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Esophageal disease as a cause of severe retrosternal chest pain
f
peter Rosen, MD
Abstractsl -
-
editor
professor of Emergency Medicine and Director of the Division of Emergency Medicine, ~jniversity of Chicago Hospitals and Clinics
Beverly Fauman, MD
-
-
assistant editor
Assistant Professor of Emergency Medicine and Psychiatry, University of Chicago Hospitals and Clinics Esophageal disease as a cause of severe retrosternal chest pain. Roberts R, Henderson R, Wigle ED, Chest
87:523-526, (May) 1975. Between J a n u a r y and.June, 1971, 11 patients were diagn()sed as having coronary artery disease based on a history of severe retr0sternal chest pain. Each had previous admissions to rule out syocardial infarction. All had coronary arteriograms of which ten were normal and one showed only a minor, nonobstructive lesion, Electrocardiograms ( E K G ) revealed no significant Q waves but six patients had nonspecific ST-T changes. The pain was described as ~'tight or gripping" in nine patients and radiating to one or both arms in seven. All noted precipitation of pain with lying down or bending over, while seven also related it to exercise. It was relieved by antacids in eight and by nitroglycerin in seven within 10 to 20 minutes. E i g h t patients admitted to some degree of dysphagia. On upper gastrointestinal (GI) tract examination, 9 of 11 had evidence of h i a t a l hernia. All h a d demonstrable disorders of esophageal motility. Hydrochloric acid perfusion of the esophagus reproduced the chest pain in 9 of 11 patients. Thus, precipitation of pain with lying down or bending over and dysphagia were two key symptoms of esophageal disease (in one series 78% of 500 patients with hiatal h e r n i a had dysphagia), while disordered esophageal motility, reproduction of pain with acid perfusion and normal coronary angiography were the definitive studies in this series. (Editor's note: Despite this knowledge, it may still be necessary to rule out coronary artery disease by admission to a coronary care unit.)
Gary L. Gerschke, MD esophageal disease; cardiac disease; hernia, hiatal Maintenance antipsychotic therapy: is the cure worse Ihan the disease? Gardos G, Cole J, Am J Psychiatry
133:32-36, (Jan) 1976. Recently, serious complications of long t e r m a n t i p s y c h o t i c therapy have come to light, such as t a r d i v e dyskinesia. AIthough most studies show relapse in psychotic patients withdrawn from pheaothiazines, the authors question whether the clinical impact of relapse has been considered, and w h e t h e r drug !herapy is therapeutic or merely prophylactic. Some conclusions Include the fact t h a t drugs seem to prevent relapse in about 40% of outpatients; presumably then, 60% would do as well without drug therapy. The a u t h o r s r e c o m m e n d t h a t chronic schizophrenic p a t i e n t s h a v e t h e b e n e f i t of a t r i a l w i t h o u t d r u g therapy, suggesting t h a t drug withdrawal be done gradually, .e drag at a time, with concomitant a n t i P a r k i n s o n i a n agents. dUbsequent therapy depends on the clinical course. If the p a t i e n t ~oes well, he is followed for a m i n i m u m of one year. In the event u~,a relapse, drug therapy is reinstituted promptly and dosage a~justed later. If dyskinesia appears or worsens within four to ;~ Weeks and is accompanied by psychotic decompensation, ? enothiazines are reinstituted. If the symptoms are mild, nothg is done; if t h e s y m p t o m s are severe, a p p r o p r i a t e d r u g ,:~ erapy is begun to control the dyskinesia - - promising results ve been obtained with Deanol and papaverine hydrochloride I~ this regard. (Editor's note: Tardive dyskinesia is, at present,
~
~[]~) 6:1 (Jan) 1977
irreversible. It is important that the emergency physician recognize the distinction between tardive dyskinesia and the dystonic side effects that appear acutely with phenothiazine therapy so that he does not compound or prolong the problem.)J. Franaszek, MD
