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Traumatic dislocations of the peroneal tendons
Abstracts in this issue were prepared by residents in the Denver General/St Anthony's/St Joseph Hospitals Emergency Medicine Residency Program.
ABSTP CTS Harvey W Meislin, MD, FACEP Co-Editor Chief, Section of Emergency Medicine University of Arizona College of Medicine
Vincent J Markovchick, MD, FACEP Co-Editor Emergency Medical Services Denver General Hospital
CORTICOSTEROIDS, ASTHMA, STATUSASTHMATICUS
A double-blind, r a n d o m i z e d clinical trial of m e t h y l p r e d n i s o l o n e in s t a t u s a s t h m a t i c u s Haskell RJ, Wong BM, Hansen JE Arch Intern Med 143:1324-1327
Jul 1983 Corticosteroids have an established role in the treatment of status asthmaticus, but optimal dosage has been undetermined. This study employs a prospective, randomized, double-blind protocol with 25 status asthmaticus patients to identify appropriate steroid dosage. All patients were treated identically in the emergency department with 1V aminophylline, SQ beta agonist and inhaled bronchodilator. If their asthma failed to resolve, they were admitted to the hospital, continued on the same medical therapy and, in addition, randomized to receive IV methylprednisolone in low (15 mg every 6 hours), medium (40 mg every 6 hours), or high (125 mg every 6 hours) dosage. Response to therapy was measured spirometrically, with FEV1. On admission most patients had an FEV1 which was 25% of predicted. The authors defined a significant response to be a rise in FEV1 to greater than 50% of predicted. High-dose patients showed this significant response somewhat faster (usually by the end of day one) than did medium-dose patients (who responded during day two). By day three, both high- and medium-dose patients had similar FEV~ values. Low-dose patients did not respond as rapidly or to the same degree as did the other two groups. Hyperglycemia was present but not significantly different in the three treatment groups. John M Wogan, MD
ANKLE INJURY
T r a u m a t i c d i s l o c a t i o n s of t h e p e r o n e a l tendons Arrowsmith SR, Fleming LL, Allman FL Am J Sports Med 11:142-146
May/Jun 1983 The tendons of Peroneus brevis and longus enter a common synovial sheath as they pass behind the lateral malleolus. The peroneal retinaculum originates on the lateral malleolus and maintains these tendons in their normal retromalleolar position. This retinaculum can be torn when violent passive dorsiflexion or inversion is actively resisted by the patient. As the peroneal tendons pull taut, they bowstring laterally around the malleolus and cause per13:3 March 1984
iosteal or bony avulsion of the malleolar attachment of the retinaculum. The patient will notice sudden pain, instability, and often a snapping sensation in the lateral aspect of the ankle. Swelling, tenderness, and ecchymosis behind the lateral malleolus frequently lead to an erroneous diagnosis of ankle sprain. Active ankle eversion (in dorsiflexion) will ,nimic the pain and may demonstrate tendon subluxation. X-ray films are frequently normal but may demonstrate an avulsed bone flake off the posterior surface of the lateral malleolus. Patients with chronic subluxation/dislocation complain of a "snapping" sensation or instability of the lateral side of the ankle when ambulating. A well-moulded, non-weightbearing cast (in slight plantar flexion to relax the tendons) is appropriate in the acute setting; however, if the tendons are clinically unstable or if the lesion is chronic, operative intervention is necessary. It is imperative that this diagnosis be considered when assessing the injured ankle. Grant D Innes, MD
HYPOTHERMIA, CATECHOLAMINERESPONSE
S y m p a t h e t i c n e r v o u s s y s t e m " s w i t c h off" with severe hyperthermia Chernow B, Lake R, Zaritsky A, et al Crit Care Med 11:677-680
Sep 1983 There are conflicting studies on the effect of hypothermia on the sympathetic nervous system. In this study five baboons were placed in cold rooms (4 C) to allow their core temperatures to drop from 37 C to 29 C. Plasma norepinephrine and epinephrine levels were measured at various temperatures, as were mean arterial pressure and heart rate. The animals were rewarmed by replacing them in a warm room, wrapping them with warmed blankets, and infusing warmed saline intravenously. Both catecholamine • levels increased between 37 and 31 C. However, between 31 C and 29 C the values decreased. Rewarming caused a secondary increase in the catecholamine levels. Mean arterial pressure and heart rate increased from 37 C to 33 C and then decreased to basal levels as temperatures dropped further to 29 C. Rewarming caused slight increases in these parameters. Thus there is evidence that the lack of catecholamine response in profound hypothermia may contribute to depressed cardiovascular function, and that exogenous catecholamines should be considered in hypothermic patients with refractory hypotension.
