- Email: [email protected]
Computerized tomography in the emergency department
cannot be seen on plain x-ray film may be present. CT scan is superior to plain radiography in diagnosing spinal injuries, and eliminates the large number (12/17, or 71%) of false-positive (47%) and false-negative (24%) results obtained when relying solely on plain roentgenograms.
2
Computerized Tomography in the Emergency Department
SA Meador, AdD; RA Walker, MD / Section of Emergency Medicine, Department of Surgery, Wayne State University School of Medicine, Detroit A retrospective study was made of 207 cranial computed tomography (CT) scans executed within 24 h of presentation to the emergency department (ED). Of all patients who entered the ED, one in 74 was scanned. Overall 32% of the scans showed acute intracranial lesions. The most frequent findings were lucencies, intracerebral hemorrhage, subdural hematoma, epidural hematoma, intracranial foreign body, intraventricular hematoma, and subarachnoid hemorrhage. The CT scans provided valuable diagnostic assistance, altering many provisional diagnoses. The time to obtain the CT was shortened significantly when the initial ex: amining physician ordered the scan without waiting for evaluation by the consultant.
3
Usefulness of Abdominal Flat Plate Radiographs in Suspected Ureteral Calculi Patients
KF Zangerle, MD; KV Iserson, MD, FACEP; JC Bjelland, MD / Section of Emergency Medicine and Department of Radiology, Arizona Health Sciences Center, Tucson The evaluation of suspected ureteral colic patients usually includes an abdominal flat plate radiograph. Between 80% and 90% of such stones are said to be visible on plain radiographs due to their calcium content; however, these radiographs do not enable the reader to localize radiopaque bodies to the ureters with confidence. The purpose of this study was to determine the usefulness of abdominal flat plate films in correctly identifying ureteral calc u l l One hundred seventeen scout films from patients who underwent IVP studies were examined by an emergency physician and a radiologist. The films were presented without history in a random, blind manner to the readers, who were asked to identify and localize all calculi and assign a confidence value to the reading. There were 50 scout films from patients whose IVPs demonstrated radiopaque stones with ureteral obstruction (38 patients with a total of 40 stones) or obstruction without visible stones (12 patients). The radiologist correctly identified 23 of the radiopaque stones (confidence = likely or better), falsely predicted 14 stones (confidence = likely or better), and failed to identify any stone in 9 of these films. The emergency physician correctly identified 14 of these stones, falsely predicted 6 stones, and failed to identify any stones in 12 of these films. There were 67 scout films from negative IVPs. The radiologist identified 42 of these films as having a possible stone and stated that 16 of these films were likely to have a ureteral stone. The emergency physician stated that 44 of these films had a possibility of a stone, and 23 of these films were likely to have a ureteral stone. Whether read by the radiologist or the emergency physician, abdominal flat plate radiographs are poor predictors of ureteral calculi and do not add significant information in suspected ureteral colic patients.
4
Accuracy of the Plain Abdominal Roentgenogram in the Diagnosis of Ureteral Calculi
CS Roth, AdD/TH Berquist, MD; BA Bowyer, MD / Departments of Internal Medicine and Radiology and Divisions of Emergency Medical Services and Gastroenterology, Mayo Clinic, Rochester, MN A plain abdominal radiograph (PAR) is commonly used to diag-
13:5 May 1984
nose and manage patients suspected of having ureteral calculi. The accuracy of the PAR for detecting ureterolithiasis in emergency department (ED) patients is not known. This study was designed to determine the sensitivity, specificity, and predictive value of the PAR for diagnosing ureteral calculi in an ED. Records of 206 adult patients (147 men, 59 women) who underwent emergency excretory urography were reviewed as part of an ED evaluation for suspected uretera] calculi. A PAR was taken shortly before the excretory urogram (EXU) was performed on all patients. Each PAR was separated from the corresponding EXU and both were reviewed for radiographic evidence of ureterolithiasis. The results of the PAR and EXU interpretations were compared. There were 92 true-positive PARS (45%), 19 false positives (9%), 56 false negatives (27%), and 39 true negatives (19%), yielding a sensitivity of 62% and a specificity of 67%. In those patients with the highest clinical probability of having a ureteral calculus, the PAR had a positive predictive value of 86% and a negative predictive value of 22%. Based on these data, we recommend the following guidelines for accurate and cost-effective radiographic evaluation of ED patients with suspected ureteral calculi: 1) a PAR should be obtained initially on all patients; 2) when there is no evidence of a ureteral calculus on the PAR, an EXU should be obtained as soon as possible; and 3) when there is radiographic evidence of a ureteral calculus on the PAR and the patient has clinical features highly consistent with ureterolithiasis, an e m e r . gency EXU is not necessary.
