Plain abdominal radiography in clinically suspected appendicitis: diagnostic yield, resource use, and comparison with CT.

This study determined the diagnostic utility and hospital resource impact of plain abdominal radiography in emergency department patients with suspected appendicitis. The authors reviewed medical records of 821 consecutive patients hospitalized for suspected appendicitis; 78% had plain abdominal radiography. Sixty-four percent had appendicitis. Radiographic findings were noted in 51% of patients with, and 47% of patients without appendicitis; no individual radiographic finding was sensitive or specific. Specific conditions were suggested in 10% of impressions; these failed to correlate with final clinical diagnoses 57% of the time. Hospital cost per abdominal radiograph was $67; cost per specific, correct radiographic diagnosis was $1,593. This is compared with $270 per appendiceal computed tomography scan (based on recent literature data). The authors conclude that plain abdominal radiographs in patients with suspected appendicitis are neither sensitive nor specific, are frequently misleading, are costly per specific and correct diagnosis, and should not be routinely obtained on patients with suspected appendicitis.

EMS Agenda for the Future: where we are...where we want to be.

During the past 30 years, emergency medical services (EMS) in the United States have experienced explosive growth. The American health care system is now transforming, providing an opportune time to examine what we have learned over the past three decades in order to create a vision for the future of EMS. Over the course of several months, a multidisciplinary steering committee collaborated with hundreds of EMS-interested individuals, organizations, and agencies to develop the EMS Agenda for the Future. Fourteen EMS attributes were identified as requiring continued development in order to realize the vision established within the Agenda. They are integration of health services, EMS research, legislation and regulation, system finance, human resources, medical direction, education systems, public education, prevention, public access, communication systems, clinical care, information systems, and evaluation. Discussion of these attributes provides important guidance for achieving a vision for the future of EMS that emphasizes its critical role in American health care.

EMS agenda for the future: where we are ... where we want to be. EMS Agenda for the Future Steering Committee.

During the past 30 years, emergency medical services (EMS) in the United States have experienced explosive growth. The American health care system is now transforming, providing an opportune time to examine what we have learned over the past three decades in order to create a vision for the future of EMS. Over the course of several months, a multidisciplinary steering committee collaborated with hundreds of EMS-interested individuals, organizations, and agencies to develop the "EMS Agenda for the Future." Fourteen EMS attributes were identified as requiring continued development in order to realize the vision established within the Agenda. They are Integration of Health Services, EMS Research, Legislation and Regulation, System Finance, Human Resources, Medical Direction, Education Systems, Public Education, Prevention, Public Access, Communication Systems, Clinical Care, Information Systems, and Evaluation. Discussion of these attributes provides important guidance for achieving a vision for the future of EMS that emphasizes its critical role in American health care.

Prospective study of blunt aortic injury: Multicenter Trial of the American Association for the Surgery of Trauma.

BACKGROUND: Blunt aortic injury is a major cause of death from blunt trauma. Evolution of diagnostic techniques and methods of operative repair have altered the management and posed new questions in recent years. METHODS: This study was a prospectively conducted multi-center trial involving 50 trauma centers in North America under the direction of the Multi-institutional Trial Committee of the American Association for the Surgery of Trauma. RESULTS: There were 274 blunt aortic injury cases studied over 2.5 years, of which 81% were caused by automobile crashes. Chest computed tomography and transesophageal echocardiography were applied in 88 and 30 cases, respectively, and were 75 and 80% diagnostic, respectively. Two hundred seven stable patients underwent planned thoracotomy and repair. Clamp and sew technique was used in 73 (35%) and bypass techniques in 134 (65%). Overall mortality was 31%, with 63% of deaths being attributable to aortic rupture; mortality was not affected by method of repair. Paraplegia occurred postoperatively in 8.7%. Logistic regression analysis demonstrated clamp and sew (p = 0.002) and aortic cross clamp time of > or = 30 minutes (p = 0.01) to be associated with development of postoperative paraplegia. CONCLUSIONS: Rupture after hospital admission remains a major problem. Although newer diagnostic techniques are being applied, at this time aortography remains the diagnostic standard. Aortic cross clamp time beyond 30 minutes was associated with paraplegia; bypass techniques, which provide distal aortic perfusion, produced significantly lower paraplegia rates than the clamp and sew approach.

Acute traumatic disruption of the thoracic aorta: emergency department management.

