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Posttraumatic shock in children: CT findings associated with hemodynamic instability
656 Editor’s Comment: With laparoscopic cholecystectomy gaining in popularity, emergency physicians must be aware of delayed complications associated with this procedure.
0 EFFECT OF HEAD ELEVATION ON INTRACRANIAL PRESSURE, CEREBRAL PERFUSION PRESSURE, AND CEREBRAL BLOOD FLOW IN HEADINJURED PATIENTS. Feldman Z, Kanter M, Robertson CS, et al. J Neurosurg. 1992;76:207-11. Twenty-two head-injured patients were monitored during the 1990 calendar year by means of intracranial pressure bolts and arterial lines in order to determine the effect of head elevation on specific variables: mean carotid pressure, intracranial pressure, cerebral perfusion pressure, cerebral blood flow, cerebral vascular resistance, cerebral metabolic rate, arteriovenous O2 extraction, PaCO,, arteriovenous lactate difference, and O2 saturation. Mean patient age was 35 years (18 to 75). All patients were intubated and hyperventilated to a pCOz 30 to 35. In the event that intracranial pressure was greater than 20 cm, hyperventilation was adjusted to a pC0, of 25 to 30. Other interventions included sedation, paralysis, mannitol, and barbiturate coma as needed. Results indicated that head elevation from O” to 30° significantly lowered both mean carotid pressure and intracranial pressure; none of the other variables achieved statistical significance. A trend in intracranial pressure was also noted: the greater the initial value at O”, the greater the reduction at 30°. [Mary L. Sparkes, MD] Editor’s Comment: Criticisms are chiefly two: 1. Patient selection and selection bias were not discussed. 2. The methods section might be extended to include a discussion of intracranial and arterial monitoring, their variability, drift, and reproducibility in this study. One wonders if, by extending this two-valued analysis (0° and 30°) to a multivalued one, an optimal level of head elevation might be determined.
0 DELAYED DIAGNOSIS OF CERVICAL SPINE INJURIES. Gerrelts BD, Petersen EU, Mabry J, et al. J Trauma. 1991;31:1622-6. A retrospective analysis was done in order to determine the incidence and outcome of delayed diagnosis of cervical spine injuries. Cervical spine roentgenograms (CSR) were performed on 1331 patients following blunt trauma; 61 (4.6%) of these had cervical fractures or dislocations documented by CSR or computed tomography (CT) scan. Patients were evaluated with an AP, lateral, odontoid, cone down Cl-2 (and swimmer’s view if needed). They also had a CT scan done if the entire cervical spine could not be visualized or if there was a suspected injury. The mechanism of injury in these patients included motor vehicle accidents, motorcycle accidents, pedestrian-automobile collisions, and falls.
The Journal of Emergency Medicine Fractures or dislocations were found during the initial evaluation by CSR in 52 of the 61 patients (85.2%). An additional 4 patients were diagnosed with the use of CT. The reasons for the delayed diagnosis in the remaining 5 patients included inadequate visualization of the entire cervical spine, incomplete films, and poor visualization secondary to severe degenerative disease. One patient also had a transverse odontoid fracture that was missed on CT scan. He developed central cord syndrome 13 days after the injury and a repeat CT scan picked up the fracture. This study reported a sensitivity of 85.2% for the 5-view CSR. The primary problems associated with missed injury were preexisting pathologic conditions and the need for more urgent procedures because of hemodynamic instability. The authors propose increased utilization of flexionextension views and CT scan in “at-risk” groups. [Eric H. Gilbert, MD]
0 METHYLPREDNISOLONE OR NALOXONE TREATMENT AFTER ACUTE SPINAL CORD INJURY: lYEAR FOLLOW-UP DATA. Bracken MB, Shepard MJ, Collins WF, et al. J Neurosurg. 1992;76:23-31. In a multicenter randomized double-blind trial, the longterm effects of high-dose methylprednisolone (30 mg/kg bolus, 5.4 mg/kg/h x 23 h) on acute spinal cord injury are compared with those of naloxone (5.4 mg/kg bolus, 4.0 mg/kg/h x 23 h) and placebo. Four hundred eighty-seven patients were randomized to one of three protocols within 8 hours of injury and followed for neurological recovery at 6 weeks, 6 months, and one year. Assessment included motor, light touch, and pinprick recovery. Statistical analysis included ANOVA and PROC LEFT TEST (SAS). Study populations did not differ significantly in prehospital care, time to loading dose, survivorship, type of injury, or operative intervention. At the end of one year, patients who had received methylprednisolone were found to be significantly improved in motor examination if they had been initially assessed as 1) plegic with total sensory loss or 2) paretic with variable sensory loss. Naloxone- and placebo-treated patients did not show significant improvement. Moreover, no drug groups improved significantly when the drug was administered 8 hours after injury. The authors conclude that study-dose methylprednisolone is indicated for spinal cord injury if begun within the first 8 hours. [Mary L. Sparkes, MD] Editor’s Comment: The authors of the second National Acute Spinal Cord Injury Study discuss possible mechanisms of action for both trial drugs and rightly anticipate objections to trial dose selection. It is interesting to speculate on the effects of higher dose naloxone in a larger test population.
