Brigham and Women’s Hospital/Harvard Medical SchoolBoston, MA

doi:10.1016/j.annemergmed.2006.03.039

1. Kwan I, Bunn F, Roberts I, on behalf of the WHO Pre-HospitalTrauma Care Steering Committee. Spinal immobilisation for traumapatients (Cochrane Review). In: The Cochrane Library, Issue 1,2005. Chichester, UK: John Wiley & Sons, Ltd.

2. Reid DC, Henderson R, Saboe L, et al. Etiology and clinical courseof missed spine fractures. J Trauma. 1987;27:980-986.

3. Davis JW, Phreaner DL, Hoyt DB, et al. The etiology of missedcervical spine injuries. J Trauma. 1993;34:342-346.

4. Kaups KL, Davis JW. Patients with gunshot wounds to the head donot require cervical spine immobilization and evaluation. J Trauma.1998;44:865-7.

Response to: Out-of-Hospital Pediatric CardiacArrest: An Epidemiologic Review and Assessmentof Current Knowledge

To the Editor:I read with interest the well-done epidemiologic review of

pediatric cardiac arrest by Donoghue, Nadkarni, Berg et al.1 Iam writing to expand upon their discussion of patients whoachieve return of spontaneous circulation through bystanderCPR alone. Although data on this group is limited, it is notabsent. Sirbaugh et al2 described 41 such children in theirprospective, population-based epidemiologic study of pediatriccardiac arrest. All of these children were submersion victims andall survived (compared with only 6 survivors from 300 childrenstill in arrest upon EMS arrival).2 This suggests that CPR isperformed more commonly than accounted for in those studiesthat enroll only patients still in arrest upon EMS arrival. It alsosuggests that bystander CPR alone may be sufficient to rescue asignificant portion of cardiac arrest victims. Donoghue et alrightly points out that it is difficult to determine if patientsresuscitated by bystander CPR alone were truly in cardiacarrest.1 Some insight into this issue can be gained by examiningthe “bystander saves” that my colleagues and I included in astudy of out-of-hospital CPR published in this journal in 1995.3

We included children who were resuscitated by bystanders priorto EMS arrival if they had documented acidosis or continuedalteration in mental status upon arrival to the ED. We described11 such patients from a total of 56 patients receiving CPR inthe out-of-hospital setting. All were submersion victims. CPRwas performed by police twice, lifeguards twice, vacationingEMTs once, a physician once, parents three times and otherbystanders in two instances. Three patients were intubated forpersistent respiratory distress, 2 for continued unconsciousnessand inability to protect the airway, 1 for apnea, and 1 had afailed intubation attempt that was not repeated. One patientsubsequently died of adult respiratory distress syndrome and 3had minor neuorologic sequelae. This information suggests thatCPR was prudent and perhaps life-saving for this group ofchildren.

The most important message from this data is that we mustincrease the number of patients with out-of-hospital cardiacarrest who receive bystander CPR. This message is concordantwith the newly released 2005 American Heart AssociationGuidelines for Cardiopulmonary Resuscitation and EmergencyCardiovascular Care.4 The 2005 Guidelines place renewedemphasis on early, aggressive CPR with minimal interruptionsas a critical component of resuscitation. Also, the AmericanAcademy of Pediatrics has published a report encouragingpediatricians to promote CPR training.5 I agree withDr. Donoghue et al that “bystander saves” deserve moreattention and study. In the meantime, we should do all we canto encourage laypersons and health care providers to becomeproficient at something of proven value—good quality CPR.

Robert W. Hickey, MDChildren’s Hospital of PittsburghDivision of Pediatric Emergency MedicinePittsburgh, PA

doi:10.1016/j.annemergmed.2006.01.046

1. Donoghue AJ, Nadkarni V, Berg RA, et al. Out-of-hospital pediatriccardiac arrest: an epidemiologic review and assessment of currentknowledge. Ann Emerg Med. 2005;46:512-522.

2. Sirbaugh PE, Pepe PE, Shook JE, et al. A prospective, population-based study of the demographics, epidemiology, management,and outcome of out-of-hospital pediatric cardiopulmonary arrest.Ann Emerg Med. 1999;33:174-184.

3. Hickey RW, Cohen DM, Strausbaugh S, et al. Pediatric patientsrequiring CPR in the prehospital setting. Ann Emerg Med. 1995;25:495-501.

