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Survival after cardiopulmonary resuscitation in the hospital
TETANUS, PROPHYLAXIS
Adequacy of antitetanus prophylaxis in six hospital emergency rooms. Brand DA, Acampora D, Gottlieb LD, et al N Engl J Med 309:636-640
Sep 1983
Twenty-three percent of patients treated at hospital emergency departments were treated incorrectly (6% undertreated and 17% overtreated)with tetanus toxoid or human tetanus immunoglobulin. This was determined by prospectively studying 620 patients seen by 169 physicians in six hospital emergency departments. Wounds were classified into three categories: very tetanus prone (contaminated by greater than 10s bacteria per gram, over 24 hours old, or containing devitalized tissue that cannot be debrided); moderately tetanus prone (contaminated by 102 to 10s bacteria per gram, crush injury or puncture wound, or wounds extending into muscle); and non-tetanus prone. If a patient were fully immunized and had received a tetanus booster within five years, no treatment was required for all categories of wounds. Only patients with moderate or very tetanus-prone wounds who were fully i m m u n i z e d and received their last booster 5 to 10 years before required a tetanus booster. AI1 patients who were fully immunized and had had a booster more than 10 years previously, required only a tetanus booster. Ali patients with incomplete immunization or uncertain history required tetanus tox0id and human tetanus immunoglobulin in doses of 250 U for patients with moderate and 500 U for very tetanus-prone wounds. Current recommendations include administration of tetanus and diphtheria toxoids (Td)rather than tetanus toxoid alone. Philip L Henneman, MD
NEAR-DROWNING
Correlation of spontaneous respiration and neurologic damage in near-drowning Jacobsen WK, Mason LJ, Briggs BA, et al
after ED stabilization. The other 50% were apneic. In the nonapneic group, 62% of the patients returned to their prenear-drowning status. Thirty-eight percent were physically or mentallyslower than before, but were able to function. In the apneic group, 31% of patients survived with incapacitating brain damage, while the remainder eventually died. Thus resumption of spontaneous breathing after resuscitation from near-drowning is a favorable prognostic indicator. This holds true even for patients who initially have a flaccid CNS motor examination. Marc J Gorayeb, MD
TETANUS IMMUNIZATION
Transplacental immunization of the human fetus to tetanUs by immunization of the mother Gill TJ, Repetti CF, Metlay LA, et al J Cfin Invest 72:987-996
The immune response to tetanus toxoid was studied in the offspring of 42 women who received it during the 5th and 8th months of pregnancy. The response was compared to the response of the offspring of 20 unimmunized women. Only the offspring of immunized women had antitetanus IgM antibody prior to DPT immunization. They also had a more rapid response to DPT (P .01) and they remained highly sensitized at 13 months of age. The authors conclude that transplacental immunization occurs in human beings , that it enhances the antibody response to subsequent immunization, and that it may be useful to circumvent the need to immunize in early neonatal life. [Editor's note: This study underscores the fact that pregnancy is not a contraindication to adrnmistration of tetanus toxoid and, m fact, it m a y be beneficial to the infant in the neonatal period.] Steve Silverstein, MD
CARDIOPULMONARY RESUSCITATION, SURVIVAL
Survival after cardiopulmonarY resuscitation in the hospital
Crit Care Med 11:487-489
Jul t983
Bedell SE, Delbanco TL, Cook EF, et al
Twenty-six near-drowned children with a Glascow Coma Scale (GCS) of 4 or less were admitted to a medical center. All cases occurred in warm fresh water. Immersion times ranged from 3 to 15 minutes. All patients required CPR at the scene and in the ED, where advanced life support measures were instituted. All patients required at least 5 to 15 minutes of CPR before a spontaneous pulse was obtained. Body temperature ranged from 35 to 37 C and PQ2 exceeded 80 torr. In the ICU the patients were treated with barbiturates, hypothermia, positive pressure ventilation, fluid management, and cardiovascular drugs when necessary. Barbiturates and hypothermia were continued for 60 to 72 hours. Thirteen of the patients (50%) had spontaneous respirations 13:1 January 1984
Annals of
N Engl J Med 309:569-576
Sep 1983
To determine prognostic factors for survival after cardiopulmonary resuscitation in the hospital, 294 consecutive patients who were resuscitated were prospectively studied. A total of 128 (44%) survived the initial resuscitation, but 31 died within 24 hours and 56 died in the hospital, leaving only 41 (14%)who were discharged. Of those patients discharged, eight (20%) were dead within six months. None of the patients with pneumonia (57), urinary output less than 300 cc per day (87), sepsis (42), or acute stroke (16) before their arrest survived. Only two of 75 patients with BUN
