Percutaneous transtracheal ventilation (PTV) is an active airway management technique that may be... more Percutaneous transtracheal ventilation (PTV) is an active airway management technique that may be an alternative to cricothyroidotomy in critically injured patients. A canine trauma model was devised to compare the ventilatory capacity and hemodynamic effects of PTV to endotracheal intubation. Mongrel dogs (25-37 kg), splenectomized 14 days previously, were anesthetized with pentobarbital and bled to a mean arterial pressure (MAP) of 20 mm Hg. Animals were maintained at this MAP for 1 hour, then resuscitated with simultaneous: a) aortic crossclamping via left thoracotomy, b) Ringer's lactate infusion, and c) active airway support. Control animals (N = 5), intubated with a cuffed endotracheal tube, were ventilated at a rate of 12 per minute, a tidal volume of 500 cc and an FIO2 of 60%. In study animals (N = 5), PTV, for a duration of 1 second, was instituted at the same rate and FIO2. There was no statistically significant difference between the two groups with regard to pO2, pCO2, pH, and hemodynamic parameters. PTV was also performed in the emergency department on four patients unresponsive to resuscitative thoracotomy for postinjury cardiac arrest. PTV rate was 12/minute; duration, 1 second; and FIO2, 100%. Mean values (+/- SEM) for pH, pO2, and pCO2 obtained after 15 minutes of PTV were 7.14 +/- 0.03, 322 +/- 49.5 torr, and 21.5 +/- 4.7 torr, respectively. PTV is comparable to endotracheal intubation with respect to oxygenation, ventilation and hemodynamic response (p greater than 0.05). Our preliminary clinical study corroborates its efficacy in the acute trauma setting and supports further clinical investigation.
Acute mountain sickness has been described in adults but little is known concerning its occurrenc... more Acute mountain sickness has been described in adults but little is known concerning its occurrence in children. Our objective was to determine the incidence of acute mountain sickness in children. A survey questionnaire was completed by 558 children (aged 9 to 14 years) after they ascended from 1600 to 2835 m and from 405 similarly aged children after travel at sea level. Three or more of the following symptoms in the high-altitude setting were considered as the case definition of acute mountain sickness: headache, loss of appetite, vomiting, fatigue, insomnia, shortness of breath, and dizziness. One hundred fifty-six (28%) of the children at 2835 m developed acute mountain sickness. Three or more symptoms developed in a smaller, but nonetheless considerable, number (86 [21%]) of children at sea level. Headache, shortness of breath, and dizziness were reported more frequently at high altitude than at low altitude, whereas the other symptoms occurred with equal frequency at the two locations. More than one fourth of the children visiting high altitude developed acute mountain sickness. A high proportion (21%) of children at sea level developed similar symptoms, suggesting that an appreciable portion of the symptoms present were due to factors other than altitude, such as travel, anxiety, or disruption of daily routine.
Objective: To determine the incidence of acute mountain sickness in a general population of visit... more Objective: To determine the incidence of acute mountain sickness in a general population of visitors to moderate elevations, the characteristics associated with it, and its effect on physical activity. • Design: A cross-sectional study.
Medical records of 150 patients with high-altitude pulmonary edema seen over a 39-month period in... more Medical records of 150 patients with high-altitude pulmonary edema seen over a 39-month period in a Colorado Rocky Mountain ski area at 2,928 m (9,600 ft) (mean age, 34.4 years; 84% male) were reviewed. The mean time to the onset of symptoms was 3 ± 1.3 days after arrival. Common symptoms were dyspnea, cough, headache, chest congestion, nausea, fever, and weakness. Orthopnea, hemoptysis, and vomiting were rare, occurring in 7%, 6%, and 16%, respectively. Symptoms of cerebral edema occurred in 14%. A temperature exceeding 1000F occurred in 20%, and 17% had a systolic blood pressure of 150 mm of mercury or higher. Blood pressures were higher in patients older than 50 years (142 mm of mercury). Rales were present in 85%, and a pulmonary infiltrate was present in 88%; both were most commonly bilateral or on the right side. The amount of infiltrate was mild. Men appeared to be more susceptible than women to high-altitude pulmonary edema. Pulse oximetry in 45 patients showed a mean oxygen saturation of 74% (38% to 93%). Treatment methods depended on severity and included a return to quarters for portable nasal oxygen, an overnight stay in the clinic for continuing oxygen, or a descent to Denver for recovery or admission to a hospital. All patients received oxygen for 2 to 4 hours in the clinic. There were no deaths or complications.
