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Pacemakers for prehospital bradyasystolic arrest
CORRESPONDENCE
antihistamines compared to the placebo, is due to the difference in antibiotic dosage. The high prevalence and severity of otitis media among Eskimos 4 and American Indians s has been well established. A few observations 6 in the United States suggest that middle ear disease is both more prevalent and more persistent among whites than among blacks. Studies of larger populations are needed, however, to Clarify this issue. In our study, the number of white patients in each group was small (DIM = 2, BPM = 4, PEH = 4, PL = 2). Two of these 12 patients were lost to follow up after the two-week evaluation. Three of the remaining ten patients were considered treatment failures (BPM = 2, PEH = 1). To arrive at any conclusions based on these small numbers would not be meaningful, and so this issue was not addressed in our manuscript. Lastly, one might question making a diagnosis of prodromal AOM in the absence of any other physical findings of the tympanic membrane except for redness, even in a child predisposed to AOM. Hyperemia of the tympanic membrane is an early sign of otitis media, but this m a y be caused by inflammation elsewhere in the m u c o u s m e m branes continuous from the nares and eustachian tube into the middle ear cleft. Because the use of decongestants7 or antihistamines 8 is controversial even in the prevention of the c o m m o n cold, we might assume that the use of such preparations in the so-called prodromal phase, to prevent development of AOM, may not be beneficial. Perhaps it will be useful to conduct
such a controlled study to resolve this question.
Kanta Bhambani, MD Department of Pediatrics Children's Hospital of Michigan Detroit 1. Behrman RE, Vaughan VC III, Nelson WE (eds): The ear, in a Textbook of Pediatrics, ed 12. Philadelphia, WB Saunders, 1983, p 1022-1031. 2. Jones FD: Treatment of otitis media in pediatric practice: Amoxicillin versus ampicillin. J Infect Dis 1974;129(suppl):S187S188. 3. Ginsberg CM, McCracken GH, Thomas ML, et al: Comparatfve pharmacokinetics of amoxicillin and ampicillin in infants and children. Pediatrics 1979;64:627-631. 4. Kaplan GJ, Fleshman JK, Bender TR, et al: Long-term effects of otitis media. A ten-year cohort study of Alaskan Eskimo children. Pediatrics 1973;52:577-585. 5. Wiet RJ, Stewart J, DeClanc GB, et al: Natural history of otitis media in the American native. Ann OtoI Rhinol Laryngol 1980;89(Suppl 68):i4-19. 6. Griffith TE: Epidemiology of otitis media - - An interracial study. Laryngoscope 1979;89:22-30. 7. Lampert RP, Robinson DS, Soyka LF: A critical look at oral decongestants. Pediatrics 1975;55:550-552. 8. West S, Brandon B, Stolley P, et al: A review of antihistamines and the common cold. Pediatrics 1975;56:100-107.
Pacemakers for Prehospital Bradyasystolic Arrest To the Editor: I read with interest the study of O m a t o et al on pacemaker insertion for prehospital bradyasystolic cardiac arrest (February 1984;13:101-103). This was a retrospective, uncontrolled review of multiple methodologies without specific exclusion or inclusion criteria, subject to sampling error and selection bias. Nonetheless, the dismal survival results corroborate the findings of larger series that retrospectively evaluated transthoracic pacing I and prospectively evaluated immediate transthoracic pacing of all patients with asystole under similar circumstances (unpublished data). While Ornato et al experienced considerably higher rates of electrical capture, at least two explanations exist: superior EMS response and care in the field, and the mixture of bradyasystoiic with asystolic patients, two disparate groups with different response, if not survival, rates. As currently performed, emergency department pacing of out-of-hospital cardiac arrest patients arriving in asystole appears unproductive. Available evidence suggests , however, that transvenous pacer placement w i t h o u t fluoroscopy is uncertain in states of low venous return, 2 that current transthoracic approaches are inaccurate (unpublished data), and that pacing is feasible in the field.3 Accordingly, we are currently engaged in two prospective multicenter investigations of immediate transthoracic pacing in the emergency department and in the field employing more reliable and accurate approachesl 160/748
J Douglas White, MD, Clinical Director Emergency Department Georgetown University Hospital Washington, DC 1. White JD: Transthoracic pacing in cardiac asystole. American Journal of Emergency Medicine 1983;3:264-266: 2. Hazard PB, Benton C, Milner JP: Transvenous cardiac pacing in cardiopulmonary resuscitation. Crit Care Med 1981;9:666-668. 3. Falk RH, Jacobs L, Sinclair A, et al: External noninvasive cardiac pacing in out-of-hospital cardiac arrest. Crit Care Med 1983;11:779-782.
