Poison exposure in children before Passover.

BACKGROUND: Extensive cleaning of homes in Israel before Passover may result in increased exposure of children to cleaning substances. OBJECTIVES: To evaluate the potential danger of Passover cleaning to children, and to study the risk factors in order to identify areas for prevention. METHODS: All cases of poison exposure in Jewish and Arab children under the age of 15 years reported to the Israel Poison Information Center during 1990-95 (n = 5,583) were analyzed for the 6 weeks before and 6 weeks after Passover. Poison exposures in Jewish children < 15 years old were studied in seven pediatric emergency rooms for the 2 weeks before and 6 weeks after Passover (n = 123). RESULTS: The IPIC data showed a highly significant 38% increase in the average weekly poison exposure rate for the 2 weeks before Passover compared with the remaining 10 weeks. Data recorded by the pediatric emergency rooms showed a twofold increase in cleaning substance poisoning during the 2 weeks before Passover compared with the following 6 weeks. The rise in exposures to cleaning substances was observed among children from secular, religious and ultra-orthodox families. In these exposures, the substance was found in open containers in 70% of cases. CONCLUSIONS: The extensive cleaning of homes among Jewish families in preparation for Passover poses the danger to young children of cleaning substance poisoning. Increasing public awareness, closer observation of children, and keeping these substances in closed containers should increase children's safety during this annual cleaning.

The use of tissue adhesion for traumatic laceration repair in the emergency department.

STUDY OBJECTIVE: To characterize the role of tissue adhesion as an adjunct in wound closure. DESIGN: Patients were subjectively selected for tissue adhesion and assessed for efficiency, pain, complications, and cost effectiveness. SETTING: The TEREM Immediate Medical Care Center Emergency Department in Jerusalem, Israel. TYPE OF PARTICIPANTS: Patients with traumatic lacerations requiring wound closure. MEASUREMENTS AND MAIN RESULTS: Lacerations considered appropriate for tissue adhesion tended to involve the scalp, chin, and forehead and were relatively shorter. The complication rate was low. This technique was painless, reduced the need for follow-up care, eliminated the need for local anesthesia and suture-removal visits, and was cost effective. Patients indicated a high level of satisfaction with tissue adhesion. CONCLUSION: Our report indicates that tissue bonding may be a preferred and cost-effective method of repair of appropriate traumatic lacerations in the ED.

Quality of pediatric care at a freestanding emergency facility.

The last decade has seen the introduction of freestanding emergency facilities, which provide an alternative to hospital emergency departments. The contribution made by these facilities to the clinical welfare of patients depends on their availability to deliver quality medical care without the need for frequent referral. This study describes the clinical experience of one such facility with pediatric patients and attempts to assess the quality of their care.

Gated radionuclide ventriculography in the evaluation of cardiac function in Duchenne's muscular dystrophy.

Left ventricular ejection fractions were determined in 38 patients with Duchenne's muscular dystrophy. No significant correlation between the severity of respiratory dysfunction or age and cardiac function was seen. We suggest that the cardiac status of each patient should be evaluated separately from his respiratory status, particularly when long-term assisted ventilation is being considered.

Sudden cardiac arrest in Israel: factors associated with successful resuscitation.

Out-of-hospital cardiac arrests were studied in Israel from 1984 to 1985. More than 3,500 patients in cardiac arrest received paramedic care. Eighty-three percent of cases were caused by underlying heart disease. Overall, 17% of patients with arrest caused by heart disease were admitted and 7% were discharged from the hospital. There was a wide variation in the percent discharged among the 15 paramedic service areas, ranging from 0% to 13%. Factors associated with successful resuscitation included witnessed collapse, rhythm of ventricular fibrillation, short interval from collapse to cardiopulmonary resuscitation (CPR) and delivery of advanced cardiac life support, collapse at public location, and bystander initiation of CPR. Improvements in survival are likely to result if CPR is more frequently and promptly initiated and the time to arrival of definitive paramedic care can be improved.

Terminating SVT-mediated recurrent ventricular fibrillation with verapamil.

Verapamil has been established as the drug of choice in the treatment of supraventricular dysrhythmias and is recognized as useful in the treatment of ischemic heart disease and hypertension. However, verapamil has not generally been considered helpful in the treatment of ventricular dysrhythmias. Five cases are reported in which verapamil was used to terminate a cycle of supraventricular tachycardia-mediated recurrent ventricular fibrillation that could not be suppressed by conventional antidysrhythmics such as lidocaine, procainamide, and bretylium, Proposed mechanisms of verapamil's beneficial effect in this usually fatal situation include (1) a reduction in oxygen consumption related to the reduction in heart rate, thereby raising the ventricular fibrillation threshold; (2) direct anti-ischemic effect; and (3) a direct antidysrhythmic effect. These proposed mechanisms are substantiated by clinical studies. On the basis of this observation, it is recommended that in a situation of supraventricular tachycardia-mediated recurrent ventricular fibrillation that cannot be terminated by conventional antidysrhythmics, the administration of verapamil should be considered.

Early prediction of left ventricular function in streptokinase-treated acute myocardial infarction.

We administered 750,000 units of intravenous streptokinase to 121 consecutive patients experiencing their first acute myocardial infarction within 4 h of pain onset. The following information was collected: hours between pain onset and streptokinase administration (TS), hours of pain after streptokinase administration (DP), initial and peak creatine phosphokinase levels (ICK and PCK), time to peak creatine phosphokinase, time to electrocardiographic ST segment resolution. Six days after the infarction, catheterization was performed to calculate ejection fraction, infarct-related regional ejection fraction, and dysfunction index. Data was analyzed using stepwise multiple regression. In patients experiencing anterior infarctions, the following equation was obtained predicting the ejection fraction (EF) with a correlation coefficient of 0.86: EF = 69 - 0.0050(PCK) - 3.7(TS) - 1.8(DP). In anterior infarctions the infarct-related ejection fraction and dysfunction index were similarly predictable. We were slightly less accurate in forecasting the outcome of inferior infarctions. The outcome of intravenous streptokinase therapy can be predicted early in the evolution of acute myocardial infarction using routinely available information.

