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Chest radiography in acute traumatic rupture of the thoracic aorta
ABSTRACTS
of peritoneal irritation away from the entrance site, had hematemesis or hematochezia, or had omental or bowel evisceration; patients with an unreliable physical examination secondary to drugs or alcohol were managed by local wound exploration and/or open peritoneal lavage; and patients without signs of peritoneal irritation and who were hemodynamically stable were admitted for 24 to 48 hours and followed by serial physical examination. A lavage was positive if the RBC count was above 100,000, WBC was above 500, or bile or amylase were present. A positive lavage was an indication for laparotomy; 39 of the 186 (20.9%) patients received a laparotomy for evisceration. Of the 39 laparotomies, eight (20.5%) were negative. The remaining 147 patients were managed according to the protocol. One hundred six patients (72%) were evaluated by serial examination. Sixty-five (44%) were discharged uneventfully after 24 to 48 hours. Forty-one patients (27.8%) required laparotomy within 3.1 hours of admission. Of these 41, one had a negative laparotomy and three had positive findings that did not require repair. Ninety of the 186 patients (48.4%) were managed without laparotomy. There were no missed injuries. The incidence of negative laparotomy was 10.4%. If the patients with evisceration were excluded, the true incidence of negative laparotomy was one of 106 {0.9%) for the clinical evaluation group and one of 41 (2.4%) who had wound exploration and/or lavage group. The purpose of "selective conservatism" is to reduce the incidence of negative laparotomy without increasing morbidity from delayed or missed injuries. Serial clinical examination, when applied selectively, is a reliable means of determining which patients with anterior abdominal stab wounds should undergo laparotomy. Tim Hutchinson, M D
thromboJysis, acute myocardial infarction, paramedics
A s y s t e m a p p r o a c h to intravenous t h r o m b o l y s i s in a c u t e m y o c a r d i a l infarction in c o m m u n i t y hospitals: The i n f l u e n c e of paramedics Hartmann J, McKeever L, Bufalino V, et al C/in Cardiol 11:812-816 Dec 1988
D u n c a n Sauer, MD
aorta, thoracic, rupture
C h e s t r a d i o g r a p h y in a c u t e t r a u m a t i c rupture of the t h o r a c i c aorta Heystraten FM, Rosenbusch G, Kingma LM, et al Acta Radiologica 29:411-417 Sep-Oct 1988
A retrospective review of the initial chest films of 123 patients who underwent aortography following blunt chest trauma was performed to determine which of 15 previously reported signs were most frequently associated with thoracic aortic rupture. Sixty-one patients had confirmed aortic rupture. Of these, 50 underwent aortography, and six went to operation without further radiological studies. Results showed the following four findings to be most specific for aortic rupture: a widened right paratracheal stripe of more than 5 mm, an opacified pulmonary window, a displaced nasogastric tube, and a widened right paraspinal interface. The absence of these findings on the initial chest film was associated with a very low incidence of rupture. Although most of the other 11 signs looked for were present in a higher percentage of patients with rupture than in those without rupture, they all proved to be nonspecific. Bruce Spears, MD
N-acetylcysteine, acetaminophen overdose
IV streptokinase was given to 110 consecutive patients during acute myocardial infarction (AMII over a three-year period in a community hospital setting. Fifty-five (50%) of all patients were transported by paramedics who notified the emergency department of the possible MI prior to departure; a cardiologist was then notified. Inclusion criteria were chest pain unrelieved by nitroglycerin and ECG changes. Patients who had relief of pain with nitroglycerin were excluded. The average time for administration of streptokinase was 107 minutes for the patients trans160/714
ported by paramedics versus 182 minutes for patients transported by other means. One hundred seven patients survived three years, for an overall mortality of 2.7%. Paramedics accurately diagnosed acute AMI in 86% of patients transported. This study indicates that paramedics are able to identify eligible candidates for acute thromb0lytic therapy and to decrease the time from recognition of signs of MI to the initiation of thrombolytic therapy in the setting of a community-based hospital. This also implies that IV streptokinase is an ideal addition to a community hospital's therapy in treating acute AMI.
