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225 skateboard injuries in children
cases with endocarditis, and Enterococcus in the one case without endocarditis. (Editor's note: For the emergency department, the significance of unexplained fever in an addict m u s t be considered serious until the source can be identified. Since these patients frequently have difficult personalities, one may reach for a trivial diagnosis to make discharging them more comfortable.) Frank Purdie, MD
w i t h recent onset (within 2 months) are hospitalized and u n d e r g o medical and neurological evaluation. They are heparinized during this period. If determined to have an appropriate lesion and to be a good surgical risk, angiography is performed. Surgery is recommended based on angiographic findings (usually when greater t h a n 50% carotid stenosis). Nonopertive p a t i e n t s with recent onset of symptoms are placed on coumadin and their pro-times maintained at 11/2 to 2 times normal. After three months coumadin is stopped and aspirin is started. Nonoperative patients with symptoms for longer t h a n three months are put on aspirin, 650 mg twice a day, unless there has been a recent change in the character of their attacks. Patients who have not had a TIA within the past 12 months are given no therapy. (Editor's note: This important review is o f interest because most emergency departments have difficulty in establishing protocols of admission for patients with TIA. Clearly, no protocol will be effective without the cooperation of medicine, neurology, a n d surgery, but this is an excellent resource article.) Robert Jorden, MD
drug abuse, heroin, splenic abscess Therapy of gonorrhea: comparison of trimethoprim. sulfamethoxazole and ampicillin. Sattler FR, Ruskin J, JAMA 240:2267-2270, (Nov) 1978. This study compared ampicillin and trimethoprim-sulfame. thoxazole in the t r e a t m e n t of gonococcal urethritis in men. The dosage for ampicillin was 3.5 gm with probenecid 1.0 gra given as a single oral dose. Of 42 patients treated with ampicillin, 41 were cured by culture. The one failure was successfully treated with trimethoprim-sulfasoxazole. Four patients treated with ampicillin had postgonococcal urethritis. The dosage of trimethoprim-sulfasoxazole was four tablets ( t r i m e t h a p r i m 320 mg and sulfasoxazole 1,600 mg) twice daily for two days. Of 43 patients treated in this way, 41 were cured. The two failures were successfully treated with ampicillin as a single dose. Two patients in this group had postgonococcal urethritis. Trimethoprim-sulfasoxazole is effective in the treatment of gonococcal urethritis in men. An earlier study in Europe, in which over 1,000 patients were treated in an identical manner, showed a cure rate of 98%. It has an advantage over tetracycline and erythromycin in that it requires fewer doses and has a h i g h e r cure rate than erythromycin. It is effective in gonococcal pharyngitis, and may also be effective in t r e a t i n g penicillinase-producing strains of gonorrhea and postgonococcal urethritis caused by C h l a m y d i a trachomatis. Although penicillin r e m a i n s the drug of choice for gonococcal u r e t h r i t i s in men, trimethoprim-sulfasoxazole a p p e a r s to be a n excellent alternate. (Editor's note: O f interest in this series was patient compliance, which was as good as the single dose ampiciUin regimen. Whether this would hold true in a larger series remains to be demonstrated.) John R. Mclnerney, MD
neurologic dysfunction, transient ischemia 225 skateboard Injuries in children. Illingworth CM, Jay A, Noble D, et al, C/in Pediatr 17:781-789, (Oct) 1978, A study of 225 skateboard injuries in children seen at the Children's Hospital, Sheffield, during an 8-month period reveals marked similarity to a previous American~survey. In a 12-month period ending June 1977 there were approximately 106,000 e m e r g e n c y visits to A m e r i c a n h o s p i t a l s due to skateboard injuries. The most common mechanisms of accidents in this study were falls for no apparent reason and skateboards hitting stones or sticks. The nature of injuries was graded on basis of severity. There were 92 fractures (40.9%). The majority of these (77%) involved the upper limb. Fourteen patients had fractures of the scaphoid, an uncommon fracture in children. These were probably due to falls on the outstretched hand. Four children had concussions, including one with a skull fracture, and eight others had minor head injuries. F r a c t u r e s necessitated manipulation u n d e r general anesthesia in 19 patients. In four cases fractures were multiple. There were no significant associations between the age of the child and the nature or severity of the injury. A total of nine children were hospitalized. Comparison of the incidence of fractures and the grade of injury with a previously reported series of playground injuries reveals a higher incidence of fractures in skateboard injuries (40.9% vs 26.5% for playground injuries). There were more concussions (6.0%) in the playground series t h a n in the skateboard series (.9%). The data in this study indicate t h a t protective clothing makes only a small contribution to prevention of injuries.