The effect of previous physical conditioning on young well-conditioned mountaineers in relationsh... more The effect of previous physical conditioning on young well-conditioned mountaineers in relationship to acquiring acute mountain sickness is controversial. Data show both increased and decreased effects on the incidence of altitude illness. How general tourists at moderate altitudes are affected is unknown. To determine the influence of sea-level habitual physical activity on the incidence of mountain sickness, we surveyed 205 participants in a scientific conference at 3,000 m (9,840 ft). A 36-item questionnaire was distributed to the subjects 48 hours after arrival at altitude. Their sea-level physical activity (SLPA) was measured by a published and validated instrument that included questions about patterns of work, sporting, and leisure-time activities. Acute mountain sickness was defined as the presence of 3 or more of the following symptoms: headache, dyspnea, anorexia, fatigue, insomnia, dizziness, or vomiting. Most of the respondents were male (62%) from sea level (89%) with a mean age of 36 ± 8.7 (standard deviation) years (range, 22 to 65). Nearly all (94%) were nonsmokers, and 28% had acute mountain sickness. The mean SLPA score was 8.0 ± 1.3 (range, 5.1 to 12.0). No statistically significant difference in mean SLPA scores was found between those with and without acute mountain sickness (8.1 versus 7.8), nor in the individual indices (work, 2.5 versus 2.4; sport, 2.9 versus 2.7; leisure, 2.8 versus 2.7). We conclude that habitual physical activity performed at sea level does not play a role in the development of altitude illness at moderate altitude in a general tourist group.
The Children's Lake Louise Score (CLLS) established the diagnostic criteria for acute mountai... more The Children's Lake Louise Score (CLLS) established the diagnostic criteria for acute mountain sickness (AMS) in preverbal children. Prospective application of the CLLS and interobserver agreement for the score had not been evaluated in a controlled trial. A study of children and their parents was used to evaluate the CLLS and determine the incidence of AMS in preverbal children. A prospective, controlled trial. Children > or =3 months and < or =36 months old and their parents living below 1645 m were studied over 7 separate days. The CLLS, measured daily by the mother as well as by the father on days 5 and 6, is the sum of scores for fussiness (FS), eating (E), playfulness (P), and sleep (S). Children were studied on days 1 and 2 at home, on day 3 after travel without altitude gain to a hotel, on day 4 at home, on days 5 and 6 at a hotel at 3109 m, and on day 7 at home. Using our previous criteria, AMS was diagnosed if the CLLS was > or =7 with both the FS > or =4 a...
We studied the physiologic and clinical responses to moderate altitude in 97 older men and women ... more We studied the physiologic and clinical responses to moderate altitude in 97 older men and women (aged 59 to 83 years) over 5 days in Vail, Colorado, at an elevation of 2,500 m (8,200 ft). The incidence of acute mountain sickness was 16%, which is slightly lower than that reported for younger persons. The occurrence of symptoms of acute mountain sickness did not parallel arterial oxygen saturation or spirometric or blood pressure measurements. Chronic diseases were present in percentages typical for ambulatory elderly persons: 19 (20%) had coronary artery disease, 33 (34%) had hypertension, and 9 (9%) had lung disease. Despite this, no adverse signs or symptoms occurred in our subjects during their stay at this altitude. Our findings suggest that persons with preexisting, generally asymptomatic, cardiovascular or pulmonary disease can safely visit moderate altitudes.
The Journal of Trauma: Injury, Infection, and Critical Care, 1985
Abstract Percutaneous transtraeheal ventilation (PTV) is an active airway management technique th... more Abstract Percutaneous transtraeheal ventilation (PTV) is an active airway management technique that may be an alternative to cricothyroidotomy in critically injured patients. A canine trauma model was devised to compare the ventilatory capacity and hemodynamic ...
Journal of the American Medical Informatics Association, 2001
To evaluate the use of a computer program to identify adverse drug events (ADEs) in the ambulator... more To evaluate the use of a computer program to identify adverse drug events (ADEs) in the ambulatory setting and to evaluate the relative contribution of four computer search methods for identifying ADEs, including diagnosis codes, allergy rules, computer event monitoring rules, and text searching.
