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Allen BR, Ashburn NP, Snavely AC, Paradee BE, Christenson RH, Nowak RM, Mumma BE, Madsen T, O'Neill JC, Stopyra JP, Mahler SA. Age and the European Society of Cardiology 0/1-hour high sensitivity troponin T algorithm for the evaluation of patients with possible acute myocardial infarction: results from the STOP-CP study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The European Society of Cardiology (ESC) 0/1-hour high sensitivity troponin (hs-cTn) algorithm is widely used in the evaluation of patients presenting to the Emergency Department (ED) with symptoms suspicious for non ST-segment elevation myocardial infarction (NSTEMI). The effect of increasing patient age with its use has not been studied in any detail.
Purpose
The objective of this secondary analysis of the STOP-CP (High Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification) United States (US) multicenter study was to evaluate the efficacy and safety of use of the ESC 0/1-hour hs-cTnT algorithm in younger, middle-aged, and older patients.
Methods
Patients (≥21 years old) presenting to the (ED) with symptoms suggestive of NSTEMI were enrolled (1/25/2017–9/6/2018) at 8 US medical centers. The ESC hs-cTnT 0/1-hour hs-cTnT algorithm was used to place patients into rule-out, observe, and rule-in NSTEMI zones. Algorithm performance for rapid NSTEMI rule-out and 30-day adverse outcomes was studied in 3 patient age (years) intervals: younger (21–45). middle aged (46–64) and older (≥65). Major adverse cardiovascular events (MACE) consisted of cardiac death, myocardial infarction, or coronary revascularization at 30-days. Fisher's exact tests were used to compare NSTEMI ruled out and MACE rates between patient age intervals. Negative likelihood ratios (NLR) with 95% confidence interval (CI) were calculated for 30-day MACE.
Results
Overall 1430 participants were enrolled with 15.7% (224/1430) young, 57.4% (821/1430) middle-aged, and 26.9% (385/1430) being older. The ESC 0/1 hour hs-cTnT algorithm NSTEMI rule-out rates were 79.9% (179/224), 62.1% (510/821) and 35.6% (137/385) respectively for these age groups (p<0.0001). The overall 30-day MACE rate was 14.2% (203/1430) with interval age rates of 7.1% (16/224) in younger, 13.1% (108/821) middle aged and 20.5% (79/385) older patients. Amongst NSTEMI ruled-out patients MACE occurred in 1.1% (2/179) of younger, 3.3% (17/510) middle aged and 2.9% (4/137) older individuals (p=0.320). NLR for 30-day MACE was 0.15 (95% CI 0.04, −0.54) in younger, 0.23 (95% CI 0.15–0.35) middle aged and 0.12 (95% CI 0.04–0.31) for older patients.
Conclusions
With increasing age ED patients were less often rapidly ruled out for NSTEMI during their initial cardiac evaluations. The STOP-CP US study demonstrated that older age interval alone was not an independent variable that increased the risk for 30-day MACE in patients ruled out for NSTEMI using the ESC 0/1 hour hs-cTnT algorithm. Our report suggests that cardiac risk stratification scores using age as an independent variable for predicting 30-day MACE in these patients require reevaluation.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Roche, Basel, Switzerland
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Affiliation(s)
- B R Allen
- University of Florida , Gainesville , United States of America
| | - N P Ashburn
- Wake Forest University , Winston-Salem , United States of America
| | - A C Snavely
- Wake Forest University , Winston-Salem , United States of America
| | - B E Paradee
- Wake Forest University , Winston-Salem , United States of America
| | - R H Christenson
- University of Maryland , Baltimore , United States of America
| | - R M Nowak
- Henry Ford Health System , Detroit , United States of America
| | - B E Mumma
- University of California , Davis , United States of America
| | - T Madsen
- University of Utah , Salt Lake City , United States of America
| | - J C O'Neill
- Wake Forest University , Winston-Salem , United States of America
| | - J P Stopyra
- Wake Forest University , Winston-Salem , United States of America
| | - S A Mahler
- Wake Forest University , Winston-Salem , United States of America
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Nowak RM, Jacobsen G, Cook B, Linoj S, Moyer M, Lanfear D. High sensitivity troponin I and newly/recently diagnosed coronavirus-19 disease patients presenting to the emergency department: values above and below the 99th percentile predict 28 day mortality. Eur Heart J 2022. [PMCID: PMC9619671 DOI: 10.1093/eurheartj/ehac544.2286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Studies indicate that the presence of cardiac injury [troponin level > the 99th percentile upper reference limit (99th % URL) using mostly contemporary assays] is predictive of death within 30 days during hospitalization of coronavirus disease 2019 (COVID-19) patients. Troponin measurements in these reports were ordered and/or resulted in the Emergency Department (ED) or during various times after hospital admission and not all patients were followed for 30 days. Purpose Our objective was to determine the 28 day survival prognostic value of Emergency Department (ED) resulted high sensitivity cardiac troponin I (hs-cTnI) measurements in all COVID-19 patients including those discharged after their ED visit or hospitalization. Methods An ED centric electronic database of COVID-19 patients (nasopharyngeal swab testing within 1 week prior to or during the ED visit) having at least 1 hs-cTnI (Beckman Coulter, Brea, CA; level of quantitation (LoQ) 4ng/L, non sex specific 99th % URL 18 ng/L) value reported during a visit to an urban, academic ED in the United States was constructed. All patients were followed for 28 days and Kaplan Meir survival curves constructed amongst predetermined initial hs-cTnI value intervals. Results From March 16-November 2, 2020 1476 consecutive ED COVID-19 patients were identified with 1044 (70.7%) having at least 1 hs-cTnI value resulted in the ED. Patients' mean age and body mass index were 60.8±16.1 years and 32.4±11.3 kg/m2 respectively. 531 (50.9%) were male, 804 (77.0%) self-identified as African American and 615 (58.9%) had 2 or more comorbidities with hypertension (42.5%), diabetes (37.4%) and hyperlipidemia (27.23%) commonest. Frequent primary presenting complaints were shortness of breath (37.7%), fever/chills (14.5%) and cough (11.9%). Hs-cTnI interval values were: 147 (14.1%) <4 (LoQ), 359 (34.4%) 4–10 and 151 (14.5%) 11–18 ng/L. Hs-cTnI values were >99th % URL in 387 (37.1%) patients with 230 (22.0%) 19–54, 63 (6.0%) 54–99 and 94 (9.0%) ≥100 (laboratory reported critical value) ng/L. 145 (13.9%) patients were discharged directly home and 2 (0.2%) died in the ED. 147 (14.1%) were admitted to an ICU with 104 (70.7%) dying. Each of the interval initial ED hs-cTnI values was associated with a different (p<0.001) 28 day survival curve. Conclusions Most COVID-19 patients had a hs-cTnI value obtained with 85.9% of these >4 ng/L. No one with an initial hs-cTnI <4 ng/L died within 28 days while increasing presenting hs-cTnI values >4 ng/L were associated with decreased 28 day survival. Our findings indicate that in COVID-19 patients detectable initial ED hs-cTnI values, whether reaching thresholds for cardiac injury or not, are highly prognostic of 28 day survival. Studies are needed to better define how hs-cTnI values could alter early management of COVID-19 disease to improve outcomes for these patients. Funding Acknowledgement Type of funding sources: Private hospital(s). Main funding source(s): Henry Ford Health System Department of Emergency Medicine
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Affiliation(s)
- R M Nowak
- Henry Ford Health System , Detroit , United States of America
| | - G Jacobsen
- Henry Ford Health System , Detroit , United States of America
| | - B Cook
- Henry Ford Health System , Detroit , United States of America
| | - S Linoj
- Henry Ford Health System , Detroit , United States of America
| | - M Moyer
- Henry Ford Health System , Detroit , United States of America
| | - D Lanfear
- Henry Ford Health System , Detroit , United States of America
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Nowak RM, O'Neill JC, Ashburn NP, Snavely AC, Paradee BE, Allen BR, Christenson RH, Mumma BE, Madsen T, Stopyra JP, Mahler SA. Patients with known coronary artery disease who are ruled out for acute myocardial infarction using a high sensitivity troponin T 0/1-hour algorithm have increased 30-day major adverse cardiac events. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The European Society of Cardiology (ESC) 0/1-hour high sensitivity troponin (hs-cTn) algorithm is widely used in the evaluation of patients presenting to the Emergency Department (ED) with symptoms suspicious for non ST-segment elevation myocardial infarction (NSTEMI). There is limited data available for the use of this algorithm comparing NSTEMI rule-out rates and 30-day adverse outcomes in patients with and without known coronary artery disease (CA), defined as prior myocardial infarction [MI], coronary revascularization, or ≥70% coronary stenosis.
Purpose
The objective of this secondary analysis of the STOP-CP (High Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification) United States (US) multicenter study was to compare the ESC 0/1-hour algorithm for rapid NSTEMI rule-out and 30-day adverse outcomes in patients with and without known CAD.
Methods
Patients (≥21 years old) presenting to the (ED) with symptoms suggestive of NSTEMI were enrolled (1/25/2017–9/6/2018) at 8 US medical centers. The ESC hs-cTnT 0/1-hour hs-cTnT algorithm was used to stratify patients into rule-out, observe, and rule-in zones. Algorithm performance for 30-day adverse outcomes was analyzed in patients with or without known CAD. Major adverse cardiovascular events (MACE) consisted of cardiac death, MI, or coronary revascularization. Fisher's exact tests were used to compare NSTEMI rule-out and 30-day MACE rates in patients with and without known CAD. Negative likelihood ratios (NLR) with a 95% confidence interval (CI) were calculated for 30-day MACE.
