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Aeromonas hydrophila infection of a puncture wound
CASE REPORT
Aeromonas Hydrophila Infection Of A Puncture Wound David Katz, MD Harold Smith, MD Ann Arbor, Michigan Aeromonas hydrophila is a gram-negative organism generally considered a pathogen of low virulence, rarely reported as causing infection in man. Recently it has been recognized as causing infection in wounds. This article reports the case of a patient who suffered a puncture wound while standing in a fresh water lake. He subsequently developed a rapidly progressing cellulitis requiring hospitalization. This organism was cultured from the wound and responded dramatically to appropriate antimicrobial therapy. Katz D, Smith H: Aeromonas hydrophila infection of a puncture wound. Ann Emerg Med 9:529-531, October 1980. aeromonas hydrophila, infection in wound; bacillus, aeromonas hydrophila, infection; infection, caused by aeromonas hydrophila; wound, infection, from aeromonas hydrophila INTRODUCTION Aeromonas hydrophila is a gram-negative bacillus, and a member of the family vibrionaceae. It is a common inhabitant of fresh water lakes and has been isolated from marine animals, soil, and tap water) '2 Until recently this organism was viewed as a pathogen Of low virulence, 1'2 and infrequently reported as causing infection in man, and then usually in immunocompromised hosts. 3 Several recent reports indicate that infection with hydrop'hila is being recognized more frequently in healthy persons. 2'4 These infections usually develop in wounds resulting from accidents occurring out-of-doors. The clinical picture of these infections is indistinguishable from typical streptococcal cellulitis, frequently resulting in improper therapy. We present a caseof hydrophila cellulitis acquired by a previously healthy man from a puncture wound sustained in a fresh water lake. CASE REPORT A 41-year-old white man presented to the St. Joseph Mercy Hospital because of the acute onset of chills, fever, and extreme pain in the right foot. Earlier that afternoon while at an inland lake he had stepped on a nail with his right foot while standing in knee-deep water. Besides noting a painless small puncture wound, which was bleeding profusely, the patient reported no other symptoms at that time. Within 6 hr to 8 hr localized pain and swelling had developed to the point at which the patient could not bear weight on the foot or even drive his automobile. Concurrently he noted the onset of intermittent chills and a temperature of 38.3 C. On initial examination the patient was experiencing extreme pain localized to the plantar surface of the right foot. Vital signs at that time demonstrated an oral temperature of 38.2 C; pulse, 112 beats/min; and blood pressure, 114/74 mm From St. Joseph Mercy Hospital, Ann Arbor, Michigan. Address for reprints: David Katz, MD, PO Box 995, Ann Arbor, Michigan 48106.
9:10 (October) 1980
Ann Emerg Med
529/49
Hg. Examination of the foot showed a 3-mm puncture wound on the lateral midplantar aspect of the right foot. This was surrounded by a 6-cm by 8cm area of erythematous, warm, swollen, tender cellulitis spreading medially and laterally from the wound. The remainder of the physical examination and history was unremarkable. On initial examination the patient was experiencing extreme pain localized to the plantar surface of the right foot. Vital signs at that time demonstrated an oral temperature of 38.2 C; pulse, 112 beats/min; and blood pressure, 114/74 mm Hg. Examination of the foot showed a 3-mm puncture wound on the lateral midplantar aspect of the right foot. This was surrounded by a 6-cm by 8-cm area of erythematous, warm, swollen, tender cellulitis spreading medially and laterally from the wound. The remainder of the physical examination and history was unremarkable. Roentgenograms of the foot showed no free gas or foreign bodies. Although no fluid or pus could be expressed from the wound, a swab of the puncture site was obtained for culture and Gram stain. The initial Gram stain showed gram-negative bacillae. The white blood count was 13,100/cu mm, with 72% segmented neutrophils, 8% band forms, 15% lymphocytes, and 5% monocytes. Adsorbed tetanus toxoid, 0.5 ml, was administered, and antibiotic therapy was initiated with gentamycin 80 mg IVPB every 8 hr and carbenicillin 5 gm IVPB every 4 hr. On the following day the cellulitis had increased to 8 cm by 12 cm and was extending medially and laterally up over the dorsal surface of the foot. However, the patient's temperature had stabilized in the 37.2 C to 37.7 C range. On the second hospital day the initial wound culture returned with the report of 2+ Pseudomonas aeruginosa and a second uncharacterized gram-negative bacillus - - subsequently identified as A hydrophila. On this same day the wound and surrounding cellulitis was incised and drained with the recovery of 3 ml of purulent material which was sent for culture. Over the ensuing three days the patient reported much improvement in his symptoms, with full recovery of the use of his foot. His temperature had returned to normal. All blood, urine, and s p u t u m cultures were negative. By the fifth hospital day the white blood count had fallen to
50/530
9,600/cu mm. The second wound culture also grew 3+ A hydrophila, sensitive to aminoglycosides, tetracycline, and chloramphenicol while resistant to ampicillin and cephalosporins. The patient was maintained on a full 10day course of gentamycin, and at discharge all swelling and tenderness had cleared and the puncture wound was healing well. Follow-up examinations have shown no untoward sequelae or residual effects.
