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PrairiEDocs e-newsletter #32 Other archived PrairiEDocs e-newsletters Surveying the land
(and web) for news (and more)
News
Briefs Simple Blood Test Could Predict Preeclampsia Spiral scan sees stroke blockage more clearly Smallpox Issues and Vaccine Concerns Continue Sense
of Humor---from George Carlin Lowdown on
Lovenox Fluid Resuscitation
of the Patient with Major Trauma Current reviews and consensus documents now recommend a more discriminating approach to the traditional practices of delivering liberal infusions of intravenous fluid to all major trauma patients with suspected or known major hemorrhage. The evolving evidence suggests that aggressive fluid resuscitation prior to hemostasis leads to additional bleeding through hydraulic acceleration of hemorrhage, soft clot dissolution, and dilution of clotting factors. Aggressive preoperative fluid infusion is still considered appropriate for unconscious patients without palpable blood pressure or for those with controllable hemorrhage (e.g. isolated extremity or head injury), However, the latest recommendations are to limit or delay intravenous fluid resuscitation preoperatively in those with uncontrollable hemorrhage (e.g. those with penetrating torso injuries), even if they are hypoperfusing. Although most clinicians still generally support fluid resuscitation for multisystem blunt trauma, particularly with head injury, the most recent experimental data have begun to challenge this traditional practice as well, suggesting a `slow infusion' approach when there is risk for uncontrolled internal bleeding. By providing oxygen delivery with slow, limited infusion, new hemoglobin-based oxygen carriers might help to resolve the current dilemma of having to limit preoperative resuscitation when there is risk of uncontrolled hemorrhage. Cervical
Spine Injury and Airway Management Cervical spine
injuries occur in 2-5% of blunt trauma patients, and 1-5% of these
injuries are initially missed. Data from the large New England
Journal of Medicine: The study directors noted that lidocaine has been the initial antiarrhythmic drug treatment recommended for patients with ventricular fibrillation that is resistant to conversion by defibrillator shocks. (ACLS now classifies this drug as Class Indeterminate-without complelling evidence or suggestion of evidence that improves outcomes in cardiac arrest). We performed a randomized trial comparing intravenous lidocaine with intravenous amiodarone (currently classified as a a Class IIb intervention by the AHA in cardiac arrest) as an adjunct to defibrillation in victims of out-of-hospital cardiac arrest. Patients were enrolled if they had out-of-hospital ventricular fibrillation resistant to three shocks, intravenous epinephrine, and a further shock; or if they had recurrent ventricular fibrillation after initially successful defibrillation. They were randomly assigned in a double-blind manner to receive intravenous amiodarone plus lidocaine placebo or intravenous lidocaine plus amiodarone placebo. The primary end point was the proportion of patients who survived to be admitted to the hospital. Results In total, 347 patients (mean [±SD] age, 67±14 years) were enrolled. The mean interval between the time at which paramedics were dispatched to the scene of the cardiac arrest and the time of their arrival was 7±3 minutes, and the mean interval from dispatch to drug administration was 25±8 minutes. After treatment with amiodarone, 22.8 percent of 180 patients survived to hospital admission, as compared with 12.0 percent of 167 patients treated with lidocaine (P=0.009; odds ratio, 2.17; 95 percent confidence interval, 1.21 to 3.83). Among patients for whom the time from dispatch to the administration of the drug was equal to or less than the median time (24 minutes), 27.7 percent of those given amiodarone and 15.3 percent of those given lidocaine survived to hospital admission (P=0.05). Study conclusions:
As compared with lidocaine, amiodarone leads to substantially higher
rates of survival to hospital admission in Editor's note:
This study still lends no additional light on amiodarone's impact
on survival-to-discharge concerns. What appears to be noteworthy
in this study is the significant gap of time from dispatch until
either drug is on board (average of 25 minutes delay). Simple Blood Test Could Predict Preclampsia A simple blood test could predict which women are at risk of pre-eclampsia, in time to prevent it before symptoms appear, researchers reported recently, Women who developed pre-eclampsia had higher-than-normal levels of a protein called SHBG early in pregnancy, a team at Massachusetts General Hospital in Boston found. "This study showed that a risk factor that can be detected many weeks before symptoms appear may be able to predict who will develop pre-eclampsia," Dr. Myles Wolf, who led the study, said. "Pre-eclampsia can be devastating, and unfortunately we do not have a way to treat women with this condition," added Dr. Ravi Thadhani, who also worked on the study. "Finding a way to predict who will develop pre-eclampsia is a necessary first step to testing new therapies." Pre-eclampsia is seen in about 5 percent of pregnant women and is marked by high blood pressure, fluid retention and protein in the urine. If not taken care of, it can lead to eclampsia -- with potentially fatal seizures, liver or kidney failure. Both mother and baby are at risk. Obese and diabetic women are especially at risk. Pre-eclampsia can be managed