0 POSTTRAUMATIC SHOCK IN CHILDREN: CT FINDINGS ASSOCIATED WITH HEMODYNAMIC INSTABILITY. Sivit CJ, Taylor GA, Bulas DI, Kushner DC, Potter BM, Eichelberger MR. Radiology. 1992;182:723-6.
Abstracts
In recent years, the management of children who sustain blunt abdominal trauma has been refined. Most are now treated nonoperatively, and computed tomography (CT) has largely replaced peritoneal lavage as the primary means of assessment of children. Hemodynamic stability is one of the essential criteria for abdominal CT in children who have sustained blunt trauma. This study retrospectively reviewed 1,018 consecutive children who had sustained blunt trauma and were suspected clinically of having intraabdominal injury. All were evaluated with intravenous contrast-enhanced CT, and all were considered to be hemodynamically stable immediately before CT. Of the 1,018 children evaluated, 27 demonstrated a characteristic hypoperfusion complex which included a dilated, fluid-filled bowel and intense enhancement of the bowel wall, mesentery, kidneys, aorta, and inferior vena cava as well as diminished caliber of the aorta and inferior vena cava. This complex was usually seen in young children (median age, 2 years). Nineteen children (70%) had arterial hypotension on admission (systolic BP less than 88 torr) but were judged to be physiologically stable after resuscitation. Five patients (19%) became hypotensive within 10 minutes of intravenous contrast material administration. Twenty-three children (85%) died. The intense multi-organ enhancement seen in the hypoperfusion complex indicates tenuous hemodynamic instability. Recognition that this constellation of CT findings is due to hypovolemic shock and not injured viscera may help avoid unnecessary laparotomy. The authors recognize that the administration of ionic contrast material may have contributed to the hypotension seen, but the numbers involved are considered too small to provide a reliable estimate of risk. [Mark D. Smith, DO] Editor’s Comment: These patients had low trauma scores, and all of them had a Glasgow coma score of 6 or less. This study shows that such patients are poor candidates for CT. Peritoneal lavage is safe, quick, and reliable in this age group.
0 DO NOT RESUSCITATE ORDERS IN THE EMERGENCY DEPARTMENT. Wrenn K, Brody S. Am J Med. 1992;92:129-33. This prospective study looks at 37 consecutive patients for whom a DNR order was written in the ED of a large innercity teaching hospital. House officers initiated the process in 65% of cases and the family was involved 89% of the time. The patients were generally either elderly, demented, and debilitated with multiple medical problems or young with malignancy or with AIDS and had become unstable or critically ill. Only 5 patients entered the decision-making process. Of these patients, 14% had discussed DNR status previously. Most families were aware of the poor prognosis of their family member and showed little reluctance in supporting the order. Seven patients died in the ED, 23 patients died during the subsequent hospitalization, and 3 patients survived to discharge. Outcome data were incomplete for 3 patients. The authors conclude that
657 the issue of DNR should be discussed between the primary physicians and the patient prior to a crisis, but in some situations the issue may have to be addressed in the ED. Criteria should be quite strict. Basic ethical principles, effective communication techniques, careful documentation, and a willingness to consult with other members of the health care team or the clergy are important aspects in the decision to write a DNR order. The family should be included whenever possible. [Jacques Blanchet, MD] Editor’s Comment: Family involvement is critical when considering DNR issues in the ED. Of equal importance is the development of protocols for EMS systems governing living wills.
