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sudden unexpected death
ABSTRACTS
positive in 56% (14 of 25) of all cases and in 87% (13 of 15) of cases in which the patient was in shock. The authors concludethat Gram staining of skin lesions in patients suspected of having an acute meningococcalinfection is a quick method of diagnosingthese infections. This technique may be especially useful in patients with sepsis and in those with inconclusiveCSF results.
Gordon Hardenbergh, MD angina; myocardialinfarction
Effect of gender on long-term outcome of angina pectoris and myocardial infarction/sudden unexpected death Orencia A, Bailey K, Yawn BP, et al JAMA 269.2392-2397 May 1993 This report from the Rochester CoronaryHeart DiseaseProject describes a 20-year experienceof the gender differences in presentation and outcomeof coronaryheart disease.Twenty thousand medical records from physicians'offices and hospitals were screenedfor diagnoses suggestiveof coronaryartery disease.A cardiologist reviewed the records and ECGsselected and assigned one of three diagnoses: angina pectoris, myocardialinfarction, or sudden unexpecteddeath. Women were significantly older at the onset of angina (67 years versus 60 years), and a smaller proportion smoked as comparedwith men. Estrogen replacementwas used by 38%. Women with angina pectoris as their initial manifestation of coronary heart disease had a risk of dying that was only 0.45 times that for men and a risk of subsequent myocardial infarction/cardiac death that was 0.47 times the risk for men with angina.Women with myocardial infarction or sudden unexpected death as their initial manifestation of coronaryheart disease had a subsequentrate of myocardial
1 72/1643
infarction and cardiac death that was no different than that of men with the same diagnosisand age.A higher proportion of women were prescribed diuretics and digoxin after an infarction, while men were more likely to receiveanticoagulants. Women with an initial hard cardiac event (myocardialinfarction or sudden unexpecteddeath) had a poorer survival as comparedwith men, but this can be attributed entirely to the women's older age at the time of the event. [Editor's note: This report is purely descriptive. No inferences should be drawn regarding differences between genders in treating coronary artery disease.j
Michael Fallen, MD thoracoscopy;diaphragmaticinjury
Prospective evaluation of thoracoscopy for diagnosing diaphragmatic injury in thoracoabdominal trauma: A preliminary report Ochsbner MG, Rozycki GS, Lucente F, et al J Trauma 34.'704-709 May 1993 This prospectiveevaluation of 14 patients with penetratingtrauma to the thoracoabdominalregion sought to determinethe value of thoracoscopyto rule out diaphragmatic injury. Includedpatients had thoracoabdominaltrauma within 24 hours of admission,hemedynamic stability, chest tube drainage of less than 1.5 L blood initially and less than 250 mL/hr for two consecutive hours, and indicationsfor exploratory laparotomy. Rigid or video thoracoscopywas performedthrough the thoracic wall in the operating room to examinethe mediastinum,pericardium, lung, chest wound, and diaphragm.The chest cavity was irrigated and a chest tube placed
under direct visualization.Thoracoscopy correctly identified the presence or absenceof diaphragmatic injury (nine and five, respectively)in all 14 patients, as comparedwith laparotomyand laparoscopy.Two complications, a subphrenicabscess and empyemaand a lung laceration, occurred. The authors concludethat thoracoscopyis a reliable alternative to laparotomyin patients at risk for diaphragmaticinjuries when abdominal exploration is not deemed mandatory.
