RMH]) who have OH and the impact this has on outcome. Also, to compare two methods of detecting OH - base excess (BE) on arterial blood gas and cardiac index (CI) obtained by the USCOMTM, a continuous wave Doppler ultrasound cardiac output monitor. Methods: Over a nine-month period, trauma patients meeting the Victorian Trauma Registry entrance criteria who presented to the RMH with normal vital signs (SBP ⬎ 100 mmHg, HR ⬍ 110 bpm) were enrolled. Each had CI obtained half hourly as clinically allowed for the first four hours of admission. This was compared with BE obtained from clinically indicated blood gases. Occult hypoperfusion was defined as CI ⬍ 2.6 l/min/m2 or BE ⬍ ⫺3. Results: Results are given (⫾ SD) unless indicated. Sixty two patients were enrolled. There were 49 males (79.0%), mean age was 49 years (range 18-91), mean Injury Severity Score 19 (⫾ 11), mean time in ED 417 (⫾ 294) minutes and mean hospital LOS was 10 (⫾ 8) days. There were 37 (59.6%) major trauma patients and two patients (3.2%) died in hospital. Ten patients (16.1%) had OH detected by the USCOM, seven (11.2%) by BE. The methods agreed on four patients. USCOM detected OH in one of the two patients who died, BE detected OH in both. Wilcoxon Rank Sum Test showed a significant association between hospital LOS and OH detected by base excess (Z ⫽ ⫺2.818, P ⫽ 0.005), but not by USCOM (Z ⫽ ⫺0.375, P ⫽ 0.71). The association between hospital LOS and OH detected by BE was also demonstrated by univariate analysis by Cox regression (Z ⫽ ⫺2.46, P ⫽ 0.014) and by multivariate analysis (Z ⫽ ⫺2.63, P ⫽ 0.008). Occult hypoperfusion detected by USCOM, the presence of major trauma, age, sex and time in ED were not associated with hospital LOS. Conclusion: Occult hypoperfusion occurs in 10-20% of patients presenting to this level 1 trauma center. It is associated with increased hospital LOS. Detection by BE performed better than non-invasive CI monitoring by the USCOM monitor. Further research is required to examine the use of BE in detecting OH in the ED setting and to determine if treatment has an effect on patient outcomes.
10
Vasopressine Improves Outcome in Out-of-Hospital Cardiopulmonary Resuscitation of Pulseless Electrical Activity in Patients With Blunt Trauma
ˇ , Strnad M, Cander D/University of Maribor, Maribor, Slovenia Grmec S
Study Objectives: An increasing body of evidence from laboratory and clinical studies suggests that vasopressine may represent a promising alternative vasopressor for use during cardiac arrest and haemorrhagic shock. Current guidelines for cardiopulmonary resuscitation recommend the use of epinephrine with vasopressin considered only as asecondary option because of limited clinical data. Clinical employment of vasopressin during hemorrhagic shock is experimental at this point in
Annals of Emergency Medicine 473
7
Serum S-100b Protein and Neuron-specific Enolase Concentrations in Patients With Carbon Monoxide Poisoning
Yardan T, Cevik Y, Donderici O, Kavalci C, Yilmaz FM, Yilmaz G, Vural K, Yuzbasioglu Y, Gunaydin YK, Sezer AA/Ondokuzmayis University, Samsun, Turkey; Ankara Education and Research Hospital, Ankara, Turkey
Study Objectives: Carbon monoxide poisoning occurs in cerebral and generalized hypoxia. The aim of the study was to assess the possible use of serum glial markers S-100B protein and neuron-specific enolase as a biochemical marker of ischemic brain injury in acute carbon monoxide poisoning. Methods: Patients with acute carbon monoxide poisoning admitted to Emergency Services of two Education and Research Hospitals (Ankara, Turkey) were included in this prospective study. Serum levels of S-100B protein and neuronspecific enolase were measured on admission. As a control group, twenty healthy adult were included the study. The patients were divided into two groups (unconscious and not unconscious) on admission. Results: Seventy patients diagnosed as carbon monoxide poisoning (mean age, 36.6⫾16.3 years; 64.3% women) were enrolled in this study. S-100B concentrations in the patient group were significantly higher than the control group (p⫽0.018). Serum neuron-specific enolase concentrations were not statistically different in between the patient group and the control group (p⫽0.0.801). There was a positive correlation between levels of S-100B and neuron-specific enolase (r⫽0.388, p⫽0.001). There were thirteen unconscious patients on admission. Values of S-100B and neuron-specific enolase were significantly higher in patients who had been unconscious than not unconscious, respectively (p⫽0.047 and p⫽0.005). In the unconscious patients, there was no significant difference levels of S-100B protein and neuron-specific enolase between who were treated with normobaric oxygen and hyperbaric oxygen, respectively (p⫽0.106 and p⫽0.825). Conclusion: Increased S-100B protein and neuron-specific enolase concentrations are related with consciousness in patients with carbon monoxide poisoning. Serum S-100B and neuron-specific enolase may be useful markers in assessment of carbon monoxide induced acute brain damage in emergency clinical practice.
