This is Journal Watch, a medical-literature
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  Contents copyright 1994, Mass. Medical Society.

Journal Watch Summaries for November 29, 1994

CONTINUED CPR IN THE EMERGENCY ROOM IS NOT ALWAYS
FUTILE.
  Arch Intern Med 1994 Nov 14; 154:2433-7.

COSTOCHONDRITIS IN PATIENTS WITH CHEST PAIN.
  Arch Intern Med 1994 Nov 14; 154:2466-9.

RADIOIODINE THERAPY FOR LARGE GOITERS.
  Ann Intern Med 1994 Nov 15; 121:757-62.

CARBAMAZEPINE FOR AGITATION IN DEMENTED ELDERLY
PATIENTS.
  J Am Geriatr Soc 1994 Nov; 42:1160-6.

COPOLYMER MEMBRANE HEALS BEDSORES IN THE ELDERLY.
  J Am Geriatr Soc 1994 Nov; 42:1180-3.

PAST MALPRACTICE CLAIMS PREDICT FUTURE LITIGATION.
  JAMA 1994 Nov 9; 272:1421-6.

CONTINUED CPR IN THE EMERGENCY ROOM IS NOT ALWAYS
FUTILE.
   When out-of-hospital cardiopulmonary resuscitation
fails, continued CPR in the emergency department is
considered to have very poor outcomes (see Journal Watch
accession number 931005003 and JAMA 1993;270:1433-6, 1457-
62). This retrospective, single-site study from Basel,
Switzerland reexamined the issue.
   During a five-year span, the emergency medical systems
(EMS) participated in 266 out-of-hospital arrests. CPR was
successful in 24 patients, and 97 were declared dead at the
scene. The other 145 patients were brought to the ED for
ongoing resuscitation; of 141 for whom charts were
available, 91 died in the ED. The remaining 50 (35 percent)
were resuscitated, and 18 (13 percent) survived to hospital
discharge after a mean stay of 44 days. At one year, 17 of
the 18 were still alive, 16 with minimal or no neurologic
damage. Survivors waited less time than nonsurvivors for the
EMS to arrive after their arrest (6 vs. 9 minutes) and more
often had CPR initiated by bystanders (44 vs. 15 percent).
No patients with electromechanical dissociation or asystole
noted in the field or in the ED survived.
   Comment: Continuing CPR in the ED is not always futile.
The authors attribute the higher survival rate (13 percent,
as compared with less than 2 percent in past studies) to
several factors, including their hospital's central location
in a small city and high termination rates of CPR in the
field, which resulted in the ED receiving fewer hopeless
cases. --CD Mulrow.
   Citation: Schoenenberger RA; et al. Survival after failed
out-of-hospital resuscitation: are further therapeutic efforts
in the emergency department futile?. Arch Intern Med 1994 Nov 14;
154:2433-7.

COSTOCHONDRITIS IN PATIENTS WITH CHEST PAIN.
   Costochondritis, or musculoskeletal chest-wall pain,
is commonly considered in the differential diagnosis of
chest pain. This prospective study compared features of
costochondritis to those of other causes of chest pain in
122 consecutive patients presenting to a New York emergency
room.
   Costochondritis was defined as pain over the
costochondral or costosternal joints produced by palpation
firm enough to induce partial blanching of the examining
finger. The 36 patients with costochondritis included a
higher proportion of women and Hispanics than patients
without costochondritis, and they were more likely to have
widespread pain, pleuritic pain, morning stiffness, and
joint pain. Age, weight, and histories of hypertension,
diabetes, and smoking did not differ between groups. Three
patients with costochondritis met criteria for fibromyalgia,
and five more had rheumatoid arthritis or osteoarthritis.
Myocardial infarction was diagnosed in 6 percent of patients
with costochondritis and 28 percent of those withoutcostochondritis.
   Comment: This moderately sized study reminds us that
patients with costochondritis often have multiple other
musculoskeletal complaints. Just as important, the presence
of costochondritis in a patient with chest pain does not
always exclude the possibility of MI. --CD Mulrow.
   Citation: Disla E; et al. Costochondritis: a prospective analysis
in an emergency department setting. Arch Intern Med 1994 Nov 14;
154:2466-9.

What would be much more interesting would be a multicenter study of
electromechanical dissociation asystole, and survival.  I've never seen
someone successfully resuscitated if they had these rhythms on arrival
in the ED, but resuscitation attempts often continue.  Is there any
reason not to stop CPR if the patient is asystolic on arrival to the
ED?

------------------
Greg Froehlich, MD
White River Junction, VT

Also, of course, there are those people who are in "EMD" for mechanical
reasons such as hypovolemia and tamponade, and with rapid therapy
it is possible that some of them could be resuscitated.  Admittedly
these may not be true EMD, but from the outside all you can tell
is that there's electrical activity and no pulse.
--
David Rind

Rob Palmer, Ph.D., EMT-P
Department of Medicinal Chemistry
University of Washington School of Pharmacy
Seattle, Washington

------------------
Greg Froehlich, MD
White River Junction, VT

Rob Palmer, PhD
Dept. of Medicinal Chemistry
University of Washington
Seattle, Washington

JRIt has always been difficult for me (must be my training) to make a fast
  and certain decision of what is asystole or emd in an arrested patient.

Asystole and EMD are very different since, by definition, EMD has a
electrical activity but no output. I have seen a number of people
return from EMD. I have had only one case of true asystole return.

Like you I always treat asystole as fine v-fib. To me asystole is a
death sentence and v-fib has the potential for reversibility.

JRIs then this talk about ending ACLS prematurely not making things worse ?
  I believe that in these situations sticking to the protocol makes things
  easier, gives you time to think things over, and is comforting to the
  family and helpers that may have started BLS.

One of the points that is often skimmed over is what happens to some
of our "successes". I run an ICU and there isn`t a day that I don`t
have a ER admitted CPR "survivor" ventilated in my unit. The number
that eventually leave hospital is depressingly low and the number with
 irreversible hypoxic encephalopathy is depressingly high.

Ted

 * 1st 1.11 ~ Let me know if you didn't receive this message!

Absolute agreement with you so far.

->there is ANY question at all, go ahead and shock.  You would certainly
->not be doing any damage by defibrillating the asystolic patient, you
->would just not gain any ground.  

Here I must disagree, and the 1994 ACLS standards agree with me. For
reference, see the ACLS standards, also see

Brown DC, Lewis AJ, Criley JM. "Asystole and its treatment: the
possible role ofthe parasympathetic nervous system in cardiac arrest"
_Journal of the American College of Emergency Physicians_
1979;8;448-452

Vassale M. "On the mechanisms underlying cardiac standstill: factors
determining success or failure of escape pacemakers in the heart"
_Journal of the American College of Cardiology_ 1985;5;35B-42B

Thompson BM, Brooks RC, Pionkowski RS, Aprahmian C, Mateer JR
"Immediate countershock treatment for asystole"
_Annals of Emergency Medicine_ 1984;13:827-829.

Stults K, Brown D, "Converting asystole"
_Journal of Emergency Medical Service_ 1984;9:38-39.

->Clearly, if you were seeing fine VF, you
->could potentially gain some ground.
->
True, but it is necessary to differentiate with some degree of
certainty between isoeletric VF and true asystole. Shocking asystole
is counterproductive; the "stunning" of the heart and the
parasympathetic nervous system are detrimental to our efforts to
restore normal circulation. The theory that 'you can't hurt anything
by shocking asystole' has been debunked.

--
"'Weird' is a relative, not absolute term." - Me