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Activated charcoal before syrup-of-ipecac-induced emesis
0.2 mg/kg of E or CPR plus 2.0 mg/kg of E through a peripheral IV line. All animals were instrumented for cerebral blood flow (CBF} measurements using radioactively labeled tracer microspheres. Baseline measurements were made during normal sinus rhythm (NSR). Ventricular fibrillation (VF) then was induced. Following 10 minutes of VF, CPR was begun with a pneumatic compressor (Michigan Instruments, Inc). CBF was measured during CPR. At the end of 3 minutes of CPR, E was administered. One m i n u t e after E a d m i n i s t r a t i o n CBF was measured again. A Wilcoxon rank sum test was used to compare blood flow between the two groups. P values < .05 were considered statistically significant. The regional CBFs during C P R + E are reported as a percentage of NSR blood flow. The regional CBFs for the 0.2-mg and 2.0-mg groups, respectively, were: left cerebral cortex, 0.47 versus 0.50; right cerebral cortex, 0.48 versus 0.50; cerebellum, 0.70 versus 1.03; midbrain/pons, 0.86 versus 0.88; medulla, 0.78 versus 1.34; and cervical spinal cord, 0.93 versus 1.21. All comparisons between groups for each organ measured had P values > .05. While there was no statistically significant improvement in regional brain blood flow seen with this higher dose of E, there was a trend in our data that demonstrated improved blood flow to more caudal CNS structures. Our preliminary report suggests that higher doses of E may further improve CBE Further studies with larger sample sizes will be required to verify this statistically.
The Relationship of Hemodynamic Parameters to Neurologic Outcome from Cardiac Arrest in the Animal Model JC Brillman (presenter), AB Sanders, CW Otto, H Fahmy, S Bragg, GA Ewy / Sections of Emergency Medicine and Cardiology and the Department of Anesthesiology, University of Arizona Health Sciences Center, Tucson, Arizona Several studies in the literature have demonstrated that specific hemodynamic parameters, the aortic diastolic and myocardial perfusion pressures, are correlated with resuscitability from cardiac arrest in the animal model. T h e relationship of these pressures to 24-hour survival and neurologic deficit is, however, unknown. Therefore a study was done to determine the correlation of hemodynamic parameters to 24-hour neurologic outcome. Ventricular fibrillation was electrically induced in 18 dogs. After 3 m i n u t e s standard CPIK was begun. Dogs were g i v e n phenylephrine or epinephrine at 9 minutes, and defibrillation was attempted at 12 minutes. Dogs underwent hemodynamic monitoring and pharmacologic support during a critical care period for 90 minutes. At 4, 8, 12, and 24 hours a standard neurologic examination was performed and deficit scores were assigned. Fourteen of eighteen dogs were initially resuscitated, and 10 lived for 24 hours following arrest. Aortic systolic pressures were Correlated positively with improved neurologic outcomes (r = .64, P < .05). This relationship was linear, and no stratification could be made whereby achievements of specific pressures would result in a good neurologic outcome. Other variables that could not be correlated with improved neurologic survival included 1) diastolic pressure, mean arterial pressure, myocardial perfusion pressure, or central venous pressures prior to defibrillation; and 2) all hemodynarnic Variables during the critical care period after defibrillation. In conclusion, the aortic systolic pressure was correlated positively w i t h i m p r o v e d neurologic o u t c o m e in this animal model of cardiac arrest. Whereas previous efforts to improve resuscitability from cardiac arrest centered on improvements in the aortic diastolic and myocardial perfusion pressures, there may be a need to focus on drugs or techniques that improve systolic pressures as well.
