Isolation of plasma membrane from human neutrophils and determination of cytochrome b and quinone content.

Analyses of plasma membrane and other subcellular fractions indicate that the primary location of cytochrome b in human neutrophils is not the plasma membrane. The procedure developed for the purification of plasma membrane from fresh human neutrophils yielded a 14-fold enrichment in the marker enzyme 5'-nucleotidase and a 10-fold enrichment in ouabain-sensitive ATPase. On sucrose density gradients, the peak density of 5'-nucleotidase activity was 1.12 g/ml, and was shifted after digitonin addition to 1.15 g/ml. Protein in the plasma membrane equalled approximately 8 percent of the whole cell protein. A b-type cytochrome was found to be present in the plasma membrane fraction at a concentration of 205 pmol/mg of protein, which is three times greater than that in the neutrophil overall. Although this cytochrome has been reported previously in the neutrophil, this is the first determination for purified plasma membrane and may indicate that b-type cytochrome has a dual localization in the human neutrophil. Differential centrifugation results suggest that the primary location is in the granules, probably specific granules. Quinone content in the plasma membrane was found to be 740 pmol/mg of protein, a concentration two times greater than in the whole cell. Such a small enhancement of quinone indicates that quinone also is not primarily located in the plasma membrane.

Aminophylline in the treatment of acute asthma when beta 2-adrenergics and steroids are provided.

BACKGROUND: The purpose of this study was to test the contribution of aminophylline in improving peak expiratory flow rate (PEFR) during emergency department treatment of acute asthma when metaproterenol sulfate and steroid therapy are also provided. METHODS: In a prospective, randomized, double-blind, and placebo-controlled trial at a municipal hospital emergency department, 44 patients with acute asthma, aged 18 to 45 years, with theophylline levels below 28 mumol/L, who had failed to achieve a PEFR of 40% predicted after one nebulized metaproterenol treatment, were recruited. An aminophylline or placebo loading dose and maintenance infusion were administered. All patients received hourly nebulized metaproterenol and initial methylprednisolone sodium succinate. The PEFR was measured hourly for 5 hours. Two-factor repeated-measures analysis of variance of improvement in PEFR ([final-initial PEFR]/predicted PEFR) was assessed. RESULTS: There was no difference in improvement of PEFR at any hour between the treatment and placebo groups. After 5 hours, the difference in improvement ratio was 0.40 (aminophylline) vs 0.36 (placebo) (P = .30; n = 22 in each group). The treatment group suffered more tremor, nausea or vomiting, and palpitations (P < .05). CONCLUSION: In the emergency department setting, aminophylline contributes no significant improvement in PEFR when beta 2-agonists and corticosteroids are being provided, while causing more side effects.

Anticholinergic drug effects on quantitative electroencephalogram, visual evoked potential, and verbal memory.

Electroencephalographic (EEG) power and coherence spectrum and visual evoked potential (VEP) recordings were made in a group of control subjects on two occasions, a week apart, before and after the subcutaneous administration of either 0.6 mg scopolamine (hyoscine-hydrobromide), a centrally acting anticholinergic drug, or 0.5 mg methscopolamine nitrate, a peripherally acting anticholinergic drug. After scopolamine administration, the EEG power spectrum significantly slowed and EEG coherence at the alpha and beta frequencies decreased. Left interhemispheric coherence increased at 1 Hz and 3-7 Hz. Methscopolamine had no significant effect on the quantitative EEG. The latency of the major positive components of the VEPs, to both flash and pattern stimuli, were not significantly affected by either drug. Verbal memory was significantly reduced after scopolamine. The results suggest that previous reports of scopolamine-induced changes in the EEG power spectrum and in verbal memory can be attributed to the central action of the drug rather than to peripheral side effects.

Nocturnal and daytime panic attacks--comparison of sleep architecture, heart rate variability, and response to sodium lactate challenge.

