HBO therapy did not add benefit to normobaric oxygen therapy in these studies.
In two parallel prospective randomized studies, researchers evaluated the effectiveness of hyperbaric oxygen therapy (HBOT) in patients (age, ≥15 years) with acute isolated carbon monoxide (CO) poisoning who presented to an academic hospital in France between 1989 and 2000. In trial A (mild poisoning), 179 patients with transient loss of consciousness received normobaric oxygen therapy (NBOT) for 6 hours or NBOT for 4 hours plus one session of HBOT. In trial B (severe poisoning), 206 comatose patients (Glasgow Coma Scale score below 8) received NBOT for 4 hours plus either one or two HBOT sessions. Each HBOT session lasted 2 hours in a multiplace chamber at 2.0 atmospheres absolute; interval between sessions was 6 to 12 hours. At baseline, 82% of patients in trial A and 65% in trial B had headaches, and 4% and 10%, respectively, had seizures.
At 1 month, patients completed a symptom questionnaire and were evaluated by an intensivist with neurology training who was blinded to treatment group. Complete recovery was defined as absence of patient-reported symptoms and normal physical and neuropsychological exam, "moderate sequelae" was defined as one or more self-reported symptoms, and "severe sequelae" was defined as any objective physical exam finding. In trial A, complete recovery rates were similar in the two groups (approximately 60%), and no patient in either group had severe sequelae. In trial B, complete recovery rates were significantly lower in the group that received two HBOT sessions than in the group that received one session (47% vs. 68%; unadjusted odds ratio, 0.42).
The trial A findings support the teaching that most patients with mild CO poisoning will improve after removal from the exposure and treatment with high-flow oxygen. The trial B finding is surprising and suggests that HBOT might not benefit even those patients with severe toxicity. Pending a larger trial with clearer toxicity definitions, physicians should contact a regional poison center or HBOT referral center to discuss with consultants the best approach for an individual patient with known CO poisoning, particularly when the treatment might involve transfer of an unstable patient.
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine January 28, 2011
Annane D et al. Hyperbaric oxygen therapy for acute domestic carbon monoxide poisoning: Two randomized controlled trials. Intensive Care Med 2010 Dec 2; [e-pub ahead of print]. (http://dx.doi.org/10.1007/s00134-010-2093-0)
The 2010 International Liaison Committee on Resuscitation Pediatric Task Force has updated the 2005 treatment recommendations for pediatric resuscitation. Highlights include the following:
- Initiate cardiopulmonary resuscitation (CPR) if there are no signs of life and a pulse is not palpated within 10 seconds.
- Provide conventional CPR (chest compressions with rescue breathing).
- Compress at least one third of the anterior-posterior dimension of the chest.
- Consider using cuffed tracheal tubes in infants and young children; cuff pressure should not exceed 25 cm H2O. Appropriate sized tubes by age are as follows:
# 3 mm for age ≤1 year
# 3.5 mm for age 1–2 years
# Age in years/4 + 3.5 mm for age >2 years
- Modify or discontinue cricoid pressure if it impedes preintubation ventilation or intubation.
- Monitor capnography to confirm endotracheal tube position, recognizing that end-tidal CO2 in infants and children might be below detectable limits for colorimetric devices (85% sensitivity and 100% specificity).
- Consider use of an esophageal detector device in children weighing >20 kg.
- Use capnography monitoring to assess effectiveness of chest compressions.
- Avoid excessive ventilation, which can decrease cerebral perfusion pressure, rates of return of spontaneous circulation (ROSC), and survival rates.
- After ROSC, titrate oxygen concentration to limit the risk for toxic oxygen byproducts.
- For pediatric septic shock, include therapy directed at normalizing central venous oxygen saturation to ≥70%.
- Do not routinely use bicarbonate or calcium for pediatric cardiac arrest: Both agents are associated with decreased survival.
These consensus recommendations are based on a thorough evaluation of the literature, and emergency physicians should know them.
Katherine Bakes, MD
Published in Journal Watch Emergency Medicine January 21, 2011
Citation(s): Kleinman ME et al. Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Pediatrics 2010 Nov; 126:e1261.
Amoxicillin–clavulanate has been shown to be the most effective treatment for acute otitis media.
As compared to placebo treatment, what were the benefits of antibiotic treatment for children 6 to 23 months of age with acute otitis media in this clinical trial?
Children who were treated with amoxicillin–clavulanate, as compared with those who received placebo, had consistently more favorable short-term outcomes, including a sustained symptomatic response, an absence of otoscopic evidence of persistent middle-ear infection, and a reduced rate of residual middle-ear effusion.
As compared to placebo treatment, was speed of resolution different for children who received antibiotic treatment in this study?
Yes, among the children who received amoxicillin–clavulanate, 35% had initial resolution of symptoms by day 2, 61% by day 4, and 80% by day 7; among children who received placebo, 28% had initial resolution of symptoms by day 2, 54% by day 4, and 74% by day 7.
As compared to placebo-treated children, what adverse effects were significantly more common among children with acute otitis media who received antibiotic treatment?
Dermatitis in the diaper area and protocol-defined diarrhea occurred commonly, and often together, among children receiving antimicrobial agents. Both protocol-defined diarrhea and diaper area dermatitis occurred significantly more frequently among children who received amoxicillin–clavulanate than those that received placebo.
The rate of bloodstream infections for central lines placed in a single emergency department was comparable to the rate for lines placed in the intensive care unit.
On January 1, 2010, The Joint Commission added to its quality measures a National Patient Safety Goal for use of maximum barrier precautions and a checklist and standardized protocol for placement of central venous catheters throughout the hospital, including in the emergency department (ED). In a retrospective chart review, researchers determined the rate of central line–associated bloodstream infections (CLABSIs) in a single urban academic ED in Boston before implementation of the checklist.
During 2007 and 2008, 656 patients underwent placement of central lines in the ED and 7 CLABSIs were reported. The CLABSI rate for lines placed in the ED was 1.93 per 1000 catheter-days. The CLABSI rate for lines placed in the hospital's ICU during 2008 was 1.51 per 1000 catheter-days, and the nationally reported rate for ICU-placed central lines was 2.05 per 1000 catheter-days.
Central lines placed in the ED are perceived as being more prone to infection than those placed in the ICU for myriad reasons, particularly the urgency with which such lines often are placed. However, in this single-hospital study, CLABSI rates were similar for lines placed in the ED and the ICU.
Richard D. Zane, MD, FAAEM
Published in Journal Watch Emergency Medicine January 7, 2011
Citation(s): LeMaster CH et al. Infection and natural history of emergency department–placed central venous catheters. Ann Emerg Med 2010 Nov; 56:492.