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246 Abstracts

erebral edema, provide important insight for any physicianaring for patients with DKA.

VARIATIONS AND GAPS IN MANAGEMENT OFCUTE ASTHMA IN ONTARIO EMERGENCY DE-ARTMENTS. Lougheed MD, Garvey N, Chapman KR, et al.hest 2009;135:724–36.

This study from Ontario, Canada examined the differencesn management of acute asthma exacerbations among 16 hos-itals. A limited number of characteristics on all hospital visitsor acute asthma exacerbation were collected from 2001 to002 (non-participants) and among these patients, 2671 pedi-tric patients and 2078 adult patients completed a questionnairend consented for additional medical record data abstractionparticipants). Data from repeat visits were collected, but onlynitial visits with a completed questionnaire were included inhe final analysis of data. Initial comparison of 15 out of the 16ospitals with complete data showed greater rates of admissionor participants compared to non-participants, and amongdults, participants were more likely to be female. Final anal-sis did show significant heterogeneity across hospitals inaseline characteristics for sociodemographic qualities, asthmaeverity, co-morbid conditions, exposures in homes, access toare, health care utilization, and management before the emer-ency department (ED) visit. Further, significant heterogeneityas noted for ED management characteristics across hospitals,

ncluding: length of stay, admission rate, presenting symptoms,ocumented triggers, examination characteristics, utilization ofeak expiratory flow rates and chest radiographs; use of inhaledronchodilators, inhaled steroids and systemic steroids in theospital, use of bronchodilators and systemic steroids at dis-harge, and in-hospital education. Referral and follow-up char-cteristics were not found to be entirely heterogeneous. Theuthors acknowledge the significant selection bias in the studyut explain that such bias would only negatively confound theesults. They highlight the significant differences in asthmaanagement across hospitals and suggest the need for knowl-

dge translation initiatives and standardized asthma manage-ent protocols. They also mention the need for further corre-

ation of baseline and pre-visit characteristics to emergencyanagement.

[Michael Prendergast, MD,

Denver Health Medical Center, Denver, CO]

Comments: Although this study has admitted bias in selec-ion and reporting, it does provide some interesting data on theifferences in asthma management between hospitals. Al-hough the authors suggest that treatment protocols and knowl-dge translation initiatives might help in minimizing theseifferences, it is unclear that this would, in fact, be the caseiven the large discrepancies in patient populations and prac-ice patterns at each participating institution.

VICKS VAPORUB INDUCES MUCIN SECRETION,ECREASES CILIARY BEAT FREQUENCY, AND IN-

REASES TRACHEAL MUCUS TRANSPORT IN THE n

ERRET TRACHEA. Abanses JC, Arima S, Rubin BK.hest 2009;135:143–8.

This animal study out of the Wake Forest School of Med-cine measured the effect of Vicks VapoRub® (VVR; Proctor

Gamble, Cincinnati, OH) on ferret airway inflammation anducociliary function. First, the authors excised trachea speci-ens from healthy ferrets, applied VVR and measured mucin

ecretion, mucociliary transport velocity, and ciliary beat fre-uency. Secondly, intubated ferrets, both healthy and thosexposed to bacterial endotoxin (lipopolysaccharide, inducingirway inflammation) were exposed to inhaled placebo orVR. Mucin secretion and lung water were then measured. In

he in vitro VVR-exposed group, mucin secretion was in-reased by 63% over controls, and ciliary beat frequency wasecreased by 35%. In the in vivo group, the bacterial endotoxinecreased mucociliary transport velocity (MCTV) in both nor-al and VVR-exposed airways, and VVR increased MCTV by

4% in inflamed airways. Neither airway inflammation norVR increased lung water. The authors conclude that VVR

timulates mucin secretion, decreases ciliary function, and in-reases MCTV in the inflamed airway, findings comparable tohe acute inflammatory stimulation seen with exposure to air-ay irritants.

[Gary Witt, MD,

Denver Health Medical Center, Denver, CO]

Comment: The impetus for this study was a case reportegarding an 18-month-old toddler exposed to Vicks VapoRuburing an upper respiratory infection who developed respira-ory distress and hypoxia. The results of this study indicate thathe active ingredients of VVR are ciliotoxic and mildly pro-nflammatory. The clinical significance of the results in humanss unknown, but parents of small children should be aware ofhe possible dangers inherent in VVR during upper respiratorynfection.

SURVIVAL WITH EMERGENCY TOURNIQUET USEO STOP BLEEDING IN MAJOR LIMB TRAUMA.ragh JF, Walters TJ, Baer DG, et al. Ann Surg 2009;249:1–7.

This prospective survey evaluated the practice of emer-ency tourniquet use in either the prehospital setting or themergency department (ED) at a combat support hospital inaghdad. Over the 7-month study period in 2006, 232 (8%) of

he 2838 patients with major limb trauma had 428 tourniquetspplied on 309 injured limbs. The patients were evaluated forhock via weak or absent radial pulses and were assessed forurvival rates and limb outcome. Casualties that had indicationsor tourniquet use but did not receive them were also evaluated.rehospital tourniquets were applied in 194 patients, of which2 died (11% mortality), whereas 38 patients received EDourniquets with 9 deaths (24% mortality, p � 0.05). The 5asualties in which tourniquets were indicated but not appliedad a 0% survival rate vs. 87% for those casualties withourniquets (p � 0.001). Furthermore, tourniquet use whenhock was absent was strongly associated with survival (90%s. 10%; p � 0.001). Four patients (1.7%) sustained transient

erve palsy at the level of the tourniquet with no resultant