Simplified dispatch-assisted CPR instructions outperform standard protocol.

OBJECTIVE: Dispatch-assisted chest compressions only CPR (CC-CPR) has gained widespread acceptance, and recent research suggests that increasing the proportion of compression time during CPR may increase survival from out-of-hospital cardiac arrest. We created a simplified CC-CPR protocol to reduce time to start chest compressions and to increase the proportion of time spent delivering chest compressions. This simplified protocol was compared to a published protocol, Medical Priority Dispatch System (MPDS) Version 11.2, recommended by the National Academies of Emergency Dispatch. METHODS: Subjects were randomized to the MPDS v11.2 protocol or a simplified protocol. Data was recorded from a Laerdal Resusci Anne Skillreporter manikin. A simulated emergency medical dispatcher, contacted by cell phone, delivered standardized instructions for both protocols. Outcomes included chest compression rate, depth, hand position, full release, overall proportion of compressions without error, time to start of CPR and total hands-off chest time. Proportions were analyzed by Wilcoxon's Rank Sum tests and time variables with Welch ANOVA and Wilcoxon's Rank Sum test. All tests used a two-sided alpha-level of 0.05. RESULTS: One hundred and seventeen subjects were randomized prospectively, 58 to the standard protocol and 59 to the simplified protocol. The average age of subjects in both groups was 25 years old. For both groups, the compression rate was equivalent (104 simplified versus 94 MPDS, p = 0.13), as was the proportion with total release (1.0 simplified versus 1.0 MPDS, p = 0.09). The proportion to the correct depth was greater in the simplified protocol (0.31 versus 0.03, p < 0.01), as was the proportion of compressions done without error (0.05 versus 0.0, p = 0.16). Time to start of chest compressions and total hands-off chest time were better in the simplified protocol (start time 60.9s versus 78.6s, p < 0.0001; hands-off chest time 69 s versus 95 s, p < 0.0001). The proportion with correct hand position, however, was worse in the simplified protocol (0.35 versus 0.84, p < 0.01). CONCLUSIONS: The simplified protocol was as good as, or better than the MPDS v11.2 protocol in every aspect studied except hand position, and the simplified protocol resulted in significant time savings. The protocol may need modification to ensure correct hand position. Time savings and improved quality of CPR achieved by the new set of instructions could be important in strengthening critical links in the cardiac chain of survival.

Effects of experimental cortical seizures on respiratory motor nerve activities in piglets.

Airway obstruction at the level of the larynx causes respiratory insufficiency during experimental seizures in spontaneously breathing, anesthetized piglets (T. E. Terndrup and W. E. Fordyce, Pediatr. Res., 38: 61-66, 1995). To investigate further the neural mechanisms of this obstruction, the activities of the phrenic nerve (PH) and the recurrent laryngeal motor branches to the thyroarytenoid (TA) and posterior cricoarytenoid (PCA) muscles were analyzed in 11 anesthetized, vagotomized, paralyzed, and ventilated piglets. After a control recording period, seizures were induced by subcortical penicillin G injections. Compared with baseline conditions, nerve activities became irregular during seizures. Extraneous TA bursts during PH activation were evident in all piglets during seizures. During ictal phases of seizures, the peak integrated activities of the PH and the expiratory component of the PCA, but not TA or inspiratory PCA activities, were significantly decreased compared with interictal phases. During seizures, a significant delay in the onset of the inspiratory component of PCA activation with respect to the onset of the PH was observed. This study helps to explain respiratory impairment during cortical seizures by providing evidence of impaired timing of activation of laryngeal dilator mechanisms and coordination with those activating the diaphragm. Cyclical PH inhibition during high-intensity cortical discharges may provide a secondary mechanism producing respiratory insufficiency during seizures.

Respiratory motor nerve activities during experimental seizures in cats.

