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Serious respiratory consequences of detergent ingestion in children
358
Patients with pyelonephritis had significantly more previous infections (usually otitis), and significantly more previous antibiotic therapy. There was also an increased incidence of UT1 among first degree relations of patients compared to controls. The authors concluded that alterations in the patients’ bacterial flora secondary to prior antibiotic use may play a role in increasing the risk of UTl. [Robin Johnson, MD] Editor’s Note: This study suggests that injudicious antibiotic therapy may result in adverse effects to a specific patient, as well as general effects borne by society at large (eg, development of resistance). However, other hypotheses such as underlying differences in host factors could just as easily explain these observations.
0 ST SEGMENT SHIFT IN UNSTABLE ANGINA: PATHOPHYSIOLOGY AND ASSOCIATION WITH CORONARY ANATOMY AND HOSPITAL OUTCOME. Langer A, Freeman MR, Armstrong PW. J Am Co11 Cardiol. 1989;13:1495-502. This prospective study was designed to test the hypothesis
that the presence of ST abnormality on admission electrocardiogram (ECG) and the presence and duration of S-T segment shift detected during 24-hour Holter monitoring early in the course of unstable angina predict angiographic severity of coronary artery disease and hospital outcome. One hundred thirty-five patients with unstable angina were followed with Holter monitoring in the fist 24 hours of hospital admission. S-T shift was evident in 44% of patients on admission ECG and in 66% on Holter monitor. During hospitalization, 7% had myocardial infarction, 4% died, and 34% had urgent coronary revascularization. Comparisons of patients with and without S-T shift on admission ECG revealed unfavorable outcome in 55% versus 25% (p < 0.025), multivessel disease in 77% versus 63% (p < 0.05), and left main coronary artery stenosis in 22% versus 7% (p < 0.025). When patients with and without S-T shift on Holter monitor ECG were compared, an unfavorable outcome was found in 48% versus 20% (p < O.OOS),multivessel disease in 76% versus 54% @ < O.Ol), and left main coronary stenosis in 18% versus 4% @ < 0.05). The duration of S-T shift was also greater in patients with unfavorable outcome, multivessel disease, or left main stenosis. A total of 593 episodes of S-T shift were recorded by Holter monitor, and only 8% were symptomatic; when compared with asymptomatic episodes, they were of longer duration and had greater magnitude. Continuous blood pressure and heart rate recording in 446 episodes showed an increase in rate pressure product at 20 and 10 minutes before onset of S-T shift as well as at the time of S-T shift, as compared with the 2 hours baseline value. The authors conclude that noninvasive tests can stratify patients with unstable angina into prognostic subsets with respect to hospital outcome and coronary anatomy, and that episodes of S-T shift associated with symptoms have greater magnitude and are of longer duration; these may be mediated in part by increased myocardial oxygen demand as defined by an increase in rate pressure product. [Napoleon B. Knight, Jr., MD]
CAUSE OF DEATH FOR PATIENTS WITH SPINAL CORD INJURIES. DeVivo MJ, Kartus PL, Stover SL, et al. Arch Intern Med. 1989;149:1761-66. 0
The Journal of Emergency
Medicine
The authors analyzed the cause of death in 5,131 patients sustaining spinal cord injuries between 1973 and 1980. Patients studied had been admitted to 1 of 7 federally designated regional spinal cord injury care systems and survived for at least 24 hours after injury. Patient follow-up was terminated December 31, 198 1, and only deaths occurring prior to this date were considered. At the end of the follow-up period, 459 patients (9%) had died. Overall, the leading cause of death was pneumonia, followed by unintentional injuries and suicides. Pneumonia was the leading cause of death among quadriplegics and persons at least 55 years of age, while among paraplegics and persons less than 55 years of age, unintentional injuries and suicides were the leading cause of death. Deaths from septicemia usually resulted from severe pressure sores or urinary tract infections. [John McGoldrick, MD]
I-J CERVICAL SPINE FRACTURES SUSTAINED BY YOUNG CHILDREN IN FORWARD FACING CAR SEATS. Fuch S, Barthel MJ, Flannery AM, Cristoffel KK.
