HIV prevalence in a midwestern emergency department.

STUDY OBJECTIVE: To determine the prevalence of human immunodeficiency virus (HIV) seropositivity of patients 15 years of age and older in our emergency department. DESIGN: HIV status was determined anonymously, and the seroprevalence rate was calculated. The 95% confidence intervals also were calculated. Twenty demographic and predictor categorical variable were cross-tabulated with HIV status to determine associations. Only gender and male homosexual preference were significantly associated by Fisher's exact test. TYPE OF PARTICIPANTS: Excess serum samples from 454 randomly selected patients 15 years of age and older who required venipuncture for their ED evaluation were included in the study. MEASUREMENTS AND MAIN RESULTS: Of the 454 serum specimens, six (1.32%) were positive for HIV. The 95% confidence interval was from 0.27% to 2.37%. All six positive patients were men. The only statistically significant risk factors associated with HIV seropositivity were male sex (P = .00112) and male homosexual preference (P = .0000). CONCLUSION: HIV seropositivity occurs in 1.32% of our ED population over the age of 15 years. The only factors that correlate with HIV seropositivity are male homosexual preference and male sex.

Thoracic spinal fractures and aortic rupture: a significant and fatal association.

We analyzed the frequency of occurrence of traumatic aortic rupture (TAR) in patients with and without thoracic spinal fractures. Among 4,676 blunt chest trauma victims admitted to the hospital between 1972 and 1988, 148 (3.2%) suffered one or more thoracic vertebral fractures. There were 73 patients with one or more fractures of the first eight thoracic vertebrae (T1 to T8); of these 73, 4 also suffered TAR (5.5%). There were 4,603 patients without fractures of T1 to T8, and 64 of these patients also suffered TAR (1.4%). This difference was significant by the chi2 and Fisher exact tests, p = 0.00378 and p = 0.021003, respectively. Additionally, all 5 patients with TAR and thoracic vertebral fractures died. We conclude that patients with one or more fractures of T1 to T8 have a statistically significant increase in the incidence of TAR.

The prevalence of Neisseria gonorrhoeae and Chlamydia trachomatis in victims of sexual assault.

The prevalence of Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) in 232 sexual assault victims who presented for examinations between August 1, 1987, and July 31, 1988, was determined. Results are reported for cervical, rectal, and oropharyngeal NG cultures and for cervical and rectal CT smears. Results from a one-week follow-up are also reported. Cervical test results from the initial sexual assault examination were compared with cervical tests on 399 randomly selected female emergency department patients who presented for other gynecological conditions or lower abdominal pain. The victims of sexual assault had ten of 210 positive cervical NG cultures (4.76%), and 13 of 213 positive cervical CT smears (6.1%) at the first visit. These prevalence rates were not significantly different (P = .3058). There were none of 28 positive rectal NG cultures (0%) and one of 22 positive rectal CT smears (4.34%) (P = .451). None of the 43 oral NG cultures was positive. Seventy-three victims returned for follow-up examination. No follow-up cervical, rectal, or oral NG cultures were positive. However, one of 53 follow-up cervical smears for CT was positive, but this was not significantly different than for cervical NG (P = .461). Sexually assaulted patients had ten of 210 (4.76%) cervical NG cultures positive, and nonassaulted patients showed 53 of 393 positives (13.4%) (P less than .001). Assaulted patients had 13 of 213 (6.1%) cervical CT smears positive, and nonassaulted patients showed 33 of 352 (9.3%) positives (P = .11).(ABSTRACT TRUNCATED AT 250 WORDS)

Thoracic aortography following blunt chest trauma.

The records of 314 patients who suffered blunt chest trauma and underwent thoracic aortography between 1968 and 1986 were retrospectively reviewed. The patients ranged in age from 7 to 84 years (mean, 37.7 years). There were 255 male and 59 female patients. The majority of injuries were the result of motor vehicle accidents. The most common indication for aortography was a widened mediastinum on chest roentgenogram (83.4%). The aortogram was positive for cardiovascular injury in 19.7% of cases. There were 47 patients with aortic rupture, 15 with subclavian artery disruption, and 1 with traumatic aortic insufficiency. Complications occurred in 1.7% of patients. Two patients sustained groin hematomas and one patient suffered an intimal tear of the ascending aorta from the angiographic catheter. None of the complications required treatment. Aberrant origin of the arch vessels occurred in 0.96% of patients, and ductus diverticulum occurred in 0.64%. There were two false-positive and no false-negative aortograms. It was concluded that thoracic aortography after trauma is accurate and safe.

Does sternal fracture increase the risk for aortic rupture?

