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Neurosurgical complications after apparently minor head injury: Assessment of risk in a series of 610 patients
Abstracts in this issue were prepared by residents in the Universityof Arizona Emergency Medicine Residency Program, Steven Seifert, MD, FACEP,on-site co-editor.
ABSTRACTS Harvey W Meislin, MD, FACEP Co-Editor Section of Emergency Medicine University of Arizona College of Medicine
Vincent J Markovchick, MD, FACEP Co-Editor Emergency Medical Services Denver General Hospital
head injury, cost-benefit analysis
Neurosurgical c o m p l i c a t i o n s a f t e r apparently minor head injury: A s s e s s m e n t of risk in a series of 610 patients Dacey RG, Alves WM, Rimel RW, et al N Neurosurg 65:203-210
August 1986
This is a prospective study of 610 patients with minor head injuries with a cost-benefit analysis of three different management schemes. The patients gave a history consistent with a cerebral concussion, and had a GCS score of 13 to 15 in the emergency department. Skull radiographs were obtained in 583 patients and 66 had cranial fracture (10.8% of 610). Nearly 20% of the 66 with skull fractures required an operative procedure, as compared to 1% of the 517 patients without skull fracture, showing a 20-fold increase in likelihood of need for surgery. Two patients with a GCS score of 15 and normal skull films subsequently underwent operative treatment. The authors show a 50% reduction in cost of management of this group if those with GCS of 15 were studied with CT scan and those with normal scans were discharged rather than admitted for observation. An initial GCS of 13 to 15 does not necessarily indicate that a patient has sustained a trivial head injury because 3% of such patients required an operative procedure. [Editor's n o t e : This study is biased in that almost all patients had skull films and were admitted for observation. The skull film versus CT rationale is unclear and unanalyzed. The important point is that a small percentage of minor head injuries result in major complications.] Douglas Butzier, MD
foreign body, rectal
Rectal foreign bodies Couch CH, Tan EGC, Watt AG Med J Aust 144:512-515 May 12, 1986
A chart review of all patients admitted to the Royal Perth Hospital in Perth, Australia, from 1968 to 1983 revealed 26 patients admitted with the diagnosis of "foreign rectal bodies." The epidemiologic characteristics of the group revealed all patients were men, 50% were over 50 years old (range, 18 to 70), and 50% were married. Ninety-two percent t24 of 26) of the objects were introduced through the rectum. Four patients presented with vibrators, four with bot16:2February 1987
tles or jars, three with sachets of heroin, three with bones (two chicken, one chop), and one each with a lemon, a zucchini, a carrot, a plastic pepper pot, a plastic ball, a crystal vase, a piece of cement, a 3-cm x 10-cm bicycle handle grip, a 3-cm x 12-cm plastic rod, a porcelain serviette ring, a piece of a toothpick, and an unspecified sharp object. One-third (9 of 26) of the patients claimed to be intoxicated at the time the object was inserted. Most patients presented to the hospital less than 24 hours after the insertion. Complications included laparotomy and proctotomy for removal of a piece of cement, an ischiorectal abscess with sinus tract formation (toothpick), rectal bleeding, and mucosal laceration. General anesthesia followed by manual removal with or without instruments was the most commonly used treatment. A number of removal methods are listed and a plan of management for nonperforating rectal foreign bodies is suggested./Editor's note: No comment.] Douglas S Campbell, MD
fracture, ankle
Sprain or fracture? An analysis of 2 0 0 0 ankle injuries Sujitkumar P, Hadfield JM, Yates DW Arch Emerg Med 3:101-106 June 1986
This group from Great Britain performed a retrospective analysis of more than 2,000 ankle injuries to develop restrictive criteria for ordering radiographs on such cases. The 1,600 patients included in the study were those with inversion-type injuries who were more than 12 years old, had no history of injury to that ankle, and did not have an obvious fracture prior to radiograph. Patients were studied for age, degree of swelling, pain, and the ability to bear weight. Eighty-nine (5.6%) patients had a significant fracture, and 73 (4.6%) had an avulsion fracture. None of the 89 patients with a significant fracture had "little pain and swelling" as compared with 55 of the 89 who had "moderate pain and swelling." Pain or swelling by themselves had a lower degree of correlation with significant injury. Three of the 73 patients with an avulsion fracture had "little pain and swelling," compared with 59 of 73 with moderate pain and swelling. The incidence of moderate or severe pain and swelling with sprains was m u c h lower (50 of 1472) but still present and could not, therefore, be used to distinguish the need for radiographs. The greatest incidence of fracture was noted in those patients more than 50 years old. The authors concluded that swelling alone is not a reliable guide to the presence of a significant fracture and that patients with mini-
