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Hemodynamic effects of rate during open-chest resuscitation
2 groups using the 2-tailed Student t test (a = .05). Comparable types of infecting organisms were cultured as revealed by multin o m i a l c h i - s q u a r e analysis w i t h c o r r e c t i o n for c o n t i n u i t y (~ = .05). When comparing the 2 regimens, the ceftriaxone group cure rate (18/20 = 90%) was not significantly different from that of the TMS-treated control group (13/13 = 100%), using the 2tailed Student t test {~ = .05). Type II error at the 50% level equals .13.
0
Lymphadenitis: Natural History and Response to Percutaneous Aspiration
G Fleisher, MD, FACEP, J Grosflam; S Selbst, MD; S Ludwig, MD / Emergency Department, The Children's Hospital of Philadelphia, PhiLadelphia Children frequently seek treatment in the emergency department (ED) for enlarged lymph nodes, often the result of a bacterial infection. While the etiologic agents of lymphadenitis in childhood have been defined clearly, optimal treatment remains uncertain. We studied lymphadenitis in children seen in an ED to determine the course of patients with fluctuant and nonfluctuant infections and to assess the roles of antibiotics, percutaneous needle aspiration (PNA), and surgical drainage as forms of therapy. During a 9-month period, all children who were diagnosed as having localized lymph node enlargement were contacted and followed by the investigators, who reviewed daily computer listings from the ED by diagnosis. The protocol called for administration of antistaphylococcal antibiotics to every patient with lymphadenitis, and for PNA of fluctuant lesions; surgical drainage was reserved for treatment failures. Forty-two children were diagnosed as having enlarged nodes, due in 32 cases to bacterial lymphadenitis. Thirty of the 32 (94%) were followed until their lesions resolved; at diagnosis, 26 had nonfluctuant and 4 had fluctuant infections. These 30 patients ranged in age from 3 mo to 17 yr; children with fluctuant nodes were younger (P < .05, t test). Subsequently fluctuanee developed in 4 of 26 lymph nodes that initially were firm to palpation. All 8 children with fluctuant lesions resolved their infections following PNA and antibiotic therapy, and 25 of 26 with initially nonfluctuant infections were cured with antibiotic therapy alone or accompanied by PNA (4 cases) when fluctuance developed. S t a p h y l o c o c c u s a u r e u s , the only pathogen isolated, was recovered from 5 infected nodes. We r e c o m m e n d antistaphylococcal antibiotics plus P N A for the treatment of lymphadenitis whenever abscess formation is detected clinically. Surgical drainage or excision should be reserved for persistent infections.
1
Hemodynamic Effects of Rate During Open-Chest Resuscitation
RL Bartlett, MD; NJ Stewart, MD; J) Raymond, MD; GL Anstadt, DVM; SD Martin, EMT / Department of Emergency Medicine, Richland Memorial Hospital, Columbia, SC Prolonged CPR using closed-chest compression (CCC) is associated with poor survival rates and neurological outcomes. The magnitude and distribution of blood flow to vital organs during CCC are inadequate after 5 to 10 rain. There is a growing body of evidence to support the use of open-chest manual compression of the heart (OCMC) for potentially salvageable patients who do not respond to standard ACLS. Del Guercio and others have reported several patients who, after failing CCC, were resuscitated successfully using OCMC. Although O C M C was first demonstrated to be an effective method of resuscitation in 1898, few studies have addressed the technical aspects of its use. Confusion still exists regarding the appropriate rate of compression. With little experimental support, it has been assumed generally that a rate of compression of 60 or less will produce the best results. Objections to the use of faster rates cite the need for an adequate ventricular filling time between compressions. This study was designed to evaluate the hemodynamic effects of compression rate during OCMC. Ventricular fibrillation was induced in 5 dogs.
13:5 May 1984
They initially were given 10 min of CCC at 60/rain, followed by 10 rain of OCMC at 60 and then 10 min of O C M C at 90. CCC produced a cardiac index (CI) of 886 {20% of pre-arrest value [PAV]), with a mean arterial pressure (MAP) of 25 m m Hg (22% of PAV). O C M C at 60 produced a CI of 1,698 (39% of PAV) with a MAP of 53 m m Hg [47% of PAV) (P < .01 and .0005, respectively, when compared to CCC). O C M C at 90 increased the CI to 2,018 [46% of PAV) and the MAP to 67 m m Hg (59% of PAV). These increases in CI and MAP with OCMC at 90 were both significant (P < .05) whcn compared to OCMC at 60. Calculation of the stroke index (SI) during O C M C at 60 and 90 revealed a decrease from 28 to 22 mL/compression. Increasing the compression rate during O C M C does decrease the SI (P < .05). However, the net effect of an increase in rate is an increase in MAP and CI. Blood flows and pressures can be improved substantially by using OCMC. Use of compression rates faster than 60/min will produce additional hemodynamic improvements.