venereal disease, gonorrhea, drug treatment
Is there excessive use of gastric lavage in the treatment of self-poisoning? Blake DR, Bramble MG, Evans JG, Lancet 2:1362-1364, (Dec) 1978. This article reviews emergency d e p a r t m e n t t r e a t m e n t of 236 cases of deliberate self-poisonings. Overall, 77% of patients had gastric lavage. The remainder neither received gastric lavage nor had the stomach emptied by other means. The authors think t h a t many patients receive gastric lavage unnecessarily, and that the decision to perform a gastric lavage should not be automatic. They point out t h a t respiratory complications occur in about 3% of patients receiving gastric lavage in specialized units, but t h a t the incidence may be higher in hospitals with inexperienced junior doctors. They think the decision to perform gastric lavage should be based on the particular drug ingested and the time since ingestion. They point out t h a t gastric lavage is probably not needed for benzodiazepines, acetaminophen, and tricyclic antidepressants. In their series there were no deaths after admission, and 14% of patients were discharged without being admitted. (Editor's note: The authors' logic is questionable. Ingestion histories are neither reliable nor complete. Single drug ingestions are rare and significant quantities of drug are present hours after ingestion. We strongly urge that all stomachs be emptied, either via lavage or ipecac, with almost no excep-
Juan M Nieto, MD
injury, pediatric, skateboard Occult splenic abscess: an unrecognized complication of heroin abuse. Fry DE, Richardson JD, Flint LM, Surgery 34:650-654, (Nov) 1978. Infectious problems, such as bacterial endocarditis, often follow the intravenous use of illicit drugs and contaminated equipment. The authors report a series of seven patients who developed splenic abscess following drug abuse. Presenting symptoms were vague: abdominal distention, pain, nausea, vomiting, and fever. In two of the seven cases, the spleen was palpably enlarged. The diagnosis was made with spleen scan in each case, but the authors emphasize the importance of both anterior and posterior scans as one view may appear normal. Equivocal cases can be confirmed-by arteriography. T r e a t m e n t by s p l e n e c t o m y (and occasionally distal pancreatectomy) was curative. Of special importance was the concomitant occurrence in sixJof the seven cases of bacterial endocarditis, which necessitated systemic antibiotic therapy. The responsible organism was Staphylococcus aureus in six
84/497
tion3 poisoning, gastric lavage
JACEP
John R. Mclnerney, MD
8:11 (November) 1979
w i t h recent onset (within 2 months) are hospitalized and u n d e r g o medical and neurological evaluation. They are heparinized during this period. If determined to have an appropriate lesion and to be a good surgical risk, angiography is performed. Surgery is recommended based on angiographic findings (usually when greater t h a n 50% carotid stenosis). Nonopertive p a t i e n t s with recent onset of symptoms are placed on coumadin and their pro-times maintained at 11/2 to 2 times normal. After three months coumadin is stopped and aspirin is started. Nonoperative patients with symptoms for longer t h a n three months are put on aspirin, 650 mg twice a day, unless there has been a recent change in the character of their attacks. Patients who have not had a TIA within the past 12 months are given no therapy. (Editor's note: This important review is o f interest because most emergency departments have difficulty in establishing protocols of admission for patients with TIA. Clearly, no protocol will be effective without the cooperation of medicine, neurology, a n d surgery, but this is an excellent resource article.) Robert Jorden, MD
drug abuse, heroin, splenic abscess Therapy of gonorrhea: comparison of trimethoprim. sulfamethoxazole and ampicillin. Sattler FR, Ruskin J, JAMA 240:2267-2270, (Nov) 1978. This study compared ampicillin and trimethoprim-sulfame. thoxazole in the t r e a t m e n t of gonococcal urethritis in men. The dosage for ampicillin was 3.5 gm with probenecid 1.0 gra given as a single oral dose. Of 42 patients treated with ampicillin, 41 were cured by culture. The one failure was successfully treated with trimethoprim-sulfasoxazole. Four patients treated with ampicillin had postgonococcal urethritis. The dosage of trimethoprim-sulfasoxazole was four tablets ( t r i m e t h a p r i m 320 mg and sulfasoxazole 1,600 mg) twice daily for two days. Of 43 patients treated in this way, 41 were cured. The two failures were successfully treated with ampicillin as a single dose. Two patients in this group had postgonococcal urethritis. Trimethoprim-sulfasoxazole is effective in the treatment of gonococcal urethritis in men. An earlier study in Europe, in which over 1,000 patients were treated in an identical manner, showed a cure rate of 98%. It has an advantage over tetracycline and erythromycin in that it requires fewer doses and has a h i g h e r cure rate than erythromycin. It is effective in gonococcal pharyngitis, and may also be effective in t r e a t i n g penicillinase-producing strains of gonorrhea and postgonococcal urethritis caused by C h l a m y d i a trachomatis. Although penicillin r e m a i n s the drug of choice for gonococcal u r e t h r i t i s in men, trimethoprim-sulfasoxazole a p p e a r s to be a n excellent alternate. (Editor's note: O f interest in this series was patient compliance, which was as good as the single dose ampiciUin regimen. Whether this would hold true in a larger series remains to be demonstrated.) John R. Mclnerney, MD