International Journal of Medical Informatics, 2001
Introduction: In inpatients, computer monitors have been used to improve the detection of adverse... more Introduction: In inpatients, computer monitors have been used to improve the detection of adverse drug events (ADEs). However, similar programs have not been available in outpatients. Objecti6e: To describe an approach for detecting incidents suggesting that an ADE may have occurred in outpatients by adapting methods from inpatient computer monitoring and developing terminology searches of electronic medical records. Methods: One year of information from the outpatient electronic medical record (EMR) at one hospital and its clinics was reviewed. Altogether, 23 064 patients and 88 514 visits were identified. Patient demographics, medical problem lists, ICD-9 claims, patient allergies, medication history and all clinic visit notes were extracted and merged. We then searched for incidents suggesting that an ADE might be present using four methods: ICD-9 claims, new allergies, computer rules linking laboratory data to known medication exposures, and a medical terminology lexicon (M 2 D 2 ™). In this report, we describe how these search methods were developed to allow for ADE identification. Conclusion: The ability to carry out such quality-related work is an example of the benefits of the outpatient EMR that may not be apparent to those institutions considering adopting it.
Honigman, Benjamin, Ed Noordewier, David Kleinman, and Michael Yaron. High altitude retinal hemor... more Honigman, Benjamin, Ed Noordewier, David Kleinman, and Michael Yaron. High altitude retinal hemorrhages in a Colorado skier. High Alt Med Biol 2:539-544, 2001.-High altitude retinal hemorrhages are commonly seen at altitudes above 4270 m. While these hemorrhages are generally asymptomatic, macular involvement may result in permanent visual acuity deficit. We present the case of a 29-year-old male recreational skier who traveled to a ski resort at 2930 m, ascended to 3470 m, and developed acute mountain sickness, high altitude pulmonary edema, and bilateral retinal hemorrhages. A funduscopic examination to determine if macular retinal hemorrhage is present may be performed by clinicians in the final assessment of patients following altitude illness.
Substantial numbers of children are exposed to moderate altitude while traveling to mountain reso... more Substantial numbers of children are exposed to moderate altitude while traveling to mountain resorts with their families. Although there has been extensive study of the adult physiologic response to altitude exposure, few studies of infants and young children exist. This investigation examines the acute physiologic responses to moderate altitude exposure among young children and the relationship of these responses to the development of acute mountain sickness (AMS). Children 3 to 36 months old participated in the prospective observational study, which included baseline measurements at 1610 m and measurements after a 24-h exposure to 3109 m. Measurements included pulse and respiratory rate, end-tidal CO(2), arterial oxygen saturation (pulse oximetry), cerebral tissue oxygenation (St(O2)) by near-infrared spectroscopy, middle cerebral artery resistive index by transcranial Doppler, lateral ventricle volumes (ultrasound), and clinical evaluation for the presence of acute mountain sickness (Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Lake Louise Score). Twenty-four children (13 girls and 11 boys, age 14.5 +/- 10.2 months) participated. After acute exposure to 3109 m, these children showed an increase in respiratory rate from 45 +/- 13 to 51.9 +/- 15 breaths/min (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.008), accompanied by a decrease of end-tidal CO(2) from 31 +/- 3 to 28 +/- 2 mm Hg (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001) and a reduction of arterial oxygen saturation from 95 +/- 2 to 91 +/- 2% (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). St(O2) also decreased from 78 +/- 8 to 67 +/- 13% (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001), and this reduction appeared to be related to age (r = 0.58, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05), with lower saturations found in younger children. No evidence of increased intracranial pressure, as assessed by middle cerebral artery resistive index, was seen during ascent. Seven subjects developed symptoms of AMS; however, no relationship was found between the physiologic changes observed and the presence of symptoms. Ascent from 1610 to 3109 m resulted in tachypnea, relative hypoxia, hypocapnia, and a reduction in cerebral tissue oxygenation (St(O2)). The reduction in St(O2) appeared to be related to age, with infants appearing to be the most susceptible to cerebral tissue oxygen desaturation at high altitude. No relationship appears to exist between the presence of AMS and the physiologic measurements.
Archives of Pediatrics & Adolescent Medicine, 1998
To establish diagnostic criteria for acute mountain sickness (AMS) in preverbal children. Nonrand... more To establish diagnostic criteria for acute mountain sickness (AMS) in preverbal children. Nonrandomized control trial. Ambulatory. Children aged 3 through 36 months and adults from the Denver, Colo, area (altitude, 1610 m). The Lake Louise Scoring System was modified, using a fussiness score as the headache equivalent and a pediatric symptom score to assess appetite, vomiting, playfulness, and ability to sleep. Acute mountain sickness was assessed by combining the fussiness and pediatric symptom scores to produce what we termed the Children&#39;s Lake Louise AMS Score (CLLS). Parents recorded the fussiness score at 11 AM, 1, 3, and 5 PM, and the pediatric symptom score at 3:00 PM each day. Each subject traveled twice, with 1 day considered a control. Days 1 and 2 were measurements at home; day 3 reflected travel without altitude change to 1615 m; and 1 week later, day 4 involved travel to 3488 m. On days 3 and 4 the accompanying adults completed the Lake Louise Scoring System. Twenty-three subjects (14 boys; mean+/-SD age, 20.7+/-9.0 months) participated. The mean CLLS demonstrated no differences on days 1, 2, or 3. On day 4, 5 subjects (21.7%) had AMS, established as a CLLS of 7 or higher, and these scores normalized 2 hours after descent. Forty-five adults participated and 9 (20%) had AMS. We define AMS in preverbal children as a CLLS of 7 or higher with a fussiness score of 4 or higher and a pediatric symptom score of 3 or higher, in the setting of recent altitude gain. The incidence of AMS in preverbal children (21.7%) was similar to that in adults (20%).