DISCUSSION
Aeromonas hydrophila is a gramnegative rod that is well documented, although infrequently, as causing infection in man. Most physicians are not aware that it can be a pathogen and do not consider it when dealing with infectious problems. This is especially true in traumatic skin wound infections, where streptococcae are usually thought to be the offending agent. This case, as well as several other r e p o r t e d cases, 2'5 demonstrates that Aeromonas infection can cause a cellulitis clinically identical to that caused by streptococcae. Symptoms of infection are usually noticed within hours of the injury. The patient commonly experiences increasing pain around the wound, with the simultaneous onset of chills and fever. The temperature can range between 37.8 C and 39.5 C. Swelling and redness will be noted around the wound, and a purulent drainage may be present. A mild to m o d e r a t e leukocytosis m a y be found, and Gram stain of the wound will frequently demonstrate gramnegative rods. This finding is frequently disregarded as a contaminant, but in fact should suggest the possibility of Aeromonas infection, especially when the wound was sustained in or around a body of fresh water. This association was nicely documented by Hanson et al, 2 who actually sampled the lake where their patient had been injured and found a high concentration of aeromonads. They also found a significant coliform count, supporting the idea that fecal pollution of fresh waters may be the source of the aeromonads. Additional evidence for this comes from the knowledge that direct isolation of Aeromonas from human stool is common. 6 This fact is important when considering other types of infections caused by Aeromonas, such as gastroenteritis of otherwise unproven cause, and septicemia in immunocompromised patients. 7 Ann Emerg Med
I n t h e l a t t e r s i t u a t i o n it is thought that the infection originates endogenously from the gastrointestinal tract. At this time the pathogenicity of Aeromonas is difficult to define, for Aeromonas infection may r e m a i n u n d i a g n o s e d in m a n y patients because other more well-recognized pathogens may also be present, or because routine microbiological screening may not differentiate other enterobacteriaceae from the morphologically and biochemically similar aeromonads. The definitive identification is made by showing a gramnegative motile rod that is oxidase positive, catalase positive, indole positive, Voges-Proskauer positive, and citrate negative. 2 It ferments glucose, mannitol, lactose, sucrose, and mannose, but does not ferment inositol, sorbitol, rhamnose, or melobiose. The most successful approach to therapy is antimicrobials combined with surgical drainage when appropriate. 2 Aeromonas has been shown~ to be sensitive to gentamycin, kanamycin, tetracycline, and chloramphenicol. The organism is frequently resistant to penicillin, ampicillin, and cephalosporin, possibly due to reported beta-lactamase production by the organism. 3 Therapy should always include an aminoglycoside, 2 preferably gentamycin. A hydrophila has been infrequently reported as an agent of human infection, especially in the immunologically competent patient. 3 This case and the latest reports noted would indicate this paucity of identification may not be truly reflective of the actual incidence of Aeromonas infections. Careful attention to presentation, clinical course, and microbiological testing may aid in the recognition of Aeromonas as a human pathogen. Finally, some might argue that the P aeruginosa isolated from the original culture was the causative organism in this case. This seems unlikely, not because Pseudomonas cannot cause infection in this setting, but because when it does it usually causes an osteomyelitis that becomes symptomatic days to weeks after the puncture wound. Patients with this p r o b l e m are not febrile, t h e r e is minimal local reaction, and there is no leukocytosis, s'l° This is in distinct contrast to the clinical picture seen in our patient and other reported cases of Aeromonas wound infection.
