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Risk factors predicting operable intracranial hematomas in head injury
Abstracts
0 INQUIRY ABOUT VICTIMIZATION EXPERIENCES. Friedman LS, Samet JH. 1992;152:1186-1190. In an attempt to investigate patient attitudes and physician practices regarding inquiries about physical or sexual abuse, confidential, written multiple choice questionnaires were given to 164 patients and 27 physicians of both private and public academic faculty practices in Boston. Data were analyzed using univariate analysis. Patient reported histories of physical abuse were 19% and 13% at the private and public practices, respectively, while histories of sexual abuse were 17% and 16%. Overall 78% of patients favored routine physical abuse inquiries, while 68% favored questions involving sexual abuse. Eighty-nine percent believed that physicians could help with sexual abuse, and 90% believed they could get help with physical abuse. Eighty-nine percent of physicians surveyed never made inquiries regarding sexual abuse during initial visits and 85% never inquired at annual visits. Similarly, 67% and 60% of physicians never asked about physical abuse at initial and annual visits, respectively. Seventy-four percent believed they could help with sexual abuse and 81% believed they could help with physical abuse. The authors noted the glaring difference between patient attitudes and physician practices and recommended that all physicians receive training on proper abuse history taking and suggested that such inquiries be made a standard part of the medical history-regardless of gender. [Scott J. Jones, MD]
Cl DIAGNOSIS OF ACUTE APPENDICITIS IN PREGNANT WOMEN: VALUE OF SONOGRAPHY. Lim HK, Bae SH, Seo GS. Am J Roentgenology. 1992;159:539-542. This was a prospective study designed to assessthe value of graded-compression sonography for the diagnosis of acute appendicitis in pregnant women. During a 48-month period, the authors performed sonograms on 45 pregnant women with clinically suspected acute appendicitis. The sonographic diagnosis was based only on the authors findings, and at the time of their exam they had no knowledge of the clinical findings, laboratory data, or surgeons’ opinion. Regardless of the sonographic diagnosis, all patients who showed progression of their signs and symptoms underwent surgery, and patients whose signs and symptoms showed resolution were observed. The sonographic findings were correlated with the surgical results in the patients who underwent surgery and with the clinical findings in the patients who did not. Sonography was nondiagnostic in 3 (7%) of the 45 patients. In 16 of the other 42 patients, sonographic findings indicated acute appendicitis. In 15 (94%) of these, the diagnosis was confirmed at surgery. The sonogram in the 16th patient was a false positive. In 26 of the 42 patients, no sonographic evidence of acute appendicitis was found. Twenty of these showed resolution of their signs and symptoms and did not have surgery. The other 6 underwent surgery for progression of their signs and symptoms but were all found to have a normal appen-
233 dix. For the 42 cases in which the sonographic findings indicated the correct diagnosis, the sensitivity was lOO%, the specificity was 96%, and the overall accuracy was 98%. The positive predictive value was 94%, and the negative predictive value was 100%. [Glenn A. Hebel, MD] Editor’s Comment: Sonography in this setting remains institution and operator dependent, the statistics are not entirely accurate as nondiagnostic ultrasounds were excluded.
0 RENAL COLIC; DIAGNOSIS AND OUTCOME. Haddad MC, Hassan SS, Shadhed MSM. Radiology. 1992; 184:83-88. In this study of 101 consecutive patients presenting with renal colic, ultrasound (US) with and without kidney, ureter, bladder (KUB) radiography was compared to intravenous urography to detect acute urinary obstruction. Each patient had an ultrasound followed by an IVP. The US diagnosis of acute urinary tract obstruction had sensitivities by 2 different readers of 91% and 92% with a specificity of 90%. With the addition of KUB the sensitivities became 94% and 97% with a specificity of 90%. There was no statistically significant difference between the US and IVP results. False negative and positive results occurred with US when grade 1 hydronephrosis and nondilated obstructive uropathy existed. This study shows US with KUB may be useful in the initial diagnosis and evaluation of kidney stones. [Michele Giad, MD] Editor’s Comment: Primarily, ultrasound would be useful in those situations where IVP would entail additional risk to patients, such as in the case of pregnancy or dye allergy.