We evaluated respiratory motor nerve activities during experimental seizures induced with subcortical penicillin. The activities of the phrenic (PH), nasolabial (NL), and hypoglossal (HG) nerves and the recurrent laryngeal motor branches to the thyroarytenoid (TA) and posterior cricoarytenoid (PCA) muscles were analyzed in 13 anesthetized, vagotomized, paralyzed, and ventilated cats. During ictal and interictal phases of seizures, nerve activities became irregular and peak integrated nerve activities increased, particularly in the case of the PH nerve. The ictal phase of seizures was associated with increased tonic activity and decreased phasic respiratory discharges, particularly in the cases of the HG, NL, and PCA nerves. During some prolonged ictal discharges, entrainment of nerve activities by cortical spiking was associated with irregular uncoordinated activation, particularly in the TA nerve. These studies help explain respiratory impairment during seizures by providing evidence of impaired coordination between activation of muscles that regulate upper airway patency and activation of the diaphragm.

Comparative review of the adverse effects of sedatives used in children undergoing outpatient procedures.

Children often fear medical procedures and interventions. Sedative agents enhance the care of these children who undergo outpatient procedures by decreasing anxiety, increasing cooperativity, and providing amnesia. Although higher dosages and intravenous administration of sedatives often produce improved sedation, adverse effects and complications are more frequent. The goals of therapeutic efficacy and safety must be balanced in all patients. The presence or anticipation of anxiety and pain helps in deciding whether to use a sedative alone, or a regimen also providing analgesia. The patient's clinical cardiorespiratory or neurological status, other relative contraindications, the duration of the intended procedure, and the presence or absence of an intravenous line will help in choosing specific drugs. Drug complications are a common cause of adverse events in patients. The combination of a sedative and analgesic, especially a benzodiazepine and an opioid given intravenously, is associated with a higher risk of serious complications. The practitioner responsible for the administration of a sedative to a child must be competent in its use and have the ability to detect and manage complications. Patients who are deeply sedated should be continuously monitored and observed by an individual dedicated to this task. Vital signs and oxygen saturation should be documented at frequent intervals and the patient should be appropriately monitored until discharge criteria have been met. The risk of serious complications with these agents may be reduced with vigorous monitoring and a judicious choice of dosage.

Respiratory drive during status epilepticus and its treatment: comparison of diazepam and lorazepam.

In order to examine the respiratory effects of tonic-clonic seizures and their treatment with i.v. diazepam or lorazepam, we utilized a spontaneously breathing piglet seizure model. A tracheostomy, arterial catheter, and epidural electrodes were inserted and pigs were maintained under ketamine anesthesia. After baseline recordings, seizures were induced with a pentylenetetrazol (PTZ) bolus and a 20 min infusion (5-6 mg/kg/min). After 10 min of PTZ infusion, randomly assigned animals received diazepam (D; N = 7; 0.5 mg/kg), lorazepam (L; N = 7; 0.2 mg/kg), or 0.9% saline (C; N = 7; controls) by rapid peripheral vein injection. Minute ventilation (Ve), Pa(CO2), and the pressure change in response to airway occlusion at end-expiration (P0.1) were measured at standard intervals. All groups had comparable increases in respiratory drive during untreated seizures. Changes in Ve and P0.1 were reduced to at or below baseline values in groups D and L, but not C, from 2 to 45 min after treatment (P < 0.05). No significant changes were observed in Pa(CO2) after either intervention. Following anticonvulsants, the cumulative duration of seizures was significantly reduced in L and D groups, compared to C (P < 0.05). We conclude that increases in respiratory drive occur during tonic-clonic seizures induced with PTZ. Amelioration of seizure activity with lorazepam or diazepam results in a reduction in respiratory drive, but not respiratory failure, in this tracheostomized model.

Glottal patency during experimental cortical seizures in piglets.