2
Comparison of Open.Chest Cardiac Massage Techniques in Dogs
.WM Barnett, MD; JK Alifinoff, MD; PM Paris, MD; RD Stewart, MD; P Safar, MD / Affiliated Residency in Emergency Medicine, Resuscitation Research Center, and Department of Anesthesiology/Critical Care Medicine, University of Pittsburgh; and Center for Emergency Medicine, Pittsburgh Manual compression of the heart during open-chest cardiac massage (OCPR) has been shown to be superior to closed-chest compression. This study sought to determine, in a canine model, the optimal hand position for manual compression of the heart. Twelve dogs were anesthetized with ketamine and orally intubated, and a n e s t h e s i a was m a i n t a i n e d w i t h n i t r o u s oxide, halothane, and pancuronium. Cannulae were placed to monitor diastolic (DBP) and systolic (SBP) blood pressures, intracranial pressure (ICP), and common carotid blood flow (CCBF). Control values were obtained under light general anesthesia and ventricular fibrillation was then induced. External CPR (ECPR) was performed with a mechanical compressor before opening the chest and pericardium through the left fifth interspace. A randomized sequence of 3 hand positions was used for OCPR, as follows: T e c h n i q u e A - - One-handed technique with thumb on left ventricle, fingers over the right ventricle, and apex in palm; T e c h n i q u e B - - Two-handed t e c h n i q u e w i t h right ventricle cupped in left hand and fingers of right hand over left ventricle; and T e c h n i q u e C - - One-handed technique with fingers of right hand over left ventricle and heart against sternum. Each was done at a rate of 60 compressions per minute with the operator blind to results during performance. All 3 techniques produced significantly greater {P < .05) DBP and CCBF when compared with ECPR. All 3 also produced significantly lower (P < .05} ICP when compared with ECPR. DBP, SBP, CCBF, and cerebral perfusion pressures were similar for techniques B and C and all were significantly greater (P < .05} than those achieved with technique A. These data suggest that techniques B and C may produce greater cardiac and cerebral blood flow during OCPR.
3
Comparative Study of Closed.Chest Compression, Open-Chest Manual Compression, and Direct Mechanical Ventricular Assistance
RL Bartlett, MD, NJ Stewart, MD; JI Raymond, MD; GL Anstadt, DVM; SD Martin, EMT / Department of Emergency Medicine, Richland Memorial Hospital, Columbia, SC Current cardiac arrest studies indicate that closed-chest c o m pression (CCC) does not provide adequate coronary and cerebral perfusion for more than 5 to 10 rain. Ditchey demonstrated coronary blood flow to be less than 1% of pre-arrest values during CCC. Cerebral perfusion studies suggest that CCC cannot reliably supply a cortical blood flow at more than 10% of normal values after the first 10 rain of resuscitation. A case control study
Annals of EmergencyMedicine
397/133
0
Lymphadenitis: Natural History and Response to Percutaneous Aspiration
G Fleisher, MD, FACEP, J Grosflam; S Selbst, MD; S Ludwig, MD / Emergency Department, The Children's Hospital of Philadelphia, PhiLadelphia Children frequently seek treatment in the emergency department (ED) for enlarged lymph nodes, often the result of a bacterial infection. While the etiologic agents of lymphadenitis in childhood have been defined clearly, optimal treatment remains uncertain. We studied lymphadenitis in children seen in an ED to determine the course of patients with fluctuant and nonfluctuant infections and to assess the roles of antibiotics, percutaneous needle aspiration (PNA), and surgical drainage as forms of therapy. During a 9-month period, all children who were diagnosed as having localized lymph node enlargement were contacted and followed by the investigators, who reviewed daily computer listings from the ED by diagnosis. The protocol called for administration of antistaphylococcal antibiotics to every patient with lymphadenitis, and for PNA of fluctuant lesions; surgical drainage was reserved for treatment failures. Forty-two children were diagnosed as having enlarged nodes, due in 32 cases to bacterial lymphadenitis. Thirty of the 32 (94%) were followed until their lesions resolved; at diagnosis, 26 had nonfluctuant and 4 had fluctuant infections. These 30 patients ranged in age from 3 mo to 17 yr; children with fluctuant nodes were younger (P < .05, t test). Subsequently fluctuanee developed in 4 of 26 lymph nodes that initially were firm to palpation. All 8 children with fluctuant lesions resolved their infections following PNA and antibiotic therapy, and 25 of 26 with initially nonfluctuant infections were cured with antibiotic therapy alone or accompanied by PNA (4 cases) when fluctuance developed. S t a p h y l o c o c c u s a u r e u s , the only pathogen isolated, was recovered from 5 infected nodes. We r e c o m m e n d antistaphylococcal antibiotics plus P N A for the treatment of lymphadenitis whenever abscess formation is detected clinically. Surgical drainage or excision should be reserved for persistent infections.