0 RISK FACTORS PREDICTING OPERABLE INTRACRANIAL HEMATOMAS IN HEAD INJURY. Gutman MB, Moulton RJ. J Neurosurg. 1992;77:9-14. There is considerable evidence to suggest that early recognition and surgical evacuation of traumatic intracranial hematomas prevent death and disability. This study was conducted to determine the risk factors that might predict the presence or absence of operable traumatic hematomas in head-injured patients. Logistic analysis was used to identify independent predictors of operable traumatic intracranial hematomas. Data were gathered prospectively on 1039 consecutive patients in a tertiary referral, regional trauma center. Patient age, Glasgow Coma Scale (GCS), pupillary inequality, and injury by falling were all independent predictors of operable intracranial hematomas (p = 0.0000, 0.0000,0.0182, and 0.0001, respectively). Injury to vehicle occupants was significantly less likely to result in operable mass lesions than other mechanisms of injury. The incidence of traumatic intracranial hematomas in patients over 50 years old was three to four times higher than those under 30. Not surprisingly the incidence of operable
234 hematomas increased with decreasing GCS. However, even at GCS of 13 to 15, patients with other risk factors had a substantial incidence of operable mass lesions. There was a 29% incidence of operable intracranial hematomas for patients with a GCS of 13 to 15, aged over 40 years and injured in a fall. It is suggested that patients who are middle-aged or older, or those injured in a fall, are at particular risk for traumatic intracranial hematomas even if the GCS is high. [Richard Klasco, MD] Editor’s Comment: This study is particularly important in identifying those groups at risk for operable intracranial lesions despite a relatively high GCS.
0 LACERATIONS INVOLVING GLASS: THE ROLE OF ROUTINE ROENTGENOGRAMS. Avner JR, Baker MD. AJDC. 1992;146:600-602. This study was designed to evaluate the necessity of obtaining roentgenograms for lacerations involving glass in the pediatric population. Over a 21 month period, 226 children presented with lacerations from glass injuries. Of these, 10 were excluded because glass was initially visible in the laceration. Of the remaining 216 children, the entire depth of the wound was visualized during initial examination in 160 patients. Of these, when the bottom of the wound was visualized and believed to be free of glass, 11 lacerations were shown to contain glass on roentgenogram. This study suggeststhat the sensitivity of physical exam is only 52%. The depth of the wound does appear to correlate with inability to visualize retained glass, as roentgenograms had a 96% sensitivity in showing glassin lacerations [J. FitzGerald, DO] of a depth greater than 0.5 cm. Editor’s Comment: Ultrasound is another option to be considered when attempting to localize a soft tissue foreign body. With glass wounds of significance a routine x-ray will minimize the medico-legal risk of a missed foreign body.
q APPROPRIATE USE OF LOCAL ANAESTHETIC FOR VENOUS CANNULATION. Harrison N, Langham BT, Bogod DG. Anaesthesia. 1992;47:210-212. Anesthesiologists and emergency physicians have long known that local infiltration with lidocaine can minimize the pain associated with venous catheterization with central lines and large bore catheters. For smaller catheters (18 gauge or lower), however, there is a widely-held opinion among both fields that the pain associated with local infiltration with lidocaine is equal to or greater than the pain associated with venous catheterization itself. To test this, the authors had 60 adult patients compare the pain of catheterization of a dorsal hand vein with either an 18 gauge, a 20 gauge, or a 22 gauge catheter with the pain of subcutaneous infiltration of 0.25 ml of a 1% xylocaine solution in the dorsum of the other hand with a 25 gauge needle. Patients were randomized into three groups of 20 with each
The Journal
of Emergency
Medicine
group testing a different catheter size versus local infiltration. The patients were blindfolded during the procedure and asked to rate their pain on a l-10 scale. Local infiltration was significantly less painful in all groups. In fact, median pain scores in all groups were 4-6 times higher for catheterization than for infiltration. Only 4 of the 60 patients found local infiltration more painful than venous catheterization. The authors conclude that subcutaneous injection of local anesthesia is beneficial prior to venous cannulation with smaller catheters. [Michael D. Witting, MD] Editor3 Comment: Time permitting, local infiltration of xylocaine should be attempted prior to venous cannulation.
