Visits to home environments by emergency medical services: a statewide study

Understanding out-of-hospital transport demographics would clarify the opportunities for injury surveillance and prevention.

OBJECTIVE

To test the hypotheses that there are demographic differences in home vs. non-home emergency medical services (EMS) scene transports and that among age groups there are differences in demographics.

METHODS

Data were extracted from the EMS State Ambulance Transport database of all reported during 1995. Transports from patient homes were compared with transports from all non-home scenes. Data extracted included age, gender, race, and type of complaint. Subgroup analysis was performed based on age groups in nonvehicular cases, safety problems, and interpersonal violence. Results were compared using a two-tailed chi-square with significance at p<0.05. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated for significant differences.

RESULTS

The study included 118,131 transported patients: 13% were children, 49% were adult between 18 and 64 years, and 38% were elder; 13% were African American, 82% were white, and 5% were other; 47% were male and 53% were female. Fifty-eight percent of the transports were for safety problems, and 17% were for interpersonal violence. Of the 118,131 transports, 56,812 (48%) were from patients' homes and 61,319 were not. Compared with EMS transports from non-home scenes, fewer home EMS transports were for injury (p<0.01, OR = 0.18, 95% CI = 0.17-0.19) and more home EMS transports were for illness (p<0.01, OR = 5.64, 95% CI = 5.49-5.79). There was no clinically significant difference in age, race, or gender. For all non-vehicular injury transports, the reason was more likely safety problems than interpersonal violence (58% vs. 17%); however, there was no difference in the percentages of type of call between the home and non-home transports. Home EMS transports were more likely interpersonal violence problems among adult patients less than 65 years old; however, among the old and young, the problems were more likely to be safety-related.

CONCLUSION

Forty-eight percent of all EMS transports are from the home. Only 18% of these EMS home transports are for injury-related problems. In general, EMS injury transports are more likely related to safety than to interpersonal violence. Among the home EMS transports, more than 50% of transports for young and old patients are safety-related. A large proportion of the home EMS transports for adults less than 65 years of age, however, are for interpersonal violence.

Deep hypothermic circulatory arrest: I. Effects of cooling on electroencephalogram and evoked potentials

BACKGROUND

Deep hypothermia is an important cerebral protectant and is critical in procedures requiring circulatory arrest. The purpose of this study was to determine the factors that influence the neurophysiologic changes during cooling before circulatory arrest, in particular the occurrence of electrocerebral silence.

METHODS

In 109 patients undergoing hypothermic circulatory arrest with neurophysiologic monitoring, five electrophysiologic events were selected for detailed study.

RESULTS

The mean nasopharyngeal temperature when periodic complexes appeared in the electroencephalogram after cooling was 29.6 degrees C +/- 3 degrees C, electroencephalogram burst-suppression appeared at 24.4 degrees C +/- 4 degrees C, and electrocerebral silence appeared at 17.8 degrees C +/- 4 degrees C. The N20-P22 complex of the somatosensory evoked response disappeared at 21.4 degrees C +/- 4 degrees C, and the somatosensory evoked response N13 wave disappeared at 17.3 degrees C +/- 4 degrees C. The temperatures of these various events were not significantly affected by any patient-specific or surgical variables, although the time to cool to electrocerebral silence was prolonged by high hemoglobin concentrations, low arterial partial pressure of carbon dioxide, and by slow cooling rates. Only 60% of patients demonstrated electrocerebral silence by either a nasopharyngeal temperature of 18 degrees C or a cooling time of 30 minutes.

CONCLUSIONS

With the high degree of interpatient variability in these neurophysiologic measures, the only absolute predictors of electrocerebral silence were nasopharyngeal temperature below 12.5 degrees C and cooling longer than 50 minutes.

Breast cancer knowledge and preventive behaviors: An urban emergency department-based survey

OBJECTIVE

To assess general knowledge and preventive behaviors regarding breast cancer among women who present to an urban emergency department.

METHODS

During a six-month study period, a convenience sampling of women aged 21 years and older who were in treatment and waiting areas was surveyed. The anonymous written survey asked about demographic variables, knowledge, and preventive behaviors regarding breast cancer. Knowledge was assessed with questions about the recommended frequency of breast self-examination and the recommended age for first mammography. Performance was assessed by questions about breast self-exam and mammography. Subgroup analysis was done by age (above and below 40 years old), race, income (above and below the median), insurance type, history of breast lump, and family history (FH) of breast cancer.

