- Email: [email protected]
Spinal epidural abscess in the pediatric age group: Case report and review of the literature
ABSTRACTS
patients who presented to the first aid station, 84% refused transport to the ED, including 7% who refused ALS care. Of the 16% transported, 34 were by basic life support and 37 by ALS. No deaths or adverse outcomes were reported. The authors state that the main problem encountered was poor documentation (which was effectively dealt with in the quality assurance reviews). The authors conclude that physicians do not need to be present at small to moderate-sized mass gatherings with adequate on-line communication in which on-scene time is less than 30 minutes in the absence of initiation of on-line medical control. Nick Peters, MD
Cardiac arrest presenting with rhythms other than ventricular fibrillation: Contribution of resuscitative efforts toward total survivorship PopePE, LevineRL, FrommREJr, et al Crit Care Med 21:1838-1843 Oec 1993 The authors prospectively studied 2,404 consecutive cardiac arrest (pulseless and apneic) patients greater than 18 years old who were treated by the Houston Emergency Medical Services system during a two-year period (1989 to 1990). Apneic, pulseless patients associated with a primary respiratory etiology, airway obstruction, submersion, trauma, or drug overdose (prospectively included under a broader database) were excluded for the purposes of this study as non-cardiac arrest. Study patients were categorized according to presenting ECG rhythm, as: 1) ventricular tachycardia/ventricular fibrillation (VT/VF), 2) asystote, 3) idioventricular rhythm (IVR), and 4) electromechanical dissociation (EMD). Presenting ECGs
MAY 1994
23:5
were defined as the initial reading obtained by paramedics or recording of automated defibrillators. Average response time from the first telephone ring at the 911 dispatch conter to arrival at the scene was five minutes for first responders and less than ten minutes for advanced life support providers. Of the 2,404 study patients (mean age, 65 + 14 years, 63% men), 193 (8%)survived (defined by successful hospital discharge). Only 9.7% of cardiac arrests were witnessed by paramedics ("monitored" arrest), but these accounted for 39 of the 193 survivors. Bystanders performed cardiopulmonary resuscitation (CPR)in 26% of the unmonitored arrests. Overall, cardiac arrest was confirmed as being witnessed in 42% of unmonitored survivors, with 65% of these involving bystander CPR.The performance of bystander CPR in witnessed arrest was correlated with survival (P= .015). Of 974 patients found in VT/VF, 150 (15.4%) survived, while 14 of 868 (1.6%) in asystole, 18 of 387 (4.7%)in IVR, 10 of 155 (6.5%)in EMD, and one of 20 (5%) in an unknown rhythm survived to hospital discharge. Thus, more than one fifth (22.2%) of patients who survived cardiac arrest in this study presented with a rhythm other than VT/VF. The authors conclude that these survival rates for asystole, lVR, and EMD are similar to other reported studies and emphasize the reasonable need to provide aggressive (initial) resuscitative attempts despite the presenting rhythm. In addition, the authors conclude that cardiac arrest patients presenting without VT/VF were unlikely to survive when the arrest was unwitnessed and bystander CPRwas not performed. GaryR Figge, MD
ANNALS OF EMERGENCY MEDICINE
Spinal epidural abscess in the pediatric age group: Case report and review of the literature Rubin G, Michowiz SD, AshkenasiA, et al Pediatr Infect Dis J 12.1007-1911 Dec 1993 This article reviews 57 reported cases of spinal epidural abscess in the pediatric age group. It emphasizes that early diagnosis and prompt treatment are crucial to avoid permanent paralysis and death. Early symptoms appearing before major neurologic deficit were described in 41 cases. Back pain (83%), fever (59%), and meningismus (34%) were the most common presenting symptoms in children. In infants, fever (73%) and irritability (64%) were common. The probable source of infection was found in 51 cases: hematogenous spread from previous soft tissue infection (26 cases), direct extension from primary infection (13 cases), and nonpenetrating spinal trauma (12 cases). The abscess was located in the thoraco and/or lumbar region in two of the three cases, and Staphylococcus aureuswas the sole responsible bacterium in 80% of cases. An aggressive workup in children with fever and back pain is suggested. The authors state that magnetic resonance imaging (MRI) is the imaging technique of choice and suggest antibiotic coverage with nafcillin and a third-generation cephalosporin. Ninety percent of cases diagnosed and treated before neurologic deficit had complete recovery. Kathleen Bratt, MD
The interactions of midazolam and fiumazenil on human memory and cognition GhoneimMM, BlockRI, Sum Ping ST, et al Anesthesiology 79.I 183-1192 Dec 1993 This prospective, randomized, double-blind crossover study evaluated the effect of flumazenil on the memory and mood alterations induced by midazolam on health volunteers. The total group of 72 subjects was divided equally into three groups that received either 0.05 mg/kg placebo or 0.5 mg/kg midazolam IV. Subjects then were asked to perform tasks that evaluated both their direct and indirect memory functions and to assess their mood and level of sedation. A single dose of either 1 mg placebo or 3 mg flumazenil then was given, and the same parameters were recorded five and then 30 minutes after the administration of flumazenil; a delayed memory test then was performed at two hours. Each subject was retested twice at one-week intervals so that responses to placebo and each dose of flumazenil were recorded. The patient groups showed no statistical difference when compared on the basis of age, education, body size, or use of tobacco or "recreational" drugs. Both the low and high doses of midazolam induced sedation and impaired memory-related tasks. Both doses of flumazenil completely reversed these effects within 30 minutes. Flumazenil given to subjects who received placebo reported no behavioral effects. The authors conclude that fiumazenil successfully reverses both the sedative and amnestic effects of midazolam. Robert J Levine, MD
