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Comparison of single-dose meperidine, butorphanol and dihydroergotamine in the treatment of vascular headache
ABSTRACTS
those referred to the clinic returned for their appointments, and of these patients (247), 49 (20%) completed the full evaluation. The Center for Epidemiological StudiesDepression scale was used to screen for depressive syndrome, with 16 used as the cutoff score (scores over 16 are increasingly associated with a risk of depressive disorder). The DSM-III criteria for panic disorder and panic attack were transformed into questions to screen for panic disorder. Forty-two patients had pain atypical for angina and no cardiac diagnosis. Five were diagnosed with stable angina and two with mitral valve prolapse. No patient had new ECG abnormalities. Thirty subjects (61%) scored positively on at least one psychopathologic screening measure, with 41% reporting depression, 43% panic attacks, and 16% panic disorder. Almost half of those reporting either depression or panic attacks also reported the other disorder. Of the 30 patients with positive screens, emergency physicians suggested a possible psychosocial contribution to the chest pain in nine (30%), but only one of the 30 received any psychiatric diagnosis ("anxiety"). The investigators conclude that depression and panic disorders may have high prevalence rates in ED patients with atypical chest pain and suggest the need to include psychiatric disorders in the diagnosis of atypical chest pain.
David Tse, MD
spleen, trauma, computed tomography
required surgery, six h a d life-threatening hemodynamic instability, and five had "gradual deterioration of their condition." None of the seven patients operated on after 24 hours had splenorrhaphy. Three of eight operated on within 24 hours had splenorrhaphy. One of ten patients with a splenic trauma score of less than 2.5 had an operation (splenectomy), but the scan on this patient was suboptimal. During the second (prospective) phase, there were 35 patients with evidence of splenic trauma on CT scanning. Of these, conservative management was successful on 26. There were no patients with a splenic trauma score of less than 2.5. Of the remainder, nine of 12 patients with a score of 2.5 or more underwent surgery, with six of nine having splenorrhaphy. There were apparently no cases of hemodynamic instability forcing surgery in phase 2. The reasons for not operating on three of the patients in stage 2 with scores of 2.5 or more were not discussed. This study is fairly typical in both its weaknesses and its strengths of the bewildering data being amassed on the use of CT for blunt abdominal trauma. It gives convincing data on the apparent nonoperative salvageability of spleens with trauma scores of less than 2.5. However, it also gives convincing data on the danger of conservative management in that there were six cases of life-threatening instability, and all cases of delayed operation resulted in splenectomy. The prospective nature of stage 2 is suspect in that the surgeons were aware of qualitative results of CT prior to the scored results and because the decision to operate was based on a multitude of clinical and radiologic data.
James Vayda, MD
Splenic trauma in adults: Impact of CT grading on management Scatamacchis S, Raptopoulo s V, Fink M, et al
Radiology 171:725-729
headache, vascular, dihydroergotamine
Jun 1989
This was a two-part study on the use of a computed tomography (CT) for the grading of injury to the spleen in blunt abdominal trauma. The first part was retrospective, using a previously developed grading system, and the second part was a prospective analysis of the effect of the system on patient management. The grading system assigned one to three points for increasing grades of splenic injury, with half-point adjustments for unclear diagnoses. Added to this score was a one-to-three-point system for grading "fluid in the peritoneum." During the prospective phase, CT was performed within 24 hours of presentation, the results of which were made available to the surgeons in qualitative form. At this time, the decision to attempt conservative management was made. Subsequently, the CT results were reviewed by an attending physician, and a splenic trauma score was tabulated. Surgeons then revised their decision to operate based on this score and on the clinical condition of the patient. All patients during this stage "had a soft abdomen and stable blood pressure and pulse rate." In stage 1, 29 patients with a discharge diagnosis of splenic trauma had CT within 24 hours of injury. Of these, 14 were managed conservatively. Of the 15 who 160/1371
Comparison of single-dose meperidine, butorphanol and dihydroergotamine in the t r e a t m e n t of vascular headache Belgrade MJ, Ling LJ, Schleevogt MB, et al
Neurology 39:590-592 Apr 1989
This nonblinded, prospective, randomized study was initiated to compare the effects of three different treatment modalities on migraine or primary vascular headaches. Treatment protocols included meperidine 75 mg plus hydroxyzine 50 mg IM; butorphanol 2 mg IM; and dihydroergotamine (DHE) 1 mg plus metoclopramide 10 mg IV. Sixty-four patients presenting to a county emergency department were randomized to the three groups; 62 completed the study. Parameters evaluated included vascular score, to evaluate for placement into study; pain score, to evaluate pre- and one-half hour post-treatment pain levels; blood pressure, pre- and 15 minute post-treatment pain levels; and narcotic-seeking scale. Post-treatm e n t pain scores were lowest in DHE group (P < .01); eight of 21 patients receiving DHE had more than 90%
Annals of Emergency Medicine
18:12 December 1989
reduction in pain compared with three of 19 patients receiving butorphanol and none of 22 receiving meperidine. No correlation was found between results and treatment, age, sex, or narcotic-seeking behavior. Side effects of DHE and metoclopramide use included transient diaphoresis, restlessness, fearfulness, flushing, and nausea. No hospitalizations were required for side effects or intractable headache. Ron Genova, MD trauma, drug use