Results
Overall 1430 patients were enrolled. Of these 31.4% (449/1430) had known CAD while 14.2% (203 /1430) experienced 30-day MACE. Using the ESC 0/1-hour hs-cTnT algorithm 39.6% (178/449) of patients with known CAD were placed in the rule-out zone compared to 66.1% (648/981) without CAD (p<0.0001). Of patients with known CAD 23.2% (104/449) had 30-day MACE compared to 10.1% (99/981) of those without known CAD (p<0.0001). Additionally, amongst those patients placed in the rule-out zone, 30-day MACE occurred in 7.9% (14/178) of individuals with known CAD and 1.4% (9/648) of those without known CAD (p<0.0001). NLR for 30-day MACE was 0.28 (95% CI 0.17–0.47) in patients with known CAD and 0.13 (95% CI 0.07–0.23) in those without CAD.
Conclusions
In the multicenter US STOP-CP study patients with known CAD were less often rapidly ruled out for NSTEMI and had higher 30-day MACE rates than those without known CAD. Patients with known CAD who were rapidly ruled out for NSTEMI had a higher 30-day MACE rate compared to those without known CAD. Our analysis suggests that patients with known CAD require further cardiac reevaluations whether they are ruled out for NSTEMI by the ESC 0/1 hour hs-cTnT algorithm or not.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Roche, Basel, Switzerland
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Affiliation(s)
- R M Nowak
- Henry Ford Health System , Detroit , United States of America
| | - J C O'Neill
- Wake Forest University , Winston-Salem , United States of America
| | - N P Ashburn
- Wake Forest University , Winston-Salem , United States of America
| | - A C Snavely
- Wake Forest University , Winston-Salem , United States of America
| | - B E Paradee
- Wake Forest University , Winston-Salem , United States of America
| | - B R Allen
- University of Florida , Gainesville , United States of America
| | - R H Christenson
- University of Maryland , Baltimore , United States of America
| | - B E Mumma
- University of California , Davis , United States of America
| | - T Madsen
- University of Utah , Salt Lake City , United States of America
| | - J P Stopyra
- Wake Forest University , Winston-Salem , United States of America
| | - S A Mahler
- Wake Forest University , Winston-Salem , United States of America
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Cross RW, Xu R, Matassov D, Hamm S, Latham TE, Gerardi CS, Nowak RM, Geisbert JB, Ota-Setlik A, Agans KN, Luckay A, Witko SE, Soukieh L, Deer DJ, Mire CE, Feldmann H, Happi C, Fenton KA, Eldridge JH, Geisbert TW. Quadrivalent VesiculoVax vaccine protects nonhuman primates from viral-induced hemorrhagic fever and death. J Clin Invest 2020; 130:539-551. [PMID: 31820871 PMCID: PMC6934204 DOI: 10.1172/jci131958] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/10/2019] [Indexed: 02/04/2023] Open
Abstract
Recent occurrences of filoviruses and the arenavirus Lassa virus (LASV) in overlapping endemic areas of Africa highlight the need for a prophylactic vaccine that would confer protection against all of these viruses that cause lethal hemorrhagic fever (HF). We developed a quadrivalent formulation of VesiculoVax that contains recombinant vesicular stomatitis virus (rVSV) vectors expressing filovirus glycoproteins and that also contains a rVSV vector expressing the glycoprotein of a lineage IV strain of LASV. Cynomolgus macaques were vaccinated twice with the quadrivalent formulation, followed by challenge 28 days after the boost vaccination with each of the 3 corresponding filoviruses (Ebola, Sudan, Marburg) or a heterologous contemporary lineage II strain of LASV. Serum IgG and neutralizing antibody responses specific for all 4 glycoproteins were detected in all vaccinated animals. A modest and balanced cell-mediated immune response specific for the glycoproteins was also detected in most of the vaccinated macaques. Regardless of the level of total glycoprotein-specific immune response detected after vaccination, all immunized animals were protected from disease and death following lethal challenges. These findings indicate that vaccination with attenuated rVSV vectors each expressing a single HF virus glycoprotein may provide protection against those filoviruses and LASV most commonly responsible for outbreaks of severe HF in Africa.
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Affiliation(s)
- Robert W. Cross
- Galveston National Laboratory and
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, Texas, USA
| | | | | | - Stefan Hamm
- Department of Viral Vaccine Discovery, Profectus BioSciences Inc., Pearl River, New York, USA
| | | | | | - Rebecca M. Nowak
- Department of Viral Vaccine Discovery, Profectus BioSciences Inc., Pearl River, New York, USA
| | - Joan B. Geisbert
- Galveston National Laboratory and
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, Texas, USA
| | | | - Krystle N. Agans
- Galveston National Laboratory and
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, Texas, USA
| | | | | | | | - Daniel J. Deer
- Galveston National Laboratory and
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Chad E. Mire
- Galveston National Laboratory and
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Heinz Feldmann
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Hamilton, Montana, USA
| | - Christian Happi
- Department of Biological Sciences and African Center of Excellence for Genomics of Infectious Diseases, Redeemer’s University, Edo, Nigeria
| | - Karla A. Fenton
- Galveston National Laboratory and
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, Texas, USA
| | - John H. Eldridge
- Department of Immunology
- Department of Viral Vaccine Development, and
- Department of Viral Vaccine Discovery, Profectus BioSciences Inc., Pearl River, New York, USA
| | - Thomas W. Geisbert
- Galveston National Laboratory and
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, Texas, USA
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Witko SE, Kotash CS, Nowak RM, Johnson JE, Boutilier LAC, Melville KJ, Heron SG, Clarke DK, Abramovitz AS, Hendry RM, Sidhu MS, Udem SA, Parks CL. An efficient helper-virus-free method for rescue of recombinant paramyxoviruses and rhadoviruses from a cell line suitable for vaccine development. J Virol Methods 2006; 135:91-101. [PMID: 16569439 DOI: 10.1016/j.jviromet.2006.02.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2005] [Revised: 02/13/2006] [Accepted: 02/20/2006] [Indexed: 11/18/2022]
Abstract
Recovery of recombinant, negative-strand, nonsegmented RNA viruses from a genomic cDNA clone requires a rescue system that promotes de novo assembly of a functional ribonucleoprotein (RNP) complex in the cell cytoplasm. This is accomplished typically by cotransfecting permissive cells with multiple plasmids that encode the positive-sense genomic RNA, the nucleocapsid protein (N or NP), and the two subunits of the viral RNA-dependent RNA polymerase (L and P). The transfected plasmids are transcribed in the cell cytoplasm by phage T7 RNA polymerase (T7 RNAP), which usually is supplied by infection with a recombinant vaccinia virus or through use of a stable cell line that expresses the polymerase. Although both methods of providing T7 RNAP are effective neither is ideal for viral vaccine development for a number of reasons. Therefore, it was necessary to modify existing technology to make it possible to routinely rescue a variety of recombinant viruses when T7 RNAP was provided by a cotransfected expression plasmid. Development of a broadly applicable procedure required optimization of the helper-virus-free methodology, which resulted in several modifications that improved rescue efficiency such as inclusion of plasmids encoding viral glycoproteins and matrix protein, heat shock treatment, and use of electroporation. The combined effect of these enhancements produced several important benefits including: (1) a helper-virus-free methodology capable of rescuing a diverse variety of paramyxoviruses and recombinant vesicular stomatitis virus (rVSV); (2) methodology that functioned effectively when using Vero cells, a suitable substrate for vaccine production; and (3) a method that enabled rescue of highly attenuated recombinant viruses, which had proven refractory to rescue using published procedures.
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Affiliation(s)
- Susan E Witko
- Wyeth Vaccines Research, 401 North Middletown Road, Pearl River, NY 10965, USA
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Parks CL, Wang HP, Kovacs GR, Vasilakis N, Kowalski J, Nowak RM, Lerch RA, Walpita P, Sidhu MS, Udem SA. Expression of a foreign gene by recombinant canine distemper virus recovered from cloned DNAs. Virus Res 2002; 83:131-47. [PMID: 11864746 DOI: 10.1016/s0168-1702(01)00430-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A canine distemper virus (CDV) genomic cDNA clone and expression plasmids required to establish a CDV rescue system were generated from a laboratory-adapted strain of the Onderstepoort vaccine virus. In addition, a CDV minireplicon was prepared and used in transient expression studies performed to identify optimal virus rescue conditions. Results from the transient expression experiments indicated that minireplicon-encoded reporter gene activity was increased when transfected cell cultures were maintained at 32 rather than 37 degrees C, and when the cellular stress response was induced by heat shock. Applying these findings to rescue of recombinant CDV (rCDV) resulted in efficient recovery of virus after transfected HEp2 or A549 cells were co-cultured with Vero cell monolayers. Nucleotide sequence determination and analysis of restriction site polymorphisms confirmed that rescued virus was rCDV. A rCDV strain also was engineered that contained the luciferase gene inserted between the P and M genes; this virus directed high levels of luciferase expression in infected cells.