Pediatrics. 1989;84:348-54.
Child passenger safety restraint laws have markedly reduced the number of fatalities to children in motor vehicle accidents. However, with the increased use of child safety seats there is the potential for different and more survivable injuries, including cervical spine injuries. The authors looked at a variety of factors in 5 cases of cervical spine injury of young children presenting to their emergency department to assess the variables contributing to cervical spine injury associated with car safety seats. The type and speed of vehicle, direction of impact, intrusion, weather, make and model of car safety seat, position of child and safety seat, method of restraining both child and seat, and restraint and injury to all other occupants were all assessed. In 3 cases the car safety seat was used incorrectly. In one of the other cases the speed of the vehicle was greater than NHTSA crash standards. The authors suggest that misuse of car seats along with anatomic and biomechanical factors in the cervical spines of children appear to have contributed to the occurrence of previously rare pediatric cervical spine injury. [Elizabeth L. Mitchell, MD] Editor’s Note: The authors of this paper quite justifiably label their conclusions as speculative, since existing evidence suggests that 70% to 80% of all child restraints are improperly used. The important point of this paper is that there are no unmixed blessings in medicine; every step forward will inevitably produce not only saved lives, but new and different injuries in new and different frequencies.
0 SERIOUS RESPIRATORY CONSEQUENCES OF DETERGENT INGESTION IN CHILDREN. Einhom A, Horton I, Altieri M, et al. Pediatrics. 1989;84:4724. In response to environmental concerns, phosphate detergents were replaced with nonphosphate detergents in the early 70s. Despite the long recognized potential for serious gastrointestinal injury following ingestion of sodium carbonate detergents, literature is scarce concerning the respiratory damage caused by detergents. This retrospective study reports 8 patients who were treated for ingestion of inhalation of nonphosphate detergent powder. All patients were 1 to 2 ‘/2 years
Abstracts
old. Each ingestion was thought to be “small” in all but one patient who was noted to vomit large amounts of detergent. Symptoms occurred within 2 hours in all patients except one who was felt to have mucosal injury to the mouth. The most common symptoms included stridor and drooling. Respiratory symptoms were present in 7 patients. Edema of the epiglottis was demonstrated by endoscopy or x-ray study in 6 patients. Four patients were intubated to protect the airway. All patients were extubated within 48 hours and were asymptomatic within 72 hours. The authors concluded that ingestion of nonphosphate detergent can cause severe upper airway compromise within 1 to 2 hours of ingestion. The amount of substance necessary to cause respiratory symptoms may be small. Because of the small number of patients, no specific recommendations for therapy could be made other than supportive and [Harold Skaggs, Jr, MD] airway control.
