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Biomedical subjects

M C Tomlanovich

Publications and source records attributed to M C Tomlanovich.

At least 19 recordsLinked to original sources
PubMed2001

Ninety-minute exclusion of acute myocardial infarction by use of quantitative point-of-care testing of myoglobin and troponin I.

BACKGROUND: Diagnostic strategies with ECG and serum cardiac markers have been used to rule out acute myocardial infarction in 6 to 12 hours. The present study evaluated whether a multimarker strategy that used point-of-care measurement of myoglobin, creatine kinase (CK)-MB, and troponin I could exclude acute myocardial infarction in </=3 hours. METHODS AND RESULTS: We prospectively enrolled consecutive patients (n=817) in the emergency department who were evaluated for possible acute myocardial infarction. In patients with nondiagnostic ECGs, we measured CK-MB, troponin I, and myoglobin with a point-of-care device at presentation and at 90 minutes, 3 hours, and 9 hours. Standard central laboratory testing of CK-MB was done at the same time intervals, and triage decisions were made by emergency physicians who were unaware of point-of-care results. Sensitivity and negative predictive value were compared for both the multimarker, point-of-care approach and the central laboratory strategy. Sensitivity and negative predictive value for point-of-care combination of myoglobin and troponin I by 90 minutes was 96.9% and 99.6%, respectively. CK-MB measurements and blood sampling at 3 hours did not improve sensitivity or negative predictive value. Median time from sampling to reporting of results was 71.0 minutes for the central laboratory versus 24.0 minutes for the point-of-care device (P<0.001). CONCLUSIONS: Acute myocardial infarction can be excluded rapidly in the emergency department by use of point-of-care measurements of myoglobin and troponin I during the first 90 minutes after presentation.

Acute Disease↗
PubMed2000

Critical care in the emergency department: A physiologic assessment and outcome evaluation.

OBJECTIVES: The changing landscape of health care in this country has seen an increase in the delivery of care to critically ill patients in the emergency department (ED). However, methodologies to assess care and outcomes similar to those used in the intensive care unit (ICU) are currently lacking in this setting. This study examined the impact of ED intervention on morbidity and mortality using the Acute Physiology and Chronic Health Evaluation (APACHE II), the Simplified Acute Physiology Score (SAPS II), and the Multiple Organ Dysfunction Score (MODS). METHODS: This was a prospective, observational cohort study over a three-month period. Critically ill adult patients presenting to a large urban ED and requiring ICU admission were enrolled. APACHE II, SAPS II, and MODS scores and predicted mortality were obtained at ED admission, ED discharge, and 24, 48, and 72 hours in the ICU. In-hospital mortality was recorded. RESULTS: Eighty-one patients aged 64 +/- 18 years were enrolled during the study period, with a 30.9% in-hospital mortality. The ED length of stay was 5.9 +/- 2.7 hours and the hospital length of stay was 12.2 +/- 16.6 days. Nine (11.1%) patients initially accepted for ICU admission were later admitted to the general ward after ED intervention. Septic shock was the predominant admitting diagnosis. At ED admission, there was a significantly higher APACHE II score in nonsurvivors (23.0 +/- 6.0) vs survivors (19.8 +/- 6.5, p = 0.04), while there was no significant difference in SAPS II or MODS scores. The APACHE II, SAPS II, and MODS scores were significantly lower in survivors than nonsurvivors throughout the hospital stay (p </= 0.001). The hourly rates of change (decreases) in APACHE II, SAPS II, and MODS scores were significantly greater during the ED stay (-0.55 +/- 0.64, -1.02 +/- 1.10, and -0.16 +/- 0.43, respectively) than subsequent periods of hospitalization in survivors (p < 0.05). There was a significant decrease in APACHE II and SAPS II predicted mortality during the ED stay (-8.0 +/- 14.0% and -6.0 +/- 14.0%, respectively, p < 0.001) and equally at 24 hours in the ICU (-7.0 +/- 13.0% and -4.0 +/- 16.0%, respectively, p </= 0.02). The APACHE II and SAPS II predicted mortality approached actual in-hospital mortality at approximately 12 hours and 36 hours after ED admission (in the ICU), respectively. CONCLUSIONS: The care provided during the ED stay for critically ill patients significantly impacts the progression of organ failure and mortality. Although this period is brief compared with the total length of hospitalization, physiologic determinants of outcome may be established before ICU admission. This study emphasizes the importance of ED intervention. It also suggests that unique physiologic assessment methodologies should be developed to examine the quality of patient care, improve the accuracy of prognostic decisions, and objectively measure the impact of clinical interventions and pathways in the ED setting.

