Significance of the initial spun hematocrit in trauma patients.

This study was designed to determine whether the initial spun hematocrit (HCT) value correlated with blood loss requiring operative intervention (OR). A spun HCT was performed on the first available blood sample from 524 admitted patients 12 years of age or older with traumatic injuries (86% blunt, 14% penetrating). Patients in the OR (n = 66) group had a lower mean HCT (35 v 41, P < .001) when compared with the non-OR group. The 81 patients with an HCT of < or = 35 required OR more frequently (41% v 7%, P < .001). An HCT of < or = 35 had a sensitivity of 50%, specificity of 90%, positive predictive value of 41%, and negative predictive value of 93% for identifying the OR group. The effect of hemodilution from intravenous fluid is difficult to assess in a retrospective clinical study.

Injuries distracting from intraabdominal injuries after blunt trauma.

While most conscious patients with severe intraabdominal injuries (IAI) will usually present with either abdominal pain or tenderness, there is a small group of awake and alert patients in whom the physical examination will be falsely negative because of the presence of associated extraabdominal ("distracting") injuries. We sought to define the types of extraabdominal injuries that could lead to a false negative physical examination for potentially severe IAI in adult victims of blunt trauma. This study was prospectively performed on consecutive blunt trauma patients over a 14-month period in our level I trauma center. Inclusion criteria were as follows: (1) Glasgow Coma Scale score of 15; (2) age 18 years or older; and (3) computed tomography (CT) of the abdomen or diagnostic peritoneal lavage (DPL) performed regardless of initial physical examination findings. Patients were questioned specifically about the presence of abdominal pain and the initial abdominal examination was documented in addition to other extraabdominal injuries. Abdominal injuries were considered to be present based upon either abdominal CT findings or a positive DPL. Patients with and without abdominal pain or tenderness were compared for the presence of IAI. A total of 350 patients were enrolled. There were 142 patients with neither abdominal pain nor tenderness (group 1) and 208 patients with either or both (group 2). Ten of the 142 patients (7.0%) in group 1 had IAI compared with 44 of the 208 patients (21.2%) in group 2 (P = .0003). Presence of pain and/or tenderness had a sensitivity of 82%, a specificity of 45%, a positive predictive value of 21%, and negative predictive value of 93%. All 10 patients in group 1, and 36 of the 44 group 2 patients, had associated extraabdominal injuries. Although the presence of abdominal pain or tenderness was associated with a significantly higher incidence of IAI, the lack of these findings did not preclude IAI.

Neonatal fever: utility of the Rochester criteria in determining low risk for serious bacterial infections.

The purpose of this study was to test the utility of the Rochester criteria in determining which febrile neonates are at low risk for serious bacterial infections (SBI). This was a retrospective study over a 5-year period of 134 patients younger than 29 days old with fever without a source evaluated in the emergency department. Results of urinalysis, lumbar puncture, peripheral white blood cell count, and cultures of blood, urine, cerebrospinal fluid, and stool were recorded. Of the 134 neonates, 71 were high-risk, 48 low-risk, and 15 were not classifiable by the available data. Nineteen of the 71 high-risk patients (26.8%) had SBI (2 patients had 2 SBI). Three of the 48 low-risk neonates (6.3%) had SBI (1 patient had 2 SBI). None of the 15 nonclassifiable patients had SBI. Employing the Rochester criteria to the fully cultured neonates who could be risk-stratified, the sensitivity, specificity, positive predictive value, and negative predictive value were 86.4%, 46.4%, 26.8%, and 93.8%, respectively. Although outpatient management of febrile neonates may be feasible, a small percentage of neonates meeting low-risk criteria will have a SBI.

Prospective crossover study of the effect of phlebotomy and intravenous crystalloid on hematocrit.