0 SURVIVAL FROM IN-HOSPITAL CARDIAC ARREST WITH INTERPOSED ABDOMINAL COUNTERPULSATION DURING CARDIOPULMONARY RESUSCITATION. Sack JB, Kesselbrenner MB, Bregman D. JAMA. 1992;267:379-85. Interposed abdominal counterpulsation (IAC) during cardiopulmonary resuscitation (CPR) is a modified technique of standard CPR that has shown several advantages in laboratory studies but has never been evaluated in inhospital cardiac arrest victims. This randomized controlled trial evaluated the return of spontaneous circulation, survival 24 hours after resuscitation, and survival at hospital discharge in patients undergoing either IAC CPR or standard CPR. Of the 135 resuscitation attempts in 103 patients, the return of spontaneous circulation was significantly greater in the group receiving IAC CPR than in the group receiving standard CPR (51% compared with 27070,P = 0.007). At 24 hours a significantly greater proportion of patients were alive from the IAC CPR group than from the standard CPR group (25% compared with 770, P = 0.02). Finally, 8 (17%) of 48 patients who received IAC CPR survived to hospital discharge neurologically intact, compared with only 3 (6%) of 55 patients from the standard CPR group, but this was not statistically significant. There were no complications found from the use of IAC CPR. This study showed that interposed abdominal counterpulsation in conjunction with CPR is an easily applied technique that appears safe and may improve meaningful survival following in-hospital cardiac arrest over standard CPR. Further studies may be helpful to further optimize [Jeffrey S. Smowton, MD] the use of this technique. Editor’s Comment: This is a small study, and the endpoints of mortality and neurologic morbidity need to be evaluated in a larger patient population.
0 EFFECT OF PRIOR ANTIBIOTIC TREATMENT ON MIDDLE EAR DISEASE IN CHILDREN. Howard Faden, Joel Bernstein, John Stanievich. Ann Otol Rhino1 Laryngol. 1992;101:89-92.
0 EFFECT OF HEAD ELEVATION ON INTRACRANIAL PRESSURE, CEREBRAL PERFUSION PRESSURE, AND CEREBRAL BLOOD FLOW IN HEADINJURED PATIENTS. Feldman Z, Kanter M, Robertson CS, et al. J Neurosurg. 1992;76:207-11. Twenty-two head-injured patients were monitored during the 1990 calendar year by means of intracranial pressure bolts and arterial lines in order to determine the effect of head elevation on specific variables: mean carotid pressure, intracranial pressure, cerebral perfusion pressure, cerebral blood flow, cerebral vascular resistance, cerebral metabolic rate, arteriovenous O2 extraction, PaCO,, arteriovenous lactate difference, and O2 saturation. Mean patient age was 35 years (18 to 75). All patients were intubated and hyperventilated to a pCOz 30 to 35. In the event that intracranial pressure was greater than 20 cm, hyperventilation was adjusted to a pC0, of 25 to 30. Other interventions included sedation, paralysis, mannitol, and barbiturate coma as needed. Results indicated that head elevation from O” to 30° significantly lowered both mean carotid pressure and intracranial pressure; none of the other variables achieved statistical significance. A trend in intracranial pressure was also noted: the greater the initial value at O”, the greater the reduction at 30°. [Mary L. Sparkes, MD] Editor’s Comment: Criticisms are chiefly two: 1. Patient selection and selection bias were not discussed. 2. The methods section might be extended to include a discussion of intracranial and arterial monitoring, their variability, drift, and reproducibility in this study. One wonders if, by extending this two-valued analysis (0° and 30°) to a multivalued one, an optimal level of head elevation might be determined.
