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Intravenous phenytoin in acute treatment of seizures
Transtracheal intubation: guidelines for safety. Pratter MR, Irwin RS, Chest 76:518-520, 1979.
stage of ED therapy which would most benefit from an objective test to help define disposition.) Frederick K. Seydel, MD
The charts of 100 consecutive and unselected patients having transtracheaI aspiration performed between 1974 and 1978 werereviewed in order to determine those patients at risk for developing life-threatening complications. Twenty different physicians performed the procedure under a rigid protocol: 1) the patients are able to cooperate and have a clearly identifiable and normal cricothyroid membrane; 2) the procedure is done only by well-trained or supervised physicians; 3) the patients have a PO2 of at least 70 mm Hg on supplemental oxygen; 4) the protime is at least 65% of control or there is a normal bleeding time or the platelet count is at least 100,000; 5) the patient receives no IPPB or treatments which might induce coughing for at least 24 hr after the procedure. Adherence to each part of the protocol ranged from 92% to 100%. Indications for the procedure were presence of pulmonary infiltrates considered likely to be infectious, where accurate bacteriologic information was considered necessary for maximum benefit to the patient. Information obtained was considered of no value if aspirated material contained previously swallowed methylene blue dye (2/44 patients). The complicatidns occurring included minimal subcutaneous emphysema (limited to the anterior portion of the neck) in 19% (10/52 patients), pneumomediastinum without pneumothorax in 3% (3/93 patients), gross but self-limited hemoptysis in one patient with normal clotting studies and platelet count, and occasional PVCs in one patient. The authors conclude that transtracheal aspiration is a safe procedure when performed by trained physicians under a standard protocol. The value of the procedure has presumably been established in previously published studies. (Editor's note: It may well be that the indications for the procedure may have been too rigidly defined in this retrospective study, but it does suggest that one should define the bleeding parameters before undertaking the invasion in the ED.) Ken Kulig, MD
asthma, evaluation of severity, patient versus physician
intubation, transtracheal, protocol; transtracheal intubation, protocol Evaluation of the severity of asthma: patients versus physicians. Shim CS, Williams MH, Am J Med 68:11-13, 1980. In an effort to assess the severity of airway obstruction, 35 asthmatic patients were asked to subjectively estimate the degree of obstruction on multiple visits to a pulmonary disease clinic. The opinions of the patients about the status of their disease were compared with objective measurements of peak expiratory flow rate and the assessment on physical examination by their pulmonary physicians. Physicians were quite inaccurate in estimating the peak expiratory flow rates, but the patients themselves were able to guess the measurements with far greater accuracy. Additionally, the patients were able to tell changes in their peak expiratory flow rates from day to day. Other symptoms, such as cough and a feeling of tightness in the chest, were also noted to be helpful in evaluating the status of the asthma, although these symptoms were not included in the study. The authors note that therapy should depend not only on how much obstruction is present, either by measurement or by the patient's estimate, but also on symptoms which may be independent of bronchoconstriction. (Editor's note: It is a common ED experience to find patients subjectively improved where physical findings [wheezes, increased respirations] are still present. It is this
9:12 (December) 1980
Shotgun arterial injuries of the extremities. Raju S, Am J Surg 138:421-425, 1979. The author reviewed 39 shotgun wounds (SGW) and 72 gunshot wounds (GSW) of the arteries of the extremities during a 13-year period to differentiate the differences of damage inflicted on extremities. His review found several important and significant differences. The type of arterial injury inflicted was usually a single lesion in GSW versus multiple lesions of extensive lengths of arteries associated with thrombosis in SGW. It was felt this accounted for the difference in distal ischemia (74% in GSW versus 90% in SGW) as well. Most importantly, SGW had significantly higher incidence of deep infection (36% versus 13%) as well as amputation (21% versus 2%) of the involved extremity. The remaining patients had a significantly higher incidence of severe permanent functional deficits (9% of GSW versus 58% of SGW). He concluded that pre-operative Or intra-operative arteriograms are obligatory in SGW to the extremities due to muliplicity and wide dispersion of arterial injuries. For the same reasons, he felt early prophylactic fasciotomy was necessary. Finally, the author concluded that shotgun arterial wounds of the extremity carry a poor prognosis for the ultimate function and rehabilitation of the injured limb. (Editor's note: The importance of arteriography is not always appreciated with S G W since there is usually clinical evidence of ischemia, but without it one may miss a subtle distant arterial injury.)
