Domiciliary mechanical ventilation in a patient with severe chronic obstructive lung disease and respiratory failure.

A patient of chronic obstructive pulmonary disease (COPD) with cor-pulmonale and chronic respiratory failure, who was given intermittent positive pressure ventilation at home, is reported. The patient did remarkably well on home mechanical ventilatory support. We believe this to be the first case report of domiciliary mechanical ventilation in a patient of COPD from India.     

An Approach to Emergency Department Photography

In the emergency department, photography requires an expedient, portable, adaptable, and relatively simple camera system to take advantage of fleeting opportunities for recording visually educational material. These prerequisites are different from those for traditional medical photography, for which relatively plentiful time and advanced equipment are routinely available. Medical photography departments provide an invaluable service, but are rarely convenient for immediate or spontaneous emergency. department photographs. Although no single system or technique is optimal in all these areas, the authors find certain components and approaches work well. They review photographic equipment, paying attention to speed, ease of use, and quality of output. They also review simple techniques such as film choice, lighting, close-up photography, standardization, copy work, and radiographs. Attention to these details can help the inexperienced photographer obtain a system and begin to enjoy the rewards of effective photography in the emergency department.     

The Evolution of Abdominal Compression in Cardiopulmonary Resuscitation

Objective: To review the history of external abdominal compression as an adjunct to cardiopulmonary resuscitation (CPR), tracking the development of five major themes over the course of the 20th century: 1) augmentation of peripheral resistance by physical means, 2) risk of hepatic injury with abdominal compression, 3) counterpulsation vs sustained compression, 4) the abdominal pump mechanism, and 5) contact compression techniques.
Methods: Literature retrieved from successive MEDLINE English-language searches was reviewed with a special emphasis on work and concepts highlighted by participants at the First Purdue Conference on Interposed Abdominal Compression-CPR, September 1992.
Results: External abdominal compression of one form or another has been studied as a means of resuscitation by many investigators throughout the 20th century. Experimental and clinical studies have shown generally consistent evidence of hemodynamic augmentation by abdominal compression during various forms of CPR. Recent advances include a modified theoretical understanding of hemodynamic mechanisms and demonstration of clinical potential in humans. Inconsistencies in published results may be due to differences in mechanical techniques of abdominal compression. Based on these studies, a modified manual technique for "contact compression" of the abdominal aorta is recommended.
Conclusions: A technique for left-of-center, angled compression of the abdominal aorta against the crest of the spine is recommended. Further well-supervised and controlled clinical trials using this standardized technique are warranted as a prelude to more widespread clinical application of abdominal compression in CPR.     

Abdominal Pumping

This article reviews the author's experience with a form of interposed abdominal compression cardiopulmonary resuscitation (IAC-CPR) in the United Kingdom. The development of the technique based upon animal resuscitation, including the use of phasic compression (abdominal pumping) for the resuscitation of rats from 30 minutes of cardiac arrest due to hypothermia, is reviewed. A simple technique for clinical use is described. The technique uses a hard-covered book or bean-shaped board applied to the abdomen below the umbilicus and compressed alternately with cardiac massage while respiration is assisted. Anecdotal clinical results suggest that further controlled clinical investigation is warranted.     

A Comparative Study of the Percutaneous versus Intraoral Technique for Mental Nerve Block

Objective: Mental nerve block is frequently used to aid repair of facial lacerations; both percutaneous and intraoral approaches to blocking this nerve are used, but have never been compared. The authors compared the two techniques for pain of administration and effectiveness of anesthesia. Methods: A prospective, randomized, single-blind, crossover study was conducted using ten healthy volunteers aged 22 to 33 years. Patients having prior experience with mental nerve blocks, lidocaine allergy, active oral/facial infection, or previous facial fractures were excluded. Bilateral mental nerve blocks were done using intraoral technique on one side and percutaneous technique on the other. Both techniques were used by the same investigator and were carried out with 27-gauge needles and 2.5 mL of 2% buffered lidocaine at room temperature injected over 20 seconds. The oral mucosa was topically anesthetized with viscous lidocaine for 1 minute prior to intraoral injection. The orders of the blocks and sides of the face anesthetized were randomized. Subjective and objective pain (visual-analog scale), efficacy (anesthesia of lower lip), time to onset, and duration of anesthesia were evaluated. Results: The intraoral technique was subjectively less painful than the percutaneous approach in nine of ten subjects (p = 0.02). Scores on the visual-analog pain scale were significantly lower for the intraoral technique (p = 0.03). Intraoral injection produced lower-lip anesthesia in 10/10 subjects versus 7/10 for percutaneous (p = 0.25). Times to onset (approximately 1–2 minutes) and durations of anesthesia (approximately one hour) were similar for the two techniques. Conclusion: The intraoral approach to the mental nerve block with adjunctive topical anesthesia was subjectively and objectively less painful than the percutaneous approach without adjunctive anesthesia. While the intraoral approach had a greater efficacy of lower-lip anesthesia and a longer duration of action, these differences were not statistically significant.     