BACKGROUND: The purpose of this study was to determine if nocturnal panic patients have greater autonomic dysregulation than patients with daytime panic. METHODS: Three groups were studied: patients who suffer from panic attacks during sleep (n = 12), those who suffer from daytime panic attacks only (n = 12), and control subjects (n = 12). Each subject underwent 24-hour holter monitoring for heart rate variability (HRV), an overnight sleep recording, and sodium lactate challenge during wakefulness. RESULTS: There was a marked subjective response to the sodium lactate challenge in the panic disorder (PD) patients but not in control subjects. Each group showed changes in HRV in response to sodium lactate challenge. The decrease in HRV measures was more marked in PD patients as a whole than in control subjects. During non-rapid eye movement (REM) sleep the value for total power (TP) was significantly higher in the nocturnal panic patients. The PD patients as a whole had higher values for TP and low-frequency (LF) power during REM sleep than control subjects. There were no significant differences between the two PD groups in sleep architecture. The PD patients as a whole had lower sleep efficiency and less stage 4 sleep than control subjects. CONCLUSIONS: These findings indicate that there are substantial differences between PD and control subjects in autonomic regulation and that there are small differences between patients with daytime panic attacks and those with sleep-related panic attacks.

Value of posterior and right ventricular leads in comparison to the standard 12-lead electrocardiogram in evaluation of ST-segment elevation in suspected acute myocardial infarction.

In this multicenter prospective trial, we studied posterior (V7 to V9) and right ventricular (V4R to V6R) leads to assess their accuracy compared with standard 12-lead electrocardiograms (ECGs) for the diagnosis of acute myocardial infarction (AMI). Patients aged >34 years with suspected AMI received posterior and right ventricular leads immediately after the initial 12-lead ECG. ST elevation of 0.1 mV in 2 leads was blindly determined and inter-rater reliability estimated. AMI was diagnosed by World Health Organization criteria. The diagnostic value of nonstandard leads was determined when 12-lead ST elevation was absent and present and multivariate stepwise regression analysis was also performed. Of 533 study patients, 64.7% (345 of 533) had AMI and 24.8% received thrombolytic therapy. Posterior and right ventricular leads increased sensitivity for AMI by 8.4% (p = 0.03) but decreased specificity by 7.0% (p = 0.06). The likelihood ratios of a positive test for 12, 12 + posterior, and 12 + right ventricular ECGs were 6.4, 5.6, and 4.5, respectively. Increased AMI rates (positive predictive values) were found when ST elevation was present on 6 nonstandard leads (69.1%), on 12 leads only (88.4%), and on both 6 and 12 leads (96.8%; p <0.001). Treatment rates with thrombolytic therapy increased in parallel with this electrocardiographic gradient. Logistic regression analysis showed that 4 leads were independently predictive of AMI (p <0.001): leads I, II, V3, V5R; V9 approached statistical significance (p = 0.055). The standard ECG is not optimal for detecting ST-segment elevation in AMI, but its accuracy is only modestly improved by the addition of posterior and right ventricular leads.

Skin and mucous membrane contacts with blood during surgical procedures: risk and prevention.

OBJECTIVE: To study the epidemiology and preventability of blood contact with skin and mucous membranes during surgical procedures. DESIGN: Observers present at 1,382 surgical procedures recorded information about the procedure, the personnel present, and the contacts that occurred. SETTING: Four US teaching hospitals during 1990. PARTICIPANTS: Operating room personnel in five surgical specialties. MAIN OUTCOME MEASURES: Numbers and circumstances of contact between the patient's blood (or other infective fluids) and surgical personnel's mucous membranes (mucous membrane contacts) or skin (skin contacts, excluding percutaneous injuries). RESULTS: A total of 1,069 skin (including 620 hand, 258 body, and 172 face) and 32 mucous membrane (all affecting eyes) contacts were observed. Surgeons sustained most contacts (19% had > or = 1 skin contact and 0.5% had > or = 1 mucous membrane-eye contact). Hand contacts were 72% lower among surgeons who double gloved, and face contacts were prevented reliably by face shields. Mucous membrane-eye contacts were significantly less frequent in surgeons wearing eyeglasses and were absent in surgeons wearing goggles or face shields. Among surgeons, risk factors for skin contact depended on the area of contact: hand contacts were associated most closely with procedure duration (adjusted odds ratio [OR], 9.4; > or = 4 versus < 1 hour); body contacts (arms, legs, and torso) with estimated blood losses (adjusted OR, 8.4; > or = 1,000 versus < 100 mL); and face contacts, with orthopedic service (adjusted OR, 7.5 compared with general surgery). CONCLUSION: Skin and mucous membrane contacts are preventable by appropriate barrier precautions, yet occur commonly during surgery. Surgeons who perform procedures similar to those included in this study should strongly consider double gloving, changing gloves routinely during surgery, or both.