Merle Miller, MD echocardiography;aorta
Use of transesophageal echocardiography in the evaluation of traumatic aortic injury Keamey PA, Smith DW, Johnson SB, eta/ J Trauma 34:696-701 May 1993 All patients with blunt chest trauma and suspectedthoracic aortic injury admitted to the trauma surgery service at the University of Kentucky were consideredfor evaluation with transesophagealechocardiography (TEE)and aortography.TEEwas performed by blinded staff cardiologists and senior fellows using twodimensionalechocardiographswith color Doppler.Arch aortographywas performed by staff radiologists or senior radiology residents. Sixty-nine patients with suggestivechest radiograph findings (72%) or suggestive histories and chest radiographs (28%) were studied. Therewere no complications.Aortographytook significantly longer than TEE(mean, 76 versus 27 minutes).TEE showed injury in seven patients; four were confirmed by aortography.One patient underwentthoracotomy based on TEEfindings alone. Aortogramsyielded false-negative results in two cases. Tears were confirmed on surgery and autopsy in one case each. Aortographyhad a
sensitivity of 67% and a specificity of 98% in this patient group; TEE had 100% sensitivity and specificity. The authors concludethat timely evaluation with TEE is an important new diagnostictool in the evaluation of the patient with blunt chest trauma. [Editor's noie: The impressive sensitivity and specificity of TEE for aortic rupture in this study have not been equalled in studies of thoracic dissection. Repeated documentation of superiority is warranted when considering a new technology as a replacement for a gold standard test. Rapid availability around the clock by an experienced echocardiographer may be a limiting factor in the use of this technology.]
Juliana Karp, MD glove, perforations
Frequency of glove perforations and subsequent blood contact in association with selected obstetric surgical procedures Chapman S, Duff P Am J Obstet Gynecol 168.1354-1357 May 1993 A prospectivestudy was performed to assessthe frequency of glove perforations associatedwith selected obstetric proceduresto determine whether time of day or urgencyof the procedureaffected the frequency of perforations. Obstetric personnel were asked to double glove for all procedures.After each procedure,all gloves were assessedfor patency with two techniques.They were inflated with air and then immersed in water to detect air bubbles.After this, the gloveswere filled with water and observedfor leaks. Five hundredforty glove sets (2,160 individual gloves)were studied from cesareandeliveries (75%}, tubal ligations (12%), and vaginal deliveries (13%). Sixty-sevenof the sets (12.4%) had at least one hole. Only
ANNALS OF EMERGENCY MEDICINE
22:10
OCTOBER1993
positive in 56% (14 of 25) of all cases and in 87% (13 of 15) of cases in which the patient was in shock. The authors concludethat Gram staining of skin lesions in patients suspected of having an acute meningococcalinfection is a quick method of diagnosingthese infections. This technique may be especially useful in patients with sepsis and in those with inconclusiveCSF results.
Gordon Hardenbergh, MD angina; myocardialinfarction
Effect of gender on long-term outcome of angina pectoris and myocardial infarction/sudden unexpected death Orencia A, Bailey K, Yawn BP, et al JAMA 269.2392-2397 May 1993 This report from the Rochester CoronaryHeart DiseaseProject describes a 20-year experienceof the gender differences in presentation and outcomeof coronaryheart disease.Twenty thousand medical records from physicians'offices and hospitals were screenedfor diagnoses suggestiveof coronaryartery disease.A cardiologist reviewed the records and ECGsselected and assigned one of three diagnoses: angina pectoris, myocardialinfarction, or sudden unexpecteddeath. Women were significantly older at the onset of angina (67 years versus 60 years), and a smaller proportion smoked as comparedwith men. Estrogen replacementwas used by 38%. Women with angina pectoris as their initial manifestation of coronary heart disease had a risk of dying that was only 0.45 times that for men and a risk of subsequent myocardial infarction/cardiac death that was 0.47 times the risk for men with angina.Women with myocardial infarction or sudden unexpected death as their initial manifestation of coronaryheart disease had a subsequentrate of myocardial
1 72/1643
