Creatine kinase as a prognostic indicator in electrical injury

whom the probability of pneumonia was clinically estimated to be greater than zero prior to obtaining a chest radiograph. In this group, the LYC would have resulted in 15 fewer chest radiographs, but 3 of 24 (13 W) infiltrates would have been missed. In the adult group, 3 of 40 (7.5%) of the infiltrates would have been missed. The previously published pediatric and adult LYC were applied to the study groups but were not found to perform better than the derived LYC. The authors conclude that the use of objective variables to determine the possibility of pneumonia and the need for chest radiograph does not improve on physicians’ [Dwight E. Peake, MD] clinical judgment. Editor’s Note: As flawed as it is, clinical judgment is still hard to beat. However, this study only presents one side of the coin. Were there any infiltrates in the group of patients (excluded here) whom clinicians decided not to x-ray?

0 EARLY VERSUS LATE FLUID RESUSCITATION: LACK OF EFFECT IN PORCINE HEMORRHAGIC SHOCK. Chudnofsky CR, Dronan SC, Syverud SA, et al. Ann Emerg Med. 1989;18:122-6. Considerable controversy exists surrounding the use of intravenous (IV) therapy in the prehospital management of trauma patients. This study compared hemodynamic effect and overall survival in a swine model of continuous hemorrhage. Twenty-eight splenectomized, immature swine were randomly assigned to prehospital (PH) and inhospital (IH) IV therapy. The animals were bled at a rate of 1.25 mL/kg/ min. After 20 minutes (simulating ambulance dispatch and travel time), the PH animals received saline at 1 mL/kg/ min; at 45 minutes, they began receiving equal proportions of saline and shed blood at 3 mL/min, simulating hospital arrival; hemorrhage was stopped at 65 minutes. The IH animals began receiving saline and shed blood at a rate of 3 mL/kg/min 35 minutes after the onset of hemorrhage; hemorrhage was stopped at 55 minutes. No statistically significant differences between groups were noted for cardiac index, bicarbonate, mean arterial pressure, or oxygen delivery. Survival was 57% in both groups. The authors conclude that early administration of intravenous fluid had no effect on hemodynamics or survival, but caution against extrapolation of their results. [Stephen Poff, MD] Editor’s Note: There are other reasons for starting a field IV: easier access, obtaining a blood sample for type and cross match or other tests. The only harm from field fluid administration would be excessive time spent to start the lines.

0 CREATINE KINASE AS A PROGNOSTIC INDICATOR IN ELECTRICAL INJURY. Ahrenholz DH, Schubert W, Solem LD. Surgery. 1988;104:741-7. This retrospective review of records analyzed 116 of 125 patients admitted for electrical injuries over an 1 l-year period. Levels of creatine kinase (CK), creatine kinase myocardial band (CK-MB), and lactate dehydrogenase (LDH)

were examined to determine if there was correlation between peak CK level, muscle damage, myocardial injury, and length of hospital stay. Patients were divided into 3 groups as follows: Group I, CK >400 U/L; Group II, CK = 400 to 2500 U/L; Group III, CK>2500 U/L. Hospital stay was significantly shorter for Group I than Group II and for Group II than Group III. The CK-MB levels did not correlate with electrocardiographic evidence of myocardial damage. However 3 patients from Group III did sustain clinical myocardial infarctions. Increased CK was associated with increasing need for skin grafting and amputation. Thus peak serum CK levels are associated with the severity of electrical conduction injuries; very low levels may be useful in ruling out deep muscle destruction. [David Rosenberg, MD] Editor’s Note: While low peak CK levels may be accurate in ruling out deep injury, emergency physicians should remember that initial levels are not the same as peak levels.

0 NONOPERATIVE MANAGEMENT OF BLUNT HEPATIC TRAUMA IN ADULTS. Farnell MB, Spencer MP, Thompson E, et al. Surgery. 1988;104:748-56. In this prospective trial, 66 consecutive patients with blunt hepatic injury were divided into 3 categories: those hemodynamically unstable from obvious intraabdominal trauma and in need of an immediate laparotomy, those hemodynamically unstable but possibly from an extraabdominal source thus requiring diagnostic peritoneal lavage, and those hemodynamically stable but in whom clinical evaluation of the abdomen was considered equivocal due to multisystem injury or altered sensorium. This third group was evaluated by abdominal computed tomography (CT) and considered for nonoperative management. Nonoperative management was chosen if the CT showed (1) contained subcapsular or intrahepatic hematoma, (2) unilocular fracture, (3) absence of devitalized liver, (4) minimal hemoperitoneum, (5) no other significant intraabdominal injuries. Of the 66 original patients, 20 initially met the nonoperative criteria and were followed by serial examinations and laboratory studies. Five of these patients had concomitant extrahepatic abdominal organ trauma on CT. Only 2 of the 20 patients failed nonoperative management. One of the remaining 18 patients died of complications from a head injury. The remaining patients recovered from their injuries without sequelae. The majority of these patients received follow up scans to document resolution of liver injury with long-term follow-up averaging 27 months. Nonoperative management of blunt hepatic injury based on CT findings may be a useful alternative in a small group of hemodynamically stable patients. [David Rosenberg, MD]

'ElCOMPARISON OF THE ORAL AND INTRAVENOUS ROUTES FOR TREATING ASTHMA WITH METHYLPREDNISOLONE AND THEOPHYLLINE.