but not cured with diuretics and sometimes bed rest. Symptoms usually start at around 20 weeks, and women with the most serious symptoms may be forced to deliver their babies early -- which puts the baby at even more risk. Wolf, Thadhani and colleagues looked at data from a study of more than 4,000 women who had various tests during pregnancy. They found 45 who had pre-eclampsia, and compared their tests to 90 women who did not. The pre-eclampsia patients had unusually low levels of a protein called SHBG or sex hormone binding globulin in early pregnancy, the researchers report in the April issue of The Journal of Clinical Endocrinology and Metabolism. The protein is associated with insulin resistance, a condition that can sometime lead to diabetes. Both overweight and lean women who had the low levels of SHBG went on to develop pre-eclampsia, the researchers found. "The fact that the association of pre-eclampsia with reduced first-trimester SHBG is also seen in lean women suggests that insulin resistance may be the true risk factor," Wolf said. "It also may provide the only clue that a lean woman is at elevated risk," he added. "There might be a window of opportunity in the first trimester when preventive treatment could be successful, but until now we did not have a simple way to identify high-risk women." The ZOLL AED
Plus Soon to Ship First Fully
Automated AED Improved and Approved for In-Hospital Use The new-generation
stand-alone unit is considerably smaller, lower in cost and more
flexible than its predecessor and includes patented biphasic defibrillation
technology and non-invasive temporary external cardiac pacing. Unlike
shock-advisory units sold for public access defibrillation, the
Powerheart is the only FDA-cleared external device that can automatically
monitor and treat patients at risk of sudden cardiac arrest (SCA),
that strikes an estimated 370,000 hospitalized patients each year.
Various clinical studies have reported the current rate of survival
of patients who suffer in-hospital SCA to be between 0 and 29 percent.
The Powerheart is marketed in the U.S. under a recurring revenue business model whereby the company places Powerhearts in a customer's facility with no up-front capital equipment charge to the hospital in exchange for an agreement to purchase a specific number of the Company's proprietary, disposable defibrillation electrodes on a monthly or quarterly basis. New Practice Guidelines for Treating Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction The American College of Cardiology and the American He art Association (ACC/AHA) have issued new practice guidelines for the treatment of unstable angina and non-ST-segment elevation myocardial infarction (MI). The new guidelines update those published in September 2000. The most important changes are in the hospital use of antiplatelet and anticoagulant therapy, reflecting the results of clinical trials including the ESSENCE and TIMI trials. Changes include
the following: When an initial noninterventional approached is planned, the patient should receive aspirin plus clopidogrel. For patients who are to undergo percutaneous cardiac intervention, clopidogrel should be started and continued for up to 9 months in patientswho are not at a high risk of bleeding, the guidelines indicate. Patients receiving clopidogrel before undergoing coronary artery bypass graft (CABG) surgery should have clopidogrel withheld at least 5 days before the procedure, the ACC/AHA recommends. Subcutaneous low-molecular weight heparin or intravenous unfractionated heparin should be added to aspirin and clopidogrel therapy, the update continues, and in patients who are to undergo catheterization or percutaneous cardiac intervention, a glycoprotein IIb/IIIa inhibitor should be added to aspirin and clopidogrel. For patients with Class IIa disease, patients with continuing ischemia and elevated troponin for whom no invasive therapy is planned should receive eptifibatide or tirofiban in addition to aspirin and low-molecular weight or unfractionated heparin. Unless CABG is planned within 24 hours, enoxaparin is preferred over unfractionated heparin. According to the guidelines, patients in this class who are to undergo catheterization or percutaneous cardiac intervention, should also be given a GP IIb/IIIa inhibitor when they are already receiving aspirin and clopidogrel. For patients with Class IIb disease, who do not have continuing ischemia and who have no other risk factors, and are not to undergo percutaneous cardiac intervention, eptifibatide or tirofiban should be given in addition to aspirin and low-molecular weight or unfractionated heparin. Patients with Class III disease without acute ST-segment elevation, true posterior MI, or a presumed new left heart bundle-branch block should receive intravenous fibrinolytic therapy. Patients not undergoing percutaneous cardiac intervention should be given abciximab, the ACC/AHA report advises. The complete guidelines are available online at www.acc.org and www.americanheart.org. Spiral scan sees stroke blockage more clearly