RESULTS

Four hundred women completed surveys. Two hundred twelve (53%) correctly knew the answers to the two knowledge questions. Knowledge was greater in women with private insurance. Knowledge of the frequency of breast self-exam was significantly greater among whites and Native Americans than among African Americans, Asians, or Hispanics. Stated performance of preventive behaviors was 72% (288) for breast self-exam and for mammography. Preventive behaviors were significantly more likely to be performed by higher-income and privately-insured women. Breast self-exam was more likely to be done in older women, those with a history of a breast lump, and those with a FH of breast cancer.

CONCLUSIONS

Women with lower income and without private insurance were less likely to be knowledgeable and practice preventive measures for detecting breast disease.

Effectiveness of forced air warming after pediatric cardiac surgery employing hypothermic circulatory arrest without cardiopulmonary bypass

STUDY OBJECTIVE

To evaluate the effectiveness of forced-air warming compared to radiant warming in pediatric cardiac surgical patients recovering from moderate hypothermia after perfusionless deep hypothermic circulatory arrest.

DESIGN

Prospective unblinded study. SETIING: Teaching hospitals.

PATIENTS

24 pediatric cardiac surgical patients.

INTERVENTION

Noncyanotic patients undergoing repair of atrial or ventricular septal defects were cooled by topical application of ice and rewarmed initially in the operating room by warm saline lavage of the pleural cavities. On arrival at the intensive care unit (ICU), patients were warmed by forced air (n = 13) or radiant heat (n = 11). The time, heart rate, and blood pressure at each 0.5 degrees C increase in rectal temperature were measured until normothermia (36.5 degrees C) to determine the instantaneous rewarming rate.

MEASUREMENTS AND MAIN RESULTS

Baseline characteristics were not different in the two groups. The mean (+/- SD) age was 5.6 +/- 3.4 years, weight was 20 +/- 8 kg, esophageal temperature for circulatory arrest was 25.7 +/- 1.3 degrees C, and duration of circulatory arrest was 25 +/- 11 minutes. The mean core temperature on arrival at the ICU was 29.9 +/- 1.3 degrees C and ranged from 26.1 to 31.5 degrees C. The mean rewarming rate for each 0.5 degrees C was greater (p < 0.05) for forced-air (2.43 +/- 1.14 degrees C/hr) than radiant heat (2.16 +/- 1.02 degrees C/hr). At core temperatures <33 degrees C, the rewarming rate for forced-air was 2.04 +/- 0.84 degrees C/hr and radiant heat was 1.68 +/- 0.84 degrees C/hr (p < 0.05). At core temperatures > or = 33 degrees C, the rewarming rate for forced air was 2.76 +/- 1.20 degrees C/hr and radiant heat was 2.46 +/- 1.08 degrees C/min (p = 0.07). Significant determinants of the rewarming rate in a multivariate regression model were age (p < 0.001), temperature (p < 0.05), time after arrival to the intensive care unit (p < 0.05), pulse pressure (p < 0. 05) and warming device (p < 0.001). The duration of ventilatory support and ICU length of stay was not different in the two groups.

CONCLUSIONS

Both forced-air and radiant heat were effective for rewarming moderately hypothermic pediatric patients. When core temperature was less than 33 degrees C, the instantaneous rewarming rate by forced air was 21% faster than by radiant heat.

The utility of anoscopy and colposcopy in the evaluation of male sexual assault victims

STUDY OBJECTIVE

We sought to compare the use of anoscopy and colposcopy in examinations of male sexual assault victims and to characterize the demographics of male sexual assault victims.

METHODS

This is a case series of 67 male sexual assault victims evaluated over an 8-year period by the Sexual Assault Forensic Examination team. The setting is a university-based emergency department serving as the primary site for examination of sexual assault victims by trained nurse practitioners and physician's assistants. Police and victims' advocates are available at the time of the examination. Anoscopy was done routinely over the entire study period in all patients with any anal penetration or involvement. Colposcopy use started in 1994 to magnify and take pictures. Patients were categorized into 2 groups. Group 1 consisted of subjects receiving only anoscopy, and group 2 consisted of subjects receiving initial colposcopy. Anoscopy in group 1 and colposcopy in group 2 were compared for positive results. A positive result was defined as an additional finding to those obtained by means of gross examination by using the test being evaluated (anoscopy versus colposcopy). Colposcopy and anoscopy were also compared among the subjects receiving both tests. Groups were compared by using a Pearson chi(2) test.

