James P. Orlowski

Hypothermia and barbiturate coma for refractory status epilepticus

Three pediatric patients with generalized status epilepticus unresponsive to therapy with conventional anticonvulsants were successfully treated with moderate hypothermia (30± to 31±C) and barbiturate coma with thiopental. All 3 patients were treated with thiopental at doses producing burst suppression or an isoelectric tracing on the EEG and thiopental and barbiturate levels were followed sequentially in the plasma. Continuous thiopental infusion rates of 5 to 55 mg/kg ± h maintained burst suppression and correlated with plasma thiopental levels of 25 to 40 mg/dl. Total doses of thiopental used to obtain and maintain burst suppression ranged from 15 to 50 g over 48 to 120 h. In all 3 patients, control of the status epilepticus was obtained. Moderate hypothermia and thiopental barbiturate coma are indicated in patients with generalized tonic-clonic status epilepticus which cannot be controlled with standard anticonvulsant drug therapy. This regimen has the advantage that the patient can be managed in an ICU without the need for general anesthesia with volatile anesthetic agents.

Drowning, near-drowning, and ice-water submersions

Drowning is the second most common cause of accidental death in children. Swimming pools and natural bodies of water close to home present the greatest risk to young children. The single most important step in the treatment of submersion accident victims is the immediate institution of resuscitative measures at the earliest possible opportunity. Ice-water submersion accidents are an important subgroup of near-drowning victims, who at times can defy predictions for outcome after profound anoxic-ischemic insults. Drowning accident prevention is an important public health measure.

The safety of intraosseous infusions: Risks of fat and bone marrow emboli to the lungs

The technique of intraosseous infusion is a life-saving emergency alternative when IV access is impossible or will be critically delayed. Concerns about its safety remain, especially concerning the risk of bone marrow and fat emboli to the lungs. We examined autopsy pulmonary specimens on two children who had received intraosseous infusions during resuscitation attempts and found an average of 0.23 to 0.71 bone marrow and fat emboli per mm 2 of lung. We studied normotensive dogs with intraosseous infusions of emergency drugs and solutions into the distal femur. Three dogs were studied with each of the following emergency drugs or solutions: controls with normal saline (0.9% NaCl), epinephrine 0.01 mg/kg, NaHCO 3 1 mEq/kg, CaCl 10 mg/kg, atropine 0.01 mg/kg, hydroxyethyl starch 6% in normal saline 10 mL/kg, 50% dextrose in water 0.25 g/kg, and lidocaine 1 mg/kg. Four hours after infusion, the animals were killed, and representative sections of the lung were examined with oil red-0 and hematoxylin and eosin stains for the presence of fat and bone marrow emboli. Fat and bone marrow emboli were found in all lung sections, varying from 0.11 to 4.48 emboli/mm 2 lung (mean, 0.91 emboli/mm 2 lung) for the emergency drugs and solutions and 0.06 to 0.53 emboli/mm 2 (mean, 0.29 emboli/mm 2 lung) for the controls. Analysis of variance revealed no significant difference ( P = .07) in mean number of fat and bone marrow emboli per square millimeter of lung among the emergency drugs and compared with controls. The 95% confidence limits for estimating the proportion of the population to develop bone marrow and fat emboli after intraosseous infusions is 0.89 to 1.00. Despite the universal finding of fat and bone marrow emboli in patients and animals in which emergency drugs were administered by the intraosseous route, there were no significant alterations in Pao 2 or intrapulmonary shunt during the four-hour study period. This suggests that although fat and bone marrow emboli are a common occurrence after intraosseous drug administration, they are not of any immediate clinical importance, do not result in a pulmonary fat embolism syndrome or adult respiratory distress syndrome that might complicate resuscitation, and should not preclude the use of the intraosseous route for resuscitation drugs when IV access is delayed or impossible. However, the pulmonary fat embolism syndrome may complicate postresuscitation care, and bone marrow and fat emboli may be of clinical importance in patients with intracardiac right-to-left shunts because of the risk of cerebral emboli and emboli to other vital organs.

