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Comparison of the intraosseous and intravenous routes of diazepam administration for pentylenetetrazol-induced seizures
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
ABSTRACTS
m a y be used in Children and i n f a n t s during status epilepticus w h e n IV access is n o t available. T h e IO and IV routes of diazepam a d m i n i s t r a t i o n were compared in a p e n t y l e n e t e t r a z o l (PTZ) seizure model. Ten domestic swine weighing 14 to 19 kg were anesthetized w i t h k e t a m i n e 20 mg/kg IM and alpha-chloralose 25 mg/kg IV and were ventilated w i t h a respirator on 35% 02. Blood pressure and lead II ECG were monitored throughout the e x p e r i m e n t . Electrocortical activity was recorded directly from the brain w i t h p l a t i n u m electrodes. All animals were given PTZ 100 mg/kg IV to induce seizure activity, and they received d i a z e p a m 0.l m g / k g IV 1 m i n u t e after t h e o n s e t of seizure through a peripheral IV (n = 5) or through an 18-gauge needle in the proximal tibia IO (n = 5). Blood samples were drawn for det e r m i n a t i o n of diazepam levels at 1, 2, 5, 10, 15, and 20 m i n u t e s after diazepam administration. Control heart rates and m e a n arterial blood pressure were similar for the two groups: 240.6 ± 11.1 and 238.7 + 7.0 beats/minute, and 128.6 -+ 12.0 and 127.2 ± 8.3 m m Hg for IV and IO, respectively, The time to onset of seizure was 20.2 ± 3.02 seconds and 16.4 ± 2.5 seconds for the IV and IO routes, respectively (P > .05). IV diazepam suppressed seizure activity in all IV animals in 38.4 + 10.8 seconds, while IO diazepam stopped it in 4 IO animals in 53.2 +_ 29.3 seconds. One IO animal had increased ictal activity for 12 minutes. Serum diazepam levels (ng/mL) and standard error for the IV and IO groups were as follows: 1 minute, 260 ± 97.2, 190 + 50.7; 2 minutes, 195.0 ± 41.0, 172.5 ± 42.7; 5 minutes, 187.5 ± 24.3, 153.3 ± 24.0; 10 minutes, 123.3 + 12.0, 153.3 ± 37.1; 15 minutes, 130.0 ± 17.3, 146.7 ± 13.3; and 20 minutes, 120.0 + 15.8, 145.0 ± 28.7, respectively. A n analysis of variance revealed no statistical difference in the 2 groups; 105 ng/mL or greater is therapeutic. The data show the IO route to be a rapid and effective m e t h o d of administering diazepam and suppressing seizure activity during status epilepticus w h e n IV access is not readily available.
Effect of Volume on the Endotracheal Absorption of Lidocaine SE Mace / Mount Sinai Medical Center, Cleveland, Ohio Lidocaine was given endotracheally in a dose of 2 or 4 mg/g to 15 dogs. Blood lidocaine levels were drawn at 5, 15, 30, and 60 m i n u t e s after administration of lidocaine. Endotracheal lidocaine was given either as a dilution w i t h normal saline (a 1:1 dilution of lidocaine and normal saline) or undiluted (Group 1, no dilution; Group 2, dilution With normal saline). Significantly higher blood lidocaine levels were obtained in the dilution group in all the time periods and w i t h either dose (2 or 4 mg/kg) (P < .001). Mean blood lidocaine levels (Ixg/mL) at 5 m i n u t e s were (2 mg/kg dose) Group 1 = 0.64, Group 2 = 3.4~ and (4 mg/kg dose} Group 1 = 1.4, Group 2 = 6.2 (P < .001). The same dose of lidocaine was diluted w i t h normal saline to a total volume of 3 m L , 6 mL, 12 mL, or 25 mL of fluid. Four additional dogs received all four dilutions of endotracheal lidocaine on different days. In each of the four dogs, blood lidocaine levels were significantly different depending on the total a m o u n t of fluid given (P < .001). In one dog at the same endotracheal lidocaine dosage, blood lidocaine levels (at 5 minutes) varied from 2 to 9.1 depending on the a m o u n t of normal saline administered with the endotracheal lidocaine. This study suggests that 1) higher blood lidocaine levels are achieved and m a i n t a i n e d longer w h e n lidocaine is diluted w i t h n o r m a l saline t h a n w h e n it is given undiluted; and 2) there may be a m a x i m a l volume at w h i c h the highest blood lidocaine level is obtained w i t h o u t a corresponding change in respiratory function.