RESULTS

Sixty-seven male sexual assault victims were evaluated between 1991 and 1998. The average age was 26+/-8 years, and the distribution of races was 30% black, 62% white, and 8% Hispanic. Results of gross examination were positive in 42 (63%) subjects. Four patients did not receive either anoscopy or colposcopy. Of the remaining 63, 25 patients had anoscopy only (group 1), and 38 patients had initial colposcopy (group 2). There were no significant differences in age, race, or rate of positive gross examination results between groups. Findings in addition to those obtained by means of gross examination were revealed by means of anoscopy in 8 (32%) of 25 subjects in group 1 and colposcopy in 3 (8%) of 38 subjects in group 2 (P =.03, difference 24%, 95% confidence interval 4% to 44%). In the 36 subjects who had both examinations, the gross examination revealed at least one finding in 22 (61%). The combination of anoscopy and colposcopy yielded positive findings in 17 subjects, including 4 subjects who had no findings on gross examination (increasing the positive rate to 26/36 [72%]).

CONCLUSION

In male sexual assault victims with anal penetration, anoscopy is significantly better for gathering evidence than is colposcopy. The addition of colposcopy and anoscopy increased the rate of cases with positive findings from 61% to 72%. These 2 methods together may be a valuable adjunct in gathering evidence of damage.

Hemodynamic monitoring of the postoperative adult cardiac surgical patient

Surgery on the central blood pump, the heart, is performed either to prevent homeostatic compromise (ie, coronary artery disease potentially causing myocardial infarction and heart failure) or to treat actual homeostatic imbalance (ie, valvular disease causing heart failure). The cardiovascular homeostatic state is what we generally define as hemodynamics. The heart must deliver adequate oxygen and nutrients to all organs at appropriate pressures to allow optimal organ function. We monitor hemodynamic variables to assess the adequacy of a given cardiac repair and to detect any organ dysfunction that may independently coexist or be intimately related with the cardiac disease or its surgical repair. Hemodynamic monitoring initially relied on vital signs and periodic physical examination. The current monitoring capabilities have field expanded to include systemic and pulmonary arterial pressures, central venous pressures, cardiac output, systemic and pulmonary vascular resistance, and systemic and mixed venous oxygen saturation. These variables reflect a synthesis of global cardiac function and the peripheral or pulmonary vascular state. Arterial blood gas analysis further assesses the adequacy of overall oxygen delivery, carbon dioxide removal and acid-base balance. Echocardiography allows a qualitative and quantitative description of both global and regional cardiac function to better define the cardiac components of any hemodynamic state.

Gender differences in state-wide EMS transports

There are gender differences in emergency medical services (EMS) transports and management based on diagnosis. Data were extracted from the EMS State Ambulance Transport database. This database exists because of a legal requirement that all EMS transports generated by 911 calls and all interhospital transports be reported to the State EMS Bureau. All ambulance transports reported to the State EMS Division during 1995 were evaluated. Cases were excluded if they were aborted, admission or discharge transports, outpatient transports, or cases listed as "other" without a diagnosis. Gender-related treatment differences were determined for problems for which EMTs have specific treatment options. These were cardiac arrest, chest pain, allergic reactions, and extremity fractures. Results were compared using a two-tailed Chi squared or Fischer's Exact with significance at P < .05. Odds Ratios (OR) and 95% confidence intervals (CIs) were calculated. There were a total of 164,595 ambulance transports reported to the State EMS Division. Of these 76,074 (46%) were men and 88,521 (54%) were women. Of these, 50,211 were excluded. This left 52,607 injury transport and 61,777 illnesses transport. Men were significantly more likely than women to have injuries related to all-terrain vehicle accidents, motorcycle accidents, RV accidents, burns, gunshot wounds, and stab wounds. Men were significantly more likely than women to have illnesses related to cardiac arrest, dead on arrivals (DOAs), drowning, and smoke inhalation. For cardiac arrest transports, significantly more male patients presented ventricular fibrillation, more males received defibrillation, lidocaine, and bicarbonate, but more women received atropine. Male chest pain patients were more likely to receive oxygen and morphine and less likely to receive nitroglycerin. Male allergic reaction patients were more likely to receive an i.v. and subcutaneous epinephrine. Male extremity fracture patients were more likely to get an i.v. line, but there was no difference in morphine use or splinting. There are numerous disease-specific gender differences in the demographics of illness and injury transported by EMS. The use of various medications and procedures may also be related to gender. Understanding these differences may help in preparing EMS professionals for patient management.

