391
children, aged 5 months to 9 years (mean 21 months); cow’s milk protein allergy and/or multiple protein allergy (intolerance) (soy protein, fish, egg, wheat), diagnosed on the basis of
repeated elimination and reintroduction of the food protein, in 20 children aged 4-21 months (mean 11 months); and "miscellaneous", mainly unclassified and transient malabsorption, in 45 children aged 5 months to 13 years (mean 23 months). Figs 1 and 2 show that in untreated coeliac disease 10 children had increased ASp-A.T. and 12 increased Ala-A.T. activities. ASp-A.T. was raised in 7 and Ala-A.T. in 6 out of 10 children with food allergy and with a severely or moderately damaged mucosa. In this group, all except 1 of the children with normal or slightly damaged mucosa had normal values. The same is true for the miscellaneous group with moderately
ACCIDENTAL HYPOTHERMIA
SIR,--We read with interest your editorial of Feb. 4, and think it would be of value to draw attention to our earlier study’ on the treatment of hypothermia. Our experience now extends to 38 patients with moderate to severe accidental hypothermia (71% had a core temperature of less than 30°C). 35 patients (92%) were successfully rewarmed to normal body temperature; a further 8 patients died between day 2 and one month, giving a survival-rate of 71%, which compares favourably with published data on similar groups of patients. The
most
important factors in the treatment of hypothermia
are:
(1) Administration of oxygen, followed in most instances by endotracheal intubation; intermittent positive-pressure ventilation is started early. (2) Insertion of an arterial catheter for blood-sampling and pressure monitoring and a central venous catheter for pressure monitoring and for the administration of warmed fluids. (No patient has been adversely affected by the manoeuvres described in [1] and [2]. Reflex cardiac slowing precipitating ventricular fibrillation has not been seen.) (3) Control of metabolic acidosis by sodium bicarbonate. Blood-gases are measured via conventional electrodes at 37°C and corrected to the patient’s temperature.
(4) Rapid external rewarming; the mean rate of rewarming our series was 12°C/h. We have had to use internal rewarming only once--a patient whose core temperature was 23 °C and who presented with ventricular fibrillation was rewarmed by mediastinal irrigation with warm fluids.2 (5) Administration of warm intravenous fluid is important if hypotension or increased peripheral vascular resistance is present. Central venous pressure and hourly urine output are useful guides to the adequacy of infusion. (6) Blood urea, electrolytes, and sugar levels are measured frequently (preferably from arterial blood). There is a variable in
Fig. 2-Serum-Ala-A.T. malabsorption.
values in 93 children
suspected
of
mucosa. On the other hand, in the miscellaneous group 5 children with normal or slightly damaged mucosa had raised levels of ASp-A.T. and 6 had increased Ala-A.T. Food allergy was suspected, but could not be verified, in 3 of these children.
damaged
-
.
-
reported by Hagander et al.the raised values, monitored serially in some children, fell to normal after 2-8 weeks of dietAs
ary treatment. These findings show that liver damage, as judged by raised aminotransferase values, occurs not only in children with gluten intolerance but also in children with intolerance to other proteins, especially when the mucosa is moderately or severely damaged. This argues in favour of the hypothesis that the liver injury in coeliac disease is connected with the damaged mucosa and might be caused not only by immune reactions but also by "toxic substances", endogenous or exogenous, absorbed from the gut.’ It is also possible that the hver injury might be due to specific or general malnutrition. The presence of liver abnormalities in cceliac children, the improvement of liver function during dietary treatment, and the fact that the liver injury in adult coeliac can be severe’ are further arguments for lifelong treatment with a gluten-free diet.
Department of Pædiatrics, Malmö General Hospital, S-214 01 Malmö, Sweden
T. LINDBERG N. O. BERG
S. BORULF
I. JAKOBSSON
pattern of changes in these values influenced to a certain extent by antecedent factors. (7) Drugs seem to have little place in initial treatment. We used steroids occasionally but not routinely. Vasopressors were tried in 4 cases though they were of no apparent value in 3. Neither heparin nor triiodothyronine (even in myxoedema coma) was used. Antibiotics were prescribed on clinical grounds and not prophylactically. Much of the confusion which surrounds the treatment of the hypothermic patient once he has reached hospital would disappear if the simple supportive regimen described above were more universally applied, preferably in an intensive-care unit. In our experience rewarming by external means is adequate. Inspired-air rewarming has little additional merit. More invasive techniques, such as mediastinal irrigation, peritoneal dialysis,3 haemodialysis, and cardiopulmonary bypass,4 will be needed very rarely. Indications for these techniques include an inadequate rate of rewarming by external methods or the occurrence of ventricular fibrillation at a temperature below 280C (our experience and that of others5 indicates that external defibrillation is unlikely to be successful below this temperature). Our results have been presented in abstract6 and report will appear elsewhere.
Department of Surgery, Infirmary, Glasgow G1 1 6NI Western
a
full clinical
I. McA. LEDINGHAM
J. G. MONE
Ledingham, I.McA., Mone, J. G. Lancet, 1972, i, 534. Linton, A. L., Ledingham, I.McA. ibid. 1966, i, 24. Soung, L. S., Swank, L., Ing, T. S., Said, R. A., Goldman, J. W., Perez, J., Geis, W. P. Can. med. Ass. J. 1977, 117, 1415. 4 Davies, D. M., Miller, E. J, Miller, I. A. Lancet, 1967, i, 1036. 5. Hegnauer, A. H., Angelakos, E. T. Ann. N.Y. Acad. Sci. 1959, 80, 336. 6 Ledingham, I.McA., Mone, J. G. in Scientific Abstracts of First World Congress on Intensive Care (edited by I.McA. Ledingham). Glasgow, 1974. 1. 2 3.