Annals of Emergency Medicine
Marc J Gorayeb, MD
205/108
ABSTP CTS Harvey W Meislin, MD, FACEP Co-Editor Chief, Section of Emergency Medicine University of Arizona College of Medicine
Vincent J Markovchick, MD, FACEP Co-Editor Emergency Medical Services Denver General Hospital
CORTICOSTEROIDS, ASTHMA, STATUSASTHMATICUS
A double-blind, r a n d o m i z e d clinical trial of m e t h y l p r e d n i s o l o n e in s t a t u s a s t h m a t i c u s Haskell RJ, Wong BM, Hansen JE Arch Intern Med 143:1324-1327
Jul 1983 Corticosteroids have an established role in the treatment of status asthmaticus, but optimal dosage has been undetermined. This study employs a prospective, randomized, double-blind protocol with 25 status asthmaticus patients to identify appropriate steroid dosage. All patients were treated identically in the emergency department with 1V aminophylline, SQ beta agonist and inhaled bronchodilator. If their asthma failed to resolve, they were admitted to the hospital, continued on the same medical therapy and, in addition, randomized to receive IV methylprednisolone in low (15 mg every 6 hours), medium (40 mg every 6 hours), or high (125 mg every 6 hours) dosage. Response to therapy was measured spirometrically, with FEV1. On admission most patients had an FEV1 which was 25% of predicted. The authors defined a significant response to be a rise in FEV1 to greater than 50% of predicted. High-dose patients showed this significant response somewhat faster (usually by the end of day one) than did medium-dose patients (who responded during day two). By day three, both high- and medium-dose patients had similar FEV~ values. Low-dose patients did not respond as rapidly or to the same degree as did the other two groups. Hyperglycemia was present but not significantly different in the three treatment groups. John M Wogan, MD
ANKLE INJURY
T r a u m a t i c d i s l o c a t i o n s of t h e p e r o n e a l tendons Arrowsmith SR, Fleming LL, Allman FL Am J Sports Med 11:142-146
May/Jun 1983 The tendons of Peroneus brevis and longus enter a common synovial sheath as they pass behind the lateral malleolus. The peroneal retinaculum originates on the lateral malleolus and maintains these tendons in their normal retromalleolar position. This retinaculum can be torn when violent passive dorsiflexion or inversion is actively resisted by the patient. As the peroneal tendons pull taut, they bowstring laterally around the malleolus and cause per13:3 March 1984
iosteal or bony avulsion of the malleolar attachment of the retinaculum. The patient will notice sudden pain, instability, and often a snapping sensation in the lateral aspect of the ankle. Swelling, tenderness, and ecchymosis behind the lateral malleolus frequently lead to an erroneous diagnosis of ankle sprain. Active ankle eversion (in dorsiflexion) will ,nimic the pain and may demonstrate tendon subluxation. X-ray films are frequently normal but may demonstrate an avulsed bone flake off the posterior surface of the lateral malleolus. Patients with chronic subluxation/dislocation complain of a "snapping" sensation or instability of the lateral side of the ankle when ambulating. A well-moulded, non-weightbearing cast (in slight plantar flexion to relax the tendons) is appropriate in the acute setting; however, if the tendons are clinically unstable or if the lesion is chronic, operative intervention is necessary. It is imperative that this diagnosis be considered when assessing the injured ankle. Grant D Innes, MD
HYPOTHERMIA, CATECHOLAMINERESPONSE
S y m p a t h e t i c n e r v o u s s y s t e m " s w i t c h off" with severe hyperthermia Chernow B, Lake R, Zaritsky A, et al Crit Care Med 11:677-680
Sep 1983 There are conflicting studies on the effect of hypothermia on the sympathetic nervous system. In this study five baboons were placed in cold rooms (4 C) to allow their core temperatures to drop from 37 C to 29 C. Plasma norepinephrine and epinephrine levels were measured at various temperatures, as were mean arterial pressure and heart rate. The animals were rewarmed by replacing them in a warm room, wrapping them with warmed blankets, and infusing warmed saline intravenously. Both catecholamine • levels increased between 37 and 31 C. However, between 31 C and 29 C the values decreased. Rewarming caused a secondary increase in the catecholamine levels. Mean arterial pressure and heart rate increased from 37 C to 33 C and then decreased to basal levels as temperatures dropped further to 29 C. Rewarming caused slight increases in these parameters. Thus there is evidence that the lack of catecholamine response in profound hypothermia may contribute to depressed cardiovascular function, and that exogenous catecholamines should be considered in hypothermic patients with refractory hypotension.
Annals of Emergency Medicine
Marc J Gorayeb, MD
205/108