William H. Spivey

Comparison of intermittent and continuously nebulized albuterol for treatment of asthma in an urban emergency department

STUDY OBJECTIVE To compare continuously nebulized albuterol with intermittent bolus nebulization of albuterol. DESIGN Consecutive block enrollment in groups of ten to continuous or intermittent therapy. SETTING Urban emergency department. TYPE OF PARTICIPANTS Patients who presented to the ED with moderate to severe asthma and did not improve after one treatment with nebulized albuterol. INTERVENTIONS All patients received an initial nebulized treatment with 2.5 mg albuterol followed by 125 mg solumedrol. Patients in the intermittent group received 2.5 mg nebulized albuterol at 30, 60, 90, and 120 minutes after the initial treatment. Patients in the continuous group received 10 mg albuterol nebulized in 70 mL over two hours. RESULTS There was no difference between groups in age, sex, or initial peak expiratory flow rate (PEFR). Ninety-nine patients were included in the study (47 continuous and 52 intermittent). There was no statistically significant difference in PEFRs or admission rate between groups over the two-hour study period. One subgroup analysis was performed on patients with PEFRs on presentation to the ED of 200 L/min or less. Mean +/- SD baseline PEFR at presentation to the ED was 135 +/- 35 in the 35 patients in the continuous group and 137 +/- 45 in the 34 patients in the intermittent group). At 120 minutes, PEFR was 296 +/- 98 in the continuous group and 244 +/- 81 in the intermittent group (P = .01). Admission: discharge ratios for this subgroup analysis were 11:24 in the continuous group and 19:14 in the intermittent group (P = .03). Mean +/- SD heart rate in the subgroup analysis was 102 +/- 21 at baseline for the continuous group and 109 +/- 22 at baseline in the intermittent group. At 120 minutes, heart rate was 90 +/- 18 in the continuous group and 104 +/- 16 in the intermittent group (P = .002). CONCLUSIONS Continuous nebulization offers no benefit over intermittent therapy in patients with an initial PEFR of more than 200 L/min. In PEFRs of 200 or less, continuous nebulization may decrease admission rate and improve PEFRs when compared with standard therapy.

Intravenous magnesium sulfate in the management of acute respiratory failure complicating asthma

IV magnesium sulfate was administered to a 72-year-old man with acute respiratory failure secondary to a severe asthma attack. The patient had clinically deteriorated despite aggressive standard treatment and evidenced acidosis and hypercarbia by arterial blood gas determination. An IV dose of 1 g MgSO4 produced rapid clinical and arterial blood gas improvement and enabled management of the patient without endotracheal intubation and mechanical ventilation. This is the first reported case of the use of IV MgSO4 to prevent intubation and assisted ventilation in a patient with acute respiratory failure complicating asthma.

Neurologic complications of cocaine abuse

The neurologic complications of cocaine toxicity are responsible for a major portion of the morbidity and mortality associated with cocaine. Most of the complications appear to be related to the hyperadrenergic state induced by cocaine and may be treated symptomatically. Diazepam is the most effective drug for cocaine-induced seizures.

