Diagnostic markers of sepsis in the emergency department.

Sepsis is defined as the systemic inflammatory response to infection. However, changes in body temperature, heart and respiratory rate and white cell count (the "SIRS" criteria) are not specific enough to identify infected patients in the emergency department. Among many biological parameters, measurement of lactate, central venous oxygen saturation (ScvO2), C-reactive protein (CRP) and procalcitonin (PCT) are of particular interest. Early (within 6h) and goal-directed (ScvO2 > 70%) resuscitation increases survival in severe sepsis and septic shock, particularly in patients with high lactate clearances. CRP and PCT are both useful markers of sepsis but PCT increases earlier, better differentiates infective from non-infective causes of inflammation, more closely correlates with sepsis severity in terms of shock and organ dysfunction and better predicts outcome when followed in time. However, PCT measurement is more costly, time-consuming, and not widespread available. New markers for rapid diagnosis of sepsis (e.g. TREM-1) are under investigation.

A case of fatal necrotizing fasciitis after intramuscular administration of diclofenac.

Necrotizing fasciitis is a rapidly progressive soft tissue infection that involves subcutaneous fat and spreads along the fascial planes. This disease has a potentially fatal outcome if not recognized in early. Several cases have been reported of a possible association between the use of non-steroidal anti-inflammatory drugs (NSAIDs) and the development or aggravation of necrotizing fasciitis. This association is still a subject of controversy. In this article we present a case of fatal necrotizing fasciitis occurring in association with intramuscular injections of diclofenac in a patient who was admitted for the symptoms of a urinary stone. Our opinion is that the intramuscular injections caused a locally aseptic necrosis, which was secondarily invaded by. Since this incident, our policy is to avoid the use of intramuscular injections of diclofenac and other NSAIDs in cases of potentially infectious diseases.

Mild hypothermia induced by a helmet device: a clinical feasibility study.

STUDY OBJECTIVE: To test the feasibility and the speed of a helmet device to achieve the target temperature of 34 degrees C in unconscious after out of hospital cardiac arrest (CA). METHODS: Patients with cardiac arrest due to asystole or pulseless electrical activity (PEA) who remained unconscious after restoration of spontaneous circulation (ROSC) were enrolled in the study and randomised into two groups: a normothermic group (NG) and a hypothermic group (HG). Bladder and tympanic temperature were monitored every 15 min. A helmet device was used to induce mild hypothermia in the HG. Later on, the effect of mild hypothermia on the haemodynamics, electrolytes, lactate, arterial pH, CaO2, CvO2 and O2 extraction ratio were analysed and compared to the values obtained from the NG. RESULTS: Thirty patients were eligible for the study, 16 were randomised into the HG and 14 were randomised into the NG. The median tympanic temperature at admission in both groups was 35.5 degrees C (range: 33.3-38.5 degrees C) and the median tympanic temperature after haemodynamic stabilisation was 35.7 degrees C (range: 33.6-38.2 degrees C). In the HG, the core and the central target temperature of 34 degrees C were achieved after a median time of 180 and 60 min, respectively after ROSC. At the start of the study, no significant differences between the NG and HG were seen. At the end of the study, lactate concentration and O2 extraction ratio were significantly lower in the HG; however the CvO2 was significantly lower in the NG. CONCLUSIONS: Mild hypothermia induced by a helmet device was feasible, easy to perform, inexpensive and effective, with no increase in complications.

The effect of mild hypothermia and induced hypertension on long term survival rate and neurological outcome after asphyxial cardiac arrest in rats.

STUDY OBJECTIVE: we studied the long-term effect of a combined treatment with resuscitative mild hypothermia and induced hypertension on survival rate and neurological outcome after asphyxial cardiac arrest (CA) in rats. METHODS: 36 male Wistar rats, were randomised into three groups: Group I (n=10): anaesthetised with halothane and N(2)O/O(2) (70/30%) had vessel cannulation but no asphyxial CA; mechanical ventilation was continued to 1 h. Group II (n=13): under the same anaesthetic conditions and vessel cannulation, was subjected to asphyxial CA of 8 min, reversed by brief external heart massage and followed by mechanical ventilation to 1 h post restoration of spontaneous circulation (ROSC). Group III (n=13): received the same insult and resuscitation as described in group II, but in contrast to the previous group, a combination treatment of hypothermia (34 degrees C) and induced hypertension was started immediately after ROSC and maintained for 60 min ROSC. Survival rate and neurological deficit (ND) scores were determined before arrest, at 2 and 24 h, and each 24-h up to 4 weeks after ROSC. RESULTS: Baseline variables were the same in the three groups. Comparison of the asphyxial CA groups (groups II and III), showed an increased, although not statistically significant, survival rate at 72 h after ROSC in group III, and it became highly significant at 4 weeks after ROSC. The ND scores were the same in both asphyxial CA groups (groups II and III). CONCLUSIONS: Resuscitative mild hypothermia and induced hypertension after asphyxial CA in rats is associated with a better survival rate. This beneficial effect persisted for 4 weeks after ROSC.