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Affiliation(s)
- Christopher L Parks
- Wyeth-Lederle Vaccines, Department of Viral Vaccine Research, 401 North Middletown Road, Pearl River, NY 10965, USA
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McCord J, Nowak RM, McCullough PA, Foreback C, Borzak S, Tokarski G, Tomlanovich MC, Jacobsen G, Weaver WD. Ninety-minute exclusion of acute myocardial infarction by use of quantitative point-of-care testing of myoglobin and troponin I. Circulation 2001; 104:1483-8. [PMID: 11571240 DOI: 10.1161/hc3801.096336] [Citation(s) in RCA: 205] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Diagnostic strategies with ECG and serum cardiac markers have been used to rule out acute myocardial infarction in 6 to 12 hours. The present study evaluated whether a multimarker strategy that used point-of-care measurement of myoglobin, creatine kinase (CK)-MB, and troponin I could exclude acute myocardial infarction in </=3 hours. METHODS AND RESULTS We prospectively enrolled consecutive patients (n=817) in the emergency department who were evaluated for possible acute myocardial infarction. In patients with nondiagnostic ECGs, we measured CK-MB, troponin I, and myoglobin with a point-of-care device at presentation and at 90 minutes, 3 hours, and 9 hours. Standard central laboratory testing of CK-MB was done at the same time intervals, and triage decisions were made by emergency physicians who were unaware of point-of-care results. Sensitivity and negative predictive value were compared for both the multimarker, point-of-care approach and the central laboratory strategy. Sensitivity and negative predictive value for point-of-care combination of myoglobin and troponin I by 90 minutes was 96.9% and 99.6%, respectively. CK-MB measurements and blood sampling at 3 hours did not improve sensitivity or negative predictive value. Median time from sampling to reporting of results was 71.0 minutes for the central laboratory versus 24.0 minutes for the point-of-care device (P<0.001). CONCLUSIONS Acute myocardial infarction can be excluded rapidly in the emergency department by use of point-of-care measurements of myoglobin and troponin I during the first 90 minutes after presentation.
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Affiliation(s)
- J McCord
- Henry Ford Hospital Center, 2799 W Grand Blvd, Detroit, MI 48202, USA.
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Tokarski GF, Kahler J, Khoury N, Tomlanovich MC, Nowak RM. 8,874 critical decision unit admissions: What are appropriate admission and discharge rates? Ann Emerg Med 1999. [DOI: 10.1016/s0196-0644(99)80156-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
A main tenet of the National Asthma Education and Prevention Program's approach is to integrate proper management of acute asthma into overall asthma care. Accordingly, we maintain that emergency physicians should be aware of emerging chronic management strategies, especially newer treatment regimens, so as to understand pre-ED treatments, provide optimum ED care, and make appropriate prescriptions and referral on discharge. This commentary discusses limitations to the new guidelines and identifies important areas for further study.
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Affiliation(s)
- S D Emond
- Department of Emergency Medicine, St Luke's-Roosevelt Hospital Center, New York, NY, USA
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10
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Abstract
Numerous clinical guidelines have been promoted to help improve the management of acute injury and illness. In November 1997, the National Asthma Education and Prevention Program released the final version of its comprehensive second Expert Panel Report, designed to distill scientific advances in asthma care and provide a set of practical tools to help guide clinician and patient decisions. The panel's recommendations for acute asthma care stress the use of the objective measures of pulmonary function to assess severity, aggressive inhaled beta 2-agonist therapy, early systemic corticosteroid administration, and early disposition decisions. This article provides a focused overview of the 146-page document and highlights aspects of the new guidelines of particular importance to emergency physicians.
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Affiliation(s)
- S D Emond
- Department of Emergency Medicine, St Luke's-Roosevelt Hospital Center, New York, NY, USA
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Martin GB, Rivers EP, Paradis NA, Goetting MG, Morris DC, Nowak RM. Emergency department cardiopulmonary bypass in the treatment of human cardiac arrest. Chest 1998; 113:743-51. [PMID: 9515852 DOI: 10.1378/chest.113.3.743] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To study the use of emergency department (ED) femoro-femoral cardiopulmonary bypass (CPB) in the resuscitation of medical cardiac arrest patients. DESIGN Prospective, uncontrolled trial. SETTING Urban academic ED staffed with board-certified emergency physicians (EPs). PARTICIPANTS Ten patients with medical cardiac arrest unresponsive to standard therapy. INTERVENTIONS Femoro-femoral CPB instituted by EPs. RESULTS The time of cardiac arrest prior to CPB (mean+/-SD) was 32.0+/-13.6 min. The cardiac output while on CPB was 4.09+/-1.03 L/min with an average of 229+/-111 min on bypass. All 10 patients had resumption of spontaneous cardiac activity while on CPB. Seven of these were weaned from CPB with intrinsic spontaneous circulation. Of these, six patients were transferred from the ED to the operating room for cannula removal and vessel repair while the other patient died in the ED soon after discontinuing CPB. Mean survival was 47.8+/-44.7 h in the six patients leaving the ED. Although these patients had successful hemodynamic resuscitation, there were no long-term survivors. CONCLUSION CPB instituted by EPs is feasible and effective for the hemodynamic resuscitation of cardiac arrest patients unresponsive to advanced cardiac life support therapy. Future efforts need to focus on improving long-term outcome.
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Affiliation(s)
- G B Martin
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48202, USA
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13
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Nowak RM. Asthma guidelines--beyond physician behavior. J Emerg Med 1997; 15:533-4. [PMID: 9279711 DOI: 10.1016/s0736-4679(97)00089-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Rady MY, Rivers EP, Nowak RM. Resuscitation of the critically ill in the ED: Responses of blood pressure, heart rate, shock index, central venous oxygen saturation, and lactate. Resuscitation 1996. [DOI: 10.1016/0300-9572(96)89045-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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Boczar ME, Howard MA, Rivers EP, Martin GB, Horst HM, Lewandowski C, Tomlanovich MC, Nowak RM. A technique revisited: Hemodynamic comparison of closed- and open-chest cardiac massage during human cardiopulmonary resuscitation. Resuscitation 1996. [DOI: 10.1016/0300-9572(96)83756-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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16
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Rady MY, Rivers EP, Nowak RM. Resuscitation of the critically ill in the ED: responses of blood pressure, heart rate, shock index, central venous oxygen saturation, and lactate. Am J Emerg Med 1996; 14:218-25. [PMID: 8924150 DOI: 10.1016/s0735-6757(96)90136-9] [Citation(s) in RCA: 202] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
To describe the simultaneous responses of systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial blood pressure (MAP), heart rate (HR), shock index (SI = HR/SBP), central venous oxyhemoglobin saturation (ScvO2), and arterial blood lactate concentration (Lact) to resuscitation of critically ill patients in the emergency department (ED), an observational descriptive study was conducted in the ED of an urban teaching hospital. Thirty- six patients admitted from the ED to the medical intensive care unit were studied. Vital signs were measured immediately on arrival to the ED (phase 1). After initial resuscitation and stabilization, ie, HR between 50 and 120 beats/min and MAP between 70 and 110 mm Hg (phase 2), ScvO2 and Lact were measured and additional therapy was given in the ED to increase ScvO2 to > 65% and decrease Lact to < 2 mmol/L, if needed (phase 3). SBP, DBP, MAP, HR. SI, ScvO2, and Lact were measured. Initial resuscitation increased SBP from 103 +/- 39 to 118 +/- 29 mm Hg (P < .05) and MAP from 67 +/- 35 to 82 +/- 22 mm Hg (P < .05) but did not affect DBP (53 +/- 35 to 63 +/- 22 mm Hg, P = NS), HR (110 +/- 26 to 110 +/- 22 beats/min, P = NS) or SI (from 1.3 +/- 0.7 to 1.0 +/- 0.3, P =NS) from phase 1 to phase 2. ScvO2 remained < 65% and/or Lact > 2.0 mmol/L in 31 of 36 patients at phase 2, and additional therapy was required. Lact was decreased (from 4.6 +/- 3.8 to 2.6 +/- 2.5 mmol/L, P < .05) and ScvO2 was increased (from 52 +/- 18 to 65 +/- 13%, P < .05) without significant additional changes in SBP, DBP, MAP, HR, or SI at phase 3. The in-hospital mortality was 14% for this group of patients. It was concluded that additional therapy is required in the majority of critically ill patients to restore adequate systemic oxygenation after initial resuscitation and hemodynamic stabilization in the ED. Additional therapy to increase ScvO2 and decrease Lact may not produce substantial responses in SBP, DBP, MAP, HR, and SI. The measurement of ScvO2 and Lact can be utilized to guide this phase of additional therapy in the ED.
