No. 41

[PubMed]

Warren DW, Kissoon N, Sommerauer JF, Rieder MJ

Department of Pediatrics, University of Western Ontario, London, Canada.

STUDY OBJECTIVES: To compare infusion rates from various intraosseous sites (tibial, medial malleolar, distal femoral, and humeral) and at a peripheral IV site under gravity and pressure flow in normovolemic and hypovolemic states.

DESIGN AND SETTING: A piglet model was used to assess rates of infusion under varying conditions in a university hospital animal laboratory. Analysis of variance was used to evaluate site differences.

PARTICIPANTS: Twenty-three Yorkshire-Landrace mix pigs (weight, 12 to 23 kg) were studied.

INTERVENTIONS: Animals were anesthetized and intubated before cannulation with 18-gauge bone marrow needles at intraosseous sites and 22-gauge Teflon catheters in peripheral vessels. Infusion rates under gravity and 300 mm Hg pressure were determined. Infusion rates under similar conditions were repeated in hypovolemic animals with acute bleeding of 25 mL/kg.

MEASUREMENTS AND MAIN RESULTS: Mean infusion rates (mL/min) for gravity versus 300 mm Hg pressure in normovolemic pigs were 13.1 versus 40.9 for peripheral IV, 11.1 versus 41.3 for humerus, 9.3 versus 29.5 for femur, 8.2 versus 24.1 for malleolus, and 4.3 versus 17.0 for tibia. Hypovolemia resulted in average decreased rates of 32%. Infusion rates were significantly different between sites and between normovolemia and hypovolemia (P = .0001).

CONCLUSION: Intravenous access is the most efficacious method of acute volume replacement. Intraosseous sites differ in the infusion rates obtained--descending order is humerus, femur, malleolus, and tibia, but each is a reasonable alternative for short-term vascular access.

PMID: 8427428, UI: 93151505

No. 42

[PubMed]

Andropoulos DB, Soifer SJ, Schreiber MD

Cardiovascular Research Institute, University of California San Francisco 94143-0106.

PMID: 2299508, UI: 90133240

No. 43

[PubMed]

Emerman CL, Pinchak AC, Hancock D, Hagen JF

Department of Emergency Medicine, Cleveland Metropolitan General Hospital, OH 44109.

Cardiopulmonary resuscitation requires effective, prompt drug administration. In order to analyze Advanced Cardiac Life Support (ACLS) recommendations for site of drug administration, we studied dye circulation times after central, femoral, and peripheral venous injection during both closed and open chest CPR using a canine arrest model. Measurements of circulation times were made after injection of indocyanine green dye at femoral, central, and peripheral venous sites. Circulation times during closed chest CPR were 62.7 +/- 19.6 sec after central injection, 86.6 +/- 23.5 sec after femoral injection, and 93.6 +/- 17.9 sec after peripheral injection (p less than .001). During closed chest CPR, peak dye concentration after central injection was significantly higher than that after peripheral injection (4.0 +/- 1.3 vs. 3.1 +/- 0.8 mg/L, p less than .01). Circulation times were significantly shorter during open chest CPR with times again shortest after central injection. This animal model suggests that prompt drug delivery during CPR is enhanced by central venous injection of medication. There appears to be no advantage in femoral over peripheral injection.

Comments:

1. Comment in: Crit Care Med 1989 Dec;17(12):1365
   Effect of injection site on circulation times during cardiac arrest.
   Martens P
   Publication Types: Comment, Letter

No. 44

[PubMed]

Mazkereth R, Paret G, Ezra D, Aviner S, Peleg E, Rosenthal T, Barzilay Z

Pediatric Intensive Care Unit, Chaim Sheba Medical Center, Tel-Hashomer, Israel.

BACKGROUND AND METHODS: Emergency endotracheal drug administration has become an acceptable route for drug delivery during cardiopulmonary resuscitation. The purpose of the present study was to determine whether the site of endotracheal epinephrine injection is an important factor in its absorption. Epinephrine (1:1000), in a dose of 0.02 mg/kg diluted in 2 mL of saline, was given to ten anesthetized mongrel dogs. Each dog was studied twice: once when the epinephrine was injected into the endotracheal tube, and on another day, through the endotracheal tube via a flexible catheter wedged into a peripheral bronchus. Arterial blood samples for plasma epinephrine concentration determinations were collected, before and at 1, 2, 5, 10, 15, and 30 mins after each intratracheal drug administration.