0 SERUM LIPASE: A BETTER TEST TO DIAGNOSE ACUTE ALCOHOLIC PANCREATITIS. Gumaste DS. The American Journal of Medicine. March 1992;92:239242. The estimation of total serum amylase continues to be a screening test for acute alcoholic pancreatitis. This prospective study attempts to determine if serum lipase is a better screening test than serum amylase to diagnose acute alcoholic pancreatitis. Patients were placed in two groups, asymptomatic alcoholics (group A) and those diagnosed as having alcoholic induced acute pancreatitis (group P). The members of group A totaled 202 patients who consumed a minimum of 150 grams of alcohol per day. The members of group P totaled 29 patients diagnosed as having acute alcoholic induced pancreatitis, confirmed by imaging studies. The level of serum amylase in group A ranged from 17 to 347 U/L, and in group P ranged from 180 to 2,985 U/ L. The serum lipase levels in group A ranged from 34 to 60 U/L in group P lipase levels ranged 1,011 to 25,706. The sensitivity of serum lipase levels greater than three times normal in detecting pancreatitis was 100% with 100% specificity. Lipase determinations may be performed rapidly, accurately and cost effectively, comparing favorably to current amylase determinations. Serum lipase thus may be a better screening test than amylase levels to diagnose acute alcoholic pancreatitis. [Peter J. Patton, DO] Editor’s Comment: The serum lipase is a more specific test than serum amylase for certain types of pancreatitis, and may be increasingly helpful as the time to obtain the result becomes more reasonable.
0 ANGIOEDEMA: 5 YEARS’ EXPERIENCE, WITH A REVIEW OF THE DISORDER’S PRESENTATION AND TREATMENT. Megerian CA, Arnold JE, Berger M. Laryngoscope 1992;102:256-260. The authors did a retrospective review of the charts of I7 patients that were admitted to the University Hospitals of Cleveland during the years 1985 to 1990 with the diagnosis of angioedema to determine age, presenting symptoms,
0 INQUIRY ABOUT VICTIMIZATION EXPERIENCES. Friedman LS, Samet JH. 1992;152:1186-1190. In an attempt to investigate patient attitudes and physician practices regarding inquiries about physical or sexual abuse, confidential, written multiple choice questionnaires were given to 164 patients and 27 physicians of both private and public academic faculty practices in Boston. Data were analyzed using univariate analysis. Patient reported histories of physical abuse were 19% and 13% at the private and public practices, respectively, while histories of sexual abuse were 17% and 16%. Overall 78% of patients favored routine physical abuse inquiries, while 68% favored questions involving sexual abuse. Eighty-nine percent believed that physicians could help with sexual abuse, and 90% believed they could get help with physical abuse. Eighty-nine percent of physicians surveyed never made inquiries regarding sexual abuse during initial visits and 85% never inquired at annual visits. Similarly, 67% and 60% of physicians never asked about physical abuse at initial and annual visits, respectively. Seventy-four percent believed they could help with sexual abuse and 81% believed they could help with physical abuse. The authors noted the glaring difference between patient attitudes and physician practices and recommended that all physicians receive training on proper abuse history taking and suggested that such inquiries be made a standard part of the medical history-regardless of gender. [Scott J. Jones, MD]
Cl DIAGNOSIS OF ACUTE APPENDICITIS IN PREGNANT WOMEN: VALUE OF SONOGRAPHY. Lim HK, Bae SH, Seo GS. Am J Roentgenology. 1992;159:539-542. This was a prospective study designed to assessthe value of graded-compression sonography for the diagnosis of acute appendicitis in pregnant women. During a 48-month period, the authors performed sonograms on 45 pregnant women with clinically suspected acute appendicitis. The sonographic diagnosis was based only on the authors findings, and at the time of their exam they had no knowledge of the clinical findings, laboratory data, or surgeons’ opinion. Regardless of the sonographic diagnosis, all patients who showed progression of their signs and symptoms underwent surgery, and patients whose signs and symptoms showed resolution were observed. The sonographic findings were correlated with the surgical results in the patients who underwent surgery and with the clinical findings in the patients who did not. Sonography was nondiagnostic in 3 (7%) of the 45 patients. In 16 of the other 42 patients, sonographic findings indicated acute appendicitis. In 15 (94%) of these, the diagnosis was confirmed at surgery. The sonogram in the 16th patient was a false positive. In 26 of the 42 patients, no sonographic evidence of acute appendicitis was found. Twenty of these showed resolution of their signs and symptoms and did not have surgery. The other 6 underwent surgery for progression of their signs and symptoms but were all found to have a normal appen-
233 dix. For the 42 cases in which the sonographic findings indicated the correct diagnosis, the sensitivity was lOO%, the specificity was 96%, and the overall accuracy was 98%. The positive predictive value was 94%, and the negative predictive value was 100%. [Glenn A. Hebel, MD] Editor’s Comment: Sonography in this setting remains institution and operator dependent, the statistics are not entirely accurate as nondiagnostic ultrasounds were excluded.
