No. 3

[PubMed]

Bochner BS, Lichtenstein LM

Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

Publication Types: Review, Review literature

Comments:

1. Comment in: N Engl J Med 1991 Dec 5;325(23):1658
   Anaphylaxis.
   Publication Types: Comment, Letter

No. 4

[PubMed]

Brown AF
（註．著者名は Brown AFが正しいのではないかと思います）

Department of Emergency Medicine, Royal Brisbane Hospital, Queensland, Australia.

This paper reviews the mechanisms of anaphylactic shock in terms of the immunoglobulin and non-immunoglobulin triggering events, and the cellular events based on the rise in intracellular cyclic AMP and calcium that release preformed granule-associated mediators and the rapidly formed, newly synthesized mediators predominantly based on arachidonic acid metabolism. These primary mediators recruit other cells with the release of secondary mediators that either potentiate or ultimately curtail the anaphylactic reaction. The roles of these mediators in the various causes of cardiovascular collapse are examined. The treatment of anaphylactic shock involves oxygen, adrenaline and fluids. The importance and safety of intravenous adrenaline are discussed. Combined H1 and H2 blocking antihistamines and steroids have a limited role. Glucagon and other adrenergic drugs are occasionally used, and several new experimental drugs are being developed.

Publication Types: Review, Review-tutorial

Comments:

1. Comment in: J Accid Emerg Med 1996 Mar;13(2):150 Anaphylactic shock.
   McHugh D
   Publication Types: Comment, Letter

No. 5

[PubMed]

Turpeinen M, Kuokkanen J, Backman A

The effects of injected adrenaline and nebulized salbutamol on acute asthma were compared in 46 children. The results showed that salbutamol had a significantly better bronchodilatory effect than adrenaline. Nebulized salbutamol is recommended as a primary method of treatment of asthmatic attacks in childhood.

Publication Types: Clinical trial, Randomized controlled trial

[PubMed]

Chamberlain D, Vincent R, Baskett P, Bossaert L, Robertson C, Juchems R, Lindner K

Publication Types: Guideline, Practice guideline

No. 6

[PubMed]

Zoll PM, Zoll RH, Falk RH, Clinton JE, Eitel DR, Antman EM

An external cardiac pacemaker-monitor has been developed that provides safe, effective noninvasive ventricular stimulation that is well tolerated in conscious patients and allows clear recognition of electrocardiographic response. The noninvasive temporary pacemaker (NTP) has now been applied in 134 patients in five hospitals. Stimulation was tolerated well in 73 of 82 conscious patients, and nine found it intolerable. The NTP was effective in evoking electrocardiographic responses in 105 patients; the 29 failures were in the presence of prolonged hypoxia or severe discomfort. The NTP was clinically useful in 82 patients: 43 of 86 were resuscitated from emergency or expected arrest, 38 of 40 were maintained in standby readiness for up to 1 month but did not require stimulation, and one of eight patients with tachycardia obtained some clinical benefit. The NTP was especially useful in 25 patients with complications or contraindications to endocardial pacing and in 57 patients in whom insertion of an endocardial electrode was avoided.

Publication Types: Clinical trial

No. 7

[PubMed]

Cummins RO, Graves JR, Larsen MP, Hallstrom AP, Hearne TR, Ciliberti J, Nicola RM, Horan S

Department of Medicine, University of Washington Medical Center, Seattle.

(whole article)

BACKGROUND. Transcutaneous cardiac pacemakers generate electrical stimuli that pace the heart through external electrodes that adhere to the chest wall. Transcutaneous pacing has been useful in some patients with bradycardia, but its efficacy in patients with asystole and full cardiac arrest has been limited, possibly because of delays in the initiation of pacing. We studied the efficacy of early transcutaneous pacing in patients with out-of-hospital asystolic cardiac arrest.

METHODS. For three years we provided transcutaneous pacemakers to about half the fire districts in a large emergency-medical-services system (the intervention group). In these districts, we authorized emergency medical technicians (EMTs) to begin transcutaneous pacing in patients with cardiac arrest and primary asystole or post-defibrillation asystole. Pacing was done as early as possible, before endotracheal intubation or intravenous medication. EMTs in the other fire districts (the control group) treated similar patients with basic cardiopulmonary resuscitation but without transcutaneous pacing.

