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BACKGROUND: Although high-quality chest compressions are an essential, lifesaving component of cardiopulmonary resuscitation, injuries are common with both manual and mechanical chest compressions. CASE REPORT: We discuss the case of a 77-year-old woman who sustained thoracic vertebral fractures after cardiopulmonary resuscitation involving both manual and mechanical chest compressions. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Routine post-cardiac arrest care should include evaluation for chest compression-related injury. If a patient has back pain, focal vertebral tenderness, or paraplegia after chest compressions, imaging to evaluate for vertebral fracture should be performed. If unable to assess for back pain or tenderness, consider imaging to evaluate for vertebral fracture in patients with kyphosis or osteopenia, as these patients are at higher risk for chest compression vertebral injury.
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Reanimación Cardiopulmonar , Paro Cardíaco , Paro Cardíaco Extrahospitalario , Fracturas de la Columna Vertebral , Traumatismos Torácicos , Anciano , Reanimación Cardiopulmonar/efectos adversos , Reanimación Cardiopulmonar/métodos , Femenino , Paro Cardíaco/complicaciones , Paro Cardíaco/terapia , Masaje Cardíaco/métodos , Humanos , Paro Cardíaco Extrahospitalario/complicaciones , Fracturas de la Columna Vertebral/complicaciones , Cuerpo VertebralRESUMEN
INTRODUCTION: The electrocardiogram (ECG) is often used to identify which hyperkalemic patients are at risk for adverse events. However, there is a paucity of evidence to support this practice. This study analyzes the association between specific hyperkalemic ECG abnormalities and the development of short-term adverse events in patients with severe hyperkalemia. METHODS: We collected records of all adult patients with potassium (K+) ≥6.5 mEq/L in the hospital laboratory database from August 15, 2010, through January 30, 2015. A chart review identified patient demographics, concurrent laboratory values, ECG within one hour of K+ measurement, treatments and occurrence of adverse events within six hours of ECG. We defined adverse events as symptomatic bradycardia, ventricular tachycardia, ventricular fibrillation, cardiopulmonary resuscitation (CPR) and/or death. Two emergency physicians blinded to study objective independently examined each ECG for rate, rhythm, peaked T wave, PR interval duration and QRS complex duration. Relative risk was calculated to determine the association between specific hyperkalemic ECG abnormalities and short-term adverse events. RESULTS: We included a total of 188 patients with severe hyperkalemia in the final study group. Adverse events occurred within six hours in 28 patients (15%): symptomatic bradycardia (n=22), death (n=4), ventricular tachycardia (n=2) and CPR (n=2). All adverse events occurred prior to treatment with calcium and all but one occurred prior to K+-lowering intervention. All patients who had a short-term adverse event had a preceding ECG that demonstrated at least one hyperkalemic abnormality (100%, 95% confidence interval [CI] [85.7-100%]). An increased likelihood of short-term adverse event was found for hyperkalemic patients whose ECG demonstrated QRS prolongation (relative risk [RR] 4.74, 95% CI [2.01-11.15]), bradycardia (HR<50) (RR 12.29, 95%CI [6.69-22.57]), and/or junctional rhythm (RR 7.46, 95%CI 5.28-11.13). There was no statistically significant correlation between peaked T waves and short-term adverse events (RR 0.77, 95% CI [0.35-1.70]). CONCLUSION: Our findings support the use of the ECG to risk stratify patients with severe hyperkalemia for short-term adverse events.
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Arritmias Cardíacas/diagnóstico , Electrocardiografía , Hiperpotasemia/complicaciones , Adulto , Anciano , Anciano de 80 o más Años , Arritmias Cardíacas/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo , Adulto JovenRESUMEN
STUDY OBJECTIVE: Most US hospitals use visual inspection for the detection of cerebrospinal fluid xanthrochromia. We compared visual inspection with spectrophotometric xanthrochromia and studied the effect of tube diameter on the sensitivity of visual inspection. METHODS: Blinded, experienced laboratory technicians visually examined unmarked samples to determine the presence or absence of xanthrochromia. Samples were prepared by lysing RBCs in distilled water. Serial dilutions were placed in clear polystyrene tubes obtained from standard lumbar puncture trays. Laboratory technicians were asked to examine each sample for xanthrochromia using visual inspection. Next, they were asked to interpret the same set of samples with the assistance of a threshold standard. Last, they were asked to interpret the same dilutions, but this time presented in a larger-diameter tube. The absorbance of each sample was measured in a double-beam spectrophotometer at wavelengths between 300 and 700 nm. Samples were said to demonstrate spectrophotometric xanthrochromia if they had an absorbance greater than 0.023 at 415 nm. RESULTS: Sixteen laboratory technicians were shown a total of 160 samples, of which 64 (40%) demonstrated spectrophotometric xanthrochromia. Visual inspection of the samples was 26.6% sensitive (95% confidence interval [CI] 16% to 38%) and 97.9% specific (95% CI 95% to 100%) for spectrophotometric xanthrochromia. Using a reference standard did not improve the performance of visual inspection, but increasing collection-tube diameter increased the sensitivity to 55% (95% CI 43% to 68%). CONCLUSION: Visual inspection is not sensitive for the detection of spectrophotometric xanthrochromia. Increasing the diameter of the collection tubes did improve sensitivity. Emergency physicians should be aware of how xanthrochromia is determined at their institutions and understand the implications of using visual detection to determine the presence or absence of xanthrochromia.