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Which children with febrile seizures need lumbar puncture?
bation (ETA). The mean PO, increased significantly from 83.6+ 110.4 mm Hg with EGTA ventilation to 189* 167.5 mm Hg after ETA. The mean Pcoz fell from 77.1~34 to 57.8* 34.4 mm Hg (PC .OOl). The authors conclude that endotracheal intubation remains the procedure of choice for airway management in out-of-hospital cardiac arrest. [Steve Silverstein, MD] Editor’s Note: As the authors note, their data actually compare the respiratory efficacy of field resuscitation with an EGTA and in-hospital resuscitation with an ETA. Their study adds to the expanding body of literature indicating that endotracheal intubation is the preferred method of airway management in the prehospital care phase of resuscitation.
0 POTENTIAL ADVERSE EFFECTS OF VOLUME LOADING ON PERFUSION OF VITAL ORGANS DURING CLOSED-CHEST RESUSCITATION. Ditchey RV , Lindenfeld JA. Circulation 1984; 69:181-189. The objective of this study was to determine the effects of blood volume expansion on vital organ perfusion pressure and blood flow duting closed chest cardiopulmonary resuscitation (CPR). Intracranial, ascending aortic, and right atrial pressures were recorded, and total and regional blood flow measured with radioactive microspheres during CPR in 12 dogs before and after the rapid infusion of 1 L of normal saline or 10% dextran solution. Total forward blood flow increased from 327.1 to 692.7 mL/min (P< .Ol) with volume loading. Blood flow to the cerebral hemispheres, cerebellum, brainstem, kidneys, and ventricular myocardium, however, was found to be significantly decreased postvolume loading. Extracranial brachiocephalic blood flow increased substantially after volume expansion and was accompanied by a significant increase in common carotid blood flow. It is postulated that these findings are due to the effects of volume loading on systemic vascular resistance during CPR. Disproportionate increases in right atria1 and intracranial pressures relative to aortic pressure after volume loading were found to reduce the average pressure differences generated across the coronary and cerebral circulations, perhaps adversely affecting the inherent autoregulatory mechanisms. The authors conclude that large increments of blood volume during CPR can reduce vital organ perfusion
despite an increase in total forward blood flow. [M. Jane Scott, MD]
0 WHICH CHILDREN WITH FEBRILE SEIZURES NEED LUMBAR PUNCTURE? Joffe A, McCormick M, DeAngelis C. Am J Dis Chifd 1983; 137:1153-1156. The purpose of this study was to identify factors obtainable from the history and physical exam that would serve as a screening test for the presence of meningitis in patients 6 months to 6 years of age presenting with a first febrile seizure to guide in the selection of patients warranting lumbar puncture (LP). The charts of 241 children presenting with a first seizure and fever undergoing LP were reviewed: 228 patients (94.6%) did not have meningitis, 13 children (5.4%) had CSF pleocytosis, and 11 of the 13 had positive CSF cultures for bacteria. Statistical analysis of 12 preselected items from the history and physical exam revealed that five items discriminated significantly between children who had meningitis and those who did not. These were (1) visit to a physician within 48 hours prior to the seizure, (2) seizure in the emergency department, (3) focal (vs generalized) seizure, (4) suspicious findings on physical exam (petechiae, cyanosis, hypotension, grunting respirations), and (5) abnormal findings on neurologic exam. Performing an LP in any child with at least one of these risk factors would have correctly identified all patients with meningitis and would have spared 62% of children without meningitis the need for an LP. The authors conclude that routine LP is not warranted if these risk factors are lacking, assuming a careful history and physical are performed and immediate follow-up for children not undergoing an LP is available. [A. Adam Cwinn, MD]
Editor’s Note: The authors address a valid controversy, that all children with a first febrile seizure may not need to undergo lumbar puncture. Their criteria for LP, however, should be viewed with caution. The frequency with which patients obtain medical care varies with their perception of illness and the accessibility of care. The first criteria for LP, therefore, should not be generalized to all groups; the last four criteria suggest an obvious need for LP. Further studies may be able to define more generalized clinical and laboratory guidelines for performing lumbar puncture in children with a first febrile seizure.
0 POTENTIAL ADVERSE EFFECTS OF VOLUME LOADING ON PERFUSION OF VITAL ORGANS DURING CLOSED-CHEST RESUSCITATION. Ditchey RV , Lindenfeld JA. Circulation 1984; 69:181-189. The objective of this study was to determine the effects of blood volume expansion on vital organ perfusion pressure and blood flow duting closed chest cardiopulmonary resuscitation (CPR). Intracranial, ascending aortic, and right atrial pressures were recorded, and total and regional blood flow measured with radioactive microspheres during CPR in 12 dogs before and after the rapid infusion of 1 L of normal saline or 10% dextran solution. Total forward blood flow increased from 327.1 to 692.7 mL/min (P< .Ol) with volume loading. Blood flow to the cerebral hemispheres, cerebellum, brainstem, kidneys, and ventricular myocardium, however, was found to be significantly decreased postvolume loading. Extracranial brachiocephalic blood flow increased substantially after volume expansion and was accompanied by a significant increase in common carotid blood flow. It is postulated that these findings are due to the effects of volume loading on systemic vascular resistance during CPR. Disproportionate increases in right atria1 and intracranial pressures relative to aortic pressure after volume loading were found to reduce the average pressure differences generated across the coronary and cerebral circulations, perhaps adversely affecting the inherent autoregulatory mechanisms. The authors conclude that large increments of blood volume during CPR can reduce vital organ perfusion
despite an increase in total forward blood flow. [M. Jane Scott, MD]
0 WHICH CHILDREN WITH FEBRILE SEIZURES NEED LUMBAR PUNCTURE? Joffe A, McCormick M, DeAngelis C. Am J Dis Chifd 1983; 137:1153-1156. The purpose of this study was to identify factors obtainable from the history and physical exam that would serve as a screening test for the presence of meningitis in patients 6 months to 6 years of age presenting with a first febrile seizure to guide in the selection of patients warranting lumbar puncture (LP). The charts of 241 children presenting with a first seizure and fever undergoing LP were reviewed: 228 patients (94.6%) did not have meningitis, 13 children (5.4%) had CSF pleocytosis, and 11 of the 13 had positive CSF cultures for bacteria. Statistical analysis of 12 preselected items from the history and physical exam revealed that five items discriminated significantly between children who had meningitis and those who did not. These were (1) visit to a physician within 48 hours prior to the seizure, (2) seizure in the emergency department, (3) focal (vs generalized) seizure, (4) suspicious findings on physical exam (petechiae, cyanosis, hypotension, grunting respirations), and (5) abnormal findings on neurologic exam. Performing an LP in any child with at least one of these risk factors would have correctly identified all patients with meningitis and would have spared 62% of children without meningitis the need for an LP. The authors conclude that routine LP is not warranted if these risk factors are lacking, assuming a careful history and physical are performed and immediate follow-up for children not undergoing an LP is available. [A. Adam Cwinn, MD]
Editor’s Note: The authors address a valid controversy, that all children with a first febrile seizure may not need to undergo lumbar puncture. Their criteria for LP, however, should be viewed with caution. The frequency with which patients obtain medical care varies with their perception of illness and the accessibility of care. The first criteria for LP, therefore, should not be generalized to all groups; the last four criteria suggest an obvious need for LP. Further studies may be able to define more generalized clinical and laboratory guidelines for performing lumbar puncture in children with a first febrile seizure.