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Affiliation(s)
- M Y Rady
- Department of Critical Care Medicine, Cleveland Clinic Foundation, OH, USA
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Affiliation(s)
- R M Nowak
- Department of Emergency Medicine, Henry Ford Health Systems, Detroit, Michigan, USA
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Smithline HA, Rivers EP, Rady MY, Blake HC, Nowak RM. Biphasic extrathoracic pressure CPR: A human pilot study. Resuscitation 1995. [DOI: 10.1016/0300-9572(95)94139-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Paradis NA, Wortsman J, Malarkey WB, Martin GB, Goetting MG, Feingold M, Nowak RM. High atrial natriuretic peptide concentrations blunt the pressor response during cardiopulmonary resuscitation in humans. Resuscitation 1995. [DOI: 10.1016/0300-9572(95)94132-s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Boczar ME, Howard MA, Rivers EP, Martin GB, Horst HM, Lewandowski C, Tomlanovich MC, Nowak RM. A technique revisited: hemodynamic comparison of closed- and open-chest cardiac massage during human cardiopulmonary resuscitation. Crit Care Med 1995; 23:498-503. [PMID: 7874901 DOI: 10.1097/00003246-199503000-00014] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To compare the hemodynamics of closed-chest cardiac massage vs. open-chest cardiac massage in patients resuscitated from cardiac arrest that occurred outside of the hospital. DESIGN Prospective, non-outcome, case series. SETTING Large urban emergency department. PATIENTS Ten adult, normothermic, nontraumatic, out-of-hospital, cardiac arrest patients who failed advanced cardiac life support (ACLS) therapy. INTERVENTIONS Patients presenting to the hospital in cardiac arrest were managed according to the ACLS protocol at the clinician's discretion. Proximal aortic and central venous pressure catheters were placed to measure arteriovenous compression- and relaxation-phase pressure gradients. After 5 mins of baseline measurements during closed-chest cardiac massage, patients underwent a left lateral thoracotomy, and open-chest cardiac massage was performed for 5 mins. MEASUREMENTS AND MAIN RESULTS The mean coronary perfusion pressure and compression-phase pressure gradients were 7.3 +/- 5.7 and 6.2 +/- 5.4 mm Hg, respectively, during closed-chest cardiac massage, while increasing to 32.6 +/- 17.8 and 32.6 +/- 29.9 mm Hg, respectively, during open-chest cardiac massage. The differences between both measurements were statistically significant (p < .05). CONCLUSIONS Open-chest cardiac massage is superior to closed-chest cardiac massage in providing relaxation-phase and compression-phase pressure gradients during cardiac arrest in patients failing current ACLS protocols. During open-chest cardiac massage, all patients exceeded the minimum coronary perfusion pressure of 15 mm Hg, which is recommended to obtain a return of spontaneous circulation. Further outcome studies are needed to determine the timeliness and appropriate indications for open-chest cardiac massage.
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Affiliation(s)
- M E Boczar
- Department of Emergency Medicine, Henry Ford Health Systems, Detroit, MI 48202
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Abstract
HYPOTHESIS Alternating intrathoracic pressure by means of a chest cuirass can cause perfusion and ventilation equal to or better than standard cardiopulmonary resuscitation (CPR) for humans in cardiac arrest. DESIGN Nonrandomized, nonblinded, crossover pilot study. SETTING Large urban emergency department. SUBJECTS Five adult normothermic, nontraumatic, out-of-hospital cardiac arrest patients unresponsive to standard advanced cardiac life support. METHOD Right atrial and aortic catheters were inserted for pressure measurement and blood gas analysis while the patient was receiving standard CPR by a pneumatic compression device (Thumper). The Thumper was then replaced by a chest cuirass (Hayek Oscillator). Pressure and blood gas measurements were then repeated. RESULTS The coronary perfusion pressure increased from -1.2 +/- 8.6 mm Hg to 6.2 +/- 6.9 mm Hg for a mean change of 7.4 +/- 3.1 mm Hg (p = 0.006). The compression phase gradient increased 10.0 +/- 21.9 mm Hg (p = 0.364). The venous to arterial PCO2 gradient decreased 44.5 +/- 32.3 mm Hg (p = 0.070). The oxygen extraction ratio increased 1.6 +/- 9.4 percent (p = 0.761). The mean arterial PO2 and PCO2 changed from 252 to 240 mm Hg (p = 0.836) and from 53 to 66 (p = 0.172) mm Hg, respectively. CONCLUSION The Hayek Oscillator chest cuirass produced a significant improvement in the coronary perfusion pressure. There was a trend for improved systemic perfusion as indicated by an improved compression phase gradient and venous to arterial PCO2 gradient, although this was not supported by the lack of improvement in the oxygen extraction ratio. The cuirass also adequately oxygenates and ventilates unassisted by positive pressure ventilation.
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Affiliation(s)
- H A Smithline
- Department of Emergency Medicine, Henry Ford Health Systems, Henry Ford Hospital, Detroit
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Paradis NA, Wortsman J, Malarkey WB, Martin GB, Goetting MG, Feingold M, Nowak RM. High atrial natriuretic peptide concentrations blunt the pressor response during cardiopulmonary resuscitation in humans. Crit Care Med 1994; 22:213-8. [PMID: 8306678 DOI: 10.1097/00003246-199402000-00010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To determine the relationship of circulating atrial natriuretic peptide concentrations to the pressor response to high-dose epinephrine in patients undergoing cardiopulmonary resuscitation (CPR) for cardiac arrest. DESIGN Prospective study. PATIENTS Fourteen normothermic, adult, prehospital and emergency department patients suffering unexpected cardiac arrest. INTERVENTION Patients received high-dose epinephrine (0.2 mg/kg) i.v. when standard advanced cardiac life support (including multiple 1-mg dosages of epinephrine) failed to result in return of spontaneous circulation. MEASUREMENTS AND MAIN RESULTS Cardiac arrest patients were separated into those patients with and without detectable serum atrial natriuretic peptide concentrations, and were termed the "low atrial natriuretic peptide" and "high atrial natriuretic peptide" groups, respectively. Their aortic pressure response to high-dose (0.02 mg/kg) epinephrine was compared. The proportion with positive assays was compared with a group of healthy control subjects. Fourteen patients were studied. Eight patients had low serum atrial natriuretic peptide concentrations and six patients had high circulating atrial natriuretic peptide concentrations. The mean concentration in the high atrial natriuretic peptide group was 151 +/- 82 pg/mL. The proportion with positive assays (six of 14 patients) was greater than in the group in spontaneous circulation (three of 29 patients) (p = .002). The maximal increase in the aortic relaxation-phase pressures after high-dose epinephrine was 9 +/- 7 torr (1.2 +/- 0.9 kPa) in the low atrial natriuretic peptide group and 0 +/- 5 torr (0 +/- 0.7 kPa) in the high atrial natriuretic peptide group (p = .03). The maximal increase in the aortic compression pressures after high-dose epinephrine was 17 +/- 13 torr (2.3 +/- 1.7 kPa) in the low atrial natriuretic peptide group and 2 +/- 10 torr (0.3 +/- 1.3 kPa) in the high atrial natriuretic peptide group (p = .03). Thus, pressor responses after high-dose epinephrine administration were observed in patients in the low atrial natriuretic peptide group, but this response was absent in patients in the high atrial natriuretic peptide group. CONCLUSIONS Cardiac arrest patients receiving CPR have higher circulating atrial natriuretic peptide concentrations than healthy subjects. High serum atrial natriuretic peptide concentrations may antagonize the vasopressor response to epinephrine. Blocking this effect of atrial natriuretic peptide may improve outcomes in patients suffering cardiac arrest.
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Affiliation(s)
- N A Paradis
- Department of Critical Care Medicine, New York University Medical Center, NY
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Schultz CH, Rivers EP, Feldkamp CS, Goad EG, Smithline HA, Martin GB, Fath JJ, Wortsman J, Nowak RM. A characterization of hypothalamic-pituitary-adrenal axis function during and after human cardiac arrest. Crit Care Med 1993; 21:1339-47. [PMID: 8396524 DOI: 10.1097/00003246-199309000-00018] [Citation(s) in RCA: 101] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This study characterizes hypothalamic-pituitary-adrenal axis function during cardiopulmonary arrest and after return of spontaneous circulation. DESIGN Prospective case series. SETTING A large urban emergency department and intensive care unit over an 8-month period. PATIENTS Two hundred five adult patients presenting in cardiopulmonary arrest to an urban emergency department. Three patients known to be taking corticosteroids were excluded from the study. MEASUREMENTS AND MAIN RESULTS Cortisol concentrations were measured before and after advanced cardiac life support and for five consecutive hours after return of spontaneous circulation. Adrenocorticotropic hormone (ACTH) concentrations were measured before advanced cardiac life support and when the cosyntropin stimulation tests were performed 6 and 24 hrs after the return of spontaneous circulation. The mean initial serum cortisol concentration was 32.0 +/- 33.1 micrograms/dL (882.9 +/- 913.2 nmol/L). Fifty-three percent of patients had cortisol concentrations of < 20 micrograms/dL (< 552 nmol/L) at the end of cardiac arrest. Among 44 patients who achieved return of spontaneous circulation, 98% had initial cortisol concentrations of > 10 micrograms/dL (> 276 nmol/L) and 73% of patients had initial cortisol concentrations of > 20 micrograms/dL (> 552 nmol/L). Mean serum cortisol concentrations increased significantly (p = .0001) from 1 to 6 hrs after return of spontaneous circulation and decreased significantly (p = .03) from 6 to 24 hrs. A serum cortisol concentration of < 30 micrograms/dL (< 828 nmol/L) was associated with a 96% and 100% mortality rate at 6 and 24 hrs, respectively. Mean ACTH concentrations were increased without a significant difference between the initial and 6-hr concentrations. Mean ACTH concentrations decreased between 6 and 24 hrs (p = .06). There were no significant responses to the cosyntropin stimulation at 6 and 24 hrs. CONCLUSIONS Cortisol concentrations after out-of-hospital cardiac arrest are lower than those concentrations reported in other stress states. There is an association between cortisol concentrations and short-term survival after cardiac arrest. Survivors have a significantly greater increase in serum cortisol concentrations than nonsurvivors during the first 24 hrs. Lower than expected cortisol concentrations for the extreme stress of cardiac arrest may have pathologic significance in the hemodynamic instability seen after return of spontaneous circulation. The etiology of the low cortisol concentrations may be primary adrenal dysfunction.