SUMMARY
Aeromonas hydrophila, a gramnegative organism generally consid9:10 (October) 1980
ered a p a t h o g e n of low virulence, was cultured from t h e p u n c t u r e wound of our p a t i e n t , who h a d d e v e l o p e d a rapidly progressing c e l l u l i t i s requiring h o s p i t a l i z a t i o n . A n t i m i c r o b i a l t h e r a p y c o n s i s t i n g of g e n t a m y c i n and carbenicillin r e s u l t e d in t h e patient's r a p i d a n d complete recovery from the infection.
al: Freshwater wound infection due to Aeromonas hydrophila. JAMA 238:10531054, 1977.
REFERENCES
5. Davis WA, Kane JG, Garagusi VF: Human Aeromonas infections: a review of the literature and a case report of endocarditis. Medicine 57:267-277, 1978.
1. Von Graevenitz A, Mensch AH: The genus Aeromonas hydrophila in human bacteriology. N Engl J Med 278:245-249, 1968. 2. Hanson PG, Standridge J, Jarrett F, et
3. Bugler RJ, Sherris JC: The clinical significance of Aeromonas hydrophila: report of two cases. Arch Intern Med 118:562-564, 1966. 4. Washington J A I I : Aeromonas hydrophila in clinical bacteriologic specimens. Ann Intern Med 76:611-614, 1972.
6. Sanyal SC, Singh SJ, Sen PC: Enteropathogenicity of Aeromonas hydrophila
and Plesimonas shigelloides. J Med Microbiol 8:195-198, 1975. 7. Ketover BP, Young LS, Armstrong D: Septicemia due to Aeromonas hydrophila: clinical and immunologic aspects. J Infect Dis 127:284-290, 1973. 8. Minnefore AB, Olson MI, Carver OH: Pseudomonas osteomyelitis following puncture wounds of the foot. Pediatrics 47:598-601, 1971. 9. Brand RA, Black H: Pseudomonas osteomyelitis following puncture wounds in children. J Bone Joint Surg 56:16371642, 1974. 10. M i l l e r EH, S e m i a n DW: Gramnegative osteomyelitis following puncture wounds of the foot. J Bone Joint Surg 57A:535-537, 1975.
UA/EM CALL FOR ABSTRACTS The Hilton Palacio del Rio in San Antonio, Texas, will be locus for the 1981 UA/EM Annual Meeting, April 12-15, 1981. Program Chairman Richard F. Edlich, MD, has announced that he will accept abstracts for the scientific papers to be presented at the Annual Meeting. Members and others in the field are urged to submit original contributions relating to emergency medicine. Papers submitted by non-UA/EM members must be accompanied by a letter of sponsorship from a member. Abstracts should be limited to 250 words and typed double-spaced on 81/2" x 11 " paper. Abstracts must be authored, co-authored, or sponsored by a UA/EM member and the name and address of each author should appear on the abstract. Deadline for submission is January 1, 1981. Mail three copies of the abstract to: Richard F. Edlich, MD, Program Chairman, UA/EM, 900 West Ottawa, PO Box 17037, Lansing, Michigan 48915. Presentations at the Annual Meeting will be limited to 10 minutes followed by a five-minute discussion period. A completed manuscript must be submitted no later than the day of the presentation at the meeting.Annals of Emergency Medicine, official journal of the American College of Emergency Physicians and the University Association for Emergency Medicine, reserves the right of first refusal on all scientific papers presented at the UA/EM Annual Meeting. If Annals does not notify authors, in writing, of its intent to publish by September 1, 1981, authors reserve the right to submit papers to other publications.
SUGGESTIONS FOR WRITING ABSTRACTS An abstract should be factual, clearly conveying the reason for the work, the methods, the results, and their significance. To make your abstract more readable, follow these guidelines: 1. Brief introduction stating why the work was done. 2. Tables and charts are not appropriate for abstracts and will be deleted. 3. Clearly state methods used, as well as whatever limitations the methods may have. 4. Clearly state results in numerical or tabular form, if appropriate. Has statistical significance been achieved? 5. Brief discussion of what the results indicate. 6. Conclusion stating the relevance of these particular findings to emergency medicine. Be sure to present the date in the abstracts. Avoid generalities, such as "the significance of these results will be discussed," or "the management will be outlined."