RESULTS: Both routes of epinephrine administration significantly increased plasma concentrations within 1 min of injection. Higher plasma epinephrine concentrations were achieved after peripheral bronchial epinephrine administration (maximal concentration 8.9 +/- 3.2 vs. 2.0 +/- 0.4 ng/mL), and the total dose absorbed was significantly (76.5 +/- 13.5 vs. 36.7 +/- 6.5 ng/min/mL, p < .05) higher. The time interval to reach maximal concentration was significantly shorter with the peripheral bronchial dosing than with the endotracheal route (1.3 +/- 0.2 vs. 2.7 +/- 0.5 min, p < .05). Neither group demonstrated a significant change in heart rate, and both had similar, minor decreases in BP for > 2 to 5 mins. There were no significant differences between the arterial blood gases of the two groups at various stages of the experiment.

CONCLUSIONS: In dogs, epinephrine administered via the peripheral bronchial route has a clear pharmacologic advantage over the endotracheal route. This advantage may be more important during cardiopulmonary resuscitation conditions and other low flow states, and may account for the failure observed with the endotracheal route in recently published clinical reports.

PMID: 1424703, UI: 93048042

No. 45

[PubMed]

Jasani MS, Nadkarni VM, Finkelstein MS, Mandell GA, Salzman SK, Norman ME

Department of Anesthesia, A.I. duPont Institute, Wilmington, DE 19899.

OBJECTIVE: To compare three endotracheal epinephrine instillation techniques in a pediatric porcine hypoxic-hypercarbic cardiopulmonary arrest model. DESIGN: Prospective, randomized, laboratory comparison of three instillation techniques.

SETTING: Large animal research facility at a children's hospital. SUBJECTS: Thirty-six preadolescent anesthetized and paralyzed Yucatan swine (mean weight 10.0 +/- 1.9 kg) with apnea-induced hypoxic and hypercarbic cardiopulmonary arrest. INTERVENTIONS: After 8 mins of cardiopulmonary arrest and 1 min of cardiopulmonary resuscitation (CPR), 500 micrograms (51 +/- 9 micrograms/kg) of radiolabeled endotracheal epinephrine was administered by direct injection (n = 17), injection via feeding catheter (n = 10), or via monitoring lumen built into the sidewall of the endotracheal tube (n = 9). CPR was resumed and continued for 5 mins. If resuscitation occurred, monitoring was continued for 1 hr. Outcome variables included successful resuscitation, pulmonary distribution, heart rate, mean arterial pressure, plasma radiolabeled epinephrine counts, and total plasma epinephrine concentrations. Analysis by Fisher's exact test, one-way analysis of variance and Pearson's phi coefficient was performed.

MEASUREMENTS AND MAIN RESULTS: Successful resuscitation occurred in 31% of all pigs with no difference between groups (p = .69). Bilateral distribution occurred in 39% with no difference between groups (p = .25). No correlation was noted between successful resuscitation and distribution (p = .65). HR, mean arterial pressure, plasma radiolabeled epinephrine counts, and total plasma epinephrine concentrations showed significant changes over time within groups, but no difference between groups at any time point. Adherence of the epinephrine dose to the endotracheal tube was < or = 1.5% in all cases.

CONCLUSIONS: Instillation of 50 micrograms/kg of endotracheal epinephrine by three different techniques during pediatric porcine asphyxial arrest does not affect resuscitation rate, pulmonary distribution, hemodynamic response, or plasma exogenous and total epinephrine concentrations. No correlation was found between successful resuscitation and bilateral distribution. Therefore, currently recommended cumbersome endotracheal epinephrine instillation techniques may offer no resuscitation advantage over commonly used direct injection in this setting.