Prehospital coronary thrombolysis. A new strategy in acute myocardial infarction.

Thirty-four patients with acute myocardial infarction were treated prospectively using a new strategy of prehospital intravenous streptokinase given by a physician-operated mobile intensive care unit. The 29 prehospital-treated patients who had experienced no previous myocardial infarction were compared to a similar group treated with streptokinase inhospital. Patients receiving streptokinase in the prehospital phase of acute myocardial infarction had smaller infarcts and better residual myocardial function than the group given streptokinase inhospital in terms of peak creatinine phosphokinase, ejection fraction, computer-derived dysfunction index, and electrocardiographic QRS score. The only difference between these groups at baseline was the duration of pain prior to initiation of streptokinase therapy. There were no major complications related to prehospital administration of streptokinase.

Knowledge of cardiopulmonary resuscitation in Jerusalem: is the community prepared to handle cardiac arrest?

A survey of 434 adults was conducted to determine the percentage of persons trained in cardiopulmonary resuscitation (CPR) in Jerusalem. Of the total, 211 (48.6%) indicated they had been trained in CPR. Increased prevalence of CPR training was seen in men under 50 and women under 40 years of age. Half of those surveyed did not know the emergency number for summoning an ambulance, but CPR-trained persons were more likely to know than were nontrained individuals. As has been shown elsewhere, increasing the frequency of bystander-initiated CPR should lead to increased survival from out-of-hospital cardiac arrest.

Early treatment of acute myocardial infarction with intravenous streptokinase. A high-risk syndrome.

Fifty-one successive patients treated with intravenous streptokinase 1.7 +/- 0.8 (mean +/- SD) hours after onset of symptoms of acute myocardial infarction were evaluated during a three-month posthospital follow-up period. Coronary angiography was performed four to nine days after the initial hospital admission. Twenty-eight patients had a second late angiogram. Forty-one patients had successful reperfusion but only 25% of all patients were without significant clinical cardiovascular manifestations during this period. Postmyocardial infarction angina pectoris occurred in 21 patients, an abnormal stress test result was present in 28 patients, eight patients developed congestive heart failure, and five patients had reinfarction. An intervention with percutaneous transluminal coronary angioplasty or coronary artery bypass graft was performed in 15 (37%) of 41 reperfused patients. A significantly higher intervention rate was present in patients treated with streptokinase within one hour following the onset of symptoms. Early reocclusion (within three months of the infarct) was noted in patients with 60% or more residual stenosis in their infarct-related coronary artery. These patients also had a significantly greater incidence of angina pectoris. Our findings indicate that early thrombolytic therapy of acute myocardial infarction preserves myocardium, and since the infarct-related artery is patent, but narrowed, the jeopardized area is responsible for a high-risk syndrome with an increased likelihood of ischemic symptoms. An early aggressive approach may be indicated, especially for patients with greater than 60% residual stenosis in their infarct-related coronary artery.

Should the Mobile Intensive Care Unit respond to pediatric emergencies?

Between October 1982 and October 1985, the Mobile Intensive Care Unit (MICU) in Jerusalem responded to 625 pediatric emergencies, representing 5% of the total MICU case load. The most common medical problem was seizures, diagnosed in 205 cases (33%). The second most frequent group related to trauma (175 cases; 28%). There were 71 cases (11.4%) of cardiac arrest. Resuscitation was attempted in 37, but there were no long-term survivors. Almost all cardiac arrest patients were found in asystole, and most had antecedent serious medical problems. Compared with the adult population, children were less likely to require or benefit from an advanced level of prehospital care. When resources for advanced care are limited, priority should be given to adult emergencies.

Importance of early initiation of intravenous streptokinase therapy for acute myocardial infarction.

The importance of timing of intravenous streptokinase (SK) administration in patients with acute myocardial infarction (AMI) was evaluated. Intravenous SK, 750,000 U, was administered within 4 hours of the onset of ischemic chest pain to 72 consecutive patients having their first AMI. Six days later, cardiac catheterization was performed to calculate global ejection fraction (EF), and computer-derived infarct-related regional EF and dysfunction index were also determined; electrocardiograms were recorded, from which QRS scores could be calculated to estimate infarct size. Of 19 patients who had an anterior AMI, 12 (63%) who received intravenous SK within 2 hours after onset of pain sustained only minimal damage in terms of global EF, infarct-related EF, dysfunction index and QRS score. All 10 patients who received SK 2 to 4 hours after pain onset had large infarcts (p less than 0.001). Of the former group, 11 of 12 patients (91%) whose pain was relieved within 1.5 hours of intravenous SK administration (presumably due to successful reperfusion) had a good outcome, whereas all 7 whose pain lasted longer did poorly (p less than 0.001). Furthermore, among patients with anterior AMI, 11 of 14 (79%) whose pain was relieved within 3.5 hours of onset had small infarcts, compared with none of the 12 patients whose pain lasted longer (p less than 0.0001). In inferior AMI, the critical time between onset of pain and initiation of intravenous SK was 1.5 hours (p less than 0.05). The timing of initiation of thrombolytic therapy and the total pain duration are critical in determining outcome in AMI, and time intervals vary depending on infarct localization.