0 DELAYED DIAGNOSIS OF CERVICAL SPINE INJURIES. Gerrelts BD, Petersen EU, Mabry J, et al. J Trauma. 1991;31:1622-6. A retrospective analysis was done in order to determine the incidence and outcome of delayed diagnosis of cervical spine injuries. Cervical spine roentgenograms (CSR) were performed on 1331 patients following blunt trauma; 61 (4.6%) of these had cervical fractures or dislocations documented by CSR or computed tomography (CT) scan. Patients were evaluated with an AP, lateral, odontoid, cone down Cl-2 (and swimmer’s view if needed). They also had a CT scan done if the entire cervical spine could not be visualized or if there was a suspected injury. The mechanism of injury in these patients included motor vehicle accidents, motorcycle accidents, pedestrian-automobile collisions, and falls.
The Journal of Emergency Medicine Fractures or dislocations were found during the initial evaluation by CSR in 52 of the 61 patients (85.2%). An additional 4 patients were diagnosed with the use of CT. The reasons for the delayed diagnosis in the remaining 5 patients included inadequate visualization of the entire cervical spine, incomplete films, and poor visualization secondary to severe degenerative disease. One patient also had a transverse odontoid fracture that was missed on CT scan. He developed central cord syndrome 13 days after the injury and a repeat CT scan picked up the fracture. This study reported a sensitivity of 85.2% for the 5-view CSR. The primary problems associated with missed injury were preexisting pathologic conditions and the need for more urgent procedures because of hemodynamic instability. The authors propose increased utilization of flexionextension views and CT scan in “at-risk” groups. [Eric H. Gilbert, MD]
0 METHYLPREDNISOLONE OR NALOXONE TREATMENT AFTER ACUTE SPINAL CORD INJURY: lYEAR FOLLOW-UP DATA. Bracken MB, Shepard MJ, Collins WF, et al. J Neurosurg. 1992;76:23-31. In a multicenter randomized double-blind trial, the longterm effects of high-dose methylprednisolone (30 mg/kg bolus, 5.4 mg/kg/h x 23 h) on acute spinal cord injury are compared with those of naloxone (5.4 mg/kg bolus, 4.0 mg/kg/h x 23 h) and placebo. Four hundred eighty-seven patients were randomized to one of three protocols within 8 hours of injury and followed for neurological recovery at 6 weeks, 6 months, and one year. Assessment included motor, light touch, and pinprick recovery. Statistical analysis included ANOVA and PROC LEFT TEST (SAS). Study populations did not differ significantly in prehospital care, time to loading dose, survivorship, type of injury, or operative intervention. At the end of one year, patients who had received methylprednisolone were found to be significantly improved in motor examination if they had been initially assessed as 1) plegic with total sensory loss or 2) paretic with variable sensory loss. Naloxone- and placebo-treated patients did not show significant improvement. Moreover, no drug groups improved significantly when the drug was administered 8 hours after injury. The authors conclude that study-dose methylprednisolone is indicated for spinal cord injury if begun within the first 8 hours. [Mary L. Sparkes, MD] Editor’s Comment: The authors of the second National Acute Spinal Cord Injury Study discuss possible mechanisms of action for both trial drugs and rightly anticipate objections to trial dose selection. It is interesting to speculate on the effects of higher dose naloxone in a larger test population.
0 POSTTRAUMATIC SHOCK IN CHILDREN: CT FINDINGS ASSOCIATED WITH HEMODYNAMIC INSTABILITY. Sivit CJ, Taylor GA, Bulas DI, Kushner DC, Potter BM, Eichelberger MR. Radiology. 1992;182:723-6.