OBJECTIVE: Systemically-induced seizures produce glottal airflow obstruction in anesthetized pigs, resulting in hypercapnia and respiratory acidosis. Cortically-induced seizures may be more representative of human seizure disorders. The purpose of this study was to describe glottal area patency (GAP) in piglets during cortically-induced seizures. METHODS: Nineteen spontaneously breathing, lightly anesthetized (alphaxalone-alphadolone IV) piglets (aged 10 +/- 2 days) were instrumented for recording nasal airflow, subglottic pressure, and electrocorticogram. Glottal visualization was achieved supraglottically using a 1.2-mm fiberoptic scope inserted through the thyrohyoid membrane. Following baseline-control, hypoxic-rebreathing, and new baseline recordings, seizures were induced using subcortical injections of crystalline penicillin G (100,000 units/ injection). Five consecutive-breath representative epochs were digitized from baseline-control, hypoxic-rebreathing, and seizure conditions. For each breath, GAP was measured at the onset of inspiratory pressure, peak of inspiratory effort (Ip), and onset of expiration. RESULTS: The piglets were physiologic at baseline-control and new baseline conditions, and showed expected increases in ventilation and GAP during rebreathing experiments. GAP was maximum at Ip under baseline and rebreathing conditions, but was significantly decreased and airway resistances were increased during seizure conditions (p < 0.05, ANOVA). CONCLUSIONS: Generalized seizure activity results in reduced GAP at the peak of inspiratory effort. Increased work of breathing during seizures is created by direct mechanical obstruction at the level of the larynx.

Terbutaline vs albuterol for out-of-hospital respiratory distress: randomized, double-blind trial.

OBJECTIVE: To determine the efficacy and safety of single doses of subcutaneous terbutaline (TERB) or nebulized albuterol (ALB) during out-of-hospital treatment for respiratory distress from asthma or chronic obstructive pulmonary disease. METHODS: Patients aged > 18 years who had respiratory distress were enrolled in a double-placebo, double-blind, randomized trial. Paramedics measured respiratory severity using an empiric score [respiratory rate, wheezing, speech, and peak expiratory flow rate (PEFR)], and the patients rated their own respiratory distress using a visual analog scale (VAS). The patients received O2 plus ALB (2.5 mg) and saline injection (n = 40) or TERB (0.25 mg) and saline aerosol (n = 43). RESULTS: The groups were similar with respect to age, gender, initial empiric scores (median score 9 for both groups), PEFRs (89 +/- 84 L/min, mean +/- SD, for ALB vs 97 +/- 84 L/min for TERB), and respiratory distress VAS scores. Both groups showed significant improvement in their respiratory distress VAS scores by the time of ED arrival. The ALB group had a greater improvement in respiratory distress VAS score than did the TERB group (p < 0.05). Empiric scores, PEFR scores, and hospital admission frequencies were not significantly different. No complication was observed. CONCLUSION: The out-of-hospital administration of either aerosolized ALB or subcutaneous TERB reduced respiratory severity. Albuterol provided greater subjective improvement in respiratory distress.

Clinical issues in acute childhood seizure management in the emergency department.

Generalized tonic-clonic seizure activity in infants and children frequently leads to an emergency department visit, often after emergency medical service personnel, such as paramedics, provide initial evaluation and treatment. Important subsets of patients who present to the emergency department include those with non-seizure-mediated movements, those with nongeneralized seizure activity, those with complications of anticonvulsant therapy, and those with status epilepticus. Recognizing, diagnosing, and treating these conditions and minimizing complications are key issues to be considered in the refinement of emergency department practice. Of the children with seizures who are seen in the emergency department, those with febrile convulsions or exacerbations of underlying seizure disorders predominate, while those with new-onset epilepsy or other seizure disorders account for a smaller proportion. Current issues in the emergency department management of seizures in children include: (1) modifying interventions to stabilize patients and simultaneously minimize the physiologic deterioration accompanying generalized seizures; (2) selection, initiation, administration, and refinement of anticonvulsant therapy; (3) minimizing complications of prolonged seizures and their treatment; (4) rapid recognition and treatment of life-threatening illnesses that underlie seizure presentations; (5) selection of appropriate diagnostic measures; and (6) use of electroencephalography in selected patients.

Impact of operator technique and device on infrared emission detection tympanic thermometry.

