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Cerebrovascular complications of the use of the “crack” form of alkaloid cocaine
ABSTRACTS
.with a higher rate among EMTs than paramedics. In 31% of the personnel, the back injuries were recurrent. There was no correlation between job experience and injury rates. Overall, injury rates were higher in EMTs than in paramedics, in women than in men, and i n personnel less than 30 years old. Approximately 96 injuries a c c o u n t e d for 48 lost w o r k days, while low back strain accounted for 375 lost work days. Guidelines for prevention are discussed, including proper lifting techniques and not attempting to lift weights beyond one's capability. .Robin Johnson, MD
prehospital care, protocols
Does p a r a m e d i c - b a s e hospital c o n t a c t result in beneficiai deviations from standard prehospital protocols? Hoffman JR, Luo J, Schriger D, et al West J Med 153:283-287 Sep 1990
In some Prehospital systems, paramedics are authorized to provide care essentially 0nly under the direct supervision of certified base hospital physicians or certified mobile intensive care nurses. For many prehospital chief complaints, treatments almost never vary and generally follow simple protocols. The authors hypothesized that the preh0spital management of patients with these complaints would be easily amenable to an algorithm-directed system and bypass the need for direct hospital communication. Four common prehospital chief complaints (abdominal pain, syncope, seizure, and altered mental status) were selected and algorithms were abstracted from standard local protocols. A retrospective review of the written and audio records of paramedic:base hospital radio contact for all patients (659) with one of these chief complaints was performed to d e t e r m i n e w h e t h e r t r e a t m e n t differed from that suggested in the abstracted algorithms. Cases that involved unanticipated treatments were reviewed to determine the basis 156/113
for the variation in treatment. Unanticipated therapies were administered to only 13 patients, all of whom had abnormal vital signs, diaphoresis, r e s p i r a t o r y distress, or a second p r o m i n e n t s y m p t o m . It was concluded that protocols could replace radio contact for most patients and that the few who might benefit from radio contact could be identified easily. S u c h selective base-station contact would not only decrease the time spent in the prehospital environment, but would dramatically diminish the number of radio contacts, thus allowing consolidation of base stations and u l t i m a t e l y translating into cost savings. [Edftor's note: It is interesting to note the variability between those prehospita] care systems requiring m a n d a t o r y base station contact and those using field management with standing protocols and select base station contact. Those of us involved with the latter type of system realize that it is a safe and efficient means of delivering prehospital care, provided there is an ongoing audit of paramedic runs.] Mark Copeland, MD
trauma, blunt chest; myocardial contusion
S u s p e c t e d myocardial contusion: Triage and indications for monitoring Wisner DH, Reed WH, Riddick RS Ann Surg 212:82-86 Jul 1990
In this r e t r o s p e c t i v e study, all 3,010 blunt trauma admissions for a 16-month c o n s e c u t i v e period tO a t r a u m a center were reviewed. Of these patients, 10l were declared dead in the emergency department; 14 had autopsy evidence of myocardial contusion, and another 12 had other types of cardiac injury. Thirteen patients died in the operating room, and one had evidence of myocardial contusion. Of the 644 patients admitted to monitored beds, there were 47 deaths. None of these p a t i e n t s had a u t o p s y evidence of myocardial contusion. There were 2,252 a d m i s s i o n s to u n m o n i t o r e d beds; nine of these patients required
Annals of EmergencyMedicine
transfer to the iCU, and two subsequently died. Neither had clinical/ autopsy evidence of myocardial contusion. Of the 95 patients admitted with diagnosis of rule-out myocardial contusion, none developed subsequent cardiac failure. A r r h y t h m i a s occurred in 19 patients, four of whom were considered serious enough to require treatment; three of these patients had conduction abnormalities on admission ECG, and the other was s u b s e q u e n t l y d e t e r m i n e d to have a benign baseline arrhythmia. CPK-MB fractions and echocardiograms were poor predictors of serious arrhythmias. It was concluded that patients with clinically significant blunt cardiac injury will manifest signs of injury shortly after trauma and that stable patients with no conduction abnormalities on admission ECG can Safely be admitted to unmonitored beds. Ilya Chern, MD
