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Biomedical subjects

D M Yealy

Publications and source records attributed to D M Yealy.

At least 19 recordsLinked to original sources
PubMed1995

Randomized, placebo-controlled evaluation of prochlorperazine versus metoclopramide for emergency department treatment of migraine headache.

STUDY OBJECTIVE: To determine the comparative efficacy of i.v. metoclopramide and prochlorperazine for the initial emergency department treatment of migraine headache. DESIGN: Prospective, randomized, double-blind, placebo-controlled trial. SETTING: Military community hospital ED with an annual census of 75,000. PARTICIPANTS: Seventy consenting adults from a convenience sample of patients presenting with migraine headache similar to that experienced in at least one prior episode. Exclusion criteria were pregnancy, fever, signs of meningismus, altered sensorium, drug or alcohol use, oxygen saturation less than 90%, recent trauma or seizure, "worst headache," abnormal blood pressure, recent (within 48 hours) use of metoclopramide or prochlorperazine, and allergy to metoclopramide or prochlorperazine. INTERVENTIONS: In a random manner, each subject received a 2-mL i.v. injection of identical-appearing fluid containing metoclopramide (10 mg), prochlorperazine (10 mg), or saline solution (placebo). No other analgesics or medications were administered during the initial study period; rescue agents were administered by the choice of the treating physician after all data were collected. MEASUREMENTS: Patients scored their nausea, pain, and sedation before receiving the 2-mL injections and at 30 minutes after injection. Ten-centimeter nonhatched visual analog scales were used for these measurements, with distance from the left end (zero) calculated for each use. Clinically important successful treatment was defined a priori as achievement of the following criteria: patient satisfaction and either a decrease of 50% or more in the 30-minute pain score (compared with the initial score) or an absolute pain score of 2.5 cm or less. Failure to achieve these criteria constituted treatment failure. Differences between groups were analyzed with the Kruskal-Wallis ANOVA and chi 2 tests. Data are reported as frequency percentages and median values, with a two-tailed P value of .05 or less considered significant. RESULTS: Nausea, pain, and sedation scores were similar in all three groups before therapy. Thirty minutes after treatment, pain scores differed among those treated with prochlorperazine (1.1 cm), with metoclopramide (3.9 cm), and with placebo (6.1 cm, P = .003). Clinical success occurred more commonly after treatment with prochlorperazine (82%) than after metoclopramide (46%) or placebo (29%, P = .03). However, metoclopramide and placebo scores did not differ (P = .14). Nausea tended to be improved after prochlorperazine, compared with metoclopramide or placebo, at 30 minutes (P = .64). Four patients (6%) returned to the ED for relapse of migraine headache within 24 hours (three in the placebo group and one in the metoclopramide group). CONCLUSION: i.v. prochlorperazine relieves the headache and tends to improve nausea better than metoclopramide in ED patients with acute migraine headache.

Adolescent↗
PubMed1995

Wide complex tachycardia.

Wide complex tachycardias present diagnostic challenges for emergency physicians. The history, physical examination, and ECG provide information required to arrive at the correct diagnosis. When a previous history of heart disease exists, VT should be suspected; however, no single clinical feature is sufficiently reliable for distinguishing VT from SVT. Patients with VT may tolerate their dysrhythmias for several hours and maintain hemodynamic stability. ECG analysis is the most useful process in differentiating SVT and VT. Characteristics suggestive of VT include evidence of AV dissociation, QRS duration of longer than 0.16 seconds, and QRS axis between -90 degrees +/- 180 degrees. Predictive QRS morphologic criteria also have been established for VT. A four-step approach to ECG analysis has been reported to accurately identify patients with VT, but prospective validation in an ED setting is lacking. The initial approach to treating patients with wide QRS tachycardias depends on hemodynamic stability. Until the identify of a dysrhythmia is certain, consider all patients to be suffering from VT. Unstable patients require immediate cardioversion. Acute treatment of stable patients includes lidocaine or procainamide. Adenosine is appropriate when wide QRS SVT is the diagnosis, and it also has been used as a diagnostic aid to identify dysrhythmias. Reports of complications with the use of adenosine as a diagnostic agent have not yet appeared but may occur after sufficient numbers of cases have accumulated. Magnesium sulfate may be useful in refractory cases of VT and torsades de pointes. Chronic treatment of patients prone to VT may include complex pharmacotherapy and AICDs. Development of new class III agents and enhancement of AICD technology may result in improved patient outcomes and the availability of more choices for emergent therapy of wide QRS tachycardias.