8
Flumazenil Revisited
Williams JS, Lee MA, Schauben J, Nasca L, Kalynynch C/University of Florida, Jacksonville, FL
Study Objectives: Flumazenil is a benzodiazepine antagonist that carries a perceived seizure risk which often limits its use by practitioners. We analyzed cases from three poison centers comprising the Florida Poison Information Center Network (FPICN) for flumazenil use in managing patients with altered mental status from a suspected overdose of benzodiazepines. Methods: This IRB approved, retrospective review was performed on cases obtained from the FPICN statewide database between 2000 and 2006 involving flumazenil use. Cases were identified by querying the database of closed/completed cases utilizing search filters for flumazenil, seizure (single, multiple, discrete, or status), muscle rigidity, dystonia, and tremor. The poison center data was collected by Specialists in Poison Information (SPIs) and toxicologists at each of the American Association of Poison Control Center (AAPCC) certified Florida centers. The study was approved by the institutional review board and the FPICN administration (centers located in Jacksonville, Miami, and Tampa). Results: During the years 2000-2006, there were 837 recorded uses of flumazenil in patients with suspected overdose reported to the FPICN. Of those, 25 cases were identified as having either seizure, muscle rigidity, dystonia, or tremor associated with the use of the antagonist. These included 4 patients who had a seizure after flumazenil use, 1 patient with seizure activity before and after flumazenil use, 1 patient with dystonia after flumazenil use (relieved by benadryl alone), 3 patients that had seizure activity greater than 3 hours after flumazenil was administered, and 6 patients that had seizures before, but not after flumazenil use. Further, there were 10 cases where flumazenil-associated seizure risk was discussed with the providers, but no adverse event including seizure reported by the SPIs. Of note, co-ingestion with tricyclic antidepressants (TCAs) was reported in 32 cases (out of the 837 total cases). Of these, there was 1 documented case of seizure; however, this occurred greater than 10 hours after flumazenil was given. Given the short duration of action of flumazenil (30-45
Volume , . : April
minutes), it would be unlikely that the flumazenil induced the seizure. All of the reported seizures were either controlled with conventional therapy or resolved spontaneously. There were no reported status epilepticus or uncontrolled seizure events. In summary, this retrospective review revealed a small incidence of flumazenilassociated seizures or dystonia in 0.6% (5/837) of patients. Removing the dystonic reaction would make the occurrence even lower (0.5% 4/837). There were no deaths reported from flumazenil use. Conclusion: Despite the reputation of flumazenil use being associated with seizures, this phenomenon remains rare in our review. In fact, seizures, muscle rigidity, dystonia, and tremors were infrequent events associated with flumazenil use in patients with suspected overdose from benzodiazepines.
9
A Comparison of the USCOM Cardiac Output Monitor With Base Excess for Detecting Occult Hypoperfusion in Emergency Department Trauma Patients
Thom O, Taylor DM, Wolfe R, Judson RT, Myles P, Krum H, Wolfe R/Box Hill Hospital, Melbourne, Australia; Austin Hospital, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia; Monash University, Melbourne, Australia
Background: Occult hypoperfusion (OH) (as indicated by a low base excess in the presence of normal vital signs) is a significant problem in trauma patients admitted to the Intensive Care Unit. It is associated with increased length of stay (LOS) and increased mortality. We do not know the prevalence of this problem in the Emergency Department (ED) setting nor its impact on patient outcome. Study Objectives: To establish the proportion of adult trauma patients presenting to a level 1 trauma center (Royal Melbourne Hospital [RMH]) who have OH and the impact this has on outcome. Also, to compare two methods of detecting OH - base excess (BE) on arterial blood gas and cardiac index (CI) obtained by the USCOMTM, a continuous wave Doppler ultrasound cardiac output monitor. Methods: Over a nine-month period, trauma patients meeting the Victorian Trauma Registry entrance criteria who presented to the RMH with normal vital signs (SBP ⬎ 100 mmHg, HR ⬍ 110 bpm) were enrolled. Each had CI obtained half hourly as clinically allowed for the first four hours of admission. This was compared with BE obtained from clinically indicated blood gases. Occult hypoperfusion was defined as CI ⬍ 2.6 l/min/m2 or BE ⬍ ⫺3. Results: Results are given (⫾ SD) unless indicated. Sixty two patients were enrolled. There were 49 males (79.0%), mean age was 49 years (range 18-91), mean Injury Severity Score 19 (⫾ 11), mean time in ED 417 (⫾ 294) minutes and mean hospital LOS was 10 (⫾ 8) days. There were 37 (59.6%) major trauma patients and two patients (3.2%) died in hospital. Ten patients (16.1%) had OH detected by the USCOM, seven (11.2%) by BE. The methods agreed on four patients. USCOM detected OH in one of the two patients who died, BE detected OH in both. Wilcoxon Rank Sum Test showed a significant association between hospital LOS and OH detected by base excess (Z ⫽ ⫺2.818, P ⫽ 0.005), but not by USCOM (Z ⫽ ⫺0.375, P ⫽ 0.71). The association between hospital LOS and OH detected by BE was also demonstrated by univariate analysis by Cox regression (Z ⫽ ⫺2.46, P ⫽ 0.014) and by multivariate analysis (Z ⫽ ⫺2.63, P ⫽ 0.008). Occult hypoperfusion detected by USCOM, the presence of major trauma, age, sex and time in ED were not associated with hospital LOS. Conclusion: Occult hypoperfusion occurs in 10-20% of patients presenting to this level 1 trauma center. It is associated with increased hospital LOS. Detection by BE performed better than non-invasive CI monitoring by the USCOM monitor. Further research is required to examine the use of BE in detecting OH in the ED setting and to determine if treatment has an effect on patient outcomes.
10
Vasopressine Improves Outcome in Out-of-Hospital Cardiopulmonary Resuscitation of Pulseless Electrical Activity in Patients With Blunt Trauma
ˇ , Strnad M, Cander D/University of Maribor, Maribor, Slovenia Grmec S
Study Objectives: An increasing body of evidence from laboratory and clinical studies suggests that vasopressine may represent a promising alternative vasopressor for use during cardiac arrest and haemorrhagic shock. Current guidelines for cardiopulmonary resuscitation recommend the use of epinephrine with vasopressin considered only as asecondary option because of limited clinical data. Clinical employment of vasopressin during hemorrhagic shock is experimental at this point in
Annals of Emergency Medicine 473