Domestic violence awareness in a medical school class: 2-year follow-up

BACKGROUND

[corrected] Previous studies have examined short-term effectiveness of domestic violence instruction. We studied the long-term effectiveness (LTE) and long-term retention (LTR) of formal instruction about domestic violence.

METHODS

A general knowledge survey on domestic violence was given before, 1 month after, and 2 years after 3 hours of instruction to medical students. Good LTE was defined as significant improvement in responses between the first and third surveys. Good LTR was defined as lack of a significant decrease in results between the second and third surveys.

RESULTS

Two years after the instruction, 104 of 148 (70%) participated. Knowledge of rates of domestic violence against women showed neither good LTE nor good LTR. Responses showed good LTE and LTR concerning domestic violence incidence among men, ethnic and socioeconomic groups being equally represented, victims not being personally responsible for the abuse, and physicians not being required to report domestic violence in the survey state. Responses showed poor LTR and LTE regarding rates of domestic violence in women and abused persons being unable to simply leave their situation.

CONCLUSIONS

Some improvement in domestic violence awareness was seen 2 years after instruction. However, some information was not retained. Domestic violence instruction should be reemphasized throughout medical school.

The effect of prior hypothermia on the physiological response to norepinephrine

OBJECTIVE

this study determines the effect of prior hypothermia on the cardiovascular responses to norepinephrine (NE) after rewarming.

METHODS

the experiment was a 2x2 controlled design with four groups of feline animals. The two variables were the presence or absence of previous cooling, and the use or non-use of NE after rewarming. During the 'cooling' phase, animals were either cooled using an external arterial-venous femoral shunt to 30 degrees C or maintained at 37 degrees C. After 'rewarming' animals were stratified to receive either NE at rates to deliver 0.2, 1.0 or 5 microg/kg per h or normal saline infusions. Animals were instrumented to measure mean arterial pressure (MAP) and cardiac output (CO) and systemic vascular resistance (SVR) was calculated.

RESULTS

there were no differences between groups at baseline and low dose NE (0.2 microg/kg per min). At 1.0 microg/kg per min, NE caused a significant increase in CO (P<0.01) and no effect of MAP or SVR in the rewarmed animals when compared with normothermic controls. In rewarmed animals 5.0 microg/kg per min NE caused a significant increase in CO (P<0.01) and no effect on MAP or SVR. In normothermic controls there was a significant increase in SVR (P=0.02) and MAP (P=0.05) and no effect on CO.

CONCLUSION

this study shows that the effect of prior hypothermia on cardiovascular responses to moderate and high doses of NE is an improved CO with no affect on SVR and MAP. This could alter the clinical utility of NE in this situation.

Regulation of membrane type-1 matrix metalloproteinase activation by proprotein convertases

Membrane type-1 matrix metalloproteinase (MT1-MMP) is the prototypical member of a subgroup of membrane-anchored proteinases that belong to the matrix metalloproteinase family. Although synthesized as a zymogen, MT1-MMP plays an essential role in extracellular matrix remodeling after an undefined process that unmasks its catalytic domain. We now report the existence of a proprotein convertase-MT1-MMP axis that regulates the processing and functional activity of the metalloproteinase. Two sets of basic motifs in the propeptide region of MT1-MMP are identified that potentially can be recognized by the proprotein convertase family of subtilisin-like proteases. Processing of proMT1-MMP as well as the expression of its proteolytic activity were blocked by mutating these recognition motifs or by inhibiting the proprotein convertases furin and PC6 with the serpin-based inhibitor alpha(1) antitrypsin Portland. Furthermore, both furin-dependent and furin-independent MT1-MMP processing pathways are identified that require tethering of the metalloproteinase to the cell surface. These findings demonstrate the existence of a proprotein convertase-MT1-MMP axis that can regulate extracellular matrix remodeling.

