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Delayed life-threatening hemothorax associated with rib fractures
7~ Jwmi
of Emergency
Medrone.
Vol 5 pp 249-255. 1987
PrInted in the USA
??
Copyright - 1987 Pergamon Jo~~rnalsLtd
-.
0 CLINICAL INDICATIONS FOR RADIOGRAPHIC EVALUATION OF BLUNT RENAL TRAUMA. Cass AS, Luxenberg M, Gleich P, et al. J Urology. 1986; 136:370-371. The evaluation of patients with blunt renal trauma is controversial. In this retrospective study the hypothesis that renal contusion can be diagnosed clinically without radiographic evaluation was tested. The medical records of 831 admitted patients with hematuria following blunt trauma were reviewed. Clinical findings recorded on initial evaluation were the degree of hematuria found on microscopic urinalysis of centrifuged urine, shock (systolic blood pressure < 100 mm Hg), and associated injuries. Radiographic evaluation consisted of initial intravenous pyelography (IVP), followed by a repeat IVP, computed tomography (CT), or aortography if the IVP showed indeterminate findings or nonvisualization of the kidney. Renal injuries were classified as (1) renal contusion, (2) renal laceration, (3) renal rupture, or (4) renal pedicle injury. Follow-up 3 months after injury included clinical evaluation and radiologic evaluation with IVP, CT, or isotope studies. Of the 831 patients studied, 494 had microhematuria without shock. Of these 494 patients, 6 (1070) had severe renal injuries (laceration in 4, rupture in 1, and pedicle injury in 1) and 488 (99%) had renal contusion. Of 334 patients with associated injuries, 5 (1.5%) had severe renal injuries, compared with only one of 160 (0.6%) patients with no associated injuries. All patients with renal contusion had no complications with nonoperative management. The data show that although most patients with microhematuria and no shock after blunt renal trauma had a renal con-
tusion and experienced no complications with nonoperative management, a small number with this clinical presentation had severe renal injuries that would have been missed without radiographic evaluation. [Michael D. Bourland, MD] Editor’s Note: It is of interest to note that of those patients with <8 red blood cells per high-power field on urinalysis, none had severe renal injury (ie, laceration, rupture, or pedicle injury).
0 DELAYED LIFE-THREATENING HEMOTHORAX ASSOCIATED WITH RIB FRACTURES. Ross RM, Cordoba A. J Trauma. 1986; 26:576-578. The authors present two cases of delayed life-threatening hemothorax occurring three to four days after severe blunt chest trauma. Each case had associated rib fractures, and the source of the hemorrhage was disrupted intercostal vessels. In both cases the patients were stable after the initial blunt chest trauma; however, the activity of coughing in one case and intermittent positive pressure breathing in the other was sufficient to cause the resultant hemorrhage. The authors stress the potential need for several days hospital observation of patients with numerous rib fractures secondary to blunt chest trauma even when the patient is clinically stable and has no other obvious intra- or extra- thoracic injuries. Hemothorax and pneumothroax associated with blunt chest trauma can usually be managed with tube thoracostomy; however, massive hemorrhage,
Abstracts-designed to keep readers up to date by providing original abstracts of current literature from all fields relating to emergency medicine-are prepared by the Emergency Medicine Residents of the University of Chicago Medical Center, Chicago, Illinois; and the Residency in Emergency Medicine of Denver General, St. Anthony’s, St. Joseph’s and Porter Hospitals, Denver, Colorado, with editorial notes by Lynnetfe Z=YZZZZ Doan-Wiggins, ,MLI, University of Chicago Medical Center and Peter Rosen. MD, B Editor-in-Chief, JEM. 0736-4679/87 249
$3.00
-t .OO
250
although rare, mandates immediate open thoracotomy and surgical therapy. [Douglas M. Davenport, MD]
0 ANALYSIS OF 76 CIVILIAN CRANIOCEREBRAL GUNSHOT WOUNDS. Clark WC, Muhlbauer MS, Watridge CB, et al. JNeurosurg. 1986; 65:9-14. The charts of 76 patients sustaining civilian gunshot wounds to the head were retrospectively studied to examine what role initial presentation has in the prediction of outcome. Patients all had (1) prompt neurosurgical evaluation including a rating of the Glasgow Coma Scale (GCS), (2) cranial computed tomography, and (3) a set protocol encompassing a team approach to evaluation and treatment of all associated injuries. Patients who were dead on arrival were excluded. The overall mortality rate was 62% and included 42 brain deaths and five deaths from other causes. In this series all patients with an initial GCS of 3 died, regardless of surgical intervention. The presence of intracranial hematomas, ventricular injury, or bihemispheric wounding was also associated with a poor outcome. The authors conclude that initial GCS is a good prognostic indicator of outcome and question the value of surgery in those cases where the initial GCS is 3. [Michael Pepper, MD] Editor’s Note: If the initial GCS is three in the emergency department as opposed to the field, we would agree that this is a very ominous prognosis, since this is the lowest one can score (even if dead).
