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Biomedical subjects

R E Fromm

Publications and source records attributed to R E Fromm.

At least 55 records · Page 3Linked to original sources
PubMed1993

Cardiac arrest presenting with rhythms other than ventricular fibrillation: contribution of resuscitative efforts toward total survivorship.

OBJECTIVE: The medical literature portrays a bleak prognosis for out-of-hospital cardiac arrest cases presenting with asystole, idioventricular rhythms with pulselessness, or primary electromechanical dissociation. In view of evolving philosophies to waive resuscitation attempts in such cases, we sought to delineate the actual contribution toward overall survivorship that is provided by resuscitation efforts for patients who have these electrocardiographic presentations. DESIGN: A prospective outcome study which analyzed all out-of-hospital cardiac arrest cases in a large city for a 2-yr period in terms of presenting electrocardiogram, age, sex, presence and status of witnesses, performance of bystander cardiopulmonary resuscitation, and survival to successful hospital discharge. SETTING: A large urban municipality (population, two million) served by a single, centralized emergency medical services program. PATIENTS: Excluding cases associated with trauma, drugs, airway obstruction, submersion or primary respiratory illness, 2,404 consecutive adult out-of-hospital cardiac arrest patients were studied. INTERVENTIONS: Standard advanced cardiac life support. MEASUREMENTS AND MAIN RESULTS: Although survival "rates" of patients with asystole, idioventricular rhythms with pulselessness, and electromechanical dissociation were low (1.6%, 4.7% and 6.9%, respectively), 22.2% of the 193 total survivors (confidence interval: +5.9%) initially presented with one of these electrocardiographic rhythms (14 asystole, 18 idioventricular rhythms with pulselessness, 10 electromechanical dissociation, plus one other). CONCLUSIONS: Despite poor survival "rates," resuscitative efforts for patients presenting with asystole, electromechanical dissociation, and idioventricular rhythms with pulselessness all contribute significantly toward a community's total survivorship from out-of-hospital cardiac arrest. Initial, aggressive attempts at resuscitation still should be emphasized in such patients.

Accelerated Idioventricular Rhythm↗
PubMed1993

Air medical transport.

Emergency air medical transport has become an integral part of the practice of medicine. In 1990, there were more than 170 air medical programs in operation in the United States. The proper and safe use of air medical transport requires a basic understanding of the medical implications of flight and the capabilities and constraints involved in transporting patients by air. The purpose of this paper is to review this information and provide guidelines for the use of air medical transport.

Aircraft↗
PubMed1992

Prospective evidence of a circadian rhythm for out-of-hospital cardiac arrests.

OBJECTIVES: Published studies have indicated a circadian rhythm in the occurrence of sudden cardiac death. However, these studies have involved either retrospective analyses of death certificates or analyses of data collected during studies of pharmacologic agents in selected populations. PURPOSE: To determine whether a circadian pattern could be clearly demonstrated in a prospective study of out-of-hospital sudden cardiac death in a large, unselected population. DESIGN: All adult cases of sudden death of presumed primary cardiac cause from a large urban population were prospectively evaluated over a 12-month period. The incidence of sudden cardiac death was analyzed using harmonic regression of the data tabulated by hour of the day. RESULTS: During the year of study, 1019 consecutive primary cardiac arrests were analyzed. A significant circadian pattern was found (P less than .0001) with the frequency of cardiac arrests increasing dramatically from 6 AM until noon. CONCLUSIONS: This prospective study of out-of-hospital cardiac arrest confirms the existence of a circadian rhythm. These data have important implications for future investigations concerning the pathophysiology of sudden cardiac deaths.

Ambulatory Care↗
PubMed1992

The incidence of pacemaker dysfunction during helicopter air medical transport.

A number of recent publications have raised concern regarding in-flight pacemaker dysfunction during air medical transport. Unfortunately the clinical importance of this problem is unknown. The authors' purpose was to examine the incidence of pacemaker use and malfunction during helicopter air medical transport, using an incidence (cohort) study of an air medical service of a tertiary-care teaching hospital. During the study period, April 1, 1987 through December 31, 1991 2,388 patients were air-transported. Cardiac patients constituted 72% of the total population. Pacemakers were used in 44 patients, temporary transvenous pacemakers in 35, permanent transvenous in five, and transcutaneous pacers in four patients. No rate-responsive pacemakers were transported. No episodes of pacemaker malfunction were observed (95% confidence interval 0 to .002 for the population as a whole). The authors conclude that pacemaker dysfunction during air medical transport is a very rare occurrence, in part due to the infrequent transport of patients requiring these devices.

Aged↗
PubMed1992

Circadian variation in the time of request for helicopter transport of cardiac patients.