Circadian rhythms and psychiatric disorders in the elderly.

This article reviews changes in circadian rhythms that have been reported to occur in the elderly psychiatric population. Data relating to circadian changes in normal aging are included where relevant. Information was obtained from: (1) a computerized MEDLINE search from 1975 to May 1996; (2) a review of bibliographies of papers obtained through the computerized search; and (3) texts on chronobiology. We could not locate any information relating to circadian rhythms and mania, anxiety, or paranoid disorders in old age. Disruption to the sleep/wake cycle, temperature, melatonin, and motor activity rhythms have been reported in dementia and depression, and disruption to some neuroendocrine and cardiovascular rhythms are reported in dementia. Disruption to circadian rhythmicity has implications for the management of dementia patients: for example, the sleep/wake and behavioral disturbances, and for the long-term management of mood disorders. A number of circadian markers have not been studied and several patient groups have received no research attention to date.

Suction catheter-assisted nasotracheal intubation.

This case series illustrates the use of a suction catheter to guide the passage of an endotracheal (ET) tube through the glottis, a technique modification which can be used when standard nasotracheal intubation is unsuccessful. The technique is appropriate for patients in whom airway management is urgent, but not emergent. Catheter-assisted nasotracheal intubation is useful when intubation is difficult because of excessive patient resistance to movement of the ET tube within the oropharynx. The clinical use of this technique is described for the following scenarios: overdose with obtundation, multiple trauma with agitation, and respiratory failure from pneumonia and pulmonary edema.

Nonhemorrhagic pontine infarct in a child following mild head trauma.

A child who presented with hemiparesis secondary to a delayed non-hemorrhagic pontine infarction following mild head trauma is described. The results of the child's workup, including computed tomography (CT), were negative. The diagnosis of nonhemorrhagic pontine infarct was made by magnetic resonance imaging (MRI). The diagnostic evaluation excluded other possible etiologies of cerebral infarction, including vasculitides, CNS infection, congenital heart disease, hypercoagulable states, and demyelinating diseases. Although trauma cannot be proven as the cause of the infarct, other known causes of infarct were excluded. There are few cases of traumatic nonhemorrhagic cerebral infarction among children in the literature; none describes diagnostic MRI findings. MRI is important in these cases, because it may reveal delayed infarction from small-vessel injury, which is not apparent on CT. This article discusses the etiology of and the diagnostic evaluation of pediatric cerebrovascular accidents and suggests the need for emergency physicians to consider trauma as a potential cause of delayed nonhemorrhagic cerebral infarct in children.

A proposed consent process in studies that use an exception to informed consent.

Federal regulations allow an exception to informed consent when it is not feasible to obtain informed consent in certain emergency research circumstances. A multicenter, randomized, single-blinded, normal saline procedure-controlled efficacy trial of diaspirin cross-linked hemoglobin (DCLHb) in acute traumatic hemorrhagic shock was conducted. The study intended to include 850 of the most severely injured trauma patients with hemorrhage and persistent hypoperfusion as demonstrated by vital signs suggestive of vascular collapse or a base deficit that signified prolonged hypoperfusion. It was anticipated that some patients would be unable to provide informed consent, and that identification and availability of some patients' legally authorized representatives (LARs) would be unlikely within the therapeutic window of the intervention. Each participating institution therefore developed a process to implement exception to informed consent. Each hospital's proposed process was reviewed by the institutional review board, the sponsor, the FDA, and the study's data monitoring committee chair. The goal was the development of local implementation processes by which the best interests of patients and their families could be fulfilled using prospective informed consent, the exception to informed consent, and consent to continue in emergency research, as appropriate for each individual patient. This paper describes the proposed implementation method developed for Cook County Hospital. It includes several important features, 1) prospective informed consent by the patient, when feasible; 2) the ability of the patient to decline participation, even when deemed incompetent to provide prospective informed consent; 3) prospective consent by the family/LAR, when feasible; 4) the use of a scripted abbreviated consent by the patient family/ LAR in life-threatening situations when it is possible only to briefly discuss the research being conducted; 5) independent approval for the use of the consent exception by a second physician immediately prior to patient enrollment; 6) the repeated use of consent to continue (both for the family/LAR and by the patient) when an exception to consent has been utilized; and 7) ongoing review of the informed consent process on a case-by-case basis by the institution's scientific review committee. The authors believe this proposed informed consent process maximizes the communication between investigators, patients and their proxies, and the institution's scientific review committee. Multiple mechanisms exist that allow for consent to be provided or declined, both prior to and after enrollment in the research protocol. The ongoing immediate review of the process allows for process enhancements to be made as needed.