RESULTS. The EMTs in the intervention group initiated transcutaneous pacing in 112 of the 278 patients with primary asystole. Of these patients, 22 (8 percent) were admitted to the hospital, and 11 (4 percent) were discharged. Among the 259 patients treated by the EMTs in the control group, 21 (8 percent) were admitted to the hospital, and 5 (2 percent) were discharged. The two groups did not differ significantly with respect to the rate of hospital admission or survival. Survival after early pacing for post-defibrillation asystole was no better than survival after pacing for primary asystole.

CONCLUSIONS. Transcutaneous pacing appears to offer no benefit in patients with asystolic cardiac arrest, even when it is performed as early as possible by EMTs in the field. Our data suggest that the widespread implementation of early transcutaneous pacing for out-of-hospital asystolic cardiac arrest would be ineffective.

Comments:

1. Comment in: N Engl J Med 1993 Oct 21;329(17):1277
   Transcutaneous pacing in patients with asystolic cardiac arrest.
   Armon C
   (whole article)
   Publication Types: Comment, Letter

No. 4

[PubMed]

Teo KK, Yusuf S, Furberg CD

Clinical Trials Branch, National Heart, Lung, and Blood Institute, Bethesda, Md.

OBJECTIVE--To investigate the effects of prophylactic therapy with antiarrhythmic agents on mortality in patients with myocardial infarction.

DATA SOURCES AND STUDY SELECTION--Data were obtained from all completed, published or unpublished, randomized, parallel controlled trials of antiarrhythmic agents, regardless of sample size. Investigators were contacted for data on patients excluded after randomization.

DATA EXTRACTION--Data on mortality were extracted by one author and confirmed where necessary by the others.

DATA SYNTHESIS--Mortality data from 138 trials on 98,000 patients were combined by the Yusuf-Peto adaptation of the Mantel-Haenszel method. There were 660 deaths among 11,712 patients allocated to receive class I agents and 571 deaths among 11,517 corresponding control patients (51 trials: odds ratio [OR], 1.14; 95% confidence interval [CI], 1.01 to 1.28; P = .03). Of 26,973 patients allocated to receive beta-blockers (class II agents), 1464 died compared with 1727 deaths among 26,295 control patients (55 trials: OR, 0.81; 95% CI, 0.75 to 0.87; P = .00001). Of 778 patients allocated to receive amiodarone (a class III agent), 77 died compared with 101 deaths in 779 control patients (eight trials: OR, 0.71; 95% CI, 0.51 to 0.97; P = .03). There were 982 deaths in 10,154 patients allocated to receive a class IV agent (calcium channel blockers) and 949 deaths in 10,188 control patients (24 trials: OR, 1.04; 95% CI, 0.95 to 1.14; P = .41).

CONCLUSIONS--The routine use of class I antiarrhythmic agents after myocardial infarction is associated with increased mortality. beta-Blockers have been conclusively demonstrated to reduce mortality. The limited data on amiodarone appear promising. Data on calcium channel blockers remain unpromising.

Publication Types: Clinical trial, Randomized controlled trial, Review, Review-tutorial

Comments:

1. Comment in: ACP J Club 1994 May-Jun;120 Suppl 3:75

No. 5

[PubMed]

Kloner RA, Hale S, Alker K, Rezkalla S

Heart Institute Research Department, Hospital of the Good Samaritan, Los Angeles, Calif. 90017.

