To the Editor. In their article entitled
"Prehospital Cardiopulmonary
Resuscitation: Is It Effective?" Cummins
and Eisenberg state: "Clinical
evidence provides strong support for
efforts to increase the percent of
persons in cardiac arrests who receive
early bystander CPR [cardiopulmonary
resuscitation]. These efforts do
no harm and clearly save lives." We
wish to report a subgroup of patients
in whom early bystander-initiated
CPR may be dramatically successful

Kenyear, S.A.

Lemon, S.M.

Rutala, W.A.

Weber, D.J.

Carolina Digital Repository

Electric- and Lightning-InducedCardiac Arrest Reversed byPrompt CardiopulmonaryResuscitationTo the Editor.\p=m-\Intheir article enti-tled "Prehospital CardiopulmonaryResuscitation: Is It Effective?" Cum-mins and Eisenberg1 state: "Clinicalevidence provides strong support forefforts to increase the percent ofpersons in cardiac arrests who receiveearly bystander CPR [cardiopulmo-nary resuscitation]. These efforts dono harm and clearly save lives." Wewish to report a subgroup of patientsin whom early bystander-initiatedCPR may be dramatically successful.Cardiac arrest induced by lightningor electricity is a unique injurybecause all patients may survive ifCPR is promptly instituted. Thepotential success rate in this sub-group can be compared with successrates for resuscitation attempts inthe hospital and in the community.When CPR is commenced in the hos-pital, a success rate of 56% has beenreported.2 Figures for resuscitation inthe community are more difficult tointerpret as reported by Cumminsand Eisenberg, who have reviewedthe results from nine centers over thelast decade.1 Because some patientsare left with a residual neurologicaldeficit, any evaluation of the successof resuscitation must therefore takeinto account the neurological outcomeas well as survival.3Report of Cases.—We report threepatients with high-voltage electrical in¬juries and one patient with a lightninginjury who were successfully resuscitatedafter cardiac arrest. The first patient, a10-year-old boy, was found apneic andpulseless by his mother five to ten minutesafter he was hit by lightning. She com¬menced CPR for eight minutes whileawaiting the arrival of trained personnel.After admission to hospital, the patientwas ventilated and had frequent runs ofventricular tachycardia. Levels of the MBisoenzyme of creatine phosphokinase wereelevated and changes suggestive of anacute inferior myocardial infarction devel¬oped but later resolved. The patient recov¬ered but had amnesia for the event andexperienced personality changes.Two firemen who sustained injuriesfrom line voltages of 8,000 and 33,000 V,respectively, were resuscitated by theircolleagues at the time of injury. Onepatient required a forequarter disarticula¬tion, although neither patient developedEdited by Drummond Rennie, MD, Senior Contrib-uting Editor; Sharon Iverson, Assistant Editor.electrocardiographic abnormalities or ele¬vated cardiac enzyme levels. Anotherpatient contacted a 7,000-V source at workand was resuscitated by a bystander. Sub¬sequent cardiac monitoring revealed noabnormality and no change in enzymelevels was detected. All three patientsrecovered and have no symptoms referableto the cardiovascular or neurological sys¬tems on follow-up that ranges from threeto seven years.Comment.—Optimally, CPR shouldcommence on cessation of the circula¬tion. Because of the peculiar patho-physiology of lightning injury, de¬layed resuscitation may be effective.It has been suggested that all cellularmetabolism ceases at the instant ofthe strike, thereby slowing cellulardegeneration.4 Also, although thepathophysiology may be different,every effort should be made to resus¬citate patients who are apparentlydead after electrical injury.Kevin T. Moran, MDJagan N. Thupari, MDAndrew M. Munster, MDBaltimore Regional Burn CenterFrancis Scott Key Medical CenterJohns Hopkins UniversitySchool of MedicineBaltimore1. Cummins RO, Eisenberg MS: Prehospital cardiopul-monary resuscitation: Is it effective? JAMA 1985;253:2408-2412.2. De Bard ML: Cardiopulmonary resuscitation: Anal-ysis of six years' experience and a review of theliterature. Ann Emerg Med 1981;10:408-411.3. Minoja G, Bandera A, Sala R, et al: Out-of-hospitalcardiac arrest: Six-month follow-up. Lancet 1985;2:775.4. Taussig HG: Death from lightning: The possibilityof living again. Ann Intern Med 1968;68:1345-1353.Response to Deltoid MuscleInjection of Hepatitis B VaccineAfter Failure to Respond toGluteal InjectionsTo the Editor.