Cl TRENDELENBURG VERSUS PASG APPLICATION-HEMODYNAMIC RESPONSE IN MAN. Pricolo VE, Burchard KW, Singh AK, et al. J Trauma. 1986; 26:718-726. This study compares the hemodynamic response of man to Trendelenburg positioning (TREND) and the application of the pneumatic antishock garment (PASG), two resuscitative therapies commonly employed to increase cardiac output and blood pressure in the setting of traumatic hemorrhagic hypoperfusion. PASG application at 20 and 40 mm Hg was compared with Trendelenburg positioning at ten degrees in 13 normovolemic persons who had undergone elective coronary artery bypass surgery during the antecedent 16 to 24 hours.
The Journal of Emergency
Medune
Parameters measured included central venous pressure (CVP), left atria1 pressure (LAP), pulmonary capiliary wedge pressure (PCWP), esophageal pressure (Pes), mean arterial pressure (MAP), cardiac index (CI), and systemic vascular resistance (PVR). PASG application at 20 and 40 mm Hg resulted in a significant increase in CVP, LAP, PCWP, and Pes; CI, however, was unchanged. Ten degrees of Trendelenburg resulted in no increase in CVP and PCWP, but CI was significantly increased over baseline. MAP was significantly raised by PASG 20 and PASG 40 but not with Trendelenburg. Pes and PVR were significantly lower with TREND than with PASG at 40 mm Hg. The authors postulate that the elevated intrathoracic pressure (as measured by Pes) following PASG application is primarily responsible for the noted elevation in CVP, LAP, and PCWP. The elevation in CVP inhibits venous return and does not allow an increase in CI following PASG compression of the legs and abdomen. Trendelenburg positioning, on the other hand, increases CI through augmented venous return without other significant hemodynamic alterations resulting from elevated intrathoracic pressure. The authors conclude that Trendelenburg positioning is superior to PASG application in promoting venous return in normovolemic man and that this effect would be similar in cases of hypovolemia. [William M. Roberts, MD] Editor’s Note: It should be emphasized that this study evaluates the hemodynamic effects of PASG on normovolemic subjects and does not evaluate the potential benefit of PASG tamponade of abdominal and retroperitoneal bleeding nor the advantageous effects of increased mean arterial pressure on cerebral and myocardial blood flow.
0 DIFFERENCE IN ACID-BASE STATE BETWEEN VENOUS AND ARTERIAL BLOOD DURING CARDIOPULMONARY RESUSCITATION. Weil MH, Rackow EC, Trevino,R, et al. N Engl J Med. 1986; 315: 153-156. The authors compare the acid-base status of arterial and mixed venous blood in 16 patients undergoing cardiopulmonary resuscitation (CPR) who had arterial and pulmonary arterial catheters in place at the time of cardiac arrest. Blood was sampled simultaneously
of Emergency
Medrone.