Comparison of two doses of endotracheal epinephrine in a cardiac arrest model

STUDY OBJECTIVE The objective of this study was to measure plasma catecholamine levels and the cardiovascular response before and after endotracheal administration of epinephrine in a swine cardiac arrest model. DESIGN Prospective, controlled laboratory investigation. TYPE OF PARTICIPANTS Twenty-one swine weighing 10 to 12 kg, anesthetized with ketamine and alpha-chloralose and ventilated with room air. INTERVENTIONS Ventricular fibrillation was induced with 90 V of 60 Hz current delivered to the right ventricle by transvenous pacemaker. Blood samples for epinephrine were drawn before arrest and every two minutes thereafter. At five minutes, external mechanical cardiac compressions were initiated. Nine animals received no further therapy and served as controls. Two groups of six animals received either 0.01 mg/kg or 0.1 mg/kg of epinephrine through the endotracheal tube at ten and 20 minutes. Blood samples were assayed for epinephrine. MEASUREMENTS Arterial blood pressure, lead II ECG, and plasma epinephrine. MAIN RESULTS Swine receiving epinephrine 0.01 mg/kg had an increase in epinephrine levels after drug administration, but these were not significantly different from control levels. The 0.1-mg/kg dose group had a significant increase in plasma epinephrine levels compared with controls and the 0.01-mg/kg dose group after receiving epinephrine at ten and 20 minutes. These increases were from 14 +/- 3 to 215 +/- 40 ng/mL (+/- SEM) at 12 minutes after arrest and from 151 +/- 56 to 402 +/- 80 ng/mL at 22 minutes after arrest. CONCLUSION These data suggest that standard dosing of epinephrine through the endotracheal tube during arrest does not produce significant increases in plasma catecholamines or blood pressure. Epinephrine 0.1 mg/kg produces a significant increase in plasma epinephrine levels, but it is not sufficient to produce a significant change in blood pressure.

A clinical trial of escalating doses of flumazenil for reversal of suspected benzodiazepine overdose in the emergency department

STUDY OBJECTIVE To determine if flumazenil, when used in doses higher than those currently recommended, could reverse the effects of a benzodiazepine (BDZ) overdose in patients who might not otherwise respond and whether the higher dose was associated with increased adverse effects. DESIGN Multicenter, randomized, double-blind, placebo-controlled, balanced, with parallel groups. Open-label flumazenil administration was available if a patient failed to respond or became resedated. SETTING Sixteen emergency departments in the United States. POPULATION Patients presenting to the ED with clinically significant signs and symptoms of a known or suspected BDZ overdose. INTERVENTIONS Patients were randomized to receive 10 mL/min of placebo or flumazenil (1 mg/10 mL) each minute for ten minutes. If there was no response, up to 3 mg of open-label flumazenil could be administered. MEASUREMENTS AND MAIN RESULTS Of 170 patients enrolled, 87 received flumazenil and 83 received placebo. The demographic characteristics of both groups were comparable. Ten minutes after the beginning of study drug infusion, patients were evaluated using the Clinical Global Impression Scale (CGIS), Glasgow Coma Scale (GSC), and Neurobehavioral Assessment Scale (NAS). The mean +/- SD CGIS score at ten minutes for BDZ-positive patients was 1.41 +/- 0.72 for patients who received flumazenil and 3.41 +/- 0.91 for the placebo group (P < .01). There was no difference in the mean CGIS score between the flumazenil (3.25 +/- 1.15) and placebo (3.75 +/- 0.69) groups in BDZ-negative patients. The GCS and NAS were also significantly better in patients who were BDZ-positive and received flumazenil. The mean +/- SD dose of flumazenil administered during the double-blind phase was 71.3 +/- 34.2 mL (7.13 mg) compared with 95.06 +/- 16.03 mL of placebo. Of the 39 patients who had BDZ-positive drug screens and received flumazenil, 29 (74%) responded to 3 mg or less. Six additional patients responded to 4 or 5 mg, and one patient responded to 8 mg. The most common adverse effects in patients who received flumazenil were injection site pain (10.3%), agitation (8%), vomiting (3.4%), dizziness (3.4%), headache (3.4%), tachycardia (3.4%), and crying (3.4%). Three patients developed seizures. Two were associated with significant tricyclic antidepressant overdoses and one with propoxyphene ingestion. Two patients had positive drug screens for BDZ. CONCLUSION Flumazenil rapidly and effectively reverses the clinical signs and symptoms of a BDZ overdose. Most patients will respond to 3 mg or less, but a small number may require a higher dose for reversal of clinical symptoms. Patients with concomitant tricyclic antidepressant overdose may be at risk for developing seizures.