STUDY OBJECTIVES: The literature has demonstrated circadian rhythms in the occurrence of nonfatal myocardial infarction, ischemia, and sudden death. We hypothesized that requests for helicopter transport of acutely ill cardiac patients followed a similar circadian pattern and differed significantly from requests for helicopter transport of other categories of patients. DESIGN: Prospective study of requests for helicopter transport of 1,128 consecutive air medically transported patients over a 24-month period. SETTING: One tertiary-care teaching hospital. MEASUREMENTS AND MAIN RESULTS: The periodic structure of the time distribution of cardiac requests for helicopter transport was examined with a two-harmonic regression analysis using a 24-hour period of oscillation. Seven hundred eighty-seven cardiac and 315 noncardiac patients could be evaluated. The times of requests for helicopter transport were tabulated into hourly intervals. Cardiac-related requests for helicopter transport were significantly different from noncardiac-related requests for helicopter transports (P less than .009 by Wilcoxon rank sum test, P less than .032 by Kolmogorov-Smirnov test). The regression model for cardiac requests for helicopter transport was also significant (P less than .0001, R2 = .81) with increasing requests for helicopter transport from 6:00 AM until 12:00 noon. CONCLUSION: The time distribution of requests for helicopter transport for cardiac patients demonstrates a striking circadian variation not observed in noncardiac patients. This observation strengthens mechanistic inferences from studies of circadian variation and suggests a "morning-loaded" staffing pattern for air medical services predominantly transporting cardiac patients.

Aircraft↗
PubMed1992

Utilization of specialized services by air transported cardiac patients: an indicator of appropriate use.

Recent studies of appropriateness of air medical transport have not specifically examined the need of cardiac patients for specialized services not available in the original community setting. This study examined the subsequent use of specialized services (i.e., coronary bypass surgery, angioplasty) by 796 consecutively aeromedically transported cardiac patients as an indicator of appropriate use of air transport. At least one specialized service was received by 552 (69.3%) patients. Preflight or transport interventions outside the clinical scope of the available ground transport system--a narrow, but objective assessment of appropriateness--were received by 507 patients and were associated with subsequent receipt of posttransport specialized services (p less than 0.0001). We conclude that the use of specialized services by cardiac patients was high and associated with an objective measure of appropriateness of transport. Studies of aeromedical transport should consider the need for specialized services in addition to intensity of care in the determination of appropriate use.

Aircraft↗
PubMed1991

Bleeding complications following initiation of thrombolytic therapy for acute myocardial infarction: a comparison of helicopter-transported and nontransported patients.

STUDY OBJECTIVE: To evaluate the effect of helicopter transport of acute myocardial infarction (AMI) patients after initiation of thrombolysis on bleeding complications through hospital discharge. DESIGN: Prospectively identified incidence (cohort) study. SETTING: Air medical service of tertiary-care teaching hospital. TYPES OF PARTICIPANTS: Ninety-five consecutive AMI patients transported within 12 hours of the initiation of thrombolysis with recombinant tissue-type plasminogen activator were compared with 119 nontransported AMI patients treated in a similar manner. RESULTS: The transported and nontransported populations were similar with regard to age, sex, and infarct location. Transport was well tolerated with no episodes of cardiac arrest or cardioversion occurring during transport. Hypotension requiring fluids or increased pressors occurred in 18 patients. Bleeding complications of all types occurred in 43.2% of the transported and 49.6% of the nontransported patients, respectively (relative risk, 0.87; 95% confidence interval, 0.65 to 1.17). CONCLUSION: Helicopter transport of AMI patients after initiation of thrombolysis appears to be safe acutely and without a clinically significant increase in risk of bleeding complications through hospital discharge when accomplished by a highly skilled team.

Aircraft↗
PubMed1991

Hypercalcemia complicating an industrial near-drowning.

A 28-year-old man presented with lethargy, solmulence, and polyuria following near-drowning in a vessel of an offshore oil rig. Laboratory evaluation demonstrated severe hypercalcemia that responded to saline diuresis and nasogastric suctioning. Calcium salts are used frequently in the drilling and completion of oil wells, and it is presumed that this patient's hypercalcemia represented acute intoxication from swallowed and aspirated fluid. This case highlights the need to consider the potential constituents of the drowning fluid in victims of near-drowning, particularly if unexplained clinical phenomena are evident.

Accidents, Occupational↗
PubMed1989

The cardiovascular response of normal humans to the administration of endotoxin.