OBJECTIVE--To determine the impact of the pneumatic antishock garment on survival in patients wit... more OBJECTIVE--To determine the impact of the pneumatic antishock garment on survival in patients with cardiac wounds. DESIGN--A retrospective review of a 6.5-year experience in a population of patients with gunshot or stab wounds to the heart (N = 70). SETTING--The city and county of Denver, Colo, where all patients were transported by paramedic ambulances to Denver General Hospital, an urban, level 1 trauma center. PATIENTS--All patients were analyzed, including those transported to the emergency department with no vital signs at the trauma scene. Only patients with definite penetrating cardiac injuries were included. METHODS--Paramedic trip sheets and emergency department, operating room, in-hospital, and autopsy records were reviewed. Demographic, clinical outcome, and treatment data were collected. A multiple logistic regression model was developed to determine which characteristics and treatment variables were independently predictive of patient outcome. The ability of each independent variable to predict outcome was determined by calculating adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS--Seventy patients (31 gunshot and 39 stab wounds) had a revised trauma score of 2.8 +/- 4.0 (mean +/- SD; range, 0-12; median, 0). Thirty-two (46%) had cardiac tamponade. Overall, 21 (30%) of the patients survived. In the logistic model, the presence of cardiac tamponade (OR, 9.1; 95% CI, 1.5 to 56.1) and a higher revised trauma score were associated with higher survival. Inflation of the pneumatic antishock garment was associated with sevenfold lower survival (adjusted OR, 0.14; 95% CI, 0.02 to 0.86); the effect was negative across all trauma score groups. --Survival in patients with penetrating cardiac wounds is highly associated with anatomic and physiologic factors, while application of the pneumatic antishock garment appears to be detrimental.
The ability of paramedics to deliver advanced trauma life support (ATLS) in an expedient fashion ... more The ability of paramedics to deliver advanced trauma life support (ATLS) in an expedient fashion for victims of trauma has been strongly challenged. In this study, the records of 114 consecutive victims of blunt trauma who underwent laparotomy or thoracotomy were reviewed. Prehospital care was rendered by paramedics operating under strict protocols. The mean response time (minutes +_ SEM) to the scene was 5.6 + 0.27. On-scene time was 13.9 +_ 0.62. The time to return to the hospital was 8.0 +_ 0.4. On-scene time included assessing hazards at the scene, patient extrication, spine immobilization (n = 98), application of oxygen (n = 94), measurement of vital signs (n = 114), splinting of 59 limbs, and the following ATLS procedures: endotracheal intubation (n = 31), IV access (n = 106), ECG monitoring (n = 69), procurement of blood for tests including type and cross (n = 58), and application of a pneumatic antishock garment (PASG) (n = 31). On-scene times were analyzed according to the number of ATLS procedures performed: insertion of one IV line (n =46), 14.8 +_ 1.03 minutes; two IV lines (n =28), 13.4 +_ 0.92; one IV line plus intubation (n = 7), 14.0 + 2.94; two IV lines plus intubation (n=9), 17.0 +_ 2.38; and two IV lines plus intubation plus PASG (n = 13), 12.4 +_ 1.36. Of the 161 IV attempts, 94% were completed successfully. Of 36 attempts at endotracheal intubation, 89% were successful. Sixteen additional trauma patients were studied prospectively: the time required to place an IV Iine was 2.98 +_ 0.37 minutes. Of 87 patients who had any vital signs in the field, 73 survived (83%). We conclude that paramedics functioning under direct medical control can perform basic life support and ATLS procedures at the scene in an expeditious manner. [Cwinn AA, Pons PT, Moore EE, Marx JA, Honigman B, Dinerman N: Prehospital advanced trauma life support for critical blunt trauma victims. Ann Emerg Med April 1987;16:399-403.]