It is clear that cocaine has cardiotoxic effects. Acute doses of cocaine suppress myocardial contractility, reduce coronary caliber and coronary blood flow, induce electrical abnormalities in the heart, and in conscious preparations increase heart rate and blood pressure. These effects will decrease myocardial oxygen supply and may increase demand (if heart rate and blood pressure rise). Thus, myocardial ischemia and/or infarction may occur, the latter leading to large areas of confluent necrosis. Increased platelet aggregability may contribute to ischemia and/or infarction. Young patients who present with acute myocardial infarction, especially without other risk factors, should be questioned regarding use of cocaine. As recently pointed out by Cregler, cocaine is a new and sometimes unrecognized risk factor for heart disease. Acute depression of LV function by cocaine may lead to the presence of a transient cardiomyopathic presentation. Chronic cocaine use can lead to the above problems as well as to acceleration of atherosclerosis. Direct toxic effects on the myocardium have been suggested, including scattered foci of myocyte necrosis (and in some but not all studies, contraction band necrosis), myocarditis, and foci of myocyte fibrosis. These abnormalities may lead to cases of cardiomyopathy. Left ventricular hypertrophy associated with chronic cocaine recently has been described. Arrhythmias and sudden death may be observed in acute or chronic use of cocaine. Miscellaneous cardiovascular abnormalities include ruptured aorta and endocarditis. Most of the cardiac toxicity with cocaine can be traced to two basic mechanisms: one is its ability to block sodium channels, leading to a local anesthetic or membrane-stabilizing effect; the second is its ability to block reuptake of catecholamines in the presynaptic neurons in the central and peripheral nervous system, resulting in increased sympathetic output and increased catecholamines. Other potential mechanisms of cocaine cardiotoxicity include a possible direct calcium effect leading to contraction of vessels and contraction bands in myocytes, hypersensitivity, and increased platelet aggregation (which may be related to increased catecholamine). The correct therapy for cocaine cardiotoxicity is not known. Calcium blockers, alpha-blockers, nitrates, and thrombolytic therapy show some promise for acute toxicity. Beta-Blockade is controversial and may worsen coronary blood flow. In patients who develop cardiomyopathy, the usual therapy for this entity is appropriate.

Publication Types: Review, Review-tutorial

No. 1

[PubMed]

Rosemurgy AS, Norris PA, Olson SM, Hurst JM, Albrink MH

Department of Surgery, University of South Florida, Tampa 33606.

Of 12,462 trauma patients cared for by prehospital services from October 1, 1989 to March 31, 1991, 138 patients underwent CPR at the scene or during transport because of the absence of blood pressure, pulse, and respiration. Ninety-six (70%) suffered blunt trauma, 42 (30%) suffered penetrating trauma. Sixty (43%) were transported by air utilizing county-wide transport protocols. None of the patients survived. Aggregate care cost $871,186.00. In 11 cases (8%), tissue for transplantation was procured (only corneas). Conclusion: Trauma patients who require CPR at the scene or in transport die. Infrequent organ procurement does not seem to justify the cost (primarily borne by hospitals), consumption of resources, and exposure of health care providers to occupational health hazards. The wisdom of transporting trauma victims suffering cardiopulmonary arrest at the scene or during transport must be questioned. Allocation of resources to these patients is not an insular medical issue, but a broad concern for our society, and society should decide if the "cost of futility" is excessive.

No. 2

[PubMed]

Hazinski MF, Chahine AA, Holcomb GW 3rd, Morris JA Jr
Vanderbilt University Medical Center, Nashville, Tennessee.

(whole article)

STUDY OBJECTIVES: To determine the survival and functional outcome of pediatric blunt trauma victims demonstrating cardiovascular collapse, including pulseless cardiopulmonary arrest or severe hypotension, on initial presentation in an emergency department.

DESIGN: Seven-year consecutive case-control series.

SETTING: Level I trauma center and university teaching hospital. PARTICIPANTS: Two thousand one hundred twenty consecutive pediatric victims of blunt trauma less than 16 years old admitted to a Level I trauma center from August 1984 through December 1991 had a mortality of 5.2%. Thirty-eight patients (1.8%) demonstrated pulseless cardiac arrest or severe hypotension (systolic blood pressure of 50 mm Hg or less) on initial presentation in the ED.

INTERVENTIONS: All patients received basic and advanced life support consistent with guidelines published by the American Heart Association, American Academy of Pediatrics, and American College of Surgeons.

MEASUREMENTS AND MAIN RESULTS: Survival, functional outcome, and donor status were reviewed. Outcome of ED resuscitation (death or reanimation), post-ED destination (morgue, operating room, or pediatric ICU) length of hospitalization, functional outcome after hospital discharge, time to death (time from admission to ED to declaration of death), cause of death, total hospital costs, total hospital charges, and organ donation were reviewed. There were no functional survivors among 38 pediatric victims of blunt trauma who presented to the ED in pulseless cardiac arrest or with severe hypotension. Eleven of the 12 patients who were transferred to the pediatric ICU died; the single survivor demonstrated profound neurologic impairment six years after hospitalization. Six of these 12 patients were eligible potential donors and resulted in four multiorgan donors during the seven-year study. The mean hospital unreimbursed care for the 38 study patients was $3,514 per patient.