9:10 (October) 1980
Ann Emerg Med
Circle appropriate category: Gastrointestinal Cardiovascular EMS Trauma Methods and Techniques Infections ED Administration Psychosocial Respiratory Burns Prehospital Care Presenter: Mailing address of Principal Author: From (Institution):
531/51
Aeromonas Hydrophila Infection Of A Puncture Wound David Katz, MD Harold Smith, MD Ann Arbor, Michigan Aeromonas hydrophila is a gram-negative organism generally considered a pathogen of low virulence, rarely reported as causing infection in man. Recently it has been recognized as causing infection in wounds. This article reports the case of a patient who suffered a puncture wound while standing in a fresh water lake. He subsequently developed a rapidly progressing cellulitis requiring hospitalization. This organism was cultured from the wound and responded dramatically to appropriate antimicrobial therapy. Katz D, Smith H: Aeromonas hydrophila infection of a puncture wound. Ann Emerg Med 9:529-531, October 1980. aeromonas hydrophila, infection in wound; bacillus, aeromonas hydrophila, infection; infection, caused by aeromonas hydrophila; wound, infection, from aeromonas hydrophila INTRODUCTION Aeromonas hydrophila is a gram-negative bacillus, and a member of the family vibrionaceae. It is a common inhabitant of fresh water lakes and has been isolated from marine animals, soil, and tap water) '2 Until recently this organism was viewed as a pathogen Of low virulence, 1'2 and infrequently reported as causing infection in man, and then usually in immunocompromised hosts. 3 Several recent reports indicate that infection with hydrop'hila is being recognized more frequently in healthy persons. 2'4 These infections usually develop in wounds resulting from accidents occurring out-of-doors. The clinical picture of these infections is indistinguishable from typical streptococcal cellulitis, frequently resulting in improper therapy. We present a caseof hydrophila cellulitis acquired by a previously healthy man from a puncture wound sustained in a fresh water lake. CASE REPORT A 41-year-old white man presented to the St. Joseph Mercy Hospital because of the acute onset of chills, fever, and extreme pain in the right foot. Earlier that afternoon while at an inland lake he had stepped on a nail with his right foot while standing in knee-deep water. Besides noting a painless small puncture wound, which was bleeding profusely, the patient reported no other symptoms at that time. Within 6 hr to 8 hr localized pain and swelling had developed to the point at which the patient could not bear weight on the foot or even drive his automobile. Concurrently he noted the onset of intermittent chills and a temperature of 38.3 C. On initial examination the patient was experiencing extreme pain localized to the plantar surface of the right foot. Vital signs at that time demonstrated an oral temperature of 38.2 C; pulse, 112 beats/min; and blood pressure, 114/74 mm From St. Joseph Mercy Hospital, Ann Arbor, Michigan. Address for reprints: David Katz, MD, PO Box 995, Ann Arbor, Michigan 48106.
9:10 (October) 1980
Ann Emerg Med
529/49
Hg. Examination of the foot showed a 3-mm puncture wound on the lateral midplantar aspect of the right foot. This was surrounded by a 6-cm by 8cm area of erythematous, warm, swollen, tender cellulitis spreading medially and laterally from the wound. The remainder of the physical examination and history was unremarkable. On initial examination the patient was experiencing extreme pain localized to the plantar surface of the right foot. Vital signs at that time demonstrated an oral temperature of 38.2 C; pulse, 112 beats/min; and blood pressure, 114/74 mm Hg. Examination of the foot showed a 3-mm puncture wound on the lateral midplantar aspect of the right foot. This was surrounded by a 6-cm by 8-cm area of erythematous, warm, swollen, tender cellulitis spreading medially and laterally from the wound. The remainder of the physical examination and history was unremarkable. Roentgenograms of the foot showed no free gas or foreign bodies. Although no fluid or pus could be expressed from the wound, a swab of the puncture site was obtained for culture and Gram stain. The initial Gram stain showed gram-negative bacillae. The white blood count was 13,100/cu mm, with 72% segmented neutrophils, 8% band forms, 15% lymphocytes, and 5% monocytes. Adsorbed tetanus toxoid, 0.5 ml, was administered, and antibiotic therapy was initiated with gentamycin 80 mg IVPB every 8 hr and carbenicillin 5 gm IVPB every 4 hr. On the following day the cellulitis had increased to 8 cm by 12 cm and was extending medially and laterally up over the dorsal surface of the foot. However, the patient's temperature had stabilized in the 37.2 C to 37.7 C range. On the second hospital day the initial wound culture returned with the report of 2+ Pseudomonas aeruginosa and a second uncharacterized gram-negative bacillus - - subsequently identified as A hydrophila. On this same day the wound and surrounding cellulitis was incised and drained with the recovery of 3 ml of purulent material which was sent for culture. Over the ensuing three days the patient reported much improvement in his symptoms, with full recovery of the use of his foot. His temperature had returned to normal. All blood, urine, and s p u t u m cultures were negative. By the fifth hospital day the white blood count had fallen to
50/530
9,600/cu mm. The second wound culture also grew 3+ A hydrophila, sensitive to aminoglycosides, tetracycline, and chloramphenicol while resistant to ampicillin and cephalosporins. The patient was maintained on a full 10day course of gentamycin, and at discharge all swelling and tenderness had cleared and the puncture wound was healing well. Follow-up examinations have shown no untoward sequelae or residual effects.