John Tucker, MD arterial injury, extremities, shotgun; extremities, arterial injury, shotgun; shotgun wounds, arterial injury, extremities
Intravenous phenytoin in acute treatment of seizures. Cranford RE, Leppik IE, Patrick B, et al, Neurology (NY) 29:1474-1479, 1979. A three-year prosPective study involving 137 patients was conducted to assess the response of seizures to intravenous phenytoin. A mean dose of 16.4 mg/kgm was given IV at a rate of 50 mg/min. One third Of patients had previously received Valium. The patients' response to therapy fell into two groups. The first group (99 patients) consisted of those patients with pre-existing epilepsy, ie, an exacerbation of previously controlled seizures or alcohol withdrawal seizures. This subset showed excellent response to phenytoin administration. The second group, consisting of those patients (38) with acute brain lesions, ie, encephalopathy, vascular disease, brain tumor or trauma, showed poor response to phenytein. The most common complication of IV phenytoin administration was hypotension, but this was always reversed by decreasing the rate of administration. No deaths in this series were attributed to phenytoin. (Editor's note: Defining status epilepticus may not be easy when seeing the first or second seizure. I f Valiuin is chosen as the initial therapy, it should be rapidly followed by Dilantin. We, too, have been doing a study on I V administration and confirm initially the safety.) Ken Jackimczyk, MD
phenytoin, intravenous, treatment of seizures; seizures, treatment with intravenous phenytoin
Ann Emerg Med
654/81
stage of ED therapy which would most benefit from an objective test to help define disposition.) Frederick K. Seydel, MD
The charts of 100 consecutive and unselected patients having transtracheaI aspiration performed between 1974 and 1978 werereviewed in order to determine those patients at risk for developing life-threatening complications. Twenty different physicians performed the procedure under a rigid protocol: 1) the patients are able to cooperate and have a clearly identifiable and normal cricothyroid membrane; 2) the procedure is done only by well-trained or supervised physicians; 3) the patients have a PO2 of at least 70 mm Hg on supplemental oxygen; 4) the protime is at least 65% of control or there is a normal bleeding time or the platelet count is at least 100,000; 5) the patient receives no IPPB or treatments which might induce coughing for at least 24 hr after the procedure. Adherence to each part of the protocol ranged from 92% to 100%. Indications for the procedure were presence of pulmonary infiltrates considered likely to be infectious, where accurate bacteriologic information was considered necessary for maximum benefit to the patient. Information obtained was considered of no value if aspirated material contained previously swallowed methylene blue dye (2/44 patients). The complicatidns occurring included minimal subcutaneous emphysema (limited to the anterior portion of the neck) in 19% (10/52 patients), pneumomediastinum without pneumothorax in 3% (3/93 patients), gross but self-limited hemoptysis in one patient with normal clotting studies and platelet count, and occasional PVCs in one patient. The authors conclude that transtracheal aspiration is a safe procedure when performed by trained physicians under a standard protocol. The value of the procedure has presumably been established in previously published studies. (Editor's note: It may well be that the indications for the procedure may have been too rigidly defined in this retrospective study, but it does suggest that one should define the bleeding parameters before undertaking the invasion in the ED.) Ken Kulig, MD
asthma, evaluation of severity, patient versus physician