CONCLUSION: No child who presented with pulseless cardiac arrest or severe hypotension following blunt trauma achieved functional survival. Reimbursed care for pediatric victims of blunt trauma demonstrating cardiovascular collapse is disproportionately poor compared with that for pediatric patients who maintain hemodynamic integrity in the ED. Half of all patients who were stabilized sufficiently for transfer to the pediatric ICU were eligible potential organ donors. Therefore aggressive resuscitation of these patients may be justified if organ donation is seriously contemplated and aggressively pursued.

No. 4

[PubMed]

Schmidt U, Frame SB, Nerlich ML, Rowe DW, Enderson BL, Maull KI, Tscherne H

Department of Surgery, University of Tennessee, Graduate School of Medicine, Knoxville 37920.

Hospital-based helicopter services from a German (GER) and an American (AMR) university-affiliated trauma center were reviewed. All patients with multiple injuries transported via helicopter from the scene to the trauma centers during a 1-year period were included. The patients were comparable regarding mechanism of injury, age, flight times, mean ISS, ISS distribution, and number of severe injuries per body region (patients with AIS score > 3 for head, thorax, and abdomen). Overall mortality was 21 of 221 (9.5%) for GER and 21 of 186 (11.3%) for AMR (NS). Survivor-based TRISS analysis yielded Z statistics of +2.459 for GER (p < 0.025) and +1.049 for AMR (NS). M statistics were 0.89 for GER, 0.874 for AMR; the W statistic +1.35 for GER. There were nine unexpected survivors (Ps < 0.50) for GER and six for AMR. There was a significantly higher (p < 0.01) number of early deaths (< 6 hours) in AMR (12; ISS = 56) than in GER (four; ISS = 64). Analysis of the prehospital data demonstrated significant differences in the mean volume of IV fluids infused: 1800 mL, GER; 825 mL, AMR (p < 0.05); rate of intubation: 82 of 221 (37.1%) GER; 24 of 186 (13.4%) AMR (p < 0.001); and thoracic decompressions: 20 of 221 (9.1%) GER; 1 of 186 (0.5%) AMR (p < 0.001). Prehospital care in the GER system is directed on scene by a trauma surgeon member of the flight crew compared with a nurse/paramedic team with remote medical control in the AMR system.

Comments:

1. Comment in: J Trauma 1993 Dec;35(6):971
   On scene helicopter transport of patients with multiple injuries--comparison of a German and an American system.
   Brown L
   Publication Types: Comment, Letter

No. 6

[PubMed]

Durham LA 3d, Richardson RJ, Wall MJ Jr, Pepe PE, Mattox KL

Cora and Webb Mading Department of Surgery, Baylor College of Medicine, Houston, Texas 77030.

Emergency center thoracotomy was performed at our facility on 389 patients from 1984 through 1989. There were no patients excluded from the study, and survival for all patients was 8.3% with survival rates of 15.2% and 7.3% for stab and gunshot wounds, respectively. Emergency center thoracotomy was performed on 42 patients suffering from isolated extrathoracic injuries with 7% survival. There were no survivors of blunt trauma in this study. Fifty-three percent of the patients arrived with cardiopulmonary resuscitation (CPR) in progress. The average time of prehospital CPR for survivors was 5.1 minutes compared with 9.1 minutes for nonsurvivors. Of the survivors, prehospital endotracheal intubation prolonged successful toleration of CPR to 9.4 minutes compared with 4.2 minutes for nonintubated surviving patients (p less than 0.001). Emergency center thoracotomy is useful in the resuscitation of victims dying of penetrating truncal trauma. Prehospital endotracheal intubation significantly lengthened the time of successful CPR.

No. 1

[PubMed]

Morgan CA, Webb RK, Cockings J, Williamson JA

Royal Victorian Eye and Ear Hospital, Melbourne, South Australia.

Eighty-seven cases of cardiac arrest from the first 2000 incidents reported to the Australian Incident Monitoring Study were reviewed. "Cardiac arrest" was taken to include patients who were either pulseless or had electrocardiographic asystole or ventricular fibrillation. Cases were grouped by primary cause--drug administration (19), vagal stimulation (16), hypoventilation (15), bleeding (13), anaphylaxis (6), direct cardiac stimulation (4) and miscellaneous (14). Overall, 20 patients died (23% of the 87 cases); all of these were in the hypoventilation, bleeding, or miscellaneous groups (4, 9 and 7 patients, respectively). Cardiac compression was performed in 66% of patients; 20% were defibrillated; adrenaline was given to 42% and bicarbonate to 3%. There was a clear anaesthetic cause for 46% of this series of arrests, and with hindsight, a preventable factor was present in over half (58%) of these. Preventative strategies regarding staffing, equipment, policy and procedures are suggested.

