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A prospective investigation of pulmonary embolism in women and men
ABSTRACTS
A CSI was defined as bony or ligamentous injury to the spine or a cervical cord injury. The results showed that of 480 patients, 17 sustained CSI (3.6%). Reliable patients with CSI (alert, able to follow complexcommands,and able to answer questions immediately) made up 14 of 439 patients (3.2%), and unreliable patients with CSI (altered mental status of any etiology) comprisedthree of 41 patients (7.3%). In reliable patients, cervical region discomfort or tenderness alone demonstratedsensitivities of 86% and 79%, respectively. A positive physicalexamination (presenceof a neurologicdeficit, cervical region discomfort or tenderness)was noted in 13 of 14 reliable patientswith CSI (sensitivity, 93%). Dueto the lack of absolute sensitivity of the studied clinical parameters, either collectively or singly, in detecting CSI,these authors suggest that excludingcervical spine radiographybased on the absenceof these threeclinical parameterscould lead to missedCSI. [Editor's note: Distracting injuries explained the onlypatient with CSI who had neither cervical pain nor a positive physical examination in this small series./t is hoped that continued study will eventually yield some reliable combination of symptoms, signs, mechanism of injury, distracting injuries, etc, to exclude CSI clinically.]
trauma patients. A total of 1,395 blunt trauma patients were studied prospectivelyover a 13-month period; 810 (58%) met the inclusion criteria of a Glasgow ComaScale score of 13 or more. All of the patients receiveda history and physical examinationas well as routine AP pelvic radiographs.Thirty-nine pelvic fractures were identified. Thirty-four of the 39 patients with fractures complainedof pain and had a positive physical examination, two either complainedof pain or had a positive examination,and three neither complainedof pain nor had a positive examination. Of the 771 patients without fractures, 743 had neither a complaint of pain nor positive examinationresults. Therefore, only three of the 746 patients (0.4%) without complaints of pain and with a normal clinical examination had fractures. Thesethree fractures were minor and did not affect the patient's clinical course. The total radiographcost in this low-yield group of 746 patients was $88,028. The authors concludethat routine AP pelvic radiographicstudies are net necessaryor cost effective in the awake blunt trauma patient and the decision to obtain a radiographic study should be based on indications provided by history and clinical examination.
Jeffrey Girkin, MD pulmonaryembolus; pulmonary
ThadStephens, MD
angiography trauma;blunt fractures, pelvic
Routine pelvic xray studies in awake blunt trauma patients: A sensible policy? Salvino CK, Esposito TJ, Smith D, eta/ J Trauma33:413-416 Oct 1992 The purposeof this study was to evaluatethe usefulnessof routine anteroposterior(AP) pelvic radiographic studies in awake blunt
MARCH 1993
22:3
A prospective investigation of pulmonary embolism in w o m e n and men Ouinn DA, ThompsonBT, rerfin ML, et al JAMA 268,'1689-1696 Oct 7, 1992 In this study, data collected in the ProspectiveInvestigation of PulmonaryEmbolism Diagnosiswere analyzedto comparethe frequency, risk factors, diagnosis,and presentation of pulmonaryembolism in men
ANNALS OF EMERGENCY MEDICINE
and women suspectedof pulmonary embolism. In addition, the accuracy of the ventilation/perfusion (V/Q) scan as a diagnostictool for men and women was evaluated.The study group consisted of 496 women and 406 men suspectedof having pulmonaryembolism,for whom a V/Q scan or pulmonaryangiogram was requested.The overall frequency of pulmonaryembolism in the study group was 29%. Interestingly, women aged 50 years or less had a lower frequency of embolismthan did men in the same age group, whereas there was no difference between sexes in patients more than 50 years old. This difference could not be attributed to any difference in frequency of risk factors between the two groups. The authors did note an increasedrisk of pulmonary embolism in women using oral contraceptives but only in those who also had undergonesurgerywithin a three-month period. The presenting signs and symptoms were compared between men and women with pulmonary embolism,and the only significant difference was that men more frequently exhibited hemoptysis, leg swelling, and pleural friction rub. The accuracy of the V/Q scan was the samefor women and men, and a pulmonaryangiogramwas frequently necessaryin both groups to confirm the diagnosis.[Editor's note: It is important to emphasize that these results are drawn from a group of patients already selected from the general population as clinicafly suspicious for pulmonary embolism. Thus, the relative frequencies of pulmonary embolism in this study should not be extrapolated directly to the general population.]