DISCUSSION
Aeromonas hydrophila is a gramnegative rod that is well documented, although infrequently, as causing infection in man. Most physicians are not aware that it can be a pathogen and do not consider it when dealing with infectious problems. This is especially true in traumatic skin wound infections, where streptococcae are usually thought to be the offending agent. This case, as well as several other r e p o r t e d cases, 2'5 demonstrates that Aeromonas infection can cause a cellulitis clinically identical to that caused by streptococcae. Symptoms of infection are usually noticed within hours of the injury. The patient commonly experiences increasing pain around the wound, with the simultaneous onset of chills and fever. The temperature can range between 37.8 C and 39.5 C. Swelling and redness will be noted around the wound, and a purulent drainage may be present. A mild to m o d e r a t e leukocytosis m a y be found, and Gram stain of the wound will frequently demonstrate gramnegative rods. This finding is frequently disregarded as a contaminant, but in fact should suggest the possibility of Aeromonas infection, especially when the wound was sustained in or around a body of fresh water. This association was nicely documented by Hanson et al, 2 who actually sampled the lake where their patient had been injured and found a high concentration of aeromonads. They also found a significant coliform count, supporting the idea that fecal pollution of fresh waters may be the source of the aeromonads. Additional evidence for this comes from the knowledge that direct isolation of Aeromonas from human stool is common. 6 This fact is important when considering other types of infections caused by Aeromonas, such as gastroenteritis of otherwise unproven cause, and septicemia in immunocompromised patients. 7 Ann Emerg Med
I n t h e l a t t e r s i t u a t i o n it is thought that the infection originates endogenously from the gastrointestinal tract. At this time the pathogenicity of Aeromonas is difficult to define, for Aeromonas infection may r e m a i n u n d i a g n o s e d in m a n y patients because other more well-recognized pathogens may also be present, or because routine microbiological screening may not differentiate other enterobacteriaceae from the morphologically and biochemically similar aeromonads. The definitive identification is made by showing a gramnegative motile rod that is oxidase positive, catalase positive, indole positive, Voges-Proskauer positive, and citrate negative. 2 It ferments glucose, mannitol, lactose, sucrose, and mannose, but does not ferment inositol, sorbitol, rhamnose, or melobiose. The most successful approach to therapy is antimicrobials combined with surgical drainage when appropriate. 2 Aeromonas has been shown~ to be sensitive to gentamycin, kanamycin, tetracycline, and chloramphenicol. The organism is frequently resistant to penicillin, ampicillin, and cephalosporin, possibly due to reported beta-lactamase production by the organism. 3 Therapy should always include an aminoglycoside, 2 preferably gentamycin. A hydrophila has been infrequently reported as an agent of human infection, especially in the immunologically competent patient. 3 This case and the latest reports noted would indicate this paucity of identification may not be truly reflective of the actual incidence of Aeromonas infections. Careful attention to presentation, clinical course, and microbiological testing may aid in the recognition of Aeromonas as a human pathogen. Finally, some might argue that the P aeruginosa isolated from the original culture was the causative organism in this case. This seems unlikely, not because Pseudomonas cannot cause infection in this setting, but because when it does it usually causes an osteomyelitis that becomes symptomatic days to weeks after the puncture wound. Patients with this p r o b l e m are not febrile, t h e r e is minimal local reaction, and there is no leukocytosis, s'l° This is in distinct contrast to the clinical picture seen in our patient and other reported cases of Aeromonas wound infection.