A prospective, open, single blind, randomized study comparing four analgesics in the treatment of peripheral injury in the emergency department.

The efficacy of four analgesics, distinct concerning analgesic power and mechanism of action, was evaluated for pain relief in patients suffering from single peripheral injury. Patients were randomly allocated to receive either propacetamol (the pro-drug of paracetamol) 20 mg/kg i.v., piritramide 0.25 mg/kg i.m., tramadol 1 mg/kg i.v. or diclofenac 1 mg/kg i.v. Pain scores were measured by the patient using the visual analogue scale (VAS) and by an observer using a 4-point verbal rating scale (VRS). Cardiorespiratory variables and side effects were recorded. One hundred and sixty patients were included, 131 completed the study. Groups matched for demography and baseline pain levels. In general pain scores decreased with time. No significant differences were found between groups at any particular time point. VAS scores were significantly (p < 0.02) lower than baseline scores 30 minutes after injection in all treatment groups except for the piritramide group where significance (p < 0.01) was reached after 60 minutes. VRS score analysis showed a similar trend although significances differed. In the piritramide group significantly more side effects were noted than in the other groups (p < 0.05). We conclude that intravenous propacetamol, tramadol and diclofenac are equally efficacious for emergency analgesic treatment of single peripheral trauma.

A safety assessment of diaspirin cross-linked hemoglobin (DCLHb) in the treatment of hemorrhagic, hypovolemic shock.

OBJECTIVE: To determine the safety and possible efficacy of diaspirin cross-linked hemoglobin (DCLHb) in the treatment of patients in Class II-IV hemorrhagic, hypovolemic shock. DESIGN: Multicenter, randomized, normal saline-controlled, dose-escalation study. SETTING: Eleven hospitals in the U.S. and Belgium. SUBJECTS: One hundred and thirty-nine (139) hospitalized patients with Class II-IV hemorrhagic, hypovolemic shock within the previous 4 hours who still were requiring therapy for shock. INTERVENTIONS: Beginning with the lowest dose, patients were randomized to receive 50, 100, or 200 mL of either 10% DCLHb or normal saline infused intravenously over 15 minutes. Following infusion of either treatment, further fluid resuscitation could be given, as necessary, to maintain perfusion. Vital signs, laboratory assessments, blood and fluid administration, complications, and adverse events were recorded at various times from the end of infusion through 72 hours after infusion. RESULTS: A total of 29 (13 DCLHb- and 16 saline-treated) patients died during the study period. Adverse events were experienced by 61% of patients in the DCLHb group and 53% of patients in the saline group; serious adverse events occurred in 28% of DCLHb-treated patients and 30% of saline-treated patients. The incidence of prospectively defined, clinical complications, including renal insufficiency and renal failure, was similar between the treatment groups except for the occurrence of dysrhythmias/conduction disorders, which occurred significantly more frequently in the saline-treated patients than the DCLHb-treated patients (p = 0.041). At the highest dose level (200 mL), statistically significant between-group differences were observed with greater increases in serum amylase, LDH, the isoenzymes LD1,2,4 and 5, and CK-MB in the DCLHb group compared to the control group; none were of clinical significance. The volume of blood administered did not differ between the groups. Overall 24- and 72-hour survival rates were similar between treatment groups, although the hospital discharge rate was slightly higher in the DCLHb-treated patients (80%) compared with the saline-treated patients (74%). CONCLUSION: Administration of 50 to 200 mL of DCLHb to patients in hemorrhagic, hypovolemic shock was not associated with evidence of end organ toxicity or significant adverse events. Further studies involving larger doses and, perhaps, earlier administration of DCLHb are warranted.

Evaluation of scoring systems in acute meningococcaemia.