Comments:

1. Comment in: Crit Care Med 1994 Jul;22(7):1071-2
   Endotracheal epinephrine in cardiac arrest.
   Zaritsky A
   Publication Types: Comment, Editorial, Review

No. 46

[PubMed]

Quinton DN, O'Byrne G, Aitkenhead AR

Twelve patients presenting to an accident and emergency department in asystolic cardiac arrest were randomly allocated to treatment with endotracheal adrenaline (five patients) or peripheral intravenous adrenaline (seven patients). Femoral-artery blood samples were taken for assay of adrenaline and noradrenaline. After intravenous adrenaline there was a good clinical and biochemical response, but after endotracheal adrenaline there was no change in serum adrenaline and no measurable clinical response. The endotracheal route of adrenaline administration is not reliable in out-of-hospital cardiac arrest.

Publication Types: Clinical trial, Randomized controlled trial

PMID: 2882234, UI: 87171808

No. 47

[PubMed]

Roberts JR, Greenburg MI, Knaub M, Baskin SI

Epinephrine in various dosages was administered to anesthetized dogs by intravenous and endotracheal routes. Both methods produced measurable effects on heart rate, blood pressure, and respiration. Tachycardia occurred more rapidly after endotracheal administration than after intravenous administration. Respiration appeared to be supported more advantageously with the larger endotracheal dosages. The maximum blood pressure rise was delayed only 60 seconds by the endotracheal route. With an endotracheally administered dose of ten times the intravenous dose, equal responses in blood pressure were obtained. However, when equal doses are compared, there is only a two to three fold increase with the intravenous route. The endotracheal route may be less toxic at higher doses, affording greater safety when large amounts of epinephrine are used. It is concluded that endotracheally administered epinephrine produces significant pharmacologic effects in anesthetized dogs.

PMID: 671937, UI: 78221531

註．referenceのKnaub MAはKnaub Mの間違いのようです。

No. 48

[PubMed]

Fiser DH

Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock. Publication Types: Review, Review literature

PMID: 2186277, UI: 90245061

No. 49

[PubMed]

Rosetti VA, Thompson BM, Miller J, Mateer JR, Aprahamian C

Substantial difficulties can be encountered when establishing rapid intravascular access in critically ill children. The historic technique of tibial intraosseous infusion is presented as an alternate intravenous route in children less than 3 years old. Review of the literature reveals this technique to be a rapid, reliable method with an acceptably low complication rate. Substances absorbed through the marrow, flow rates, technical difficulties, and complications are discussed.

PMID: 4025988, UI: 85277492

No. 50

[PubMed]

Brown CG, Werman HA

Division of Emergency Medicine, Ohio State University, Columbus 43210.

A number of studies have suggested that following a prolonged cardiopulmonary arrest, large doses of alpha-adrenergic agonists that possess post-synaptic alpha-2 agonist properties, i.e. epinephrine and norepinephrine, may be required to enhance myocardial and cerebral hemodynamics. While initial human studies using large doses of epinephrine have shown improved hemodynamics over standard therapy, hospital discharge rates and neurological outcome have been discouraging. This probably reflects the fact that the administration of epinephrine was employed late in the resuscitation effort. Future studies using larger doses of epinephrine as the initial pharmacologic intervention during cardiopulmonary resuscitation (CPR) will help to determine whether there is any therapeutic benefit. In addition, a number of questions still remain unanswered in delineating the specific alpha and beta adrenergic agonist components which will maximally enhance hemodynamics and resuscitation rates during CPR. This will help determine whether norepinephrine or a yet unsynthesized adrenergic agonist may be more beneficial for use during cardiac arrest.

Publication Types: Review, Review-tutorial

PMID: 1967848, UI: 90139932

No. 51

[PubMed]

Goetting MG, Paradis NA

Department of Pediatrics, Henry Ford Hospital, Detroit, Michigan 48202.

STUDY OBJECTIVE: Animal studies suggest that the standard dose of epinephrine (SDE) for treatment of cardiac arrest in human beings may be too low. We compared the outcome after SDE with that after high-dose epinephrine (HDE) in children with refractory cardiac arrest.

DESIGN: Prospective intervention versus historic control groups.