OBJECTIVE: To compare the changes in hematocrit (Hct) between phlebotomized and nonphlebotomized individuals given IV crystalloid. METHODS: A prospective, crossover volunteer study was performed comparing Hct changes immediately and 30 minutes after IV crystalloid bolus in 20 healthy adults with and without prebolus phlebotomy. In the control portion, volunteers were given a 15-mL/kg bolus of normal saline over 30 minutes with Hct determination before (H1), immediately after (H2), and 30 minutes after (H3) crystalloid infusion. At least 7 days later, the same subjects were phlebotomized 1 unit of blood and then administered a 15-mL/kg IV bolus of normal saline 30 minutes later. Hcts were obtained before (H4) and 30 minutes after (H5) phlebotomy (immediately prior to crystalloid infusion). Hcts were also obtained immediately after (H6) and 30 minutes after (H7) crystalloid infusion. A post-hoc test performance analysis was then performed to determine the Hct drop thresholds that would yield the maximal sensitivity and specificity for 500 mL of blood loss (via phlebotomy) in this population. RESULTS: The Hct (%) drops in the nonphlebotomized individuals receiving IV fluids averaged 4.5 +/- 1.3 immediately and 3.2 +/- 1.3 30 minutes after infusion. These drops were different (p < 0.05) from the Hct drop in individuals receiving IV fluids after phlebotomy, which averaged 6.6 +/- 1.5 and 5.7 +/- 1.1, respectively. Post-hoc analysis revealed that Hct drops of 5.4 immediately, or 4.3 at 30 minutes after infusion, had a sensitivity of > 90% and a specificity of 75% for identification of patients in the phlebotomy group. CONCLUSIONS: The practice of measuring serial Hcts may be helpful to identify trauma patients with occult blood loss. A prospective clinical trial is needed to validate these Hct drop thresholds (immediate and 30 minutes postinfusion) in crystalloid-resuscitated trauma patients.

A retrospective review of positive chlamydial cultures in emergency department patients.

This study evaluated the accuracy of diagnosis and treatment of chlamydial infection based solely on clinical presentation in the emergency department (ED). The signs and symptoms of women with chlamydial infection confirmed by cervical culture were identified and compared between appropriately treated and nontreated groups to determine which clinical features tended to lead to the correct or incorrect diagnosis. The study also determined which signs and symptoms were consistently present in the entire study group. Two hundred thirty-three charts of female ED patients with positive cervical chlamydial cultures were obtained via computerized records from the microbiology lab and reviewed retrospectively. Only 20% of the patients were correctly diagnosed as having a sexually transmitted disease and only 24% were properly treated during their initial ED visit. Although abdominal pain and vaginal discharge were the most frequent symptom and sign, only 70% and 54% of all patients had these clinical manifestations, respectively. Patients with vaginal discharge and cervical motion tenderness were significantly (P < .01) more likely to be treated in the ED. Patients with urinary tract symptoms and pregnancy were significantly (P < .01) less likely to be treated in the ED. Cervical cultures should be performed during all pelvic examinations because of the variability in the clinical presentation of chlamydial infection. A follow-up system must be in place to identify positive cultures and locate patients to ensure appropriate treatment.

Lack of a hyperkalemic response in emergency department patients receiving succinylcholine.

OBJECTIVE: To determine whether serum potassium (K) levels increase significantly following succinylcholine (SCh)-assisted intubation in ED patients. METHODS: A prospective, noncontrolled, consecutive case series design was used to evaluate the change in serum K levels in ED patients who received SCh for emergency intubation. The study was performed at an academic medical center staffed by board-certified emergency physicians. The subjects were 100 consecutive prescreened ED patients with various diagnoses who received SCh for intubation. The eligible subjects had serum K levels determined prior to and 5 minutes after administration of a 1.0-1.5-mg/kg i.v. dose of SCh. Serum K levels were measured by the ion-selective electrode assay method. RESULTS: The mean change in serum K levels was -0.04 mmol/L (95% CI -0.14 to 0.06). The maximum increase was 1.10 mmol/L. The serum K level rose in 46 cases, decreased in 46 cases, and was unchanged in eight cases. No instance of SCh-induced cardiac arrest was identified. CONCLUSION: Changes in serum K levels following SCh administration in prescreened ED patients were minimal. A hyperkalemic response is uncommon in ED patients who undergo SCh-assisted intubation.

An unusual presentation of cat scratch encephalitis.

Cat scratch disease is an infectious illness that has been recognized since the 1880s; however, our understanding and knowledge of it is still evolving (1). It was not until 1991 that the etiologic species, Rochalimaea, was finally confirmed (2,3). Only recently have the breadth of its clinical spectrum and the population at risk been appreciated. We now realize that signs and symptoms that had been considered cardinal for diagnosis may be absent. Cat scratch disease was known to afflict primarily children and adolescent; however, the incidence of CSD is increasing in immunocompromised groups, such as AIDS and transplant patients (3,4). The recent discovery of the infectious agent and improved understanding of the disease process have led to new approaches in diagnosis and treatment. We present a report of a patient with cat scratch disease who presented with seizure and altered mental status secondary to encephalitis.