Preliminary data on the use of infrared emission detection (IRED) tympanic thermometers suggest that operator technique may be important in IRED readings. No systematic investigation of specific technique and available IRED devices has previously been performed. In a prospective, blinded trial, 40 healthy adult subjects using six IRED thermometers with two techniques were examined in random sequence. Differences between IRED tympanic, oral, and rectal temperatures were compared using ANOVA. Significant differences were observed between all temperatures, the IRED devices, and the method of probe insertion. Differences between oral or rectal temperatures and IRED tympanic readings were reduced by an ear tug (as for routine otoscopy) for all but one device. An "ear tug" results in increased IRED readings that may improve accuracy of tympanic thermometers using IRED.

Sedative-analgesic agent administration in children: analysis of use and complications in the emergency department.

The frequency of, indications for, and complications from non-acetaminophen sedative-analgesic agents (SAAs) administered to children less than 16 years of age in the emergency department (ED) were determined by a retrospective review. All 21,353 charts from a single university hospital ED over a 16-month period were included. Few children (N = 759; 3.5%) received SAAs. Of 919 total doses, 13% of children received a second and 4.5% received a third SAA. The group was 59% male. Most children were < or = 10 years of age. Sixty-two percent of SAAs were either sedatives or opioids. Sedatives given included chloral hydrate, diazepam, lorazepam, midazolam, and phenobarbital. Opioids given included morphine, codeine, and meperidine. Indications for SAAs included painful procedures, analgesia, radiographic imaging, and seizure activity. Complications (N = 51; 6.7%) included inadequate sedation, vomiting, and respiratory depression or oxygen desaturation. Respiratory depression or oxygen desaturation occurred only after intravenous administration of SAAs for seizures. In children, non-acetaminophen SAAs are used most commonly in younger patients requiring sedation for painful procedures or for radiologic imaging. Respiratory depression was observed only after intravenous administration of anticonvulsants.

The influence of diazepam or lorazepam on the frequency of endotracheal intubation in childhood status epilepticus.

Anticonvulsant management of status epilepticus (SE) may result in respiratory depression, often requiring endotracheal intubation (ETI). By examining rates of ETI in childhood SE after intravenous diazepam or lorazepam, when administered alone or in combination with phenytoin, the influence of anticonvulsants on the frequency of ETI during SE was determined. The medical records of 142 consecutive children younger than 16 years of age admitted from a university hospital ED with seizures during a 28-month period were retrospectively reviewed. SE was identified in 38 (27%) of cases. Records of children with SE were reviewed for demographic, seizure severity, and management variables. Twelve patients were excluded, ten of whom received concomitant phenobarbital. Patients receiving lorazepam had ETI rate of 27% (4/15), compared to 73% (8/11) in the diazepam group (P = 0.026, Fisher's exact). The groups were not significantly different in age, weight, sex, seizure type, seizure duration, and appropriate anticonvulsant dosage. A prospective, randomized trial comparing lorazepam and diazepam is warranted to confirm the apparent advantage of lorazepam in reducing respiratory depression.

Spontaneous pneumothorax complicating pregnancy--case report and review of the literature.

Patients with a spontaneous pneumothorax frequently present for care in the emergency department. The occurrence of spontaneous pneumothorax during parturition occurs rarely. We describe a case of spontaneous pneumothorax during the first trimester of pregnancy, which resolved with tube thoracostomy. The patient delivered vaginally a healthy 4.3 kg male at term under epidural anesthesia. We discuss spontaneous pneumothorax and review reported cases during pregnancy.

Comparison of ventilation performance: standard resuscitation bag and the resuscitation bag controller.