Emergency applications of intraosseous infusion

Vascular access is an important step in the care of the critically ill child but can be very difficult and time consuming. Recently, intraosseous infusion has experienced a resurgence as a rapid alternative to venous cannulation. Several cases illustrate the usefulness of this technique in the emergency department. Included are the first reports of the use of intraosseous diazepam and succinylcholine.

Pediatric resuscitation without an intravenous line

The case of a 3-month-old male infant who was found unresponsive and cyanotic in a crib at home is presented. On arrival in the emergency department the child was receiving basic cardiopulmonary resuscitation (CPR) by a rescue squad and was without vital signs in asystole. The patient achieved a stable rhythm and blood pressure before intravenous access was obtained. Epinephrine and atropine were given via the endotracheal route and sodium bicarbonate through intraosseous infusion.

Intraosseous diazepam suppression of pentylenetetrazol-induced epileptogenic activity in pigs

Intravenous access for the administration of antiepileptic drugs can be both time-consuming and difficult in an actively seizing infant. We conducted a study to examine the intraosseous route as an alternate means of vascular access for the administration of diazepam in a pentylenetetrazol-seizure model in pigs. Epileptogenic activity was induced with pentylenetetrazol 100 mg/kg in 15 domestic swine that had undergone craniotomies for electrocortical recording. Diazepam (0.1 mg/kg) was administered IV (n = 5) or intraosseously (n = 5); control animals received no drug (n = 5). Epileptogenic activity was suppressed below control levels within one minute in the IV group and within two minutes in the intraosseous group. A two-way analysis of variance did not show a significant difference between the IV and intraosseous routes; however, both were significantly different when compared to the control. There also was no significant difference in plasma diazepam levels between the two groups at one, two, five, ten, 15, and 20 minutes. Our study demonstrated that the intraosseous route is a rapid and effective alternative for diazepam administration.

Regional distribution of myocardial β-adrenoceptors in the cat

Abstract The purpose of this study was to delineate the distribution of β-adrenoceptor density in the cat heart, with an emphasis on areas within the left ventricle. β-Adrenoceptor densities, determined for hearts obtained from five cats, were not significantly different in the left and rights atria, i.e. 47.6 ± 7.2 and 32.8 ± 7.5 fmol/mg protein, respectively. β-Adrenoceptor densities for the septum and right ventricle were 105.4 ± 15.0 and 65.0 ± 14.0 fmol/mg protein, respectively. The β-adrenoceptor density for the proximal distribution of the left anterior descending artery LV1, distal distribution of the left anterior descending artery LV2 and posterior wall of the left ventricle LV3 were: 81.3 ± 11.5, 145.1 ± 20.8 and 165.4 ± 35.8 fmol/mg protein, respectively. Thus, the distribution of the β-adrenoceptor densities was greatest in the apex of the left ventricle. The data suggest that there are regional differences in the β-adrenoceptor densities among the areas of the heart and within the left ventricle. These differences may be related to functional differences.

Death notification in the emergency department: a survey of residents and attending physicians.

STUDY OBJECTIVE To delineate the topics discussed with families during the death notification process and to identify which of these topics are stressful to the physician. Also, the survey served as a needs assessment in designing an educational program for emergency medicine residents in death notification. DESIGN AND PARTICIPANTS Forty-five residents and 20 attendings physicians in emergency medicine at the Medical College of Pennsylvania were given an anonymous, self-administered, 47-item questionnaire seeking demographic information and assessing topics discussed during notification, perceived importance to the family of these topics, and the stressfulness of these topics. RESULTS One hundred percent of the participants responded to the survey. Hospital care, prehospital care, and cause of death were most often discussed with the family, although no topic was discussed 100% of the time by all physicians. Those items that may be perceived as emotionally charged, such as organ donation and autopsy, were rated as more stressful and were less frequently addressed during notification. CONCLUSION Factual information is discussed most often, and emotional issues are considered most stressful. Therefore, a program in death notification must address those issues that must be handled during a notification and provide mechanisms for residents to feel comfortable with emotional responses from the family.