STUDY OBJECTIVE: To evaluate the safety and effectiveness of temporary IV antihypertensive therapy in patients with acute traumatic thoracic aortic disruption. DESIGN: Retrospective chart review of all patients treated for proven traumatic aortic disruption during the ten-year period of 1980 through 1989. SETTING: Emergency department of a large, urban, Level I trauma center. INTERVENTIONS: Preoperative IV beta-blockade and nitroprusside after initial resuscitation in hemodynamically stable patients. RESULTS: Thirty-seven patients with angiographically proven aortic disruption were separated retrospectively into one of three groups. Group 1 (15 patients without preoperative antihypertensive therapy) had two deaths. Group 2 (15 patients treated for two to seven hours [mean, 3.8 hours] before surgery with antihypertensives) had one death. Group 3 (seven patients treated with antihypertensives for 24 hours to four months before surgery to allow recovery from associated severe injuries) had one death. There were no complications resulting from antihypertensive therapy. CONCLUSION: Temporary antihypertensive therapy appears to be safe and effective in patients with aortic disruption.

High risk pediatric emergency air transport.

INTRODUCTION: Pediatric Emergency Air Transports (PEATs) at Massachusetts General Hospital, Boston, Massachusetts, were reviewed between November 1986 and December 1987. Severity of illness, complications, and outcome of PEATs were compared with ground transports. Factors associated with PEAT survival were identified. METHODS: Severity of illness was measured using a modified Denver Patient Status Category (DPSC) method and the Therapeutic Intervention Scoring System (TISS). There were 35 PEATs (30 helicopter, five fixed-wing) and 96 ground transports. RESULTS: Mean severity of illness for patients was greater in PEAT than for the ground transport (PEAT DPSC score=4.23+/-1.06 versus ground DPSC=3.57+/-0.89 [SD], p=.0005). The PEAT mortality was associated with a greater mean severity of illness (TISS survivors=19.1+/-11.4 versus non-survivors=44.3+/-9.5, p=.0001), but not with: the presence of an on-flight physician; transport delay; transport duration; age; sex; history of chronic illness; or intra-transport medical complications. CONCLUSIONS: Compared to ground transports, PEATs were used for higher risk patients.

Traumatic hemipelvectomy: report of two survivors and review.

Two surviving patients with traumatic hemipelvectomy are presented. Rapid transport, aggressive initial resuscitation, and attention to detail in the rehabilitation phase are necessary for the successful management of these patients. The viability of the psoas muscle should be assessed, because of the high possibility of avulsion. Associated nerve injury and complicating meningitis can be serious problems in the management of such patients. There is need to include this entity in the existing classifications of pelvic fractures. Hemipelvectomy is proposed as an alternative in the management of the severe unilateral open pelvic fracture with uncontrollable bleeding.

Time related response of urinary cyclic adenosine monophosphate to trauma.

Urinary cyclic adenosine monophosphate levels were measured in 150 patients with accidental injury of varying causes. Thirty-eight healthy adults of both sexes serving as controls excreted 2.21 to 6.85 micromoles of cyclic adenosine monomphosphate per gram of creatinine, mean 4.34 +/- 1.25. In 120 patients with trauma on admission, the excretion was increased by 15.7 per cent, p less than 0.05, and the changes showed a time related pattern. In patients admitted within the first 30, 60 and 120 minutes after trauma, the mean excretion was changed by 19, 10 and minus 2.8 per cent, respectively, and in those admitted between two and 24 hours by 30 per cent. Twelve patients with differing types of trauma showed a mean 24 hour excretion reaching its peak on the first day, 44 per cent, and declining to its nadir of 2.25 micromoles per gram of creatinine on the third day, minus 47 per cent, p less than 0.01. A second rise reached its peak on the fifth day, p less than 0.05. Thereafter, the excretion fluctuated widely with peaks significantly above and below the control range, and we were unable to correlate these changes with any specific factors. In post-traumatic acute renal failure, the nucleotide excretion fell within several hours and usually reached low values, that is, below 0.25 micromoles per 1,000 milliliters per 24 hours within one to three days. In general, the excretory pattern for cyclic adenosine monophosphate followed that of creatinine clearance, but in the diuretic phase of the recovering kidney, the cyclic adenosine monophosphate levels remained more depressed than those of creatinine. The high sensitivity of urinary cyclic adenosine monophosphate to abnormalities in renal function suggests its potential as a clinical indicator.