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Management of isolated radial or ulnar arteries at the forearm
Abstracts
For helmeted riders in whom the most severe injury was in only one anatomic region, the trunk was the most common injury site (36%), whereas for unhehneted riders the head or neck was the most common injury site (64% ). Concerning head and neck injuries, the percentage of riders with no head and neck injury Maximum Abbreviated Injury Score [MAIS] was higher in helmeted riders (27%) than in unhelmeted riders (15%). All’ riders wearing helmets had a MAIS head and neck score of <5, whereas 15% of unhelmeted riders had a MAIS level 5 injury in this region. The distribution of trunk injuries by helmet use were not significantly different. A few studies have suggested that helmets may not protect the head and neck against injuries distal from the point of impact to the helmet and may cause certain head and neck injuries. The hypotheses that the increased mass of the helmet may produce higher traction force on the junction of the head and neck, and that the increased size of the helmeted head may lead to an increased torque on the neck and skull base were not supported by the data of this study. This study showed that cervical spine injuries were almost nine times as common among unhelmeted riders, and all but one instance of cervical spine injury of any type occurred in unhehneted riders. This study provides evidence that helmets not only reduce the overall number and severity of head and neck injuries, but also protect against base-of-skull fractures, cervical spine fractures, dislocations, cord injuries, and brain stem injuries. The results of this study expand earlier reports showing that helmets provide protection for all types and location of head injuries. [Randolph G. Cleveland, MD ] Editor’s Comment: Further ammunition to help politicians finally realize that helmets are effective preventative measures.
0 GUIDELINES FOR THE MANAGEMENT OF TRANSIENT ISCHEMIC ATTACKS. Feinbert WM, Albers WG, Garnett HJ, et al. Circulation. 89(6):2950-65. This article reflects the latest recommendations by a nationally recognized panel on the comprehensive management of Transient Ischemic Attacks (TIA). The recommendations are based on an extensive review of the current literature and consensus among panel members. The authors have defined TIA’s as temporary focal brain or retinal deficits caused by vascular disease that resolves completely in less than 24 h. The salient feature of this article as it relates to emergency medicine is that patients with a TIA have a 24-29% risk of stroke over 5 years, 12-13% in the first year, and 4-8070 in the first month. There is a higher risk of evolution to stroke in patients with multiple frequent TIA’s, and those with known ventricular thrombi. The diagnostic evaluation of patients seen within one week of TIA should be completed within one week or less. The initial studies required include blood work, electrocardiography, computed tomography, and carotid ultrasound. Initiation of aspirin at 325 mg/d has been shown to reduce stroke or death. The authors do not advocate the use of high-dose aspirin as initial therapy. Ticlopidine 250 mg
591
BID is an alternative in patients who cannot take aspirin, or in patients with continued symptoms despite ASA therapy. Although there is no evidence to recommend routine use of anticoagulants, anticoagulation is an option for patients who have a major cardiac source of embolism. [ Paul0 Berger, MD]
Cl EFFECTS OF INTRAVENOUS NITROGLYCERIN AND NITROGLYCERIN AND METOCLOPRAMIDE ON INTRAVARICEAL PRESSURE: A DOUBLE BLIND, RANDOMIZED STUDY. Satin SK, Saraya AS. Am J Gastroenterol. 1995;90( 1):48-53. This study attempts to find pharmacologic means to control intravariceal pressure which could be utilized in the treatment of the patient with gastrointestinal bleeding. Twenty patients participated in this double-blind study and were randomized to receive either a high dose of intravenous (IV) nitroglycerin or IV nitroglycerin and metoclopramide. All patients had portal hypertension and large esophageal varices, and both medications have been considered to reduce either portal pressure or flow. High dose nitroglycerin was not noted to reduce intravariceal pressure significantly compared with the baseline. Nitroglycerin and metoclopramide together, however, did significantly decrease the variceal pressure @ < 0.01) by 29.5 f 24.1%. Although this study was small and much further research is necessary to evaluate the efficacy of these agents, it may provide a first step to control actively bleeding varices. [Susan J. Lewis, MD] Editor’s Comment: If further studies suggest, this may prove to be a useful temporizing approach to bleeding varices while the patient awaits sclerotherapy or other definitive management.
