Michael C. Tomlanovich

Early lactate clearance is associated with improved outcome in severe sepsis and septic shock

Objective:Serial lactate concentrations can be used to examine disease severity in the intensive care unit. This study examines the clinical utility of the lactate clearance before intensive care unit admission (during the most proximal period of disease presentation) as an indicator of outcome in severe sepsis and septic shock. We hypothesize that a high lactate clearance in 6 hrs is associated with decreased mortality rate. Design:Prospective observational study. Setting:An urban emergency department and intensive care unit over a 1-yr period. Patients:A convenience cohort of patients with severe sepsis or septic shock. Interventions:Therapy was initiated in the emergency department and continued in the intensive care unit, including central venous and arterial catheterization, antibiotics, fluid resuscitation, mechanical ventilation, vasopressors, and inotropes when appropriate. Measurements and Main Results:Vital signs, laboratory values, and Acute Physiology and Chronic Health Evaluation (APACHE) II score were obtained at hour 0 (emergency department presentation), hour 6, and over the first 72 hrs of hospitalization. Therapy given in the emergency department and intensive care unit was recorded. Lactate clearance was defined as the percent decrease in lactate from emergency department presentation to hour 6. Logistic regression analysis was performed to determine independent variables associated with mortality. One hundred and eleven patients were enrolled with mean age 64.9 ± 16.7 yrs, emergency department length of stay 6.3 ± 3.2 hrs, and overall in-hospital mortality rate 42.3%. Baseline APACHE II score was 20.2 ± 6.8 and lactate 6.9 ± 4.6 mmol/L. Survivors compared with nonsurvivors had a lactate clearance of 38.1 ± 34.6 vs. 12.0 ± 51.6%, respectively (p = .005). Multivariate logistic regression analysis of statistically significant univariate variables showed lactate clearance to have a significant inverse relationship with mortality (p = .04). There was an approximately 11% decrease likelihood of mortality for each 10% increase in lactate clearance. Patients with a lactate clearance ≥10%, relative to patients with a lactate clearance <10%, had a greater decrease in APACHE II score over the 72-hr study period and a lower 60-day mortality rate (p = .007). Conclusions:Lactate clearance early in the hospital course may indicate a resolution of global tissue hypoxia and is associated with decreased mortality rate. Patients with higher lactate clearance after 6 hrs of emergency department intervention have improved outcome compared with those with lower lactate clearance.

Comparison of peak expiratory flow and FEV1 admission criteria for acute bronchial asthma.

One hundred nine episodes of acute bronchial asthma were studied utilizing PEFR and FEV1 measurements to determine objective patient disposition criteria. Of patients with both a pre-treatment PEFR less than 100 L/min, and a post-treatment value less than 300 L/min, 92% required admission or had an unsuccessful OPD course. Of patients with a pre-treatment PEFR less than 100 L/min and an improvement less than 60 L/min after initial terbutaline, 85% were admitted or had problems after discharge. PEFR correlated well with FEV1 at all stages of treatment.

Ballistics: a pathophysiologic examination of the wounding mechanisms of firearms: Part II

Wounds caused by firearms are a frequent occurrence in urban emergency centers. Understanding of the underlying pathophysiologic mechanisms involved in wound production is very important in treatment of these injuries. Part I of this article reports studies on the interaction of projectiles with both the atmosphere and human tissue to produce wounds. Part II will examine the types of wounds formed by specific firearms, and the recent innovations in both weapons and ammunition which are altering the severity of shooting injuries.