5
Correlation of Historical and Physical Findings with Fractures in Knee Injuries
WH Spivey, MD; RJ Sa/omone, MD; R McDowell, MD / Division of Emergency Medicine, The Medical College of Pennsylvania, Philadelphia To determine the clinical indications for radiographic examination of the traumatized knee, a prospective study was conducted of 250 patients presenting to a residency-based emergency department and affiliated hospitals. The patients included in the study were those with trauma to one knee within 72 h of presentation to the emergency department. Patients with multiple injuries from trauma were excluded. Historical data included mechanism of injury, ability to ambulate, ability to bear weight on the affected knee, and time course of pain and swelling. Physical data included appearance of the knee; presence of contusion, effusion, or abrasion; stability of the joint; and results of McMurray's test. Computer-assisted single and multifactional analysis of the data was performed to determine those factors that had the highest statistical correlation with a fracture. Historical data that strongly correlated with a fracture included the inability to ambulate (P < .002) and the inability to bear weight on the injured knee (P < .001). The mechanism of injury (ie, direct trauma, twisting the knee, etc) was not useful in predicting a fracture. A difference in the gross appearance of the injured knee when compared to the normal knee was the most significant factor of the physical examination in predicting a fracture (P < .002). A gross difference was observed in all fractures. Tenderness (P < .003) and decreased range of active flexion of the knee (P < .02) also correlated strongly with fractures. Effusion, ecchymosis, and li.gamentous laxity were not helpful in predicting fractures. No historical data or positive physical findings were found to be 100% predictive of a fracture; however, several factors were strongly indicative of a fracture. The inability to bear weight or ambulate, a difference in the gross appearance of the knee, tenderness, and a decrease in the active range of flexion had high correlations with fractures. The presence of these historical and physical findings is a strong indication that radiographic examination may be beneficial.
6
Ventilation During CPR: Two-Rescuer Standards Reappraised
RJ Melker, MD; MJ Banner, RRT / Departments of Anesthesiology, Pediatrics, and Surgery, University of Florida College of Medicine, Gainesville
Annals of Emergency Medicine
403/139
2
Computerized Tomography in the Emergency Department
SA Meador, AdD; RA Walker, MD / Section of Emergency Medicine, Department of Surgery, Wayne State University School of Medicine, Detroit A retrospective study was made of 207 cranial computed tomography (CT) scans executed within 24 h of presentation to the emergency department (ED). Of all patients who entered the ED, one in 74 was scanned. Overall 32% of the scans showed acute intracranial lesions. The most frequent findings were lucencies, intracerebral hemorrhage, subdural hematoma, epidural hematoma, intracranial foreign body, intraventricular hematoma, and subarachnoid hemorrhage. The CT scans provided valuable diagnostic assistance, altering many provisional diagnoses. The time to obtain the CT was shortened significantly when the initial ex: amining physician ordered the scan without waiting for evaluation by the consultant.
3
Usefulness of Abdominal Flat Plate Radiographs in Suspected Ureteral Calculi Patients
KF Zangerle, MD; KV Iserson, MD, FACEP; JC Bjelland, MD / Section of Emergency Medicine and Department of Radiology, Arizona Health Sciences Center, Tucson The evaluation of suspected ureteral colic patients usually includes an abdominal flat plate radiograph. Between 80% and 90% of such stones are said to be visible on plain radiographs due to their calcium content; however, these radiographs do not enable the reader to localize radiopaque bodies to the ureters with confidence. The purpose of this study was to determine the usefulness of abdominal flat plate films in correctly identifying ureteral calc u l l One hundred seventeen scout films from patients who underwent IVP studies were examined by an emergency physician and a radiologist. The films were presented without history in a random, blind manner to the readers, who were asked to identify and localize all calculi and assign a confidence value to the reading. There were 50 scout films from patients whose IVPs demonstrated radiopaque stones with ureteral obstruction (38 patients with a total of 40 stones) or obstruction without visible stones (12 patients). The radiologist correctly identified 23 of the radiopaque stones (confidence = likely or better), falsely predicted 14 stones (confidence = likely or better), and failed to identify any stone in 9 of these films. The emergency physician correctly identified 14 of these stones, falsely predicted 6 stones, and failed to identify any stones in 12 of these films. There were 67 scout films from negative IVPs. The radiologist identified 42 of these films as having a possible stone and stated that 16 of these films were likely to have a ureteral stone. The emergency physician stated that 44 of these films had a possibility of a stone, and 23 of these films were likely to have a ureteral stone. Whether read by the radiologist or the emergency physician, abdominal flat plate radiographs are poor predictors of ureteral calculi and do not add significant information in suspected ureteral colic patients.
