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A place for aspiration in the treatment of spontaneous pneumothorax
Abstracts in this issue were prepared by residents in the Denver General/St Anthony's/StJoseph Hospitals Emergency Medicine Residency Program.
ABSTRACTS 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
PNEUMOTHORAX, SPONTANEOUS
A place for aspiration in the treatment of spontaneous pneumothorax Jones JS Thorax 40:66~67 Jan 1985
This retrospective study was undertaken to determine whether large spontaneous pneumothoraces (> 20%) could be aspirated with a fine needle and then managed as ff they had been small pneumothoraces (< 20%) from the start. Of 195 patients with spontaneous pneumothorax, 100 had a large pneumothorax. Thirty-one patients were excluded from the study because of complicating disease. Sixty-nine patients were treated by needle aspiration through the second anterior intercostal space. The average initial aspiration from the 69 patients was 1.1 L. Chest radiographs were obtained after 3 h to show the effect of the aspiration. Reexpansion was sufficient in 45 of 69 patients {65%) for the case to be managed as a small pneumothorax on an outpatient basis. The recurrence rate was 11.1%. Of the 95 patients with a small pneumothorax, 3 required tube thoracostomy for progressive lung collapse; the. remainder were discharged and encouraged to resume normal activities. The recurrence rate in this group was 11.6%. The author concluded that 137 patients (70%) had a closed pneumothorax at the time of diagnosis and that tube thoracostomy in all patients with a large pneumothorax would have represented overtreatment for this condition. William H Campbell, MD
ENDOMETRIOSIS, INTESTINAL
Intestinal endometriosis Groom RD, Donovan ML, Schwesinger WH Am J Surg 148:660-667 Nov 1985
A retrospective analysis of the authors' 22-year experience with 15 patients who had symptomatic intestinal endometriosis was performed. Endometriosis occurs in about 15% of menstruating women; intestinal involvement is found in 3% to 37% of these. Endometriosis is defined by the presence of endometrial tissue at an extrauterine site and is thought to be caused by retrograde menstruation with implantation. It usually appears as asymptomatic, small, superficial, serosal implants on segments of the 152/477
bowel lying in the pelvis; however, cyclical hormonal influence can cause the tissue to imlSlant more deeply in the intestinal wall and cause symptoms. Usually only 1 site is severely involved and will account for most symptoms. Intestinal endometriosis should be part of the differential diagnosis of recurring lower abdominal pain and other episodic bowel s y m p t o m s in w o m e n of reproductive age. Recurrent, crampy, lower abdominal pain is the most common symptom; the sigmoid and rectosigmoid colons are the most common sites. Involvement at these sites can cause localized pain in the colon and rectum, constipation or diarrhea, pain on defecation, and small-caliber stools. Rectal bleeding is uncommon. Worsening of these symptoms just before or during menstruation suggests intestinal endometriosis. Surgical excision is the definitive treatment. Eva M Carey, MD VENTRICULAR FIBRILLATION, OUT-OF-HOSPITAL
Prognostic significance of field response in o u t - o f - h o s p i t a l
ventricular
fibrillation
Warner LL, Hoffman JR, Baraff LJ Chest 87:22-28 Jan 1985
A retrospective analysis of patients with prehospital ventricular fibrillation (VF) was undertaken to identify in-field characteristics of potential survivors as compared to those with a poor prognosis. The authors examined initial field response to defibrillation, achievement of organized cardiac rhythm (defined as any electrical activity other than VF or asystole), and generation of pulses as major branch points to separate survivors from nonsurvivors. In 94 cases reviewed, only one of 37 patients who failed to achieve an organized rhythm in response to one or two countershocks survived to hospital discharge, compared to 9 of 57 who did achieve organized rhythms (P < .05). Six of 20 patients (30%) with initial supraventricular rhythms survived, but only 4 of 49 patients (8%) with an initial idioventricular rhythm survived. There were no survivors among 56 patients who failed to achieve pulses in the field; 10 of 38 who regained pulses survived (P < .01). No significant difference in survival to discharge was noted between patients who developed pulses immediately with an organized rhythm and those who later developed pulses in the field after initial defibrillation into pulseless rhythms. The authors point out that standard therapy for "electromechanical dissociation" may be detrimental to eventual recovery of pulses when altered hemodynamics instead of true dissociation give rise to
