than-recommend dose. The patients who received excessivedosing of enoxaparin were older (median age 78 vs. 66 years,respectively), smaller (median body mass index 26.2 vs. 27.8,respectively), and more likely to be female (59.5% vs. 38.2%,respectively) than patients who received the recommendeddoses of enoxaparin (p � 0.001). Excessive dosing of enox-aparin was associated with a higher incidence of major bleed-ing (odds ratio [OR] 1.43; 95% confidence interval [CI] 1.18–1.75) and death (OR 1.35; 95% CI 1.02–1.77) compared topatients receiving recommended doses of enoxaparin. Lower-than-recommended dosing of enoxaparin was associated with atrend toward increased mortality (OR 1.25; 95% CI 0.93–1.68).The authors conclude that although enoxaparin is an effectivedrug in the treatment of non-ST elevation ACS, nearly 1 in 5patients received excessive enoxaparin dosing, and that thiswas independently associated with an increased risk of majorbleeding and death.

[Elijah Edwards, MD,

Denver Health Medical Center, Denver, CO]

Editor’s Comment: Enoxaparin is recommended for use inpatients with non-ST elevation ACS but may be associated withsignificant problems if overdosed. Patient risk factors for over-dosing, such as older age, lower weight, and female gender,should be considered in the Emergency Department and takeninto account before the dosing and administration of enoxapa-rin.

e OUTCOME FROM PEDIATRIC CARDIAC ARRESTASSOCIATED WITH TRAUMA. Crewdson K, Lockey D,Davies G. Resuscitation 2007;75:29–34.

This study from the United Kingdom is a retrospectivereview of pediatric trauma patients requiring cardiopulmonaryresuscitation (CPR) in the pre-hospital setting, examining sur-vival rates of those patients, and identifying characteristics thatmay be associated with survival. Eighty pediatric trauma pa-tients, age 15 years or less, who received pre-hospital CPRwere identified from the London Helicopter Emergency Med-ical Service trauma database during a 10-year period (July 1994to June 2004). The London Helicopter Emergency MedicalService is a physician-led pre-hospital trauma service. CPR wasidentified by the use of high-dose adrenaline, external or inter-nal cardiac compressions, or defibrillation on scene or duringtransfer. Of the 80 children requiring pre-hospital CPR, 19(23.75%) survived to discharge from the Emergency Depart-ment, and 7 (8.75%) survived to be discharged from the hos-pital. Of the 7 survivors discharged from the hospital, 3 hadsustained hypoxic injuries, 2 had suffered asphyxial injuryassociated with blunt trauma, one had had a spinal cord injury,and the other had sustained a blunt injury in the setting of aknown congenital cardiac problem. There were no survivors ofpenetrating trauma. This study demonstrated improved but stillpoor outcomes as related in previous studies for pediatricpatients requiring pre-hospital CPR after trauma. The authorssuggest that outcomes may be better in physician-attended

pre-hospital resuscitations and that patients sustaining hypoxicor asphyxia injuries may do better than those sustaining hypo-volemic cardiac arrest.

[Brad Talley, MD,

Denver Health Medical Center, Denver, CO]

Editor’s Comment: This study confirms that cardiac arrestin pediatric trauma patients is rare and has poor outcomes.Children who sustain traumatic cardiac arrest precipitated byhypoxic or asphyxial insults may have the best chance ofsurviving with aggressive out-of-hospital resuscitation.

e SALINE OR ALBUMIN FOR FLUID RESUSCITA-TION IN PATIENTS WITH TRAUMATIC BRAIN IN-JURY. Myburgh J, Cooper JD, Finfer S, et al. N Engl J Med2007;357:874–84.

This study from New Zealand and Australia is a post hocanalysis of patient outcomes from the Saline vs. Albumin FluidEvaluation (SAFE) study. The SAFE trial was a double-blind,randomized, controlled trial comparing albumin and saline usein intensive care unit patients in 16 hospitals across Australiaand New Zealand over a 2 1/2 year period. In this study,investigators conducted a sub-group analysis of patients withtraumatic brain injury (TBI), analyzing outcomes based onmortality and functional neurological status at 24 months. In-terviews were conducted by trained assessors using a telephonequestionnaire to determine functional neurological outcomes.Criteria for traumatic brain injury were met if patients had ahistory of trauma, evidence of trauma on head computed to-mography scan, and Glasgow Coma Scale score � 13. Fourhundred sixty patients were followed, of whom 231 receivedalbumin and 229 received saline. The two groups were similarwith regards to physiologic and demographic parameters. At 24months, 33.2% of patients who received albumin had died,compared with 20.4% of patients who received saline (relativerisk 1.63, 95% confidence interval 1.17–2.26, p value 0.003.) Inpatients with severe head injury (Glasgow Coma Scale score3–8), the relative risk of death in patients who received albu-min was 1.88 (95% confidence interval 1.31–2.70). The authorsconcluded that the rate of death in TBI patients who receivedalbumin was significantly higher than in those who receivedsaline, particularly in patients with severe TBI, suggesting thatsaline is preferable to albumin in resuscitation of patients withTBI. The mechanism behind this difference is unclear, but maybe due to exacerbations of vasogenic or cytotoxic cerebraledema from albumin.

[Jessica Brooks, MD,

Denver Health Medical Center, Denver, CO]

Comment: Although it is a post hoc analysis, and thuspossessive of less power than a properly designed prospectivetrial, this study indicates that Emergency Physicians should beusing normal saline as opposed to albumin to resuscitate pa-tients with traumatic brain injury. It is another in a long line ofstudies that demonstrate similar results in a wide range ofdisease states. The diminishment of any role for the ED use ofalbumin continues with this information.

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