0 RENAL COLIC; DIAGNOSIS AND OUTCOME. Haddad MC, Hassan SS, Shadhed MSM. Radiology. 1992; 184:83-88. In this study of 101 consecutive patients presenting with renal colic, ultrasound (US) with and without kidney, ureter, bladder (KUB) radiography was compared to intravenous urography to detect acute urinary obstruction. Each patient had an ultrasound followed by an IVP. The US diagnosis of acute urinary tract obstruction had sensitivities by 2 different readers of 91% and 92% with a specificity of 90%. With the addition of KUB the sensitivities became 94% and 97% with a specificity of 90%. There was no statistically significant difference between the US and IVP results. False negative and positive results occurred with US when grade 1 hydronephrosis and nondilated obstructive uropathy existed. This study shows US with KUB may be useful in the initial diagnosis and evaluation of kidney stones. [Michele Giad, MD] Editor’s Comment: Primarily, ultrasound would be useful in those situations where IVP would entail additional risk to patients, such as in the case of pregnancy or dye allergy.
0 RISK FACTORS PREDICTING OPERABLE INTRACRANIAL HEMATOMAS IN HEAD INJURY. Gutman MB, Moulton RJ. J Neurosurg. 1992;77:9-14. There is considerable evidence to suggest that early recognition and surgical evacuation of traumatic intracranial hematomas prevent death and disability. This study was conducted to determine the risk factors that might predict the presence or absence of operable traumatic hematomas in head-injured patients. Logistic analysis was used to identify independent predictors of operable traumatic intracranial hematomas. Data were gathered prospectively on 1039 consecutive patients in a tertiary referral, regional trauma center. Patient age, Glasgow Coma Scale (GCS), pupillary inequality, and injury by falling were all independent predictors of operable intracranial hematomas (p = 0.0000, 0.0000,0.0182, and 0.0001, respectively). Injury to vehicle occupants was significantly less likely to result in operable mass lesions than other mechanisms of injury. The incidence of traumatic intracranial hematomas in patients over 50 years old was three to four times higher than those under 30. Not surprisingly the incidence of operable
234 hematomas increased with decreasing GCS. However, even at GCS of 13 to 15, patients with other risk factors had a substantial incidence of operable mass lesions. There was a 29% incidence of operable intracranial hematomas for patients with a GCS of 13 to 15, aged over 40 years and injured in a fall. It is suggested that patients who are middle-aged or older, or those injured in a fall, are at particular risk for traumatic intracranial hematomas even if the GCS is high. [Richard Klasco, MD] Editor’s Comment: This study is particularly important in identifying those groups at risk for operable intracranial lesions despite a relatively high GCS.