t o m s after s u b m e r s i o n , so-called "secondary drowning," is de* rived from retrospective analysis, frequently of patients who had established p u l m o n a r y pathology. Characterizing subsets of victims could reduce unnecessary hospitalization of some patients and promote vigorous evaluation of those at risk. We prospectively evaluated a large saltwater beach population. Swimmers were eligible for the study if they exhibited coughing, cyanosis, loss of consciousness in the water, tachypnea, or vomiting, or if they requested medical a t t e n t i o n after submersion. A m o n g an estimated 33,170,000 beach visits during one summer, there were 5,474 rescues (any contact w i t h a bather), w i t h 53 patients entered in the study. Thirty-two (60%) of the victims were released on the beach, and none of the 27 victims followed up by telephone required medical care after the initial episode. Twenty-one patients (40%) were transported to a hospital for further evaluation. Ten presented on the beach w i t h findings m a n d a t i n g ICU admission. The other 11 patients (21%) had m i n i m a l symptoms w h e n t h e y e m e r g e d f r o m t h e water. T h r e e developed severe s y m p t o m s in the ED m a n d a t i n g ICU admission, while 8 were observed in the ED or as inpatients w i t h o u t sequelae. Four of the 8 had an abnormal chest radiograph, acidosis, or hypoxemia despite m i n i m a l clinical findings. The need for these studies in the ED is reinforced. Study limitations include the small final pat i e n t population and lack of laboratory studies on all patients. We conclude that experienced lifeguards can effectively triage subm e r s i o n victims, t h a t m i l d s y m p t o m s progress to m a r k e d distress in only a few patients, and that patients who develop delayed distress do so w i t h i n a few hours. ED observation for 4 tO 6 hours could screen effectively for those patients requiring inpatient therapy.
0
Appendicitis in the Elderly: A Diagnostic Challenge
SR Klein, L Layden (presenter), JF Wright, RA White / Department of Surgery, Harbor/UCLA Medical Center, Torrance, California A c u t e appendicitis is u n c o m m o n in p a t i e n t s more t h a n 60 years old, but this age group accounts for a significant proportion of the morbidity and mortality related to this entity. To establish a profile of the disease in this population, the charts of 94 patients age 60 to 95 w i t h pathologically proven acute appendicitis were reviewed. Sixty-two percent were in their 60s, and 20% were more t h a n 80 years old. Thirty-one percent had s y m p t o m s more than 48 hours prior to presentation. The most frequent presenting s y m p t o m was abdominal pain (93%), but only 66% had right lower q u a d r a n t localization. A t presentation, 70% of patients had fever exceeding 37.2 C, and 83% had leukocytosis (WBC count > 10,000). Operation was carried out w i t h i n 24 hours of presentation in 81%, but was delayed more than 48 hours in 15% as a result of an incorrect admitting diagnosis in all cases. The overall incidence of perforation was 62%. This was related directly to the duration of the illness, and occurred in 84% of those w i t h s y m p t o m s for more than 48 hours, compared to an incidence of 20% in those w i t h s y m p t o m s present less t h a n 24 hours. T h e overall c o m p l i c a t i o n rate was 50%, w h i c h rose to 75% in those w i t h perforation. The most c o m m o n complication was wound infection. Four patients (4%) died, three of t h e m having had a delay in operation of more than 48 hours; all had perforation at surgery. We conclude t h a t delay in the patient seeking medical care or the physician arriving at the prompt diagnosis and proceeding w i t h early surgical i n t e r v e n t i o n are the factors related to the elevated morbidity and mortality observed in acute appendicitis in the elderly.