Drug u s e in t r a u m a v i c t i m s Rivara FP J Trauma 29:462-470 Apr 1989
The authors determined the prevalence of drugs in fatal and nonfatal trauma victims. Urine was available from 525 (40%) of 1,314 adults seen with trauma at Harborview Medical Center, Seattle, from February to August 1986. After e x c l u d i n g p a t i e n t s r e c e i v i n g o p i a t e s or benzodiazepines under medical supervision, 452 emergency department patients and 160 medical examiner's office (MEO) cases were entered into the study. Blood was drawn in 316 of 452 ED patients for blood alcohol determination and 159 of 168 MEO patients. In addition, urine was available from 160 MEO patients (68.1%) who died within 24 hours. No MEO patients had been taking medically supervised opiates or benzodiazepines. Marijuana, cocaine, opiates, and benzodiazepines were tested on each patient's urine, using the EMIT enzyme immunoassay. Tests were positive for at least one drug in 40.3% of ED and 18.7% of MEO samples. Marijuana was the most c o m m o n drug found. Alcohol was present in more than one third of ED and MEO patients. Overall, alcohol and/or drugs were present in 60.2% of ED and 47.7% of MEO patients. No data were found to support a relationship between drug use and injury or hospital outcome. Blood assays may clarify any temporal relationship to drugs and trauma. Sam Perler, MD
ectopic pregnancy, progesterone
Preventing ruptured ect o p i c p r e g n a n c y wi th a single serum p r o g est ero n e Stovall TG, Line FW, Cope BJ, et al Am J Obstet Gynecot 160:1425-1431 Jun 1989
The diagnosis of ectopic pregnancy by serial quantitative 13-hCG levels is inherently delayed by the necessity of waiting 48 hours between blood samples. This prospective study used a single serum progesterone and quantitative 18:12 December 1989
Annals of
f3-hCG level to determine management of patients with possible ectopic pregnancies. Patients were followed according to an algorithm dependent on both values. Patients with progesterone levels less than 15 ng/mL, or between 15 and 25 ng/mL with f~-hCG levels between 2,500 and 100,000 mIU, underwent urgent reevaluation and ultrasonography. Patients with progesterone levels above 25 ng/mL, or between 15 and 25 ng/mL with ~-hCG above 100,000 mIU, were scheduled for follow-up in the obstetric clinic. Sixty-seven ectopic pregnancies were diagnosed out of 582 patients in the first trimester of pregnancy. Twenty-four ectopic pregnancies (39%) were ruptured at the time of initial emergency department visit, and two ruptured prior to diagnosis. Fifty-four patients with ectopic pregnancies (80%) had progesterone levels of less than 15 ng/mL, and only one (1.5%) had a level above 25 ng/ mL. Only nine of 387 patients with viable intrauterine pregnancies had progesterone levels below 10 ng/mL. The authors compare their results with a retrospective chart review of 53 patients with ectopic pregnancy, of which 42 (79%) were ruptured and 11 (21%) unruptured. The authors conclude that utilization of progesterone measurements decreased the frequency of ruptured ectopic pregnancies from 79% to 39%. The authors also conclude that use of progesterone levels can decrease the time of diagnosis of ectopic pregnancy from 48 to 72 hours to less than 24 hours. Carol Federiuk, MD acetaminophen, varicella, fever
A c e t a m i n o p h e n . More harm than good for chickenpox? Dorsan T, DeAngelis E, Baumgardner R, et al J Pediatr 114:1045-1048 Jun 1989
Although antipyretic administration is a c o m m o n response to fever in children, some data have suggested that decreasing fever may actually worsen or prolong viral shedding. This randomized, blinded study was designed to determine whether acetaminophen affects the duration or severity of childhood varicella. Children with varicella aged 1 to 12 years were included in the study if they could be enrolled within 36 hours of initial appearance of a skin lesion. Sixty-eight children comprised the study group, 37 of whom received acetaminophen; 31 received placebo by use of a random numbers table. A temperature and symptom diary Was kept by the parents of each child for six days. A separate diary traced each child's random visits to ten households during the study. There was no overall difference between the groups in any of the scaled symptoms such as itching, activity, appetite, or overall condition. The number of days until total scabbing was longer in the acetaminophen group than in the placebo group. Children in the acetaminophen group were more active than those in the placebo group on day 2 but had more itching on day 4. No other significant difference between the groups was
EmergencyMedicine
1372/161
those referred to the clinic returned for their appointments, and of these patients (247), 49 (20%) completed the full evaluation. The Center for Epidemiological StudiesDepression scale was used to screen for depressive syndrome, with 16 used as the cutoff score (scores over 16 are increasingly associated with a risk of depressive disorder). The DSM-III criteria for panic disorder and panic attack were transformed into questions to screen for panic disorder. Forty-two patients had pain atypical for angina and no cardiac diagnosis. Five were diagnosed with stable angina and two with mitral valve prolapse. No patient had new ECG abnormalities. Thirty subjects (61%) scored positively on at least one psychopathologic screening measure, with 41% reporting depression, 43% panic attacks, and 16% panic disorder. Almost half of those reporting either depression or panic attacks also reported the other disorder. Of the 30 patients with positive screens, emergency physicians suggested a possible psychosocial contribution to the chest pain in nine (30%), but only one of the 30 received any psychiatric diagnosis ("anxiety"). The investigators conclude that depression and panic disorders may have high prevalence rates in ED patients with atypical chest pain and suggest the need to include psychiatric disorders in the diagnosis of atypical chest pain.