Physicians working in emergency rooms typically do a physical examination of stroke patients, including a standard CT scan of the head. They also ask patient or their families a series of questions about symptoms to assess the location and nature of the stroke. A standard CT scan can quickly determine whether the stroke is ischemic or hemorrhagic. However, high-speed helical CT scans (sometimes called spiral CT), which use a contrast dye, give physicians a view of blood flow inside vessels and the pattern of blood distribution throughout the brain. Helical scanners also allow them to quickly determine if a stroke is ischemic and find where a blockage exists, says study author Michael H. Lev, M.D. The scan can also show the doctor if the vessel is partially or completely blocked, and can show which areas of the brain are not getting enough blood. "The bottom line is that this is a convenient, cost- effective, minimally invasive way to rapidly get more information that can help acute stroke patients," says Lev. "Most emergency departments in the U.S. have a CT scanner, and the majority are helical scanners. Our study shows they can be used for the brain." Information from these scans could help physicians assess how best to treat ischemic stroke patients. "It may turn out that the patient isn't having a stroke at all, as happened with four of our patients," says Lev, who is director of the neurovascular laboratory at Massachusetts General Hospital and an assistant professor of radiology at Harvard Medical School in Boston. "It may be a seizure, a migraine headache, or a drastic drop in blood sugar mimicking a stroke." About 600,000 Americans suffer a first or recurrent stroke each year and about 167,000 of them die. The only approved therapy for acute ischemic stroke is a clot-busting (fibrinolytic) drug either through the veins within three hours after the onset of symptoms, or by infusing it directly into a brain artery, usually within six hours. Fibrinolytic drugs do not benefit people with hemorrhagic strokes, and can worsen the bleeding in the brain. Massachusetts General now uses the helical CT scans as standard treatment for stroke patients brought to the emergency room. "We had established helical CT as an accurate technique for determining where the damage occurs," says Lev. "The question for our study was to find out how useful it is in diagnosing stroke in addition to what we were using already." He and his colleagues selected the medical records of 40 acute stroke patients (23 men and 17 women) who had received helical CT scans. Neurologists on the hospital's stroke team reviewed each case. They answered a series of questions at five points in the patients' assessments. The first point was when the patient's physical examination, symptoms and initial CT scan without th e contrast dye were completed. The last was when all the data, including results from the helical CT scan, was available. At each point the neurologists were asked to give the stroke location, how much brain tissue was affected, which blood vessel was obstructed, and the severity of the stroke. Their answers were compared to the final assessment made after the patient had been released from the hospital. The average
accuracy of the neurologists' answers between their first and final
stroke assessments rose from 40 percent to 80 percent for stroke
location and from 40 percent to 78 percent in identifying the blocked
vessel. Determining the brain area affected by the stroke rose from
55 percent to 83 percent and the accuracy of their classification
increased from 55 percent to 88 percent. Smallpox Issues and Vaccine Concerns Continue New research suggests that existing US stockpiles of smallpox vaccine could be diluted to protect more Americans from the quickly spreading deadly virus, which public health officials fear could be used in a biological attack. But the question of whether the threat is real enough to warrant mass vaccination is still being debated. In a report
released March 2002, investigators say they were able to dilute
samples of smallpox vaccine to a 1-to-10 ratio and The naturally occurring smallpox was eradicated in the 1970s by a worldwide vaccination effort. In the US, routine vaccination was stopped in 1972 because the risks of the vaccine itself came to outweigh the odds of infection. Severe side effects of the vaccine are rare, but included several deaths. For every million people vaccinated, one to 2 will die and hundreds more will become seriously ill, studies show. Smallpox vaccine contains a live, related virus called vaccinia virus that, in a small number of cases, can trigger serious skin or systemic reactions. Late last year, the federal government contracted with a Massachusetts firm to manufacture more than 200 million new doses of smallpox vaccine by the end of 2002. At the same time, officials have been looking into the feasibility of extending existing doses, all produced before 1983, by diluting them. The new study suggests it is feasible, but questions remain. For one, the study included 680 healthy young adults who had never been vaccinated against smallpox. It's unclear if adults who were vaccinated years ago can be re-inoculated with a diluted vaccine, said lead author Dr. Robert B. Belshe of St. Louis University in Missouri. An even larger, more complicated question is whether to once again launch a smallpox vaccination program in the US. Public officials consider the odds of a smallpox attack quite low; the vaccine can be given shortly after exposure to the virus to treat infected individuals and contain outbreaks. "It's an open debate," Belshe said. Given a choice between mass preemptive vaccination or waiting until the need arises, he added, "my opinion is, we should go with the latter and wait until there's a real event." Altough there were no life-threatening vaccine side effects in this study, Belshe said, "more serious adverse events might occur if millions are vaccinated." The current CDC