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Evaluation of blunt abdominal trauma in the third trimester of pregnancy: Maternal and fetal considerations
pect for adverse interactions. This study done with house officers in July and September in a university hospital setting makes it difficult to extrapolate the data to all EDs, but it does emphasize the need for careful consideration of pOtential adverse drug interaction.] Robert S Van Hare, MD
pregnancy, trauma
Evaluation of blunt a b d o m i n a l t r a u m a in the third t r i m e s t e r of pregnancy: M a t e r n a l and fetal c o n s i d e r a t i o n s Williams JK, McClain L, Rosemurgy AS, et al Obstet Gynecol 75:33-37 Jan 1990
This was a retrospective review of 84 pregnant women with gestational age of more than 25 weeks who sustained potentially major trauma to the uterus in the form of falls, motor vehicle accidents , or assaults. Patients were admitted to perinatal special care for monitoring of fetal heart rate and maternal contractions as well as ultrasonographic study. Length of stay and treatment were individualized. All Rh-negative women were given prophylactic Rh immune globulin at 28 weeks' gestation. The most frequent complication of trauma was preterm labor, w h i c h occurred in 17 (20%) of the patients. Fifteen of those were successfully treated with tocolysis. Two of the 84 patients had placental abruption, one of which was associated with a ruptured uterus and fetal death. Both were diagnosed on presentation with ultrasonography. No case of fetal injury without maternal injury was found. It was concluded that women with trauma to the uterus in the third trimester should be evaluated with fetal monitoring and ultrasound in order to determine preterm labor and placental abruption and if these studies are normal, monitoring for more than a few hours may not be indicated.
Laurie Vande Krol, MD
electrical injury, myocardial damage
Clinical p r e d i c t o r s of m y o c a r d i a l d a m a g e a f t e r high v o l t a g e e l e c t r i c a l injury Chandra NC, Siu CO, Munster AM Crit Care Med 18:293-297 Mar 1990
A retrospective study to identify early clinical predictors of myocardial necrosis in patients exposed to highvoltage electrical body injury was presented. Twenty-four patients with high-voltage electrical injury and no evidence of arc burns were evaluated. In 13 of 24 (group A) 19:7 July 1990
the diagnosis of myocardial damage was confirmed by total creatine kinase (CK) and creatine kinase-MB (CK-MB) isoenzyme elevation. In 11 of 24 patients (group B) CK-MB was negative, indicating absence of myocardial damage. Group A patients were in contact with voltage ranging from 3,000 to 130,000 V. Group B patients were in contact with a range of 440 to 7,000 V. ECG changes occurred in ten of 13 group A patients and four of 11 group B patients. No patient in either group gave a history suggestive of myocardial ischemia after the electrical injury. The pathways of electricity through the body as mapped by a line drawn between wound(s) of entrance and exit were vertical in all group A patients versus five of 11 group B patients {P < .003). Group A patients also had significantly greater (P < .001) body surface burns (16.0%) than group B (4.0%). It was concluded that patients at highest risk for myocardial damage are those who have sustained a highvoltage electrical injury, have extensive surface burns, and have upper and lower segment entrance and exit wounds.
John McGoldrick, M D
myocardial infarction, echocardiography
U s e f u l n e s s of t w o - d i m e n s i o n a l e c h o c a r d i o g r a p h y for i m m e d i a t e d e t e c t i o n of m y o c a r d i a l i s c h e m i a in the e m e r g e n c y room Peels CH, Visser CA, Kupper JF, et al Am J Cardiol 65:687-691 Mar 1990
Approximately 30% of patients admitted to the hospital with chest pain have acute myocardial infarction, while 8% are inappropriately discharged from the emergency department. Two-dimensional echocardiography (2-DE) was performed on 43 patients presenting to the ED with chest pain to look for regional asynergy, the earliest sign of ischemia. Patients were included if the history and examination were consistent with myocardial infarction, they had no history of coronary artery disease, and the ECG was negative for ischemia. The left ventricle was divided into 13 regions. Presence of hypokinesis, alkinesia, or dyskinesia in one or more regions was considered positive. 2-DE performed by a cardiology resident was compared against CPK-MB isoenzymes and coronary angiography, which was considered positive if there was more than 50% stenosis. Sensitivity of 2-DE for detection of acute myocardial infarction was 92% (12 of 13), specificity 53% (16 of 30), and negative predictive accuracy 94% (16 of 17). It was concluded that in patients presenting to the ED with chest pain and a nondiagnostic ECG, 2-DE can identify most patients with coronary artery disease and can accurately rule out an acute myocardial infarction. [Editor's note: This is an interesting use of 2-DE in the ED in an effort to improve diagnostic accuracy. Unfortunately, this is not a readily available study in most EDs.