APACHE↗
PubMed1995

A technique revisited: hemodynamic comparison of closed- and open-chest cardiac massage during human cardiopulmonary resuscitation.

OBJECTIVE: To compare the hemodynamics of closed-chest cardiac massage vs. open-chest cardiac massage in patients resuscitated from cardiac arrest that occurred outside of the hospital. DESIGN: Prospective, non-outcome, case series. SETTING: Large urban emergency department. PATIENTS: Ten adult, normothermic, nontraumatic, out-of-hospital, cardiac arrest patients who failed advanced cardiac life support (ACLS) therapy. INTERVENTIONS: Patients presenting to the hospital in cardiac arrest were managed according to the ACLS protocol at the clinician's discretion. Proximal aortic and central venous pressure catheters were placed to measure arteriovenous compression- and relaxation-phase pressure gradients. After 5 mins of baseline measurements during closed-chest cardiac massage, patients underwent a left lateral thoracotomy, and open-chest cardiac massage was performed for 5 mins. MEASUREMENTS AND MAIN RESULTS: The mean coronary perfusion pressure and compression-phase pressure gradients were 7.3 +/- 5.7 and 6.2 +/- 5.4 mm Hg, respectively, during closed-chest cardiac massage, while increasing to 32.6 +/- 17.8 and 32.6 +/- 29.9 mm Hg, respectively, during open-chest cardiac massage. The differences between both measurements were statistically significant (p < .05). CONCLUSIONS: Open-chest cardiac massage is superior to closed-chest cardiac massage in providing relaxation-phase and compression-phase pressure gradients during cardiac arrest in patients failing current ACLS protocols. During open-chest cardiac massage, all patients exceeded the minimum coronary perfusion pressure of 15 mm Hg, which is recommended to obtain a return of spontaneous circulation. Further outcome studies are needed to determine the timeliness and appropriate indications for open-chest cardiac massage.

Aged↗
PubMed1990

An evaluation of cocaine-induced chest pain.

STUDY OBJECTIVE: To determine if enzymatic evidence of acute myocardial injury is present in patients complaining of chest pain after cocaine use when the ECG is normal or nondiagnostic. DESIGN: Serial ECG and creatinine kinase (CK) and CK isoenzymes (CK-ISO) determinations were performed at time of emergency department presentation and every six hours over 12 hours on individuals complaining of chest pain within six hours of last cocaine use. SETTING: ED of an urban tertiary care center. TYPE OF PARTICIPANTS: Forty-two individuals with a mean age of 28.5 years. INTERVENTIONS: Patients with positive CK-ISOs were admitted immediately to formally rule out myocardial infarction. Patients developing ECG changes during observation period also were admitted even if CK-ISOs were normal. Patients with unchanged ECGs and normal CK-ISOs were discharged after 12 hours of observation. RESULTS: Eight patients (19%) had elevated CK and CK-ISO values at presentation. Two of these patients had elevated values on three sequential determinations and were believed to have sustained acute myocardial infarction. Six patients had elevated CK and CK-ISOs at presentation only. ECGs remained normal or nondiagnostic in all patients. CONCLUSIONS: Enzymatic evidence of acute myocardial injury may occur in patients who develop chest pain after cocaine use and have normal or nondiagnostic ECGs. This injury may reflect acute infarction or transient ischemia. Single or serial normal or nondiagnostic ECGs do not rule out ischemia or injury in this group of patients.

Adult↗
PubMed1989

The effect of cardiopulmonary bypass resuscitation on cardiac arrest induced lactic acidosis in dogs.

The adequacy of end organ blood flow following a cardiac arrest varies depending on the artificial reperfusion technique utilized and may critically affect patient outcome. Both oxygen consumption (VO2) and arterial lactate values have previously been used to assess tissue perfusion. Cardiopulmonary bypass resuscitation (CPB) is a reperfusion technique capable of providing near normal end organ blood flow. The purpose of this investigation was to study the effect of femoro-femoral veno-arterial CPB resuscitation compared to standard CPR on VO2 and arterial lactic acid values after a prolonged cardiac arrest. Ten mongrel dogs were electrically fibrillated and left in cardiopulmonary arrest without therapy for 12 min. Resuscitation was attempted according to a standardized protocol utilizing either CPB (n = 5) or standard external CPR (n = 5). Oxygen consumption values and arterial lactic acid samples were obtained at baseline, at timed intervals throughout resuscitation and after return of spontaneous circulation in successfully resuscitated dogs. Baseline hemodynamic and biochemical measurements were similar in both treatment groups (P greater than 0.05). Oxygen consumption (440 +/- 50 ml/min/M2) and mean arterial lactic acid values (7.44 +/- 2.25 mmol/l) were significantly higher at 1 min of resuscitation in CPB-treated dogs compared to dogs treated with CPR (60 +/- 10 ml/min/M2) (3.16 +/- 0.69 mmol/l) respectively (P less than 0.05). Mean arterial lactic acid values rose significantly at each sampling interval during CPR (P less than 0.05) but began to decrease after 5 min of resuscitation in the CPB animals and were not significantly different than baseline after 60 min of bypass (P greater than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Acidosis, Lactic↗
PubMed1987

