Max Koenigsberg

Naloxone-induced pulmonary edema.

We present the case of a 68-year-old woman with acute pulmonary edema secondary to the administration of naloxone to reverse an inadvertent narcotic overdose. The patient presented following a 12-hour history of increasingly bizarre behavior and confusion. A total IV dose of 1.6 mg naloxone was administered in an attempt to reverse the suspected overconsumption of a codeine-containing cough suppressant. She immediately became agitated, tachycardic, and diaphoretic; a clinical diagnosis of acute pulmonary edema was made. Following treatment with furosemide, nitroglycerin, and morphine sulfate, the patient recovered completely without further incident. Although naloxone is thought to be a safe drug with few complications, it should not be used indiscriminantly, and the smallest doses necessary to elicit the desired response should be used.

Drug use patterns at major rock concert events

STUDY OBJECTIVE To describe alcohol and drug use patterns in patients presenting to first aid stations at major rock concerts. METHODS We retrospectively reviewed all charts generated at the first aid stations of five major rock concerts featuring the rock groups Pink Floyd, the Grateful Dead, and the Rolling Stones. The first aid stations, located at a sports stadium, were staffed by paramedics, emergency medicine nurses, and physicians. We recorded the following data: patient demographics, history of drug or ethanol use, time spent by patient in first aid station, treatment rendered, diagnosis, and patient disposition. RESULTS A total of 253, 286 spectators attended the five concert events. The rate of use of the first aid station was 1.2 per 1,000 patrons. The average age of the patrons was 26.3 +/- 7.9 years (range, 3 to 56 years). The most common diagnoses were minor trauma 130 (42%) and ethanol or illicit drug intoxication 98 (32%). Of the patients treated, 147 (48%) admitted to using illicit drugs or ethanol while attending the concerts. The median time spent in the first aid station was 15 +/- 22.5 minutes (range, 5 to 150 minutes). One hundred patients (32.5%) were treated and released, 98 (32%) were transported to emergency departments, and 110 (35.5%) signed out against medical advice. CONCLUSION Minor trauma and the use of illicit drugs and ethanol were common in spectators presenting to first aid stations at these concert events. Physicians and paramedical personnel working at rock concerts should be aware of the current drug use patterns and should be trained in treating such drug use.

Medical Control of Mass Gatherings: Can Paramedics Perform Without Physicians On-site?

OBJECTIVE Evaluate the experience of paramedic personnel at mass gatherings in the absence of on-site physicians. DESIGN Retrospective review of patients evaluated by paramedics with emergency medical services (EMS) medical control. SETTING First-aid facility operated by paramedics at an outdoor amphitheater involving 32 (predominantly rock music) concerts in accordance with the Chicago EMS System, June through September 1990. PARTICIPANTS A total of 438 patients (< or = 0.1% on-site population) were evaluated. INTERVENTIONS Presentations to the first-aid facility were viewed as if the patient was presenting to an ambulance. Transportation to an emergency department was strongly recommended for all encounters. Time from presentation to the first-aid facility until disposition was limited to 30 minutes in the absence of on-line [direct] medical control. Refusal of care was accepted. On-line [direct] medical control with the EMS resource hospital was initiated as needed. Off-line [indirect] medical control consisted of weekly reviews of all patients records and periodic site visits. RESULTS Of the 438 patients, 366 (84%) refused further care, including 31 patients (7%) who refused advanced life support (ALS) level care. Seventy-two patients (16%) were transported; 37 by ALS and 35 by basic life support (BLS) units. On-line [direct] medical control was initiated in all ALS patients that were transported as well as for those who refused care. No known deaths or adverse outcomes occurred, based on lack of inquiries or complaints from the local EMS system, emergency departments receiving transported patients, law enforcement agencies, 9-1-1 emergency response providers, venue management, or security. No request for medical records from law firms have occurred. Problems noted initially were poor documentation and a tendency not to document all encounters (e.g., dispensing band-aids, tampons, earplugs, etc.). Concerns noted included: initial and subsequent vital signs, times of arrival, interventions, dispositions, and patient conditions of refusal. Specific problems with documentation of refusals at disposition included: appropriate mental status, speech, and gait; release with an accompanying family member or friend; and parental notification and approval of care for minors. There also was an initial tendency not to establish on-line [direct] medical control for ALS refusal or BLS medicolegal issues. CONCLUSIONS The medical system configuration modeled after practices of prehospital care, demonstrates physicians did not need to be on-site when adequate EMS medical control existed with less than 30 minutes on-scene time.