5
Digital Hydrofluoric Acid Burns: Treatment with Intraarterial Calcium Infusion
14:8 August 1985
MV Vance, SC Curry, DB Kunkel, PJ Ryan / Central Arizona Regional Poison Management Center, St Luke's Medical Center, Phoenix, Arizona Hydrofluoric acid (HF) produces a unique chemical burn due to tissue penetration by fluoride ion. Fluoride ion interferes with calcium activity in a variety of cell membranes and calcium-dependent processes, resulting in severe pain and deep tissue destruction. The currently accepted methods of treating HF burns include application of topical soaks or Ointments with calcium or magnesium salts for minor burns and local injection of calcium gluconate for more severe burns. Digital bums also may require nail removal and direct injection into the nail bed. We present a series of patients with moderate to severe HF burns involving one or more fingers who were treated with selective intraarterial calcium infusion of diluted IL66%) calcium salts. All patients had excellent relief of symptoms and marked improvement of the burn lesions following one to three four-hour infusions of calcium chloride or calcium gluconate. Only one patient required subsequent surgical intervention for grafting of a full-thickness burn, and one patient developed transient spasm at the site of percutaneous arterial line insertion. Intraarterial calcium infusion for the treatment of HF burns of the fingers provides many therapeutic advantages, including elimination of painful calcium injection directly into fingertips, avoidance of such debilitating procedures as fingernail removal, and assurance that all affected cells are receiving adequate amounts of calcium to replenish depleted stores and to "neutralize" remaining free fluoride ion.
Activated Charcoal Before Syrup-ofipe©ac-lnduced Emesis GE Freedman, EP Krenselak, S Pasternak (presenter) / Mercy Hospital; Pittsburgh Poison Center, Children's Hospital of Pittsburgh; and the Center for Emergency Medicine of Western Pennsylvania, Pittsburgh, Pennsylvania It is commonly stated that activated charcoal will prevent the emetic effect of syrup of ipecac. Although not clinically substantiated, this view has become dogma. A study was performed to observe the effects of activated charcoal on the emetic properties of syrup of ipecac and to develop an efficient protocol for treatment of the nonobtunded overdose patient. Ten volunteers, who ingested 2.6 g aspirin orally as a marker drug, were administered 60 cc syrup of ipecac plus 480 cc water through a nasal gastric tube. Five minutes later, a 50-g aqueous charcoal slurry was infused through the tube, the tube was removed, and the subjects were observed for emesis. The subjects acted as their own controls and were subsequently administered only 2.6 g aspirin orally. Eight of ten subjects (80%) had a significant emetic response, the other two had nausea without emesis. Serum salicylate levels measured two hours after salicylate ingestion showed an average reduction of 57% from control in the subjects with emesis (8 of 10) compared to an average reduction of 48% in the subjects without emesis (2 of 10). Our study illustrates that activated charcoal may not prevent the emetic effects of syrup of ipecac. The protocol developed allows the very early administration of activated charcoal compared to conventional teaching, and has been shown to be effective in reducing marker drug levels with or without emesis.
Comparison of the Intraosseous and Intravenous Routes of Diazepam Administration for PentylenetetrazolInduced Seizures WH Spivey, HD Unger (presenter), RM McNamara, CM Lathers / Departments of Emergency Medicine and Pharmacology, Medical College of Pennsylvania, Philadelphia, Pennsylvania This study examines an alternative route of administration for diazepam in the control of seizure activity. The intraosseous route [IO), through the bone, is much simpler than IV access and
Annals of Emergency Medicine
825/159
The Relationship of Hemodynamic Parameters to Neurologic Outcome from Cardiac Arrest in the Animal Model JC Brillman (presenter), AB Sanders, CW Otto, H Fahmy, S Bragg, GA Ewy / Sections of Emergency Medicine and Cardiology and the Department of Anesthesiology, University of Arizona Health Sciences Center, Tucson, Arizona Several studies in the literature have demonstrated that specific hemodynamic parameters, the aortic diastolic and myocardial perfusion pressures, are correlated with resuscitability from cardiac arrest in the animal model. T h e relationship of these pressures to 24-hour survival and neurologic deficit is, however, unknown. Therefore a study was done to determine the correlation of hemodynamic parameters to 24-hour neurologic outcome. Ventricular fibrillation was electrically induced in 18 dogs. After 3 m i n u t e s standard CPIK was begun. Dogs were g i v e n phenylephrine or epinephrine at 9 minutes, and defibrillation was attempted at 12 minutes. Dogs underwent hemodynamic monitoring and pharmacologic support during a critical care period for 90 minutes. At 4, 8, 12, and 24 hours a standard neurologic examination was performed and deficit scores were assigned. Fourteen of eighteen dogs were initially resuscitated, and 10 lived for 24 hours following arrest. Aortic systolic pressures were Correlated positively with improved neurologic outcomes (r = .64, P < .05). This relationship was linear, and no stratification could be made whereby achievements of specific pressures would result in a good neurologic outcome. Other variables that could not be correlated with improved neurologic survival included 1) diastolic pressure, mean arterial pressure, myocardial perfusion pressure, or central venous pressures prior to defibrillation; and 2) all hemodynarnic Variables during the critical care period after defibrillation. In conclusion, the aortic systolic pressure was correlated positively w i t h i m p r o v e d neurologic o u t c o m e in this animal model of cardiac arrest. Whereas previous efforts to improve resuscitability from cardiac arrest centered on improvements in the aortic diastolic and myocardial perfusion pressures, there may be a need to focus on drugs or techniques that improve systolic pressures as well.