No. 2

[PubMed]

Keenan RL, Shapiro JH, Dawson K

Department of Anesthesiology, Medical College of Virginia/Virginia Commonwealth University, Richmond.

STUDY OBJECTIVE: To determine whether the presence of pediatric anesthesiologists decreases the frequency of anesthetic-related cardiac arrests in infants (children who are 1 year of age or younger). DESIGN: A comparative retrospective study of anesthetics and cardiac arrests during a 7-year period.

SETTING: The main operating room (OR) suite of a large university hospital.

PATIENTS: All patients age 1 year or less undergoing surgical anesthesia from July 1983 through March 1990.

INTERVENTIONS: Computerized anesthetic and operative patients records were queried for patient age, ASA physical status, body weight, surgical procedure, intraoperative complications, and the identity of the attending anesthesiologist. In each case, it was determined whether a pediatric anesthesiologist was in attendance and whether a cardiac arrest due to anesthesia occurred. Pediatric anesthesiologists were identified as those with pediatric fellowship training or the equivalent. The study population was divided into two groups: (1) the pediatric anesthesiologist group, with 2,310 patients whose anesthetics were supervised by pediatric anesthesiologists; (2) the nonpediatric anesthesiologist group, with 2,033 patients.

MEASUREMENTS AND MAIN RESULTS: Mean age and weight were comparable in the two groups, and the distribution of physical status did not differ. No anesthesia-related cardiac arrests occurred in the pediatric anesthesiologist group; four anesthetic cardiac arrests occurred in the nonpediatric anesthesiologist group, for a frequency of 19.7 per 10,000 anesthetics. This difference between provider groups is significant (Fisher's exact probability test, p = 0.048).

CONCLUSIONS: The results suggest that the use of pediatric anesthesiologists for all infants 1 year of age or younger might decrease anesthetic morbidity in this age-group.

Comments:

1. Comment in: J Clin Anesth 1991 Nov-Dec;3(6):431-2
2. Comment in: J Clin Anesth 1992 Jul-Aug;4(4):343-6

No. 3

[PubMed]

Olsson GL, Hallen B

Department of Paediatric Anaesthesia, St Gorans Hospital, Stockholm, Sweden.

With the aid of a computer-based anaesthetic record-keeping system, all cardiac arrests during anaesthesia at the Karolinska Hospital between July 1967 and December 1984 were retrieved. There were a total of 170 cardiac arrests and 250,543 anaesthetics in the data file, which gives an incidence of 6.8 cardiac arrests per 10,000 anaesthetics. Sixty patients died, constituting a mortality of 2.4 per 10,000 anaesthetics: 42 were considered as inevitable deaths (rupture of aortic or cerebral aneurysm, multitrauma, etc.); 13 cases of cardiac arrest were considered as non-anaesthetic, i.e. complications due to surgery and other procedures. Nine of these patients died. 115 cases of cardiac arrest were considered as caused by the anaesthetic and nine of these patients died. Thus mortality caused by anaesthesia was 0.3 per 10,000 anaesthetics. The most common cause of cardiac arrest due to anaesthesia was hypoxia because of ventilatory problems (27 patients), postsuccinylcholine asystole (23 patients) and post-induction hypotension (14 patients). The highest mortality was seen when spinal or epidural anaesthetics were given to patients with impaired physical status including hypovolaemia. The incidence of cardiac arrest has declined considerably during the period studied, and this coincides with an increasing number of qualified anaesthetists employed in the department during the same period.

No. 2

[PubMed]

Goodwin AP, Pearce AJ

Day Surgery Unit, Addenbrooke's Hospital, Cambridge.

The important part of resuscitation in late pregnancy is the relief of aortocaval compression. A manoeuvre to relieve aortocaval compression (the human wedge) is described and evaluated. Eighteen qualified midwives performed basic life support in the supine and wedged position employing the human wedge. Performance was assessed using the Laerdal Resusci Anne Skillmeter. There was no difference (p = 0.4761) in performance of mouth-to-mouth expired air ventilation between the two positions. External cardiac compressions were performed significantly better (p = 0.0005) in the wedged position than in the supine position. The human wedge may provide an alternative to other methods of relieving aortocaval compression.

