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Decongestants or antihistamines in acute otitis media
Opinions expressed in the Correspondence section are those of the authors, and not necessarily of the editors, ACEP, or UAEM. The editors reserve the right to edit and publish letters as space permits.
CORRESPONDENCE Low-Flow Side A r m s on I n t r o d u c e r s To the Editor: I recently had cause to disassemble an 8 French Cordis introducer (which has been reviewed in Annals as a trauma line twice this year). I was astounded to find that the fluid from the side port attachment must pass through a hole approximately the size of a 22-gauge needle on its way to the 8 French catheter. It is important to note that with this configuration, this port is the rate-limiting portion of the apparatus. Your readers should not confuse the volumedelivering capacity of such an introducer with that of an 8 French catheter (in which the rate-limiting factor is the internal diameter of the Connecting ports of regular intravenous tubing). I feel this is an important consideration, and in a critical situation one should not be misled by the "8 French" diameter of the introducer. Thomas Barry, MD PGY-3 Emergency Medicine Resident Wilmington Medical Center Wilmington, Delaware
To the Editor: Dr Barry has a good point. The problem of low-flow side arms on Swan introducers has been documented and com-
mented on recently.i, 2 Indeed, the side arms of such equipment are inappropriate for resuscitation: gravity flow rate of the Cordis side arm is only 45 cc/minJ Recognizing this problem, the lumen of the side arm tubing and its female hub have now been increased in most brands to permit very high flows - - about 250 cc/min.3, 4 Of course, the placement of a pressure bladder about the IV bag will increase flow to > 600 cc/min. When buying such equipment, "caveat emptor" is the password; one must know the product.
Robert H Dailey, MD Highland General Hospital Oakland, California 1. Benumof J, Trousdale R, Alfery D, et al: Large catheter sheath introducers and their side port functional gauge. Anesth Analg 1981;60:216-217. 2. Apter RL: Large-bore catheter sheaths for large-volume fluids. Ann Emerg Med 1982;11:285. 3. Andersen H, Benumof J, Trousdale F, et al: Increasing the functional gauge of the side port of large catheter sheath introducers. Anesthesiology 1982;56:57-59. 4. Benumof J, Wyte S, Rogers S: A large catheter sheath introducer with an increased side-port functional gauge. Crit Care Med 1983;11:660-662.
D e c o n g e s t a n t s or A n t i h i s t a m i n e s in A c u t e Otitis M e d i a To the Editor: This letter is in reference to the article entitled 'Acute Otitis Media in Children: Are Decongestants or Antihistamines Necessary?" by Bhambani, Foulds, Swamy, Eldis, and Fischel (January 1983;12:13-16). After conducting what is clearly a well-reasoned, carefully planned study regarding the efficacy of decongestants and antihistamines in d o c u m e n t e d acute o t i t i s media (AOM), Bhambani and coworkers raise questions regarding the efficacy of their use. We feel the article may help lead to changes in practice and teaching (previously based on empiric use of these products to improve eustachian tube patency). The following should, therefore, be clarified to aid in the understanding of the applicability of the results: 1. Given that varying antibiotic dosages were used (20 to 40 t~g/kg/day of amoxicillin) throughout experimental and placebo groups, were the groups comparable in terms of numbers of patients 5eceiving any one dose of antibiotics? 2. Given that 90% of the patients studied were black, were the results of the remaining 10% (nonblack) patients comparable when analyzed separately, and did they appear equally throughout the groups? (This i s possibly quite an important consideration in practices dealing with different populations of patients.) Lastly, the article addresses the issue of resolution of established AOM. We wonder whether the use of antihista13:9 September 1984 (Part 1)
mines or decongestants would prove, under controlled study, to be of benefit in resolving prodromal AOM symptomato!ogy (ie, ear pain with minimal erythema; in absence of drum opacification, loss of yellow color or reflux, or obliteration of landmarks) in those predisposed to these infections.
