Statement
on
the "Heimlich Maneuver"
The American Medical Association Commission on Emergency Medical Services recognizes that choking on foreign objects is a true medical emergency. This problem is addressed in the Standards on Cardiopulmonary Resuscitation and Emergency Cardiac Care as published in a supplement to
JAMA (Feb 18, 1974).
More
recently,
a maneuver
popularly known as the "Heimlich maneuver" has been used by a number of persons and case histories have been offered regarding the efficacy of this maneuver. The Commission believes that any training in the application of the Heimlich maneuver should follow generally recognized guidelines for determining the cause of a person's inability to breathe. The maneuver has been successful in removing food blocking the airway. However, in order to adequately evaluate the maneuver, the Commission further believes that additional data should be obtained concerning its use in choking situations and whether or not it was used in emergencies that mimic or simulate choking, such as seizure, heart attack, and other syncopal episodes. In summary, the Commission believes the maneuver to be a most important addition to the emergency care pro¬ cedures for the person choking on food or other objects that shut off the airway. The proper position of the maneu¬ ver in the sequence of procedures previously recommended in the supplement to JAMA must be determined. The Com¬ mission recommends that the National Academy of Sci¬ ences—National Research Council, the American Heart Association, and other comparable organizations interested in emergency care procedures collect and evaluate data to determine the place of the Heimlich maneuver in the in¬ struction of the public in proper emergency care practices.
AMA Commission on Emergency Medical Services
October\p=m-\Immunization
Action Month
For the third consecutive year, October has been designated Immunization Action Month. As in the past, the 1975 campaign is designed to focus the attention of health care professionals and the general public on the inadequate immunization levels among preschool children (1 to 4
old) against poliomyelitis, measles, rubella, mumps, diphtheria, pertussis, and tetanus.
years
Address editorial communications to the
Editor,
535 N Dearborn St,
Immunization Action Month was initiated as a national campaign in 1973 to reverse the declining trend of immunization levels during the last decade. Prior to 1974, immunization levels in preschool children had declined significantly. With poliomyelitis vaccine, for example, 84.1% of preschool children were immunized in 1963 (three or more doses of vaccine); in 1973, the proportion had declined to 60.4%. Similar trends were noted for the other six communicable diseases. Current vaccine distribution figures and the latest US Immunization Survey indicate that the declining immunization levels were stemmed in 1974. Nevertheless, these levels are still too low. In spite of the availability of effective vaccines, approximately 5.3 million of the nearly 13.2 million 1- to 4-year-old children in this country are un¬
protected against polio, measles, rubella, diphtheria, per¬ or tetanus, according to the US Immunization Survey conducted each year by the Center for Disease Control (At¬
tussis,
lanta) and the Bureau of 35.5% of all preschoolers
the Census. It is estimated that are
unprotected against measles,
that 8 million children in this same group are currently unprotected against mumps, and that 36.9% remain vul¬ nerable to polio. Such immunization levels are low enough to permit the introduction and spread of disease, and until they are brought to within the safety zone, children will still be afflicted with polio, youngsters will struggle through life mentally and physically crippled from encephalitic measles complications, diphtheria epidemics will occur, infants will die of whooping cough, and babies will continue to be born with the deformities of congenital rubella syndrome. The month-long immunization campaign is sponsored by the Center for Disease Control in conjunction with a number of public and private health agencies including the American Medical Association, American Academy of Pediatrics, American Academy of Family Physicians, Na¬ tional Medical Association, and other medical, nursing, and public health groups as well as pharmaceutical firms and voluntary service organizations. As part of the campaign, physicians and health depart¬ ments are encouraged to arrange for an audit of their pa¬ tient records immediately, determine immunization needs, and arrange for necessary vaccinations. Personal immuniza¬ tion audit forms are being distributed to private and public health personnel by the Center for Disease Control. Such efforts on the part of health care professionals will