TYPE OF PARTICIPANTS: Two similar groups of 20 consecutive patients each (median ages, 2.5 and 3 years) with witnessed cardiac arrest who remained in arrest after at least two SDEs (0.01 mg/kg).

INTERVENTIONS: Treatment with an additional SDE versus HDE (0.2 mg/kg).

MEASUREMENTS AND MAIN RESULTS: The rates of return of spontaneous circulation and long-term survival were compared. Fourteen of the HDE group (70%) had return of spontaneous circulation, whereas none of the SDE group did (P less than .001). Eight children survived to discharge after HDE, and three were neurologically intact at follow-up. No significant toxicity from HDE was observed. CONCLUSION: HDE provided a higher return of spontaneous circulation rate and a better long-term outcome than SDE in our series of pediatric cardiac arrest. HDE may warrant incorporation into standard resuscitation protocols at an early enough point to prevent irreversible brain injury.

Publication Types:Clinical trial

Comments:

1. Comment in: Ann Emerg Med 1991 Jan;20(1):104-5
   High-dose epinephrine in pediatric cardiac arrest.
   Brown CG, Kelen GD
   Publication Types: Clinical trial, Comment, Editorial

2. Comment in: Ann Emerg Med 1993 Apr;22(4):758-9
   Postarrest hypertension in pediatric patients.
   Wasserberger J, Ordog GJ
   Publication Types: Comment, Letter

No. 52

[PubMed]

Berkowitz ID, Gervais H, Schleien CL, Koehler RC, Dean JM, Traystman RJ

Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland 21205.

Although epinephrine increases cerebral blood flow (CBF) and left ventricular blood flow (LVBF) during cardiopulmonary resuscitation (CPR), the effects of high dosages on LVBF and CBF and cerebral O2 uptake have not been examined during prolonged CPR. We determined whether log increment dosages of epinephrine would enhance LVBF and CBF and cerebral O2 uptake in an infant swine CPR model. We compared these responses with epinephrine to those with the alpha-adrenergic agonist, phenylephrine. CPR was performed in five groups (n = 6) of pentobarbital-anesthetized piglets (3.5-5.6 kg) receiving a continuous epinephrine infusion (0, 1, 10, and 100 micrograms.kg-1.min-1) or phenylephrine infusion (40 micrograms.kg-1.min-1). Plasma epinephrine concentrations increased 10-100-fold in the control group during CPR and in a stepwise manner such that concentrations were increased by more than 10(4) in the 100 micrograms.kg-1.min-1 epinephrine group. In the control group with no epinephrine infusion, LVBF decreased to less than 10 ml.min-1.100 g-1 by 5 min of CPR. With epinephrine in dosages of 10 and 100 micrograms.kg-1.min-1, LVBF at 5 min was 75 +/- 19 and 44 +/- 15 ml.min-1.100 g-1, respectively, which was significantly greater than values in the control group. With more prolonged CPR, LVBF remained significantly greater than that in the control group but only at 10 micrograms.kg-1.min-1 of epinephrine. Phenylephrine also increased LVBF for 10 min of CPR when compared with the control group. All dosages of epinephrine and phenylephrine maintained CBF close to prearrest values for 20 min of CPR. With prolonged CPR, 10 and 100 micrograms.kg-1.min-1 epinephrine resulted in significantly greater CBF than that in the control group. Incremental dosages of epinephrine did not statistically increase cerebral O2 uptake or lower the cerebral fractional O2 extraction when compared with the control group, despite the higher CBF that was generated. In this immature animal CPR model, 10 micrograms.kg-1.min-1 epinephrine is an optimal dosage for maximizing both CBF and LVBF, a dosage that substantially exceeds the current recommended epinephrine dosage for human infant CPR. In addition, for short periods of CPR, 40 micrograms.kg-1.min-1 phenylephrine increases CBF and LVBF to levels similar to those generated by high dosages of epinephrine.

PMID: 1741496, UI: 92074602

No. 53

[PubMed]

Callaham M, Madsen CD, Barton CW, Saunders CE, Pointer J

Division of Emergency Medicine, University of California, San Francisco.

OBJECTIVE--To determine the relative efficacy of high- vs standard-dose catecholamines in initial treatment of prehospital cardiac arrest.