The emergency department electrocardiogram and hospital complications in myocardial infarction patients.

OBJECTIVE: To determine whether acute myocardial infarction (AMI) patients who have negative ECGs on presentation have significantly lower complication rates than do those AMI patients who have positive ECGs on presentation. METHODS: Retrospective, cohort analysis comparing rates of hospital complications (ventricular fibrillation or tachycardia, shock, atrial arrhythmia or bradyarrhythmia with systolic blood pressure < or = 90 mm Hg, pulmonary edema) or interventions among patients with a final hospital diagnosis of AMI and an initially negative vs positive ECG. A negative ECG was normal or had nonspecific ST-segment and/or T-wave abnormalities (upright, flattened T waves; an isolated inverted T wave; ST depression < 0.1 mV; tall T waves with J-point elevation) or minor nonischemic abnormalities. Sample size was adequate to detect a 30% between-group difference in complication rates [alpha = 0.05, 1 - beta (power) = 0.80]. RESULTS: The 27 negative-ECG AMI patients differed from the 38 control patients in (mean +/- SD) age [57 +/- 12 vs 66 +/- 12 years, p < 0.01] but not in gender or history of AMI. The negative- and positive-ECG groups had similar rates of hospital complications [30% (95% CI: 13-47%) vs 42% (95% CI: 26-58%), p = 0.44] and intensive procedures [19% (95% CI: 4-34%) vs 29% (95% CI: 15-43%), p = 0.50], respectively. The negative-ECG patients with hospital complications had ECG evolution precede the event in 83% (95% CI: 69-97%) of cases; persistently negative-ECG patients had no complications [(95% CI: 0-33%), p = 0.06]. CONCLUSIONS: Negative- and positive-ECG AMI patients do not have moderate or large differences in the rates of in-hospital complications. Most negative-ECG patients who suffer complications evolve ECG changes prior to the event and such changes indicate the potential need for a higher level of care.

The informed consent process and the use of the exception to informed consent in the clinical trial of diaspirin cross-linked hemoglobin (DCLHb) in severe traumatic hemorrhagic shock. DCLHb Traumatic Hemorrhagic Shock study group.

UNLABELLED: In the clinical trial of diaspirin cross-linked hemoglobin (DCLHb), optimal therapy required the immediate enrollment of patients with severe, uncompensated, traumatic hemorrhagic shock. When it was not feasible to obtain prospective consent, an exception to informed consent was used according to FDA regulation 21 CFR 50.24. OBJECTIVES: To examine the informed consent process and the use of the consent exception and consent to continue (CTC), and to describe the patients for whom this process was used. METHODS: This was a multicenter, randomized, controlled, single-blinded efficacy trial of DCLHb as an adjunct to standard therapy in the treatment of severe, traumatic hemorrhagic shock. Patients with unstable vital signs or a critical base deficit were treated, with a primary study endpoint of 28-day mortality. RESULTS: During the 11-month study period, 112 patients were randomized in 18 U.S. trauma centers, and data from 98 of the infused patients were analyzed. Prospective consent was obtained from two patients, three family members, and one legally authorized representative (LAR) (6%). Consent to continue was requested for 89 patients (89%), and full participation was granted for 87 of these patients (98%). Consent to continue was provided by 54 (98%) of the 55 patients approached. The mean number of days for family/LAR CTC was 1.1 +/-3.8 days, and 50% of the time it was obtained on the day of study enrollment. Patient CTC was obtained in an average of 13 +/- 23 days, with a median of four days. Patients treated in this protocol were more likely to have sustained penetrating trauma than the overall trauma patient population treated in these trauma centers (44% vs 21%, p = 0.002). CONCLUSIONS: Informed consent in this study of an emergent therapy most often involved the use of the consent exception and consent to continue, the latter of which occurred in a timely manner. Nearly all of those who were approached for CTC approved full participation in the study, suggesting acceptance of the process outlined in the new regulations. Patients treated in a hemorrhagic shock clinical trial may differ from the general trauma patient population.