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.

Shock index and prediction of traumatic hemorrhagic shock 28-day mortality: data from the DCLHb resuscitation clinical trials.

Introduction To assess the ability of the shock index (SI) to predict 28-day mortality in traumatic hemorrhagic shock patients treated in the diaspirin cross-linked hemoglobin (DCLHb) resuscitation clinical trials. Methods We used data from two parallel DCLHb traumatic hemorrhagic shock efficacy trials, one in U.S. emergency departments, and one in the European Union prehospital setting to assess the relationship between SI values and 28-day mortality. Results In the 219 patients, the mean age was 37 years, 64% sustained a blunt injury, 48% received DCLHb, 36% died, and 88% had an SI≥1.0 at study entry. The percentage of patients with an SI≥1.0 dropped by 57% (88 to 38%) from the time of study entry to 120 minutes after study resuscitation (p<0.001). Patients with a SI≥1.0, 1.4, and 1.8 at any time point were 2.3, 2.7, and 3.1 times, respectively, more likely to die by 28 days than were patients with SI values below these cutoffs (p<0.001). Similarly, after 120 minutes of resuscitation, patients with a SI≥1.0 were 3.9× times more likely to die by 28 days (40 vs. 15%, p<0.001). Although the distribution of SI values differed based on treatment group, the receiver operator characeristics data showed no difference in SI predictive ability for 28-day mortality in patients treated with DCLHb. Conclusion In these traumatic hemorrhagic shock patients, the shock index correlates with 28-day mortality, with higher SI values indicating greater mortality risk. Although DCLHb treatment did alter the distribution of SI values, it did not influence the ability of the SI to predict 28-day mortality.

Assaults from penetrating trauma in the State of Illinois

This study was undertaken to evaluate the incidence, epidemiology, and temporal relationships of assaults in the State of Illinois from penetrating trauma presenting to Level I and Level II trauma centers, and to project the impact of these variables on hospital staffing. A retrospective analysis was performed on 4 months of data (7/1/92 to 10/31/92) provided by the Illinois Department of Public Health describing consecutive assaults with firearms or knives presenting to all Level I and Level II trauma facilities in the State of Illinois. Data were analyzed for epidemiological parameters including age, gender, and race. Other variables analyzed included trauma score, Glasgow Coma Scale (GCS) score, ethanol levels, urine toxicology results, and mortality. The data were also analyzed for temporal patterns of hospital presentations with respect to the time of day and day of the week. A total of 1,288 cases of penetrating wounds were analyzed. Of these, 881 (68.4%) resulted from firearms and 407 (31.6%) resulted from stab wounds. Ages of all penetrating trauma victims ranged from less than 1 year to 84 years of age. The mean age for firearm victims was 25.0 +/- 10.8 (SD) years and 30.5 +/- 11.4 years for stabbing victims. Ninety percent of penetrating trauma victims were male and 10% were female. Seventy-two percent of the victims were African-American, 13% Hispanic, 13% Caucasian, and 2% other. Alcohol levels were available for 727 of the 1,288 (56.4%) patients. Of these 727, 433 (59.6%) had measurable levels. The results of drug screens were available for 582 of the 1,288 (45.1%) victims. Of these 582, 208 (35.7%) were positive. Other than alcohol, cocaine was the most frequently detected drug, accounting for 58.4% of the positive drug screens. Firearm victims had significantly lower trauma scores (10.5 v 11.2) and GCS scores (13.2 v 14.3) than stab victims. Significant circadian patterns of penetrating trauma were observed for both types of assaults. For assaults with firearms, the circadian rhythm peaked at 23.1 +/- 0.36 hours. For assaults with knives, the circadian rhythm peaked at 23.7 +/- 0.44 hours. Weekly patterns were not statistically significant for each individual type of assault. However, when the data were pooled, a weekly pattern peaking on Thursday was observed. These patterns of presentation for assaults are a significant finding that may have implications for hospital staff scheduling of trauma center physicians, nurses, technicians, security, social service, and other ancillary staff.