Percutaneous transtracheal ventilation (PTV) is an active airway management technique that may be... more Percutaneous transtracheal ventilation (PTV) is an active airway management technique that may be an alternative to cricothyroidotomy in critically injured patients. A canine trauma model was devised to compare the ventilatory capacity and hemodynamic effects of PTV to endotracheal intubation. Mongrel dogs (25-37 kg), splenectomized 14 days previously, were anesthetized with pentobarbital and bled to a mean arterial pressure (MAP) of 20 mm Hg. Animals were maintained at this MAP for 1 hour, then resuscitated with simultaneous: a) aortic crossclamping via left thoracotomy, b) Ringer&#39;s lactate infusion, and c) active airway support. Control animals (N = 5), intubated with a cuffed endotracheal tube, were ventilated at a rate of 12 per minute, a tidal volume of 500 cc and an FIO2 of 60%. In study animals (N = 5), PTV, for a duration of 1 second, was instituted at the same rate and FIO2. There was no statistically significant difference between the two groups with regard to pO2, pCO2, pH, and hemodynamic parameters. PTV was also performed in the emergency department on four patients unresponsive to resuscitative thoracotomy for postinjury cardiac arrest. PTV rate was 12/minute; duration, 1 second; and FIO2, 100%. Mean values (+/- SEM) for pH, pO2, and pCO2 obtained after 15 minutes of PTV were 7.14 +/- 0.03, 322 +/- 49.5 torr, and 21.5 +/- 4.7 torr, respectively. PTV is comparable to endotracheal intubation with respect to oxygenation, ventilation and hemodynamic response (p greater than 0.05). Our preliminary clinical study corroborates its efficacy in the acute trauma setting and supports further clinical investigation.
Acute mountain sickness has been described in adults but little is known concerning its occurrenc... more Acute mountain sickness has been described in adults but little is known concerning its occurrence in children. Our objective was to determine the incidence of acute mountain sickness in children. A survey questionnaire was completed by 558 children (aged 9 to 14 years) after they ascended from 1600 to 2835 m and from 405 similarly aged children after travel at sea level. Three or more of the following symptoms in the high-altitude setting were considered as the case definition of acute mountain sickness: headache, loss of appetite, vomiting, fatigue, insomnia, shortness of breath, and dizziness. One hundred fifty-six (28%) of the children at 2835 m developed acute mountain sickness. Three or more symptoms developed in a smaller, but nonetheless considerable, number (86 [21%]) of children at sea level. Headache, shortness of breath, and dizziness were reported more frequently at high altitude than at low altitude, whereas the other symptoms occurred with equal frequency at the two locations. More than one fourth of the children visiting high altitude developed acute mountain sickness. A high proportion (21%) of children at sea level developed similar symptoms, suggesting that an appreciable portion of the symptoms present were due to factors other than altitude, such as travel, anxiety, or disruption of daily routine.
Objective: To determine the incidence of acute mountain sickness in a general population of visit... more Objective: To determine the incidence of acute mountain sickness in a general population of visitors to moderate elevations, the characteristics associated with it, and its effect on physical activity. • Design: A cross-sectional study.
Medical records of 150 patients with high-altitude pulmonary edema seen over a 39-month period in... more Medical records of 150 patients with high-altitude pulmonary edema seen over a 39-month period in a Colorado Rocky Mountain ski area at 2,928 m (9,600 ft) (mean age, 34.4 years; 84% male) were reviewed. The mean time to the onset of symptoms was 3 ± 1.3 days after arrival. Common symptoms were dyspnea, cough, headache, chest congestion, nausea, fever, and weakness. Orthopnea, hemoptysis, and vomiting were rare, occurring in 7%, 6%, and 16%, respectively. Symptoms of cerebral edema occurred in 14%. A temperature exceeding 1000F occurred in 20%, and 17% had a systolic blood pressure of 150 mm of mercury or higher. Blood pressures were higher in patients older than 50 years (142 mm of mercury). Rales were present in 85%, and a pulmonary infiltrate was present in 88%; both were most commonly bilateral or on the right side. The amount of infiltrate was mild. Men appeared to be more susceptible than women to high-altitude pulmonary edema. Pulse oximetry in 45 patients showed a mean oxygen saturation of 74% (38% to 93%). Treatment methods depended on severity and included a return to quarters for portable nasal oxygen, an overnight stay in the clinic for continuing oxygen, or a descent to Denver for recovery or admission to a hospital. All patients received oxygen for 2 to 4 hours in the clinic. There were no deaths or complications.