David Tse, MD
spleen, trauma, computed tomography
required surgery, six h a d life-threatening hemodynamic instability, and five had "gradual deterioration of their condition." None of the seven patients operated on after 24 hours had splenorrhaphy. Three of eight operated on within 24 hours had splenorrhaphy. One of ten patients with a splenic trauma score of less than 2.5 had an operation (splenectomy), but the scan on this patient was suboptimal. During the second (prospective) phase, there were 35 patients with evidence of splenic trauma on CT scanning. Of these, conservative management was successful on 26. There were no patients with a splenic trauma score of less than 2.5. Of the remainder, nine of 12 patients with a score of 2.5 or more underwent surgery, with six of nine having splenorrhaphy. There were apparently no cases of hemodynamic instability forcing surgery in phase 2. The reasons for not operating on three of the patients in stage 2 with scores of 2.5 or more were not discussed. This study is fairly typical in both its weaknesses and its strengths of the bewildering data being amassed on the use of CT for blunt abdominal trauma. It gives convincing data on the apparent nonoperative salvageability of spleens with trauma scores of less than 2.5. However, it also gives convincing data on the danger of conservative management in that there were six cases of life-threatening instability, and all cases of delayed operation resulted in splenectomy. The prospective nature of stage 2 is suspect in that the surgeons were aware of qualitative results of CT prior to the scored results and because the decision to operate was based on a multitude of clinical and radiologic data.
James Vayda, MD
Splenic trauma in adults: Impact of CT grading on management Scatamacchis S, Raptopoulo s V, Fink M, et al
Radiology 171:725-729
headache, vascular, dihydroergotamine
Jun 1989
This was a two-part study on the use of a computed tomography (CT) for the grading of injury to the spleen in blunt abdominal trauma. The first part was retrospective, using a previously developed grading system, and the second part was a prospective analysis of the effect of the system on patient management. The grading system assigned one to three points for increasing grades of splenic injury, with half-point adjustments for unclear diagnoses. Added to this score was a one-to-three-point system for grading "fluid in the peritoneum." During the prospective phase, CT was performed within 24 hours of presentation, the results of which were made available to the surgeons in qualitative form. At this time, the decision to attempt conservative management was made. Subsequently, the CT results were reviewed by an attending physician, and a splenic trauma score was tabulated. Surgeons then revised their decision to operate based on this score and on the clinical condition of the patient. All patients during this stage "had a soft abdomen and stable blood pressure and pulse rate." In stage 1, 29 patients with a discharge diagnosis of splenic trauma had CT within 24 hours of injury. Of these, 14 were managed conservatively. Of the 15 who 160/1371
Comparison of single-dose meperidine, butorphanol and dihydroergotamine in the t r e a t m e n t of vascular headache Belgrade MJ, Ling LJ, Schleevogt MB, et al
Neurology 39:590-592 Apr 1989
This nonblinded, prospective, randomized study was initiated to compare the effects of three different treatment modalities on migraine or primary vascular headaches. Treatment protocols included meperidine 75 mg plus hydroxyzine 50 mg IM; butorphanol 2 mg IM; and dihydroergotamine (DHE) 1 mg plus metoclopramide 10 mg IV. Sixty-four patients presenting to a county emergency department were randomized to the three groups; 62 completed the study. Parameters evaluated included vascular score, to evaluate for placement into study; pain score, to evaluate pre- and one-half hour post-treatment pain levels; blood pressure, pre- and 15 minute post-treatment pain levels; and narcotic-seeking scale. Post-treatm e n t pain scores were lowest in DHE group (P < .01); eight of 21 patients receiving DHE had more than 90%
Annals of Emergency Medicine
18:12 December 1989
reduction in pain compared with three of 19 patients receiving butorphanol and none of 22 receiving meperidine. No correlation was found between results and treatment, age, sex, or narcotic-seeking behavior. Side effects of DHE and metoclopramide use included transient diaphoresis, restlessness, fearfulness, flushing, and nausea. No hospitalizations were required for side effects or intractable headache. Ron Genova, MD trauma, drug use