Implementation of an out-of-hospital termination of resucitation policy

OBJECTIVE To evaluate the implementation of an out-of-hospital termination of resuscitation policy in an urban EMS setting. METHODS A descriptive study characterizing the implementation of an out-of-hospital termination of resuscitation policy in the Chicago EMS system. It includes a retrospective telemetry record review analyzing the utilization and compliance with the policy. The newly implemented policy involved field termination of resuscitation for all nontraumatic, adult cardiac arrest victims presenting in asystole who were not responsive to a standard trial of resuscitation. RESULTS Over the three-month study period, 228 resuscitations of adult, nontraumatic cardiac arrest victims were identified and submitted for review. The group of 142 cardiac arrest victims who presented in asystole and received resuscitative efforts were categorized into four groups. Group I included 34 cardiac arrests for which resuscitation was terminated in the field following policy criteria. Group II included eight cardiac arrests for which resuscitation was terminated but the patients did not meet criteria for termination of resuscitation. Group III included 84 cardiac arrests for which resuscitation was not terminated because the patients did not meet criteria for out-of-hospital termination. Group IV included 16 cardiac arrests for which resuscitative efforts were continued, although the patients met indications for field termination. CONCLUSIONS Field termination of resuscitation is practical in the setting of asystole unresponsive to aggressive resuscitative efforts. The implementation of such an out-of-hospital termination of resuscitation policy is complicated by many problems and is best accomplished by a gradual implementation process. Through this process all members of the EMS community can address practical and ethical issues and grow comfortable with the ongoing evolution of out-of-hospital therapy.

A simple treatment of post-lumbar-puncture headache

We report a case of post-lumbar-puncture headache successfully treated with intravenous caffeine sodium benzoate. The patient presented to the emergency department with a severe headache three days after a myelogram of the lumbar region. Caffeine sodium benzoate (500 mg) in 1 liter of fluid (D5LR) intravenously over one and a half hours was administered. The patient reported complete resolution of symptoms and no recurrence of headache. Caffeine sodium benzoate is a simple treatment of post-lumbar-puncture headaches. It should be considered as a safe alternative to an epidural blood patch for the treatment of post-lumbar-puncture headaches.

Diaspirin Cross-Linked Hemoglobin Infusion Did Not Influence Base Deficit and Lactic Acid Levels in Two Clinical Trials of Traumatic Hemorrhagic Shock Patient Resuscitation

BACKGROUND Diaspirin cross-linked hemoglobin (DCLHb) has demonstrated a pressor effect that could adversely affect traumatic hemorrhagic shock patients through diminished perfusion to vital organs, causing base deficit (BD) and lactate abnormalities. METHODS Data from two parallel, multicenter traumatic hemorrhagic shock clinical trials from 17 US Emergency Departments and 27 European Union prehospital services using DCLHb, a hemoglobin-based resuscitation fluid. RESULTS In the 219 patients, the mean age was 37.3 years, 64% of the patients sustained a blunt injury, 48% received DCLHb resuscitation, and the overall 28-day mortality rate was 36.5%. BD data did not differ by treatment group (DCLHb vs. normal saline [NS]) at any time point. Study entry BD was higher in patients who died when compared with survivors in both studies (US: -14.7 vs. -9.3 and European Union: -11.1 vs. -4.1 mEq/L, p < 0.003) and at the first three time points after resuscitation. No differences in BD based on treatment group were observed in either those who survived or those who died from the hemorrhagic shock. US lactate data did not differ by treatment group (DCLHb vs. NS) at any time point. Study entry lactates were higher in US patients who ultimately died when compared with survivors (82.4 vs. 56.1 mmol/L, p < 0.003) and at all five postresuscitation time points. No lactate differences were observed between DCLHb and NS survivors or in those who died based on treatment group. CONCLUSIONS Although patients who died had more greatly altered perfusion than those who survived, DCLHb treatment of traumatic hemorrhagic shock patients was not associated with BD or lactate abnormalities that would indicate poor perfusion.

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 systems 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.