0 MANAGEMENT OF ISOLATED RADIAL OR ULNAR ARTERIES AT THE FOREARM. Aftabuddin M, Islam N, Jafar MA, et al. J Trauma: Injury, Infection, and Critical Care. 1995;38( 1):149-51. The authors in this prospective study reviewed 96 patients with acute injuries to either radial or ulnar arteries without obvious associated major injuries or hand ischemia secondary to arterial injury. The surgical management was divided into two groups: (1) 50 cases where ligation of either the radial (36 pts) or ulnar ( 14 pts) artery was done, and (2) 46 cases who underwent radical arterial reconstruction (26 pts) or ulnar arterial reconstruction (20 pts). Six months to six years post-operative follow up was done. Of the 46 reconstructed arteries, 52% were patent on followup. The collateral arteries appeared to be a factor causing this low patency rate. None of the 96 patients who had undergone repair or ligation experienced subsequent exercise induced claudication. In the ligation group, 54% noticed subjective hand weakness compared to 52% of the
592
repair group. Subsequent paresthesias were present in 30% of the ligated group compared to 268 of the repair group. Cold sensitivity was present in 16% of the ligated group compared to 13% of the repair group. The authors state that cold sensitivity was not related to arterial management and patency of vessels and may be associated with unnoticed nerve injury. They conclude that ligation of either the radial or ulnar artery following trauma is not associated with any significant long term ischemic sequelae, provided that clinical examination at the time of injury confirms adequacy of circulation via the other wrist vessel. One intact functional artery distal to the elbow is sufficient for limb viability and vascular function. Therefore, in the absence of acute hand ischemia, ligation of a lacerated radial or ulnar artery is safe, easy, cost-effective, and can be done [Randolph G. Cleveland, MD] in rural hospitals.
?? USE OF ORAL CONTRAST MATERIAL IN ABDOMINAL TRAUMA CT SCANS: IS IT DANGEROUS? Federle MP, Peitzman A, Krugh J. J Trauma: Injury, Infection and Critical Care. 1995;38( l):Sl-3. A retrospective chart review of 506 consecutive patients who had computed tomography (CT) evaluation of acute blunt abdominal trauma was performed. The purpose of this study was to determine the potential risk of aspiration associated with the use of oral contrast medium for bowel opacification in abdominal trauma CT scanning. All patients received a dilute 2.5% solution of iodinated oral contrast. Obtunded patients were intubated and received the contrast material via a nasogastric or orogastric tube. Radiographic reports, progress notes, and discharge summaries were reviewed for evidence of aspiration. Of the 506 patients, only one was found to have aspiration temporally related to the administration of contrast material. This patient had inadvertent insertion of the nasogastric tube into the right mainstem bronchus prior to contrast administration. The patient received intravenous antibiotics for 7 days and left the hospital in good condition. The authors concluded that iodinated contrast material for stomach and bowel opacification during CT scanning is safe. [Mark Prather, MD] Editor’s Comment: As many of these patients are immobilized, aspiration is a significant risk even in patients with a normal mental status. With obtunded patients in this setting, airway protection is mandatory.
0 EARLY DEFINITIVE ABDOMINAL EVALUATION IN THE TRIAGE OF UNCONSCIOUS NORMOTENSIVE BLUNT TRAUMA PATIENTS. Pratt J, Nichols S, Brennan R, et al. J Trauma. 1994;37(5):792-7. In this retrospective study, the authors reviewed a series of unconscious blunt trauma patients with a GCS c 8 and systolic blood pressure > 90 mmHg to determine the need for immediate diagnostic peritoneal lavage (DPL). The hy-
The Journal of Emergency Medicine pothesis of this study was that life-threatening abdominal injury frequently occurs in these patients and injuries cannot be consistently identified from vital signs alone. Between 1981 and 1992, 3672 consecutive blunt trauma patients were studied and divided into four categories based on initial systolic blood pressure and GCS. Two hundred and ninety patients were normotensive and unconscious at initial examination. Of these 290 patients, 198 (69qo) underwent diagnostic peritoneal lavage, and in 32 the results were positive. Thirty-one underwent laparatomy and in 29 abdominal hemorrhage was identified. Of the 166 negative DPLs, 16 underwent laparatomy based on other clinical findings. Of the 150 who did not undergo laparatomy, there were no missed injuries. To put differences in vital signs into clinical context, the outcome of patients evaluated without DPL was examined. Calculation of the predictive power of that initial information was made based on clinical and laparatomy outcomes. The sensitivity of initial clinical data in identifying abdominal injuries requiring emergent surgical intervention falls below that of DPL alone (56% vs. 68%‘0).The authors conclude that the diagnosis of injuries is unnecessarily missed and delayed when triage protocols are used that do not include immediate DPL of unconscious normotensive blunt trauma patients. The authors recommend that all unconscious blunt trauma patients undergo immediate DPL upon arrival in the ED regardless of initial vital signs. [Randolph Graves Cleveland, MD] Editor’s Comment: Given the likelihood of missing intraabdominal injuries when relying on physical examination in these unresponsive patients, a peritoneal lavage is the fastest, most accurate way to proceed towards further evaluation of closed head injury in the operating room.