Vol 5 pp 249-255. 1987
PrInted in the USA
??
Copyright - 1987 Pergamon Jo~~rnalsLtd
-.
0 CLINICAL INDICATIONS FOR RADIOGRAPHIC EVALUATION OF BLUNT RENAL TRAUMA. Cass AS, Luxenberg M, Gleich P, et al. J Urology. 1986; 136:370-371. The evaluation of patients with blunt renal trauma is controversial. In this retrospective study the hypothesis that renal contusion can be diagnosed clinically without radiographic evaluation was tested. The medical records of 831 admitted patients with hematuria following blunt trauma were reviewed. Clinical findings recorded on initial evaluation were the degree of hematuria found on microscopic urinalysis of centrifuged urine, shock (systolic blood pressure < 100 mm Hg), and associated injuries. Radiographic evaluation consisted of initial intravenous pyelography (IVP), followed by a repeat IVP, computed tomography (CT), or aortography if the IVP showed indeterminate findings or nonvisualization of the kidney. Renal injuries were classified as (1) renal contusion, (2) renal laceration, (3) renal rupture, or (4) renal pedicle injury. Follow-up 3 months after injury included clinical evaluation and radiologic evaluation with IVP, CT, or isotope studies. Of the 831 patients studied, 494 had microhematuria without shock. Of these 494 patients, 6 (1070) had severe renal injuries (laceration in 4, rupture in 1, and pedicle injury in 1) and 488 (99%) had renal contusion. Of 334 patients with associated injuries, 5 (1.5%) had severe renal injuries, compared with only one of 160 (0.6%) patients with no associated injuries. All patients with renal contusion had no complications with nonoperative management. The data show that although most patients with microhematuria and no shock after blunt renal trauma had a renal con-
tusion and experienced no complications with nonoperative management, a small number with this clinical presentation had severe renal injuries that would have been missed without radiographic evaluation. [Michael D. Bourland, MD] Editor’s Note: It is of interest to note that of those patients with <8 red blood cells per high-power field on urinalysis, none had severe renal injury (ie, laceration, rupture, or pedicle injury).
0 DELAYED LIFE-THREATENING HEMOTHORAX ASSOCIATED WITH RIB FRACTURES. Ross RM, Cordoba A. J Trauma. 1986; 26:576-578. The authors present two cases of delayed life-threatening hemothorax occurring three to four days after severe blunt chest trauma. Each case had associated rib fractures, and the source of the hemorrhage was disrupted intercostal vessels. In both cases the patients were stable after the initial blunt chest trauma; however, the activity of coughing in one case and intermittent positive pressure breathing in the other was sufficient to cause the resultant hemorrhage. The authors stress the potential need for several days hospital observation of patients with numerous rib fractures secondary to blunt chest trauma even when the patient is clinically stable and has no other obvious intra- or extra- thoracic injuries. Hemothorax and pneumothroax associated with blunt chest trauma can usually be managed with tube thoracostomy; however, massive hemorrhage,
Abstracts-designed to keep readers up to date by providing original abstracts of current literature from all fields relating to emergency medicine-are prepared by the Emergency Medicine Residents of the University of Chicago Medical Center, Chicago, Illinois; and the Residency in Emergency Medicine of Denver General, St. Anthony’s, St. Joseph’s and Porter Hospitals, Denver, Colorado, with editorial notes by Lynnetfe Z=YZZZZ Doan-Wiggins, ,MLI, University of Chicago Medical Center and Peter Rosen. MD, B Editor-in-Chief, JEM. 0736-4679/87 249
$3.00
-t .OO
250
although rare, mandates immediate open thoracotomy and surgical therapy. [Douglas M. Davenport, MD]
0 ANALYSIS OF 76 CIVILIAN CRANIOCEREBRAL GUNSHOT WOUNDS. Clark WC, Muhlbauer MS, Watridge CB, et al. JNeurosurg. 1986; 65:9-14. The charts of 76 patients sustaining civilian gunshot wounds to the head were retrospectively studied to examine what role initial presentation has in the prediction of outcome. Patients all had (1) prompt neurosurgical evaluation including a rating of the Glasgow Coma Scale (GCS), (2) cranial computed tomography, and (3) a set protocol encompassing a team approach to evaluation and treatment of all associated injuries. Patients who were dead on arrival were excluded. The overall mortality rate was 62% and included 42 brain deaths and five deaths from other causes. In this series all patients with an initial GCS of 3 died, regardless of surgical intervention. The presence of intracranial hematomas, ventricular injury, or bihemispheric wounding was also associated with a poor outcome. The authors conclude that initial GCS is a good prognostic indicator of outcome and question the value of surgery in those cases where the initial GCS is 3. [Michael Pepper, MD] Editor’s Note: If the initial GCS is three in the emergency department as opposed to the field, we would agree that this is a very ominous prognosis, since this is the lowest one can score (even if dead).