We retrospectively reviewed the records of 99 patients who suffered sternal fractures between 1968 and 1987. Patients ranged in age from 5 to 86 years. The most common cause of injury was a motor vehicle accident. The 99 patients were compared with a concurrent series of 2,106 patients with chest injuries and no sternal fractures. Traumatic aortic rupture occurred in 2 of 99 patients with sternal fractures (2%) and in 75 of 2,106 patients without sternal fracture (3.6%). This difference was not statistically significant by the Fisher exact test (p = 0.326). We conclude that traumatic aortic rupture does not occur more commonly in patients with sternal fracture when compared with other patients with blunt chest injuries.

An analysis of risk factors for death at the scene following traumatic aortic rupture.

The hospital or medical examiner records of 75 victims of traumatic aortic rupture (TAR) were reviewed retrospectively. Among the 75 victims, 51 (68%) died at the scene. Those dead at the scene had higher Injury Severity Scores, 59.3 +/- 13.8, than those who survived to be hospitalized, 42.6 +/- 13.3 (p less than 0.001). The mean age of victims dead at the scene was not different than the mean age of those who arrived alive at the hospital. The incidence of death at the scene was significantly higher for patients with head injuries (p less than 0.01), victims with a second intrathoracic injury (p less than 0.025), and patients with associated intra-abdominal injury (p less than 0.001) compared to those without these injuries. A second fatal injury occurred in 51 (41.2%) of victims who died at the scene.

Emergency carotid artery thrombectomy for postpartum hemiplegia.

The case of a 22-year-old patient who suffered from postpartum hemiplegia due to thrombosis of the internal carotid artery is reported. She was treated aggressively with pentobarbital coma, angiography, and thrombectomy and recovered with minimal deficit.

Brachial plexus injuries from blunt trauma--a harbinger of vascular and thoracic injury.

We reviewed the records of 59 patients who suffered brachial plexus injuries following blunt trauma between the years 1974 and 1984. The age of the patients ranged from 2 to 84 years, with a mean of 35.3 years. Forty-five were male patients. The majority of injuries (53%) were caused by motor vehicle accidents. Direct trauma was the mechanism of injury for 33 patients, traction for 18, shoulder dislocation for six, and acromioclavicular separation for two. The injuries occurred on the left side in 33 (56%); the right side in 23 (39%), and bilaterally in three (5%). Eight patients (14%) suffered complete brachial plexus palsies, and 51 (86%) incurred partial palsies. Nine patients (15.2%) presented in shock. Severe associated injuries occurred in this group of patients and included multiple rib fractures, hemopneumothorax, pulmonary contusion, head injuries, and upper extremity fractures. Subclavian artery injuries occurred in three patients, axillary artery in two patients, and an internal carotid injury in one patient. Complete resolution of the palsy occurred in 25 patients, partial resolution occurred in 17 cases, and the brachial plexus palsy remained permanent in nine. Eight patients were lost to follow-up. Brachial plexus injuries frequently occur in association with severe trauma, are usually partial palsies, and resolve partially or completely in two-thirds of cases. In addition, 10% of these patients suffered major vascular injuries and 10% incurred significant chest trauma.

Risk factors for the development of renal failure following the surgical treatment of traumatic aortic rupture.

A retrospective study of 44 patients who were treated surgically for traumatic aortic rupture was undertaken to determine risk factors for the development of postoperative renal failure. Renal failure occurred in 11 of 41 patients (27%) eligible for analysis. The Pearson product-moment correlation showed no significant relationship between the occurrence of renal failure and the patient's age, injury severity score, initial blood pressure, or the interval between accident and thoracotomy. Renal failure was significantly correlated with cross-clamping only (r = .2751, p = .043). There was no relationship between renal failure and total cross-clamp times. The mortality rate was significantly higher for patients with renal failure.

Emergency management of hand injuries. When to repair, when to refer.

The primary care physician can accurately diagnose hand injuries by obtaining a thorough patient history and performing a complete physical examination of the hand. When the severity of injury is doubtful, immobilization in a splint with next-day referral is appropriate. Immediate consultation should be obtained with nerve or vascular damage, fracture-dislocation injuries, open fractures, substantial skin loss, or flexor tendon injuries at or distal to the wrist.

The influence of verapamil on dopamine's ability to augment cardiac output.

Calcium channel blockers are used in the treatment of angina pectoris, cardiac arrhythmia, and hypertension. Sporadic reports of hypotensive reactions to verapamil have indicated that these reactions are not reversed readily by catecholamine administration. This study was conducted to test the hypothesis that verapamil pretreatment does not alter the ability of dopamine in conventional doses to augment cardiac output. Twelve mongrel dogs, weighing 19 to 25 kg, were anesthetized with pentobarbital and placed on a respirator. Heart rate, cardiac output, and the right atrial, pulmonary artery, pulmonary capillary wedge, and central aortic pressures were measured directly. Dopamine, 10 micrograms/kg/min, increased cardiac index by 52.4 mL/kg/min over baseline. The dopamine was stopped and the animals were allowed to return to baseline. Dopamine, 10 micrograms/kg/min, was administered again after pretreatment with 0.15 mg/kg verapamil, and it increased cardiac index by 47.9 mL/kg/min over the second baseline control. The results were not statistically different using the Student t test for paired data (P greater than .05). It is concluded that verapamil does not affect dopamine's ability to augment cardiac output in the dosages tested.