psychiatry, antipsychotic therapy, phenothiazines First rib fracture: a hallmark of severe trauma. Richardson JD, McEIvein RB, Trimkle JK, Ann Surg 181:251-254, 1975. Fifty-five cases of patients sustaining fracture of the first rib are reviewed. Most (50/55) of the injuries occurred in automobile accidents. The first rib fracture is i m p o r t a n t for its association with severe injuries and high mortality. Chest injuries occurring with high incidence include unilateral pneumothorax, hemothorax, severe p u l m o n a r y contusion, myocardial contusion, and hemopericardium. Abdominal injuries were liver lacerations, splenic, intestinal and r e n a l injuries. Twenty-nine of the 55 patients suffered neurologic injury, most having loss of consciousness. Three-fourths of patients had additional fractures other t h a n ribs, and t h r e e h a d subclavian artery injury. Overall, mortality was 36%.The authors demonstrate a high correlation of severe injury associated with fracture of the first rib~ The evaluation of such patients may be difficult because of accompanying central nervous system injury. Some of the associated injuries, although severe and life-threatening, may be unapparent at the onset. The requirement, then, in a patient with a fracture of the first rib is singularly aggressive and anticipatory management. (Editor's note: The significance of this article is the high incidence of neurologic injury. The emergency physician may miss the associated internal injuries if he focuses only on the head.) Martin Kohn, MD
trauma, multiple, first rib fractures Comparison of the cardiopulmonary effects of subcutaneously administered epinephrine and terbutaline in patients with reversible airway obstruction. Arnory
DW, Burnham SC, Cheney Jr, FW, Chest 67:279-285, (March) 1975. The cardiopulmonary effects of epinephrine (p. 25rag subQ) and t e r b u t a l i n e (p, 5rag subQ) were compared in a double-blind crossover study involving 23 patients with obstructive airway disease. While t r e a t m e n t with epinephrine produced significant increases in forced vital capacity, forced expiratory volume one second, maximal expiratory flow rate, and maximal midexpiratory flow, t e r b u t a l i n e sulfate caused even more pronounced increases in all four p a r a m e t e r s and had a longer duration of action. The only significant cardiovascular effect observed with both drugs was a tachycardia, w h i c h was g r e a t e r w i t h terbutaline. From this study, it was concluded t h a t subcutaneously a d m i n i s t e r e d t e r b u t a l i n e s u l f a t e is a more effective b r o n chodilator t h a n epinephrine. Vincent Markovcbick, MD cardiovasology;
cardiopulmonary
effects, epinephrine,
terbutaline sulfate
38/63
peter Rosen, MD
Abstractsl -
-
editor
professor of Emergency Medicine and Director of the Division of Emergency Medicine, ~jniversity of Chicago Hospitals and Clinics
Beverly Fauman, MD
-
-
assistant editor
Assistant Professor of Emergency Medicine and Psychiatry, University of Chicago Hospitals and Clinics Esophageal disease as a cause of severe retrosternal chest pain. Roberts R, Henderson R, Wigle ED, Chest
87:523-526, (May) 1975. Between J a n u a r y and.June, 1971, 11 patients were diagn()sed as having coronary artery disease based on a history of severe retr0sternal chest pain. Each had previous admissions to rule out syocardial infarction. All had coronary arteriograms of which ten were normal and one showed only a minor, nonobstructive lesion, Electrocardiograms ( E K G ) revealed no significant Q waves but six patients had nonspecific ST-T changes. The pain was described as ~'tight or gripping" in nine patients and radiating to one or both arms in seven. All noted precipitation of pain with lying down or bending over, while seven also related it to exercise. It was relieved by antacids in eight and by nitroglycerin in seven within 10 to 20 minutes. E i g h t patients admitted to some degree of dysphagia. On upper gastrointestinal (GI) tract examination, 9 of 11 had evidence of h i a t a l hernia. All h a d demonstrable disorders of esophageal motility. Hydrochloric acid perfusion of the esophagus reproduced the chest pain in 9 of 11 patients. Thus, precipitation of pain with lying down or bending over and dysphagia were two key symptoms of esophageal disease (in one series 78% of 500 patients with hiatal h e r n i a had dysphagia), while disordered esophageal motility, reproduction of pain with acid perfusion and normal coronary angiography were the definitive studies in this series. (Editor's note: Despite this knowledge, it may still be necessary to rule out coronary artery disease by admission to a coronary care unit.)