cerebrovascular accidents, cocaine
Cerebrovascular complications of the u s e of the " c r a c k " form of alkaloid cocaine Levine SR, Brust JCM, Futrell N, et al N Engl J Med 323:699-704 Sep 1990
A mixed prospective and retrospective review of 28 patients who had strokes temporally related to the use of alkaloid cocaine (crack) was performed. Patients were included in the study if there was a confirmatory history of smoking crack cocaine within 72 hours of their neurologic event. P a t i e n t s were e x c l u d e d f r o m the study if they had used cocaine hydrochloride in the recent past or if the nature of their cocaine use was in doubt. Toxicology screening was performed on 16 of the 28 patients and was positive for cocaine in all 16. The mean age of the patients was 34 years (range, 23 to 49 years). Eighteen (64%) had acute neurologic sympt o m s i m m e d i a t e l y or w i t h i n one hour of using crack, and five (18%) developed s y m p t o m s within one to 20:1 January 1991
ABSTRACTS
three hours. Three patients had documented transient ischemic attacks in association w i t h previous cocaine use. All 28 Patients underwent head computed tomography scan examinations, with 16 (57%)being abnormal. In the remaining patients, the diagnosis was made on clinical examination. Cerebral angiograms were performed in 15 patients and no evidence of vasculitis was seen. The
20:1 January 1991
m o s t c o m m o n a b n o r m a l i t y found was cerebral infarction, documented in 18 (64%). The territories of the middle cerebral artery (ten), anterior cerebral artery (three), posterior cerebral artery (one), and vertebrobasilar arteries (four) were affected. Ten patients had intracerebral hemorrhage, subarachnoicl (five), intraparenchymal (four), and intraventricular (one). There was one death in this series.
Annals of Emergency Medicine
Other risk factors for stroke among the p a t i e n t s included m i l d m i t r a l valve prolapse (four), hypertension (four), tobacco use (eight), and regular alcohol use (six). It was concluded that a thorough drug history and toxicologic screening should be performed in all young patients suffering from stroke.
Wayne Guerra, MD
114/157
.with a higher rate among EMTs than paramedics. In 31% of the personnel, the back injuries were recurrent. There was no correlation between job experience and injury rates. Overall, injury rates were higher in EMTs than in paramedics, in women than in men, and i n personnel less than 30 years old. Approximately 96 injuries a c c o u n t e d for 48 lost w o r k days, while low back strain accounted for 375 lost work days. Guidelines for prevention are discussed, including proper lifting techniques and not attempting to lift weights beyond one's capability. .Robin Johnson, MD
prehospital care, protocols
Does p a r a m e d i c - b a s e hospital c o n t a c t result in beneficiai deviations from standard prehospital protocols? Hoffman JR, Luo J, Schriger D, et al West J Med 153:283-287 Sep 1990
In some Prehospital systems, paramedics are authorized to provide care essentially 0nly under the direct supervision of certified base hospital physicians or certified mobile intensive care nurses. For many prehospital chief complaints, treatments almost never vary and generally follow simple protocols. The authors hypothesized that the preh0spital management of patients with these complaints would be easily amenable to an algorithm-directed system and bypass the need for direct hospital communication. Four common prehospital chief complaints (abdominal pain, syncope, seizure, and altered mental status) were selected and algorithms were abstracted from standard local protocols. A retrospective review of the written and audio records of paramedic:base hospital radio contact for all patients (659) with one of these chief complaints was performed to d e t e r m i n e w h e t h e r t r e a t m e n t differed from that suggested in the abstracted algorithms. Cases that involved unanticipated treatments were reviewed to determine the basis 156/113