intubation, transtracheal, protocol; transtracheal intubation, protocol Evaluation of the severity of asthma: patients versus physicians. Shim CS, Williams MH, Am J Med 68:11-13, 1980. In an effort to assess the severity of airway obstruction, 35 asthmatic patients were asked to subjectively estimate the degree of obstruction on multiple visits to a pulmonary disease clinic. The opinions of the patients about the status of their disease were compared with objective measurements of peak expiratory flow rate and the assessment on physical examination by their pulmonary physicians. Physicians were quite inaccurate in estimating the peak expiratory flow rates, but the patients themselves were able to guess the measurements with far greater accuracy. Additionally, the patients were able to tell changes in their peak expiratory flow rates from day to day. Other symptoms, such as cough and a feeling of tightness in the chest, were also noted to be helpful in evaluating the status of the asthma, although these symptoms were not included in the study. The authors note that therapy should depend not only on how much obstruction is present, either by measurement or by the patient's estimate, but also on symptoms which may be independent of bronchoconstriction. (Editor's note: It is a common ED experience to find patients subjectively improved where physical findings [wheezes, increased respirations] are still present. It is this
9:12 (December) 1980
Shotgun arterial injuries of the extremities. Raju S, Am J Surg 138:421-425, 1979. The author reviewed 39 shotgun wounds (SGW) and 72 gunshot wounds (GSW) of the arteries of the extremities during a 13-year period to differentiate the differences of damage inflicted on extremities. His review found several important and significant differences. The type of arterial injury inflicted was usually a single lesion in GSW versus multiple lesions of extensive lengths of arteries associated with thrombosis in SGW. It was felt this accounted for the difference in distal ischemia (74% in GSW versus 90% in SGW) as well. Most importantly, SGW had significantly higher incidence of deep infection (36% versus 13%) as well as amputation (21% versus 2%) of the involved extremity. The remaining patients had a significantly higher incidence of severe permanent functional deficits (9% of GSW versus 58% of SGW). He concluded that pre-operative Or intra-operative arteriograms are obligatory in SGW to the extremities due to muliplicity and wide dispersion of arterial injuries. For the same reasons, he felt early prophylactic fasciotomy was necessary. Finally, the author concluded that shotgun arterial wounds of the extremity carry a poor prognosis for the ultimate function and rehabilitation of the injured limb. (Editor's note: The importance of arteriography is not always appreciated with S G W since there is usually clinical evidence of ischemia, but without it one may miss a subtle distant arterial injury.)
John Tucker, MD arterial injury, extremities, shotgun; extremities, arterial injury, shotgun; shotgun wounds, arterial injury, extremities
Intravenous phenytoin in acute treatment of seizures. Cranford RE, Leppik IE, Patrick B, et al, Neurology (NY) 29:1474-1479, 1979. A three-year prosPective study involving 137 patients was conducted to assess the response of seizures to intravenous phenytoin. A mean dose of 16.4 mg/kgm was given IV at a rate of 50 mg/min. One third Of patients had previously received Valium. The patients' response to therapy fell into two groups. The first group (99 patients) consisted of those patients with pre-existing epilepsy, ie, an exacerbation of previously controlled seizures or alcohol withdrawal seizures. This subset showed excellent response to phenytoin administration. The second group, consisting of those patients (38) with acute brain lesions, ie, encephalopathy, vascular disease, brain tumor or trauma, showed poor response to phenytein. The most common complication of IV phenytoin administration was hypotension, but this was always reversed by decreasing the rate of administration. No deaths in this series were attributed to phenytoin. (Editor's note: Defining status epilepticus may not be easy when seeing the first or second seizure. I f Valiuin is chosen as the initial therapy, it should be rapidly followed by Dilantin. We, too, have been doing a study on I V administration and confirm initially the safety.) Ken Jackimczyk, MD
phenytoin, intravenous, treatment of seizures; seizures, treatment with intravenous phenytoin
Ann Emerg Med
654/81