Ventricular Fibrillation in Pediatric Cardiac Arrest

Correspondence Another Positive-Pressure Tip Charles V PollackJr, MA, MD, FACEP Ventricular Fibrillation in Pediatric Cardiac Arrest LiMa Quan, MD, FACEP, FAAP Cyndra Mogayzd, MD Emergency Medicine and Health Care Reform Otto F Rogers, MD Reply Lewis Goldfrank, MD Relief of Capsaicin Contact Dermatitis William Anderson, MD, FACEP Reply SaraIyn R Williams, MD Richard F Clark, MD No Support for Intravenous Lidocaine Airway Reflex Suppression During Rapid Sequence Intubation R Ben Zemenick, DO, FACEP Kombucha "Mushroom" Hepatotoxicity Andrew D Perton, MD Julie A Patterson, MD Norman N Yanofsky, MD Pulse Oximet~7 Monitoring: Blinded by the Light, Lulled by the Beeps Steven D Nathan, MD Frederick L Glauser, MD

Copyright © by the American College of Emergency Physicians.

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Another PositivePressure Tip

endorse his policy of congratulating the caregived

To the Editor.

Charles V PollackJr, MA, AdD,FACEP Departmentof EmergencyMedicine Maricopa Medical Center Phoenix, Arizona

I read with interest Dr Backlin's description of a mouth-to-mouth positive-pressure technique for the expulsion of nasal foreign bodies in children [July 1995;25:554-555]. I was taught this technique by an elderly sage, a general practitioner, years ago, and like Dr Backlin I have used it successfully and atraumaticalty with several patients. I was also taught, however, a "user-friendly" modification of the reported method. A 4x4-inch gauze pad can be shaped into a "parachute" and positioned outside the obstructed nostril, between the faces of the patient and the caregiver. Properly placed, this gauze will not only capture the escaping foreign body but make postprocedure cleanup a bit more agreeable for the caregiver. Although I suggest this change in Dr Backlin's protocol, I heartily

Ventricular Fibrillation in Pediatric Cardiac Arrest To the Editor: In three recent studies of pediatric out-of-hospital cardiac arrest, the frequency of ventricular fibrillation (VF) varied from 11% to 19% [July 1995;25:484-491 (Mogayzel et al), 492-494 (Appleton et al), 495-501 (Hickey et al)]. Hazinski [July 1995;25:540-543] questioned the reason for the differences. We believe the explanation rests with differences in the determination of both the numerators (number of ventricular fibrillation cases) and the denominators (number of car-

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diac arrest resuscitations) among the three studies. The first difference is case identification. Whereas Appleton et al relied solely on computer identification of VF from the emergency medical services (EMS) cardiac arrest database, we {Mogayzel et al) reviewed the medical incident forms and Hickey et al reviewed the charts for each pediatric cardiac arrest case identified by their database. The last method would tend to enhance case identification. The second difference is inclusion criteria. Appleton et al included sudden infant death syndrome (SIDS) cases and excluded trauma patients. They found prevalences of VF of 3% in 0- to 7-year-elds, 11% in 8- to 14year-olds, and 18% in 15-to 19-yearolds. The decreased prevalence of VF in the youngest age group was probably due to the increased number of asystolic cases due to SIDS. Inclusion or exclusion of SIDS and trauma cases is a significant issue. SIDS represents 25% of reported series of out-of-hospital pediatric cardiac arrest ~,z, and trauma accounted for 55% to 70% of the cardiac arrest cases studied by Hickey et al and by us and for two of the five VF survivors studied by Megayzel at el. If the objective of a study is to characterize a prehospital experience or frequency of procedures, then SIDS and trauma victims shou/d be included. If the goal is to test or describe effectiveness of an

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intervention or predictors of outcome, SIDS victims should be excluded. The third difference is exclusion criteria. The most likely explanation for the different VF prevatences and the more significant research issue is probably the definition of cardiac arrest resuscitation. Of the 287 cardiac arrest patients in the King County, Washington, EMS database, we excluded 118 (42%} because the narrative report described stiffness or dependent lividity. If these patients are included the prevalence of VF is 1fl of 278, the same 6% Appleton found in his unreviewed patients aged 0 to 19 years old. Despite the existence of EMS system protocols for deciding when and in whom to attempt resuscitation, EMS personnel are often more aggressive in their response to and care of the pediatric patient than in the adult patient. Therefore the cases of pediatric patients in EMS cardiac arrest databases demand scrutiny. The real question iz; not, What is the prevalence of VF in the pediatric patient? The real question is, What factor or factors are associated with good outcome? Our CPR guidelines are based on the we/I-documented high prevalence of respiratory causes of pediatric cardiac arrest but on no other data. Despite the highest level of prehospital arway care provided, none of the inLact survivors in our patient population had a respiratory cause of arrest, presumany because the patients with hypoxic insults were not salvageable. A major pediatric CPR challenge is to determine what conditions are salvageable and to write guidelines accordingly.