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Affiliation(s)
- C H Schultz
- Gerard B. Martin Resucitation Unit, Department of Emergency Medicine, Henry Ford Health Systems, Detroit, MI
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Rivers EP, Lozon J, Enriquez E, Havstad SV, Martin GB, Lewandowski CA, Goetting MG, Rosenberg JA, Paradis NA, Nowak RM. Simultaneous radial, femoral, and aortic arterial pressures during human cardiopulmonary resuscitation. Crit Care Med 1993; 21:878-83. [PMID: 8504656 DOI: 10.1097/00003246-199306000-00016] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To examine the validity of interchanging arterial sites and their responses to graded doses of epinephrine during human cardiopulmonary resuscitation (CPR). DESIGN Consecutive case series. SETTING Large, urban Emergency Department. PATIENTS Adult, normothermic, nonhemorrhagic cardiac arrest patients. INTERVENTIONS While receiving advanced cardiac life support, patients received right atrial (n = 40), aortic (n = 40), radial (n = 40), and femoral (n = 17) artery catheters. Pressures were measured simultaneously at baseline, after 0.01 mg/kg and 0.2 mg/kg of epinephrine. MEASUREMENTS AND MAIN RESULTS The mean aortic compression-phase pressure was 9.3 +/- 10 (SD), 8.1 +/- 11, and 4.4 +/- 9.5 mm Hg higher than radial artery pressure at baseline, after 0.01 mg/kg, and 0.2 mg/kg of epinephrine, respectively (all statistically significant). When compared with the femoral artery at the same time points, the mean aortic compression-phase pressure was also 3.0 +/- 6.8, 1.9 +/- 8, and 0.6 +/- 7.7 mm Hg higher, respectively (none statistically significant). The aortic relaxation-phase pressure was 1.3 +/- 3.6, 1.1 +/- 3.8, and 1.6 +/- 2.5 mm Hg lower than the radial artery at baseline, after 0.01 mg/kg and 0.2 mg/kg of epinephrine, respectively (all statistically significant). When compared with the femoral artery at the same time points, the aortic relaxation-phase pressure was 0.6 +/- 2.0, 0.3 +/- 3.3, and 0.3 +/- 2.4 mm Hg lower, respectively (none statistically significant). CONCLUSIONS Radial artery relaxation-phase pressure, although statistically higher, correlated with aortic relaxation-phase pressure. Femoral artery relaxation-phase pressure was not statistically different from aortic relaxation-phase pressure. Aortic pressure was statistically higher and had a lower correlation with radial artery pressures during compression phase. The aortic to radial artery and aortic to femoral artery compression-phase gradients abated with increasing doses of epinephrine therapy. Caution must be used when substituting compression-phase pressure obtained at radial or femoral artery sites for aortic pressure during human CPR. Coronary artery perfusion pressures obtained with radial and femoral arteries correlate with aortic pressure when measuring the response to vasopressor therapy during CPR when an interpretable waveform exists.
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Affiliation(s)
- E P Rivers
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48202
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Wortsman J, Paradis NA, Martin GB, Rivers EP, Goetting MG, Nowak RM, Cryer PE. Functional responses to extremely high plasma epinephrine concentrations in cardiac arrest. Crit Care Med 1993; 21:692-7. [PMID: 8482090 DOI: 10.1097/00003246-199305000-00012] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To evaluate the action of high-dose epinephrine by measuring simultaneously its vasopressor and norepinephrine releasing effects in humans during cardiac arrest. DESIGN A prospective study on consecutive patients admitted with cardiac arrest. SETTING Emergency Department in a large, urban hospital. PATIENTS Eighteen patients with out-of-hospital cardiac arrest undergoing cardiopulmonary resuscitation (CPR). INTERVENTIONS Catheterization of both the aorta and right atrium for the recording of pressure and collection of blood samples. Throughout the study period (12.5 mins), 18 patients received epinephrine at both the standard dose (1 mg, approximately 0.015 mg/kg) and high dose (0.2 mg/kg). Blood samples were drawn five times, every 2.5 mins. MEASUREMENTS AND MAIN RESULTS Plasma epinephrine and norepinephrine concentrations; aorta, right atrial, and coronary perfusion pressures. Epinephrine concentrations (normal at rest = 160 +/- 10 [SEM] pmol/L) were increased at the time of the first sample (2.5 mins) by approximately 3,000-fold (to approximately 0.5 mumol/L), and, increased further to 12,000-fold (approximately 2.0 mumol/L) during the study. Aortic pressure increased from 20 +/- 3 to 28 +/- 3 mm Hg (p < .001), and coronary perfusion pressure increased from 4 +/- 3 to 10 +/- 3 mm Hg (p < .001). Simultaneous plasma norepinephrine concentrations were 30-fold higher than the normal resting value of 1.30 +/- 0.04 nmol/L, and increased by 90-fold during the study (p < .001). The spectral distributions of the individual correlations between plasma epinephrine and norepinephrine concentrations were segregated into high correlations (r > .83) in 12 of 18 patients and low r values (r = .29 to .79) in the remaining six patients. The distribution of the correlations was nonuniform by the Kolmogorov-Smirnov goodness-of-fit test with p < .001; this profile suggests that norepinephrine responsiveness to epinephrine can separate two populations, one of which (r > .83) would have preserved viability of the corresponding epinephrine receptors. The correlations between plasma epinephrine concentrations and coronary perfusion pressures were distributed more evenly, also in a nonuniform pattern (p < .02 by Kolmogorov-Smirnov goodness-of-fit test) and the relationship between the two sets of correlations was not significant. CONCLUSIONS Despite the very high prevailing plasma epinephrine concentrations during cardiac arrest, further epinephrine increases still elicit biological responses. The present work provides physiologic support for the use of large doses of epinephrine during the course of CPR.
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Affiliation(s)
- J Wortsman
- Department of Medicine, Southern Illinois University School of Medicine, Springfield 62794-9230
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Rivers EP, Rady MY, Martin GB, Fenn NM, Smithline HA, Alexander ME, Nowak RM. Venous hyperoxia after cardiac arrest. Characterization of a defect in systemic oxygen utilization. Chest 1992; 102:1787-93. [PMID: 1446489 DOI: 10.1378/chest.102.6.1787] [Citation(s) in RCA: 82] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Supranormal mixed venous oxygen saturation (mixed venous hyperoxia), although reported, has never been characterized in humans resuscitated from cardiac arrest (postarrest cardiogenic shock). By contrast, cardiogenic shock without cardiopulmonary arrest (primary cardiogenic shock) is accompanied by mixed venous hypoxia under similar conditions of low oxygen delivery (DO2). The appearance of mixed venous hyperoxia indicates an excessive supply relative to demand in perfused tissue or cellular impairment of oxygen utilization, ie, low systemic oxygen consumption (VO2). Failure to improve VO2 has been associated with a poor outcome in other shock states. STUDY OBJECTIVE This study evaluates the clinical significance of mixed venous hyperoxia and its implications for impaired systemic oxygen utilization. The oxygen transport patterns in surviving and nonsurviving cardiac arrest patients are compared for their prognostic and therapeutic implications. STUDY DESIGN Consecutive, nonrandomized series. SETTING Large urban emergency department (ED). PARTICIPANTS Adult normothermic, nontraumatic out-of-hospital cardiac arrest patients presenting to the ED who develop a return of spontaneous circulation (ROSC). INTERVENTIONS On arrival to the ED, a fiberoptic catheter was placed in the central venous position for continuous central venous oxygen saturation monitoring (ScvO2). A proximal aortic catheter was placed via the femoral artery for blood pressure monitoring. Upon ROSC, the fiberoptic catheter was advanced to the pulmonary artery. Mean arterial pressure (MAP), cardiac index (CI), VO2, DO2, systemic oxygen extraction ratio (OER), and systemic vascular resistance index (SVRI-dynes.s/cm5.m2) were measured immediately and every 30 min. The duration of cardiac arrest (DCA) in minutes and amount of epinephrine (milligrams) administered during ACLS was recorded. MEASUREMENTS AND RESULTS Twenty-three patients were entered into the study. Survivors (living more than 24 h) and nonsurvivors (living less than 24 h) were compared. CONCLUSIONS These findings indicate an impairment of systemic oxygen utilization in postarrest cardiogenic shock patients. In spite of a lower DO2 than survivors, the OER in nonsurvivors remained lower than expected. Venous hyperoxia is a clinical manifestation of this derangement. Epinephrine dose may have a causal relationship. The inability to attain a VO2 of greater than 90 ml/min.m2 after the first 6 h of aggressive therapy was associated with a 100 percent mortality in 24 h.