The effect of previous physical conditioning on young well-conditioned mountaineers in relationsh... more The effect of previous physical conditioning on young well-conditioned mountaineers in relationship to acquiring acute mountain sickness is controversial. Data show both increased and decreased effects on the incidence of altitude illness. How general tourists at moderate altitudes are affected is unknown. To determine the influence of sea-level habitual physical activity on the incidence of mountain sickness, we surveyed 205 participants in a scientific conference at 3,000 m (9,840 ft). A 36-item questionnaire was distributed to the subjects 48 hours after arrival at altitude. Their sea-level physical activity (SLPA) was measured by a published and validated instrument that included questions about patterns of work, sporting, and leisure-time activities. Acute mountain sickness was defined as the presence of 3 or more of the following symptoms: headache, dyspnea, anorexia, fatigue, insomnia, dizziness, or vomiting. Most of the respondents were male (62%) from sea level (89%) with a mean age of 36 ± 8.7 (standard deviation) years (range, 22 to 65). Nearly all (94%) were nonsmokers, and 28% had acute mountain sickness. The mean SLPA score was 8.0 ± 1.3 (range, 5.1 to 12.0). No statistically significant difference in mean SLPA scores was found between those with and without acute mountain sickness (8.1 versus 7.8), nor in the individual indices (work, 2.5 versus 2.4; sport, 2.9 versus 2.7; leisure, 2.8 versus 2.7). We conclude that habitual physical activity performed at sea level does not play a role in the development of altitude illness at moderate altitude in a general tourist group.
The Children's Lake Louise Score (CLLS) established the diagnostic criteria for acute mountai... more The Children's Lake Louise Score (CLLS) established the diagnostic criteria for acute mountain sickness (AMS) in preverbal children. Prospective application of the CLLS and interobserver agreement for the score had not been evaluated in a controlled trial. A study of children and their parents was used to evaluate the CLLS and determine the incidence of AMS in preverbal children. A prospective, controlled trial. Children > or =3 months and < or =36 months old and their parents living below 1645 m were studied over 7 separate days. The CLLS, measured daily by the mother as well as by the father on days 5 and 6, is the sum of scores for fussiness (FS), eating (E), playfulness (P), and sleep (S). Children were studied on days 1 and 2 at home, on day 3 after travel without altitude gain to a hotel, on day 4 at home, on days 5 and 6 at a hotel at 3109 m, and on day 7 at home. Using our previous criteria, AMS was diagnosed if the CLLS was > or =7 with both the FS > or =4 a...
We studied the physiologic and clinical responses to moderate altitude in 97 older men and women ... more We studied the physiologic and clinical responses to moderate altitude in 97 older men and women (aged 59 to 83 years) over 5 days in Vail, Colorado, at an elevation of 2,500 m (8,200 ft). The incidence of acute mountain sickness was 16%, which is slightly lower than that reported for younger persons. The occurrence of symptoms of acute mountain sickness did not parallel arterial oxygen saturation or spirometric or blood pressure measurements. Chronic diseases were present in percentages typical for ambulatory elderly persons: 19 (20%) had coronary artery disease, 33 (34%) had hypertension, and 9 (9%) had lung disease. Despite this, no adverse signs or symptoms occurred in our subjects during their stay at this altitude. Our findings suggest that persons with preexisting, generally asymptomatic, cardiovascular or pulmonary disease can safely visit moderate altitudes.
The Journal of Trauma: Injury, Infection, and Critical Care, 1985
Abstract Percutaneous transtraeheal ventilation (PTV) is an active airway management technique th... more Abstract Percutaneous transtraeheal ventilation (PTV) is an active airway management technique that may be an alternative to cricothyroidotomy in critically injured patients. A canine trauma model was devised to compare the ventilatory capacity and hemodynamic ...
Journal of the American Medical Informatics Association, 2001
To evaluate the use of a computer program to identify adverse drug events (ADEs) in the ambulator... more To evaluate the use of a computer program to identify adverse drug events (ADEs) in the ambulatory setting and to evaluate the relative contribution of four computer search methods for identifying ADEs, including diagnosis codes, allergy rules, computer event monitoring rules, and text searching.