Linda Ouan, MD, FACEP,FAAP Cyndra Mogayzel, MD Department of Pediatrics University of Washington School of Medicine Seattle, Washington i. Eisenberg M, Bergner L, Hallstrom A: Epidemiolog7 of cardiac arrest and

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resuscitation in children. Ann Ernerg Med 1983;12:672- 674. 2. Losek JD, Hennes H, Glaser P, et al: Prehospital care of the pulseless, nonbreathing pediatric patient. Am J Emerg Meal 1987;5:370-374.

Emergency Medicine and Health Care Reform To the Editor. ) found the recent article by Goldfrank [June 1995;25:692-694] shocking. Because it was an editorial in Annals of EmergencyMedicine, do the members of ACEPshare Dr Goldfrank's Ol~inions?I certainly hope net. Dr Goldfrank's basic premise seems to be that the only two choices in the current health care debate ere a sinpie-payer universal-coveragesystem and regression to social Darwinism That is utter nonsense. Social Darwinism was rejected by all thinking people long ago. It has no place in the current debate. I do not favor a single-payer system, but by Dr Goldfrank's logic l must therefore be a social Darwinist. Wake up, Dr Goldfrank--there are many other ways to improve our health care system besides your single-payer system. Because a single-payer system was net imposed on us by Congress, there are now literally thousands of health care reform experiments going on across the country. What will the final "system" look like? Only time will tell. I have enough confidence in the creative people of America that the "system" will be far more humane, innovative, efficient, and higher in quality than any monolithic single-payer system. Our society has a vested interest in having a healthy population. Therefore it is everyone's interest that immunization rates be high, that infant mortality rates be low, and that many other prevention methods he emphasized. It is also

ANNALS OF EMERGENCY MEDICINE

in everyone's interest for health care to be of high quality (because quality costs less in the long run), available, and efficient. Most of this can be done in the private sector, so let the race for the best solutions continue. WlTat we are seeing is real reform, not fuzzy promises that somehow guarantee the medical equivalent of a free lunch for everyone. The problem is that the ride we are on is and will be very rough. Quick an~Jperfect solutions to our health care problems do not exist. The solutions to our problems are being created in that muchmaligned central area of our society called the marketplace. Where, then, does emergency medicine fit into this massive reform we are seeing? Exactly in the middle. We truly are the safety net. We have a difficult but rewarding job to play in the health care system of today and in the future. The well thought out article by Dr Young and Dr Sklar in the same issue of Annals [April 1995; 25:666-674] did an excellent job of summarizing the problems health care reform presents to our society.

Otto F Rogers, MD Director of Emergency Services Highsmith-Rainey Hospital Fayettevilfe, North Carolina In reply. I am impressed with Dr Rogers' optimism and faith in the marketplace, but I analyze the evolving health care changes differently, Entrance into the marketplace usually requires money, the very commodity the poor seem to lack. In the current marketplace, while budgets are being slashed for patient care, there is a dramatic increase in the salaries of tile leaders of health care and managed care organizations. This is an unconscionable reallocation of our scarce resources. I believe that health care is a right. The fact that 40 million Americans

remain uninsured in our thriving marketplace is a national disgrace.

Lewis Goldfrank, MD Director of Emergency Services New York University and Bellevue Hospital Centers Medical Director of the New York City Poison Control Center New York, New York i

Relief of Capsaicin Contact Dermatitis To the Editor. With regard to a recent Annals article [May 1995;25:713-715], it has been my experience that repeated application of milk compresses is the best analgesic measure for the burning sensation caused by accidental exposure to the capsaicin in chili peppers. This is correlative to the relief milk provides the capsaicinexposed era! mucosa during adventures in exotic dining.

William Anderson, MD, FACEP Laguna Beach, Cafifomia In reply. New ideas are always weiceme in the treatment of any challenging diagnosis such as contact dermatitis associated with capsaicin. We appreciate the input from Dr Andersen with regard to his experiencewith the application of milk compresses to the affected area. Many home remedies have been suggested for capsaicin pain relief, ranging from vinegar~to vegetable oil immersion.2 The most consistent relief reported in the literature2,3 is achieved with the application of l/docaine jelly to the affected area. Oral analgesics may also be used. However, a remedy such as a milk compress may certainly be tried for initial management.

Saraiyn R Williams, MD Richard F Clark, MD University of Cafifomia, San Diego, Medical Center San Diego, California

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