0 AMINOPHYLLINE THERAPY DOES NOT IMPROVE OUTCOME AND INCREASES ADVERSE EFFECTS IN CHILDREN HOSPITALIZED WITH ACUTE ASTHMATIC EXACERBATIONS. Strauss RE, Wertheim DL, Bonagura VR, et al. Pediatrics. 93(2);1994: 205-g. The purpose of this study was to examine the effectiveness and adverse effects of aminophylline (Am) treatment in children hospitalized with asthmatic exacerbations. Patients between 5 and 18 years of age admitted through two emergency departments with acute asthmatic exacerbations were considered for the study. Among patients excluded from the study were those admitted to the intensive care unit. Patients were admitted to the hospital after failing to respond to three nebulized albuterol treatments in the emergency department. Baseline oxygen saturations, peak flow, and Wood-Downes clinical symptom scores were recorded. Subjects subsequently received standardized therapy with albuterol and intravenous glucocorticoids. Patients were randomized to double-blinded treatment with either intravenous Am or placebo. Physicians converted intravenous steroids and Am to oral preparations at their discretion as clinical improvement occurred. The principle
For helmeted riders in whom the most severe injury was in only one anatomic region, the trunk was the most common injury site (36%), whereas for unhehneted riders the head or neck was the most common injury site (64% ). Concerning head and neck injuries, the percentage of riders with no head and neck injury Maximum Abbreviated Injury Score [MAIS] was higher in helmeted riders (27%) than in unhelmeted riders (15%). All’ riders wearing helmets had a MAIS head and neck score of <5, whereas 15% of unhelmeted riders had a MAIS level 5 injury in this region. The distribution of trunk injuries by helmet use were not significantly different. A few studies have suggested that helmets may not protect the head and neck against injuries distal from the point of impact to the helmet and may cause certain head and neck injuries. The hypotheses that the increased mass of the helmet may produce higher traction force on the junction of the head and neck, and that the increased size of the helmeted head may lead to an increased torque on the neck and skull base were not supported by the data of this study. This study showed that cervical spine injuries were almost nine times as common among unhelmeted riders, and all but one instance of cervical spine injury of any type occurred in unhehneted riders. This study provides evidence that helmets not only reduce the overall number and severity of head and neck injuries, but also protect against base-of-skull fractures, cervical spine fractures, dislocations, cord injuries, and brain stem injuries. The results of this study expand earlier reports showing that helmets provide protection for all types and location of head injuries. [Randolph G. Cleveland, MD ] Editor’s Comment: Further ammunition to help politicians finally realize that helmets are effective preventative measures.