0 LACERATIONS INVOLVING GLASS: THE ROLE OF ROUTINE ROENTGENOGRAMS. Avner JR, Baker MD. AJDC. 1992;146:600-602. This study was designed to evaluate the necessity of obtaining roentgenograms for lacerations involving glass in the pediatric population. Over a 21 month period, 226 children presented with lacerations from glass injuries. Of these, 10 were excluded because glass was initially visible in the laceration. Of the remaining 216 children, the entire depth of the wound was visualized during initial examination in 160 patients. Of these, when the bottom of the wound was visualized and believed to be free of glass, 11 lacerations were shown to contain glass on roentgenogram. This study suggeststhat the sensitivity of physical exam is only 52%. The depth of the wound does appear to correlate with inability to visualize retained glass, as roentgenograms had a 96% sensitivity in showing glassin lacerations [J. FitzGerald, DO] of a depth greater than 0.5 cm. Editor’s Comment: Ultrasound is another option to be considered when attempting to localize a soft tissue foreign body. With glass wounds of significance a routine x-ray will minimize the medico-legal risk of a missed foreign body.
q APPROPRIATE USE OF LOCAL ANAESTHETIC FOR VENOUS CANNULATION. Harrison N, Langham BT, Bogod DG. Anaesthesia. 1992;47:210-212. Anesthesiologists and emergency physicians have long known that local infiltration with lidocaine can minimize the pain associated with venous catheterization with central lines and large bore catheters. For smaller catheters (18 gauge or lower), however, there is a widely-held opinion among both fields that the pain associated with local infiltration with lidocaine is equal to or greater than the pain associated with venous catheterization itself. To test this, the authors had 60 adult patients compare the pain of catheterization of a dorsal hand vein with either an 18 gauge, a 20 gauge, or a 22 gauge catheter with the pain of subcutaneous infiltration of 0.25 ml of a 1% xylocaine solution in the dorsum of the other hand with a 25 gauge needle. Patients were randomized into three groups of 20 with each
The Journal
of Emergency
Medicine
group testing a different catheter size versus local infiltration. The patients were blindfolded during the procedure and asked to rate their pain on a l-10 scale. Local infiltration was significantly less painful in all groups. In fact, median pain scores in all groups were 4-6 times higher for catheterization than for infiltration. Only 4 of the 60 patients found local infiltration more painful than venous catheterization. The authors conclude that subcutaneous injection of local anesthesia is beneficial prior to venous cannulation with smaller catheters. [Michael D. Witting, MD] Editor3 Comment: Time permitting, local infiltration of xylocaine should be attempted prior to venous cannulation.
0 SERUM LIPASE: A BETTER TEST TO DIAGNOSE ACUTE ALCOHOLIC PANCREATITIS. Gumaste DS. The American Journal of Medicine. March 1992;92:239242. The estimation of total serum amylase continues to be a screening test for acute alcoholic pancreatitis. This prospective study attempts to determine if serum lipase is a better screening test than serum amylase to diagnose acute alcoholic pancreatitis. Patients were placed in two groups, asymptomatic alcoholics (group A) and those diagnosed as having alcoholic induced acute pancreatitis (group P). The members of group A totaled 202 patients who consumed a minimum of 150 grams of alcohol per day. The members of group P totaled 29 patients diagnosed as having acute alcoholic induced pancreatitis, confirmed by imaging studies. The level of serum amylase in group A ranged from 17 to 347 U/L, and in group P ranged from 180 to 2,985 U/ L. The serum lipase levels in group A ranged from 34 to 60 U/L in group P lipase levels ranged 1,011 to 25,706. The sensitivity of serum lipase levels greater than three times normal in detecting pancreatitis was 100% with 100% specificity. Lipase determinations may be performed rapidly, accurately and cost effectively, comparing favorably to current amylase determinations. Serum lipase thus may be a better screening test than amylase levels to diagnose acute alcoholic pancreatitis. [Peter J. Patton, DO] Editor’s Comment: The serum lipase is a more specific test than serum amylase for certain types of pancreatitis, and may be increasingly helpful as the time to obtain the result becomes more reasonable.
0 ANGIOEDEMA: 5 YEARS’ EXPERIENCE, WITH A REVIEW OF THE DISORDER’S PRESENTATION AND TREATMENT. Megerian CA, Arnold JE, Berger M. Laryngoscope 1992;102:256-260. The authors did a retrospective review of the charts of I7 patients that were admitted to the University Hospitals of Cleveland during the years 1985 to 1990 with the diagnosis of angioedema to determine age, presenting symptoms,