MUSCULOSKELETAL CHEST PAIN WITH ANGINA. Levine PR, Mascette AM. South Med J. 1989;82:580-5. Musculoskeletal chest pain is a recognized source of confusion in the diagnosis of chest pain. This prospective study evaluated patients referred for nonurgent coronary arteriography using a systemic physical examination protocol (involving 15 different maneuvers) to identify musculoskeletal sources of chest pain. A rheumatologist took a brief musculoskeletal history and then systematically examined each patient. For each maneuver, patients were asked whether there was no tenderness, tenderness not reproducing their chest pain, or tenderness reproducing their chest pain. They then underwent coronary arteriography after which two separate cardiologists classified them as typical angina, atypical angina, or nonanginal chest pain. Of the 62 patients evaluated, 7 (11%) had musculoskeletal tenderness that reproduced their chest pain. Of the 7, 6 had a normal or nonspecific resting electrocardiogram (EKG), 1 had EKG evidence of previous myocardial infarction. In 6 cases, the cardiologist’s prearteriography and postarteriography impression was nonanginal chest pain; in 1, the impression before and after arteriography was typical angina. Of the 7 patients, 5 had normal coronary angiograms. Of the 55 patients not having reproducible chest pain, 35 had significant coronary artery disease on arteriography . The authors concluded that the musculoskeletal examination should be an integral part of every cardiac evaluation and that the demonstration of musculoskeletal chest pain which reproduces the patient’s original discomfort, combined with the low suspicion of coronary artery disease based on noninvasive evaluation, could reduce the incidence of unnecessary invasive cardiac testing. [Harold L. Skaggs, Jr., MD] Editor’s Note: While the authors’ conclusions may in fact be true, this study does not provide sufficient evidence to conclude that the risk of coronary artery disease is any less in patients with chest tenderness reproducing their pain. I-J
0 RAPID REDUCTION OF SEVERE ASYMPTOMATIC HYPERTENSION. Zeller KR, Kuhnert LV, Matthews C. Arch Inter Med. 1989;146:2186-9. Rapid reduction of severe asymptomatic hypertension has become a common emergency department procedure. This study was designed to determine whether antihypertensive
359
loading is superior to the initiation of maintenance therapy without loading. Sixty-four asymptomatic patients with severe hypertension (116-139 mmHg) were randomized to treatment with either hourly doses of clonidine (4-dose maximum) and chlorthaldone followed by maintenance therapy (Group l), or an initial dose of clonidine followed by hourly placebo and subsequent maintenance therapy (Group 2), or initiation of maintenance therapy without prior loading (Group 3). Groups one and two showed no significant difference in the time required to reduce blood pressure to what were considered to be acceptable levels. Also, at 24 hours there was no significantdifference between the blood pressure in patients in Groups 1, 2, and 3. At one week, the 44 patients who were available for follow-up demonstrated adequate control of blood pressure without significant difference between the 3 groups. Significant mobidity was neither seen with, nor prevented by, rapidly lowering blood pressure in this study, though others studies showing morbidity secondary to rapid treatment were referenced. The authors concluded that in light of these data and the reported risk of antihypertensive loading that the common practice of acute oral antihypertensive loading to treat severe asymptomatic hypertension should be reconsidered. [Harold L. Skaggs, Jr., MD] Editor’s Note: This study supports what many have long suspected; that the “benefits” of rapid antihypertensive treatment in the emergency department are short-lived at best.
0 EVALUATION OF COLOEIMETIUC DIPSTICK TEST TO DETECT ALCOHOL IN SALIVA: A PILOT STUDY. Schwartz RH, O’Donnell RM, ‘l’home MM, Getson PR, Hicks JM. Ann Emerg Med. 1989;18:1001-3. This study estimated the accuracy of a dipstick test for detection of alcohol in saliva by comparing its results to simultaneously drawn serum alcohol levels in 53 patients brought to the emergency department for examination and evaluation of possible alcohol intoxication. The dipstick is placed under the patient’s tongue until it is saturated with saliva and then held for two minutes before being compared with the color chart. Different shades of green to blue determine levels of 0.0, 0.02, 0.05, 0.1, 0.3 g/dL. The dipstick was found to be 90.9% sensitive and 71.4% specific when the alcohol level was greater than 0.1 g/dl, but concordance at lower levels was poor. The authors conclude that the dipstick may be useful as a rapid screening test of the presence of alcohol, although definitive diagnosis of alcohol intoxication would require confirmation by another quantitative method. [Satish Patel, MD]
0 OCCUPATIONAL ILLNESS: CASE DETECTION BY POISON CONTROL SURVEILLANCE. Blanc PD, Rempel D, Maizlish N, et al. Ann Intern Med. 1989;111:2384. This prospective study elicited circumstances of exposure, symptoms, and health care from 461 symptomatic potential occupational exposure victims, health care providers, and involved third parties. These amounted to 7.8% of the nearly 6000 symptomatic cases logged during a 6-month period by the San Francisco Bay Area Regional Poison Control Center. One third (135) of study-eligible exposed persons declined or were
Patients with pyelonephritis had significantly more previous infections (usually otitis), and significantly more previous antibiotic therapy. There was also an increased incidence of UT1 among first degree relations of patients compared to controls. The authors concluded that alterations in the patients’ bacterial flora secondary to prior antibiotic use may play a role in increasing the risk of UTl. [Robin Johnson, MD] Editor’s Note: This study suggests that injudicious antibiotic therapy may result in adverse effects to a specific patient, as well as general effects borne by society at large (eg, development of resistance). However, other hypotheses such as underlying differences in host factors could just as easily explain these observations.