International Journal of Medical Informatics, 2001
Introduction: In inpatients, computer monitors have been used to improve the detection of adverse... more Introduction: In inpatients, computer monitors have been used to improve the detection of adverse drug events (ADEs). However, similar programs have not been available in outpatients. Objecti6e: To describe an approach for detecting incidents suggesting that an ADE may have occurred in outpatients by adapting methods from inpatient computer monitoring and developing terminology searches of electronic medical records. Methods: One year of information from the outpatient electronic medical record (EMR) at one hospital and its clinics was reviewed. Altogether, 23 064 patients and 88 514 visits were identified. Patient demographics, medical problem lists, ICD-9 claims, patient allergies, medication history and all clinic visit notes were extracted and merged. We then searched for incidents suggesting that an ADE might be present using four methods: ICD-9 claims, new allergies, computer rules linking laboratory data to known medication exposures, and a medical terminology lexicon (M 2 D 2 ™). In this report, we describe how these search methods were developed to allow for ADE identification. Conclusion: The ability to carry out such quality-related work is an example of the benefits of the outpatient EMR that may not be apparent to those institutions considering adopting it.
Honigman, Benjamin, Ed Noordewier, David Kleinman, and Michael Yaron. High altitude retinal hemor... more Honigman, Benjamin, Ed Noordewier, David Kleinman, and Michael Yaron. High altitude retinal hemorrhages in a Colorado skier. High Alt Med Biol 2:539-544, 2001.-High altitude retinal hemorrhages are commonly seen at altitudes above 4270 m. While these hemorrhages are generally asymptomatic, macular involvement may result in permanent visual acuity deficit. We present the case of a 29-year-old male recreational skier who traveled to a ski resort at 2930 m, ascended to 3470 m, and developed acute mountain sickness, high altitude pulmonary edema, and bilateral retinal hemorrhages. A funduscopic examination to determine if macular retinal hemorrhage is present may be performed by clinicians in the final assessment of patients following altitude illness.
Substantial numbers of children are exposed to moderate altitude while traveling to mountain reso... more Substantial numbers of children are exposed to moderate altitude while traveling to mountain resorts with their families. Although there has been extensive study of the adult physiologic response to altitude exposure, few studies of infants and young children exist. This investigation examines the acute physiologic responses to moderate altitude exposure among young children and the relationship of these responses to the development of acute mountain sickness (AMS). Children 3 to 36 months old participated in the prospective observational study, which included baseline measurements at 1610 m and measurements after a 24-h exposure to 3109 m. Measurements included pulse and respiratory rate, end-tidal CO(2), arterial oxygen saturation (pulse oximetry), cerebral tissue oxygenation (St(O2)) by near-infrared spectroscopy, middle cerebral artery resistive index by transcranial Doppler, lateral ventricle volumes (ultrasound), and clinical evaluation for the presence of acute mountain sickness (Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Lake Louise Score). Twenty-four children (13 girls and 11 boys, age 14.5 +/- 10.2 months) participated. After acute exposure to 3109 m, these children showed an increase in respiratory rate from 45 +/- 13 to 51.9 +/- 15 breaths/min (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.008), accompanied by a decrease of end-tidal CO(2) from 31 +/- 3 to 28 +/- 2 mm Hg (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001) and a reduction of arterial oxygen saturation from 95 +/- 2 to 91 +/- 2% (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). St(O2) also decreased from 78 +/- 8 to 67 +/- 13% (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001), and this reduction appeared to be related to age (r = 0.58, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05), with lower saturations found in younger children. No evidence of increased intracranial pressure, as assessed by middle cerebral artery resistive index, was seen during ascent. Seven subjects developed symptoms of AMS; however, no relationship was found between the physiologic changes observed and the presence of symptoms. Ascent from 1610 to 3109 m resulted in tachypnea, relative hypoxia, hypocapnia, and a reduction in cerebral tissue oxygenation (St(O2)). The reduction in St(O2) appeared to be related to age, with infants appearing to be the most susceptible to cerebral tissue oxygen desaturation at high altitude. No relationship appears to exist between the presence of AMS and the physiologic measurements.
Archives of Pediatrics & Adolescent Medicine, 1998
To establish diagnostic criteria for acute mountain sickness (AMS) in preverbal children. Nonrand... more To establish diagnostic criteria for acute mountain sickness (AMS) in preverbal children. Nonrandomized control trial. Ambulatory. Children aged 3 through 36 months and adults from the Denver, Colo, area (altitude, 1610 m). The Lake Louise Scoring System was modified, using a fussiness score as the headache equivalent and a pediatric symptom score to assess appetite, vomiting, playfulness, and ability to sleep. Acute mountain sickness was assessed by combining the fussiness and pediatric symptom scores to produce what we termed the Children&#39;s Lake Louise AMS Score (CLLS). Parents recorded the fussiness score at 11 AM, 1, 3, and 5 PM, and the pediatric symptom score at 3:00 PM each day. Each subject traveled twice, with 1 day considered a control. Days 1 and 2 were measurements at home; day 3 reflected travel without altitude change to 1615 m; and 1 week later, day 4 involved travel to 3488 m. On days 3 and 4 the accompanying adults completed the Lake Louise Scoring System. Twenty-three subjects (14 boys; mean+/-SD age, 20.7+/-9.0 months) participated. The mean CLLS demonstrated no differences on days 1, 2, or 3. On day 4, 5 subjects (21.7%) had AMS, established as a CLLS of 7 or higher, and these scores normalized 2 hours after descent. Forty-five adults participated and 9 (20%) had AMS. We define AMS in preverbal children as a CLLS of 7 or higher with a fussiness score of 4 or higher and a pediatric symptom score of 3 or higher, in the setting of recent altitude gain. The incidence of AMS in preverbal children (21.7%) was similar to that in adults (20%).