infarction and cardiac death that was no different than that of men with the same diagnosisand age.A higher proportion of women were prescribed diuretics and digoxin after an infarction, while men were more likely to receiveanticoagulants. Women with an initial hard cardiac event (myocardialinfarction or sudden unexpecteddeath) had a poorer survival as comparedwith men, but this can be attributed entirely to the women's older age at the time of the event. [Editor's note: This report is purely descriptive. No inferences should be drawn regarding differences between genders in treating coronary artery disease.j
Michael Fallen, MD thoracoscopy;diaphragmaticinjury
Prospective evaluation of thoracoscopy for diagnosing diaphragmatic injury in thoracoabdominal trauma: A preliminary report Ochsbner MG, Rozycki GS, Lucente F, et al J Trauma 34.'704-709 May 1993 This prospectiveevaluation of 14 patients with penetratingtrauma to the thoracoabdominalregion sought to determinethe value of thoracoscopyto rule out diaphragmatic injury. Includedpatients had thoracoabdominaltrauma within 24 hours of admission,hemedynamic stability, chest tube drainage of less than 1.5 L blood initially and less than 250 mL/hr for two consecutive hours, and indicationsfor exploratory laparotomy. Rigid or video thoracoscopywas performedthrough the thoracic wall in the operating room to examinethe mediastinum,pericardium, lung, chest wound, and diaphragm.The chest cavity was irrigated and a chest tube placed
under direct visualization.Thoracoscopy correctly identified the presence or absenceof diaphragmatic injury (nine and five, respectively)in all 14 patients, as comparedwith laparotomyand laparoscopy.Two complications, a subphrenicabscess and empyemaand a lung laceration, occurred. The authors concludethat thoracoscopyis a reliable alternative to laparotomyin patients at risk for diaphragmaticinjuries when abdominal exploration is not deemed mandatory.
Merle Miller, MD echocardiography;aorta
Use of transesophageal echocardiography in the evaluation of traumatic aortic injury Keamey PA, Smith DW, Johnson SB, eta/ J Trauma 34:696-701 May 1993 All patients with blunt chest trauma and suspectedthoracic aortic injury admitted to the trauma surgery service at the University of Kentucky were consideredfor evaluation with transesophagealechocardiography (TEE)and aortography.TEEwas performed by blinded staff cardiologists and senior fellows using twodimensionalechocardiographswith color Doppler.Arch aortographywas performed by staff radiologists or senior radiology residents. Sixty-nine patients with suggestivechest radiograph findings (72%) or suggestive histories and chest radiographs (28%) were studied. Therewere no complications.Aortographytook significantly longer than TEE(mean, 76 versus 27 minutes).TEE showed injury in seven patients; four were confirmed by aortography.One patient underwentthoracotomy based on TEEfindings alone. Aortogramsyielded false-negative results in two cases. Tears were confirmed on surgery and autopsy in one case each. Aortographyhad a
sensitivity of 67% and a specificity of 98% in this patient group; TEE had 100% sensitivity and specificity. The authors concludethat timely evaluation with TEE is an important new diagnostictool in the evaluation of the patient with blunt chest trauma. [Editor's noie: The impressive sensitivity and specificity of TEE for aortic rupture in this study have not been equalled in studies of thoracic dissection. Repeated documentation of superiority is warranted when considering a new technology as a replacement for a gold standard test. Rapid availability around the clock by an experienced echocardiographer may be a limiting factor in the use of this technology.]
Juliana Karp, MD glove, perforations
Frequency of glove perforations and subsequent blood contact in association with selected obstetric surgical procedures Chapman S, Duff P Am J Obstet Gynecol 168.1354-1357 May 1993 A prospectivestudy was performed to assessthe frequency of glove perforations associatedwith selected obstetric proceduresto determine whether time of day or urgencyof the procedureaffected the frequency of perforations. Obstetric personnel were asked to double glove for all procedures.After each procedure,all gloves were assessedfor patency with two techniques.They were inflated with air and then immersed in water to detect air bubbles.After this, the gloveswere filled with water and observedfor leaks. Five hundredforty glove sets (2,160 individual gloves)were studied from cesareandeliveries (75%}, tubal ligations (12%), and vaginal deliveries (13%). Sixty-sevenof the sets (12.4%) had at least one hole. Only
ANNALS OF EMERGENCY MEDICINE
22:10
OCTOBER1993