The American journal of emergency medicine
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This study evaluates the cardiac and neurologic risks associated with the antagonization of the benzodiazepine component of mixed drug overdoses, when cyclic antidepressants are also implicated. Twenty-four mongrel dogs were anesthetized and ventilated. Electroencephalogram, electrocardiogram, and tidal carbon dioxide and arterial pressure were continuously recorded. ⋯ The mechanism of this effect remains unclear, as it could be unrelated to the antagonization of midazolam sedation. Given the problem of extrapolating animal data to humans, these results suggest that bolus administration of high doses of flumazenil in mixed intoxication implicating benzodiazepine and cyclic antidepressants has the potential to precipitate convulsions and/or arrhythmias. A slowly titrated administration of the antidote, as usually recommended, could prevent these effects.
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Comparative Study
Orthostatic vital signs: variation with age, specificity, and sensitivity in detecting a 450-mL blood loss.
The authors conducted this study to: (1) determine the effect of age on orthostatic vital signs; and (2) to define the sensitivity and specificity of alternative definitions of "abnormal" orthostatic vital signs in blood donors sustaining an acute 450-mL blood loss. The population studied were 100 healthy adult volunteer blood donors and 100 self-sufficient ambulatory citizens attending a senior citizens daytime activity center. Subjects with a history of orthostatic hypotension were excluded. ⋯ Mean orthostatic vital sign changes were as follows: pulse rate, 2 +/- 7 beats per minute; systolic blood pressure, -3 +/- 9 mm Hg; and diastolic blood pressure, 1 +/- 7 mm Hg. There was no clinically meaningful variance in orthostatic blood pressure changes with age. For a given specificity, pulse rate increase was the most sensitive of the orthostatic vital signs used alone; a pulse rise of greater than 20 beats per minute had a sensitivity of 9% with a specificity of 98%.(ABSTRACT TRUNCATED AT 250 WORDS)
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Comparative Study
Cervical spine injuries in blunt trauma patients requiring emergent endotracheal intubation.
Airway management in the blunt trauma patient is complicated by the potential for causing or exacerbating an injury to the cervical cord if an unstable cervical fracture is present. The records of 987 blunt trauma patients who required emergent endotracheal intubation over a 5-year period were retrospectively reviewed to determine the incidence and type of cervical spine injury and the incidence of injury based on airway management. Sixty of the patients (6.1%) had a cervical fracture; 53 were potentially unstable injuries by radiographic criteria. ⋯ One patient developed a neurologic deficit after nasotracheal intubation. Because of a possible selection bias in which severely injured patients were preferentially referred to this trauma center, the true incidence of cervical spine injuries may be lower than the 6.1% we found. The authors conclude that the incidence of serious cervical spine injury in a very severely injured population of blunt trauma patients is relatively low, and that commonly used methods of precautionary airway management rarely lead to neurologic deterioration.
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The authors devised a percutaneous dilatational method which they believe trained physicians and nonphysicians (emergency medical technicians and paramedics) can use with safety and speed. With one blade of a modified nasal speculum embedded in a tapered small pigtail-dilator catheter, the closed, flattened instrument is forced through the cricothyroid ligament, with a twisting motion, and then opened. Only the skin is incised 1 cm in length. ⋯ At the proper depth the speculum is opened transversely, and a cuffed tracheostomy tube with an internal diameter of 6 mm is inserted. The instrument is removed and immediate suctioning and active ventilation is possible. The authors developed the use of this instrument in trials on a mannequin and on 25 cadavers.
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The initial evaluation and management of cervical spine injuries is of critical importance because of the impact of early treatment and management on the patient's eventual outcome. The devastation and cost of missing even one unstable cervical spine fracture is tremendous. ⋯ Recently, however, the concept of the occult cervical spine fracture has been challenged. Does the entity of an occult cervical spine fracture exist? If so, how should this affect our indications for obtaining cervical spine radiographs? The author presents the case of an unstable occult cervical spine fracture and a review of the literature.