children, aged 5 months to 9 years (mean 21 months); cow’s milk protein allergy and/or multiple protein allergy (intolerance) (soy protein, fish, egg, wheat), diagnosed on the basis of
repeated elimination and reintroduction of the food protein, in 20 children aged 4-21 months (mean 11 months); and "miscellaneous", mainly unclassified and transient malabsorption, in 45 children aged 5 months to 13 years (mean 23 months). Figs 1 and 2 show that in untreated coeliac disease 10 children had increased ASp-A.T. and 12 increased Ala-A.T. activities. ASp-A.T. was raised in 7 and Ala-A.T. in 6 out of 10 children with food allergy and with a severely or moderately damaged mucosa. In this group, all except 1 of the children with normal or slightly damaged mucosa had normal values. The same is true for the miscellaneous group with moderately
ACCIDENTAL HYPOTHERMIA
SIR,--We read with interest your editorial of Feb. 4, and think it would be of value to draw attention to our earlier study’ on the treatment of hypothermia. Our experience now extends to 38 patients with moderate to severe accidental hypothermia (71% had a core temperature of less than 30°C). 35 patients (92%) were successfully rewarmed to normal body temperature; a further 8 patients died between day 2 and one month, giving a survival-rate of 71%, which compares favourably with published data on similar groups of patients. The
most
important factors in the treatment of hypothermia
are:
(1) Administration of oxygen, followed in most instances by endotracheal intubation; intermittent positive-pressure ventilation is started early. (2) Insertion of an arterial catheter for blood-sampling and pressure monitoring and a central venous catheter for pressure monitoring and for the administration of warmed fluids. (No patient has been adversely affected by the manoeuvres described in [1] and [2]. Reflex cardiac slowing precipitating ventricular fibrillation has not been seen.) (3) Control of metabolic acidosis by sodium bicarbonate. Blood-gases are measured via conventional electrodes at 37°C and corrected to the patient’s temperature.
(4) Rapid external rewarming; the mean rate of rewarming our series was 12°C/h. We have had to use internal rewarming only once--a patient whose core temperature was 23 °C and who presented with ventricular fibrillation was rewarmed by mediastinal irrigation with warm fluids.2 (5) Administration of warm intravenous fluid is important if hypotension or increased peripheral vascular resistance is present. Central venous pressure and hourly urine output are useful guides to the adequacy of infusion. (6) Blood urea, electrolytes, and sugar levels are measured frequently (preferably from arterial blood). There is a variable in
Fig. 2-Serum-Ala-A.T. malabsorption.
values in 93 children
suspected
of
mucosa. On the other hand, in the miscellaneous group 5 children with normal or slightly damaged mucosa had raised levels of ASp-A.T. and 6 had increased Ala-A.T. Food allergy was suspected, but could not be verified, in 3 of these children.
damaged
-
.
-
reported by Hagander et al.the raised values, monitored serially in some children, fell to normal after 2-8 weeks of dietAs
ary treatment. These findings show that liver damage, as judged by raised aminotransferase values, occurs not only in children with gluten intolerance but also in children with intolerance to other proteins, especially when the mucosa is moderately or severely damaged. This argues in favour of the hypothesis that the liver injury in coeliac disease is connected with the damaged mucosa and might be caused not only by immune reactions but also by "toxic substances", endogenous or exogenous, absorbed from the gut.’ It is also possible that the hver injury might be due to specific or general malnutrition. The presence of liver abnormalities in cceliac children, the improvement of liver function during dietary treatment, and the fact that the liver injury in adult coeliac can be severe’ are further arguments for lifelong treatment with a gluten-free diet.
Department of Pædiatrics, Malmö General Hospital, S-214 01 Malmö, Sweden
T. LINDBERG N. O. BERG
S. BORULF
I. JAKOBSSON
pattern of changes in these values influenced to a certain extent by antecedent factors. (7) Drugs seem to have little place in initial treatment. We used steroids occasionally but not routinely. Vasopressors were tried in 4 cases though they were of no apparent value in 3. Neither heparin nor triiodothyronine (even in myxoedema coma) was used. Antibiotics were prescribed on clinical grounds and not prophylactically. Much of the confusion which surrounds the treatment of the hypothermic patient once he has reached hospital would disappear if the simple supportive regimen described above were more universally applied, preferably in an intensive-care unit. In our experience rewarming by external means is adequate. Inspired-air rewarming has little additional merit. More invasive techniques, such as mediastinal irrigation, peritoneal dialysis,3 haemodialysis, and cardiopulmonary bypass,4 will be needed very rarely. Indications for these techniques include an inadequate rate of rewarming by external methods or the occurrence of ventricular fibrillation at a temperature below 280C (our experience and that of others5 indicates that external defibrillation is unlikely to be successful below this temperature). Our results have been presented in abstract6 and report will appear elsewhere.
Department of Surgery, Infirmary, Glasgow G1 1 6NI Western
a
full clinical
I. McA. LEDINGHAM
J. G. MONE
Ledingham, I.McA., Mone, J. G. Lancet, 1972, i, 534. Linton, A. L., Ledingham, I.McA. ibid. 1966, i, 24. Soung, L. S., Swank, L., Ing, T. S., Said, R. A., Goldman, J. W., Perez, J., Geis, W. P. Can. med. Ass. J. 1977, 117, 1415. 4 Davies, D. M., Miller, E. J, Miller, I. A. Lancet, 1967, i, 1036. 5. Hegnauer, A. H., Angelakos, E. T. Ann. N.Y. Acad. Sci. 1959, 80, 336. 6 Ledingham, I.McA., Mone, J. G. in Scientific Abstracts of First World Congress on Intensive Care (edited by I.McA. Ledingham). Glasgow, 1974. 1. 2 3.