EmergencyMedicine
75/129
ABSTRACTS
greater than 50 and six of 137 patients previously confined to their home before hospitalization survived. Survival figures for arrests lasting less than 15 minutes, longer than 15 minutes, and longer than 30 minutes were 44%, 5% and 0%, respectively. Patients resuscitated within 15 minutes who were alert and did not require pressors 24 hours after their arrest had a survival rate of 92%. However, of patients whose resuscitation was longer than 15 minutes and who were comatose or who required pressors, only 12% survived. At discharge, 38 of 41 patients were alert and oriented, but all were severely depressed and reported a decrease m functional status. [Editor's note: Although this study was performed on all inpatients, its results may be helpful to the ED physician in deciding when to terminate ACLS. Of particular interest is that there were no survivors in the group who required CPR for longer than 30 minutes.] Philip L Henneman, MD
8.75% of the patients were lost to follow up. Seventy-seven percent of patients reported no complications, while 23% reported minor complications. No major complications occurred, and there Were no "delayed hemo/pneumothoraces." The authors estimate a savings of $991.80 per patient with outpatient versus inpatient treatment. They propose that 3 to 4 hours of observation is adequate if history, physical examination, Vital signs, and CXR indicate a benign injury. The data suggest that prophylactic antibiotics are not warranted, a n d that a follow up CXR is unnecessary unless clinical deterioration is evident. Grant D Innes, MD
ACUTE MYOCARDIAL INFARCTION; ST DEPRESSION
"Reciprocal" depression of the ST segment in acute myocardial infarction
GUNSHOT WOUNDS, CHEST
Jennings K, Reid S, Julian D G Br Med J 287:634-637
Outpatient m a n a g e m e n t of 357 gunshot wounds to the chest
Sep 1983
Ordog GJ, Balasubramaniam S, Wasserberger J
Traditionally ST depression in leads distant from those showing the ST elevation of acute myocardial infarction has been considered to be "reciprocal" and a benign electrical oddity. More recently, many have considered such changes to be a reflection of ischemia in those distant areas. In this study, 103 patients with definite myocardial infarctions were studied~ 35% had reciprocal changes, and of these, about equal numbers had anterior or inferior infarcts. These patients were compared with infarct patients not demonstrating reciprocal changes. Prior to discharge, patients were treadmill tested, and 63% of those who had had reciprocal changes demonstrated ischemia compared to only 19% of MI patients without reciprocal changes. Additionally, of 30 patients who subsequently underwent coronary angiography, 13 of 14 (93%) with reciprocal changes had a greater than 50% stenosis of the artery supplying the "reciprocal" area, while 15 of 22 patients (68%)without reciprocal changes had multivessel disease. Patients with reciprocal changes had larger infarcts as measured by CK levels, and they also had more frequent in-hospital ventricular fibrillation. [Editor's note: This study will not alter emergency department management of acute myocardial infarction, but may have important implications for the infarct patient's continuing care and long-term prognosis.] Gerald B Pogoriler, MD
J Trauma 23:832-835
Sep 1983
The availability and increasing use of handguns has led to rising numbers of civilian gunshot wounds. This study prospectively reviews 357 gunshot wounds to the chest in victims aged 3 to 60 (mean age, 22.5 years). Handguns and shotguns were (in order) the two most commonly used weapons. The shoulder area was the most frequent site of injury, followed by the anterior and posterior chest. Leftsided wounds were twice as common as right-sided wounds. Multiple Wounds were present in 32% of victims, and most often involved the arms. Drugs or alcohol were present in 30% of victims. Patients with stable vital signs, a "superficial" wound, and a normal physical examination were treated as outpatients if initial inspiratory/expiratory chest films were normal. Laboratory investigations usually obtained included CBC, electrolytes, glucose, BUN, urinalysis, alcohol, and toxicology screen. Wounds were irrigated, debrided, and dressed, but not closed primarily. Appropriate tetanus immunization was provided, and 73% of patients received prophylactic antibiotics. Repeat chest films were not done. Mean time in the emergency department was 4.59 hours. Follow up was scheduled for two, 30, and 90 days; only