Patients expected to develop life-threatening complications in acute meningococcal infections require early recognition and appropriate monitoring. Different prognostic scoring systems have been developed. Three of them, chosen according to their bedside availability, were compared with our clinical observations. Twenty consecutive cases of proven meningococcal infection were admitted to the paediatric intensive care unit (PICU) of the Free University of Brussels (AZ-VUB). Biological and clinical features required for prognostic scoring were evaluated as soon as possible after admission. Glasgow meningococcal sepsis prognostic score (GMSPS), Neisseria sepsis index (NESI) and Algren criteria were retrospectively calculated and evaluated for their prognostic significance. Neisseria meningitidis was cultured from blood and cerebrospinal fluid in 11 patients and from blood in only nine patients. The age of the patients was between 1 and 15 years (mean 4.1 years). All patients received the same therapy on admission. Four patients died with a multiorgan failure within 18 hours. The three scoring systems in these four patients predicted death. Overall, the GMSPS score, the NESI score and the Algren criteria predicted death in respectively 10, nine and five patients. Death was falsely predicted in six patients by the GMSPS score, in five patients by the NESI score and in one patient by the Algren criteria. The Algren criteria predicted the severity of the clinical process more accurately than did the GMSPS and NESI scores. However, such predictability should be cautiously used even when 100% mortality is predicted. It might be used in decision-making in regard to the following issues: patient transfer to tertiary centres and mode of transportation, monitoring of patients in intensive care units, early insertion of invasive cardiovascular monitoring catheters and consideration of new or even experimental therapy. However, one should be extremely cautious of taking any therapeutically or ethical decision on the basis of one or more of the described scoring system, since we showed the lack of precision concerning the outcome of paediatric patients with meningococcaemia.

Management of ingested foreign bodies in childhood: our experience and review of the literature.

The management of foreign bodies in the gastrointestinal tract is not standardized. Retrospectively, we analysed the management of 174 cases of accidental ingestion of foreign bodies in children. No child had ingested more than one foreign object. The ingested foreign bodies were: coins, toy parts, jewels, batteries, 'sharp' materials such as needles and pins, fish and chicken bone, and 'large' amounts of food. Of the patients 51% had transient symptoms at the moment of ingestion, such as retrosternal pain, cyanosis and dysphasia. Attempts to extract the foreign body either by a magnet tube, endoscopy or McGill forceps was performed in 83 patients. The majority of the extracted foreign bodies were batteries and sharp materials. The outcome of all the patients was excellent. No complications were observed.

Successful use of an intraosseous infusion in an 800 grams preterm infant.

An intravascular access line for the administration of life support drugs and volume expanders may be particularly difficult, especially in very small premature babies. We report on the successful use of an intraosseous accessline in an 800 grams preterm infant for the administration of drugs and fluid. The use and technique of an intraosseous access is an important emergency alternative which may be lifesaving, even in very preterm babies, when other methods fail.

Severe encephalopathy in a child: an uncommon cause.

Cat scratch disease (CSD) is usually a self-limited disease. Although extremely uncommon, the involvement of the central nervous system has been previously reported in CSD. The intention of this paper is to make physicians aware that CSD could be complicated by encephalopathy. Seizures in some patients could be the only clinical manifestation and are resistant to the common anti-epileptic therapy. The seizures resolve with supportive care.

Open chest cardiopulmonary resuscitation in out-of-hospital cardiac arrest.

Because closed chest cardiopulmonary resuscitation (CCCPR) achieve restoration of spontaneous circulation (ROSC) in less than 50% of cases, and because of the apparent physiological superiority of open-chest cardiopulmonary resuscitation (OCCPR), we evaluated OCCPR in out-of hospital cardiac arrest in cases who did not respond to standard external cardiopulmonary resuscitation with advanced life support. Over a period of 12 years, OCCPR was performed in 33 patients with out-of-hospital cardiac arrest arising from different causes, after unsuccessful attempts to achieve ROSC with CCCPR efforts over 7-121 min (median 25 min). With OCCPR, ROSC was achieved in 13/33 patients. Of these, two recovered to discharge (one with no neurological deficit and one with mild brain damage). The other 11 rearrested either in the emergency department after a median period of 70 min of resuscitation, or in the intensive care unit after a median period of 104 h. One case of iatrogenic cardiac injury was observed. The OCCPR attempts were well accepted by the public. Our data suggest that OCCPR is more effective than CCCPR in achieving ROSC outside hospital in patients with major cardiac disease and prolonged arrest. OCCPR is feasible in the out-of-hospital setting. Survival without neurological deficit cannot be expected when CCCPR with no-flow is continued beyond 25 min.

Future directions for resuscitation research. V. Ultra-advanced life support.