Gary L. Gerschke, MD esophageal disease; cardiac disease; hernia, hiatal Maintenance antipsychotic therapy: is the cure worse Ihan the disease? Gardos G, Cole J, Am J Psychiatry
133:32-36, (Jan) 1976. Recently, serious complications of long t e r m a n t i p s y c h o t i c therapy have come to light, such as t a r d i v e dyskinesia. AIthough most studies show relapse in psychotic patients withdrawn from pheaothiazines, the authors question whether the clinical impact of relapse has been considered, and w h e t h e r drug !herapy is therapeutic or merely prophylactic. Some conclusions Include the fact t h a t drugs seem to prevent relapse in about 40% of outpatients; presumably then, 60% would do as well without drug therapy. The a u t h o r s r e c o m m e n d t h a t chronic schizophrenic p a t i e n t s h a v e t h e b e n e f i t of a t r i a l w i t h o u t d r u g therapy, suggesting t h a t drug withdrawal be done gradually, .e drag at a time, with concomitant a n t i P a r k i n s o n i a n agents. dUbsequent therapy depends on the clinical course. If the p a t i e n t ~oes well, he is followed for a m i n i m u m of one year. In the event u~,a relapse, drug therapy is reinstituted promptly and dosage a~justed later. If dyskinesia appears or worsens within four to ;~ Weeks and is accompanied by psychotic decompensation, ? enothiazines are reinstituted. If the symptoms are mild, nothg is done; if t h e s y m p t o m s are severe, a p p r o p r i a t e d r u g ,:~ erapy is begun to control the dyskinesia - - promising results ve been obtained with Deanol and papaverine hydrochloride I~ this regard. (Editor's note: Tardive dyskinesia is, at present,
~
~[]~) 6:1 (Jan) 1977
irreversible. It is important that the emergency physician recognize the distinction between tardive dyskinesia and the dystonic side effects that appear acutely with phenothiazine therapy so that he does not compound or prolong the problem.)J. Franaszek, MD
psychiatry, antipsychotic therapy, phenothiazines First rib fracture: a hallmark of severe trauma. Richardson JD, McEIvein RB, Trimkle JK, Ann Surg 181:251-254, 1975. Fifty-five cases of patients sustaining fracture of the first rib are reviewed. Most (50/55) of the injuries occurred in automobile accidents. The first rib fracture is i m p o r t a n t for its association with severe injuries and high mortality. Chest injuries occurring with high incidence include unilateral pneumothorax, hemothorax, severe p u l m o n a r y contusion, myocardial contusion, and hemopericardium. Abdominal injuries were liver lacerations, splenic, intestinal and r e n a l injuries. Twenty-nine of the 55 patients suffered neurologic injury, most having loss of consciousness. Three-fourths of patients had additional fractures other t h a n ribs, and t h r e e h a d subclavian artery injury. Overall, mortality was 36%.The authors demonstrate a high correlation of severe injury associated with fracture of the first rib~ The evaluation of such patients may be difficult because of accompanying central nervous system injury. Some of the associated injuries, although severe and life-threatening, may be unapparent at the onset. The requirement, then, in a patient with a fracture of the first rib is singularly aggressive and anticipatory management. (Editor's note: The significance of this article is the high incidence of neurologic injury. The emergency physician may miss the associated internal injuries if he focuses only on the head.) Martin Kohn, MD
trauma, multiple, first rib fractures Comparison of the cardiopulmonary effects of subcutaneously administered epinephrine and terbutaline in patients with reversible airway obstruction. Arnory
DW, Burnham SC, Cheney Jr, FW, Chest 67:279-285, (March) 1975. The cardiopulmonary effects of epinephrine (p. 25rag subQ) and t e r b u t a l i n e (p, 5rag subQ) were compared in a double-blind crossover study involving 23 patients with obstructive airway disease. While t r e a t m e n t with epinephrine produced significant increases in forced vital capacity, forced expiratory volume one second, maximal expiratory flow rate, and maximal midexpiratory flow, t e r b u t a l i n e sulfate caused even more pronounced increases in all four p a r a m e t e r s and had a longer duration of action. The only significant cardiovascular effect observed with both drugs was a tachycardia, w h i c h was g r e a t e r w i t h terbutaline. From this study, it was concluded t h a t subcutaneously a d m i n i s t e r e d t e r b u t a l i n e s u l f a t e is a more effective b r o n chodilator t h a n epinephrine. Vincent Markovcbick, MD cardiovasology;
cardiopulmonary
effects, epinephrine,
terbutaline sulfate
38/63