Setting-based practice variation in the management of simple febrile seizure.

OBJECTIVE: To identify provider-based differences in the ED assessment and management of children presenting with uncomplicated, first-time febrile seizures. METHODS: Multicenter, retrospective cohort study of seven EDs in-the Chicago area: two tertiary academic pediatric EDs (PEDs) and five community-based general EDs (GEDs). The visits of all patients with a discharge diagnosis including the term "seizure" were identified from a 30-month period. Records of patients who met criteria for simple, first-time febrile seizure were reviewed (age 6-60 months; temperature > or =38.0 degrees C; single, generalized, tonic-clonic seizure <20 minutes; "alert" or "arousable" on presentation; absence of known neurologic disease). RESULTS: Four hundred fifty-five records were included: 330 and 125 patients presenting to GEDs and PEDs, respectively. The two groups did not differ in mean age, vital signs, reported duration of seizure, or prior antibiotic use. Lumbar puncture (LP) was performed more often in the GED group (33% vs 22%). No patients were found to have bacterial meningitis. The patients in the GED group were more likely to receive parenteral antibiotics in the ED (56% vs 22%) and to be admitted or transferred (18% vs 4%). In a logistic regression model incorporating age, temperature, seizure duration, seizure in the ED, prior antibiotic use, primary care, and insurance status, the GED patients remained more likely to have an LP (OR 1.5), receive parenteral antibiotics (OR 2.5), and be admitted or transferred (OR 2.5). CONCLUSIONS: There were significant setting-based differences in the evaluation and management of children with simple febrile seizures presenting to GEDs and PEDs.

Aspiration of free blood from the peritoneal cavity does not mandate immediate laparotomy.

The objective was to establish the relationship between the aspiration of free blood (+ASP) versus diagnostic peritoneal lavage (DPL), abdominal injury severity, hemodynamic instability, and the need for immediate operative intervention. We prospectively compared the significance of +ASP to +DPL in our level I trauma center. Consecutive patients received sequential needle tap, catheter aspiration (ASP), and DPL. If gross blood was withdrawn during the tap or ASP, it was returned to the peritoneal cavity before completing the DPL. The DPL was considered positive if there were > 100,000 RBCs for blunt injuries or anterior abdominal stab wounds, or > 10,000 RBCs for other penetrating injuries. During a 12-month period, 566 patients fulfilled the study criteria; they were 50 per cent blunt and 50 per cent penetrating trauma. There were 70 patients with both +ASP/+DPL, 30 with -ASP/+DPL and 4 with +ASP but -DPL. Exploratory laparotomy was performed on these 104 patients (18.4%), 22 of which were considered nontherapeutic. The ATI was statistically higher in the +ASP patients (14.9 +/- 12.9 versus 8.5 +/- 8.2, P < 0.05) but was not clinically different. Overall injury severity and hemodynamic stability were not different in the two groups. The sensitivity of DPL at detecting intra-abdominal injury was higher than the ASP group (98% versus 72%), but the specificities were equal (98%). Because +ASP patients are not more critically injured or unstable than +DPL patients, and because DPL is more accurate in detecting the need for operative intervention, aspiration should be abandoned as part of the DPL procedure in patients with abdominal trauma.

Nerve injuries in the hand.

Nerve injuries of the hand are an important problem for the emergency physician because most are diagnosed in the emergency setting. Successful diagnosis and treatment are critical if the injured patient is to regain full hand function. Emergency department management relies on the knowledge of hand and forearm functional anatomy and techniques for diagnosing loss of nerve function. Once a nerve injury has been diagnosed, issues such as primary versus secondary repair must be discussed with the hand surgeon. The hand surgeon must consider whether to pursue an epineurial or fascicular repair and must use additional techniques for diagnosing return of nervous function. Lack of nerve regeneration, chronic paresthesias, neuromas, and sympathetic dystrophy can complicate the successful return of hand nerve function after injury.

A novel curriculum for teaching research methodology.