DESIGN--Randomized, prospective, double-blind clinical trial.

SETTING--Prehospital emergency medical system of a major US city.

PATIENTS--All adults in nontraumatic cardiac arrest, treated by paramedics, who would receive epinephrine according to American Heart Association advanced cardiac life support guidelines.

INTERVENTIONS--High-dose epinephrine (HDE, 15 mg), high-dose norepinephrine bitartrate (NE, 11 mg), or standard-dose epinephrine (SDE, 1 mg) was blindly substituted for advanced cardiac life support doses of epinephrine.

MAIN OUTCOME MEASURES--Restoration of spontaneous circulation in the field, admission to hospital, hospital discharge, and Cerebral Performance Category score. RESULTS--Of 2694 patients with cardiac arrests during the study period, resuscitation was attempted on 1062 patients. Of this total, 816 patients met study criteria and were enrolled. In the entire cardiac arrest population, 63% of the survivors were among the 11% of patients who were defibrillated by first responders. The three drug treatment groups were similar for all independent variables. Thirteen percent of patients receiving HDE regained a pulse in the field vs 8% of those receiving SDE (P = .01), and 18% of HDE patients were admitted to the hospital vs 10% of SDE patients who were admitted to the hospital (P = .02). Similar trends for NE were not significant. There were 18 survivors; 1.7% of HDE patients and 2.6% of NE patients were discharged from the hospital compared with 1.2% of SDE patients, but this was not significant (P = .37; beta = .38). There was a nonsignificant trend for Cerebral Performance Category scores to be worse for HDE (3.2) and NE patients (3.7) than for SDE patients (2.3) (P = .10; beta = .31). No significant complications were identified. High-dose epinephrine did not produce longer hospital or critical care unit stays. CONCLUSIONS--High-dose epinephrine significantly improves the rate of return of spontaneous circulation and hospital admission in patients who are in prehospital cardiac arrest without increasing complications. However, the increase in hospital discharge rate is not statistically significant, and no significant trend could be determined for neurological outcome. No benefit of NE compared with HDE was identified. Further study is needed to determine the optimal role of epinephrine in prehospital cardiac arrest.

Publication Types: Clinical trial, Randomized controlled trial

Comments:

1. Comment in: JAMA 1993 Mar 17;269(11):1383
   High-dose epinephrine in cardiopulmonary resuscitation.
   Polin K, Leikin JB
   Publication Types: Comment, Letter

2. Comment in: JAMA 1993 Mar 17;269(11):1383; discussion 1383-4
   High-dose epinephrine in cardiopulmonary resuscitation.
   Heiselman DE
   Publication Types: Comment, Letter

No. 54

[PubMed]

No. 55

[PubMed]

Stiell IG, Hebert PC, Weitzman BN, Wells GA, Raman S, Stark RM, Higginson LA, Ahuja J, Dickinson GE

Division of Emergency Medicine, University of Ottawa, Ont., Canada.

BACKGROUND. Recent studies suggest that doses of epinephrine of 0.1 mg per kilogram of body weight or higher may improve myocardial and cerebral blood flow as well as survival in cardiac arrest. Such studies have called into question the traditional dose of epinephrine (0.007 to 0.014 mg per kilogram) recommended for advanced cardiac life support.

METHODS. We randomly assigned 650 patients who had had cardiac arrest either in or outside the hospital to receive up to five doses of high-dose (7 mg) or standard-dose (1 mg) epinephrine at five-minute intervals according to standard protocols for advanced cardiac life support. Patients who collapsed outside the hospital received no advanced-life-support measures other than defibrillation before reaching the hospital.

RESULTS. There was no significant difference between the high-dose group (n = 317) and the standard-dose group (n = 333) in the proportions of patients who survived for one hour (18 percent vs. 23 percent, respectively) or who survived until hospital discharge (3 percent vs. 5 percent). Among the survivors, there was no significant difference in the proportions who remained in the best category of cerebral performance (90 percent vs. 94 percent) and no significant difference in the median Mini-Mental State score (36 vs. 37). The exploration of clinically important subgroups, including those with out-of-hospital arrest (n = 335) and those with in-hospital arrest (n = 315), failed to identify any patients who appeared to benefit from high-dose epinephrine and suggested that some patients may have worse outcomes after high-dose epinephrine.