Abstracts
In recent years, the management of children who sustain blunt abdominal trauma has been refined. Most are now treated nonoperatively, and computed tomography (CT) has largely replaced peritoneal lavage as the primary means of assessment of children. Hemodynamic stability is one of the essential criteria for abdominal CT in children who have sustained blunt trauma. This study retrospectively reviewed 1,018 consecutive children who had sustained blunt trauma and were suspected clinically of having intraabdominal injury. All were evaluated with intravenous contrast-enhanced CT, and all were considered to be hemodynamically stable immediately before CT. Of the 1,018 children evaluated, 27 demonstrated a characteristic hypoperfusion complex which included a dilated, fluid-filled bowel and intense enhancement of the bowel wall, mesentery, kidneys, aorta, and inferior vena cava as well as diminished caliber of the aorta and inferior vena cava. This complex was usually seen in young children (median age, 2 years). Nineteen children (70%) had arterial hypotension on admission (systolic BP less than 88 torr) but were judged to be physiologically stable after resuscitation. Five patients (19%) became hypotensive within 10 minutes of intravenous contrast material administration. Twenty-three children (85%) died. The intense multi-organ enhancement seen in the hypoperfusion complex indicates tenuous hemodynamic instability. Recognition that this constellation of CT findings is due to hypovolemic shock and not injured viscera may help avoid unnecessary laparotomy. The authors recognize that the administration of ionic contrast material may have contributed to the hypotension seen, but the numbers involved are considered too small to provide a reliable estimate of risk. [Mark D. Smith, DO] Editor’s Comment: These patients had low trauma scores, and all of them had a Glasgow coma score of 6 or less. This study shows that such patients are poor candidates for CT. Peritoneal lavage is safe, quick, and reliable in this age group.
0 DO NOT RESUSCITATE ORDERS IN THE EMERGENCY DEPARTMENT. Wrenn K, Brody S. Am J Med. 1992;92:129-33. This prospective study looks at 37 consecutive patients for whom a DNR order was written in the ED of a large innercity teaching hospital. House officers initiated the process in 65% of cases and the family was involved 89% of the time. The patients were generally either elderly, demented, and debilitated with multiple medical problems or young with malignancy or with AIDS and had become unstable or critically ill. Only 5 patients entered the decision-making process. Of these patients, 14% had discussed DNR status previously. Most families were aware of the poor prognosis of their family member and showed little reluctance in supporting the order. Seven patients died in the ED, 23 patients died during the subsequent hospitalization, and 3 patients survived to discharge. Outcome data were incomplete for 3 patients. The authors conclude that
657 the issue of DNR should be discussed between the primary physicians and the patient prior to a crisis, but in some situations the issue may have to be addressed in the ED. Criteria should be quite strict. Basic ethical principles, effective communication techniques, careful documentation, and a willingness to consult with other members of the health care team or the clergy are important aspects in the decision to write a DNR order. The family should be included whenever possible. [Jacques Blanchet, MD] Editor’s Comment: Family involvement is critical when considering DNR issues in the ED. Of equal importance is the development of protocols for EMS systems governing living wills.
0 SURVIVAL FROM IN-HOSPITAL CARDIAC ARREST WITH INTERPOSED ABDOMINAL COUNTERPULSATION DURING CARDIOPULMONARY RESUSCITATION. Sack JB, Kesselbrenner MB, Bregman D. JAMA. 1992;267:379-85. Interposed abdominal counterpulsation (IAC) during cardiopulmonary resuscitation (CPR) is a modified technique of standard CPR that has shown several advantages in laboratory studies but has never been evaluated in inhospital cardiac arrest victims. This randomized controlled trial evaluated the return of spontaneous circulation, survival 24 hours after resuscitation, and survival at hospital discharge in patients undergoing either IAC CPR or standard CPR. Of the 135 resuscitation attempts in 103 patients, the return of spontaneous circulation was significantly greater in the group receiving IAC CPR than in the group receiving standard CPR (51% compared with 27070,P = 0.007). At 24 hours a significantly greater proportion of patients were alive from the IAC CPR group than from the standard CPR group (25% compared with 770, P = 0.02). Finally, 8 (17%) of 48 patients who received IAC CPR survived to hospital discharge neurologically intact, compared with only 3 (6%) of 55 patients from the standard CPR group, but this was not statistically significant. There were no complications found from the use of IAC CPR. This study showed that interposed abdominal counterpulsation in conjunction with CPR is an easily applied technique that appears safe and may improve meaningful survival following in-hospital cardiac arrest over standard CPR. Further studies may be helpful to further optimize [Jeffrey S. Smowton, MD] the use of this technique. Editor’s Comment: This is a small study, and the endpoints of mortality and neurologic morbidity need to be evaluated in a larger patient population.
0 EFFECT OF PRIOR ANTIBIOTIC TREATMENT ON MIDDLE EAR DISEASE IN CHILDREN. Howard Faden, Joel Bernstein, John Stanievich. Ann Otol Rhino1 Laryngol. 1992;101:89-92.