\p=m-\Werecently reporteda multivariate analysis of the riskfactors associated with a poor immu-nogenic response to the hepatitis Bplasma vaccine among 194 employeesof a community hospital.1 The vaccinehad been stored and administeredaccording to manufacturer's recom-mendations. Employees received allthree doses of the vaccine in thebuttock with a 2.5-cm, 23-gauge nee-dle. Overall, only 56% (108/194) of theemployees developed antibody to hep-atitis B surface antigen (anti-HBs)as measured by the enzyme-linkedimmunosorbent assay (Abbott). Ahigh body weight-height index (ameasure of obesity) was found to bepredictive of a lack of antibodyresponse.To date, 41 of the 86 employees whoinitially failed to develop anti-HBshave received two additional doses ofthe vaccine in the deltoid using a2.5-cm, 23-gauge needle. The initialrepeated immunization was con-Guidelinesfor LettersLetters will be published at the discre¬tion of the editor as space permits andsubject to editing and abridgment.They should be typewritten double-spaced and submitted in duplicate.They should not exceed 500 words oftext. References, if any, should be heldto a minimum, preferably five or fewer.Letters discussing a recent JAMA articleshould be received within one month ofthe article's publication. Letters mustnot duplicate other material publishedor submitted for publication. An assign¬ment of copyright is essential for publi¬cation. It is not feasible routinely toreturn unpublished letters unless such isrequested. Letters not meeting theseguidelines are generally not acknowl¬edged. Also see "Instructions for Au¬thors."ducted 425 \m=+-\15 days after the comple-tion of the primary series, and thesecond immunization 34 \m=+-\1days lat-er. Repeated anti-HBs determina¬tions were done 95 ±1 days after thelast vaccine dose by radioimmunoas-say (Ausab, Abbott). Overall, 75.6%(31/41) of the employees had substan¬tial detectable anti-HBs (ratio of testsample value to mean negative con¬trol value [P/N ratio], >10), an addi¬tional 14.6% (6/41) had low-levelreactivity in the test (P/N ratio, 2.1 to10), while only 9.8% (4/41) had nodetectable antibody (P/N ratio,<2.1). Among poor responders (P/Nratio, <10), seven of ten had aweight-height index greater than thesex-adjusted 75th percentile for UScitizens, as compared with only 11 of31 responders (P/N ratio, >10)(P=.061, two-tailed Fisher's exacttest).We conclude that for subjects whoremain seronegative after three dosesof the hepatitis B plasma vaccinegiven by buttock injection, two addi¬tional intramuscular doses into thedeltoid lead to development of anti-HBs in the vast majority of cases.David J. Weber, MDWilliam A. Rutala, PhDStephanie A. Kenyear, RNStanley M. Lemon, MDUniversity of North CarolinaSchool of MedicineChapel Hill1. Weber DJ, Rutala WA, Samsa GP, et al: Obesity as apredictor of poor antibody response to hepatitis Bplasma vaccine. JAMA 1985;254:3187-3189.The Retrieval of MedicalLiteratureTo the Editor.\p=m-\Thearticle and edito-rial about MEDIS, the full-text medi-

Response to Deltoid Muscle Injection of Hepatitis B Vaccine After Failure to Respond to Gluteal Injections

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Response to Deltoid Muscle Injection of Hepatitis B Vaccine After Failure to Respond to Gluteal Injections

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