0 ST SEGMENT SHIFT IN UNSTABLE ANGINA: PATHOPHYSIOLOGY AND ASSOCIATION WITH CORONARY ANATOMY AND HOSPITAL OUTCOME. Langer A, Freeman MR, Armstrong PW. J Am Co11 Cardiol. 1989;13:1495-502. This prospective study was designed to test the hypothesis
that the presence of ST abnormality on admission electrocardiogram (ECG) and the presence and duration of S-T segment shift detected during 24-hour Holter monitoring early in the course of unstable angina predict angiographic severity of coronary artery disease and hospital outcome. One hundred thirty-five patients with unstable angina were followed with Holter monitoring in the fist 24 hours of hospital admission. S-T shift was evident in 44% of patients on admission ECG and in 66% on Holter monitor. During hospitalization, 7% had myocardial infarction, 4% died, and 34% had urgent coronary revascularization. Comparisons of patients with and without S-T shift on admission ECG revealed unfavorable outcome in 55% versus 25% (p < 0.025), multivessel disease in 77% versus 63% (p < 0.05), and left main coronary artery stenosis in 22% versus 7% (p < 0.025). When patients with and without S-T shift on Holter monitor ECG were compared, an unfavorable outcome was found in 48% versus 20% (p < O.OOS),multivessel disease in 76% versus 54% @ < O.Ol), and left main coronary stenosis in 18% versus 4% @ < 0.05). The duration of S-T shift was also greater in patients with unfavorable outcome, multivessel disease, or left main stenosis. A total of 593 episodes of S-T shift were recorded by Holter monitor, and only 8% were symptomatic; when compared with asymptomatic episodes, they were of longer duration and had greater magnitude. Continuous blood pressure and heart rate recording in 446 episodes showed an increase in rate pressure product at 20 and 10 minutes before onset of S-T shift as well as at the time of S-T shift, as compared with the 2 hours baseline value. The authors conclude that noninvasive tests can stratify patients with unstable angina into prognostic subsets with respect to hospital outcome and coronary anatomy, and that episodes of S-T shift associated with symptoms have greater magnitude and are of longer duration; these may be mediated in part by increased myocardial oxygen demand as defined by an increase in rate pressure product. [Napoleon B. Knight, Jr., MD]
CAUSE OF DEATH FOR PATIENTS WITH SPINAL CORD INJURIES. DeVivo MJ, Kartus PL, Stover SL, et al. Arch Intern Med. 1989;149:1761-66. 0
The Journal of Emergency
Medicine
The authors analyzed the cause of death in 5,131 patients sustaining spinal cord injuries between 1973 and 1980. Patients studied had been admitted to 1 of 7 federally designated regional spinal cord injury care systems and survived for at least 24 hours after injury. Patient follow-up was terminated December 31, 198 1, and only deaths occurring prior to this date were considered. At the end of the follow-up period, 459 patients (9%) had died. Overall, the leading cause of death was pneumonia, followed by unintentional injuries and suicides. Pneumonia was the leading cause of death among quadriplegics and persons at least 55 years of age, while among paraplegics and persons less than 55 years of age, unintentional injuries and suicides were the leading cause of death. Deaths from septicemia usually resulted from severe pressure sores or urinary tract infections. [John McGoldrick, MD]
I-J CERVICAL SPINE FRACTURES SUSTAINED BY YOUNG CHILDREN IN FORWARD FACING CAR SEATS. Fuch S, Barthel MJ, Flannery AM, Cristoffel KK.