Chicago 60610
Downloaded From: http://jama.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
be augmented by the effects of a public awareness pro¬ gram that will be conducted simultaneously to educate parents about the seriousness of these diseases and the availability of vaccines, and to motivate them to have their children immunized and to keep accurate immunization records. Immunization Action Month has been a successful mo¬ tivational tool in the effort to reverse the trend of declin¬ ing immunization levels. Its long-range objective, how¬ ever, is the immunization of a minimum of 90% of the susceptible 1- to 4-year-old children prior to their first year of school. To achieve this goal, Immunization Action Month 1975 must be characterized by renewed persistence in our efforts to improve immunization levels and maintain a high level of concern about dangers that often seem re¬ mote in the face of more immediate day-to-day problems. John J. Witte, MD Center for Disease Control Atlanta
Platelet
Aggregation
Heightened platelet sensitivity to aggregating agents\p=m-\ adenosine diphosphate (ADP), epinephrine, collagen\p=m-\has
been reported in some diseases that are not primarily disorders of hemostasis, but that often predispose to abnormal thrombotic complications. Is the increased platelet aggregation incidental, or is it a factor in this predisposition ? Thirty years ago, Duguid1 suggested that continual laying down of microthrombi on the arterial intima is a fundamental cause of atherosclerosis, but this hypothesis still awaits definitive confirmation. Sano et al2 demonstrated an eightfold increase in platelet sensitivity to the aggregating action of ADP in 12 patients during acute myocardial infarction and stroke. Increased sensitivity to platelet aggregants has been noted also as late as 16 months3 after
myocardial infarction, as well as in angina without infarction.4 And, curiously, the enhanced sensitivity has been observed in hyperbetalipoproteinemia5\p=m-\a genetic trait con-
ducive to atherosclerosis. Interpretation of these observations is somewhat complicated by recent doubts6 about the reliability of the aggregometer in recording platelet aggregation. Nor is inter¬ pretation made simpler by the reported changes in the shape of platelets from small, round spheres to larger "spread" forms, characteristic of early stages of thrombosis, in patients with ischémie heart disease. Schatz and Gross7 describe an increase in the number of these forms in 14 pa¬ tients with both acute and chronic ischémie heart disease. More important, when the plasma of these patients was mixed with platelets of control subjects, the number of "spread" forms was also increased. Clearly, the plasma of patients with ischémie heart disease contains a factor that induces platelets to undergo characteristic morphologic
It is not clear whether this factor is related to the "transferable factor," identified in 1967 by Bolton et al8 as the cause of abnormal sensitivity of platelets to ADP. Abnormal increase in platelet sensitivity to ADP and other aggregants has been also observed in diabetes. Sagel et
changes.
al9 demonstrated this increase in seven prediabetic, 12 la¬ diabetic, and 20 frankly diabetic patients. It was most pronounced in the last group, particularly when the diabe¬ tes was severe. Significantly, the second phase of aggrega¬ tion (after four minutes) was reversed by aspirin, tolbutamide, and dextrose. This reversal suggests a possible use of antiaggregating agents in the treatment or prevention of diabetic microagiopathy and thrombotic complications of atherosclerosis. While these therapeutic possibilities are in the realm of the future, some diagnostic uses of aggregation abnormal¬ ities are close at hand. The abnormalities, however, are not those of increased, but of decreased platelet aggregation. Defective aggregating response to epinephrine was reported by Zucker and Mielke10 and by Neemeh et al11 in patients with essential thrombocythemia and polycythemia vera. By contrast, the response was normal in patients with second¬ ary thrombocytosis. Confirmjng these observations in a more extensive study with three antiaggregating agents, Ginsburg12 suggests that this difference could prove useful in differentiating thrombocytosis associated with poly¬ cythemia vera and essential thrombocythemia from thrombo¬ cytosis secondary to a malignant lesion or chronic inflamma¬ tory disease. Diagnostic, therapeutic, and conceptual implications of abnormal platelet aggregation have yet to be fully ex¬ tent
plored.