Decision Trees↗
PubMed1994

Development of an acute cutaneous swine model for Loxosceles envenomation.

STUDY OBJECTIVE: To develop an acute cutaneous swine model for Loxosceles envenomation which could be used to objectively compare various treatment modalities. PARTICIPANTS: Nine weanling, mixed-breed domestic piglets. INTERVENTIONS: Piglets were injected intradermal in the hindlimb with Loxosceles deserta venom in increasing doses and concentrations until consistently large lesions were obtained. A minimum of 3 injections/venom preparation were carried out, with no more than 2 injections/animal. Repeat injections in the same animal were separated by 8 d. MEASUREMENTS AND MAIN RESULTS: All lesions were measured daily for erythema and necrosis for 7 consecutive days. Data are reported as individual and mean maximal values. The piglets receiving 0.1, 0.2 or 0.3 ml of 5 microliters venom/ml saline developed small inconsistent lesions, with the largest necrotic lesion 5 mm. Those injected with 0.3 ml of venom diluted 15 microliters/ml saline developed small necrotic lesions (mean 4 mm, maximal 10 mm). All piglets injected with 25 microliters of venom diluted to 0.3 ml developed large necrotic lesions (mean 33 mm) with substantial erythema (mean 177 mm). CONCLUSION: Intradermal injection of 0.1 ml of 25 microliters purified Loxosceles deserta venom diluted to 0.3 ml with sterile saline produced large necrotic lesions in piglets. This model may be used to study Loxosceles envenomation and treatment.

Animals↗
PubMed1994

Transvenous pacemakers.

The emergency physician should be familiar with the four general categories of TP complications: malfunctions, infections and dermatitis, vascular complications, and psychiatric complications (Table 2). Each category of complication can be readily evaluated and initially managed based on a few simple steps.

Emergencies↗
PubMed1993

Activated charcoal surface area and its role in multiple-dose charcoal therapy.

The study hypothesis was to prove that increasing the surface area (SA) of activated charcoal (AC) will enhance theophylline elimination in multiple-dose AC therapy. Five healthy, nonsmoking, nonmedicated, volunteer men ranging from the ages of 18 to 24 years old were entered onto the study. A prospective, randomized, crossover study was conducted with each subject serving as their own control. Subjects fasted overnight before receiving 8 mg/kg of intravenous theophylline at the beginning of a control phase and two study phases. No AC was administered in the control phase. Two experimental phases compared Actidose Aqua AC (1,500 m2/g; Paddock Laboratories, Inc, Minneapolis, MN) with Norit A Supra AC (2,000 m2/g; Norit NV, Amersfoort, the Netherlands). In each phase, 50 g of the AC was administered orally after the conclusion of the theophylline infusion. Subsequent 50-g doses of the AC preparation were administered at 4 and 8 hours after the initial dose of AC. Serial blood samples for theophylline level determinations were obtained at 0.5, 1.0, 1.5, 2.0, 3.0, 4.0, 6.0, 8.0, 10.0, and 12.0 hours after the completion of the theophylline infusion. For each of the three data sets, the absolute area under the absorption curve (A-AUC) was calculated to infinity using the trapezoidal rule. Additionally, the relative area under the absorption curve (R-AUC) was determined for each data set. Data were analyzed using repeated measures of analysis of variance (ANOVA) and Tukey's test. The alpha error was set at 0.05.(ABSTRACT TRUNCATED AT 250 WORDS)

Administration, Oral↗
PubMed1993

Oral labetalol versus oral nifedipine in hypertensive urgencies in the ED.

Therapy in hypertensive urgencies is debated and complicated by the side effects of available agents. In a prospective, randomized, open labeled study, the use of oral labetalol, an alpha- and beta-adrenergic blocker, with oral nifedipine in hypertensive urgencies in the emergency department was compared. Patients with diastolic blood pressures (DBP) of more than 120 mm Hg without criteria for a hypertensive emergency were eligible. The drugs were given in a loading manner with doses and timing based on their respective pharmacokinetics until a DBP of 110 mm Hg or lower was obtained or 4 hours had passed. Either an initial labetalol dose of 200 mg and a repeat dose of 100 to 200 mg at 2 hours, depending on the DBP or nifedipine, 10-mg bite and swallow every hour up to a total dose of 20 mg were given. Ten patients were enrolled into each study group. A 100% response rate was defined as a DBP of 110 mm Hg or less was observed for nifedipine and an 80% response rate for labetalol (P > .2) was observed. The mean time to control was 67.5 minutes for labetalol and 60.0 minutes for nifedipine (P > .2). The pretreatment pressure for labetalol was 195/127 mm Hg and for nifedipine was 198/128 mm Hg (P > .2), which decreased to a posttreatment pressure for labetalol of 154/100 mm Hg and for nifedipine of 163/100 mm Hg (P > .2). The mean decrease in systolic (SBP)/DBP was 42.6/26.5 mm Hg with labetalol and 34.9/28.4 mm Hg for nifedipine (P > .2). No significant side effects occurred with either drug.(ABSTRACT TRUNCATED AT 250 WORDS)

Administration, Oral↗
PubMed1993

Therapeutic and diagnostic efficacy of adenosine in wide-complex tachycardia.