130/76
Annals of EmergencyMedicine
13:1 January 1984
Adequacy of antitetanus prophylaxis in six hospital emergency rooms. Brand DA, Acampora D, Gottlieb LD, et al N Engl J Med 309:636-640
Sep 1983
Twenty-three percent of patients treated at hospital emergency departments were treated incorrectly (6% undertreated and 17% overtreated)with tetanus toxoid or human tetanus immunoglobulin. This was determined by prospectively studying 620 patients seen by 169 physicians in six hospital emergency departments. Wounds were classified into three categories: very tetanus prone (contaminated by greater than 10s bacteria per gram, over 24 hours old, or containing devitalized tissue that cannot be debrided); moderately tetanus prone (contaminated by 102 to 10s bacteria per gram, crush injury or puncture wound, or wounds extending into muscle); and non-tetanus prone. If a patient were fully immunized and had received a tetanus booster within five years, no treatment was required for all categories of wounds. Only patients with moderate or very tetanus-prone wounds who were fully i m m u n i z e d and received their last booster 5 to 10 years before required a tetanus booster. AI1 patients who were fully immunized and had had a booster more than 10 years previously, required only a tetanus booster. Ali patients with incomplete immunization or uncertain history required tetanus tox0id and human tetanus immunoglobulin in doses of 250 U for patients with moderate and 500 U for very tetanus-prone wounds. Current recommendations include administration of tetanus and diphtheria toxoids (Td)rather than tetanus toxoid alone. Philip L Henneman, MD
NEAR-DROWNING
Correlation of spontaneous respiration and neurologic damage in near-drowning Jacobsen WK, Mason LJ, Briggs BA, et al
after ED stabilization. The other 50% were apneic. In the nonapneic group, 62% of the patients returned to their prenear-drowning status. Thirty-eight percent were physically or mentallyslower than before, but were able to function. In the apneic group, 31% of patients survived with incapacitating brain damage, while the remainder eventually died. Thus resumption of spontaneous breathing after resuscitation from near-drowning is a favorable prognostic indicator. This holds true even for patients who initially have a flaccid CNS motor examination. Marc J Gorayeb, MD
TETANUS IMMUNIZATION
Transplacental immunization of the human fetus to tetanUs by immunization of the mother Gill TJ, Repetti CF, Metlay LA, et al J Cfin Invest 72:987-996
The immune response to tetanus toxoid was studied in the offspring of 42 women who received it during the 5th and 8th months of pregnancy. The response was compared to the response of the offspring of 20 unimmunized women. Only the offspring of immunized women had antitetanus IgM antibody prior to DPT immunization. They also had a more rapid response to DPT (P .01) and they remained highly sensitized at 13 months of age. The authors conclude that transplacental immunization occurs in human beings , that it enhances the antibody response to subsequent immunization, and that it may be useful to circumvent the need to immunize in early neonatal life. [Editor's note: This study underscores the fact that pregnancy is not a contraindication to adrnmistration of tetanus toxoid and, m fact, it m a y be beneficial to the infant in the neonatal period.] Steve Silverstein, MD
CARDIOPULMONARY RESUSCITATION, SURVIVAL
Survival after cardiopulmonarY resuscitation in the hospital
Crit Care Med 11:487-489
Jul t983
Bedell SE, Delbanco TL, Cook EF, et al
Twenty-six near-drowned children with a Glascow Coma Scale (GCS) of 4 or less were admitted to a medical center. All cases occurred in warm fresh water. Immersion times ranged from 3 to 15 minutes. All patients required CPR at the scene and in the ED, where advanced life support measures were instituted. All patients required at least 5 to 15 minutes of CPR before a spontaneous pulse was obtained. Body temperature ranged from 35 to 37 C and PQ2 exceeded 80 torr. In the ICU the patients were treated with barbiturates, hypothermia, positive pressure ventilation, fluid management, and cardiovascular drugs when necessary. Barbiturates and hypothermia were continued for 60 to 72 hours. Thirteen of the patients (50%) had spontaneous respirations 13:1 January 1984
Annals of
N Engl J Med 309:569-576
Sep 1983
To determine prognostic factors for survival after cardiopulmonary resuscitation in the hospital, 294 consecutive patients who were resuscitated were prospectively studied. A total of 128 (44%) survived the initial resuscitation, but 31 died within 24 hours and 56 died in the hospital, leaving only 41 (14%)who were discharged. Of those patients discharged, eight (20%) were dead within six months. None of the patients with pneumonia (57), urinary output less than 300 cc per day (87), sepsis (42), or acute stroke (16) before their arrest survived. Only two of 75 patients with BUN