Efficacy of N - a c e t y l c y s t e i n e in the t r e a t m e n t of a c e t a m i n o p h e n overdose Smilkstein MJ, Knapp GI, Kulig KW, et al N Engl J Med 319:1557-1562 Dec 1988
This national multicenter study Was conducted from 1976 to 1985 during investigationat use of N-acetylcysteine (NAC) as an antidote for acetaminophen overdose. Of 11,195 cases of acetaminophen overdose reported to the
Annals of EmergencyMedicine
18:6 June 1989
of peritoneal irritation away from the entrance site, had hematemesis or hematochezia, or had omental or bowel evisceration; patients with an unreliable physical examination secondary to drugs or alcohol were managed by local wound exploration and/or open peritoneal lavage; and patients without signs of peritoneal irritation and who were hemodynamically stable were admitted for 24 to 48 hours and followed by serial physical examination. A lavage was positive if the RBC count was above 100,000, WBC was above 500, or bile or amylase were present. A positive lavage was an indication for laparotomy; 39 of the 186 (20.9%) patients received a laparotomy for evisceration. Of the 39 laparotomies, eight (20.5%) were negative. The remaining 147 patients were managed according to the protocol. One hundred six patients (72%) were evaluated by serial examination. Sixty-five (44%) were discharged uneventfully after 24 to 48 hours. Forty-one patients (27.8%) required laparotomy within 3.1 hours of admission. Of these 41, one had a negative laparotomy and three had positive findings that did not require repair. Ninety of the 186 patients (48.4%) were managed without laparotomy. There were no missed injuries. The incidence of negative laparotomy was 10.4%. If the patients with evisceration were excluded, the true incidence of negative laparotomy was one of 106 {0.9%) for the clinical evaluation group and one of 41 (2.4%) who had wound exploration and/or lavage group. The purpose of "selective conservatism" is to reduce the incidence of negative laparotomy without increasing morbidity from delayed or missed injuries. Serial clinical examination, when applied selectively, is a reliable means of determining which patients with anterior abdominal stab wounds should undergo laparotomy. Tim Hutchinson, M D
thromboJysis, acute myocardial infarction, paramedics
A s y s t e m a p p r o a c h to intravenous t h r o m b o l y s i s in a c u t e m y o c a r d i a l infarction in c o m m u n i t y hospitals: The i n f l u e n c e of paramedics Hartmann J, McKeever L, Bufalino V, et al C/in Cardiol 11:812-816 Dec 1988
D u n c a n Sauer, MD
aorta, thoracic, rupture
C h e s t r a d i o g r a p h y in a c u t e t r a u m a t i c rupture of the t h o r a c i c aorta Heystraten FM, Rosenbusch G, Kingma LM, et al Acta Radiologica 29:411-417 Sep-Oct 1988
A retrospective review of the initial chest films of 123 patients who underwent aortography following blunt chest trauma was performed to determine which of 15 previously reported signs were most frequently associated with thoracic aortic rupture. Sixty-one patients had confirmed aortic rupture. Of these, 50 underwent aortography, and six went to operation without further radiological studies. Results showed the following four findings to be most specific for aortic rupture: a widened right paratracheal stripe of more than 5 mm, an opacified pulmonary window, a displaced nasogastric tube, and a widened right paraspinal interface. The absence of these findings on the initial chest film was associated with a very low incidence of rupture. Although most of the other 11 signs looked for were present in a higher percentage of patients with rupture than in those without rupture, they all proved to be nonspecific. Bruce Spears, MD
N-acetylcysteine, acetaminophen overdose
IV streptokinase was given to 110 consecutive patients during acute myocardial infarction (AMII over a three-year period in a community hospital setting. Fifty-five (50%) of all patients were transported by paramedics who notified the emergency department of the possible MI prior to departure; a cardiologist was then notified. Inclusion criteria were chest pain unrelieved by nitroglycerin and ECG changes. Patients who had relief of pain with nitroglycerin were excluded. The average time for administration of streptokinase was 107 minutes for the patients trans160/714
ported by paramedics versus 182 minutes for patients transported by other means. One hundred seven patients survived three years, for an overall mortality of 2.7%. Paramedics accurately diagnosed acute AMI in 86% of patients transported. This study indicates that paramedics are able to identify eligible candidates for acute thromb0lytic therapy and to decrease the time from recognition of signs of MI to the initiation of thrombolytic therapy in the setting of a community-based hospital. This also implies that IV streptokinase is an ideal addition to a community hospital's therapy in treating acute AMI.
Efficacy of N - a c e t y l c y s t e i n e in the t r e a t m e n t of a c e t a m i n o p h e n overdose Smilkstein MJ, Knapp GI, Kulig KW, et al N Engl J Med 319:1557-1562 Dec 1988
This national multicenter study Was conducted from 1976 to 1985 during investigationat use of N-acetylcysteine (NAC) as an antidote for acetaminophen overdose. Of 11,195 cases of acetaminophen overdose reported to the
Annals of EmergencyMedicine
18:6 June 1989