Stimulus compounding enhances conditioned suppression produced by cocaine-paired stimuli

When 2 stimuli that occasion cocaine self-administration are presented in compound, their ability to increase cocaine-reinforced operant responding is substantially enhanced. The goal of the present experiment was to determine whether stimulus compounding could produce analogous enhancements of a classically conditioned drug effect. Food-maintained responding in rats was suppressed by a tone and a light that were individually paired with response-independent cocaine (3 mg/kg iv). This conditioned suppression was significantly enhanced when the stimuli were presented together in a stimulus-compounding test. The magnitude of this enhancement was similar to that in previous studies in which responding was suppressed by shock-paired stimuli. These results demonstrate that multiple drug-related cues interact in a predictable manner to influence both operant and classically conditioned behavior.

Blood pressure in acute vaso-occlusive crises of sickle cell disease

OBJECTIVE

We compared blood pressure (BP) in patients with sickle cell disease (SCD)-related crises and black patients without SCD.

METHODS

We retrospectively reviewed charts of emergency department (ED) patients with SCD crises in a 2-year period, recording BPs and demographic and SCD data. A cohort of consecutive black patients without SCD was compared.

RESULTS

Included were 459 SCD-related visits, 187 by men and 272 by women, representing 106 patients. Women had significantly lower BP than men, diastolic BP was significantly lower in patients with hemoglobin SS disease than in those with hemoglobin SC disease, and systolic BP was significantly lower in patients with bilateral versus unilateral pain. One SCD patient had a history of hypertension. The 125 non-SCD patients, excluding 25 with a history of hypertension, had significantly higher systolic and diastolic BP than patients in SCD crisis.

CONCLUSION

No patients seen in SCD crisis were hypertensive. Patients who were female, had SS disease, or had bilateral pain had lower BP. Significantly higher BP and more hypertension occurred in black patients without SCD.

Spontaneous splenic rupture due to subcutaneous heparin therapy

We report a case of spontaneous splenic rupture in a 59-year-old woman who was receiving 15,000 units of heparin subcutaneously (s.c. ) twice a day for deep venous thrombosis (DVT) prophylaxis. Her past medical history included multiple DVT, pulmonary emboli, and ovarian cancer stage III-C with known ascites. The diagnosis of splenic rupture was initially missed because of the ascites. This case illustrates both a previously undescribed complication of s.c. heparin therapy and a failure of ultrasound diagnosis. We emphasize the unique presentation, difficulty in diagnosis, and need for early surgical involvement to ensure the most favorable outcome.

EMT domestic violence knowledge and the results of an educational intervention

The objective of this study was to determine levels of knowledge regarding domestic violence (DV), and the effectiveness of formal instruction about DV. A general knowledge survey of DV was given before and approximately 4 to 6 months after 3 hours of instruction given by Emergency Medicine and Law Enforcement faculty. A Emergency medical service (EMS) consisting of 73% paramedic-level providers in a metropolitan urban/suburban area. Differences in DV knowledge before and after the instruction were the main outcome measures. In the preinstruction series, 46 emergency medical technicians (EMTs) participated. After the instruction 19 EMTs participated (42%). Thirty-five percent of EMTs before instruction and 37% after instruction correctly identified the prevalence of DV against women as 15% to 30%. Thirty-five percent of EMTs before instruction and 63% after instruction (P < .05) correctly identified the prevalence of DV against men as 0% to 15%. Before instruction 54% knew that DV is equal among races, and 79% after instruction (P < .05). Before instruction 37% of EMTs knew that DV is equal in different socioeconomic groups and 68% after instruction (P < .05). The percent of EMTs who knew that the victim is not responsible for the abuse was 50% before instruction and 89% after instruction (P < .05). Before instruction, the results on a knowledge questionnaire were 54% correct, after instruction, results improved to 71% correct. Improvement in understanding of DV was shown for 4 of 11 questions after 3 hours of instruction. These results indicate the need for more instruction on DV for EMTs.