Annals of EmergencyMedicine
848/165
pregnancy, trauma
Evaluation of blunt a b d o m i n a l t r a u m a in the third t r i m e s t e r of pregnancy: M a t e r n a l and fetal c o n s i d e r a t i o n s Williams JK, McClain L, Rosemurgy AS, et al Obstet Gynecol 75:33-37 Jan 1990
This was a retrospective review of 84 pregnant women with gestational age of more than 25 weeks who sustained potentially major trauma to the uterus in the form of falls, motor vehicle accidents , or assaults. Patients were admitted to perinatal special care for monitoring of fetal heart rate and maternal contractions as well as ultrasonographic study. Length of stay and treatment were individualized. All Rh-negative women were given prophylactic Rh immune globulin at 28 weeks' gestation. The most frequent complication of trauma was preterm labor, w h i c h occurred in 17 (20%) of the patients. Fifteen of those were successfully treated with tocolysis. Two of the 84 patients had placental abruption, one of which was associated with a ruptured uterus and fetal death. Both were diagnosed on presentation with ultrasonography. No case of fetal injury without maternal injury was found. It was concluded that women with trauma to the uterus in the third trimester should be evaluated with fetal monitoring and ultrasound in order to determine preterm labor and placental abruption and if these studies are normal, monitoring for more than a few hours may not be indicated.
Laurie Vande Krol, MD
electrical injury, myocardial damage
Clinical p r e d i c t o r s of m y o c a r d i a l d a m a g e a f t e r high v o l t a g e e l e c t r i c a l injury Chandra NC, Siu CO, Munster AM Crit Care Med 18:293-297 Mar 1990
A retrospective study to identify early clinical predictors of myocardial necrosis in patients exposed to highvoltage electrical body injury was presented. Twenty-four patients with high-voltage electrical injury and no evidence of arc burns were evaluated. In 13 of 24 (group A) 19:7 July 1990
the diagnosis of myocardial damage was confirmed by total creatine kinase (CK) and creatine kinase-MB (CK-MB) isoenzyme elevation. In 11 of 24 patients (group B) CK-MB was negative, indicating absence of myocardial damage. Group A patients were in contact with voltage ranging from 3,000 to 130,000 V. Group B patients were in contact with a range of 440 to 7,000 V. ECG changes occurred in ten of 13 group A patients and four of 11 group B patients. No patient in either group gave a history suggestive of myocardial ischemia after the electrical injury. The pathways of electricity through the body as mapped by a line drawn between wound(s) of entrance and exit were vertical in all group A patients versus five of 11 group B patients {P < .003). Group A patients also had significantly greater (P < .001) body surface burns (16.0%) than group B (4.0%). It was concluded that patients at highest risk for myocardial damage are those who have sustained a highvoltage electrical injury, have extensive surface burns, and have upper and lower segment entrance and exit wounds.
John McGoldrick, M D
myocardial infarction, echocardiography
U s e f u l n e s s of t w o - d i m e n s i o n a l e c h o c a r d i o g r a p h y for i m m e d i a t e d e t e c t i o n of m y o c a r d i a l i s c h e m i a in the e m e r g e n c y room Peels CH, Visser CA, Kupper JF, et al Am J Cardiol 65:687-691 Mar 1990
Approximately 30% of patients admitted to the hospital with chest pain have acute myocardial infarction, while 8% are inappropriately discharged from the emergency department. Two-dimensional echocardiography (2-DE) was performed on 43 patients presenting to the ED with chest pain to look for regional asynergy, the earliest sign of ischemia. Patients were included if the history and examination were consistent with myocardial infarction, they had no history of coronary artery disease, and the ECG was negative for ischemia. The left ventricle was divided into 13 regions. Presence of hypokinesis, alkinesia, or dyskinesia in one or more regions was considered positive. 2-DE performed by a cardiology resident was compared against CPK-MB isoenzymes and coronary angiography, which was considered positive if there was more than 50% stenosis. Sensitivity of 2-DE for detection of acute myocardial infarction was 92% (12 of 13), specificity 53% (16 of 30), and negative predictive accuracy 94% (16 of 17). It was concluded that in patients presenting to the ED with chest pain and a nondiagnostic ECG, 2-DE can identify most patients with coronary artery disease and can accurately rule out an acute myocardial infarction. [Editor's note: This is an interesting use of 2-DE in the ED in an effort to improve diagnostic accuracy. Unfortunately, this is not a readily available study in most EDs.
Annals of EmergencyMedicine
848/165