neurologic dysfunction, transient ischemia 225 skateboard Injuries in children. Illingworth CM, Jay A, Noble D, et al, C/in Pediatr 17:781-789, (Oct) 1978, A study of 225 skateboard injuries in children seen at the Children's Hospital, Sheffield, during an 8-month period reveals marked similarity to a previous American~survey. In a 12-month period ending June 1977 there were approximately 106,000 e m e r g e n c y visits to A m e r i c a n h o s p i t a l s due to skateboard injuries. The most common mechanisms of accidents in this study were falls for no apparent reason and skateboards hitting stones or sticks. The nature of injuries was graded on basis of severity. There were 92 fractures (40.9%). The majority of these (77%) involved the upper limb. Fourteen patients had fractures of the scaphoid, an uncommon fracture in children. These were probably due to falls on the outstretched hand. Four children had concussions, including one with a skull fracture, and eight others had minor head injuries. F r a c t u r e s necessitated manipulation u n d e r general anesthesia in 19 patients. In four cases fractures were multiple. There were no significant associations between the age of the child and the nature or severity of the injury. A total of nine children were hospitalized. Comparison of the incidence of fractures and the grade of injury with a previously reported series of playground injuries reveals a higher incidence of fractures in skateboard injuries (40.9% vs 26.5% for playground injuries). There were more concussions (6.0%) in the playground series t h a n in the skateboard series (.9%). The data in this study indicate t h a t protective clothing makes only a small contribution to prevention of injuries.
venereal disease, gonorrhea, drug treatment
Is there excessive use of gastric lavage in the treatment of self-poisoning? Blake DR, Bramble MG, Evans JG, Lancet 2:1362-1364, (Dec) 1978. This article reviews emergency d e p a r t m e n t t r e a t m e n t of 236 cases of deliberate self-poisonings. Overall, 77% of patients had gastric lavage. The remainder neither received gastric lavage nor had the stomach emptied by other means. The authors think t h a t many patients receive gastric lavage unnecessarily, and that the decision to perform a gastric lavage should not be automatic. They point out t h a t respiratory complications occur in about 3% of patients receiving gastric lavage in specialized units, but t h a t the incidence may be higher in hospitals with inexperienced junior doctors. They think the decision to perform gastric lavage should be based on the particular drug ingested and the time since ingestion. They point out t h a t gastric lavage is probably not needed for benzodiazepines, acetaminophen, and tricyclic antidepressants. In their series there were no deaths after admission, and 14% of patients were discharged without being admitted. (Editor's note: The authors' logic is questionable. Ingestion histories are neither reliable nor complete. Single drug ingestions are rare and significant quantities of drug are present hours after ingestion. We strongly urge that all stomachs be emptied, either via lavage or ipecac, with almost no excep-
Juan M Nieto, MD
injury, pediatric, skateboard Occult splenic abscess: an unrecognized complication of heroin abuse. Fry DE, Richardson JD, Flint LM, Surgery 34:650-654, (Nov) 1978. Infectious problems, such as bacterial endocarditis, often follow the intravenous use of illicit drugs and contaminated equipment. The authors report a series of seven patients who developed splenic abscess following drug abuse. Presenting symptoms were vague: abdominal distention, pain, nausea, vomiting, and fever. In two of the seven cases, the spleen was palpably enlarged. The diagnosis was made with spleen scan in each case, but the authors emphasize the importance of both anterior and posterior scans as one view may appear normal. Equivocal cases can be confirmed-by arteriography. T r e a t m e n t by s p l e n e c t o m y (and occasionally distal pancreatectomy) was curative. Of special importance was the concomitant occurrence in sixJof the seven cases of bacterial endocarditis, which necessitated systemic antibiotic therapy. The responsible organism was Staphylococcus aureus in six
84/497
tion3 poisoning, gastric lavage
JACEP
John R. Mclnerney, MD
8:11 (November) 1979