Clinical evaluation of ventilation performance during resuscitation is largely subjective. A mechanical device, the resuscitation bag controller (RC), which encircles the bag and allows controlled compression may improve the precision and accuracy of ventilation with manual resuscitation bags (MRB). We hypothesize that more precise, controlled pressure ventilation can be delivered with the RC, compared to the MRB. Prehospital (N = 13) and hospital personnel (N = 12) who routinely perform manual ventilation were randomized to either method of ventilation. Operators were instructed to ventilate an intubated adult mannequin. The percent of breaths delivered within a specified range, 800 to 1200 mL, was compared using simple regression analysis. The precision of tidal volume (TV) and peak airway pressure (PAP) was compared between methods and groups using the coefficient of variation. Comparison for significant differences between methods and groups in the number of breaths with a TV less than 800 mL and those with pressures greater than 30 cm H20 was performed using chi square or Fisher's exact test. There were no significant differences in the percent of acceptable breaths or mean TV delivered between methods or groups. The precision (i.e., reproducibility of the same value) of TV for both methods was best for hospital personnel. PAPS were less than or equal to 30 cm H2O for 93% of all breaths. Hospital personnel delivered a significantly greater percent of inadequate (less than 0.8 L) breaths, 19 versus 7.4%, and excessive pressure breaths, 9.2 versus 4.2%, when compared to prehospital personnel. We conclude that the resuscitation bag controller offers little advantage over standard bag resuscitation for adult resuscitation.(ABSTRACT TRUNCATED AT 250 WORDS)

Sudden death associated with undiagnosed Graves' disease.

Hyperthyroidism may result in multiple symptoms attributable to an excess of thyroid hormone. We report a case of Graves' disease in association with sudden death in a previously healthy, undiagnosed young female. This case illustrates an unusual initial presentation of Graves' disease.

The performance of two tympanic thermometers in a pediatric emergency department.

In a prospective, unblinded, controlled study, 303 children underwent comparison of rectal (RT) and right-sided tympanic membrane (TMT) temperatures. Digital electronic thermometers were used for RT, while two different infrared detection devices assessed TMT. The performance of TMT devices were compared using correlation with RT, fever detection, and ease of use. Correlation between RT and the two devices was good, r = 0.70 and r = 0.69, with little influence of patient age on performance. Using receiver operating characteristics curves to assess fever screening. Thermoscan performed somewhat better than First Temp. Staff rated the Thermoscan as significantly easier to use.

The impact of moderate ambient temperature variance on the relationship between oral, rectal, and tympanic membrane temperatures.

We examined the effect of moderate ambient temperature variance on the relationship between oral (OT), rectal (RT), and tympanic membrane (TMT) temperature in 21 healthy adults. Calibrated digital electronic thermometers were used to assess OT and RT, while TMT was measured using an infrared detection device and microprocessor. Recordings were made at baseline and after 15 and 20 minutes of exposure to either warm (35 degrees C) or cool (18.3 degrees C) environmental temperatures. Differences were examined for the three temperature sites and times using repeat measures analysis of variance. No significant differences in RT (37.7 degrees +/- 0.3 degrees C; mean +/- SD) were observed at any time. Both OT (+0.5 degrees C) and TMT (+0.7 degrees C) were significantly changed during warm, but not cool exposure, compared to baseline conditions. We conclude that OT and TMT have a predictable relationship to RT at normal ambient temperature. However, in warm examination areas, spuriously elevated OT and TMTs may occur.

Comparison of pulmonary artery, rectal, and tympanic membrane temperatures in adult intensive care unit patients.

Tympanic thermometry using infrared thermography technology offers a noninvasive, rapid temperature measurement tool which may be useful for selected intensive care unit (ICU) patients. Multiple comparisons of pulmonary artery catheter (PAC), rectal (R), and tympanic membrane (TM) temperatures were performed in nine adult ICU patients using PAC temperatures as the gold standard. The correlation between R (r = 0.93) and PAC was significantly better than TM (r = 0.74) temperatures. However, PAC (37.2 +/- 0.06 degrees C; mean +/- SEM) and TM (37.1 +/- 0.08 degrees C) temperatures were not significantly different, whereas R (37.6 +/- 0.07 degrees C) was significantly warmer than both (P less than .05). Differences between either R (+0.4 degrees C) or TM (-0.1 degrees C) and PAC temperatures were consistent over selected ranges between 35 degrees C and 40 degrees C. The performance of TM and R was similar in the ability to predict PAC temperatures.

Infant ventilation and oxygenation by basic life support providers: comparison of methods.