Incidence of "Secondary Drowning" After Saltwater Immersion FD Pratt (presenter), BE Haynes / Department of Emergency Medicine, Harbor/UCLA Medical Center, Torrance, California The reported incidence of delayed p u l m o n a r y and CNS symp-
160/826
11
Fixed Atlanto.Axial Rotatory Subluxation: A Radiographic Finding of Questionable Clinical Significance
Annals of Emergency Medicine
14:8 August 1985
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
ABSTRACTS
m a y be used in Children and i n f a n t s during status epilepticus w h e n IV access is n o t available. T h e IO and IV routes of diazepam a d m i n i s t r a t i o n were compared in a p e n t y l e n e t e t r a z o l (PTZ) seizure model. Ten domestic swine weighing 14 to 19 kg were anesthetized w i t h k e t a m i n e 20 mg/kg IM and alpha-chloralose 25 mg/kg IV and were ventilated w i t h a respirator on 35% 02. Blood pressure and lead II ECG were monitored throughout the e x p e r i m e n t . Electrocortical activity was recorded directly from the brain w i t h p l a t i n u m electrodes. All animals were given PTZ 100 mg/kg IV to induce seizure activity, and they received d i a z e p a m 0.l m g / k g IV 1 m i n u t e after t h e o n s e t of seizure through a peripheral IV (n = 5) or through an 18-gauge needle in the proximal tibia IO (n = 5). Blood samples were drawn for det e r m i n a t i o n of diazepam levels at 1, 2, 5, 10, 15, and 20 m i n u t e s after diazepam administration. Control heart rates and m e a n arterial blood pressure were similar for the two groups: 240.6 ± 11.1 and 238.7 + 7.0 beats/minute, and 128.6 -+ 12.0 and 127.2 ± 8.3 m m Hg for IV and IO, respectively, The time to onset of seizure was 20.2 ± 3.02 seconds and 16.4 ± 2.5 seconds for the IV and IO routes, respectively (P > .05). IV diazepam suppressed seizure activity in all IV animals in 38.4 + 10.8 seconds, while IO diazepam stopped it in 4 IO animals in 53.2 +_ 29.3 seconds. One IO animal had increased ictal activity for 12 minutes. Serum diazepam levels (ng/mL) and standard error for the IV and IO groups were as follows: 1 minute, 260 ± 97.2, 190 + 50.7; 2 minutes, 195.0 ± 41.0, 172.5 ± 42.7; 5 minutes, 187.5 ± 24.3, 153.3 ± 24.0; 10 minutes, 123.3 + 12.0, 153.3 ± 37.1; 15 minutes, 130.0 ± 17.3, 146.7 ± 13.3; and 20 minutes, 120.0 + 15.8, 145.0 ± 28.7, respectively. A n analysis of variance revealed no statistical difference in the 2 groups; 105 ng/mL or greater is therapeutic. The data show the IO route to be a rapid and effective m e t h o d of administering diazepam and suppressing seizure activity during status epilepticus w h e n IV access is not readily available.
Effect of Volume on the Endotracheal Absorption of Lidocaine SE Mace / Mount Sinai Medical Center, Cleveland, Ohio Lidocaine was given endotracheally in a dose of 2 or 4 mg/g to 15 dogs. Blood lidocaine levels were drawn at 5, 15, 30, and 60 m i n u t e s after administration of lidocaine. Endotracheal lidocaine was given either as a dilution w i t h normal saline (a 1:1 dilution of lidocaine and normal saline) or undiluted (Group 1, no dilution; Group 2, dilution With normal saline). Significantly higher blood lidocaine levels were obtained in the dilution group in all the time periods and w i t h either dose (2 or 4 mg/kg) (P < .001). Mean blood lidocaine levels (Ixg/mL) at 5 m i n u t e s were (2 mg/kg dose) Group 1 = 0.64, Group 2 = 3.4~ and (4 mg/kg dose} Group 1 = 1.4, Group 2 = 6.2 (P < .001). The same dose of lidocaine was diluted w i t h normal saline to a total volume of 3 m L , 6 mL, 12 mL, or 25 mL of fluid. Four additional dogs received all four dilutions of endotracheal lidocaine on different days. In each of the four dogs, blood lidocaine levels were significantly different depending on the total a m o u n t of fluid given (P < .001). In one dog at the same endotracheal lidocaine dosage, blood lidocaine levels (at 5 minutes) varied from 2 to 9.1 depending on the a m o u n t of normal saline administered with the endotracheal lidocaine. This study suggests that 1) higher blood lidocaine levels are achieved and m a i n t a i n e d longer w h e n lidocaine is diluted w i t h n o r m a l saline t h a n w h e n it is given undiluted; and 2) there may be a m a x i m a l volume at w h i c h the highest blood lidocaine level is obtained w i t h o u t a corresponding change in respiratory function.
