Correlation Between Inferior Vena Cava/Aorta Diameter Index and CVP - A Retrospective Study

PURPOSE: To evaluate whether the inferior vena cava/aorta diameter index correlates with central venous pressure (CVP) in the emergency department. METHODS: We selected patients who had computed tomography and had their central venous pressure checked between September 2008 and December 2008. Measurement of the IVC and aorta diameters was performed in conjunction with computed tomography. Subjects were divided into two groups: those with a CVP of less than 8 cm H2O (group A), and those with a CVP greater than 8 cm H2O (group B). Data collected included the patient's age, sex, height, systolic blood pressure, heart rate, hemoglobin level, IVC diameter and aorta diameter. We analyzed the correlation between the IVC/aorta index and the CVP. RESULTS: A total of 80 patients were enrolled in the study. Of the 80, 39 patients were assigned to group A and 41 to group B. The mean IVC diameter in group A was 14.98+/-2.58 mm; in group B it was and 18.84+/-3.01 (p<0.01). The IVC/aorta index in group A was 0.72+/-0.12; in group B it was 0.96+/-0.20 (p<0.01). The correlation coefficient for CVP and IVC was 0.72 (p<0.01); for CVP and aorta it was - 1.5 (p=0.17); for CVP and the IVC/aorta index it was 0.69 (p<0.01). CONCLUSION: The IVC/aorta index is related to the CVP. There is a difference in the IVC diameter and IVC/aorta index between groups A and B. The IVC/aorta index may be a predictor of body fluid status in the emergency department.

Which Structures does a Rescuer compress in One Rescuer Cardiopulmonary Resuscitation for Infant?

PURPOSE: We studied which structures were compressed in 1 rescuer cardiopulmonary resuscitation (CPR) in order to determine the optimal compression site on infants. METHODS: Charts and multidirectional computed tomography of infants who presented in the hospitals from March, 2004 to March, 2009 were reviewed retrospectively. We measured the length of the sternum (Stotal), the index finger` s mark (L1) and the two fingers` mark (L2) that were located on the sternum during one rescuer CPR simulation. We studied those structures located at the following points: the lower half of the sternum (Stotal/2), the sternum at the inter-nipple line (Xn), the point of maximal anterior-posterior heart diameter (Xm), and the lower margin of L1 and L2 from Stotal/2, Xn, Xm. RESULTS: Of 75 enrolled infants, Stotal was 5.68+/-2.00 cm; Xn was 2.11+/-1.47 cm; Xm was 1.43+/-1.18 cm; L1 was 1.25+/- 0.21 cm; L2 was 2.88=/-0.33 cm; the ratio of Xm to Stotal was 0.24+/-0.19. 16(21.3%) had ascending aorta, 31(41.3%) had aortic root, and 14(18.7%) had a left ventricular outflow tract in Stotal/2. 14(18.7%) had aortic root, 35(46.7%) had left ventricular outflow tract in Xn. All had left ventricle in the Xm. 12(16.0%) had liver in the lower margin of L1 from Xm. All had liver in the lower margin of L2 from Xm. CONCLUSION: We knew that we had compressed the aortic root, left ventricular outflow tract as we complied with the 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. However, the left ventricle was located at the lower quarter of the sternum.

Comparison between the Glasgow Coma Scale and Simplified Motor Score as a Tools to Predict Outcome for Adult Stroke Patients

PURPOSE: We wanted to evaluate the utility of the Simplified Motor Score (SMS) for prediction of outcome for adult stroke patients. METHODS: This was a prospective study of adult stroke patients from May to October, 2007. Emergency medicine residents independently checked the Glasgow Coma Scale (GCS) for each patient at the same time that interns otherwise, senior medical students (MS) and nurses checked the 3-point SMS within 5 minutes of patients arrival at our emergency care center. We telephoned the patients or their families to inform them of intubation, or death and to check the cerebral performance category (CPC) on the first- day and- first month after the patients' visits. RESULTS: Fifty-eight patients were enrolled in this study. Each SMS of evaluation by interns, MS and nurses was correlated with GCS (Correlation Coefficient=0.63, 0.59, 0.61; p<0.01, respectively). In the case of mortality within 24 hours, the AUC (area under the curve) for GCS was 0.46 and the AUCs for SMS of interns, MS and nurses were 0.94, 0.94, and 0.94. In the case of intubation within 24 hours, the AUC for GCS was 0.81 and the AUCs for SMS of interns, MS and nurses were 0.78, 0.79, and 0.77. In the case of CPC at one month, the AUC for GCS was 0.82 and the AUCs for SMS of interns, MS and nurses were 0.74, 0.75, and 0.73, respectively. CONCLUSION: The accuracy of SMS was equal to that of GCS for predicting outcome for adult stroke patients in such parameters as mortality, intubation and CPC.