Comments:

1. Comment in: Anaesthesia 1992 Dec;47(12):1102
   The human wedge.
   Kempen PM
   Publication Types: Comment, Letter

No. 1

[PubMed]

Kushner M, Peters RW

A 56-year-old man developed sinus node dysfunction culminating in 27 seconds of asystole during a thrombotic stroke. Bradyarrhythmias resolved over a period of 96 hours, at which time sinus node recovery times were normal. Sinus node dysfunction has not recurred during the two years of follow-up. We suggest that cardiac rhythm be closely monitored in acute stroke patients.

No. 1

[PubMed]

Van Hoeyweghen RJ, Bossaert LL, Mullie A, Martens P, Delooz HH, Buylaert WA, Calle PA, Corne L

University of Antwerp, Belgium.

STUDY OBJECTIVES: To study whether age of the cardiac arrest patient is related to prognostic factors and survival.

STUDY DESIGN: Retrospective analysis of a prospective registration of cardiac arrest events in the mobile ICUs of seven participating hospitals.

STUDY POPULATION: Two thousand seven hundred seventy-six out-of-hospital cardiac arrests in which advanced life support was initiated. Cardiac arrests with a precipitating event requiring specific therapeutic consequences and with specific prognosis were not included in the analysis (eg, trauma, exsanguination, drowning, sudden infant death syndrome).

RESULTS: Neither resuscitation rate (23%) nor mortality caused by a neurologic reason (9%) was significantly different between age groups. Mortality after CPR of non-neurologic etiology was significantly higher in the elderly patient (younger than 40 years, 16%; 40 to 69 years, 19%; 70 to 79 years, 30%; 80 years or older, 34%; P less than .005) and had a negative effect on survival in resuscitated elderly patients (P less than .05). Elderly patients more frequently had a dependent lifestyle before the arrest (P less than .025), an arrest of cardiac origin (P less than .001), electromechanical dissociation as the type of cardiac arrest (P less than .025), and a shorter duration of advanced life support in unsuccessful resuscitation attempts (r = -.178, P less than .0001).

CONCLUSION: Because survival two weeks after CPR was not significantly different between age groups, we suggest that decision making in CPR should not be based on age but on factors with better predictive power for outcome and quality of survival. Comments:

1. Comment in: Ann Emerg Med 1993 Oct;22(10):1637-8
   Ann Emerg Med 1993 Oct;22(10):1637-8
   Prognostic implications of age.
   Wuerz RC, Holliman CJ
   Publication Types: Comment, Letter

No. 1

[PubMed]

Longstreth WT Jr, Cobb LA, Fahrenbruch CE, Copass MK

Divisions of Neurology, Harborview Medical Center, Seattle 98104-2499.

We examined the relation between age and outcomes in patients treated for out-of-hospital cardiac arrest in Seattle, Wash. Considering all out-of-hospital cardiac arrests treated by paramedics over a recent 5-year period, 386 (27%) of 1405 consecutive patients aged 70 years or older were resuscitated and admitted to a hospital vs 474 (29%) of 1624 younger patients; 140 elderly patients (10%) were discharged alive vs 223 younger patients (14%). Of the 140 elderly patients, 112 went home and 28 went to a nursing home. Considering only patients whose initial rhythms were ventricular fibrillation, the percent of patients discharged alive was substantially higher: 120 (24%) of 493 for elderly patients and 194 (30%) of 639 for younger patients. Elderly patients can benefit from attempted resuscitation from out-of-hospital cardiac arrest.

Comments:

1. Comment in: JAMA 1990 Oct 24-31;264(16):2118
   Life-sustaining therapies in elderly persons.
   Tuteur PG, Tuteur SD
   Publication Types: Comment, Editorial

2. Comment in: JAMA 1991 Feb 20;265(7):866-7
   The utility of CPR in elderly persons.
   Publication Types: Comment, Letter

No. 3

[PubMed]