Cl TRENDELENBURG VERSUS PASG APPLICATION-HEMODYNAMIC RESPONSE IN MAN. Pricolo VE, Burchard KW, Singh AK, et al. J Trauma. 1986; 26:718-726. This study compares the hemodynamic response of man to Trendelenburg positioning (TREND) and the application of the pneumatic antishock garment (PASG), two resuscitative therapies commonly employed to increase cardiac output and blood pressure in the setting of traumatic hemorrhagic hypoperfusion. PASG application at 20 and 40 mm Hg was compared with Trendelenburg positioning at ten degrees in 13 normovolemic persons who had undergone elective coronary artery bypass surgery during the antecedent 16 to 24 hours.
The Journal of Emergency
Medune
Parameters measured included central venous pressure (CVP), left atria1 pressure (LAP), pulmonary capiliary wedge pressure (PCWP), esophageal pressure (Pes), mean arterial pressure (MAP), cardiac index (CI), and systemic vascular resistance (PVR). PASG application at 20 and 40 mm Hg resulted in a significant increase in CVP, LAP, PCWP, and Pes; CI, however, was unchanged. Ten degrees of Trendelenburg resulted in no increase in CVP and PCWP, but CI was significantly increased over baseline. MAP was significantly raised by PASG 20 and PASG 40 but not with Trendelenburg. Pes and PVR were significantly lower with TREND than with PASG at 40 mm Hg. The authors postulate that the elevated intrathoracic pressure (as measured by Pes) following PASG application is primarily responsible for the noted elevation in CVP, LAP, and PCWP. The elevation in CVP inhibits venous return and does not allow an increase in CI following PASG compression of the legs and abdomen. Trendelenburg positioning, on the other hand, increases CI through augmented venous return without other significant hemodynamic alterations resulting from elevated intrathoracic pressure. The authors conclude that Trendelenburg positioning is superior to PASG application in promoting venous return in normovolemic man and that this effect would be similar in cases of hypovolemia. [William M. Roberts, MD] Editor’s Note: It should be emphasized that this study evaluates the hemodynamic effects of PASG on normovolemic subjects and does not evaluate the potential benefit of PASG tamponade of abdominal and retroperitoneal bleeding nor the advantageous effects of increased mean arterial pressure on cerebral and myocardial blood flow.
0 DIFFERENCE IN ACID-BASE STATE BETWEEN VENOUS AND ARTERIAL BLOOD DURING CARDIOPULMONARY RESUSCITATION. Weil MH, Rackow EC, Trevino,R, et al. N Engl J Med. 1986; 315: 153-156. The authors compare the acid-base status of arterial and mixed venous blood in 16 patients undergoing cardiopulmonary resuscitation (CPR) who had arterial and pulmonary arterial catheters in place at the time of cardiac arrest. Blood was sampled simultaneously