Standard external cardiopulmonary resuscitation (SECPR) frequently produces very low perfusion pressures, which are inadequate to achieve restoration of spontaneous circulation (ROSC) and intact survival, particularly when the heart is diseased. Ultra-advanced life support (UALS) techniques may allow support of vital organ systems until either the heart recovers or cardiac repair or replacement is performed. Closed-chest emergency cardiopulmonary bypass (CPB) provides control of blood flow, pressure, composition and temperature, but has so far been applied relatively late. This additional low-flow time may preclude conscious survival. An easy, quick method for vessel access and a small preprimed system that could be taken into the field are needed. Open-chest CPR (OCCPR) is physiologically superior to SECPR, but has also been initiated too late in prior studies. Its application in the field has recently proven feasible. Variations of OCCPR, which deserve clinical trials inside and outside hospitals, include 'minimally invasive direct cardiac massage' (MIDCM), using a pocket-size plunger-like device inserted via a small incision and 'direct mechanical ventricular actuation' (DMVA), using a machine that pneumatically drives a cup placed around the heart. Other novel UALS approaches for further research include the use of an aortic balloon catheter to improve coronary and cerebral blood flow during SECPR, aortic flush techniques and a double-balloon aortic catheter that could allow separate perfusion (and cooling) of the heart, brain and viscera for optimal resuscitation of each. Decision-making, initiation of UALS methods and diagnostic evaluations must be rapid to maximize the potential for ROSC and facilitate decision-making regarding long-term circulatory support versus withdrawal of life support for hopeless cases. Research and development of UALS techniques needs to be coordinated with cerebral resuscitation research.

Gitaloxin poisoning in a child.

Gitaloxin is a digitalis glycoside used for the same indications as digoxin and digitoxin. The successful outcome for a 2 1/2-year-old boy who accidentally ingested 3 mg of gitaloxin (100 times the normal therapeutic dose) is reported. At admission the child presented with irregular heart rhythm. He subsequently started vomiting, even after continuous gastric feeding. Only 48 h after ingestion of gitaloxin he became somnolent and developed bradyarrhythmia. The symptoms disappeared 96 h later; the bradyarrhythmia, however, (second-degree atrioventricular block) decreased progressively only after 120 h. The initial clinical presentation of gitaloxin poisoning may be misleading and careful observation in a pediatric intensive care unit is mandatory. A cross-reaction between the fluorescence polarization immunoassay for digitoxin and the radioimmunoassay for gitaloxin was found and was used as a helpful, but rough, estimate of the severity of gitaloxin poisoning, in the absence of a specific measurement of gitaloxin.

Benzodiazepine use among elderly patients presenting at the emergency room.

This study evaluated the prevalence of benzodiazepine intake by elderly patients presenting at the emergency room of a university hospital. Of 388 patients, 42.5% used one or more benzodiazepine (BZD) drugs in the week prior to admission. There were significantly more women among the BZD users (P < 0.05). Mean duration of intake was long (62 months), but daily dosage was adjusted to age. Of the BZD using patients, 27% took a BZD with long elimination half life. No relationship was found between the BZD intake and the occurrence of falls. Fallers were significantly older (P = 0.019) and were more often women (P = 0.046).

Adrenaline dosage during cardiopulmonary resuscitation: a critical review.

Since the end of the nineteenth century adrenaline has been used for the treatment of cardiac arrest. Since the 1960s a standard 1 mg dose administered intravenously every 5 min is common practice in cardiopulmonary resuscitation. Because of growing interest in the pharmacological aspects of cardiopulmonary resuscitation, experimental studies in animals conducted in the 1980s suggested the use of higher doses of adrenaline. Several case reports of successfully resuscitated patients who had been given high dose adrenaline were published, but large, prospective, randomized, controlled clinical trials in humans found no statistically significant improvement in survival rates between high dose and standard dose resuscitated patients. It seems that 1 mg adrenaline given intravenously every 3-5 min during resuscitation for cardiac arrest remains the standard.

Survival after out-of-hospital cardiac arrest in elderly patients. Belgian Cerebral Resuscitation Study Group.

STUDY OBJECTIVES: To study whether age of the cardiac arrest patient is related to prognostic factors and survival. STUDY DESIGN: Retrospective analysis of a prospective registration of cardiac arrest events in the mobile ICUs of seven participating hospitals. STUDY POPULATION: Two thousand seven hundred seventy-six out-of-hospital cardiac arrests in which advanced life support was initiated. Cardiac arrests with a precipitating event requiring specific therapeutic consequences and with specific prognosis were not included in the analysis (eg, trauma, exsanguination, drowning, sudden infant death syndrome). RESULTS: Neither resuscitation rate (23%) nor mortality caused by a neurologic reason (9%) was significantly different between age groups. Mortality after CPR of non-neurologic etiology was significantly higher in the elderly patient (younger than 40 years, 16%; 40 to 69 years, 19%; 70 to 79 years, 30%; 80 years or older, 34%; P less than .005) and had a negative effect on survival in resuscitated elderly patients (P less than .05). Elderly patients more frequently had a dependent lifestyle before the arrest (P less than .025), an arrest of cardiac origin (P less than .001), electromechanical dissociation as the type of cardiac arrest (P less than .025), and a shorter duration of advanced life support in unsuccessful resuscitation attempts (r = -.178, P less than .0001). CONCLUSION: Because survival two weeks after CPR was not significantly different between age groups, we suggest that decision making in CPR should not be based on age but on factors with better predictive power for outcome and quality of survival.