Kristy A Genners, MD
advancedcardiac life support; cardiac arrest, epinephrine; high-dose epinephrine
High-dose epinephrine in adult cardiac arrest Stiell I, Hebert P, Weitzrnan B, et al N Engl J Med 227:1045-1050 Oct 1992 This randomized,prospective,doubleblind study comparedthe effects of high-doseand standard-dose epinephrineon the survival of victims of cardiac arrest. Six hundred fifty patients were randomlytreated with either high-dose(7 rag) or standard-dose(1 mg) epinephrine every five minutes up to five doses. Patients suffering prehospital cardiac arrests receivedno advanced cardiac life support measuresother than defibrillation until arrival at the hospital. The study group consisted of 317 patients in the high-doseand 333 in the standard-dosegroup. The two groups had similar demographic and medical characteristics except for a greater prevalenceof ischemic heart disease in the high-dosegroup (44% comparedwith 31%). There was no statistical difference between the two groups at survival to one hour (18% high-doseversus 23% standard-dose,P= .12) or at survival to discharge(3% high-dose versus 5% standard-dose,P= .38). The neurologicstatus of the survivors of both groups were comparable with similar proportionsremaining in the best cerebral performance categoryat discharge.Stratification of data into.clinically important subgroups failed to show any improved outcomewith high-dose epinephrine.In fact, the subgroup that receivedhigh-doseepinephrine more than ten minutes after arrest had a significantly lower resuscitation rate than the subgroupthat received standard-doseepinephrine in this setting. The authors concluded that high-doseepinephrinedid not improvesurvival or neurologic outcomes in adults suffering from cardiac arrest.
Sheila M AIton, MD
62 1 / 1 5 3
A CSI was defined as bony or ligamentous injury to the spine or a cervical cord injury. The results showed that of 480 patients, 17 sustained CSI (3.6%). Reliable patients with CSI (alert, able to follow complexcommands,and able to answer questions immediately) made up 14 of 439 patients (3.2%), and unreliable patients with CSI (altered mental status of any etiology) comprisedthree of 41 patients (7.3%). In reliable patients, cervical region discomfort or tenderness alone demonstratedsensitivities of 86% and 79%, respectively. A positive physicalexamination (presenceof a neurologicdeficit, cervical region discomfort or tenderness)was noted in 13 of 14 reliable patientswith CSI (sensitivity, 93%). Dueto the lack of absolute sensitivity of the studied clinical parameters, either collectively or singly, in detecting CSI,these authors suggest that excludingcervical spine radiographybased on the absenceof these threeclinical parameterscould lead to missedCSI. [Editor's note: Distracting injuries explained the onlypatient with CSI who had neither cervical pain nor a positive physical examination in this small series./t is hoped that continued study will eventually yield some reliable combination of symptoms, signs, mechanism of injury, distracting injuries, etc, to exclude CSI clinically.]
trauma patients. A total of 1,395 blunt trauma patients were studied prospectivelyover a 13-month period; 810 (58%) met the inclusion criteria of a Glasgow ComaScale score of 13 or more. All of the patients receiveda history and physical examinationas well as routine AP pelvic radiographs.Thirty-nine pelvic fractures were identified. Thirty-four of the 39 patients with fractures complainedof pain and had a positive physical examination, two either complainedof pain or had a positive examination,and three neither complainedof pain nor had a positive examination. Of the 771 patients without fractures, 743 had neither a complaint of pain nor positive examinationresults. Therefore, only three of the 746 patients (0.4%) without complaints of pain and with a normal clinical examination had fractures. Thesethree fractures were minor and did not affect the patient's clinical course. The total radiographcost in this low-yield group of 746 patients was $88,028. The authors concludethat routine AP pelvic radiographicstudies are net necessaryor cost effective in the awake blunt trauma patient and the decision to obtain a radiographic study should be based on indications provided by history and clinical examination.