Bedell SE, Delbanco TL, Cook EF, Epstein FH

Little is known about prognostic factors that determine outcomes after in-hospital cardiopulmonary resuscitation. We studied prospectively 294 consecutive patients who were resuscitated in a university teaching hospital. Forty-one patients (14 per cent) were discharged from the hospital; three quarters of them were still alive six months later. A multivariate analysis revealed that pneumonia, hypotension, renal failure, cancer, and a homebound life style before hospitalization were significantly associated with in-hospital mortality (P less than 0.05). None of the 58 patients with pneumonia and none of the 179 in whom resuscitation took longer than 30 minutes survived to be discharged. On the other hand, fully 42 per cent of the patients who survived for 24 hours after resuscitation left the hospital. At the time of discharge from the hospital and again six months later, 93 per cent of the survivors were mentally intact. Although depression was generally present at the time of discharge, it tended to resolve subsequently. However, all patients reported some decrease in functional capacity, often attributed to fear. This persisted at six months after discharge. Age alone did not appear to influence the prognosis for survival after cardiopulmonary resuscitation or the adjustment to chronic illness after discharge from the hospital.

No. 5

[PubMed]

Tresch DD, Thakur RK, Hoffmann RG, Aufderheide TP, Brooks HL

Medical College of Wisconsin, Department of Cardiology, Milwaukee 53226.

To obtain further information concerning differences in the mechanism of out-of-hospital cardiac arrest between elderly and younger patients, 381 consecutive patients who experienced out-of-hospital cardiac arrest, and whose arrest was witnessed by paramedics, were studied. In 91% of cases the arrest occurred at the time the patient's cardiac rhythm was monitored. Patients were divided into 2 age groups: elderly patients were greater than 70 years (187) and younger patients were less than 70 years (194). Elderly patients more commonly had a past history of heart failure (25 vs 10%, p less than 0.003) and were more commonly taking digoxin (40 vs 20%, p less than 0.005) and diuretics (35 vs 25%, p less than 0.004). Before the cardiac arrest, elderly patients were more likely to be complaining of dyspnea (53 vs 40%, p less than 0.009), whereas younger patients were more likely to complain of chest pain (27 vs 13%, p less than 0.001). Forty-two percent of younger patients demonstrated ventricular fibrillation as the initial out-of-hospital rhythm associated with the arrest, compared to only 22% of elderly patients (p less than 0.001). Besides patient age, initial cardiac rhythm varied according to the patient's complaint preceding the arrest. Sixty-eight percent of patients with chest pain demonstrated ventricular fibrillation, whereas only 21% of patients with dyspnea demonstrated ventricular fibrillation. Elderly patients could be as successfully resuscitated as younger patients; however, 24% of younger patients survived, compared to only 10% of elderly patients (p less than 0.001).

No. 6

[PubMed]

Tresch DD, Thakur RK, Hoffmann RG, Olson D, Brooks HL

Division of Cardiology, Medical College of Wisconsin, Milwaukee 53226.

PURPOSE: Elderly and younger patients who were successfully resuscitated and hospitalized following out-of-hospital cardiac arrest were studied to determine if there was a significant difference in hospital course and long-term survival between the two groups.

PATIENTS AND METHODS: The study consisted of 214 consecutive patients, divided into two age groups: elderly (more than 70 years, n = 112) and younger (less than 70 years, n = 102). Hospital charts and paramedic run data were retrospectively reviewed for each patient and findings were compared between the two age groups.

RESULTS: Prior to cardiac arrest, 47 of 112 (42 percent) elderly patients had a history of heart failure, compared with 19 of 102 (18 percent) younger patients, and were more commonly taking digitalis (51 percent versus 29 percent) and diuretics (47 percent versus 26 percent). Younger patients, however, more often had an acute myocardial infarction at the time of the cardiac arrest (33 percent versus 16 percent). At the time of cardiac arrest, 83 percent of younger patients demonstrated ventricular fibrillation, compared with 71 percent of the elderly. In contrast, electromechanical dissociation was five times more common in the elderly patients. Although hospital deaths were more common in the elderly (71 percent versus 53 percent), the length of hospitalization and stay in intensive care units were not significantly different between the age groups. The number of neurologic deaths was similar in both age groups, as were residual neurologic impairments. Only five elderly patients and six younger patients required placement in extended-care facilities. Calculated long-term survival curves demonstrated similar survival in both age groups, with approximately 65 percent of hospital survivors alive at 24 months after hospital discharge.

CONCLUSION: Resuscitation of elderly patients in whom out-of-hospital cardiac arrest occurs is reasonable and appropriate, according to the findings of this study. Even though elderly patients are more likely than younger patients to die during hospitalization, the hospital stay of the elderly is not longer, the elderly do not have more residual neurologic impairments, and survival after hospital discharge is similar to that in younger patients.