smallpox-response plan is in line with this thinking. The agency has a so-called "ring-vaccination" plan, in which patients with suspected or confirmed smallpox will be isolated and their contacts traced, vaccinated and watched closely. But not everyone agrees that this is the best approach. Others argue for a program of voluntary smallpox vaccination once stores are sufficient. An immediate benefit would be eliminating smallpox as an effective biological weapon. Vaccinating after a terrorist attack, which could involve multiple sites in the US, and could prove to be a logistical nightmare, he argues. Moreover, he points out, people can be infected with smallpox--and be contagious--for days before they are visibly sick. "Post-exposure containment of a terrorist-induced smallpox outbreak is unlikely to be successful," Bicknell asserts. Smallpox symptoms, including high fever, fatigue, and severe headaches and backaches, appear about 12 to 14 days after exposure. A rash develops on the face, arms and legs, then quickly spreads to the rest of the body. The virus is not contagious before symptoms appear. But once pox develop in the mouth, the disease can be spread by coughing, shedding scabs, or talking to anyone within a few feet. An announcement
has been made that HHS is negotiating with Aventis-Pasteur for the
acquisition of some 85 million additional Vaccine-maker Aventis-Pasteur announced recently that it will donate all 85 million doses of 40-year-old smallpox vaccine to the federal government at no charge, dramatically increasing the nation's supply at a time of mounting anxiety over a biological attack. By year's end,
America a will have at least 286 million doses of vaccine, he said.
Aides said later that figure could be as high as 711 million doses,
depending on how far the Aventis vaccine can be diluted. The vaccine had been stored frozen in 2-liter bottles in a warehouse at the company's U.S. subsidiary in Swiftwater, Pennsylvania. Over the past 2 decades, Aventis officials have periodically considered destroying the vaccine and regularly consulted with the government on that question. When the anthrax attacks occurred, Aventis called again. Soon thereafter, the vaccine was transferred to vials and moved to a secure location. The Aventis vaccine is similar to 15.4 million doses of a smallpox vaccine known as Dryvax, produced by Wyeth Pharmaceuticals, that are already in the government's possession. Both vaccines were grown from the same seed stock, and both were made using calf skins recently, federal researchers announced that the Dryvax vaccine can be safely diluted 5-fold, meaning those stocks could be used to vaccinate many more people. Over the next 6 to 8 weeks, the National Institutes of Health will conduct clinical trials on the Aventis vaccine and then perform dilution tests. Aventis-Pasteur, which is still finalizing the agreement, estimates that its vaccine is worth $150 million. HHS also recently signed agreements with Acambis Inc. and Baxter International Inc. to buy by the end of this year a total of 209 million doses of a newer vaccine that is grown on tissue cell culture. Sense
of Humor: …Don't
sweat the petty things and don't pet the sweaty things. Burn care
education can be found at: To obtain a copy of "Vaccines Across the Life Span, 2001"-(a comprehensive listing of recommended vaccinations from infancy through adulthood) or related articles, go to: http://www.immunizationed.org In light of
the events surrounding 9/11/01, NIOSH has updated some protective
equipment standards. Quotable Quotes Flannery O'Connor (1925-1964) author Everywhere I
go I'm asked if I think the university stifles writers. My opinion
is that they don't stifle enough of them. There's many a Anybody who has survived his childhood has enough information about life to last him the rest of his days. Conviction without experience makes for harshness. Marcel Marceau (1923-____) French actor, pantomimist Do not the most moving moments of our lives find us all without words? To communicate through silence is a link between the thoughts of man. Never get a mime talking. He won't stop. Ovid (43BC-17AD) Roman poet Seeking is all very well, but holding requires greater talent: Seeking involves some luck; now the demand is for skill. Those things that nature denied to human sight, she revealed to the eyes of the soul. Luck affects everything; let your hook always be cast. In the stream where you least expect it, there will be fish. Everything comes gradually and at its appointed hour. In an easy cause anyone can be eloquent; the slightest strength is enough to break what is already shattered. ERDOCS e-mail group (listserv) As a Clinician providing
acute and emergency medical care, you are invited to visit and participate
in our new ERDOCS group at eGroups, a free, easy-to-use email group
service! You have plenty of experiences to share, questions to ask,
concerns and opinions to voice, suggestions, news to post, tips
to offer, etc. and can do so within this framework. This is a versatile
system for posting things to be sent to a group to peruse, respond
to, or simply be aware of. It eliminates conventional mail delays
and allows you to review and post at your leisure. (We still have
the more open-ended [any visitor can observe/post] discussion group
at the ACUTE CARE, INC. web site). Our goal is to give you a variety of
feedback and communication tools. This e-newsletter is available through the generous unrestricted
support of
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