An evaluation of cocaine-induced chest pain

STUDY OBJECTIVE To determine if enzymatic evidence of acute myocardial injury is present in patients complaining of chest pain after cocaine use when the ECG is normal or nondiagnostic. DESIGN Serial ECG and creatinine kinase (CK) and CK isoenzymes (CK-ISO) determinations were performed at time of emergency department presentation and every six hours over 12 hours on individuals complaining of chest pain within six hours of last cocaine use. SETTING ED of an urban tertiary care center. TYPE OF PARTICIPANTS Forty-two individuals with a mean age of 28.5 years. INTERVENTIONS Patients with positive CK-ISOs were admitted immediately to formally rule out myocardial infarction. Patients developing ECG changes during observation period also were admitted even if CK-ISOs were normal. Patients with unchanged ECGs and normal CK-ISOs were discharged after 12 hours of observation. RESULTS Eight patients (19%) had elevated CK and CK-ISO values at presentation. Two of these patients had elevated values on three sequential determinations and were believed to have sustained acute myocardial infarction. Six patients had elevated CK and CK-ISOs at presentation only. ECGs remained normal or nondiagnostic in all patients. CONCLUSIONS Enzymatic evidence of acute myocardial injury may occur in patients who develop chest pain after cocaine use and have normal or nondiagnostic ECGs. This injury may reflect acute infarction or transient ischemia. Single or serial normal or nondiagnostic ECGs do not rule out ischemia or injury in this group of patients.

Spirometric evaluation of acute bronchial asthma

Spirograms were obtained before and after emergency therapy in 85 episodes of acute bronchial asthma in 82 patients. The clinical status of all patients after emergency treatment was reevaluated 48 hours later. Patients could be divided into three groups: I) admissions; II) patients discharged but with later respiratory problems; and III) patients who were discharged and did well. The mean pre- and posttreatment one second forced expiratory volume (FEV1.0) was significantly different among all three groups. FEV1.0 less than or equal to 0.6 liter before treatment, or an FEV1.0 less than or equal to 1.6 liter after emergency treatment, was associated with an unfavorable course. Eighty-eight percent of Group I patients (admissions) had either an initial FEV1.0 less than or equal to 0.6 liter, or a posttreatment FEV1.0 less than or equal to 1.6 liter. Among all patients whose initail FEV1.0 was less than or equal to 0.6 liter, 80% were either admitted or had subsequent respiratory problems; 75% of all patients whose posttreatment FEV1.0 was less than or equal to 1.6 liter were either admitted or developed subsequent respiratory problems. Moreover, 90% of patients who had both a pretreatment FEV1.0 less than or equal to 0.6 liter and a posttreatment FEV1.0 less than or equal to 1.6 liter were admitted or had subsequent significant airway obstruction. We conclude that spirometry can identify asthmatic patients who require admission or who will have significant airway obstruction within 48 hours after discharge from the emergency department.

Bretylium tosylate as initial treatment for cardiopulmonary arrest: Randomized comparison with placebo

To evaluate the therapeutic effectiveness of intravenous bretylium tosylate as a first-line drug for patients in cardiopulmonary arrest, a randomized, double-blind study was conducted, comparing bretylium with a normal saline placebo. Fifty-nine patients presenting to the emergency department with cardiopulmonary arrest due mainly to ventricular fibrillation or asystole initially received either bretylium (10 mg/kg) or placebo in a rapid intravenous bolus and were then otherwise treated according to standard American Heart Association guidelines. If ventricular fibrillation or asystole persisted, a second bolus of bretylium or normal saline was given after 20 minutes. Thirty-five percent of patients presenting with ventricular fibrillation or asystole who received bretylium were successfully resuscitated, whereas 6% of patients who received placebo survived (P less than 0.05). These findings serve to suggest that the early use of bretylium tosylate in cardiopulmonary arrest improves survival.

Aortic and right atrial pressures during standard and simultaneous compression and ventilation cpr in human beings

Coronary perfusion pressure, as reflected by the diastolic aortic to right atrial (Ao-RA) pressure gradient, has been shown to correlate well with coronary blood flow during standard external CPR (SE-CPR) and is an important determinant of successful cardiac resuscitation. Few studies have documented such Ao-RA gradients in human beings, however. Twenty patients sustaining out-of-hospital cardiopulmonary arrests and basic cardiac life support were instrumented with thoracic aortic and right atrial catheters on arrival in the emergency department. The mean time from arrival in the ED to catheter placement was 16.5 +/- 6.0 minutes. With SE-CPR, peak systolic aortic and right atrial pressures were 73.7 +/- 20.2 mm Hg and 69.6 +/- 18.3 mm Hg, respectively. End diastolic aortic and right atrial pressures were 27.9 +/- 7.3 mm Hg and 20.3 +/- 7.2 mm Hg, respectively, with an end diastolic gradient of 7.9 +/- 9.1 mm Hg. Three patients had systolic Ao-RA gradients of more than 25 mm Hg, which is consistent with some cardiac compression as a mechanism of flow. Five patients also had one-minute trials of simultaneous compression and ventilation CPR (SCV-CPR). Ao-RA end diastolic gradients decreased in four of the five during SCV-CPR. No patient in this study was resuscitated successfully. We conclude that ED SE-CPR provides little coronary perfusion for victims of prehospital cardiac arrest. Although SCV-CPR has been shown to improve carotid blood flow in human beings, it appears to have an adverse effect on the already minimal myocardial perfusion provided by SE-CPR.