0 GUIDELINES FOR THE MANAGEMENT OF TRANSIENT ISCHEMIC ATTACKS. Feinbert WM, Albers WG, Garnett HJ, et al. Circulation. 89(6):2950-65. This article reflects the latest recommendations by a nationally recognized panel on the comprehensive management of Transient Ischemic Attacks (TIA). The recommendations are based on an extensive review of the current literature and consensus among panel members. The authors have defined TIA’s as temporary focal brain or retinal deficits caused by vascular disease that resolves completely in less than 24 h. The salient feature of this article as it relates to emergency medicine is that patients with a TIA have a 24-29% risk of stroke over 5 years, 12-13% in the first year, and 4-8070 in the first month. There is a higher risk of evolution to stroke in patients with multiple frequent TIA’s, and those with known ventricular thrombi. The diagnostic evaluation of patients seen within one week of TIA should be completed within one week or less. The initial studies required include blood work, electrocardiography, computed tomography, and carotid ultrasound. Initiation of aspirin at 325 mg/d has been shown to reduce stroke or death. The authors do not advocate the use of high-dose aspirin as initial therapy. Ticlopidine 250 mg
591
BID is an alternative in patients who cannot take aspirin, or in patients with continued symptoms despite ASA therapy. Although there is no evidence to recommend routine use of anticoagulants, anticoagulation is an option for patients who have a major cardiac source of embolism. [ Paul0 Berger, MD]
Cl EFFECTS OF INTRAVENOUS NITROGLYCERIN AND NITROGLYCERIN AND METOCLOPRAMIDE ON INTRAVARICEAL PRESSURE: A DOUBLE BLIND, RANDOMIZED STUDY. Satin SK, Saraya AS. Am J Gastroenterol. 1995;90( 1):48-53. This study attempts to find pharmacologic means to control intravariceal pressure which could be utilized in the treatment of the patient with gastrointestinal bleeding. Twenty patients participated in this double-blind study and were randomized to receive either a high dose of intravenous (IV) nitroglycerin or IV nitroglycerin and metoclopramide. All patients had portal hypertension and large esophageal varices, and both medications have been considered to reduce either portal pressure or flow. High dose nitroglycerin was not noted to reduce intravariceal pressure significantly compared with the baseline. Nitroglycerin and metoclopramide together, however, did significantly decrease the variceal pressure @ < 0.01) by 29.5 f 24.1%. Although this study was small and much further research is necessary to evaluate the efficacy of these agents, it may provide a first step to control actively bleeding varices. [Susan J. Lewis, MD] Editor’s Comment: If further studies suggest, this may prove to be a useful temporizing approach to bleeding varices while the patient awaits sclerotherapy or other definitive management.
0 MANAGEMENT OF ISOLATED RADIAL OR ULNAR ARTERIES AT THE FOREARM. Aftabuddin M, Islam N, Jafar MA, et al. J Trauma: Injury, Infection, and Critical Care. 1995;38( 1):149-51. The authors in this prospective study reviewed 96 patients with acute injuries to either radial or ulnar arteries without obvious associated major injuries or hand ischemia secondary to arterial injury. The surgical management was divided into two groups: (1) 50 cases where ligation of either the radial (36 pts) or ulnar ( 14 pts) artery was done, and (2) 46 cases who underwent radical arterial reconstruction (26 pts) or ulnar arterial reconstruction (20 pts). Six months to six years post-operative follow up was done. Of the 46 reconstructed arteries, 52% were patent on followup. The collateral arteries appeared to be a factor causing this low patency rate. None of the 96 patients who had undergone repair or ligation experienced subsequent exercise induced claudication. In the ligation group, 54% noticed subjective hand weakness compared to 52% of the
592
repair group. Subsequent paresthesias were present in 30% of the ligated group compared to 268 of the repair group. Cold sensitivity was present in 16% of the ligated group compared to 13% of the repair group. The authors state that cold sensitivity was not related to arterial management and patency of vessels and may be associated with unnoticed nerve injury. They conclude that ligation of either the radial or ulnar artery following trauma is not associated with any significant long term ischemic sequelae, provided that clinical examination at the time of injury confirms adequacy of circulation via the other wrist vessel. One intact functional artery distal to the elbow is sufficient for limb viability and vascular function. Therefore, in the absence of acute hand ischemia, ligation of a lacerated radial or ulnar artery is safe, easy, cost-effective, and can be done [Randolph G. Cleveland, MD] in rural hospitals.