We sought to develop a unique educational course for emergency medicine residents that provides the essential knowledge, the practical skills, and the motivation to complete a research project during the residency. A 5-day mandatory course was designed for first-year emergency medicine residents. Unique features of the curriculum include 1) didactic lectures paired with workshops teaching practical skills and 2) the use of a hypothetical research question ("mock project") that is utilized for practical experience at each step and results in an oral presentation of the completed research project. The course was evaluated with pre- and post-tests of general research knowledge, quality of the final presentations, and a post-course questionnaire. Following completion of the course, the 16 emergency medicine resident participants showed significant improvement in research knowledge, as evidenced by higher median post-test scores and an absolute increase in the pass rate of 50%. Residents' final course presentations were given ratings of "above average" to "superior" by all observing faculty members. Finally, 87.5% of the residents felt that developing a mock project during the course ("hands-on" experience) increased their confidence and interest in conducting future academic research. Thus, an introductory course in research methodology that utilizes didactic lectures paired with appropriate practical workshops and incorporates completion of a mock research project may provide an effective method for teaching emergency medicine residents to conduct research.

The use of intraperitoneal infusion for the outpatient treatment of hypovolemia in Somalia.

INTRODUCTION: The civil war in Somalia has destroyed the medical system and left hundreds of thousands of people without access to medical care. Samaritan's Purse and World Medical Missions, two relief organizations, developed mobile medical teams to provide health care to urban and rural Somalia. Gastroenteritis with severe dehydration was encountered frequently, and difficult intravenous (i.v.) access presented a challenging dilemma for patients who were unable to tolerate oral or nasogastric fluid administration. HYPOTHESIS: Intraperitoneal (i.p.) fluid infusion may be used to treat dehydration in patients with poor venous access and ongoing fluid losses. METHODS: Two mobile medical teams treated patients from 1 January to 1 April 1993. Intraperitoneal fluid infusions were given to 16 patients with severe dehydration in whom i.v. access was unobtainable. Children received approximately 80 ml/kg of 0.45% normal saline, and adults received 40 ml/kg of 0.9% normal saline. Patients were reexamined at one and seven days. RESULTS: A total of 25,659 patients were seen in the mobile medical clinics during a 3-month period. Dehydration was diagnosed in 1,833 (7.1%) patients, and 1,203 (4.7%) patients were found to be malnourished. Sixteen patients were treated with i.p. fluid infusions, 14 patients (87.5%) survived, and two patients (12.5%) died, both within 24 hours. In one patient (6.3%), subcutaneous infiltration occurred without subsequent adverse effects. CONCLUSION: This case series found that in the mobile clinic setting in Somalia, i.p. fluid administration improved the hydration status in patients with significant dehydration. Although i.v. infusion remains the treatment of choice when oral or nasogastric fluid administration is not possible, i.p. infusion is easily performed and may be an important alternative in disaster settings.

Mobile medical relief and military assistance in Somalia.

INTRODUCTION: Mobile medical clinics were established by an international medical relief organization to provide health care to victims of the war in Somalia. The study's purpose was to examine the prevalence of diseases seen and the effectiveness of mobile medical clinics, and to evaluate military support in security and care provisions. METHODS: This is a descriptive case series conducted over a 6-month period. Physicians determined clinical diagnoses, and clinic personnel assigned security scores (one to five) based on: 1) crowd control; 2) the incidence of looting; and 3) threats of violence by individuals demanding treatment. SETTING: Mobile medical teams that provided health care to regions in urban and rural Somalia assisted by United States and Italian military forces. PARTICIPANTS: At 149 mobile clinics, 25,265 patients were treated. INTERVENTIONS: Medical treatment included dispensing medications, intravenous rehydration, and minor surgical procedures. The effectiveness of security measures was scored based on: 1) effective crowd control; 2) the lack of theft or threats of violence; and 3) the unimpaired operation of the clinic. RESULTS: Medical teams treated 25,265 patients. The most common medical problems encountered were skin infections (19.5%), upper and lower respiratory tract infections (16.1%), and gastroenteritis with dehydration (7.1%). Malnutrition was seen in 4.7% of cases, and trauma accounted for only 0.7% of complaints. When military escorts were provided, the mean security score was 43% higher (4.85 +/- 0.46) as compared to the absence of a military escort (3.40 +/- 0.60) (p < 0.001). CONCLUSIONS: Mobile medical clinics were found to be effective in this setting despite difficult conditions, limited therapeutic modalities, and few in-patient facilities. Infectious diseases were most common, while malnutrition and trauma were less commonly seen. The cooperation of United States and Italian military forces facilitated relief efforts by maintaining security, particularly in unstable areas.

The prehospital use of nitroglycerin according to standing medical orders in an urban EMS system.

