Stephen H. Thomas

Can correct closed-chest compressions be performed during prehospital transport?

INTRODUCTIONnThe resuscitation rate from out-of-hospital cardiac arrest is low. There are many factors to be considered as contributing to this phenomenon. One factor not previously considered is the impact of a moving ambulance environment on the ability to perform closed-chest compressions.nnnHYPOTHESISnProper closed-chest compressions can be performed in a moving ambulance.nnnMETHODSnA cardiopulmonary resuscitation (CPR) training mannequin with an attached skill meter (Skillmeter ResusciAnnie, Laerdal, Armonk, N.Y., USA) that measures each chest compression for proper depth and hand placement was used. Ten emergency medical technician-basic (EMT-B) certified prehospital providers were assigned into one of five teams. Each team performed a total of four sessions of five minutes of continuous closed-chest compressions on the mannequin. Two sessions were done by each team: one in the control environment with the mannequin placed on the floor, and the other in the experimental environment with the mannequin placed in the back of a moving ambulance. The ambulance was operated without warning lights and siren, and all traffic rules were obeyed. The percentage of correct closed-chest compressions was recorded for each session, and the mean values were compared using Students t-test with alpha set at 0.01 for statistical significance.nnnRESULTSnTen sessions of compressions were done in both environments. The mean percentage of correct compressions was 77.6 +/- 15.6 for the control group and 45.6 +/- 18.3 for the ambulance group (p = 0.0005).nnnCONCLUSIONnA moving ambulance environment appears to impair the ability to perform closed-chest compressions.

The ability to perform closed chest compressions in helicopters

Critically ill patients are often transported by air ambulances. Although these patients are likely to require cardiopulmonary resuscitation (CPR) during transport, the effects of the air medical transport environment on CPR efficacy have never been studied. A manikin model was used to assess the ability of flight nurses to perform effective chest compressions while in flight and when stationery on the helipad. The results demonstrate that flight nurses were able to perform chest compressions as effectively in the in-flight setting as in the stationary setting. Chest c compressions performed in the BK-117 helicopter were as effective as those performed in the control environment, but compressions performed in the BO-105 were significantly less effective than controls. In conclusion, in a manikin model, chest compressions are substandard in the BO-105 helicopter because of the limited space available in the aircraft.

Utilization of a pressure-sensing monitor to improve in-flight chest compressions

Previous research at the Division of Air Medical Services at East Carolina University School of Medicine has demonstrated impairment of chest compression efficacy in the setting of an airborne BO-105 helicopter. This study was undertaken to determine whether in-flight compression efficacy could be improved with utilization of a pressure-sensing monitor providing real-time feedback during cardiopulmonary resuscitation (CPR). Ten flight nurses each performed two minutes of in-flight chest compressions on a mannequin that electronically assessed compression depth and hand placement. The session was then repeated using the pressure-sensing device. The mean proportion of correct compressions (95.7 +/- 3.2%) achieved with utilization of the pressure-sensing monitor was significantly higher (P < .01) than the corresponding proportion for the control group (33.4 +/- 12.1%). This study demonstrated that the difficulties of performing effective in-flight chest compressions are largely overcome with utilization of a pressure-sensing device providing real-time feedback on compression efficacy.

Emergency department treatment of migraine, tension, and mixed-type headache

The complaint of headache is frequently encountered in the emergency department, but most patients with cephalalgia have a benign etiology for their pain. At least 90% of patients presenting with headache are diagnosed as suffering from benign vascular or muscle-tension (for example, migraine, tension, or mixed-type) headache. There is no consensus on the ideal therapeutic approach to these patients. Classically utilized narcotic therapy suffers from problems with efficacy, relapse, and potential for abuse and addiction. However, other agents have successively proved to be imperfect as well, despite the many therapeutic approaches that have been suggested in the medical literature. While no one drug has emerged as clearly superior for treatment of acute benign headache, recent investigations have clarified the role of certain therapies. This review is intended to familiarize emergency physicians with the latest information on most recommended therapeutic approaches to the patient with headache.

Intravenous versus rectal prochlorperazine in the treatment of benign vascular or tension headache: A randomized, prospective, double-blind trial

STUDY OBJECTIVEnTo compare the effectiveness of i.v. and PR prochlorperazine for treatment of acute benign vascular or tension headache.nnnDESIGNnProspective, randomized, double-blind trial.nnnSETTINGnUniversity emergency department with 50,000 annual census.nnnPARTICIPANTSnForty-five adult patients enrolled on 46 visits.nnnINTERVENTIONSnPatients received 10 mg prochlorperazine i.v. and placebo suppository or 25 mg prochlorperazine PR and placebo injection. Pain assessment was made using a 10-cm visual-analog scale; scores were analyzed using Wilcoxon/Kruskal-Wallis rank-sum tests (alpha of .01).nnnRESULTSnMean 60-minute pain scores for i.v. and PR groups were 0.6 and 3.5, respectively (P = .0002). Two patients (8.7%) in the i.v. group and six patients (26.1%) in the PR group required rescue analgesia (P = .12).nnnCONCLUSIONni.v. prochlorperazine appears to provide more effective relief than PR prochlorperazine for benign vascular or tension headaches.