INTRODUCTION: Little information is available in the performance of infant ventilation by basic life support (BLS) personnel. HYPOTHESIS: There are no significant differences between mouth-to-mouth (M-M), mouth-to-mask (M-Ma), pediatric bag-mask (PBM), and adult bag-mask (ABM) devices in the percent of acceptable breaths delivered by BLS providers. METHODS: Fifty certified BLS providers performed five ventilation methods in random sequences for 60 seconds each on a 5kg infant mannequin following standardized instructions. Supplemental oxygen, 10 l/min, was supplied with one M-Ma trial and PBM methods. Airway patency, peak airway pressure (PAP), ventilatory rate (VR), tidal volume, and delivered oxygen concentration (FiO 2) were recorded. The percent of breaths with excessive PAP (i.e., greater than 30 mmHg), percent of acceptable breaths using loose (i.e., 25-125ml) and strict (i.e., 50-100ml) criteria, and FiO 2 at 15, 30, 45, and 60 seconds were compared between ventilation methods using ANOVA. RESULTS: For all subjects and those with a patent airway (n=36), there were no significant differences in the percentage of acceptable breaths produced by PBM (56+/-6) (mean+/-SEM; all subjects) and ABM (41+/-6.2) was significantly greater than M-Ma, with and without a patent airway. Although RR and the percentage of excessive breaths were not significantly different, the percentage of acceptable breaths and FiO 2 delivered with each ventilation method was significantly better in the patent airway group.(ABSTRACT TRUNCATED AT 250 WORDS)

Nasal versus oral midazolam for sedation of anxious children undergoing laceration repair.

STUDY OBJECTIVE: To compare the efficacy and safety of a single dose of midazolam, as an oral solution of 0.5 mg/kg, or nasal drops of 0.25 mg/kg, in children undergoing emergency department laceration repair. DESIGN: Double-blind, double-placebo, randomized trial. Children underwent standard wound care when judged to demonstrate a reduction in anxiety following study medication. PARTICIPANTS: Fifty-eight patients between 1 and 10 years of age with uncomplicated lacerations judged to be anxious by emergency physicians. RESULTS: An anxiety score and vital signs were recorded at routine intervals. Groups were comparable with respect to age, laceration characteristics, initial vital signs, and anxiety scores. Both groups demonstrated reductions (mean +/- SD) in anxiety scores over time (P < .05; maximum at 10 minutes; 1.2 +/- 0.9 mm for nasal and 0.8 +/- 1.3 for oral), with no significant differences between groups (repeat-measures ANOVA). Median observer-rated effectiveness using a visual analog scale (maximum effectiveness, 10 mm) was not significantly different between groups: nasal, 7.6 mm and oral, 6.9 (Mann-Whitney U test: minimum detectable difference, 0.7, with alpha = 0.05 and beta = 0.2). Complications were judged to be minor only, and were more frequent in the nasal group (5 of 28, 4 with nasal burning) versus 1 of 26 in the oral group. Time from midazolam to ED discharge was not significantly different between groups: nasal, 54 +/- 15 minutes and oral, 57 +/- 16 minutes. CONCLUSION: A single dose of oral or nasal midazolam results in reduced anxiety and few complications in selected children undergoing laceration repair in the ED. The oral route was associated with fewer administration problems.

Influence of otitis media on the correlation between rectal and auditory canal temperatures.

In a noninterventional, controlled, single-blinded trial, 251 children were examined in a university hospital emergency department setting to study the influence of acute otitis media on the relationship between rectal and auditory canal temperatures. Bilateral auditory canal temperatures were measured using an infrared detection probe and microprocessor by nursing staff blinded to the presence of acute otitis media. Correlation between rectal and auditory canal temperatures in children with (r = .81) and without (r = .75) acute otitis media were not significantly different. There was no significant difference between infected (38.1 degrees C +/- 1.0 degree C) and uninfected ears (38.0 degrees C +/- 1.0 degree C) with unilateral otitis (n = 75). Although significantly higher than in uninfected children, auditory canal temperatures of children with acute otitis media reflected elevated rectal temperatures and not differences in auditory canal temperatures between ears.