Wide-complex tachycardia is one of the most challenging problems faced by emergency physicians. Adenosine is an endogenous nucleoside that has gained recent popularity as an anti-arrhythmic drug in the setting of supraventricular tachycardia. We present the cases of two patients with stable wide-complex tachycardia in which adenosine was administered for therapeutic and diagnostic effects. Both patients quickly converted into sinus rhythm with subsequent diagnoses of atrioventricular reciprocating tachycardia secondary to Wolff-Parkinson-White syndrome. The role of adenosine in the acute management of wide-complex tachycardia is discussed.

Adenosine↗
PubMed1993

An experimental algorithm versus standard advanced cardiac life support in a swine model of out-of-hospital cardiac arrest.

STUDY OBJECTIVE: To compare an experimental algorithm with standard advanced cardiac life support in a swine model of out-of-hospital cardiac arrest. DESIGN: Randomized, controlled experimental trial. SETTING/TYPE OF PARTICIPANT: Animal laboratory using swine. INTERVENTIONS: Eighteen swine (17.8 to 23.7 kg) were sedated, intubated, anesthetized, and instrumented for monitoring of arterial and central venous pressures and ECG. Ventricular fibrillation was induced using a bipolar pacing catheter. Animals were randomized to treatment with the experimental algorithm or standard advanced cardiac life support therapy after eight minutes of untreated ventricular fibrillation. The experimental algorithm consisted of starting CPR; giving high-dose epinephrine (0.20 mg/kg), lidocaine (1.0 mg/kg), bretylium (5.0 mg/kg), and propranolol (0.5 to 1.0 mg) by peripheral IV; hyperventilating (20 to 25 breaths per minute); and delaying countershock (5 J/kg) 60 seconds after completion of drug delivery. Data were analyzed with the Student's t-test and Fisher's exact test. MEASUREMENTS AND MAIN RESULTS: Outcome variables were arterial and central venous pressures, return of spontaneous circulation, and one-hour survival. Hemodynamics were not different between groups during CPR. Return of spontaneous circulation occurred in seven of nine swine (77%) in the experimental algorithm group versus two of nine swine (22%) in the advanced cardiac life support group (P = .057). Four of nine swine (44%) in the experimental algorithm group survived to one hour versus none of the animals in the advanced cardiac life support group (P = .041). CONCLUSION: In this swine model of out-of-hospital cardiac arrest, animals treated with an experimental algorithm had a significant improvement in one-hour survival compared with those treated with advanced cardiac life support.

Algorithms↗
PubMed1993

How much "significance" is significant? The transition from animal models to human trials in resuscitation research.

Animal models of resuscitation must be analyzed carefully before applying any interventions to human resuscitation. In addition to statistical concerns, the investigator must assess the clinical significance of the animal experience with an intervention. No single species is perfect, and the researcher must be aware of the major differences in primate, swine, canine, and rodent models. Interventions useful across species are more likely to be beneficial than those useful in one isolated species. After evaluating the animals used, the design in a series of animal experiments should be clinically applicable and the results reproducible. Finally, both process and outcome variables should be evaluated and improved in animal models before applying a new intervention to clinical care.

Animals↗
PubMed1993

Post-dural-puncture headache: characteristics, management, and prevention.

Post-dural-puncture headache is a common complication after both diagnostic and therapeutic procedures. Prompt recognition of the clinical syndrome, followed by supportive and corrective actions, can decrease the morbidity in those afflicted. The most useful preventive measure during dural puncture in adult patients is the use of smaller cannulae with the bevel aimed parallel to the long axis of the spine.

Adolescent↗
PubMed1992

The comparative efficacy of various multiple-dose activated charcoal regimens.