Interhospital Transfer of Cardiac Patients: Does Air Transport Make a Difference?

INTRODUCTIONnThe purpose of this study was to compare the outcome of interhospital transported cardiac patients for whom bias in selecting transport mode was removed due to helicopter unavailability.nnnMETHODSnPatients with the diagnosis of unstable angina or myocardial infarction who underwent transport by ground only because helicopter transport was not available, were compared to patients transported by helicopter. Patients were matched by gender and referring hospital. Ninety-six patients were studied and both groups were comparable in age, diagnosis, Killip classification, treatment with thrombolytics and post-transport procedures.nnnRESULTSnThere were no statistically significant differences between the groups for mean ICU days (5.3 air vs. 3.5 ground) and mean hospital days (9.9 vs. 8.2, respectively). No differences were detected in the proportions of deaths within 72 hours of arriving at the receiving institution (1/48 air vs. 0/48 ground), but air transportation was associated with more total deaths (9/48 vs. 1/48, respectively).nnnCONCLUSIONnIt appears that the interhospital transport of cardiac patients by air offers no outcome advantage over ground transport.

Acute toxicity from baking soda ingestion

Sodium bicarbonate is an extremely well-known agent that historically has been used for a variety of medical conditions. Despite the widespread use of oral bicarbonate, little documented toxicity has occurred, and the emergency medicine literature contains no reports of toxicity caused by the ingestion of baking soda. Risks of acute and chronic oral bicarbonate ingestion include metabolic alkalosis, hypernatremia, hypertension, gastric rupture, hyporeninemia, hypokalemia, hypochloremia, intravascular volume depletion, and urinary alkalinization. Abrupt cessation of chronic excessive bicarbonate ingestion may result in hyperkalemia, hypoaldosteronism, volume contraction, and disruption of calcium and phosphorus metabolism. The case of a patient with three hospital admissions in 4 months, all the result of excessive oral intake of bicarbonate for symptomatic relief of dyspepsia is reported. Evaluation and treatment of patients with acute bicarbonate ingestion is discussed.

Is oral endotracheal intubation efficacy impaired in the helicopter environment

INTRODUCTIONnPatients transported by helicopter often require advanced airway management. The purpose of this study was to determine whether or not the in-flight environment of air medical transport in a BO-105 helicopter impairs the ability of flight nurses to perform oral endotracheal intubation.nnnSETTINGnThe study was conducted in an MBB BO-105 helicopter.nnnMETHODSnFlight nurses performed three manikin intubations in each of the two study environments: on an emergency department stretcher and in-flight in the BO-105 helicopter.nnnRESULTSnThe mean time required for in-flight intubation (25.9 +/- 10.9 seconds) was significantly longer than the corresponding time (13.2 +/- 2.8 seconds) required for intubation in the control setting (ANOVA, F = 38.7, p < .001). All intubations performed in the control setting were placed correctly in the trachea; there were two (6.7%) esophageal intubations in the in-flight setting. The difference in appropriate endotracheal intubation between the two settings was not significant (chi 2 = 0.3; p > 0.05).nnnCONCLUSIONnOral endotracheal intubation in the in-flight setting of the BO-105 helicopter takes approximately twice as long as intubation in a ground setting. The results support pre-flight intubation of patients who appear likely to require urgent intubation during air medical transport in the BO-105 helicopter.

Exacerbation of verapamil-induced hyperglycemia with glucagon

To evaluate the effects of verapamil intoxication and glucagon treatment on blood glucose levels in an intact canine model, 15 mg/kg verapamil was administered intravenously over a 30-minute period to mongrel dogs under pentobarbital anesthesia. Animals in the experimental group subsequently were administered 2.5 mg glucagon followed by an infusion of 2.5 mg per hour; control group animals were administered an equal volume of saline. Blood glucose was assessed before verapamil administration (baseline), and at 10 minutes (time 10) and 60 minutes (time 60) after completion of the verapamil infusion. Glucose values were compared between control and experimental groups using Dunnetts method (P = .05). At baseline, no animals were hyperglycemic and there was no difference in glucose levels. Animals in both groups became hyperglycemic after verapamil infusion. At time 10, the experimental group had significantly higher glucose levels (265 +/- 17.1 mg/dL) than the control group (209 +/- 18.3 mg/dL). By time 60, there was no significant difference between glucose values in the control (262 +/- 31.4) and experimental (246 +/- 24.8) groups. It was concluded that verapamil intoxication consistently resulted in hyperglycemia in this model. Glucagon therapy was associated with an early but nonsustained exacerbation of verapamil-induced hyperglycemia.

Bilateral epidural empyemas in an adolescent

Epidural empyema is an unusual cause of headache that may be encountered in the emergency department. The collection of suppurative fluid usually results from local spread of sinusitis, although many other predisposing factors have also been described. Patients with epidural empyema usually present with nonspecific cephalalgia that may be accompanied by fever and leukocytosis but is unlikely to be associated with focal neurological findings. The case of an adolescent who presented to our emergency department twice in 6 days with persistent headache is reported; cranial computed tomography performed on the second visit demonstrated bilateral epidural empyema. This entity is uncommon, but may certainly be encountered by the emergency physician.