Cervical fracture as the initial presentation of multiple myeloma.

Cervical-spine injury may occur in elderly patients with a history of minor trauma. We present the case of a patient who suffered a pathologic cervical-spine fracture as the initial presentation of multiple myeloma. A review of the medical conditions that predispose the elderly to cervical-spine fracture in the absence of major trauma is presented.

Ketorolac tromethamine use in a university-based emergency department.

OBJECTIVE: To assess the use of parenteral ketorolac tromethamine (KT) in the emergency department (ED). METHODS: During a six-month period, KT was administered in an uncontrolled, nonblinded fashion to a series of ED patients experiencing acute pain. The patients rated pain on a previously validated visual analog pain scale before receiving KT. They repeated this procedure one hour after KT administration, prior to additional analgesia, or preceding release, whichever came first. Analgesic response was assessed by comparing pretreatment and posttreatment pain scores for the entire study population by the Wilcoxon rank sum test. Possible effects of specific variables (patient age, gender, race, indication for KT, route, dose, previous use of NSAIDs, and concurrent administration of muscle relaxants) were assessed using the Kruskal-Wallis test. RESULTS: Of the 445 patients enrolled, 375 (84%) reported pain relief with KT, only seven (2%) worsened, and the remainder (14%) reported no change. Overall pain reduction was 37.6 +/- 27.2 (SD) mm (100-mm scale) for the entire study population. The pain scores obtained after KT administration were significantly lower than those obtained prior to KT administration (p < 0.001). The only variable that significantly influenced pain score reduction was indication for KT (p = 0.001). Nephrolithiasis and toothache patients had the largest mean reductions in pain. No significant side effect was reported. CONCLUSION: Parenteral KT is a useful and safe analgesic for ED patients. The agent generally provides analgesia and is particularly promising for patients with nephrolithiasis or toothache.

Azygos vein laceration following a vertical deceleration injury.

A 41-year-old man presented with respiratory distress and hypotension after a 30-foot fall from a tree. Despite fluid resuscitation, the patient expired in the operating room. Autopsy revealed an azygos vein laceration at the junction of the superior vena cava as the cause of death. Azygos vein and superior vena caval lacerations are rare following blunt chest trauma, including vertical deceleration injury. Early suspicion of vascular injuries with aggressive fluid resuscitation and surgical intervention remain the only hope for survival from this highly lethal injury.

Lingual artery hematoma resulting in upper airway obstruction.

A case of upper airway obstruction from a lingual artery hematoma after suturing of a puncture wound to the tongue is reported. The anatomy of the tongue and upper airway is reviewed to better understand the mechanism of obstruction. The emergency physician should be aware of this rare and potentially lethal complication to what might initially seem to be a trivial injury.

Epidural hematoma: an unusual presentation.

The authors present a patient with a traumatic epidural hematoma who complained only of headache and presented to the emergency department 48 hours after a fall. Mental status and neurological examination were normal. This delayed presentation is more commonly seen when a subdural hematoma is present but may result from epidural bleeding. Delayed formation of a traumatic epidural hematoma may occur when the following are present: elevated intracranial pressure, hypovolemic shock, a concomitant mass lesion, coagulopathy, bleeding from dural or diploic veins, a dural sinus laceration, a traumatic pseudoaneurysm, or an arteriovenous fistula. Although criteria for computed tomography of patients with head injuries remain variable in the literature, delayed presentation of epidural bleeding must be considered in the differential diagnosis of posttraumatic headache irregardless of the time interval or neurological presentation.

Radiographic changes with radial head subluxation in children.

Radial head subluxation (RHS) produces no radiographic abnormalities according to most experts. However, recent anecdotal case reports have identified displacement of the radiocapitellar line (RCL) in pediatric patients with RHS. To verify this finding, we retrospectively reviewed all patients less than 5 years of age who received elbow and forearm radiographs in our emergency department. From January 1988 through April 1989, we identified 20 cases of RHS. Of the 20 radiographs, 5 (25%) were read by the attending radiologist as abnormal due to RCL displacement indicating subluxation of the radiocapitellar articulation. All 5 of these radiographs had RCL displacement greater than 3 mm. The remaining normal radiographs had RCL displacement less than or equal to 3 mm. The presence of RCL displacement without disruption of the radiocapitellar articulation confirms the diagnosis of RHS, but does not appear to change treatment or outcome in this subset of patients. In addition, radiographs may not be mandatory when the diagnosis of RHS is certain. We suggest obtaining radiographs if the history (i.e., fall) or physical examination is atypical or if reduction is unsuccessful to rule out more serious injuries such as radial head dislocation or fracture.