?? USE OF ORAL CONTRAST MATERIAL IN ABDOMINAL TRAUMA CT SCANS: IS IT DANGEROUS? Federle MP, Peitzman A, Krugh J. J Trauma: Injury, Infection and Critical Care. 1995;38( l):Sl-3. A retrospective chart review of 506 consecutive patients who had computed tomography (CT) evaluation of acute blunt abdominal trauma was performed. The purpose of this study was to determine the potential risk of aspiration associated with the use of oral contrast medium for bowel opacification in abdominal trauma CT scanning. All patients received a dilute 2.5% solution of iodinated oral contrast. Obtunded patients were intubated and received the contrast material via a nasogastric or orogastric tube. Radiographic reports, progress notes, and discharge summaries were reviewed for evidence of aspiration. Of the 506 patients, only one was found to have aspiration temporally related to the administration of contrast material. This patient had inadvertent insertion of the nasogastric tube into the right mainstem bronchus prior to contrast administration. The patient received intravenous antibiotics for 7 days and left the hospital in good condition. The authors concluded that iodinated contrast material for stomach and bowel opacification during CT scanning is safe. [Mark Prather, MD] Editor’s Comment: As many of these patients are immobilized, aspiration is a significant risk even in patients with a normal mental status. With obtunded patients in this setting, airway protection is mandatory.
0 EARLY DEFINITIVE ABDOMINAL EVALUATION IN THE TRIAGE OF UNCONSCIOUS NORMOTENSIVE BLUNT TRAUMA PATIENTS. Pratt J, Nichols S, Brennan R, et al. J Trauma. 1994;37(5):792-7. In this retrospective study, the authors reviewed a series of unconscious blunt trauma patients with a GCS c 8 and systolic blood pressure > 90 mmHg to determine the need for immediate diagnostic peritoneal lavage (DPL). The hy-
The Journal of Emergency Medicine pothesis of this study was that life-threatening abdominal injury frequently occurs in these patients and injuries cannot be consistently identified from vital signs alone. Between 1981 and 1992, 3672 consecutive blunt trauma patients were studied and divided into four categories based on initial systolic blood pressure and GCS. Two hundred and ninety patients were normotensive and unconscious at initial examination. Of these 290 patients, 198 (69qo) underwent diagnostic peritoneal lavage, and in 32 the results were positive. Thirty-one underwent laparatomy and in 29 abdominal hemorrhage was identified. Of the 166 negative DPLs, 16 underwent laparatomy based on other clinical findings. Of the 150 who did not undergo laparatomy, there were no missed injuries. To put differences in vital signs into clinical context, the outcome of patients evaluated without DPL was examined. Calculation of the predictive power of that initial information was made based on clinical and laparatomy outcomes. The sensitivity of initial clinical data in identifying abdominal injuries requiring emergent surgical intervention falls below that of DPL alone (56% vs. 68%‘0).The authors conclude that the diagnosis of injuries is unnecessarily missed and delayed when triage protocols are used that do not include immediate DPL of unconscious normotensive blunt trauma patients. The authors recommend that all unconscious blunt trauma patients undergo immediate DPL upon arrival in the ED regardless of initial vital signs. [Randolph Graves Cleveland, MD] Editor’s Comment: Given the likelihood of missing intraabdominal injuries when relying on physical examination in these unresponsive patients, a peritoneal lavage is the fastest, most accurate way to proceed towards further evaluation of closed head injury in the operating room.
0 AMINOPHYLLINE THERAPY DOES NOT IMPROVE OUTCOME AND INCREASES ADVERSE EFFECTS IN CHILDREN HOSPITALIZED WITH ACUTE ASTHMATIC EXACERBATIONS. Strauss RE, Wertheim DL, Bonagura VR, et al. Pediatrics. 93(2);1994: 205-g. The purpose of this study was to examine the effectiveness and adverse effects of aminophylline (Am) treatment in children hospitalized with asthmatic exacerbations. Patients between 5 and 18 years of age admitted through two emergency departments with acute asthmatic exacerbations were considered for the study. Among patients excluded from the study were those admitted to the intensive care unit. Patients were admitted to the hospital after failing to respond to three nebulized albuterol treatments in the emergency department. Baseline oxygen saturations, peak flow, and Wood-Downes clinical symptom scores were recorded. Subjects subsequently received standardized therapy with albuterol and intravenous glucocorticoids. Patients were randomized to double-blinded treatment with either intravenous Am or placebo. Physicians converted intravenous steroids and Am to oral preparations at their discretion as clinical improvement occurred. The principle