116 5
patients who presented to the first aid station, 84% refused transport to the ED, including 7% who refused ALS care. Of the 16% transported, 34 were by basic life support and 37 by ALS. No deaths or adverse outcomes were reported. The authors state that the main problem encountered was poor documentation (which was effectively dealt with in the quality assurance reviews). The authors conclude that physicians do not need to be present at small to moderate-sized mass gatherings with adequate on-line communication in which on-scene time is less than 30 minutes in the absence of initiation of on-line medical control. Nick Peters, MD
Cardiac arrest presenting with rhythms other than ventricular fibrillation: Contribution of resuscitative efforts toward total survivorship PopePE, LevineRL, FrommREJr, et al Crit Care Med 21:1838-1843 Oec 1993 The authors prospectively studied 2,404 consecutive cardiac arrest (pulseless and apneic) patients greater than 18 years old who were treated by the Houston Emergency Medical Services system during a two-year period (1989 to 1990). Apneic, pulseless patients associated with a primary respiratory etiology, airway obstruction, submersion, trauma, or drug overdose (prospectively included under a broader database) were excluded for the purposes of this study as non-cardiac arrest. Study patients were categorized according to presenting ECG rhythm, as: 1) ventricular tachycardia/ventricular fibrillation (VT/VF), 2) asystote, 3) idioventricular rhythm (IVR), and 4) electromechanical dissociation (EMD). Presenting ECGs
MAY 1994
23:5
were defined as the initial reading obtained by paramedics or recording of automated defibrillators. Average response time from the first telephone ring at the 911 dispatch conter to arrival at the scene was five minutes for first responders and less than ten minutes for advanced life support providers. Of the 2,404 study patients (mean age, 65 + 14 years, 63% men), 193 (8%)survived (defined by successful hospital discharge). Only 9.7% of cardiac arrests were witnessed by paramedics ("monitored" arrest), but these accounted for 39 of the 193 survivors. Bystanders performed cardiopulmonary resuscitation (CPR)in 26% of the unmonitored arrests. Overall, cardiac arrest was confirmed as being witnessed in 42% of unmonitored survivors, with 65% of these involving bystander CPR.The performance of bystander CPR in witnessed arrest was correlated with survival (P= .015). Of 974 patients found in VT/VF, 150 (15.4%) survived, while 14 of 868 (1.6%) in asystole, 18 of 387 (4.7%)in IVR, 10 of 155 (6.5%)in EMD, and one of 20 (5%) in an unknown rhythm survived to hospital discharge. Thus, more than one fifth (22.2%) of patients who survived cardiac arrest in this study presented with a rhythm other than VT/VF. The authors conclude that these survival rates for asystole, lVR, and EMD are similar to other reported studies and emphasize the reasonable need to provide aggressive (initial) resuscitative attempts despite the presenting rhythm. In addition, the authors conclude that cardiac arrest patients presenting without VT/VF were unlikely to survive when the arrest was unwitnessed and bystander CPRwas not performed. GaryR Figge, MD
ANNALS OF EMERGENCY MEDICINE
Spinal epidural abscess in the pediatric age group: Case report and review of the literature Rubin G, Michowiz SD, AshkenasiA, et al Pediatr Infect Dis J 12.1007-1911 Dec 1993 This article reviews 57 reported cases of spinal epidural abscess in the pediatric age group. It emphasizes that early diagnosis and prompt treatment are crucial to avoid permanent paralysis and death. Early symptoms appearing before major neurologic deficit were described in 41 cases. Back pain (83%), fever (59%), and meningismus (34%) were the most common presenting symptoms in children. In infants, fever (73%) and irritability (64%) were common. The probable source of infection was found in 51 cases: hematogenous spread from previous soft tissue infection (26 cases), direct extension from primary infection (13 cases), and nonpenetrating spinal trauma (12 cases). The abscess was located in the thoraco and/or lumbar region in two of the three cases, and Staphylococcus aureuswas the sole responsible bacterium in 80% of cases. An aggressive workup in children with fever and back pain is suggested. The authors state that magnetic resonance imaging (MRI) is the imaging technique of choice and suggest antibiotic coverage with nafcillin and a third-generation cephalosporin. Ninety percent of cases diagnosed and treated before neurologic deficit had complete recovery. Kathleen Bratt, MD
The interactions of midazolam and fiumazenil on human memory and cognition GhoneimMM, BlockRI, Sum Ping ST, et al Anesthesiology 79.I 183-1192 Dec 1993 This prospective, randomized, double-blind crossover study evaluated the effect of flumazenil on the memory and mood alterations induced by midazolam on health volunteers. The total group of 72 subjects was divided equally into three groups that received either 0.05 mg/kg placebo or 0.5 mg/kg midazolam IV. Subjects then were asked to perform tasks that evaluated both their direct and indirect memory functions and to assess their mood and level of sedation. A single dose of either 1 mg placebo or 3 mg flumazenil then was given, and the same parameters were recorded five and then 30 minutes after the administration of flumazenil; a delayed memory test then was performed at two hours. Each subject was retested twice at one-week intervals so that responses to placebo and each dose of flumazenil were recorded. The patient groups showed no statistical difference when compared on the basis of age, education, body size, or use of tobacco or "recreational" drugs. Both the low and high doses of midazolam induced sedation and impaired memory-related tasks. Both doses of flumazenil completely reversed these effects within 30 minutes. Flumazenil given to subjects who received placebo reported no behavioral effects. The authors conclude that fiumazenil successfully reverses both the sedative and amnestic effects of midazolam. Robert J Levine, MD
116 5