Pediatrics. 1989;84:348-54.
Child passenger safety restraint laws have markedly reduced the number of fatalities to children in motor vehicle accidents. However, with the increased use of child safety seats there is the potential for different and more survivable injuries, including cervical spine injuries. The authors looked at a variety of factors in 5 cases of cervical spine injury of young children presenting to their emergency department to assess the variables contributing to cervical spine injury associated with car safety seats. The type and speed of vehicle, direction of impact, intrusion, weather, make and model of car safety seat, position of child and safety seat, method of restraining both child and seat, and restraint and injury to all other occupants were all assessed. In 3 cases the car safety seat was used incorrectly. In one of the other cases the speed of the vehicle was greater than NHTSA crash standards. The authors suggest that misuse of car seats along with anatomic and biomechanical factors in the cervical spines of children appear to have contributed to the occurrence of previously rare pediatric cervical spine injury. [Elizabeth L. Mitchell, MD] Editor’s Note: The authors of this paper quite justifiably label their conclusions as speculative, since existing evidence suggests that 70% to 80% of all child restraints are improperly used. The important point of this paper is that there are no unmixed blessings in medicine; every step forward will inevitably produce not only saved lives, but new and different injuries in new and different frequencies.
0 SERIOUS RESPIRATORY CONSEQUENCES OF DETERGENT INGESTION IN CHILDREN. Einhom A, Horton I, Altieri M, et al. Pediatrics. 1989;84:4724. In response to environmental concerns, phosphate detergents were replaced with nonphosphate detergents in the early 70s. Despite the long recognized potential for serious gastrointestinal injury following ingestion of sodium carbonate detergents, literature is scarce concerning the respiratory damage caused by detergents. This retrospective study reports 8 patients who were treated for ingestion of inhalation of nonphosphate detergent powder. All patients were 1 to 2 ‘/2 years
Abstracts
old. Each ingestion was thought to be “small” in all but one patient who was noted to vomit large amounts of detergent. Symptoms occurred within 2 hours in all patients except one who was felt to have mucosal injury to the mouth. The most common symptoms included stridor and drooling. Respiratory symptoms were present in 7 patients. Edema of the epiglottis was demonstrated by endoscopy or x-ray study in 6 patients. Four patients were intubated to protect the airway. All patients were extubated within 48 hours and were asymptomatic within 72 hours. The authors concluded that ingestion of nonphosphate detergent can cause severe upper airway compromise within 1 to 2 hours of ingestion. The amount of substance necessary to cause respiratory symptoms may be small. Because of the small number of patients, no specific recommendations for therapy could be made other than supportive and [Harold Skaggs, Jr, MD] airway control.