Multiple-dose activated charcoal therapy is used in the management of poisoning emergencies to enhance the elimination of enterohepatically and enteroenterically secreted toxins. This study was conducted to determine if increasing the frequency of activated charcoal administration would enhance the elimination of a toxin. In this crossover study, five healthy adult volunteers were randomly assigned to either a control phase or one of three study phases. Subjects in the control phase and each of the study phases received an intravenous infusion of aminophylline (8 mg/kg). During the study phases each subject additionally received activated charcoal 50 gm and activated charcoal 12.5 gm every hour, 25 gm every 2 hours, or 50 gm every 4 hours over a 8-hour period for a cumulative activated charcoal dose of 150 gm. Ten blood samples were obtained over 12 hours and analyzed for theophylline concentrations. Using area under the curve and half-life calculations it was determined that each of the dosage regimens significantly reduced the reabsorption of theophylline and the plasma half-life when compared with control. There were no significant differences between any of the treatment groups. Decreasing the dose but increasing the frequency of activated charcoal administration is as effective as the traditional every 4 hour-therapy regimen.

Administration, Oral↗
PubMed1992

Intranasal midazolam as a sedative for children during laceration repair.

We performed a retrospective chart review to determine the onset, duration, safety, and clinical sedative effects of 0.2 to 0.5 mg/kg intranasal midazolam in young children during laceration repair. Of 408 children treated for lacerations during an 8-month period, 42 (10%) received intranasal midazolam. Documentation was adequate for detailed analysis in 40 cases. Data are reported as mean +/- standard deviation and the frequency with 95% confidence limit (CL) estimates. The mean age of the study population was 32 +/- 9 months (range 12 months to 6 years), and the mean body mass was 14.5 +/- 3 kg. Topical or injected local anesthesia was used in 37 cases. Overall, 73% (CL 56% to 85%) of the children achieved adequate sedation. However, those receiving 0.2 to 0.29 mg/kg had adequate sedation in only 27% (CL 6% to 60%) of the cases compared with 80% (CL 52% to 95%) and 100% (CL 79% to 100%) when 0.3 to 0.39 and 0.4 to 0.5 mg/kg respectively were administered. When achieved, sedation occurred within 12 +/- 4 minutes, recovery occurred at 41 +/- 9 minutes, and discharge occurred at 56 +/- 11 minutes. No vomiting or clinically significant oxygen desaturation (defined as a drop of > 4% or to < 91%) was observed. We conclude that intranasal midazolam is a safe and effective sedative for laceration repair under local anesthesia in preschool-aged children. We recommend a dose of 0.3 to 0.5 mg/kg, with treatment failure less likely after 0.4 to 0.5 mg/kg compared with less than 0.3 mg/kg.

Administration, Intranasal↗
PubMed1992

Is admission after intravenous heroin overdose necessary?

STUDY OBJECTIVES: To investigate the time of onset and incidence of complications in patients presenting to the emergency department with an IV heroin overdose and the need for routine admission of such patients. METHODS: A retrospective chart review of hospital and emergency medical service records of 124 patient visits involving IV heroin overdose over a five-month period. We also reviewed the death certificates of 115 persons having succumbed to a narcotic overdose over a 44-month period and compared these with our hospital records. SETTING: Urban county hospital. TYPE OF PARTICIPANTS: Patients presenting to the ED with an IV heroin overdose. RESULTS: There were five deaths in the ED, 12 hospital admissions, and 107 patients who were discharged home. Neither delayed onset of pulmonary edema nor recurrence of respiratory depression was observed. Of the 115 persons having succumbed to a narcotic overdose, eight had been seen previously at our hospital for a heroin overdose. There is no evidence that any of these eight deaths would have been prevented by a 24-hour hospital observation period. CONCLUSION: Complications arising from an IV overdose of heroin are usually evident on arrival in the ED or shortly thereafter. On retrospective review we have found no evidence that admission to the hospital and 24 hours of observation are of benefit to patients who are awake, alert, and lacking evidence of pulmonary complications after an IV heroin overdose.

Adult↗
PubMed1992

Relapsing polychondritis: an unusual cause of painful auricular swelling.

Auricular pain, redness, and swelling are usually the result of infectious cellulitis. However, relapsing polychondritis is another cause of this symptom complex and is the result of an autoimmune phenomenon. It presents with inflammation and destruction of both articular and nonarticular cartilage, with the external ear and joint cartilage most often involved. Although usually indolent with multiple acute exacerbations, relapsing polychondritis can be rapidly fatal if the airway or cardiovascular system is involved. We present a case of relapsing polychondritis initially mistaken for auricular cellulitis. The clinical manifestations and course of relapsing polychondritis are reviewed, along with the emergency department management.

Acute Disease↗