PURPOSE: The purposes of this study are to quantify the use of nitroglycerin (NTG) in prehospital care, to detect deviations from the Standing Medical Orders (SMO), to determine the effectiveness of its administration, and the incidence of clinically significant adverse reactions (hypotension, bradycardia). METHOD: Retrospective review of 7683 Advanced Life Support (ALS) telemetry, base-station contacts over a three month period (June, July, August 1990) to identify all prehospital patient contacts in which NTG was utilized. SETTING: The Resource Hospital/Telemetry Base-Station and two community hospitals/Telemetry Base-Stations for the Chicago North EMS System. RESULTS: There were 445 runs in which NTG was indicated as per SMO. Two hundred eighty-eight patients (64.7%) received NTG for appropriate indications as per SMO, 203 for ischemic chest pain (45.6%), 79 for pulmonary edema (17.7%), and six for both (1.3%). There were 157 (35.5%) runs in which NTG was indicated, but not administered. There were 22 patients who received NTG for indications that deviated from the SMO. Reassessment data concerning the subjective symptom was completed on 118 patients (40.9%), 92 (45.3%) patients with chest pain and 26 with dyspnea (32.9%). Following the administration of NTG, 21 patients (10.1%) with chest pain were unchanged, while 13 with dyspnea (15.3%) improved, 13 patients (15.3%) were unchanged, and none worsened. In 121 patients, the systolic blood pressure (SBP) decreased, while 24 were unchanged (5.4%), and 28 had an increase (6.3%). The mean initial value SBP was 176 +/- 44 mmHg and the repeat mean SBP was 164 +/- 41 mmHg with a mean decrease of 12 +/- 22 mmHg. The diastolic blood pressure (DBP) decreased in 87 patients, was unchanged in 53 (11.9%), and increased in 33 (7.4%). The initial mean DBP was 97 +/- 24 mmHg, the repeat mean DBP was 92 +/- 23 mmHg, a mean decrease of 5 +/- 15 mmHg. Only one patient became hypotensive with the administration of NTG and was successfully resuscitated with a fluid bolus of 300 ml normal saline. CONCLUSIONS: In this EMS system, NTG is under-utilized based on the indications delineated by this system's SMOs. Reassessment is documented infrequently, but when completed, clinically significant adverse reactions are rare. Since the incidence of hypotension and bradycardia are rare, the inability to establish an IV line should not preclude the administration of NTG.

Outcome in an urban pediatric trauma system with unified prehospital emergency medical services care.

HYPOTHESIS: Pediatric mortality is predicted by age, presence of head trauma, head trauma with a low Glasgow Coma Scale (GCS) score, a low Pediatric Trauma Score (PTS), and transport directly to a pediatric trauma center. POPULATION: Studied were 1,429 patients younger than 16 years old admitted to or declared dead on arrival (DOA) in a pediatric trauma center from January through October, 1988. The trauma system, which served 3-million persons, included six pediatric trauma centers. METHODS: Data were obtained by a retrospective review of summary statistics provided to the Chicago Department of Health by the pediatric trauma centers. RESULTS: Overall mortality was 4.8% (68 of 1429); 32 of the patients who died (47.1%) were DOA. The in-hospital mortality rate was 2.6%. Head injury was the principal diagnosis in 46.2% of admissions and was a factor in 72.2% of hospital deaths. The mortality rate was 20.3% in children with a GCS < or = 10 and 0.4% when the GCS was > 10 (odds ratio [OR] = 67.0, 95% CI = 15.0-417.4). When the PTS was < or = 5, mortality was 25.6%; with a PTS > 5, the mortality was 0.2% (OR = 420.7, 95% CI = 99.3-2,520). Although transfers to a pediatric trauma center accounted for 73.6% of admissions, direct field triage to a pediatric trauma center was associated with a 3.2 times greater mortality risk (95% CI = 1.58-6.59). Mortality rates were equal for all age groups. Pediatric trauma center volume did not influence mortality rates. CONCLUSIONS: Head injury and death occur in all age groups, suggesting the need for broad prevention strategies. Specific GCS and PTS values that predict mortality can be used in emergency medical services (EMS) triage protocols. Although the high proportion of transfers mandates systemwide transfer protocols, the lower mortality in these patients suggests appropriate EMS field triage. These factors should be considered as states develop pediatric trauma systems.