MUSCULOSKELETAL CHEST PAIN WITH ANGINA. Levine PR, Mascette AM. South Med J. 1989;82:580-5. Musculoskeletal chest pain is a recognized source of confusion in the diagnosis of chest pain. This prospective study evaluated patients referred for nonurgent coronary arteriography using a systemic physical examination protocol (involving 15 different maneuvers) to identify musculoskeletal sources of chest pain. A rheumatologist took a brief musculoskeletal history and then systematically examined each patient. For each maneuver, patients were asked whether there was no tenderness, tenderness not reproducing their chest pain, or tenderness reproducing their chest pain. They then underwent coronary arteriography after which two separate cardiologists classified them as typical angina, atypical angina, or nonanginal chest pain. Of the 62 patients evaluated, 7 (11%) had musculoskeletal tenderness that reproduced their chest pain. Of the 7, 6 had a normal or nonspecific resting electrocardiogram (EKG), 1 had EKG evidence of previous myocardial infarction. In 6 cases, the cardiologist’s prearteriography and postarteriography impression was nonanginal chest pain; in 1, the impression before and after arteriography was typical angina. Of the 7 patients, 5 had normal coronary angiograms. Of the 55 patients not having reproducible chest pain, 35 had significant coronary artery disease on arteriography . The authors concluded that the musculoskeletal examination should be an integral part of every cardiac evaluation and that the demonstration of musculoskeletal chest pain which reproduces the patient’s original discomfort, combined with the low suspicion of coronary artery disease based on noninvasive evaluation, could reduce the incidence of unnecessary invasive cardiac testing. [Harold L. Skaggs, Jr., MD] Editor’s Note: While the authors’ conclusions may in fact be true, this study does not provide sufficient evidence to conclude that the risk of coronary artery disease is any less in patients with chest tenderness reproducing their pain. I-J
0 RAPID REDUCTION OF SEVERE ASYMPTOMATIC HYPERTENSION. Zeller KR, Kuhnert LV, Matthews C. Arch Inter Med. 1989;146:2186-9. Rapid reduction of severe asymptomatic hypertension has become a common emergency department procedure. This study was designed to determine whether antihypertensive
359
loading is superior to the initiation of maintenance therapy without loading. Sixty-four asymptomatic patients with severe hypertension (116-139 mmHg) were randomized to treatment with either hourly doses of clonidine (4-dose maximum) and chlorthaldone followed by maintenance therapy (Group l), or an initial dose of clonidine followed by hourly placebo and subsequent maintenance therapy (Group 2), or initiation of maintenance therapy without prior loading (Group 3). Groups one and two showed no significant difference in the time required to reduce blood pressure to what were considered to be acceptable levels. Also, at 24 hours there was no significantdifference between the blood pressure in patients in Groups 1, 2, and 3. At one week, the 44 patients who were available for follow-up demonstrated adequate control of blood pressure without significant difference between the 3 groups. Significant mobidity was neither seen with, nor prevented by, rapidly lowering blood pressure in this study, though others studies showing morbidity secondary to rapid treatment were referenced. The authors concluded that in light of these data and the reported risk of antihypertensive loading that the common practice of acute oral antihypertensive loading to treat severe asymptomatic hypertension should be reconsidered. [Harold L. Skaggs, Jr., MD] Editor’s Note: This study supports what many have long suspected; that the “benefits” of rapid antihypertensive treatment in the emergency department are short-lived at best.
0 EVALUATION OF COLOEIMETIUC DIPSTICK TEST TO DETECT ALCOHOL IN SALIVA: A PILOT STUDY. Schwartz RH, O’Donnell RM, ‘l’home MM, Getson PR, Hicks JM. Ann Emerg Med. 1989;18:1001-3. This study estimated the accuracy of a dipstick test for detection of alcohol in saliva by comparing its results to simultaneously drawn serum alcohol levels in 53 patients brought to the emergency department for examination and evaluation of possible alcohol intoxication. The dipstick is placed under the patient’s tongue until it is saturated with saliva and then held for two minutes before being compared with the color chart. Different shades of green to blue determine levels of 0.0, 0.02, 0.05, 0.1, 0.3 g/dL. The dipstick was found to be 90.9% sensitive and 71.4% specific when the alcohol level was greater than 0.1 g/dl, but concordance at lower levels was poor. The authors conclude that the dipstick may be useful as a rapid screening test of the presence of alcohol, although definitive diagnosis of alcohol intoxication would require confirmation by another quantitative method. [Satish Patel, MD]
0 OCCUPATIONAL ILLNESS: CASE DETECTION BY POISON CONTROL SURVEILLANCE. Blanc PD, Rempel D, Maizlish N, et al. Ann Intern Med. 1989;111:2384. This prospective study elicited circumstances of exposure, symptoms, and health care from 461 symptomatic potential occupational exposure victims, health care providers, and involved third parties. These amounted to 7.8% of the nearly 6000 symptomatic cases logged during a 6-month period by the San Francisco Bay Area Regional Poison Control Center. One third (135) of study-eligible exposed persons declined or were