5
Digital Hydrofluoric Acid Burns: Treatment with Intraarterial Calcium Infusion
14:8 August 1985
MV Vance, SC Curry, DB Kunkel, PJ Ryan / Central Arizona Regional Poison Management Center, St Luke's Medical Center, Phoenix, Arizona Hydrofluoric acid (HF) produces a unique chemical burn due to tissue penetration by fluoride ion. Fluoride ion interferes with calcium activity in a variety of cell membranes and calcium-dependent processes, resulting in severe pain and deep tissue destruction. The currently accepted methods of treating HF burns include application of topical soaks or Ointments with calcium or magnesium salts for minor burns and local injection of calcium gluconate for more severe burns. Digital bums also may require nail removal and direct injection into the nail bed. We present a series of patients with moderate to severe HF burns involving one or more fingers who were treated with selective intraarterial calcium infusion of diluted IL66%) calcium salts. All patients had excellent relief of symptoms and marked improvement of the burn lesions following one to three four-hour infusions of calcium chloride or calcium gluconate. Only one patient required subsequent surgical intervention for grafting of a full-thickness burn, and one patient developed transient spasm at the site of percutaneous arterial line insertion. Intraarterial calcium infusion for the treatment of HF burns of the fingers provides many therapeutic advantages, including elimination of painful calcium injection directly into fingertips, avoidance of such debilitating procedures as fingernail removal, and assurance that all affected cells are receiving adequate amounts of calcium to replenish depleted stores and to "neutralize" remaining free fluoride ion.
Activated Charcoal Before Syrup-ofipe©ac-lnduced Emesis GE Freedman, EP Krenselak, S Pasternak (presenter) / Mercy Hospital; Pittsburgh Poison Center, Children's Hospital of Pittsburgh; and the Center for Emergency Medicine of Western Pennsylvania, Pittsburgh, Pennsylvania It is commonly stated that activated charcoal will prevent the emetic effect of syrup of ipecac. Although not clinically substantiated, this view has become dogma. A study was performed to observe the effects of activated charcoal on the emetic properties of syrup of ipecac and to develop an efficient protocol for treatment of the nonobtunded overdose patient. Ten volunteers, who ingested 2.6 g aspirin orally as a marker drug, were administered 60 cc syrup of ipecac plus 480 cc water through a nasal gastric tube. Five minutes later, a 50-g aqueous charcoal slurry was infused through the tube, the tube was removed, and the subjects were observed for emesis. The subjects acted as their own controls and were subsequently administered only 2.6 g aspirin orally. Eight of ten subjects (80%) had a significant emetic response, the other two had nausea without emesis. Serum salicylate levels measured two hours after salicylate ingestion showed an average reduction of 57% from control in the subjects with emesis (8 of 10) compared to an average reduction of 48% in the subjects without emesis (2 of 10). Our study illustrates that activated charcoal may not prevent the emetic effects of syrup of ipecac. The protocol developed allows the very early administration of activated charcoal compared to conventional teaching, and has been shown to be effective in reducing marker drug levels with or without emesis.
Comparison of the Intraosseous and Intravenous Routes of Diazepam Administration for PentylenetetrazolInduced Seizures WH Spivey, HD Unger (presenter), RM McNamara, CM Lathers / Departments of Emergency Medicine and Pharmacology, Medical College of Pennsylvania, Philadelphia, Pennsylvania This study examines an alternative route of administration for diazepam in the control of seizure activity. The intraosseous route [IO), through the bone, is much simpler than IV access and
Annals of Emergency Medicine
825/159