Comparison of Ultrasound-assisted Lumbar Puncture with Lumbar Puncture using Palpation of Landmarks in Aged Patients in an Emergency Center

PURPOSE: We evaluated the utility of ultrasound-assisted lumbar puncture (UALP) in aged patients who visited our emergency center. METHODS:This was a prospective, randomized, controlled study. From July to December 2007 we enrolled patients who were at least 60 years of age . Patients were divided into a group that had lumbar puncture (LP) using landmark palpation (group A) and a UALP group (group B). We did between-group comparisons for the number of attempts, procedure time, the number of LP failures, and whether traumatic LP was done. For all hypotheses, a significance level of 0.05 was used. Variables are reported as percentages and mean +/-standard deviation. RESULTS: We enrolled sixty aged patients: 30 in group A and 30 in group B. There were 5 cases of LP failure in group A and none in group B (p<0.05). There were 6 cases of traumatic lumbar puncture in group A, and one case in group B (p=0.05). The number of attempts was 3.3+/-2.4 in group A and 1.5+/-0.8 in group B (p<0.05). It took 10.6+/-7.7 minutes to finish each LP in group A compared to 5.3+/-4.2 minutes in group B (p<0.05). CONCLUSION: The use of ultrasound-assisted lumbar puncture significantly reduces the number of failures, the number of attempts, and the procedure time in aged patients.

A Case of Status Epilepticus Following High Dose of Intradermal Lidocaine Injection

Lidocaine is widely used as local anesthetic agent in the emergency department. Lidocaine crosses the blood brain barrier rapidly, and has been recognized generally as a proconvulsant drug. Acute lidocaine intoxication has a variety of causes, most of which related to excessive or inappropriate therapeutic dose. It has been recommended the total amount of lidocaine should not exceed 5 mg/kg without epinephrine and 7 mg/kg with epinephrine. We present a case of a patient who developed generalized convulsive status epilepticus following administration of lidocaine for epidermograft.

Utility of Optic Nerve Sheath Diameter Measured by Ultrasonography for the Detection of Increased Intracranial Pressure in Adults

PURPOSE: To evaluate the utility of ONSD (optic nerve sheath diameter) measured by US (ultrasonography) in detecting the presence of increased intracranial pressure. METHODS: This prospective study was done from October, 2007, to March, 2008. Patients who were 18 years or younger, had a recent ocular or periocular disease, had an abnormal Q test (Queckenstedtis test), or were uncooperative were excluded. The patients were divided into group A (increased CSF pressure group > or =200 mmCSF) and group B (normal CSF pressure <200 mmCSF). The ONSDs were measured using a 3~12 MHz ultrasonographic probe on the closed eyelids. We analyzed the correlation between the CSF (cerebrospinal fluid) pressure and the ONSD. RESULTS: There were 21 patients in group A and 70 patients in group B. The mean for binocular ONSDs in group A was 5.1+/-0.6 mm and 4.5+/-0.4 mm in group B (plt;0.01). The CSF pressure correlated with the ONSD (Correlation Coefficient=0.54) (plt;0.01). In the ROC curve (Receiver operating characteristic curve) for ONSD to distinguish group A from B, the AUC was 0.8 (95% confidence interval 0.7~0.9) with a sensitivity of 81.0%, and a specificity of 75.7% when the cut off value was set at 4.7 mm. CONCLUSION: The ONSD was related to the CSF pressure, with a difference in the ONSD between group A and group B. The ONSD, as measured by US, can be used to detect the presence of high ICP.

Advanced Cardiac Life Support for Hyperkalemic Cardiac Arrest

The acceptable total number of electrical shocks used in treating cardiac arrest is not exactly defined in any of the literature. It is generally expressed as "the more trials the less chance". Electrical therapy should be promptly performed in the presence of "shockable"rhythm. But for pulseless patients bystander cardiopulmonary resuscitation (CPR) should be done on instead. The most reasonable number of attempts of electrical therapy and the length of CPR or unresponsive ventricular fibrillation or pulseless ventricular tachycardia are not well defined. We report the case of 57-year-old woman presenting with mental change due to sustained pulseless ventricular tachycardia who survived to hospital discharge without neurological sequelae after 45 defibrillations and prolonged CPR for 86 minutes.