Marc A Cherniwchan, MD Emergency Medicine Journal Club University of Toronto Toronto, Ontario, Canada
Author's Reply: The recommended dose of amoxicillin for the treatment of acute otitis media is 20 to 40 i~g/kg/day 1 based on treatment data published in the literature.2, 3 Patients in our study received doses of 40 ~g/kg/day rounded to the nearest half teaspoon but not exceeding 40 t~g/kg/day and to a maximum of 750 t~g/day (adult dose). Clearly this meant that children weighing more than 20 kg would get less than 40 ~g/kg/day, The groups were comparable in age and weight distribution and, based on this, the groups would be comparable in terms of average dose per kilogram of antibiotic received. Thus we do not think that the outcome of the study, ie, lack of any beneficial effect of decongestants or
Annals of Emergency Medicine
747/159
CORRESPONDENCE Low-Flow Side A r m s on I n t r o d u c e r s To the Editor: I recently had cause to disassemble an 8 French Cordis introducer (which has been reviewed in Annals as a trauma line twice this year). I was astounded to find that the fluid from the side port attachment must pass through a hole approximately the size of a 22-gauge needle on its way to the 8 French catheter. It is important to note that with this configuration, this port is the rate-limiting portion of the apparatus. Your readers should not confuse the volumedelivering capacity of such an introducer with that of an 8 French catheter (in which the rate-limiting factor is the internal diameter of the Connecting ports of regular intravenous tubing). I feel this is an important consideration, and in a critical situation one should not be misled by the "8 French" diameter of the introducer. Thomas Barry, MD PGY-3 Emergency Medicine Resident Wilmington Medical Center Wilmington, Delaware
To the Editor: Dr Barry has a good point. The problem of low-flow side arms on Swan introducers has been documented and com-
mented on recently.i, 2 Indeed, the side arms of such equipment are inappropriate for resuscitation: gravity flow rate of the Cordis side arm is only 45 cc/minJ Recognizing this problem, the lumen of the side arm tubing and its female hub have now been increased in most brands to permit very high flows - - about 250 cc/min.3, 4 Of course, the placement of a pressure bladder about the IV bag will increase flow to > 600 cc/min. When buying such equipment, "caveat emptor" is the password; one must know the product.
Robert H Dailey, MD Highland General Hospital Oakland, California 1. Benumof J, Trousdale R, Alfery D, et al: Large catheter sheath introducers and their side port functional gauge. Anesth Analg 1981;60:216-217. 2. Apter RL: Large-bore catheter sheaths for large-volume fluids. Ann Emerg Med 1982;11:285. 3. Andersen H, Benumof J, Trousdale F, et al: Increasing the functional gauge of the side port of large catheter sheath introducers. Anesthesiology 1982;56:57-59. 4. Benumof J, Wyte S, Rogers S: A large catheter sheath introducer with an increased side-port functional gauge. Crit Care Med 1983;11:660-662.
D e c o n g e s t a n t s or A n t i h i s t a m i n e s in A c u t e Otitis M e d i a To the Editor: This letter is in reference to the article entitled 'Acute Otitis Media in Children: Are Decongestants or Antihistamines Necessary?" by Bhambani, Foulds, Swamy, Eldis, and Fischel (January 1983;12:13-16). After conducting what is clearly a well-reasoned, carefully planned study regarding the efficacy of decongestants and antihistamines in d o c u m e n t e d acute o t i t i s media (AOM), Bhambani and coworkers raise questions regarding the efficacy of their use. We feel the article may help lead to changes in practice and teaching (previously based on empiric use of these products to improve eustachian tube patency). The following should, therefore, be clarified to aid in the understanding of the applicability of the results: 1. Given that varying antibiotic dosages were used (20 to 40 t~g/kg/day of amoxicillin) throughout experimental and placebo groups, were the groups comparable in terms of numbers of patients 5eceiving any one dose of antibiotics? 2. Given that 90% of the patients studied were black, were the results of the remaining 10% (nonblack) patients comparable when analyzed separately, and did they appear equally throughout the groups? (This i s possibly quite an important consideration in practices dealing with different populations of patients.) Lastly, the article addresses the issue of resolution of established AOM. We wonder whether the use of antihista13:9 September 1984 (Part 1)
mines or decongestants would prove, under controlled study, to be of benefit in resolving prodromal AOM symptomato!ogy (ie, ear pain with minimal erythema; in absence of drum opacification, loss of yellow color or reflux, or obliteration of landmarks) in those predisposed to these infections.
Marc A Cherniwchan, MD Emergency Medicine Journal Club University of Toronto Toronto, Ontario, Canada
Author's Reply: The recommended dose of amoxicillin for the treatment of acute otitis media is 20 to 40 i~g/kg/day 1 based on treatment data published in the literature.2, 3 Patients in our study received doses of 40 ~g/kg/day rounded to the nearest half teaspoon but not exceeding 40 t~g/kg/day and to a maximum of 750 t~g/day (adult dose). Clearly this meant that children weighing more than 20 kg would get less than 40 ~g/kg/day, The groups were comparable in age and weight distribution and, based on this, the groups would be comparable in terms of average dose per kilogram of antibiotic received. Thus we do not think that the outcome of the study, ie, lack of any beneficial effect of decongestants or
Annals of Emergency Medicine
747/159