Congenital diaphragmatic hernia presenting as massive gastrothorax.

Delayed herniation of abdominal contents through a congenital diaphragmatic hernia may occur beyond the neonatal period. The case of a 29-month-old child with a Bochdalek hernia presenting as acute respiratory failure is presented. Chest radiography showed a tension gastrothorax that was misread as a tension pneumothorax. Tube thoracostomy resulted in clinical improvement by perforating and decompressing the stomach. Nasogastric tube placement confirmed herniation of the stomach into the left chest and is the initial treatment of choice when a tension gastrothorax is identified. A congenital diaphragmatic hernia must be recognized promptly so that rapid gastric decompression and surgical repair of the diaphragmatic defect can be performed.

Lack of a tachycardic response to hypotension with ruptured ectopic pregnancy.

The concept that tachycardia is a reliable indicator of shock has recently been challenged in patients with hemoperitoneum. The purpose of this study was to document whether patients with ruptured ectopic pregnancy manifest a tachycardic response to hypotension and to define the relationship between hemodynamic response and blood loss resulting from hemoperitoneum. A retrospective chart review of 154 patients with documented ectopic pregnancy identified 20 (13.0%) hypotensive patients (systolic blood pressure less than or equal to 90 mm Hg). Eleven (55%) patients were not tachycardic (pulse rate less than 100 beats/min) and nine (45%) patients were tachycardic. The quantity of hemoperitoneum varied widely in each group and did not correlate with the hemodynamic response. These results support the proposed theory that hemoperitoneum may trigger a parasympathetic reflex, resulting in a pulse rate inappropriate for the degree of hypotension. A vasovagal reflex may play a role in those patients without significant hemoperitoneum. The diagnosis of hypovolemic shock must be considered when hypotension is present without tachycardia.

CNS toxoplasmosis as the initial presentation of the acquired immunodeficiency syndrome.

Neurological manifestations are present in 30% to 60% of patients with acquired immunodeficiency syndrome (AIDS) and may be the initial presentation in 10% to 20% of cases. Central nervous system toxoplasmosis now represents the most common focal brain lesion in patients with AIDS and possibly the most common opportunistic infection. A case of fulminant central nervous system toxoplasmosis as the initial presentation of AIDS is presented. Emergency physicians will be confronted with neurological complications of AIDS with increasing frequency in the future and should maintain a high index of suspicion for human immunodeficiency virus infection in young patients with neurological dysfunction.

Hysterical stridor: a benign cause of upper airway obstruction.

We present the cases of three patients with stridor that resolved spontaneously. Paradoxical vocal cord motion was documented in one patient. Normal vocal cord motion was present in the other two patients, but stridor had resolved in both cases. Many different terms have been used to describe this entity in the literature. Emergency physicians must recognize the subtle signs of hysterical stridor. Once more serious etiologies are ruled out, sedation and reassurance instead of aggressive airway intervention are required for this benign condition.

Lack of tachycardic response to hypotension in penetrating abdominal injuries.

Vital signs upon arrival to the emergency department were studied retrospectively in 59 consecutive patients with isolated penetrating abdominal injuries to determine their chronotropic response to hypotension. Forty-three patients with documented intraperitoneal injury were included in the study and separated into hypotensive and normotensive groups using a systolic blood pressure of 90 or 100 mm Hg. The difference in mean pulse rates between normotensive and hypotensive groups was not statistically significant (P greater than 0.05) although a wide range of pulse rates was noted in both groups. Nearly half of all hypotensive patients were not tachycardic, defined as a pulse rate less than 100. Similar findings were observed when the 117 sets of vital signs recorded both in the field and in the emergency department were analyzed as independent pieces of data. Several mechanisms are proposed for the lack of tachycardia in the presence of hypotension. This data suggest that tachycardia may not be a reliable sign of hypovolemic shock when defined by blood pressure criteria in these patients.

Blunt pelvic trauma.

Blunt pelvic trauma results in significant morbidity and mortality from associated genitourinary, neurological, vascular, and visceral damage. Diagnosis begins in the ED with the initial trauma evaluation. Proper treatment using a multidisciplinary approach and cooperation between orthopedist, urologist, trauma surgeon, and emergency physician should minimize complications.