4. Emergency Cardiovascular Care Committee and Subcommittees ofthe American Heart Association. 2005 American Heart AssociationGuidelines for Cardiopulmonary Resuscitation and EmergencyCardiovascular Care. Circulation. 2005;112(suppl IV):IV-I-IV-211.

5. Pyles LA, Knapp J. Role of pediatricians in advocating life supporttraining courses for parents and the public. Pediatrics.2004;114:e761-e765.

Seven Days of Gamma-Hydroxybutyrate (GHB)Use Produces Severe Withdrawal

To the Editor:We describe a case of gamma-hydroxybutyrate (GHB)

withdrawal precipitated by ingesting GHB every 2-3 hoursfor only 7 days.

A 29-year-old healthy woman presented to the emergencydepartment awake, staring straight ahead, but not answeringquestions and inconsistently following commands. Hersymptoms began one day earlier after abruptly stopping GHBuse. Eight days prior to presentation, the patient began to useGHB as a sleep aid and intoxicant to help overcome personalissues. Her frequency of dosing quickly escalated to 3 ouncesof GHB every 2-3 hours in a “round-the-clock” fashion. Theconcentration of GHB remains unknown because the patientexhausted her supply, which caused her to stop using GHB.

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Over the past year, she used GHB once or twice a month priorto aerobic workouts. The patient occasionally drank alcohol andsmoked cigarettes. The history was reported by a roommate andlater confirmed by the patient.

On arrival her blood pressure was 145/95 mm Hg, pulse 132beats/min, respirations 16 breaths/min, and oral temperatureof 37.2°C (98.7°F). Her pupils were 7 mm and reactive andwithout nystagmus. Her mucous membranes were dry; neck wassupple; and abdomen was soft with bowel sounds. Her skin wascool and dry without a rash. A limited neurologic exam foundnormal tone and reflexes without tremor or clonus.

Her electrocardiogram revealed a narrow complex sinustachycardia of 140 beats/min. Her laboratory work up,including routine urine drug screen for amphetamines,barbiturates, benzodiazepines, cocaine, and opioids, was non-contributory. One liter of normal saline failed to reduce(decrease) her tachycardia.

During the subsequent 24 hours she developed increasingagitation, delirium, insomnia, and visual hallucinations. Herpulse rate and blood pressure increased and the patient becamediaphoretic. A continuous lorazepam infusion was initiated andcontinued for two days, which reversed her tachycardia whileproducing a somnolent state. While in the ICU she received atotal of 56 mg of lorazepam, and was discharged on a low dosetaper of lorazepam.

Prior to this report, severe GHB withdrawal has only beendescribed in the context of long-term and frequent, almostcontinuous daily use of GHB and related compounds. Mostprevious cases of withdrawal are precipitated by round-the-clockGHB abuse every 2-3 hours for several months to years.1–3 Theshortest previously reported induction period described is 2months.1

Short induction periods have also been described for otheragents that commonly produce withdrawal. Ethanoladministered daily can induce withdrawal in as littleas 16 days,4 and administration of benzodiazepine andopioids can induce withdrawal in as little as 7 days.5

This case demonstrates that severe GHB withdrawal can beinduced by a short, 7-day induction period. Milder symptomsare likely after shorter periods of use. Patients who presentfollowing frequent use of GHB for even short periods shouldbe evaluated for signs of withdrawal.

Eric Perez, MDJason Chu, MDTheodore Bania, MDDepartment of Emergency MedicineSt Lukes/Roosevelt HospitalNew York, NY

doi:10.1016/j.annemergmed.2006.03.040

1. Dyer JE, Roth B, Hyma B. Gamma-hydroxybutyrate withdrawalsyndrome. Ann Emerg Med. 2001;37:147-153.

2. McDaniel CH, Miotto K. Gamma hydroxybutyrate (GHB) and gammabutyrolactone (GBL) withdrawal: five case studies. J PsychoactiveDrugs. 2001;33:143-149.

3. Miotto K, Darakjian J, Basch J, et al. Gamma-hydroxybutyricacid:patterns of use, effects and withdrawal. Am J Addict. 2001;10:232-241.

4. Isbell H, Fraser HF, Wikler A, et al. An experimental study of theetiology of “rum fits” and delirium tremens. Q J Stud Alcohol.1953;16:1-33.

5. Cammarano WB, Pittit JF, Weitz S, et al. Acute withdrawalsyndrome related to the administration of analgesia and sedationin adult intensive care patients. Crit Care Med. 1998;26:676-684.

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