4
Accuracy of the Plain Abdominal Roentgenogram in the Diagnosis of Ureteral Calculi
CS Roth, AdD/TH Berquist, MD; BA Bowyer, MD / Departments of Internal Medicine and Radiology and Divisions of Emergency Medical Services and Gastroenterology, Mayo Clinic, Rochester, MN A plain abdominal radiograph (PAR) is commonly used to diag-
13:5 May 1984
nose and manage patients suspected of having ureteral calculi. The accuracy of the PAR for detecting ureterolithiasis in emergency department (ED) patients is not known. This study was designed to determine the sensitivity, specificity, and predictive value of the PAR for diagnosing ureteral calculi in an ED. Records of 206 adult patients (147 men, 59 women) who underwent emergency excretory urography were reviewed as part of an ED evaluation for suspected uretera] calculi. A PAR was taken shortly before the excretory urogram (EXU) was performed on all patients. Each PAR was separated from the corresponding EXU and both were reviewed for radiographic evidence of ureterolithiasis. The results of the PAR and EXU interpretations were compared. There were 92 true-positive PARS (45%), 19 false positives (9%), 56 false negatives (27%), and 39 true negatives (19%), yielding a sensitivity of 62% and a specificity of 67%. In those patients with the highest clinical probability of having a ureteral calculus, the PAR had a positive predictive value of 86% and a negative predictive value of 22%. Based on these data, we recommend the following guidelines for accurate and cost-effective radiographic evaluation of ED patients with suspected ureteral calculi: 1) a PAR should be obtained initially on all patients; 2) when there is no evidence of a ureteral calculus on the PAR, an EXU should be obtained as soon as possible; and 3) when there is radiographic evidence of a ureteral calculus on the PAR and the patient has clinical features highly consistent with ureterolithiasis, an e m e r . gency EXU is not necessary.
5
Correlation of Historical and Physical Findings with Fractures in Knee Injuries
WH Spivey, MD; RJ Sa/omone, MD; R McDowell, MD / Division of Emergency Medicine, The Medical College of Pennsylvania, Philadelphia To determine the clinical indications for radiographic examination of the traumatized knee, a prospective study was conducted of 250 patients presenting to a residency-based emergency department and affiliated hospitals. The patients included in the study were those with trauma to one knee within 72 h of presentation to the emergency department. Patients with multiple injuries from trauma were excluded. Historical data included mechanism of injury, ability to ambulate, ability to bear weight on the affected knee, and time course of pain and swelling. Physical data included appearance of the knee; presence of contusion, effusion, or abrasion; stability of the joint; and results of McMurray's test. Computer-assisted single and multifactional analysis of the data was performed to determine those factors that had the highest statistical correlation with a fracture. Historical data that strongly correlated with a fracture included the inability to ambulate (P < .002) and the inability to bear weight on the injured knee (P < .001). The mechanism of injury (ie, direct trauma, twisting the knee, etc) was not useful in predicting a fracture. A difference in the gross appearance of the injured knee when compared to the normal knee was the most significant factor of the physical examination in predicting a fracture (P < .002). A gross difference was observed in all fractures. Tenderness (P < .003) and decreased range of active flexion of the knee (P < .02) also correlated strongly with fractures. Effusion, ecchymosis, and li.gamentous laxity were not helpful in predicting fractures. No historical data or positive physical findings were found to be 100% predictive of a fracture; however, several factors were strongly indicative of a fracture. The inability to bear weight or ambulate, a difference in the gross appearance of the knee, tenderness, and a decrease in the active range of flexion had high correlations with fractures. The presence of these historical and physical findings is a strong indication that radiographic examination may be beneficial.
6
Ventilation During CPR: Two-Rescuer Standards Reappraised
RJ Melker, MD; MJ Banner, RRT / Departments of Anesthesiology, Pediatrics, and Surgery, University of Florida College of Medicine, Gainesville
Annals of Emergency Medicine
403/139