Evaluation of a new chemical dip strip for detecting ketonemia in the emergency setting.

The utility of a new urine dipstick, Chemstrip uK, was evaluated using serum in place of urine to quantify serum ketones in 29 acutely ill patients with suspected ketosis treated in the emergency department. The serum Chemstrip uK method accurately predicted the level of ketonemia as assessed by the Acetest tablet method (r = .94; P less than .0001). There were no false-negative and no false-positive results. The use of this strip is recommended for evaluating subjects with suspected ketosis.

Adolescent↗
PubMed1987

Cardiopulmonary bypass vs CPR as treatment for prolonged canine cardiopulmonary arrest.

Although in vitro studies have demonstrated functional recovery of neurons after prolonged ischemia, in vivo experience with patients resuscitated from cardiopulmonary arrest demonstrates much less cerebral resistance to global ischemia. The purpose of our investigation was to compare the effectiveness of femoro-femoral veno-arterial cardiopulmonary bypass (CPB) to standard cardiopulmonary resuscitation in the treatment of prolonged cardiopulmonary arrest. Ten mongrel dogs were electrically fibrillated and left in cardiopulmonary arrest without any therapy for 12 minutes. Subsequently, either CPB (n = 5) or CPR (n = 5) was initiated and resuscitation attempted according to a standardized protocol that included administration of the calcium channel blocker lidoflazine in an effort to optimize cerebral and myocardial recovery. If there was return of spontaneous circulation, the animal was managed in an intensive care setting with invasive hemodynamic monitoring and ventilatory support for up to nine hours. Neurologic function was graded using a standardized neurologic deficit scoring (NDS) system at 12 hours after insult and daily for one week or until death. Prearrest hemodynamic and metabolic parameters were comparable in both groups (P greater than .05). All CPB animals were resuscitated successfully and alive at 24 hours after insult as opposed to none in the CPR group (P less than .005). In addition, three of the CPB animals were neurologically normal at final grading with NDS scores of zero. The other two CPB animals had persistent severe neurologic impairment and a mean NDS score of 51%. Thus CPB is more effective than CPR in the treatment of prolonged cardiopulmonary arrest. The improved outcome probably results primarily from improvement in blood flow with CPB.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1987

Lactic acidosis during closed-chest CPR in dogs.

Survival after out-of-hospital cardiac arrest is intimately related to the time from cardiovascular collapse to the initiation of CPR, or downtime. Furthermore, the reperfusion technique that optimizes coronary and cerebral blood flow after cardiac arrest may also be dependent on downtime. Peak blood lactate levels have been shown to be unchanged throughout resuscitation and predictive of downtime in dogs subjected to cardiopulmonary arrest and open cardiac massage. The purpose of this study was to determine the course of arterial lactate levels in dogs subjected to a fibrillatory cardiopulmonary arrest and conventional closed-chest CPR (CCPR). Fourteen dogs were subjected to five minutes of cardiopulmonary arrest and 30 minutes of CCPR. Resuscitation was performed according to a standardized protocol. Arterial lactic acid samples were collected at timed intervals throughout the experiment. Mean arterial lactic acid levels increased significantly with each sampling interval during 30 minutes of CCPR (overall P less than .05). In nine dogs successfully resuscitated, there were no significant differences in mean arterial lactic acid levels after the return of spontaneous circulation (ROSC). Open-chest resuscitation after five minutes of ventricular fibrillation in dogs results in peak lactic acid levels that do not change significantly once internal cardiac massage is initiated. In contrast, CCPR in similarly arrested dogs does not appear to provide adequate tissue oxygenation and/or perfusion to prevent continuous lactic acid accumulation.

Acidosis, Lactic↗
PubMed1987

Selective venous hypercarbia during human CPR: implications regarding blood flow.