Should semi-automatic defibrillators be used by emergency medical technicians in Belgium? The Belgian Cerebral Resuscitation Study Group.

Early external defibrillation is the single most effective intervention in patients with out-of-hospital cardiac arrest. Literature data indicate that instructing emergency medical technicians (EMTs) to use defibrillators is beneficial, provided the local emergency medical system is well organized. We tried to estimate the potential benefit of early defibrillation in some centres in Belgium by retrospectively analyzing the data from the Belgian Cardio-Pulmonary-Cerebral Resuscitation Registry collected between 1983 and 1987 in Belgian centres with a Mobile Intensive Care Unit (MICU). The data show that 2310 out of 3371 patients (69%) were first attended by the EMTs; on subsequent arrival of the MICU-teams, 584 of these 2310 patients i.e. 17% of the whole study population, presented with ventricular fibrillation. Analysis of estimated time factors in these 2310 patients revealed that the median time interval between collapse and start of resuscitation by EMTs was 8 min; the median time interval between collapse and start of MICU-resuscitation attempts was 16 min. The duration of EMT-resuscitation before MICU-arrival was probably more than 5 min and 10 min in 58% and 23% of the cases respectively. It is concluded that EMTs can be expected to reach a substantial number of ventricular fibrillation victims within a few minutes after the collapse and many minutes before arrival of the MICU. Therefore, training of EMTs in the use of semi-automatic defibrillators seems worthwhile in MICU-served regions in Belgium.

Plasma concentrations and haemodynamic effects of nimodipine in patients resuscitated after cardiac arrest.

As the pharmacokinetics of a drug may be altered in haemodynamically compromised patients, the plasma concentrations and haemodynamic effects of the calcium entry blocker nimodipine have been examined in patients resuscitated after out-of-hospital cardiac arrest. In 7 patients nimodipine was infused at increasing rates up to 30 micrograms.kg-1.h-1. The plasma concentrations increased with increasing dose; at the highest dose a mean steady-state plasma concentration of 22.1 ng.ml-1 was obtained, and the mean plasma clearance was 1.41.kg-1.h-1. There were no marked changes in mean arterial blood pressure or heart rate. In 9 other patients nimodipine was given as a bolus infusion of 10 micrograms.kg-1 over 3 min, followed by a continuous infusion of 30 micrograms.kg-1.h-1. A mean steady-state plasma concentration of 17.6 ng.ml-1 was obtained and the mean plasma clearance was 1.91.kg-1.h-1. Heart rate did not change significantly, but the mean arterial blood pressure fell. The data indicate that in patients resuscitated after cardiac arrest, the pharmacokinetics of nimodipine are not markedly different from patients with other conditions, e.g. subarachnoid haemorrhage. However, if a loading dose is given to obtain a steady-state concentration sooner, there will be a fall in arterial blood pressure.

Predictive value of Glasgow coma score for awakening after out-of-hospital cardiac arrest. Cerebral Resuscitation Study Group of the Belgian Society for Intensive Care.

The Glasgow coma score (GCS) during days 1-6 after cardiac arrest was used to predict neurological outcome in 360 resuscitated victims of out-of-hospital cardiac arrest. A predictive rule based on the best GCS of 216 patients resuscitated in 1983-84 (prediction group) was constructed, and its predictive power was tested on 133 patients treated in 1985 (test group). Neurological outcome was correctly predicted 2 days after cardiac arrest in 80% of the prediction group, with a best GCS of 10 or above and 4 or below as cutoff points. For patients with a best GCS of 5-9, prediction of outcome was possible 6 days after cardiac arrest, with a best GCS of 8 during the first 6 days as the single cutoff point. The rule was then validated in the test group: the sensitivity was 96%; the specificity 86%; the negative predictive value 97%; and the positive predictive value 77%. These data suggest that this simple GCS-based rule can be helpful in predicting outcome in patients resuscitated after out-of-hospital cardiac arrest, but confirmation of these data is required in a prospective study in a larger number of patients.