1
Hemodynamic Effects of Rate During Open-Chest Resuscitation
RL Bartlett, MD; NJ Stewart, MD; J) Raymond, MD; GL Anstadt, DVM; SD Martin, EMT / Department of Emergency Medicine, Richland Memorial Hospital, Columbia, SC Prolonged CPR using closed-chest compression (CCC) is associated with poor survival rates and neurological outcomes. The magnitude and distribution of blood flow to vital organs during CCC are inadequate after 5 to 10 rain. There is a growing body of evidence to support the use of open-chest manual compression of the heart (OCMC) for potentially salvageable patients who do not respond to standard ACLS. Del Guercio and others have reported several patients who, after failing CCC, were resuscitated successfully using OCMC. Although O C M C was first demonstrated to be an effective method of resuscitation in 1898, few studies have addressed the technical aspects of its use. Confusion still exists regarding the appropriate rate of compression. With little experimental support, it has been assumed generally that a rate of compression of 60 or less will produce the best results. Objections to the use of faster rates cite the need for an adequate ventricular filling time between compressions. This study was designed to evaluate the hemodynamic effects of compression rate during OCMC. Ventricular fibrillation was induced in 5 dogs.
13:5 May 1984
They initially were given 10 min of CCC at 60/rain, followed by 10 rain of OCMC at 60 and then 10 min of O C M C at 90. CCC produced a cardiac index (CI) of 886 {20% of pre-arrest value [PAV]), with a mean arterial pressure (MAP) of 25 m m Hg (22% of PAV). O C M C at 60 produced a CI of 1,698 (39% of PAV) with a MAP of 53 m m Hg [47% of PAV) (P < .01 and .0005, respectively, when compared to CCC). O C M C at 90 increased the CI to 2,018 [46% of PAV) and the MAP to 67 m m Hg (59% of PAV). These increases in CI and MAP with OCMC at 90 were both significant (P < .05) whcn compared to OCMC at 60. Calculation of the stroke index (SI) during O C M C at 60 and 90 revealed a decrease from 28 to 22 mL/compression. Increasing the compression rate during O C M C does decrease the SI (P < .05). However, the net effect of an increase in rate is an increase in MAP and CI. Blood flows and pressures can be improved substantially by using OCMC. Use of compression rates faster than 60/min will produce additional hemodynamic improvements.
2
Comparison of Open.Chest Cardiac Massage Techniques in Dogs
.WM Barnett, MD; JK Alifinoff, MD; PM Paris, MD; RD Stewart, MD; P Safar, MD / Affiliated Residency in Emergency Medicine, Resuscitation Research Center, and Department of Anesthesiology/Critical Care Medicine, University of Pittsburgh; and Center for Emergency Medicine, Pittsburgh Manual compression of the heart during open-chest cardiac massage (OCPR) has been shown to be superior to closed-chest compression. This study sought to determine, in a canine model, the optimal hand position for manual compression of the heart. Twelve dogs were anesthetized with ketamine and orally intubated, and a n e s t h e s i a was m a i n t a i n e d w i t h n i t r o u s oxide, halothane, and pancuronium. Cannulae were placed to monitor diastolic (DBP) and systolic (SBP) blood pressures, intracranial pressure (ICP), and common carotid blood flow (CCBF). Control values were obtained under light general anesthesia and ventricular fibrillation was then induced. External CPR (ECPR) was performed with a mechanical compressor before opening the chest and pericardium through the left fifth interspace. A randomized sequence of 3 hand positions was used for OCPR, as follows: T e c h n i q u e A - - One-handed technique with thumb on left ventricle, fingers over the right ventricle, and apex in palm; T e c h n i q u e B - - Two-handed t e c h n i q u e w i t h right ventricle cupped in left hand and fingers of right hand over left ventricle; and T e c h n i q u e C - - One-handed technique with fingers of right hand over left ventricle and heart against sternum. Each was done at a rate of 60 compressions per minute with the operator blind to results during performance. All 3 techniques produced significantly greater {P < .05) DBP and CCBF when compared with ECPR. All 3 also produced significantly lower (P < .05} ICP when compared with ECPR. DBP, SBP, CCBF, and cerebral perfusion pressures were similar for techniques B and C and all were significantly greater (P < .05} than those achieved with technique A. These data suggest that techniques B and C may produce greater cardiac and cerebral blood flow during OCPR.
3
Comparative Study of Closed.Chest Compression, Open-Chest Manual Compression, and Direct Mechanical Ventricular Assistance
RL Bartlett, MD, NJ Stewart, MD; JI Raymond, MD; GL Anstadt, DVM; SD Martin, EMT / Department of Emergency Medicine, Richland Memorial Hospital, Columbia, SC Current cardiac arrest studies indicate that closed-chest c o m pression (CCC) does not provide adequate coronary and cerebral perfusion for more than 5 to 10 rain. Ditchey demonstrated coronary blood flow to be less than 1% of pre-arrest values during CCC. Cerebral perfusion studies suggest that CCC cannot reliably supply a cortical blood flow at more than 10% of normal values after the first 10 rain of resuscitation. A case control study
Annals of EmergencyMedicine
397/133