Optimum position for external cardiac compression in infants and young children

Ninety-seven pediatric patients (age less than 17 years) undergoing routine upright chest roentgenograms in the posteroanterior projection and 90 children undergoing supine anteroposterior chest roentgenograms had lead markers placed at the suprasternal notch and xiphoid prior to taking the roentgenograms. The position of the geometric center of the cardiac silhouette in relation to the sternum was recorded as a percentage of the distance along the sternum. The heart lies under the lower one-third of the sternum (greater than 67%) in all cases at all ages. Ten pediatric patients (between 1 month and 3 years of age) who sustained cardiac arrest while in the Pediatric and Surgical Intensive Care Unit and who had arterial pressure monitoring lines already in place were monitored with a two- or four-channel strip-chart recorder during external cardiac compression (ECC) performed by staff members who were blinded from the results of the strip-chart recording. The ECC performers were instructed to perform ECC at either the midsternum at the level of the victims nipples or at the lower one-third of the sternum 1.5 to 2 cm above the tip of the xiphoid, and then to switch on command. In every instance in which the patients served as their own controls (ECC performed at both the midsternum and lower one-third of the sternum in random sequence), the performance of ECC over the lower one-third of the sternum resulted in significantly better systolic and mean arterial blood pressures (P less than .001).(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic factors in pediatric cases of drowning and near-drowning

Ninety-three cases of drowning or near-drowning in the pediatric age group between 1972 and 1976 were reviewed. A scoring system for prognostic factors was developed using one point for each of five unfavorable factors involved in the drowning or near-drowning of each patient. The prognostic factors were 1) age less than three years; 2) maximum submersion time estimated longer than five minutes; 3) resuscitation not attempted for at least ten minutes after rescue; 4) patient in coma on admission to hospital, and 5) arterial blood pH of less than or equal to 7.10. This scoring system significantly predicted the eventual outcome of patients who had experienced the postsubmersion syndrome. Patients with scores of less than or equal to 2 had a 90% chance of full recovery; those with scores of greater than or equal to 3 had only a 5% probability of survival. The early institution of resuscitative efforts was the single most important factor influencing survival.

Endotracheal epinephrine is unreliable

When intravenous access cannot be obtained in an emergency, the endotracheal route of emergency drug administration can be used for epinephrine, atropine, and lidocaine. Optimal drug dosages for endotracheal administration as well as the amount and type of diluent are presently unknown. We compared central intravenous, peripheral intravenous, intraosseous, and intratracheal administration of epinephrine 1:10,000 in both normotensive and hemorrhagic shock dogs. The shock model consisted of 50% blood volume depletion over 15 min. Epinephrine was administered in a dose of 0.01 mg/kg (0.1 cc/kg) by the intraosseous route, central, and peripheral intravenous routes followed by a 5 cc normal saline flush. Intratracheal administration consisted of epinephrine 0.01 and 0.02 mg/kg diluted 1:1 and 1:2 with normal saline or sterile water and administered deep into the tracheo-bronchial tree using a 30-cm catheter. The effect of epinephrine was assessed by the response of the arterial blood pressure. Epinephrine was equally effective by the intraosseous, central intravenous, and peripheral intravenous routes in terms of time to onset of action, time to peak effect, and magnitude of effect on systolic, diastolic, and mean arterial pressures in both the shock and non-shock animals. The duration of effect was significantly longer (P less than 0.02) for the intraosseous route of administration. The endotracheal route of administration was unreliable and not reproducible in either the normotensive or shock animals. In 8/12 episodes in normotensive animals, including 5 trials with double doses of 0.02 mg/kg and dilutions of 1:1 and 1:2, and in 4/9 studies with shock animals including three with double doses, there was no discernable response of systolic or diastolic blood pressure.