SUMMARY
Aeromonas hydrophila, a gramnegative organism generally consid9:10 (October) 1980
ered a p a t h o g e n of low virulence, was cultured from t h e p u n c t u r e wound of our p a t i e n t , who h a d d e v e l o p e d a rapidly progressing c e l l u l i t i s requiring h o s p i t a l i z a t i o n . A n t i m i c r o b i a l t h e r a p y c o n s i s t i n g of g e n t a m y c i n and carbenicillin r e s u l t e d in t h e patient's r a p i d a n d complete recovery from the infection.
al: Freshwater wound infection due to Aeromonas hydrophila. JAMA 238:10531054, 1977.
REFERENCES
5. Davis WA, Kane JG, Garagusi VF: Human Aeromonas infections: a review of the literature and a case report of endocarditis. Medicine 57:267-277, 1978.
1. Von Graevenitz A, Mensch AH: The genus Aeromonas hydrophila in human bacteriology. N Engl J Med 278:245-249, 1968. 2. Hanson PG, Standridge J, Jarrett F, et
3. Bugler RJ, Sherris JC: The clinical significance of Aeromonas hydrophila: report of two cases. Arch Intern Med 118:562-564, 1966. 4. Washington J A I I : Aeromonas hydrophila in clinical bacteriologic specimens. Ann Intern Med 76:611-614, 1972.
6. Sanyal SC, Singh SJ, Sen PC: Enteropathogenicity of Aeromonas hydrophila
and Plesimonas shigelloides. J Med Microbiol 8:195-198, 1975. 7. Ketover BP, Young LS, Armstrong D: Septicemia due to Aeromonas hydrophila: clinical and immunologic aspects. J Infect Dis 127:284-290, 1973. 8. Minnefore AB, Olson MI, Carver OH: Pseudomonas osteomyelitis following puncture wounds of the foot. Pediatrics 47:598-601, 1971. 9. Brand RA, Black H: Pseudomonas osteomyelitis following puncture wounds in children. J Bone Joint Surg 56:16371642, 1974. 10. M i l l e r EH, S e m i a n DW: Gramnegative osteomyelitis following puncture wounds of the foot. J Bone Joint Surg 57A:535-537, 1975.
UA/EM CALL FOR ABSTRACTS The Hilton Palacio del Rio in San Antonio, Texas, will be locus for the 1981 UA/EM Annual Meeting, April 12-15, 1981. Program Chairman Richard F. Edlich, MD, has announced that he will accept abstracts for the scientific papers to be presented at the Annual Meeting. Members and others in the field are urged to submit original contributions relating to emergency medicine. Papers submitted by non-UA/EM members must be accompanied by a letter of sponsorship from a member. Abstracts should be limited to 250 words and typed double-spaced on 81/2" x 11 " paper. Abstracts must be authored, co-authored, or sponsored by a UA/EM member and the name and address of each author should appear on the abstract. Deadline for submission is January 1, 1981. Mail three copies of the abstract to: Richard F. Edlich, MD, Program Chairman, UA/EM, 900 West Ottawa, PO Box 17037, Lansing, Michigan 48915. Presentations at the Annual Meeting will be limited to 10 minutes followed by a five-minute discussion period. A completed manuscript must be submitted no later than the day of the presentation at the meeting.Annals of Emergency Medicine, official journal of the American College of Emergency Physicians and the University Association for Emergency Medicine, reserves the right of first refusal on all scientific papers presented at the UA/EM Annual Meeting. If Annals does not notify authors, in writing, of its intent to publish by September 1, 1981, authors reserve the right to submit papers to other publications.
SUGGESTIONS FOR WRITING ABSTRACTS An abstract should be factual, clearly conveying the reason for the work, the methods, the results, and their significance. To make your abstract more readable, follow these guidelines: 1. Brief introduction stating why the work was done. 2. Tables and charts are not appropriate for abstracts and will be deleted. 3. Clearly state methods used, as well as whatever limitations the methods may have. 4. Clearly state results in numerical or tabular form, if appropriate. Has statistical significance been achieved? 5. Brief discussion of what the results indicate. 6. Conclusion stating the relevance of these particular findings to emergency medicine. Be sure to present the date in the abstracts. Avoid generalities, such as "the significance of these results will be discussed," or "the management will be outlined."
9:10 (October) 1980
Ann Emerg Med
Circle appropriate category: Gastrointestinal Cardiovascular EMS Trauma Methods and Techniques Infections ED Administration Psychosocial Respiratory Burns Prehospital Care Presenter: Mailing address of Principal Author: From (Institution):
531/51