ABSTRACTS cardiographyshowed a blunting of the left ventricular dysfunctionwith esmolol infusion. In the absenceof I~-blockade,the left ventricular ejection fraction significantly decreased from 55% to 38% after acute coronary occlusion(P< .05)in contrast to no significantdecrease(52% vs 49%) with l&blockade.In addition, I&blockade delayedthe onset of segmental wall motion abnormalitiesand reduced the decline in cardiac output. The authors concludedthat the use of I~ blockadediminishes the ischemic effects of acute myocardial hypoperfusion.[Editor's note: Esmolol is almost the ideal a-blocker for emergency situations because it has an ultrashort duration of action, making it titratable by drip infusion. It can be used even in those patients who have relative contraindications to f~ blockers due to its rapid elimination half-life of about nine minutes.]
culatory fistula through the heating mechanism of a modified commercially available counter-currentfluid warmer to achieve rapid extracorporeal rewarming. Heparinwas infused into the afferent limb of the heat exchangerand reversedwith protamine in the efferent limb. The rewarming rate achieved in this case was 1 C every 15.4 minutes. The patient survivedwith full neurologic recovery.While continuousarterovenous rewarming is analogousto cardiac bypass in that it infuses warm blood directly into the heart, it avoids the need for a blood pump, membraneoxygenator,and systemic heparinization,making it applicable to patients who have a contraindication to anticoagulation or in hospitals where cardiac bypass is not available.
Evaluation and treatment of blunt renal trauma
Continuous arteriovenous rewarming: Report of a new teehnique for treating hypothermia Gentilello LM, Rifley WJ J Trauma31:1151-1154 Aug 1991 Presentlyavailable methods of treating hypothermiainclude heating blankets, radiant warmers, body cavity lavage,and airway rewarming. Evenwith extreme effort, rewarming rates with these techniques generally do not exceed 1 C per hour. Cardiacbypass provides rapid effective treatment for hypothermia, but the need for systemic heparinizationcontraindicates its use in multiple trauma victims. The authors report the use of continuous arteriovenousrewarming in a victim of multiple trauma and severe hypothermia refractory to other rewarming techniques.Arterial and venous catheters were usedto create a cir-
Mark Copeland, MD
Herschorn S, Radomski SB, Shoskes DA, et al J Urol 146.274-277 Aug 1991 A retrospectiveanalysis of 126 patients with blunt renal trauma was performed in order to define the need for further radiological studies and to determine which are most helpful. Injuries were classified as minor if there was a contusion, subcapsular hematoma,or superficial laceration; moderate if there was a deep laceration through the corticomedullaryjunction or into the collecting system causing extravasation; and major if there was a pedicle injury or a shattered kidney. Seventy-two percentwere minor, 17% moderate,and 11% had major renal injury. The most common cause of injury (67%) was motor vehicle accidents. All of the 14 patients with a major injury, and 20 of the 21 patients with a moderate injury presentedwith gross hematuria (the other patient presented with microscopichematuria and
hypovolemicshock). Fifteen patients underwentboth an intravenouspyelogram and computedtomography(CT) scan. Sevenof the 15 had a normal intravenouspyelogram.Of these seven, four had an abnormal CT scan. Long-termcomplications included sepsis in nine patients and hypertension in four. Eighty-seven percent of the patients in the study had an excellent outcomewith no clinical, biochemical,or radiolagical evidenceof renal pathologyat follow-up. Eight percent had a good outcome, ie, a kidney with less than normal function. Two patients had renal failure, and four patients died, but of causes unrelated to the renal injury. The authors concludedthat most patients with blunt renal injury can be managedconservativelyand that any patient who presents with gross hematuria or microscopic hematuria and shock should undergo further radiological evaluation. Otherwise, further studies are not necessary unless they are indicated because of concomitant injuries. CT scan appearsto be the most sensitive and specific test available.
dose of 5.6 mg/kg aminophylline followed by 0.9 mg/kg/hr infusion while the placebo group received equivalent volume of placebo. Spirometry reading (FEV~,FVC,and PEFR)were obtained initially and every 60 to 120 minutes thereafter. The results showed no difference between the two groups' spirometry reading, patient evaluation of treatment regimen,physician assessment of response,or time in the department. Interestingly,there was a significant difference in the admission rates of the two groups with 6% of the aminophylline-treated group requiring admission,compared with 21% of the placebogroup (P= .016). The aminophylline-treated group had a median theophylline blood level at the end of their emergency departmentcourse of 9.7 mg/L comparedwith 2.4 mg/L for the control group. The authors concluded that aminophyllineappearsto decreasehospital admissionsin patients with acute exacerbationof asthma or chronic obstructive pulmonarydisease.
Andrew Ziller, MD
Eric Gilbert, MD thrombolytics aminophylline
Aminophylline therapy for acute bronehospastie disease in the emergency room Wrenn K, Slovis CM, Murphy F, et al Ann Intern Med 115.2241-2247 Aug 1991 This was a randomized,doubleblind, placebo-controlledstudy involving 133 patients with either asthma or chronic obstructive pulmonary disease. Patients excluded from the study were those who had taken a theophylline preparation in the past 24 hours and those who had a contraindicationto corticosteroids or I&-agonists.All patients enrolled in the study receivedmetaproterenol nebulizertreatments and 80 mg of IV methylprednisolone.Patientswere randomizedto receive a loading
A prospective, randomized trial comparing combination halfdose tissue-type plasminogen activator and streptokinase with full-dose tissuetype plasminogen activator Grines CL, Nissen SE, Booth DC, eta/ Circulation 84:540-548 Aug 1991 A randomized,prospectivetrial comparing a combinedregimenof tissue-type plasminogenactivator (tPA) and streptokinase(SK)with conventional tPA therapy was performed. Two hundredsixteen patients were randomizedwithin sixhours ~.
ANNALS OF EMERGENCY MEDIClNE 21:1 JANUARY1992