Anesthetic considerations of an infant with Beckwith-Wiedemann syndrome

The case of a 3-day-old infant with Beckwith-Wiedemann syndrome who required anesthetic care during closure of an abdominal wall defect is presented. Beckwith-Wiedemann syndrome comprises a constellation of clinical features, including macroglossia, macrosomia, omphalocele, visceromegaly, mild microcephaly, facial nevus flammeus, horizontal earlobe creases, and renal medullary dysplasia. Due to the high rate of omphalocele in this syndrome, anesthetic care is frequently required during the neonatal period. Many of these infants (greater than 50%) are born prematurely. Therefore, their anesthetic care may be further complicated by associated diseases of prematurity, such as hyaline membrane disease. Additional anesthetic implications of this syndrome relate to the occurrence and management of hypoglycemia and polycythemia. Careful intraoperative management of glucose homeostasis is particularly important, since eventual neurologic outcome and intelligence will be normal provided prolonged neonatal hypoglycemia is avoided. Preoperative evaluation of the cardiac and genitourinary system, including echocardiography and renal ultrasound, are recommended because of the frequent occurrence of associated anomalies with omphalocele.     

Metastatic colon carcinoma to oral soft tissues

Metastatic tumors to the oral cavity are uncommon. Most of these cases involve the mandible or the maxilla. Rarely, metastasis occurs to the oral soft tissues from a distant primary tumor. The lung and breast are the most common primary sites. It is extremely rare to have an oral soft-tissue metastasis from a carcinoma of the colon. A case of primary adenocarcinoma of the colon with metastasis to the soft tissues of the mouth is described. Three similar case reports are reviewed. A metastatic lesion to the oral cavity could be the first indication of the presence of a primary tumor.     

A parallel group randomised comparative study of felodipine and nifedipine in hypertension.

We compared the antihypertensive effects and tolerability of a new calcium channel antagonist felodipine with nifedipine in an open randomised parallel group study in 49 patients with moderate hypertension (diastolic blood pressure 105-120 mm Hg). After two weeks run in period felodipine 5 mg and 10 mg once daily was compared with nifedipine 10 mg tid for an active treatment period of 4 weeks. Twenty three patients (mean age 42 +/- 10 years) received felodipine 5 mg once daily for first 2 weeks and 10 mg once daily for subsequent 2 weeks. Twenty six patients (mean age 45 +/- 9 years) received nifedipine 10 mg tid for 4 weeks. The mean reduction in supine diastolic blood pressure in two groups was 17 +/- 6 mm Hg (nifedipine) and 19 +/- 8 mm Hg (felodipine) (p = NS). The goal diastolic blood pressure of less than or equal to 90 mm Hg was achieved in 31 percent (nifedipine group) and 43.5 percent (felodipine group) of patients (p = NS). Side effects were common with both drugs; however, the tolerability was better with felodipine than with nifedipine. In conclusion felodipine was as effective as nifedipine and had the advantage of once a day dosage.     

Infusion clearance of subcutaneous iothalamate versus standard renal clearance

 Accurate, timed urine collections for the measurement of glomerular filtration rate (GFR) may be impractical in infants or in patients with urological abnormalities. GFR may be measured without urine collection using a constant subcutaneous infusion of iothalamate. We compare the infusion clearance with conventional renal clearance in 14 children and young adults. The mean clearance ratio (infusion clearance/renal clearance ± 1 SD) was 0.99±0.1 and the mean discrepancy between the two methods was 8.5%±4.7%. The 95% limits of agreement for the ratio of the two methods are 0.83–1.23. These data indicate that subcutaneous infusion of iothalamate is a practical method for measuring GFR in children without a urine collection. Received March 18, 1996; received in revised form February 12, 1997; accepted March 26, 1997