Thirty-five patients presenting to the emergency department in cardiopulmonary arrest had simultaneous measurement of central venous (cv) and arterial (a) blood gases during CPR with a pneumatic chest compressor and ventilator. The mean cv, arterial pH, and PCO2 values were markedly different (P less than .001). The mean pH gradient (pHa - pHcv) was .31 +/- .10 units and the mean PCO2 gradient (PcvCO2 - PaCO2) was 60.5 +/- 23.6 torr. This selective venous hypercarbia is probably due to a cardiac output that is inadequate to eliminate the CO2 produced from both residual aerobic metabolism and the buffering of anaerobically produced lactic acid. Central venous blood gases are probably a better reflection of actual tissue environment during prolonged cardiac arrest than are arterial blood gases.

Aged↗
PubMed1986

Catheter aspiration for simple pneumothorax.

A prospective study was conducted in the emergency setting to determine the efficacy of treatment of simple pneumothorax by catheter aspiration. Patients who were successfully treated were discharged to home. Sixty-one patients with a total of 76 pneumothoraces were involved in the study. The overall success rate was 75.6%, with an 82% success rate for needle-induced, 75% for traumatic, and 45% for spontaneous pneumothorax. The duration of symptoms, the size of the pneumothorax, the patient's age, and a prior history of pneumothorax did not affect the outcome. The poorest results were noted with spontaneous pneumothoraces, as would be expected since a majority of these patients have preexistent lung disease. Catheter aspiration of simple pneumothorax offers a cost-effective approach to this clinical problem.

Adult↗
PubMed1986

Aortic and right atrial pressures during standard and simultaneous compression and ventilation CPR in human beings.

Coronary perfusion pressure, as reflected by the diastolic aortic to right atrial (Ao-RA) pressure gradient, has been shown to correlate well with coronary blood flow during standard external CPR (SE-CPR) and is an important determinant of successful cardiac resuscitation. Few studies have documented such Ao-RA gradients in human beings, however. Twenty patients sustaining out-of-hospital cardiopulmonary arrests and basic cardiac life support were instrumented with thoracic aortic and right atrial catheters on arrival in the emergency department. The mean time from arrival in the ED to catheter placement was 16.5 +/- 6.0 minutes. With SE-CPR, peak systolic aortic and right atrial pressures were 73.7 +/- 20.2 mm Hg and 69.6 +/- 18.3 mm Hg, respectively. End diastolic aortic and right atrial pressures were 27.9 +/- 7.3 mm Hg and 20.3 +/- 7.2 mm Hg, respectively, with an end diastolic gradient of 7.9 +/- 9.1 mm Hg. Three patients had systolic Ao-RA gradients of more than 25 mm Hg, which is consistent with some cardiac compression as a mechanism of flow. Five patients also had one-minute trials of simultaneous compression and ventilation CPR (SCV-CPR). Ao-RA end diastolic gradients decreased in four of the five during SCV-CPR. No patient in this study was resuscitated successfully. We conclude that ED SE-CPR provides little coronary perfusion for victims of prehospital cardiac arrest. Although SCV-CPR has been shown to improve carotid blood flow in human beings, it appears to have an adverse effect on the already minimal myocardial perfusion provided by SE-CPR.

Aged↗
PubMed1986

Alternate therapy for traumatic pneumothorax in "pocket shooters".

Traumatic pneumothorax is a common complication of the IV drug abusers in Detroit who utilize the "pocket shot" (the central approach to the internal jugular vein). Fourteen patients who sustained a total of 16 pneumothoraces (two with bilateral collapse) and who underwent catheter aspiration of a simple pneumothorax (CASP) were studied prospectively. The sizes ranged from less than 10% to 100%. In addition, there was one tension pneumothorax and one pneumomediastinum. The 16 CASP procedures produced 13 successful lung expansions (82%). The remaining three were treated with tube thoracostomy and admission. Twelve of the 13 patients in whom the procedure was successful returned for followup, and all of these had 100% continued full expansion. CASP appears to be a safe, efficacious, and cost-effective treatment for the drug abuser with simple traumatic pneumothorax. With the current pressures of cost containment, this less-invasive approach with outpatient management should be studied as initial potential treatment for any simple pneumothorax.

Adult↗
PubMed1986

Use of bretylium tosylate as prophylaxis and treatment in hypothermic ventricular fibrillation in the canine model.