Annals of Emergency Medicine
Continued on page 478 14:5 May 1985
ABSTRACTS 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
PNEUMOTHORAX, SPONTANEOUS
A place for aspiration in the treatment of spontaneous pneumothorax Jones JS Thorax 40:66~67 Jan 1985
This retrospective study was undertaken to determine whether large spontaneous pneumothoraces (> 20%) could be aspirated with a fine needle and then managed as ff they had been small pneumothoraces (< 20%) from the start. Of 195 patients with spontaneous pneumothorax, 100 had a large pneumothorax. Thirty-one patients were excluded from the study because of complicating disease. Sixty-nine patients were treated by needle aspiration through the second anterior intercostal space. The average initial aspiration from the 69 patients was 1.1 L. Chest radiographs were obtained after 3 h to show the effect of the aspiration. Reexpansion was sufficient in 45 of 69 patients {65%) for the case to be managed as a small pneumothorax on an outpatient basis. The recurrence rate was 11.1%. Of the 95 patients with a small pneumothorax, 3 required tube thoracostomy for progressive lung collapse; the. remainder were discharged and encouraged to resume normal activities. The recurrence rate in this group was 11.6%. The author concluded that 137 patients (70%) had a closed pneumothorax at the time of diagnosis and that tube thoracostomy in all patients with a large pneumothorax would have represented overtreatment for this condition. William H Campbell, MD
ENDOMETRIOSIS, INTESTINAL
Intestinal endometriosis Groom RD, Donovan ML, Schwesinger WH Am J Surg 148:660-667 Nov 1985
A retrospective analysis of the authors' 22-year experience with 15 patients who had symptomatic intestinal endometriosis was performed. Endometriosis occurs in about 15% of menstruating women; intestinal involvement is found in 3% to 37% of these. Endometriosis is defined by the presence of endometrial tissue at an extrauterine site and is thought to be caused by retrograde menstruation with implantation. It usually appears as asymptomatic, small, superficial, serosal implants on segments of the 152/477
bowel lying in the pelvis; however, cyclical hormonal influence can cause the tissue to imlSlant more deeply in the intestinal wall and cause symptoms. Usually only 1 site is severely involved and will account for most symptoms. Intestinal endometriosis should be part of the differential diagnosis of recurring lower abdominal pain and other episodic bowel s y m p t o m s in w o m e n of reproductive age. Recurrent, crampy, lower abdominal pain is the most common symptom; the sigmoid and rectosigmoid colons are the most common sites. Involvement at these sites can cause localized pain in the colon and rectum, constipation or diarrhea, pain on defecation, and small-caliber stools. Rectal bleeding is uncommon. Worsening of these symptoms just before or during menstruation suggests intestinal endometriosis. Surgical excision is the definitive treatment. Eva M Carey, MD VENTRICULAR FIBRILLATION, OUT-OF-HOSPITAL
Prognostic significance of field response in o u t - o f - h o s p i t a l
ventricular
fibrillation
Warner LL, Hoffman JR, Baraff LJ Chest 87:22-28 Jan 1985
A retrospective analysis of patients with prehospital ventricular fibrillation (VF) was undertaken to identify in-field characteristics of potential survivors as compared to those with a poor prognosis. The authors examined initial field response to defibrillation, achievement of organized cardiac rhythm (defined as any electrical activity other than VF or asystole), and generation of pulses as major branch points to separate survivors from nonsurvivors. In 94 cases reviewed, only one of 37 patients who failed to achieve an organized rhythm in response to one or two countershocks survived to hospital discharge, compared to 9 of 57 who did achieve organized rhythms (P < .05). Six of 20 patients (30%) with initial supraventricular rhythms survived, but only 4 of 49 patients (8%) with an initial idioventricular rhythm survived. There were no survivors among 56 patients who failed to achieve pulses in the field; 10 of 38 who regained pulses survived (P < .01). No significant difference in survival to discharge was noted between patients who developed pulses immediately with an organized rhythm and those who later developed pulses in the field after initial defibrillation into pulseless rhythms. The authors point out that standard therapy for "electromechanical dissociation" may be detrimental to eventual recovery of pulses when altered hemodynamics instead of true dissociation give rise to
Annals of Emergency Medicine
Continued on page 478 14:5 May 1985