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Affiliation(s)
- E P Rivers
- Department of Emergency Medicine, Henry Ford Health Systems, Detroit, MI 48202
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Rady MY, Rivers EP, Martin GB, Smithline H, Appelton T, Nowak RM. Continuous central venous oximetry and shock index in the emergency department: use in the evaluation of clinical shock. Am J Emerg Med 1992; 10:538-41. [PMID: 1388378 DOI: 10.1016/0735-6757(92)90178-z] [Citation(s) in RCA: 107] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Initial therapy of shock in the emergency department (ED) emphasizes the normalization of physiologic variables such as heart rate (HR), mean arterial pressure (MAP), and central venous pressure (CVP) rather than restoration of adequate tissue oxygenation. After hemodynamic stabilization of MAP, CVP, and HR, the authors examined tissue oxygenation as indicated by continuous central venous oximetry (SCVO2), lactic acid concentration, and shock index (SI). Sixteen consecutive nonrandomized patients presenting to the ED of a large urban hospital in shock (MAP < 60 mm Hg, HR > 120 beats/min, and altered sensorium) were initially resuscitated with fluid, blood, inotropes, and/or vasoactive drug therapy to normalize MAP, CVP, and HR. In addition, SCVO2, arterial lactate concentration, and SI were measured after completion of resuscitation in the ED. Eight patients (group no. 1) had inadequate tissue oxygenation reflected by low SCVO2 (less than 65%). Four patients in group no. 1 had elevated arterial lactic acid concentration. All group no. 1 patients had an elevated SI (> 0.7) suggesting persistent impairment of left ventricular stroke work. Eight patients (group no. 2) had normal or elevated SCVO2 (> 65%). In group no. 2, arterial lactic acid concentration was elevated in six and SI in seven patients. Normalization of hemodynamic variables does not adequately reflect the optimal endpoint of initial therapy in shock in the ED. Most (94%) of these patients continue to have significant global ischemia and cardiac dysfunction as indicated by reduced SCVO2 and elevated lactic acid concentration and SI. Systemic tissue oxygenation should be monitored and optimized in the ED in these critically ill patients.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- M Y Rady
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48202
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Rivers EP, Martin GB, Smithline H, Rady MY, Schultz CH, Goetting MG, Appleton TJ, Nowak RM. The clinical implications of continuous central venous oxygen saturation during human CPR. Ann Emerg Med 1992; 21:1094-101. [PMID: 1514720 DOI: 10.1016/s0196-0644(05)80650-x] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
STUDY OBJECTIVE The purpose of this study was to observe, measure, and describe the changes in central venous oxygen saturation during CPR and immediately after return of spontaneous circulation. It also was to examine the clinical utility of continuous central venous oxygen saturation monitoring as a indicator of return of spontaneous circulation during CPR in human beings. DESIGN AND SETTING Eight-month, prospective, non-outcome, observational, nonrandomized case series in the ED of a large urban hospital. TYPES OF PATIENTS: Adult normothermic, nontraumatic, out-of-hospital cardiopulmonary arrests. INTERVENTIONS All patients were managed according to advanced cardiac life support guidelines. A proximal aortic and double-lumen central venous catheter was placed. Central venous oxygen saturation was measured continuously spectrophotometrically with a fiberoptic catheter in the central venous location. MEASUREMENTS Aortic blood pressure and central venous oxygen saturation were simultaneously measured throughout each resuscitation. Return of spontaneous circulation was defined as a systolic blood pressure of more than 60 mm Hg for more than five minutes. RESULTS One hundred patients who experienced 68 episodes of cardiac arrest were studied. Patients with return of spontaneous circulation had a higher initial and statistically higher mean and maximal central venous oxygen saturation than those without return of spontaneous circulation (P = .23, .0001, and .0001, respectively; P less than .05 is significant). No patient attained return of spontaneous circulation without reaching a central venous oxygen saturation of at least 30%. Only one of 68 episodes of return of spontaneous circulation was attained without reaching a central venous oxygen saturation of at least 40%. A central venous oxygen saturation of greater than 72% was 100% predictive of return of spontaneous circulation. CONCLUSION Continuous central venous oxygen saturation monitoring can serve as a reliable indicator of return of spontaneous circulation during CPR in human beings.
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Affiliation(s)
- E P Rivers
- Department of Emergency Medicine, Henry Ford Health Systems, Detroit, Michigan
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Paradis NA, Martin GB, Goetting MG, Rivers EP, Feingold M, Nowak RM. Aortic pressure during human cardiac arrest. Identification of pseudo-electromechanical dissociation. Chest 1992; 101:123-8. [PMID: 1729058 DOI: 10.1378/chest.101.1.123] [Citation(s) in RCA: 89] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
We measured aortic pressure during clinically apparent cardiac electromechanical dissociation (EMD). Patients with pulse pressures were designated as having pseudo-EMD; those without, as having true EMD. Of the 200 patients studied, 54 presented with EMD, and 40 others developed it during resuscitation. Of the 94 with EMD, 39 were found to have pseudo-EMD. We compared the two types of EMD for electrocardiographic duration, return of palpable pulses, and response to standard- and high-dose epinephrine. The mean resting aortic pressure was 18 +/- 11 mm Hg in patients with true EMD and 28 +/- 11 mm Hg in those with pseudo-EMD. The mean pulse pressure in patients with pseudo-EMD was 6.3 +/- 3.5 mm Hg. Patients with pseudo-EMD had a higher proportion of witnessed arrests, higher PaO2, and lower PaCO2 than patients with true EMD. Patients with pseudo-EMD had shorter QR and QRS durations than patients with true EMD. They had a better response to standard- and high-dose epinephrine than patients with true EMD. Many patients diagnosed clinically to be in EMD have mechanical cardiac activity; this should be considered when interpreting the results of cardiac arrest research.
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Affiliation(s)
- N A Paradis
- Department of Emergency Medical Services, Bellevue Hospital Center, New York University Medical Center, New York
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Gentile NT, Martin GB, Appleton TJ, Moeggenberg J, Paradis NA, Nowak RM. Effects of arterial and venous volume infusion on coronary perfusion pressures during canine CPR. Resuscitation 1991; 22:55-63. [PMID: 1658894 DOI: 10.1016/0300-9572(91)90064-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Intraarterial (IA) volume infusion has been reported to be more effective than intravenous (IV) infusion in treating cardiac arrest due to exsanguination. A rapid IA infusion was felt to raise intraaortic pressure and improve coronary perfusion pressure (CPP). The purpose of this study was to determine if IA or IV volume infusion could augment the effect of epinephrine on CPP during CPR in the canine model. Nineteen mongrel dogs with a mean weight of 26.3 +/- 4.2 kg were anesthetized and mechanically ventilated. Thoracic aortic (Ao), right atrial (RA) and pulmonary artery catheters were placed for hemodynamic monitoring. Additional Ao and central venous catheters were placed for volume infusion. Ventricular fibrillation was induced and Thumper CPR was begun after 5 min (t = 5). At t = 10, all dogs received 45 micrograms/kg IV epinephrine. Six animals received epinephrine alone (EPI). Five dogs received EPI plus a 500 cc bolus of normal saline over 3 min intravenously (EPI/IV). Another group (n = 8) received EPI plus the same fluid bolus through the aortic catheter (EPI/IA). Resuscitation was attempted at t = 18 using a standard protocol. There was a significant increase in CPP over baseline in all groups. The changes in CPP from baseline induced by EPI, EPI/IV and EPI/IA were 20.6 +/- 3.7, 22.8 +/- 4.2 and 22.2 +/- 2.4 mmHg, respectively. Volume loading did not augment the effect of therapeutic EPI dosing. By increasing both preload and afterload, volume administration may in fact be detrimental during CPR.
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Affiliation(s)
- N T Gentile
- Hartford Hospital, Department of Emergency Medicine, CT 06115
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32
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Goetting MG, Paradis NA, Appleton TJ, Rivers EP, Martin GB, Nowak RM. Aortic-carotid artery pressure differences and cephalic perfusion pressure during cardiopulmonary resuscitation in humans. Crit Care Med 1991; 19:1012-7. [PMID: 1860324 DOI: 10.1097/00003246-199108000-00007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Animal studies have shown an aortic-carotid artery pressure difference during cardiopulmonary resuscitation (CPR), which compromises cerebral perfusion. This pressure difference is most marked with prolonged CPR and can be abolished with administration of high doses of epinephrine. To better understand the mechanism of cerebral blood flow during CPR in humans, we determined the aortic-carotid artery pressure difference, the cephalic perfusion pressure (the carotid artery-jugular vein pressure difference), and thoracic inlet venous "valving" (the central venous-jugular vein pressure difference), while administering standard doses of epinephrine. DESIGN Prospective study with randomization as to which side the carotid artery was catheterized. SETTING The resuscitation room of a large urban hospital's emergency department. PATIENTS Fifteen adults in normothermic, nontraumatic prehospital cardiac arrest treated according to Advanced Cardiac Life Support guidelines, including administration of 1 mg epinephrine iv every 5 mins. INTERVENTIONS The descending aorta, cervical common carotid artery, internal jugular vein, and central venous system were catheterized. Pressures were recorded during standard CPR for 5 mins after administration of 1 mg epinephrine iv. MEASUREMENTS AND MAIN RESULTS Most patients received CPR for greater than 20 mins before the first epinephrine dose and for greater than 45 mins before pressure recording as described above. There was no significant difference between aortic and carotid artery compression and relaxation phase pressures. The mean +/- SD compression central venous-jugular vein pressure difference was 22.1 +/- 15.0 mm Hg, and the mean cephalic perfusion pressure was 20.8 +/- 19.5 mm Hg. CONCLUSIONS There is no clinically important aortic-carotid artery pressure difference during human CPR using the standard dose of epinephrine, even with prolonged CPR. Despite carotid artery patency and thoracic inlet venous valving, the cephalic perfusion pressure is low during CPR in humans.
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Affiliation(s)
- M G Goetting
- Department of Pediatrics, Henry Ford Hospital, Detroit, MI 48202
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33
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34
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Rivers EP, Paradis NA, Martin GB, Goetting ME, Rosenberg JA, Smithline HA, Appleton TJ, Nowak RM. Cerebral lactate uptake during cardiopulmonary resuscitation in humans. J Cereb Blood Flow Metab 1991; 11:479-84. [PMID: 2016356 DOI: 10.1038/jcbfm.1991.91] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Animal studies have shown cerebral lactate uptake under conditions of anoxia and ischemia. Cerebral lactate uptake in humans during cardiopulmonary resuscitation (CPR) has not been previously reported in the literature. Forty-five patients receiving CPR underwent simultaneous sampling through jugular venous bulb, right atrial, and central aortic catheterization. The mean net cerebral lactate uptake (central aortic minus jugular venous bulb) was 0.76 +/- 1.86 and 0.80 +/- 2.03 mM on initial measurement and 10 min later, respectively. Both measurements were statistically significant (p = 0.01) compared to normal controls who have net cerebral output of lactate of -0.18 +/- 0.1 mM. Seventy-one percent of all patients had a cerebral uptake on initial sampling and this gradient persisted upon sampling 10 min later in 68% of the remaining 40 patients who did not have a return of spontaneous circulation. Among multiple variables measured, patients who exhibited a cerebral lactate uptake were 13.2 years younger (p = 0.004), received an additional 7.6 min of CPR (p = 0.05), and had a mean arterial lactate concentration of 4.8 mM higher (p = 0.005) than the nonuptake group. The pathophysiologic explanation of cerebral lactate uptake during CPR is multifactorial and includes utilization and/or diffusion.