CONCLUSION. High-dose epinephrine was not found to improve survival or neurologic outcomes in adult victims of cardiac arrest.

Publication Types: Clinical trial, Randomized controlled trial

Comments:

1. Comment in: N Engl J Med 1993 Mar 11;328(10):735 High-dose epinephrine in cardiopulmonary resuscitation.
   Mattana J, Singhal PC
   Publication Types: Comment, Letter
   (whole article)

No. 56

[PubMed]

Brown CG, Martin DR, Pepe PE, Stueven H, Cummins RO, Gonzalez E, Jastremski M

Department of Emergency Medicine, Ohio State University, Columbus 43210.

BACKGROUND. Experimental and uncontrolled clinical evidence suggests that intravenous epinephrine in doses higher than currently recommended may improve outcome after cardiac arrest. We conducted a prospective, multicenter study comparing standard-dose epinephrine with high-dose epinephrine in the management of cardiac arrest outside the hospital.

METHODS. Adult patients were enrolled in the study if they remained in ventricular fibrillation, or if they had asystole or electromechanical dissociation, at the time the first drug was to be administered to treat the cardiac arrest. Patients were randomly assigned to receive either 0.02 mg of epinephrine per kilogram of body weight (standard-dose group, 632 patients) or 0.2 mg per kilogram (high-dose group, 648 patients), both given intravenously. RESULTS. In the standard-dose group 190 patients (30 percent) had a return of spontaneous circulation, as compared with 217 patients (33 percent) in the high-dose group; 136 patients (22 percent) in the standard-dose group and 145 patients (22 percent) in the high-dose group survived to be admitted to the hospital. Twenty-six patients (4 percent) in the standard-dose group and 31 (5 percent) in the high-dose group survived to discharge from the hospital. Ninety-two percent of the patients discharged in the standard-dose group and 94 percent in the high-dose group were conscious at the time of hospital discharge. None of the differences in outcome between the groups were statistically significant.

CONCLUSIONS. In this study, we were unable to demonstrate any difference in the overall rate of return of spontaneous circulation, survival to hospital admission, survival to hospital discharge, or neurologic outcome between patients treated with a standard dose of epinephrine and those treated with a high dose.

Publication Types: Clinical trial, Multicenter study, Randomized controlled trial

Comments:

1. Comment in: N Engl J Med 1993 Mar 11;328(10):735; discussion 735-6
   High-dose epinephrine in cardiopulmonary resuscitation.
   Mattana J, Singhal PC
   Publication Types: Comment, Letter
   whole article

No. 57

[PubMed]

Berg RA, Otto CW, Kern KB, Hilwig RW, Sanders AB, Henry CP, Ewy GA

Department of Pediatrics, Steele Memorial Children's Research Center, Tucson, AZ, USA.

OBJECTIVE: To determine whether high-dose epinephrine administration during cardiopulmonary resuscitation (CPR) in a swine pediatric asphyxial cardiac arrest model improves outcome (i.e., resuscitation rate, survival rate, and neurologic function) compared with standard-dose epinephrine.

DESIGN: A randomized, blinded study.

SETTING: A large animal cardiovascular laboratory at a university. SUBJECTS: Thirty domestic piglets (3 to 4 months of age) were randomized to receive standard-dose epinephrine (0.02 mg/kg) or high-dose epinephrine (0.2 mg/kg) during CPR after 10 mins of cardiac standstill with loss of aortic pulsation after endotracheal tube clamping.

INTERVENTIONS: Two minutes of CPR were provided, followed by advanced pediatric life support. Successfully resuscitated animals were supported in an intensive care unit (ICU) setting for 2 hrs and then observed for 24 hrs.