Author's Reply: In a n ongoing study of out-of-hospital nontraurnatic cardiac arrest, we are finding that patients presenting with bradyasystole, compared to patients initially found to be in ventricular fibrillation, have been down longer in the field prior to arrival of the paramedic unit. As a group, they are more likely to be severely acidotic on arrival in the emergency department and to respond poorly to drug intervention. Our pacemaker study confirmed that pacing will save very few of these patients if initiated after the patient arrives in the emergency department. By then, it appears to be
Annals of Emergency Medicine
13:9 September 1984 (Part 1)
antihistamines compared to the placebo, is due to the difference in antibiotic dosage. The high prevalence and severity of otitis media among Eskimos 4 and American Indians s has been well established. A few observations 6 in the United States suggest that middle ear disease is both more prevalent and more persistent among whites than among blacks. Studies of larger populations are needed, however, to Clarify this issue. In our study, the number of white patients in each group was small (DIM = 2, BPM = 4, PEH = 4, PL = 2). Two of these 12 patients were lost to follow up after the two-week evaluation. Three of the remaining ten patients were considered treatment failures (BPM = 2, PEH = 1). To arrive at any conclusions based on these small numbers would not be meaningful, and so this issue was not addressed in our manuscript. Lastly, one might question making a diagnosis of prodromal AOM in the absence of any other physical findings of the tympanic membrane except for redness, even in a child predisposed to AOM. Hyperemia of the tympanic membrane is an early sign of otitis media, but this m a y be caused by inflammation elsewhere in the m u c o u s m e m branes continuous from the nares and eustachian tube into the middle ear cleft. Because the use of decongestants7 or antihistamines 8 is controversial even in the prevention of the c o m m o n cold, we might assume that the use of such preparations in the so-called prodromal phase, to prevent development of AOM, may not be beneficial. Perhaps it will be useful to conduct
such a controlled study to resolve this question.
Kanta Bhambani, MD Department of Pediatrics Children's Hospital of Michigan Detroit 1. Behrman RE, Vaughan VC III, Nelson WE (eds): The ear, in a Textbook of Pediatrics, ed 12. Philadelphia, WB Saunders, 1983, p 1022-1031. 2. Jones FD: Treatment of otitis media in pediatric practice: Amoxicillin versus ampicillin. J Infect Dis 1974;129(suppl):S187S188. 3. Ginsberg CM, McCracken GH, Thomas ML, et al: Comparatfve pharmacokinetics of amoxicillin and ampicillin in infants and children. Pediatrics 1979;64:627-631. 4. Kaplan GJ, Fleshman JK, Bender TR, et al: Long-term effects of otitis media. A ten-year cohort study of Alaskan Eskimo children. Pediatrics 1973;52:577-585. 5. Wiet RJ, Stewart J, DeClanc GB, et al: Natural history of otitis media in the American native. Ann OtoI Rhinol Laryngol 1980;89(Suppl 68):i4-19. 6. Griffith TE: Epidemiology of otitis media - - An interracial study. Laryngoscope 1979;89:22-30. 7. Lampert RP, Robinson DS, Soyka LF: A critical look at oral decongestants. Pediatrics 1975;55:550-552. 8. West S, Brandon B, Stolley P, et al: A review of antihistamines and the common cold. Pediatrics 1975;56:100-107.
Pacemakers for Prehospital Bradyasystolic Arrest To the Editor: I read with interest the study of O m a t o et al on pacemaker insertion for prehospital bradyasystolic cardiac arrest (February 1984;13:101-103). This was a retrospective, uncontrolled review of multiple methodologies without specific exclusion or inclusion criteria, subject to sampling error and selection bias. Nonetheless, the dismal survival results corroborate the findings of larger series that retrospectively evaluated transthoracic pacing I and prospectively evaluated immediate transthoracic pacing of all patients with asystole under similar circumstances (unpublished data). While Ornato et al experienced considerably higher rates of electrical capture, at least two explanations exist: superior EMS response and care in the field, and the mixture of bradyasystoiic with asystolic patients, two disparate groups with different response, if not survival, rates. As currently performed, emergency department pacing of out-of-hospital cardiac arrest patients arriving in asystole appears unproductive. Available evidence suggests , however, that transvenous pacer placement w i t h o u t fluoroscopy is uncertain in states of low venous return, 2 that current transthoracic approaches are inaccurate (unpublished data), and that pacing is feasible in the field.3 Accordingly, we are currently engaged in two prospective multicenter investigations of immediate transthoracic pacing in the emergency department and in the field employing more reliable and accurate approachesl 160/748
J Douglas White, MD, Clinical Director Emergency Department Georgetown University Hospital Washington, DC 1. White JD: Transthoracic pacing in cardiac asystole. American Journal of Emergency Medicine 1983;3:264-266: 2. Hazard PB, Benton C, Milner JP: Transvenous cardiac pacing in cardiopulmonary resuscitation. Crit Care Med 1981;9:666-668. 3. Falk RH, Jacobs L, Sinclair A, et al: External noninvasive cardiac pacing in out-of-hospital cardiac arrest. Crit Care Med 1983;11:779-782.
Author's Reply: In a n ongoing study of out-of-hospital nontraurnatic cardiac arrest, we are finding that patients presenting with bradyasystole, compared to patients initially found to be in ventricular fibrillation, have been down longer in the field prior to arrival of the paramedic unit. As a group, they are more likely to be severely acidotic on arrival in the emergency department and to respond poorly to drug intervention. Our pacemaker study confirmed that pacing will save very few of these patients if initiated after the patient arrives in the emergency department. By then, it appears to be
Annals of Emergency Medicine
13:9 September 1984 (Part 1)