Samuel Vaisrub, MD Senior Editor
1. Duguid JB: Thrombosis as a factor in the pathogenesis of coronary atherosclerosis. J Pathol Bacteriol 58:207-212, 1946. 2. Sano T, Boxer MGJ, Boxer LA, et al: Platelet sensitivity to aggregation in normal and diseased groups: A method for assessment of platelet aggregability. Thromb Diath Haemorrh 25:524-531, 1971. 3. Salky N, Dugdale M: Platelet abnormalities in ischemic heart disease. Am J Cardiol 32:612-617, 1973. 4. Frishman WH, Weksler B, Christodoulou JP, et al: Reversal of abnormal platelet aggregability and change in exercise tolerance in patients with angina pectoris following oral propranolol. Circulation 50:887-896,
1974. 5. Carvalho
ACA, Colman RW, Lees RS: Platelet function in hyperlipoproteinemia. N Engl J Med 290:434-438, 1974. 6. Deliliers GL, Pogliana E, Praga C: Is platelet aggregation by isoantibodies always real aggregation? N Engl J Med 292:1241, 1975. 7. Schatz EJ, Gross I: Blood platelet response to plasma from patients with ischemic heart disease. Am J Cardiol 35:204-210, 1975. 8. Bolton CH, Hampton JR, Mitchell JR: Nature of the transferable factor which causes abnormal platelet behavior in vascular disease. Lancet 2:1101-1105, 1967. 9. Sagel J, Colwell JA, Crook L, et al: Increased platelet aggregation in early diabetus mellitus. Ann Intern Med 82:733-738, 1975. 10. Zucker S, Mielke CH: Classification of thrombocytosis based on platelet function tests: Correlation with haemorrhagic and thrombotic complications. J Lab Clin Med 80:385-394, 1972. 11. Neemeh JA, Bowie W, Thompson JH, et al: Quantitation of platelet aggregation in myeloproliferative disorders. Am J Clin Pathol 57:336\x=req-\ 347, 1972. 12. Ginsburg AD: Platelet function in patients with high platelet counts. Ann Intern Med 82:506-511, 1975.
Downloaded From: http://jama.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
on
the "Heimlich Maneuver"
The American Medical Association Commission on Emergency Medical Services recognizes that choking on foreign objects is a true medical emergency. This problem is addressed in the Standards on Cardiopulmonary Resuscitation and Emergency Cardiac Care as published in a supplement to
JAMA (Feb 18, 1974).
More
recently,
a maneuver
popularly known as the "Heimlich maneuver" has been used by a number of persons and case histories have been offered regarding the efficacy of this maneuver. The Commission believes that any training in the application of the Heimlich maneuver should follow generally recognized guidelines for determining the cause of a person's inability to breathe. The maneuver has been successful in removing food blocking the airway. However, in order to adequately evaluate the maneuver, the Commission further believes that additional data should be obtained concerning its use in choking situations and whether or not it was used in emergencies that mimic or simulate choking, such as seizure, heart attack, and other syncopal episodes. In summary, the Commission believes the maneuver to be a most important addition to the emergency care pro¬ cedures for the person choking on food or other objects that shut off the airway. The proper position of the maneu¬ ver in the sequence of procedures previously recommended in the supplement to JAMA must be determined. The Com¬ mission recommends that the National Academy of Sci¬ ences—National Research Council, the American Heart Association, and other comparable organizations interested in emergency care procedures collect and evaluate data to determine the place of the Heimlich maneuver in the in¬ struction of the public in proper emergency care practices.
AMA Commission on Emergency Medical Services
October\p=m-\Immunization
Action Month
For the third consecutive year, October has been designated Immunization Action Month. As in the past, the 1975 campaign is designed to focus the attention of health care professionals and the general public on the inadequate immunization levels among preschool children (1 to 4
old) against poliomyelitis, measles, rubella, mumps, diphtheria, pertussis, and tetanus.