for the variation in treatment. Unanticipated therapies were administered to only 13 patients, all of whom had abnormal vital signs, diaphoresis, r e s p i r a t o r y distress, or a second p r o m i n e n t s y m p t o m . It was concluded that protocols could replace radio contact for most patients and that the few who might benefit from radio contact could be identified easily. S u c h selective base-station contact would not only decrease the time spent in the prehospital environment, but would dramatically diminish the number of radio contacts, thus allowing consolidation of base stations and u l t i m a t e l y translating into cost savings. [Edftor's note: It is interesting to note the variability between those prehospita] care systems requiring m a n d a t o r y base station contact and those using field management with standing protocols and select base station contact. Those of us involved with the latter type of system realize that it is a safe and efficient means of delivering prehospital care, provided there is an ongoing audit of paramedic runs.] Mark Copeland, MD
trauma, blunt chest; myocardial contusion
S u s p e c t e d myocardial contusion: Triage and indications for monitoring Wisner DH, Reed WH, Riddick RS Ann Surg 212:82-86 Jul 1990
In this r e t r o s p e c t i v e study, all 3,010 blunt trauma admissions for a 16-month c o n s e c u t i v e period tO a t r a u m a center were reviewed. Of these patients, 10l were declared dead in the emergency department; 14 had autopsy evidence of myocardial contusion, and another 12 had other types of cardiac injury. Thirteen patients died in the operating room, and one had evidence of myocardial contusion. Of the 644 patients admitted to monitored beds, there were 47 deaths. None of these p a t i e n t s had a u t o p s y evidence of myocardial contusion. There were 2,252 a d m i s s i o n s to u n m o n i t o r e d beds; nine of these patients required
Annals of EmergencyMedicine
transfer to the iCU, and two subsequently died. Neither had clinical/ autopsy evidence of myocardial contusion. Of the 95 patients admitted with diagnosis of rule-out myocardial contusion, none developed subsequent cardiac failure. A r r h y t h m i a s occurred in 19 patients, four of whom were considered serious enough to require treatment; three of these patients had conduction abnormalities on admission ECG, and the other was s u b s e q u e n t l y d e t e r m i n e d to have a benign baseline arrhythmia. CPK-MB fractions and echocardiograms were poor predictors of serious arrhythmias. It was concluded that patients with clinically significant blunt cardiac injury will manifest signs of injury shortly after trauma and that stable patients with no conduction abnormalities on admission ECG can Safely be admitted to unmonitored beds. Ilya Chern, MD
cerebrovascular accidents, cocaine
Cerebrovascular complications of the u s e of the " c r a c k " form of alkaloid cocaine Levine SR, Brust JCM, Futrell N, et al N Engl J Med 323:699-704 Sep 1990
A mixed prospective and retrospective review of 28 patients who had strokes temporally related to the use of alkaloid cocaine (crack) was performed. Patients were included in the study if there was a confirmatory history of smoking crack cocaine within 72 hours of their neurologic event. P a t i e n t s were e x c l u d e d f r o m the study if they had used cocaine hydrochloride in the recent past or if the nature of their cocaine use was in doubt. Toxicology screening was performed on 16 of the 28 patients and was positive for cocaine in all 16. The mean age of the patients was 34 years (range, 23 to 49 years). Eighteen (64%) had acute neurologic sympt o m s i m m e d i a t e l y or w i t h i n one hour of using crack, and five (18%) developed s y m p t o m s within one to 20:1 January 1991
ABSTRACTS
three hours. Three patients had documented transient ischemic attacks in association w i t h previous cocaine use. All 28 Patients underwent head computed tomography scan examinations, with 16 (57%)being abnormal. In the remaining patients, the diagnosis was made on clinical examination. Cerebral angiograms were performed in 15 patients and no evidence of vasculitis was seen. The
20:1 January 1991
m o s t c o m m o n a b n o r m a l i t y found was cerebral infarction, documented in 18 (64%). The territories of the middle cerebral artery (ten), anterior cerebral artery (three), posterior cerebral artery (one), and vertebrobasilar arteries (four) were affected. Ten patients had intracerebral hemorrhage, subarachnoicl (five), intraparenchymal (four), and intraventricular (one). There was one death in this series.
Annals of Emergency Medicine
Other risk factors for stroke among the p a t i e n t s included m i l d m i t r a l valve prolapse (four), hypertension (four), tobacco use (eight), and regular alcohol use (six). It was concluded that a thorough drug history and toxicologic screening should be performed in all young patients suffering from stroke.
Wayne Guerra, MD
114/157