Annals of EmergencyMedicine
230/137
ABSTRACTS Harvey W Meislin, MD, FACEP Co-Editor Section of Emergency Medicine University of Arizona College of Medicine
Vincent J Markovchick, MD, FACEP Co-Editor Emergency Medical Services Denver General Hospital
head injury, cost-benefit analysis
Neurosurgical c o m p l i c a t i o n s a f t e r apparently minor head injury: A s s e s s m e n t of risk in a series of 610 patients Dacey RG, Alves WM, Rimel RW, et al N Neurosurg 65:203-210
August 1986
This is a prospective study of 610 patients with minor head injuries with a cost-benefit analysis of three different management schemes. The patients gave a history consistent with a cerebral concussion, and had a GCS score of 13 to 15 in the emergency department. Skull radiographs were obtained in 583 patients and 66 had cranial fracture (10.8% of 610). Nearly 20% of the 66 with skull fractures required an operative procedure, as compared to 1% of the 517 patients without skull fracture, showing a 20-fold increase in likelihood of need for surgery. Two patients with a GCS score of 15 and normal skull films subsequently underwent operative treatment. The authors show a 50% reduction in cost of management of this group if those with GCS of 15 were studied with CT scan and those with normal scans were discharged rather than admitted for observation. An initial GCS of 13 to 15 does not necessarily indicate that a patient has sustained a trivial head injury because 3% of such patients required an operative procedure. [Editor's n o t e : This study is biased in that almost all patients had skull films and were admitted for observation. The skull film versus CT rationale is unclear and unanalyzed. The important point is that a small percentage of minor head injuries result in major complications.] Douglas Butzier, MD
foreign body, rectal
Rectal foreign bodies Couch CH, Tan EGC, Watt AG Med J Aust 144:512-515 May 12, 1986
A chart review of all patients admitted to the Royal Perth Hospital in Perth, Australia, from 1968 to 1983 revealed 26 patients admitted with the diagnosis of "foreign rectal bodies." The epidemiologic characteristics of the group revealed all patients were men, 50% were over 50 years old (range, 18 to 70), and 50% were married. Ninety-two percent t24 of 26) of the objects were introduced through the rectum. Four patients presented with vibrators, four with bot16:2February 1987
tles or jars, three with sachets of heroin, three with bones (two chicken, one chop), and one each with a lemon, a zucchini, a carrot, a plastic pepper pot, a plastic ball, a crystal vase, a piece of cement, a 3-cm x 10-cm bicycle handle grip, a 3-cm x 12-cm plastic rod, a porcelain serviette ring, a piece of a toothpick, and an unspecified sharp object. One-third (9 of 26) of the patients claimed to be intoxicated at the time the object was inserted. Most patients presented to the hospital less than 24 hours after the insertion. Complications included laparotomy and proctotomy for removal of a piece of cement, an ischiorectal abscess with sinus tract formation (toothpick), rectal bleeding, and mucosal laceration. General anesthesia followed by manual removal with or without instruments was the most commonly used treatment. A number of removal methods are listed and a plan of management for nonperforating rectal foreign bodies is suggested./Editor's note: No comment.] Douglas S Campbell, MD
fracture, ankle
Sprain or fracture? An analysis of 2 0 0 0 ankle injuries Sujitkumar P, Hadfield JM, Yates DW Arch Emerg Med 3:101-106 June 1986
This group from Great Britain performed a retrospective analysis of more than 2,000 ankle injuries to develop restrictive criteria for ordering radiographs on such cases. The 1,600 patients included in the study were those with inversion-type injuries who were more than 12 years old, had no history of injury to that ankle, and did not have an obvious fracture prior to radiograph. Patients were studied for age, degree of swelling, pain, and the ability to bear weight. Eighty-nine (5.6%) patients had a significant fracture, and 73 (4.6%) had an avulsion fracture. None of the 89 patients with a significant fracture had "little pain and swelling" as compared with 55 of the 89 who had "moderate pain and swelling." Pain or swelling by themselves had a lower degree of correlation with significant injury. Three of the 73 patients with an avulsion fracture had "little pain and swelling," compared with 59 of 73 with moderate pain and swelling. The incidence of moderate or severe pain and swelling with sprains was m u c h lower (50 of 1472) but still present and could not, therefore, be used to distinguish the need for radiographs. The greatest incidence of fracture was noted in those patients more than 50 years old. The authors concluded that swelling alone is not a reliable guide to the presence of a significant fracture and that patients with mini-
Annals of EmergencyMedicine
230/137