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Affiliation(s)
- E P Rivers
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan 48202
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35
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Abstract
We used 31P nuclear magnetic resonance spectroscopy to study the cerebral metabolic function of eight patients with severe postischemic anoxic encephalopathy secondary to cardiac arrest. Spectroscopy was performed at 18 +/- 13 and 64 +/- 20 hours after resuscitation. Glasgow Coma Scale scores at the time of initial and repeat spectroscopy were 3.6 +/- 1.2 and 3.5 +/- 1.2, respectively. In those patients whose spectra were of adequate quality to monitor pH, all demonstrated tissue alkalosis in at least one brain region. The mean brain pH at initial spectroscopy was 7.14 +/- 0.09 and was significantly alkalotic when compared with age- and sex-matched normal controls (pH = 6.98 +/- 0.04, p less than 0.0001). Five of the eight patients showed at least one region of persistent alkalosis at repeat spectroscopy, whereas one patient demonstrated severe acidosis with a pH of 6.42. Spectra demonstrated marked metabolic heterogeneity, ranging from normal in appearance to complete obliteration of all high-energy phosphates with only inorganic phosphate remaining.
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Affiliation(s)
- G B Martin
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48202
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36
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Paradis NA, Martin GB, Rosenberg J, Rivers EP, Goetting MG, Appleton TJ, Feingold M, Cryer PE, Wortsman J, Nowak RM. The effect of standard- and high-dose epinephrine on coronary perfusion pressure during prolonged cardiopulmonary resuscitation. JAMA 1991; 265:1139-44. [PMID: 1996000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We studied the effect of standard and high doses of epinephrine on coronary perfusion pressure during cardiopulmonary resuscitation in 32 patients whose cardiac arrest was refractory to advanced cardiac life support. Simultaneous aortic and right atrial pressures were measured and plasma epinephrine levels were sampled. Patients remaining in cardiac arrest after multiple 1-mg doses of epinephrine received a high dose of 0.2 mg/kg. The increase in the coronary perfusion pressures was 3.7 +/- 5.0 mm Hg following a standard dose, not a statistically significant change. The increase after a high dose was 11.3 +/- 10.0 mm Hg; this was both statistically different than before administration and larger than after a standard dose. High-dose epinephrine was more likely to raise the coronary perfusion pressure above the previously demonstrated critical value of 15 mm Hg. The highest arterial plasma epinephrine level after a standard dose was 152 +/- 162 ng/mL, and after a high dose, 393 +/- 289 ng/mL. Because coronary perfusion pressure is a good predictor of outcome in cardiac arrest, the increase after high-dose epinephrine may improve rates of return of spontaneous circulation.
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Affiliation(s)
- N A Paradis
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48202
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37
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Cryer PE, Wortsman J, Shah SD, Nowak RM, Deftos LJ. Plasma chromogranin A as a marker of sympathochromaffin activity in humans. Am J Physiol 1991; 260:E243-6. [PMID: 1996627 DOI: 10.1152/ajpendo.1991.260.2.e243] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The extent to which the sympathochromaffin system compared with other endocrine/neuroendocrine tissues contributes to the plasma chromogranin A pool has not been defined. To test the hypothesis that the sympathochromaffin system is the major source of circulating chromogranin A only when that system is activated markedly, we measured chromogranin A concentrations in 200 human plasma samples known to have a broad range of norepinephrine and epinephrine concentrations, reflecting therefore a broad range of sympathochromaffin activity at the time of sampling. Plasma chromogranin A and norepinephrine concentrations were highly correlated when the sympathochromaffin system was activated markedly (cardiac arrest samples, n = 13, r = 0.8392, P less than 0.0005) and when there was release of large amounts of norepinephrine from tumors (pheochromocytoma samples, n = 17, r = 0.8132, P less than 0.001). However, when the sympathochromaffin system was activated less markedly, resulting in plasma catecholamine concentrations that spanned the physiological and lower pathophysiological range (nonpheochromocytoma noncardiac arrest samples, n = 170), correlations between plasma chromogranin A and norepinephrine (r = 0.2877, P less than 0.0001) and epinephrine (r = 0.3814, P less than 0.0001) levels were relatively weak, although still statistically significant. Thus, at basal through moderate stress levels, norepinephrine and epinephrine concentrations accounted for only approximately 10-15% of the variance in plasma chromogranin A levels. We conclude that, although plasma chromogranin A concentrations are a valid marker of sympathochromaffin activity in humans, they are not a sensitive marker under physiological conditions.
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Affiliation(s)
- P E Cryer
- Division of Endocrinology, Washington University School of Medicine, St. Louis, Missouri 63110
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38
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Abstract
Since the highest plasma epinephrine levels have been recorded during resuscitation, we evaluated the isolated effect of cardiac arrest upon adrenomedullary secretion. We determined plasma epinephrine in dogs resuscitated with cardiopulmonary bypass (CPB) after cardiac arrest periods of 12 (CPB-12; n = 4) or 16 min (CPB-16; n = 5). Through 2 h of CPB and the following 6 h of critical care, there was no difference between CPB-12 and CPB-16 regarding most cardiopulmonary functional variables. Plasma epinephrine was markedly elevated immediately after initiation of CPB (p less than .01 at 1 min CPB vs. basal) and returned rapidly to basal concentrations. Comparison of plasma epinephrine levels between CPB and standard CPR groups showed that responses to cardiac arrest were similar (p greater than .05 at 1 min CPB vs. 11.5 min CPR). We conclude that cardiac arrest is the main or sole determinant of the plasma epinephrine elevation of resuscitation.
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Affiliation(s)
- J Wortsman
- Department of Medicine, Southern Illinois University, Springfield 62794-9230
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39
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Abstract
End-tidal carbon dioxide (ETCO2) has been shown to correlate with coronary perfusion pressure (CPP) during CPR and has been proposed as a useful noninvasive monitor of CPR efficacy. The effects of therapeutic epinephrine dosing on ETCO2 and CPP in six dogs were examined. Ventricular fibrillation was induced and left untreated for five minutes before CPR was initiated. After five minutes of CPR, epinephrine 0.045 mg/kg IV was administered. CPP and ETCO2 were compared immediately before and two minutes after epinephrine administration. There was a significant increase in CPP from 12.2 +/- 9.6 to 26.8 +/- 7.1 mm Hg (P = .006) after epinephrine. This was accompanied by a significant decrease in ETCO2 from 8.2 +/- 2.9 to 3.8 +/- 2.0 mm Hg (P = .01). These data indicate that after epinephrine administration, caution must be exercised in using ETCO2 as an indicator of CPP.
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Affiliation(s)
- G B Martin
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan 48202
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40
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Martin GB, Nowak RM, Paradis N, Rosenberg J, Walton D, Smith M, Eisiminger R, Welch KM. Characterization of cerebral energetics and brain pH by 31P spectroscopy after graded canine cardiac arrest and bypass reperfusion. J Cereb Blood Flow Metab 1990; 10:221-6. [PMID: 2303538 DOI: 10.1038/jcbfm.1990.38] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Recovery of cerebral energy metabolism is used to indicate CNS viability after ischemia. This study utilized 31P nuclear magnetic resonance (NMR) spectroscopy to measure cerebral energy state and intracellular pH in dogs subjected to 8, 12, or 16 min of cardiac arrest and reperfusion using cardiopulmonary bypass. Spectra were obtained throughout ischemia and initial reperfusion and repeated at 30 and 144 h post ischemia. Neurologic deficit scoring was performed at 12 and 24 h post insult and then daily. High-energy phosphates were depleted by the end of all ischemic intervals. Recovery occurred within 60 min of reperfusion and persisted with no differences in the rate of return between groups (p greater than 0.05). Brain pH (pHb) decreased by the end of ischemia in all groups (p less than 0.0001). Neither the pHb nadir nor its recovery differed between groups (p greater than 0.05). Although longterm neurologic outcome differed between groups, the spectra were similar. Assessment of cerebral energy state using 31P NMR spectroscopy does not appear to be a sensitive indicator of neurologic outcome after global ischemia in dogs. Return of high-energy phosphates may be a necessary but not sufficient condition for cerebral recovery after ischemia. The return of high-energy phosphates after a 16-min cardiac arrest, however, indicates a potential for neurological recovery.
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Affiliation(s)
- G B Martin
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48202
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41
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Abstract
We present the case of a patient with cardiac arrest and resuscitation in whom, consistent with direct cardiac compression, large aortic-to-right atrial systolic pressure gradients occurred. Forward blood flow during CPR was sufficient for the patient to maintain consciousness. Although aortic-to-right atrial diastolic gradients adequate to maintain coronary perfusion in experimental models were generated, in our patient, cardiac function could not be restored and the resuscitation was ultimately unsuccessful.