Experimental study of extracorporeal perfusion for septic shock

The authors evaluated the efficacy of treatment by extracorporeal perfusion on experimental canine septic shock. Canine septic shock was produced by intravenous infusion of Escherichia coli endotoxin and treated by three techniques: no treatment (Sham), hemoperfusion over Polymyxin B immobilized fiber (PMX), and plasma perfusion over anion exchange resin (Resin). The 24 hr survival rates of the Sham, PMX, and Resin groups were 0%, 80%, and 40%, respectively. In the PMX group, blood pressure was significantly better over 6 hr than that recorded in the Sham group. In the PMX group, phagocytic function evaluated by neutrophil function, opsonic index, and complement were better than that of the Sham group. In addition, blood endotoxin levels in the PMX group were significantly lower, resulting in a significant suppression of TNF release. In the Resin group, some parameters were significantly better than those of the Sham group, but the efficacy of this treatment was less than that of the PMX treatment. Hemoperfusion over Polymyxin B immobilized fibers can detoxify circulatory endotoxin, resulting in improvement of systemic and organic disorders caused by sepsis.

The hemodynamic and cardiovascular effects of near-drowning in hypotonic, isotonic, or hypertonic solutions

It has been postulated that near-drowning in fresh water may cause hemodilution and hypervolemia due to the hypotonicity of the aspirated water. In contrast, near-drowning in seawater, because of its hypertonicity, may lead to hypovolemic shock. We evaluated the hemodynamic effects of the instillation of 20 mL/kg of solutions of various tonicities (sterile water, 0.225% sodium chloride, 0.45% sodium chloride, normal saline, 2% sodium chloride, and 3% sodium chloride) into the lungs of anesthetized dogs and compared the results with those for control animals who were made anoxic for five minutes. There was no difference in the hemodynamic effects of hypotonic, isotonic, or hypertonic solutions when compared with anoxic controls. There was an immediate fall in cardiac output and increase in pulmonary capillary wedge pressure, central venous pressure, and pulmonary vascular resistance, regardless of the solution, which was statistically the same as the changes in the anoxic controls (P greater than .02). Likewise, the effective dynamic compliance of the lungs decreased precipitously, was indistinguishable between solutions, and was not statistically different from the anoxic controls (P greater than .10). The pulmonary capillary wedge pressure and central venous pressure peaked at ten minutes and then declined gradually over four hours independent of the tonicity of the aspirated fluid. The cardiac output and effective dynamic compliance of the lung dropped rapidly and remained depressed throughout the experiment, and the pulmonary vascular resistance gradually worsened throughout the four hours of study. Similar results occurred with the anoxic controls. The cardiovascular changes that occur with near-drowning and aspiration of water are not dependent on the tonicity of the aspirated fluid but are the direct result of anoxia.

Emergency alternatives to intravenous access. Intraosseous, intratracheal, sublingual, and other-site drug administration.

Difficulties and delays in establishing intravenous access are not uncommon in emergency situations in pediatrics. Alternatives to venous cannulation exist, including intraosseous access, intratracheal drug administration, sublingual and intralingual injection, the intrapenile route, and intracardiac injection. Each of these emergency alternatives to intravenous access is discussed from the historical, technical, utilitarian, and risk-benefit aspects. It is concluded that the intraosseous effective alternative to intravenous access in emergency situations.

Complications of airway intrusion in 100 consecutive cases in a pediatric ICU.

One-hundred consecutive patients who underwent orotracheal intubation (OT), nasotracheal intubation (NT), or tracheostomy in the pediatric ICU were evaluated for complications of these airway invasions. Twelve patients had major complications as a result of airway intervention. The mortality for patients requiring mechanical ventilation was 17% as compared with a total overall mortality of 8.3% for patients in the pediatric ICU. Major complications occurred in 10% of patients who had orotracheal intubation, in 11% of patients who had nasotracheal intubations, and in 26% of patients subjected to tracheostomy. Laryngotracheobronchitis (croup) was the primary diagnosis associated with the highest rate of complications. An association was found between the occurrence of seizures or hypoperfusion state (shock) while intubated and the occurrence of major complications of airway intrusion. Acquired infections of the respiratory tract with Hemophilus influenzae, Pseudomonas, Klebsiella, and Candida albicons were also associated with a high rate of complications.