Risk factors for survival following surgical treatment of traumatic aortic rupture.

Linear discriminate analysis was used to determine the effects of age and Injury Severity Score on survival in 37 consecutive patients treated surgically for traumatic rupture of the thoracic aorta. Pearson product moment correlations were calculated between associated injuries and survival. The age of the injured patients was the only variable that correlated statistically with survival: the lower the patient's age, the greater the chance of survival (r = 0.3535; p = 0.016). The severity of the injury, as represented by the Injury Severity Score, showed a tendency toward decreased survival with increasing Injury Severity Score (r = -0.2523; p = 0.066). Specific types of associated injuries did not correlate with survival. Survival rates were not statistically different for patients who underwent cardiopulmonary bypass compared with those in whom a temporary plastic shunt was used (chi-square = 1.72; p = 0.19). We conclude that age is the most significant factor in predicting survival in patients who undergo surgical repair of traumatic aortic rupture.

Significance of symptoms and signs in patients with traumatic aortic rupture.

The records of 50 patients with traumatic aortic rupture (Group I) and 50 patients with blunt chest trauma but negative aortograms (Group II) were reviewed retrospectively. Symptoms and signs referable to the chest and thoracic aorta were recorded and compared in Group I and Group II patients. Each patient's chart was evaluated for chest pain, respiratory distress, thoracic back pain, hypotension, hypertension, and decreased femoral pulses. None of the symptoms or signs attained statistical significance between Group I and Group II patients. The only significant difference between Group I and Group II patients was in the injury severity score (ISS). The mean ISS for aortic rupture patients was 42.1 +/- 11.6 (SD), but was only 19.9 +/- 11.4 (SD) (P less than .001) for patients without aortic rupture. We conclude that the diagnosis of aortic rupture in patients sustaining blunt chest trauma cannot be accurately predicted or excluded on the basis of the patients' presenting complaints or physical findings.

The management of subclavian artery injuries following blunt thoracic trauma.

The records of 15 patients who sustained blunt rupture of the subclavian artery were reviewed. The findings on physical examination included arterial hypotension, unilateral absence of the radial pulse, brachial plexus palsy, and supraclavicular hematoma. The chest roentgenographic findings included wide mediastinums, apical pleural hematomas, and first rib fractures. Fourteen patients survived to undergo angiography and operation. Arterial continuity was restored by primary anastomosis, synthetic grafts, and venous interposition grafts. Ligation of a pseudoaneurysm was carried out in 1 patient with a complete brachial plexus palsy. Amputation of an upper extremity was required in 1 patient. Two patients died postoperatively. We conclude that blunt subclavian artery injuries may be suspected clinically. Absent upper extremity pulses, a wide mediastinum, unrelenting thoracic hemorrhage, and persistent hypotension dictate the necessity for aortography. Relative indications for angiography include brachial plexus palsy, apical pleural hematoma, and a fractured first rib.

Injuries associated with fractures of the transverse processes of the thoracic and lumbar vertebrae.

The records of 92 patients who sustained fractures of the transverse processes of thoracic or lumbar vertebrae between 1976 and mid-1982 were reviewed. The majority were injured in motor vehicle accidents. Trauma to abdominal viscera occurred in 19 patients including hepatic injuries in six, splenic injuries in 12, and colonic injuries in five. Hematuria was present in 51 patients and five of 51 had urinary tract injury requiring operative treatment. None of 34 patients without hematuria incurred anatomic disruption of the urinary tract. Thirty-two patients suffered other associated injuries, including thoracic, orthopedic, maxillofacial, and cerebral trauma. Fifteen patients incurred other spinal injuries. The overall mortality was 11% (ten patients). The mean Injury Severity Score in the 92 patients was 13.9. The frequency of abdominal visceral trauma with this bony injury (19/92-21%) suggests great energy expenditure and should alert physicians to seek other severe injuries.

Ovarian ectopic pregnancy.

We present the case of a 27-year-old woman with left lower quadrant pain, tenderness, and rebound tenderness. Culdocentesis demonstrated non-clotting blood, and exploratory laparotomy showed an ovarian ectopic pregnancy. A wedge resection of the ovary was accomplished and the patient recovered completely. Ovarian ectopic pregnancy is an uncommon presentation of ectopic pregnancy.