t o m s after s u b m e r s i o n , so-called "secondary drowning," is de* rived from retrospective analysis, frequently of patients who had established p u l m o n a r y pathology. Characterizing subsets of victims could reduce unnecessary hospitalization of some patients and promote vigorous evaluation of those at risk. We prospectively evaluated a large saltwater beach population. Swimmers were eligible for the study if they exhibited coughing, cyanosis, loss of consciousness in the water, tachypnea, or vomiting, or if they requested medical a t t e n t i o n after submersion. A m o n g an estimated 33,170,000 beach visits during one summer, there were 5,474 rescues (any contact w i t h a bather), w i t h 53 patients entered in the study. Thirty-two (60%) of the victims were released on the beach, and none of the 27 victims followed up by telephone required medical care after the initial episode. Twenty-one patients (40%) were transported to a hospital for further evaluation. Ten presented on the beach w i t h findings m a n d a t i n g ICU admission. The other 11 patients (21%) had m i n i m a l symptoms w h e n t h e y e m e r g e d f r o m t h e water. T h r e e developed severe s y m p t o m s in the ED m a n d a t i n g ICU admission, while 8 were observed in the ED or as inpatients w i t h o u t sequelae. Four of the 8 had an abnormal chest radiograph, acidosis, or hypoxemia despite m i n i m a l clinical findings. The need for these studies in the ED is reinforced. Study limitations include the small final pat i e n t population and lack of laboratory studies on all patients. We conclude that experienced lifeguards can effectively triage subm e r s i o n victims, t h a t m i l d s y m p t o m s progress to m a r k e d distress in only a few patients, and that patients who develop delayed distress do so w i t h i n a few hours. ED observation for 4 tO 6 hours could screen effectively for those patients requiring inpatient therapy.
0
Appendicitis in the Elderly: A Diagnostic Challenge
SR Klein, L Layden (presenter), JF Wright, RA White / Department of Surgery, Harbor/UCLA Medical Center, Torrance, California A c u t e appendicitis is u n c o m m o n in p a t i e n t s more t h a n 60 years old, but this age group accounts for a significant proportion of the morbidity and mortality related to this entity. To establish a profile of the disease in this population, the charts of 94 patients age 60 to 95 w i t h pathologically proven acute appendicitis were reviewed. Sixty-two percent were in their 60s, and 20% were more t h a n 80 years old. Thirty-one percent had s y m p t o m s more than 48 hours prior to presentation. The most frequent presenting s y m p t o m was abdominal pain (93%), but only 66% had right lower q u a d r a n t localization. A t presentation, 70% of patients had fever exceeding 37.2 C, and 83% had leukocytosis (WBC count > 10,000). Operation was carried out w i t h i n 24 hours of presentation in 81%, but was delayed more than 48 hours in 15% as a result of an incorrect admitting diagnosis in all cases. The overall incidence of perforation was 62%. This was related directly to the duration of the illness, and occurred in 84% of those w i t h s y m p t o m s for more than 48 hours, compared to an incidence of 20% in those w i t h s y m p t o m s present less t h a n 24 hours. T h e overall c o m p l i c a t i o n rate was 50%, w h i c h rose to 75% in those w i t h perforation. The most c o m m o n complication was wound infection. Four patients (4%) died, three of t h e m having had a delay in operation of more than 48 hours; all had perforation at surgery. We conclude t h a t delay in the patient seeking medical care or the physician arriving at the prompt diagnosis and proceeding w i t h early surgical i n t e r v e n t i o n are the factors related to the elevated morbidity and mortality observed in acute appendicitis in the elderly.
Incidence of "Secondary Drowning" After Saltwater Immersion FD Pratt (presenter), BE Haynes / Department of Emergency Medicine, Harbor/UCLA Medical Center, Torrance, California The reported incidence of delayed p u l m o n a r y and CNS symp-
160/826
11
Fixed Atlanto.Axial Rotatory Subluxation: A Radiographic Finding of Questionable Clinical Significance
Annals of Emergency Medicine
14:8 August 1985