Jeffrey Girkin, MD pulmonaryembolus; pulmonary
ThadStephens, MD
angiography trauma;blunt fractures, pelvic
Routine pelvic xray studies in awake blunt trauma patients: A sensible policy? Salvino CK, Esposito TJ, Smith D, eta/ J Trauma33:413-416 Oct 1992 The purposeof this study was to evaluatethe usefulnessof routine anteroposterior(AP) pelvic radiographic studies in awake blunt
MARCH 1993
22:3
A prospective investigation of pulmonary embolism in w o m e n and men Ouinn DA, ThompsonBT, rerfin ML, et al JAMA 268,'1689-1696 Oct 7, 1992 In this study, data collected in the ProspectiveInvestigation of PulmonaryEmbolism Diagnosiswere analyzedto comparethe frequency, risk factors, diagnosis,and presentation of pulmonaryembolism in men
ANNALS OF EMERGENCY MEDICINE
and women suspectedof pulmonary embolism. In addition, the accuracy of the ventilation/perfusion (V/Q) scan as a diagnostictool for men and women was evaluated.The study group consisted of 496 women and 406 men suspectedof having pulmonaryembolism,for whom a V/Q scan or pulmonaryangiogram was requested.The overall frequency of pulmonaryembolism in the study group was 29%. Interestingly, women aged 50 years or less had a lower frequency of embolismthan did men in the same age group, whereas there was no difference between sexes in patients more than 50 years old. This difference could not be attributed to any difference in frequency of risk factors between the two groups. The authors did note an increasedrisk of pulmonary embolism in women using oral contraceptives but only in those who also had undergonesurgerywithin a three-month period. The presenting signs and symptoms were compared between men and women with pulmonary embolism,and the only significant difference was that men more frequently exhibited hemoptysis, leg swelling, and pleural friction rub. The accuracy of the V/Q scan was the samefor women and men, and a pulmonaryangiogramwas frequently necessaryin both groups to confirm the diagnosis.[Editor's note: It is important to emphasize that these results are drawn from a group of patients already selected from the general population as clinicafly suspicious for pulmonary embolism. Thus, the relative frequencies of pulmonary embolism in this study should not be extrapolated directly to the general population.]
Kristy A Genners, MD
advancedcardiac life support; cardiac arrest, epinephrine; high-dose epinephrine
High-dose epinephrine in adult cardiac arrest Stiell I, Hebert P, Weitzrnan B, et al N Engl J Med 227:1045-1050 Oct 1992 This randomized,prospective,doubleblind study comparedthe effects of high-doseand standard-dose epinephrineon the survival of victims of cardiac arrest. Six hundred fifty patients were randomlytreated with either high-dose(7 rag) or standard-dose(1 mg) epinephrine every five minutes up to five doses. Patients suffering prehospital cardiac arrests receivedno advanced cardiac life support measuresother than defibrillation until arrival at the hospital. The study group consisted of 317 patients in the high-doseand 333 in the standard-dosegroup. The two groups had similar demographic and medical characteristics except for a greater prevalenceof ischemic heart disease in the high-dosegroup (44% comparedwith 31%). There was no statistical difference between the two groups at survival to one hour (18% high-doseversus 23% standard-dose,P= .12) or at survival to discharge(3% high-dose versus 5% standard-dose,P= .38). The neurologicstatus of the survivors of both groups were comparable with similar proportionsremaining in the best cerebral performance categoryat discharge.Stratification of data into.clinically important subgroups failed to show any improved outcomewith high-dose epinephrine.In fact, the subgroup that receivedhigh-doseepinephrine more than ten minutes after arrest had a significantly lower resuscitation rate than the subgroupthat received standard-doseepinephrine in this setting. The authors concluded that high-doseepinephrinedid not improvesurvival or neurologic outcomes in adults suffering from cardiac arrest.
Sheila M AIton, MD
62 1 / 1 5 3