No. 7

[PubMed]

Bayer AJ, Chadha JS, Farag RR, Pathy MS

The symptoms associated with acute myocardial infarction in a series of 777 elderly hospitalized patients are reviewed. Their ages ranged from 65 to 100, with a mean of 76.0 years. The spectrum of presentation changed significantly with increasing age. Chest pain or discomfort were less frequently reported, although present in the majority of patients up to 85 years. Syncope, stroke, and acute confusion became more common and were often the sole presenting symptom. Shortness of breath, although the most frequently reported symptom in the absence of chest pain, was equally common at all ages. Thus, in patients aged 85 years or over, "atypical" presentation of myocardial infarction became the rule, and in the very old the clinician must be prepared to screen for the diagnosis in most acutely ill patients.

No. 8

[PubMed]

Weaver WD, Litwin PE, Martin JS, Kudenchuk PJ, Maynard C, Eisenberg MS, Ho MT, Cobb LA, Kennedy JW, Wirkus MS

MITI Project Coordinating Center, University of Washington, Seattle 98102.

The findings in 3,256 consecutive patients hospitalized for acute myocardial infarction were tabulated to assess the history, treatments and outcome in the elderly; 1,848 patients (56%) were greater than 65 years of age, including 28% who were aged greater than or equal to 75 years. The incidence of prior angina, hypertension and heart failure (only 3% of patients less than 55 years of age had a history of heart failure compared with 24% greater than or equal to 75 years old) was found to increase with age. Twenty-nine percent of patients less than 75 years of age were treated with a systemic thrombolytic drug compared with only 5% of patients older than 75 years. Mortality rates increased strikingly with advanced age (less than 2% in patients less than or equal to 55, 4.6% in those 55 to 64, 12.3% in those 65 to 74 and 17.8% in those greater than or equal to 75 years). Both the incidence of complicating illness and a nondiagnostic electrocardiogram (ECG) increased with age. In a multivariate analysis of outcome in older patients (greater than or equal to 65 years), adverse events were related to both prior history of heart failure (odds ratio 3.9) and increasing age (odds ratio 1.4 per each decade of age). Outcome was not improved by treatment with thrombolytic drugs, but these agents were prescribed to only 12% of patients greater than 65 years of age, thereby reducing the power for detecting such an effect.

Publication Types: Clinical trial, Multicenter study

No. 9

[PubMed]

Doorey AJ, Michelson EL, Topol EJ

Department of Medicine, Medical Center of Delaware, Newark 19713.

OBJECTIVE--To assess the use of thrombolytic therapy for acute myocardial infarction, evaluating whether inclusion and exclusion criteria should be altered as well as the public health implications of any such alterations.

DATA SOURCES--Data obtained were from English-language articles on the use of thrombolytic therapy in acute myocardial infarction. Articles that reported on inclusion and exclusion criteria as well as specific complications of this therapy were specifically sought. The review included articles under the terms thrombolytic therapy and acute myocardial infarction in the National Library of Medicine's MEDLINE database.

STUDY SELECTION--Studies selected for detailed review were those reporting specifics about inclusion and exclusion criteria and efficacy. Data extraction guidelines for assessing data quality included study size, patient population, detail of patient information acquired, and consecutive patient enrollment.

DATA SYNTHESIS--Thrombolytic therapy can provide substantial decrements of morbidity and mortality of acute myocardial infarction in the subset of patients who receive this therapy, but is underused in the United States. Advanced age per se should not be an exclusion criterion. Improvements can be made in electrocardiographic diagnosis of acute myocardial infarction. Many of the clinical conditions initially excluded from thrombolytic consideration, such as hypertension or having received cardiopulmonary resuscitation, are only relative contraindications. The benefit/risk ratio in treatment of these patients is often acceptable. Several well-documented points of delay from onset of symptoms to treatment can be minimized, and accelerated therapy can result in a reduction in mortality rates. CONCLUSION--Significant public health benefits will result from greater use of thrombolytic therapy in acute myocardial infarction.

Publication Types: Review, Review-tutorial

Comments:

1. Comment in: JAMA 1993 Apr 14;269(14):1793
   Diagnosis of myocardial infarction by emergency department physicians.
   Checchio LM
   Publication Types: Comment, Letter