We conducted a study to determine if bretylium tosylate (BT) is effective in the prophylaxis and treatment of hypothermic ventricular fibrillation (VF) in the setting of various maneuvers thought to induce this lethal arrhythmia. Twenty-two mongrel dogs were cooled to 24 C after being placed in a cold room. At 24 C, a double-blinded placebo or BT solution was infused. The dogs then were removed from the cold. They underwent the following sequential maneuvers: oral endotracheal extubation and intubation, central line and nasogastric tube placement, vigorous movement, and Swan-Ganz catheter insertion. If VF ensued, arterial blood gases were drawn, and BT was given only if refractory to countershock and epinephrine. Of the dogs that were given placebo, six of 11 (55%) fibrillated with manipulation, as compared with one of 11 (9%) dogs pretreated with BT (P = .067). Three of the 11 dogs that received BT fibrillated within minutes of its infusion. In the placebo dogs that fibrillated, four required BT and two defibrillated with countershock alone or with epinephrine prior to achieving stable rhythms.

Animals↗
PubMed1986

Hyperkalemia during cardiac arrest and resuscitation in the canine model.

Although recent clinical reports have noted hypokalemia after resuscitation from cardiac arrest, extensive animal work indicates that potassium is released from cells during ischemia. This study was undertaken to define the changes that occur in serum potassium ion during cardiac arrest and resuscitation in a canine model. Fourteen dogs were subjected to 5 min of cardiac arrest followed by 30 min of closed-chest CPR (CCPR). Resuscitation was performed according to a standardized protocol. Serum potassium increased significantly (p less than .001) from baseline, remained elevated 5 min after return of spontaneous circulation (ROSC), but declined to baseline levels at 15 min post-ROSC. Increases in interstitial potassium would be expected to be even greater due to the poor exchange between interstitial and intravascular compartments during CCPR. Interstitial hyperkalemia may play a role in the genesis of wide-complex electromechanical dissociation and may explain the reported success of calcium chloride in treating this problem.

Animals↗
PubMed1985

Lactic acidosis as a predictor of downtime during cardiopulmonary arrest in dogs.

Studies have shown that over 50% of cardiovascular deaths occur before hospitalization. A major factor associated with survival in cases of out-of-hospital cardiac arrest is the time from cardiovascular collapse to the initiation of cardiopulmonary resuscitation (CPR) or "downtime." The purpose of this study was to determine whether blood lactate levels could be used to predict downtime in the canine cardiac arrest model. Femoral arterial and Swan-Ganz catheters were placed in 22 mongrel dogs, and ventricular fibrillation was electrically induced. The dogs remained in ventricular fibrillation without ventilation for 5, 10, 15, 30, or 60 minutes. After the predetermined fibrillation time, a left anterolateral thoracotomy was performed, and open-chest cardiac massage was begun. Arterial and mixed venous lactate levels were determined for every 5 minutes during 30 minutes of cardiopulmonary resuscitation. The correlation coefficient between the mixed venous and arterial lactate levels was 0.96 or greater during all stages of resuscitation. Peak serum lactate level increased linearly in relation to downtime. The increase in lactate level was not evident until after CPR was begun, and it remained at peak levels or decreased insignificantly, despite optimal open-chest CPR. Linear regression analysis revealed that 84% of the variability in serum lactate levels could be explained by downtime differences. In this model, blood lactate level is a reliable and objective measure of downtime and may be a useful indicator of the adequacy of CPR if levels decrease or remain stable. The clinical implications of this study lie with the use of blood lactate levels in the emergency department to guide the aggressiveness of resuscitative efforts.

Acidosis↗
PubMed1985

Central venous and mixed venous oxygen saturation: comparison during canine open-chest cardiopulmonary resuscitation.

Mixed venous oxygen saturation (MVO2) is a valuable parameter in monitoring critically ill patients because it serves as an index of the adequacy of the oxygen delivery system. Mixed venous oxygen saturation as reflected by the easily obtainable central venous oxygen saturation (CVO2) may prove useful during cardiopulmonary resuscitation (CPR) as an indicator of both the adequacy of varying CPR regimens and the efficacy of pharmacological interventions. This study investigates the relationship between CVO2 and MVO2 and its clinical usefulness during CPR. Swan-Ganz and central venous catheters were placed in 20 mongrel dogs. Ventricular fibrillation was then induced and, after predetermined downtimes ranging from 5 to 60 minutes, thoracotomy was performed, and open-chest bimanual cardiac massage was started. Central venous and mixed venous blood-gas samples were drawn every five minutes during a 30-minute period of CPR. The correlation between CVO2 and MVO2 was 0.8719 (P less than 0.001) before arrest but deteriorated at all times during CPR with values ranging from 0.1589 (P = 0.542) to 0.5781 (P = 0.024). Although statistically significant at times, the correlation between CVO2 and MVO2 during CPR is not consistently high enough to enable the routine substitution of CVO2 for MVO2 in assessing the oxygen delivery system.

Animals↗