OBJECTIVE--To determine the impact of the pneumatic antishock garment on survival in patients wit... more OBJECTIVE--To determine the impact of the pneumatic antishock garment on survival in patients with cardiac wounds. DESIGN--A retrospective review of a 6.5-year experience in a population of patients with gunshot or stab wounds to the heart (N = 70). SETTING--The city and county of Denver, Colo, where all patients were transported by paramedic ambulances to Denver General Hospital, an urban, level 1 trauma center. PATIENTS--All patients were analyzed, including those transported to the emergency department with no vital signs at the trauma scene. Only patients with definite penetrating cardiac injuries were included. METHODS--Paramedic trip sheets and emergency department, operating room, in-hospital, and autopsy records were reviewed. Demographic, clinical outcome, and treatment data were collected. A multiple logistic regression model was developed to determine which characteristics and treatment variables were independently predictive of patient outcome. The ability of each independent variable to predict outcome was determined by calculating adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS--Seventy patients (31 gunshot and 39 stab wounds) had a revised trauma score of 2.8 +/- 4.0 (mean +/- SD; range, 0-12; median, 0). Thirty-two (46%) had cardiac tamponade. Overall, 21 (30%) of the patients survived. In the logistic model, the presence of cardiac tamponade (OR, 9.1; 95% CI, 1.5 to 56.1) and a higher revised trauma score were associated with higher survival. Inflation of the pneumatic antishock garment was associated with sevenfold lower survival (adjusted OR, 0.14; 95% CI, 0.02 to 0.86); the effect was negative across all trauma score groups. --Survival in patients with penetrating cardiac wounds is highly associated with anatomic and physiologic factors, while application of the pneumatic antishock garment appears to be detrimental.
The ability of paramedics to deliver advanced trauma life support (ATLS) in an expedient fashion ... more The ability of paramedics to deliver advanced trauma life support (ATLS) in an expedient fashion for victims of trauma has been strongly challenged. In this study, the records of 114 consecutive victims of blunt trauma who underwent laparotomy or thoracotomy were reviewed. Prehospital care was rendered by paramedics operating under strict protocols. The mean response time (minutes +_ SEM) to the scene was 5.6 + 0.27. On-scene time was 13.9 +_ 0.62. The time to return to the hospital was 8.0 +_ 0.4. On-scene time included assessing hazards at the scene, patient extrication, spine immobilization (n = 98), application of oxygen (n = 94), measurement of vital signs (n = 114), splinting of 59 limbs, and the following ATLS procedures: endotracheal intubation (n = 31), IV access (n = 106), ECG monitoring (n = 69), procurement of blood for tests including type and cross (n = 58), and application of a pneumatic antishock garment (PASG) (n = 31). On-scene times were analyzed according to the number of ATLS procedures performed: insertion of one IV line (n =46), 14.8 +_ 1.03 minutes; two IV lines (n =28), 13.4 +_ 0.92; one IV line plus intubation (n = 7), 14.0 + 2.94; two IV lines plus intubation (n=9), 17.0 +_ 2.38; and two IV lines plus intubation plus PASG (n = 13), 12.4 +_ 1.36. Of the 161 IV attempts, 94% were completed successfully. Of 36 attempts at endotracheal intubation, 89% were successful. Sixteen additional trauma patients were studied prospectively: the time required to place an IV Iine was 2.98 +_ 0.37 minutes. Of 87 patients who had any vital signs in the field, 73 survived (83%). We conclude that paramedics functioning under direct medical control can perform basic life support and ATLS procedures at the scene in an expeditious manner. [Cwinn AA, Pons PT, Moore EE, Marx JA, Honigman B, Dinerman N: Prehospital advanced trauma life support for critical blunt trauma victims. Ann Emerg Med April 1987;16:399-403.]
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