Drug u s e in t r a u m a v i c t i m s Rivara FP J Trauma 29:462-470 Apr 1989
The authors determined the prevalence of drugs in fatal and nonfatal trauma victims. Urine was available from 525 (40%) of 1,314 adults seen with trauma at Harborview Medical Center, Seattle, from February to August 1986. After e x c l u d i n g p a t i e n t s r e c e i v i n g o p i a t e s or benzodiazepines under medical supervision, 452 emergency department patients and 160 medical examiner's office (MEO) cases were entered into the study. Blood was drawn in 316 of 452 ED patients for blood alcohol determination and 159 of 168 MEO patients. In addition, urine was available from 160 MEO patients (68.1%) who died within 24 hours. No MEO patients had been taking medically supervised opiates or benzodiazepines. Marijuana, cocaine, opiates, and benzodiazepines were tested on each patient's urine, using the EMIT enzyme immunoassay. Tests were positive for at least one drug in 40.3% of ED and 18.7% of MEO samples. Marijuana was the most c o m m o n drug found. Alcohol was present in more than one third of ED and MEO patients. Overall, alcohol and/or drugs were present in 60.2% of ED and 47.7% of MEO patients. No data were found to support a relationship between drug use and injury or hospital outcome. Blood assays may clarify any temporal relationship to drugs and trauma. Sam Perler, MD
ectopic pregnancy, progesterone
Preventing ruptured ect o p i c p r e g n a n c y wi th a single serum p r o g est ero n e Stovall TG, Line FW, Cope BJ, et al Am J Obstet Gynecot 160:1425-1431 Jun 1989
The diagnosis of ectopic pregnancy by serial quantitative 13-hCG levels is inherently delayed by the necessity of waiting 48 hours between blood samples. This prospective study used a single serum progesterone and quantitative 18:12 December 1989
Annals of
f3-hCG level to determine management of patients with possible ectopic pregnancies. Patients were followed according to an algorithm dependent on both values. Patients with progesterone levels less than 15 ng/mL, or between 15 and 25 ng/mL with f~-hCG levels between 2,500 and 100,000 mIU, underwent urgent reevaluation and ultrasonography. Patients with progesterone levels above 25 ng/mL, or between 15 and 25 ng/mL with ~-hCG above 100,000 mIU, were scheduled for follow-up in the obstetric clinic. Sixty-seven ectopic pregnancies were diagnosed out of 582 patients in the first trimester of pregnancy. Twenty-four ectopic pregnancies (39%) were ruptured at the time of initial emergency department visit, and two ruptured prior to diagnosis. Fifty-four patients with ectopic pregnancies (80%) had progesterone levels of less than 15 ng/mL, and only one (1.5%) had a level above 25 ng/ mL. Only nine of 387 patients with viable intrauterine pregnancies had progesterone levels below 10 ng/mL. The authors compare their results with a retrospective chart review of 53 patients with ectopic pregnancy, of which 42 (79%) were ruptured and 11 (21%) unruptured. The authors conclude that utilization of progesterone measurements decreased the frequency of ruptured ectopic pregnancies from 79% to 39%. The authors also conclude that use of progesterone levels can decrease the time of diagnosis of ectopic pregnancy from 48 to 72 hours to less than 24 hours. Carol Federiuk, MD acetaminophen, varicella, fever
A c e t a m i n o p h e n . More harm than good for chickenpox? Dorsan T, DeAngelis E, Baumgardner R, et al J Pediatr 114:1045-1048 Jun 1989
Although antipyretic administration is a c o m m o n response to fever in children, some data have suggested that decreasing fever may actually worsen or prolong viral shedding. This randomized, blinded study was designed to determine whether acetaminophen affects the duration or severity of childhood varicella. Children with varicella aged 1 to 12 years were included in the study if they could be enrolled within 36 hours of initial appearance of a skin lesion. Sixty-eight children comprised the study group, 37 of whom received acetaminophen; 31 received placebo by use of a random numbers table. A temperature and symptom diary Was kept by the parents of each child for six days. A separate diary traced each child's random visits to ten households during the study. There was no overall difference between the groups in any of the scaled symptoms such as itching, activity, appetite, or overall condition. The number of days until total scabbing was longer in the acetaminophen group than in the placebo group. Children in the acetaminophen group were more active than those in the placebo group on day 2 but had more itching on day 4. No other significant difference between the groups was
EmergencyMedicine
1372/161