years
Address editorial communications to the
Editor,
535 N Dearborn St,
Immunization Action Month was initiated as a national campaign in 1973 to reverse the declining trend of immunization levels during the last decade. Prior to 1974, immunization levels in preschool children had declined significantly. With poliomyelitis vaccine, for example, 84.1% of preschool children were immunized in 1963 (three or more doses of vaccine); in 1973, the proportion had declined to 60.4%. Similar trends were noted for the other six communicable diseases. Current vaccine distribution figures and the latest US Immunization Survey indicate that the declining immunization levels were stemmed in 1974. Nevertheless, these levels are still too low. In spite of the availability of effective vaccines, approximately 5.3 million of the nearly 13.2 million 1- to 4-year-old children in this country are un¬
protected against polio, measles, rubella, diphtheria, per¬ or tetanus, according to the US Immunization Survey conducted each year by the Center for Disease Control (At¬
tussis,
lanta) and the Bureau of 35.5% of all preschoolers
the Census. It is estimated that are
unprotected against measles,
that 8 million children in this same group are currently unprotected against mumps, and that 36.9% remain vul¬ nerable to polio. Such immunization levels are low enough to permit the introduction and spread of disease, and until they are brought to within the safety zone, children will still be afflicted with polio, youngsters will struggle through life mentally and physically crippled from encephalitic measles complications, diphtheria epidemics will occur, infants will die of whooping cough, and babies will continue to be born with the deformities of congenital rubella syndrome. The month-long immunization campaign is sponsored by the Center for Disease Control in conjunction with a number of public and private health agencies including the American Medical Association, American Academy of Pediatrics, American Academy of Family Physicians, Na¬ tional Medical Association, and other medical, nursing, and public health groups as well as pharmaceutical firms and voluntary service organizations. As part of the campaign, physicians and health depart¬ ments are encouraged to arrange for an audit of their pa¬ tient records immediately, determine immunization needs, and arrange for necessary vaccinations. Personal immuniza¬ tion audit forms are being distributed to private and public health personnel by the Center for Disease Control. Such efforts on the part of health care professionals will
Chicago 60610
Downloaded From: http://jama.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
be augmented by the effects of a public awareness pro¬ gram that will be conducted simultaneously to educate parents about the seriousness of these diseases and the availability of vaccines, and to motivate them to have their children immunized and to keep accurate immunization records. Immunization Action Month has been a successful mo¬ tivational tool in the effort to reverse the trend of declin¬ ing immunization levels. Its long-range objective, how¬ ever, is the immunization of a minimum of 90% of the susceptible 1- to 4-year-old children prior to their first year of school. To achieve this goal, Immunization Action Month 1975 must be characterized by renewed persistence in our efforts to improve immunization levels and maintain a high level of concern about dangers that often seem re¬ mote in the face of more immediate day-to-day problems. John J. Witte, MD Center for Disease Control Atlanta
Platelet
Aggregation
Heightened platelet sensitivity to aggregating agents\p=m-\ adenosine diphosphate (ADP), epinephrine, collagen\p=m-\has
been reported in some diseases that are not primarily disorders of hemostasis, but that often predispose to abnormal thrombotic complications. Is the increased platelet aggregation incidental, or is it a factor in this predisposition ? Thirty years ago, Duguid1 suggested that continual laying down of microthrombi on the arterial intima is a fundamental cause of atherosclerosis, but this hypothesis still awaits definitive confirmation. Sano et al2 demonstrated an eightfold increase in platelet sensitivity to the aggregating action of ADP in 12 patients during acute myocardial infarction and stroke. Increased sensitivity to platelet aggregants has been noted also as late as 16 months3 after
myocardial infarction, as well as in angina without infarction.4 And, curiously, the enhanced sensitivity has been observed in hyperbetalipoproteinemia5\p=m-\a genetic trait con-
ducive to atherosclerosis. Interpretation of these observations is somewhat complicated by recent doubts6 about the reliability of the aggregometer in recording platelet aggregation. Nor is inter¬ pretation made simpler by the reported changes in the shape of platelets from small, round spheres to larger "spread" forms, characteristic of early stages of thrombosis, in patients with ischémie heart disease. Schatz and Gross7 describe an increase in the number of these forms in 14 pa¬ tients with both acute and chronic ischémie heart disease. More important, when the plasma of these patients was mixed with platelets of control subjects, the number of "spread" forms was also increased. Clearly, the plasma of patients with ischémie heart disease contains a factor that induces platelets to undergo characteristic morphologic
It is not clear whether this factor is related to the "transferable factor," identified in 1967 by Bolton et al8 as the cause of abnormal sensitivity of platelets to ADP. Abnormal increase in platelet sensitivity to ADP and other aggregants has been also observed in diabetes. Sagel et
changes.