Catheter aspiration for simple pneumothorax

A prospective study was conducted in the emergency setting to determine the efficacy of treatment of simple pneumothorax by catheter aspiration. Patients who were successfully treated were discharged to home. Sixty-one patients with a total of 76 pneumothoraces were involved in the study. The overall success rate was 75.6%, with an 82% success rate for needle-induced, 75% for traumatic, and 45% for spontaneous pneumothorax. The duration of symptoms, the size of the pneumothorax, the patients age, and a prior history of pneumothorax did not affect the outcome. The poorest results were noted with spontaneous pneumothoraces, as would be expected since a majority of these patients have preexistent lung disease. Catheter aspiration of simple pneumothorax offers a cost-effective approach to this clinical problem.

Sequential treatment of a simple pneumothorax

In a prospective investigation of isolated simple pneumothorax, the treatment of 35 patients with a total of 37 pneumothoraces was studied. A standardized sequential treatment approach was followed for evacuation of the pneumothorax and maintenance of lung reexpansion. The protocol involved catheter placement using a Seldinger technique, aspirations, and documentation of reexpansion by chest radiography and observation. Reaccumulation of air was treated with Heimlich valve attachment to the catheter at intrapleural pressure and further observation. Continued air leak following Heimlich valve attachment was treated with chest catheter suction using a Pleurovac at -20 cm H2O pressure. Chest tube thoracostomy was performed for continued failure of reexpansion. In 22 of the 37 pneumothoraces (59%) simple catheter aspiration maintained lung reexpansion without complications. In the remaining 15 pneumothoraces (41%), seven (47%) responded to Heimlich valve attachment, and three (20%) maintained expansion with chest catheter suction. Chest tube thoracotomy was required to maintain expansion in 33% (five) of those who failed catheter suction (14% of all pneumothoraces studied). Patients treated successfully with simple catheter aspiration were sent home. Patients requiring a Heimlich valve, chest catheter suction, or chest tube thoracostomy were hospitalized. Use of these catheter techniques resulted in lower cost and was associated with shorter hospitalizations than in chest tube thoracostomy. Our study suggests that sequential treatment of simple pneumothorax should be considered as a cost-effective and therapeutically successful alternative to immediate chest thoracostomy in selected cases.

The prognostic significance of serial myoglobin, troponin I, and creatine kinase-MB measurements in patients evaluated in the emergency department for acute coronary syndrome.

STUDY OBJECTIVE We sought to determine the value of serial measurements of myoglobin, cardiac troponin I (cTnI), and creatine kinase-MB (CK-MB) to predict 30-day adverse events in patients evaluated in the emergency department (ED) for possible acute coronary syndrome. METHODS Serum myoglobin, cTnI, and CK-MB levels were measured at presentation, 90 minutes, 3 hours, and 9 hours in patients evaluated in the ED for possible acute coronary syndrome. In 764 consecutive patients, the ability of each individual marker and combination of markers to predict a 30-day adverse event (death or myocardial infarction) over time was calculated. RESULTS There were 109 (14%) patients with an adverse event at 30 days (84 myocardial infarctions and 43 deaths). The sensitivities of initial measurements of myoglobin, cTnI, and CK-MB for identifying adverse events were 60%, 47%, and 52%, respectively. The combined sensitivity of myoglobin and cTnI measurements during a 9-hour period was 94%; specificity was 50%. Measurement of CK-MB did not improve sensitivity. CONCLUSION The measurement of both myoglobin and cTnI during a 9-hour period was the most predictive of subsequent adverse events in patients evaluated in the ED for possible acute coronary syndrome.