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Effect of volume on the endotracheal absorption of lidocaine
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
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Fixed Atlanto.Axial Rotatory Subluxation: A Radiographic Finding of Questionable Clinical Significance
Annals of Emergency Medicine
14:8 August 1985
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