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Affiliation(s)
- J R Lewinter
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan 48202
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42
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Paradis NA, Martin GB, Goetting MG, Rosenberg JM, Rivers EP, Appleton TJ, Nowak RM. Simultaneous aortic, jugular bulb, and right atrial pressures during cardiopulmonary resuscitation in humans. Insights into mechanisms. Circulation 1989; 80:361-8. [PMID: 2752563 DOI: 10.1161/01.cir.80.2.361] [Citation(s) in RCA: 130] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Pressure gradients across and between the head and chest were studied during mechanical cardiopulmonary resuscitation (CPR) in 22 humans. Patients in medical cardiac arrest, managed by ACLS guidelines, underwent placement of aortic arch (Ao), jugular venous bulb (JVB), and right atrial (RA) catheters. Simultaneous pressures were measured, and intercatheter gradients were calculated. The JVB to RA pressure difference is the gradient between the cervical and central venous circulations. It was negative when averaged throughout the CPR cycle and was more negative during compression than relaxation, -19 +/- 12 and -2 +/- 6 mm Hg, respectively. This indicates that the intrathoracic pressure rise was not transmitted to the jugular venous system, supporting the concept of a competent jugular valve mechanism during CPR. It is consistent with the thoracic pump model of cerebral perfusion. JVB to RA was positive only during early relaxation, allowing blood return from the head. The Ao to JVB gradient, although not equal to cerebral perfusion pressure, is the maximum potential pressure gradient for blood flow across the cerebral vasculature. It was positive throughout CPR, 25 +/- 17 during compression, and 9 +/- 10 mm Hg during relaxation. The Ao to RA gradient during the relaxation phase is CPR coronary perfusion pressure. In most patients, it was minimally positive in both phases of the CPR cycle: 7 +/- 14 in compression and 7 +/- 9 mm Hg during relaxation. This appears to be inadequate in providing sufficient blood flow to meet the metabolic needs of the myocardium. Four patients had larger gradients during compression suggestive of cardiac compression.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- N A Paradis
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48202
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43
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Gentile NT, Martin GB, Moeggenberg J, Appleton TJ, Paradis NA, Nowak RM. Effects of arterial and venous volume infusion on coronary perfusion pressure during canine CPR. Ann Emerg Med 1989. [DOI: 10.1016/s0196-0644(89)80704-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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44
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Appleton TJ, Paradis N, Martin GB, Bovell D, Goetting MG, Rivers EP, Nowak RM. Coronary perfusion pressures during CPR are higher in patients with eventual return of spontaneous circulation. Ann Emerg Med 1989. [DOI: 10.1016/s0196-0644(89)80806-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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45
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Carden DL, Martin GB, Nowak RM, Foreback CC, Tomlanovich MC. The effect of cardiopulmonary bypass resuscitation on cardiac arrest induced lactic acidosis in dogs. Resuscitation 1989; 17:153-61. [PMID: 2546231 DOI: 10.1016/0300-9572(89)90067-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The adequacy of end organ blood flow following a cardiac arrest varies depending on the artificial reperfusion technique utilized and may critically affect patient outcome. Both oxygen consumption (VO2) and arterial lactate values have previously been used to assess tissue perfusion. Cardiopulmonary bypass resuscitation (CPB) is a reperfusion technique capable of providing near normal end organ blood flow. The purpose of this investigation was to study the effect of femoro-femoral veno-arterial CPB resuscitation compared to standard CPR on VO2 and arterial lactic acid values after a prolonged cardiac arrest. Ten mongrel dogs were electrically fibrillated and left in cardiopulmonary arrest without therapy for 12 min. Resuscitation was attempted according to a standardized protocol utilizing either CPB (n = 5) or standard external CPR (n = 5). Oxygen consumption values and arterial lactic acid samples were obtained at baseline, at timed intervals throughout resuscitation and after return of spontaneous circulation in successfully resuscitated dogs. Baseline hemodynamic and biochemical measurements were similar in both treatment groups (P greater than 0.05). Oxygen consumption (440 +/- 50 ml/min/M2) and mean arterial lactic acid values (7.44 +/- 2.25 mmol/l) were significantly higher at 1 min of resuscitation in CPB-treated dogs compared to dogs treated with CPR (60 +/- 10 ml/min/M2) (3.16 +/- 0.69 mmol/l) respectively (P less than 0.05). Mean arterial lactic acid values rose significantly at each sampling interval during CPR (P less than 0.05) but began to decrease after 5 min of resuscitation in the CPB animals and were not significantly different than baseline after 60 min of bypass (P greater than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- D L Carden
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48202
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46
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Rivers EP, Paradis NA, Martin GB, Goetting MG, Appleton TJ, Nowak RM. Cerebral lactate uptake during prolonged global ischemia in human beings. Ann Emerg Med 1989. [DOI: 10.1016/s0196-0644(89)80809-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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47
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Thompson BM, Nowak RM, Hourani JM. The prognostic value of the Glasgow Coma Scale measured 24 hours after inpatient single cardiopulmonary arrest and resuscitation. Ann Emerg Med 1989. [DOI: 10.1016/s0196-0644(89)80712-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Rosenberg JM, Martin GB, Paradis NA, Nowak RM, Walton D, Appleton TJ, Welch KM. The effect of CO2 and non-CO2-generating buffers on cerebral acidosis after cardiac arrest: A 31P NMR study. Ann Emerg Med 1989; 18:341-7. [PMID: 2539765 DOI: 10.1016/s0196-0644(89)80565-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
There is controversy regarding the use of alkalinizing agents during reperfusion after cardiac arrest. The potential deleterious effects of sodium bicarbonate (bicarb) administration, including paradoxic cerebral acidosis, have led to the search for alternative agents. Tromethamine (tris) is a non-CO2-generating buffer that has been proposed for use during cardiopulmonary resuscitation. The purpose of this experiment was to compare the ability of tris with bicarb to correct brain pH (pH B) during reperfusion after a 12-minute cardiac arrest. Adult mongrel dogs were instrumented and placed in the bore of a Bruker Biospec 1.89 tesla superconducting magnet system. Ventricular fibrillation was induced; after 12 minutes, cardiopulmonary bypass was initiated and maintained for two hours with minimum flows of 80 mL/kg/min. Bicarb (n = 5) or tris (n = 5) were administered to correct arterial pH as rapidly as possible. 31P NMR spectra were obtained at baseline and throughout ischemia and reperfusion. The pH B was determined with the inorganic phosphate relative to the phosphocreatine resonance signal shift. Profile analysis indicates a difference between groups (P less than .02) related to an initial delay in pH B correction in the tris group. By 48 minutes of reperfusion, pH B did not differ between the groups. Moreover, there was no evidence of paradoxic cerebral acidosis in the bicarb group. Although tris corrects blood pH as quickly as bicarb, it is less effective in correcting pH B. Absence of paradoxic acidosis may be caused by efficient elimination of CO2 by cardiopulmonary bypass.
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Affiliation(s)
- J M Rosenberg
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan 48202
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49
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Abstract
Although hypokalemia has been reported after cardiac arrest and successful resuscitation, experimental data indicate that potassium is released from cells during ischemia. The purpose of this investigation was to study serum potassium concentration ([K+]) during closed chest cardiopulmonary resuscitation (CC-CPR) in humans. Twenty-two patients presenting to the emergency department (ED) in cardiopulmonary arrest had simultaneous measurement of central venous and arterial [K+] and blood gases during CC-CPR utilizing current advanced cardiac life support protocols and a pneumatic chest compressor and ventilator. Mean arterial and central venous [K+] were 5.0 +/- 1.3 and 5.6 +/- 2.9 mEq/L, respectively, (p greater than .05) with 7 patients having [K+] of greater than 6 mEq/L. Significant hyperkalemia does occur in some patients during cardiac arrest and CC-CPR. Because poor tissue perfusion during CC-CPR impairs exchange between the interstitial and intravascular compartments, increases in interstitial [K+] would be expected to be even greater. Interstitial hyperkalemia may play a role in the genesis of wide complex electromechanical dissociation (EMD) seen after prolonged cardiac arrest. Since calcium has long been known to be beneficial in the treatment of hyperkalemia-induced dysrhythmias, the success of calcium chloride in treating wide complex EMD may be on the basis of this phenomenon.
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Affiliation(s)
- G B Martin
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48202
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50
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Abstract
Survival after out-of-hospital cardiac arrest is intimately related to the time from cardiovascular collapse to the initiation of CPR, or downtime. Furthermore, the reperfusion technique that optimizes coronary and cerebral blood flow after cardiac arrest may also be dependent on downtime. Peak blood lactate levels have been shown to be unchanged throughout resuscitation and predictive of downtime in dogs subjected to cardiopulmonary arrest and open cardiac massage. The purpose of this study was to determine the course of arterial lactate levels in dogs subjected to a fibrillatory cardiopulmonary arrest and conventional closed-chest CPR (CCPR). Fourteen dogs were subjected to five minutes of cardiopulmonary arrest and 30 minutes of CCPR. Resuscitation was performed according to a standardized protocol. Arterial lactic acid samples were collected at timed intervals throughout the experiment. Mean arterial lactic acid levels increased significantly with each sampling interval during 30 minutes of CCPR (overall P less than .05). In nine dogs successfully resuscitated, there were no significant differences in mean arterial lactic acid levels after the return of spontaneous circulation (ROSC). Open-chest resuscitation after five minutes of ventricular fibrillation in dogs results in peak lactic acid levels that do not change significantly once internal cardiac massage is initiated. In contrast, CCPR in similarly arrested dogs does not appear to provide adequate tissue oxygenation and/or perfusion to prevent continuous lactic acid accumulation.
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Affiliation(s)
- D L Carden
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan 48202
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