al9 demonstrated this increase in seven prediabetic, 12 la¬ diabetic, and 20 frankly diabetic patients. It was most pronounced in the last group, particularly when the diabe¬ tes was severe. Significantly, the second phase of aggrega¬ tion (after four minutes) was reversed by aspirin, tolbutamide, and dextrose. This reversal suggests a possible use of antiaggregating agents in the treatment or prevention of diabetic microagiopathy and thrombotic complications of atherosclerosis. While these therapeutic possibilities are in the realm of the future, some diagnostic uses of aggregation abnormal¬ ities are close at hand. The abnormalities, however, are not those of increased, but of decreased platelet aggregation. Defective aggregating response to epinephrine was reported by Zucker and Mielke10 and by Neemeh et al11 in patients with essential thrombocythemia and polycythemia vera. By contrast, the response was normal in patients with second¬ ary thrombocytosis. Confirmjng these observations in a more extensive study with three antiaggregating agents, Ginsburg12 suggests that this difference could prove useful in differentiating thrombocytosis associated with poly¬ cythemia vera and essential thrombocythemia from thrombo¬ cytosis secondary to a malignant lesion or chronic inflamma¬ tory disease. Diagnostic, therapeutic, and conceptual implications of abnormal platelet aggregation have yet to be fully ex¬ tent
plored.
Samuel Vaisrub, MD Senior Editor
1. Duguid JB: Thrombosis as a factor in the pathogenesis of coronary atherosclerosis. J Pathol Bacteriol 58:207-212, 1946. 2. Sano T, Boxer MGJ, Boxer LA, et al: Platelet sensitivity to aggregation in normal and diseased groups: A method for assessment of platelet aggregability. Thromb Diath Haemorrh 25:524-531, 1971. 3. Salky N, Dugdale M: Platelet abnormalities in ischemic heart disease. Am J Cardiol 32:612-617, 1973. 4. Frishman WH, Weksler B, Christodoulou JP, et al: Reversal of abnormal platelet aggregability and change in exercise tolerance in patients with angina pectoris following oral propranolol. Circulation 50:887-896,
1974. 5. Carvalho
ACA, Colman RW, Lees RS: Platelet function in hyperlipoproteinemia. N Engl J Med 290:434-438, 1974. 6. Deliliers GL, Pogliana E, Praga C: Is platelet aggregation by isoantibodies always real aggregation? N Engl J Med 292:1241, 1975. 7. Schatz EJ, Gross I: Blood platelet response to plasma from patients with ischemic heart disease. Am J Cardiol 35:204-210, 1975. 8. Bolton CH, Hampton JR, Mitchell JR: Nature of the transferable factor which causes abnormal platelet behavior in vascular disease. Lancet 2:1101-1105, 1967. 9. Sagel J, Colwell JA, Crook L, et al: Increased platelet aggregation in early diabetus mellitus. Ann Intern Med 82:733-738, 1975. 10. Zucker S, Mielke CH: Classification of thrombocytosis based on platelet function tests: Correlation with haemorrhagic and thrombotic complications. J Lab Clin Med 80:385-394, 1972. 11. Neemeh JA, Bowie W, Thompson JH, et al: Quantitation of platelet aggregation in myeloproliferative disorders. Am J Clin Pathol 57:336\x=req-\ 347, 1972. 12. Ginsburg AD: Platelet function in patients with high platelet counts. Ann Intern Med 82:506-511, 1975.
Downloaded From: http://jama.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