EmergencyMedicine
75/129
ABSTRACTS
greater than 50 and six of 137 patients previously confined to their home before hospitalization survived. Survival figures for arrests lasting less than 15 minutes, longer than 15 minutes, and longer than 30 minutes were 44%, 5% and 0%, respectively. Patients resuscitated within 15 minutes who were alert and did not require pressors 24 hours after their arrest had a survival rate of 92%. However, of patients whose resuscitation was longer than 15 minutes and who were comatose or who required pressors, only 12% survived. At discharge, 38 of 41 patients were alert and oriented, but all were severely depressed and reported a decrease m functional status. [Editor's note: Although this study was performed on all inpatients, its results may be helpful to the ED physician in deciding when to terminate ACLS. Of particular interest is that there were no survivors in the group who required CPR for longer than 30 minutes.] Philip L Henneman, MD
8.75% of the patients were lost to follow up. Seventy-seven percent of patients reported no complications, while 23% reported minor complications. No major complications occurred, and there Were no "delayed hemo/pneumothoraces." The authors estimate a savings of $991.80 per patient with outpatient versus inpatient treatment. They propose that 3 to 4 hours of observation is adequate if history, physical examination, Vital signs, and CXR indicate a benign injury. The data suggest that prophylactic antibiotics are not warranted, a n d that a follow up CXR is unnecessary unless clinical deterioration is evident. Grant D Innes, MD
ACUTE MYOCARDIAL INFARCTION; ST DEPRESSION
"Reciprocal" depression of the ST segment in acute myocardial infarction
GUNSHOT WOUNDS, CHEST
Jennings K, Reid S, Julian D G Br Med J 287:634-637
Outpatient m a n a g e m e n t of 357 gunshot wounds to the chest
Sep 1983
Ordog GJ, Balasubramaniam S, Wasserberger J
Traditionally ST depression in leads distant from those showing the ST elevation of acute myocardial infarction has been considered to be "reciprocal" and a benign electrical oddity. More recently, many have considered such changes to be a reflection of ischemia in those distant areas. In this study, 103 patients with definite myocardial infarctions were studied~ 35% had reciprocal changes, and of these, about equal numbers had anterior or inferior infarcts. These patients were compared with infarct patients not demonstrating reciprocal changes. Prior to discharge, patients were treadmill tested, and 63% of those who had had reciprocal changes demonstrated ischemia compared to only 19% of MI patients without reciprocal changes. Additionally, of 30 patients who subsequently underwent coronary angiography, 13 of 14 (93%) with reciprocal changes had a greater than 50% stenosis of the artery supplying the "reciprocal" area, while 15 of 22 patients (68%)without reciprocal changes had multivessel disease. Patients with reciprocal changes had larger infarcts as measured by CK levels, and they also had more frequent in-hospital ventricular fibrillation. [Editor's note: This study will not alter emergency department management of acute myocardial infarction, but may have important implications for the infarct patient's continuing care and long-term prognosis.] Gerald B Pogoriler, MD
J Trauma 23:832-835
Sep 1983
The availability and increasing use of handguns has led to rising numbers of civilian gunshot wounds. This study prospectively reviews 357 gunshot wounds to the chest in victims aged 3 to 60 (mean age, 22.5 years). Handguns and shotguns were (in order) the two most commonly used weapons. The shoulder area was the most frequent site of injury, followed by the anterior and posterior chest. Leftsided wounds were twice as common as right-sided wounds. Multiple Wounds were present in 32% of victims, and most often involved the arms. Drugs or alcohol were present in 30% of victims. Patients with stable vital signs, a "superficial" wound, and a normal physical examination were treated as outpatients if initial inspiratory/expiratory chest films were normal. Laboratory investigations usually obtained included CBC, electrolytes, glucose, BUN, urinalysis, alcohol, and toxicology screen. Wounds were irrigated, debrided, and dressed, but not closed primarily. Appropriate tetanus immunization was provided, and 73% of patients received prophylactic antibiotics. Repeat chest films were not done. Mean time in the emergency department was 4.59 hours. Follow up was scheduled for two, 30, and 90 days; only
130/76
Annals of EmergencyMedicine
13:1 January 1984