MEASUREMENTS AND MAIN RESULTS: Electrocardiogram, thoracic aortic blood pressure, and right atrial blood pressure were monitored continuously until the intensive care period ended. Survival rate and neurologic outcome were determined. Return of spontaneous circulation was obtained in 13 of 15 high-dose epinephrine piglets vs. ten of 15 standard-dose epinephrine piglets (p < .20). Four of 13 high-dose piglets died in the ICU period after initial resuscitation vs. 0 of ten standard-dose piglets (p < or = .05). Nine high-dose piglets survived 2 hrs vs. ten standard-dose piglets. Three piglets in each group survived for 24 hrs, but all were severely neurologically impaired. Two minutes after resuscitation, piglets treated with high-dose epinephrine had higher heart rates (210 +/- 24 vs. 189 +/- 40 beats/min, p < .05) and higher aortic diastolic pressures (121 +/- 39 vs. 74 +/- 40 mm Hg, p < .01). Within 10 mins of return of spontaneous circulation, severe tachycardia (> 240 beats/min) was more frequently noted in the high-dose group than in the standard-dose group (p < .05). All four high-dose piglets that died in the ICU period experienced ventricular fibrillation within 10 mins of return of spontaneous circulation. CONCLUSIONS: High-dose epinephrine did not improve 2-hr survival rate, 24-hr survival rate, or neurologic outcome. High-dose epinephrine resulted in severe tachycardia and hypertension immediately after resuscitation and in a higher mortality rate immediately after resuscitation.

Publication Types: Clinical trial, Randomized controlled trial

PMID: 8874308, UI: 97028294

No. 58

[PubMed]

Callaham M

PMID: 1949784, UI: 92056731

No. 59

[PubMed]

Bush CM, Jones JS, Cohle SD, Johnson H

Department of Emergency Medicine, Butterworth Hospital, Grand Rapids, MI, USA.

(whole article)

STUDY OBJECTIVE: To assess the type, rate, and severity of unanticipated complications of CPR (external cardiac compressions and ventilation) in a pediatric population.

METHODS: A retrospective review was undertaken of the records from all deceased children ( < 12 years old) who had been given CPR during an 8-year period (1988 through 1995). Patients with historical or physical evidence of preceding trauma were excluded. Clinical and autopsy records were abstracted for patient demographics, clinical findings, duration of CPR, persons administering CPR, and medical examiner summaries. RESULTS: Two hundred eleven children (mean age, 19.0 months) met the inclusion criteria and were entered into the study. The most common cause of cardiac arrest was sudden infant death syndrome (56%), followed by drowning (8%), congenital heart disease (7%), and pneumonia (4%). Mean duration of CPR was 45 minutes (range, 3 to 180 minutes). Fifteen children (7%) had at least one injury as a result of CPR; 7 (3%) had injuries that were considered medically significant. These included retroperitoneal hemorrhage (n = 2), pneumothorax (n = 1), pulmonary hemorrhage (n = 1), epicardial hematoma (n = 1), and gastric perforation (n = 1); in spite of prolonged resuscitation performed with variable degrees of skill, only one patient was noted to have rib fractures. CONCLUSION: Significant iatrogenic injuries are rare in children who receive CPR; they occur in approximately 3% of cases. Recognizing the possibility of a complication may help in the management of children who survive cardiac arrest. Regardless of resuscitation history, abuse should be considered whenever traumatic injuries are encountered.

PMID: 8669737, UI: 96266189

No. 60

[PubMed]

Spevak MR, Kleinman PK, Belanger PL, Primack C, Richmond JM

Department of Radiology, University of Massachusetts Medical Center, Worchester 01655.

OBJECTIVE--To determine the incidence of rib fractures visible at autopsy or with postmortem radiographs after cardiopulmonary resuscitation (CPR) in infants younger than 1 year.

DESIGN--Retrospective review. SETTING--Medical examiner's office in a county consisting of a medium-sized city, towns, and rural areas. PATIENTS--Ninety-one infants (56 males, 35 females; mean age, 2.4 months; age range, 26 hours to 8.5 months) without evidence of child abuse who had undergone CPR before death.

METHODS--Medical records, skeletal surveys, and autopsy results were reviewed. RESULTS--No patient had rib fractures. CONCLUSIONS--Cardiopulmonary resuscitation is unlikely to cause rib fractures in infants.

PMID: 8057518, UI: 94335164