Marked abnormalities in cardiovascular function accompany septic shock, and bacterial endotoxin is believed to be one of the principal mediators of these abnormalities. To evaluate the cardiovascular effects of endotoxemia in humans, we measured hemodynamic variables in nine normal subjects given an intravenous bolus dose of endotoxin (Escherichia coli, 4 ng per kilogram of body weight) and in six normal subjects given a bolus dose of saline, before and three hours after administration. All the subjects then underwent volume loading with normal saline (mean, 2217 ml) during the fourth and fifth hours after administration of the bolus, and the measurements were repeated. Three hours after the administration of endotoxin and before volume loading, the cardiac index had increased by 53 percent and the heart rate by 36 percent (both changes were significant; P less than or equal to 0.008), and the systemic vascular-resistance index had decreased by 46 percent (P = 0.004). After volume loading (five hours after the administration of endotoxin), the left ventricular ejection fraction decreased by 1 percent of the base-line value in the subjects given endotoxin, but increased by 14 percent in the controls (P = 0.008). The left ventricular end-diastolic and end-systolic volume indexes increased by 18 percent (P = 0.07) and 24 percent (P = 0.042), respectively. Left ventricular performance, as measured by the ratio of the peak systolic pressure to the end-systolic volume index, was depressed (a decrease of 0.90 in the subjects given endotoxin vs. an increase of 0.76 in the controls; P = 0.024). We conclude that the administration of endotoxin to normal subjects causes a depression of left ventricular function that is independent of changes in left ventricular volume or vascular resistance. The changes in function are similar to those observed in septic shock and suggest that endotoxin is a major mediator of the cardiovascular dysfunction in this condition.

Adult↗
PubMed1984

Hemophilic arthropathy complicated by polyarticular septic arthritis.

A case of multiple pyarthroses due to Staphylococcus aureus occurring in a severe classical hemophiliac is presented. Successful management depended on drainage of the infected joints and a prolonged course of antibiotics. Several criteria are suggested for recognition of hemophiliacs who might benefit from joint aspiration as a diagnostic tool for the presence of septic arthritis.

Adult↗
PubMedDate not supplied

Congestive heart failure and pulmonary edema for the emergency physician.

Congestive heart failure (CHF) and pulmonary edema are major health problems in the United States as well as across the rest of the developing world. The prevalence of CHF and pulmonary edema in the general population results in a significant number of these patients presenting to Emergency Departments (EDs). Mortality from these disorders is substantial, with a 5-year mortality rate for patients requiring hospitalization of approximately 50%. Understanding of the clinical syndromes of CHF and pulmonary edema requires review of the basic determinants of cardiovascular performance. Preload, afterload, contractility, and heart rate may all be modified by pharmacological or mechanical techniques. Diuretics, vasodilators, cardiac glycosides, and other inotropes all may play a role in the ED management of CHF. In rare instances, mechanical devices for support of the heart and circulation may be indicated.

Diagnosis, Differential↗
PubMedDate not supplied

Acute thoracic aortic dissection: the basics.

With an increasing incidence, aortic dissection is the most common acute illness of the aorta. In the setting of chronic hypertension, with or without other risk factors for aortic dissection, this diagnosis should be considered a diagnostic possibility in patients presenting to the emergency department with acute chest or back pain. Left untreated, about 75% of patients with dissections involving the ascending aorta die within 2 weeks of an acute episode. But with successful initial therapy, the 5-year survival rate increases to 75%. Hence, timely recognition of this disease entity coupled with urgent and appropriate management is the key to a successful outcome in a majority of the patients. This article reviews acute thoracic aortic dissection, including ED diagnosis and management.

Acute Disease↗
PubMedDate not supplied

Mechanical ventilation: past and present.

Emergency physicians commonly manage patients with acute respiratory failure who require assisted mechanical ventilation. Several different modes of positive pressure mechanical ventilation can be used to manage these patients when they present to the emergency department. These modes of ventilation have evolved over the last three decades. A comprehensive review of the most important historical moments in mechanical ventilation as well as the different modes commonly used in the emergency department are presented. In addition, new techniques in noninvasive mechanical ventilation are presented.

Emergencies↗
PubMedDate not supplied

Carbon monoxide poisoning: a review for clinicians.

Carbon monoxide (CO) poisoning continues to be a significant health problem both in the United States and in many other countries. CO poisoning is associated with a high incidence of severe morbidity and mortality. Epidemics of CO poisoning commonly occur during winter months and sources include: smoke from fires, fumes from heating systems burning fuels, and exhaust fumes from motor vehicles. The history of exposure and carboxyhemoglobin levels should alert the physician to this diagnosis. In the absence of exposure history, CO poisoning should be considered when two or more patients are simultaneously sick. The clinical presentation is non-specific and may range from nausea and headache to profound central nervous system dysfunction. The mainstay of therapy for CO poisoning is supplemental oxygen, ventilatory support, and monitoring for cardiac dysrhythmias. This article reviews up-to-date information of this potentially devastating exposure.

Carbon Monoxide Poisoning↗