Intra-aortic balloon pump associated with dynamic left ventricular outflow tract obstruction after valve replacement for aortic stenosis

An unstable patient with critical aortic stenosis had an intra-aortic balloon pump placed preoperatively for hemodynamic support and alleviation of symptoms. After separation from cardiopulmonary bypass following aortic valve replacement, the patient was hypotensive with increased pulmonary artery pressures. Transesophageal echocardiography revealed left ventricular outflow tract obstruction associated with systolic anterior motion of the mitral valve and severe mitral regurgitation. This pathophysiology was present when ventricular systole was preceded by balloon counterpulsation, but was absent during unassisted systole. This case report demonstrates a potentially significant untoward effect of intra-aortic balloon pump augmentation after aortic valve replacement for aortic stenosis. The timely diagnosis of this iatrogenic condition in the operating room permitted the prompt implementation of appropriate management strategies and avoided unnecessary surgical intervention.

Effects of compounding drug-related stimuli: escalation of heroin self-administration

Previous experiments have demonstrated that presenting independently established discriminative stimuli in compound can substantially increase operant responding maintained by food reinforcement or shock avoidance. Recently, this phenomenon was also shown to occur with cocaine self-administration. The present study further assessed the generality of these stimulus-compounding effects by systematically replicating them with heroin self-administration. Rats' nose-poke responses produced intravenous heroin (0.025 mg/kg per infusion) on a variable-ratio schedule when either a tone or a light was present. In the absence of these stimuli, responding was not reinforced. Once discriminative control by the tone and light had been established, the stimuli were presented in compound under extinction (with heroin discontinued) or maintenance conditions (with heroin available during test-stimulus presentations). In extinction, the tone-light compound increased responding approximately threefold compared to tone or light alone. Under maintenance conditions, compounding increased heroin intake approximately twofold. These effects closely matched those obtained earlier with cocaine. This consistency across pharmacological classes and across drug and nondrug reinforcers further confirms that (a) self-administered drugs support conditioning and learning in a manner similar to that supported by other reinforcers; and (b) multiple drug-related cues interact in lawful and predictable ways to affect drug seeking and consumption.

Domestic violence in a university emergency department

BACKGROUND

We attempted to determine the prevalence and demographics of domestic violence (DV) among male and female patients in a university emergency department (ED).

METHODS

The validated Index of Spouse Abuse (ISA) was used. Patients aged 18 years or older seen during 28 randomly selected 4-hour shifts were eligible.

RESULTS

Of the 97 participants in the study, 57 were female. One man and 3 women were victims of present physical DV, with 1 male and 2 female victims of present nonphysical abuse. Three of the 40 men and 22 of the 57 women had been victims of past physical violence. One man and 15 women had been victims of past nonphysical abuse. Alcohol use, suicidal ideation, family history, and psychiatric history were all strongly correlated with DV.

CONCLUSIONS

The prevalence of DV past was significantly higher in the females. Present violence was more rare and less than that reported in other ED studies.

Nicardipine intravenous bolus dosing for acutely decreasing arterial blood pressure during general anesthesia for cardiac operations: pharmacokinetics, pharmacodynamics, and associated effects on left ventricular function

The objective of this study was to evaluate the efficacy of nicardipine, a dihydropyridine calcium channel antagonist, administered as an IV bolus dose to acutely decrease arterial pressure in anesthetized cardiac surgical patients. We performed a double-blind, randomized, self-controlled, dose-ranging study in 40 adult cardiac surgical patients to determine the pharmacokinetics and pharmacodynamics of nicardipine 0.25 mg, 0.50 mg, 1.00 mg, and 2.00 mg administered as an IV bolus. Transesophageal echocardiography was used to assess left ventricular preload, afterload, and global systolic function. Plasma nicardipine concentration was measured using high-performance liquid chromatography. Nicardipine selectively decreased arterial pressure in a dose-dependent manner with a maximum response within 100 s and recovery to half the maximum response within 3-7 min without associated changes in heart rate. The decreases in arterial pressure were associated with only small decreases in left ventricular end-systolic wall stress and small increases in global left ventricular systolic function without changes in left ventricular end-diastolic cavity area or cardiac output. The time course for nicardipine bolus was consistent with a two-compartment pharmacokinetic model with rapid redistribution from a small central compartment.

IMPLICATIONS

Nicardipine was effective for selectively decreasing arterial blood pressure acutely, but had no effects on ventricular preload or cardiac output. The absence of dose-dependent changes in cardiac output, left ventricular systolic performance, and left ventricular afterload despite significant decreases in arterial pressure suggested that nicardipine had a small negative inotropic action.