- Email: [email protected]
Smoke inhalation injury: Evaluation of radiographic manifestations and pulmonary dysfunction
Abstracts in this issue were prepared by residents in the Denver General/St Anthony's/St Joseph Hospitals Emergency Medicine Residency Program.
ABSTRACTS Harvey W Meislin, MD, FACEP Section 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
deep venous thrombosis, cellulitis
O e d e m a protein c o n c e n t r a t i o n s for d i f f e r e n t i a t i o n of cellulitis and d e e p venous thrombosis Berlyne GM, Li J, Kwan T, et al Lancet 728-729
Sep 1989
Edema fluid from 15 inpatients with previously known diagnoses of cellulitis (five) or deep venous thrombosis (nine), with an acutely swollen, hot leg was obtained to determine if the tissue-fluid protein concentration could help differentiate between deep venous thrombosis and cellulitis. The mean tissue-fluid protein concentration in deep venous thrombosis was 5.5 g/L compared with 19.8 g/L in cellulitis (P < .001). There was no overlap between the high tissue-fluid protein concentrations in cellulitis and the much lower levels in deep venous thrombosis. Tissue-fluid was obtained from the swollen leg by aspiration through a 25-gauge needle, and protein levels were measured with colorimetry. The diagnosis of deep venous thrombosis was confirmed by venography or Doppler ultrasound. [Editor's note: This simple, accurate technique m a y be a useful screening test when venography or Doppler ultrasound is not readily available.]
blood flow was significantly reduced in both the cocaine bolus and infusion groups (26% and 38%, respectively) but unchanged in the control group. Cocaine caused significant reduction in heart rate (17% with bolus protocol, 14% with infusion protocol, no change in saline protocol). Left ventrieular dP/dt was decreased in all groups (bolus, 34%; infusion, 41%; saline, 8%). While cocaine had no effect on systemic arterial pressure or left ventricular pressure, left ventricular end-diastolic pressure was increased. No ECG changes were noted in the control group but PR and QT intervals were significantly lengthened with cocaine administration. Echocardiograms revealed dilation of the left ventricle in both cocaine-treated groups. A second protocol was performed to determine if cocaine causes vasoconstriction of coronary arteries. Seven dogs received a cocaine bolus (10 mg/kg), and two control dogs received a saline bolus. Coronary angiogram was performed prior to treatment and repeated three to five minutes after injection. Circumflex artery diameter did not change in the control group; however, in cocaine-treated dogs, the circumflex artery diameter was reduced 15 -+ 4% (P < .04) with a range of 2% to 29%. It was concluded that in this study model rapidly administered cocaine depresses left ventricular function, causes left ventricular dilation, and is associated with coronary artery vasoconstriction and reduced myocardial blood flow.
James Bodenhamer, MD
Marc A Davis, MD smoke inhalation cocaine, cardiovascular effects
S m o k e i n h a l a t i o n injury: Evaluation of r a d i o g r a p h i c m a n i f e s t a t i o n s and p u l m o n a r y dysfunction
A d v e r s e e f f e c t s of c o c a i n e on c a r d i o v a s c u l a r d y n a m i c s , m y o c a r d i a l blood flow, and c o r o n a r y a r t e r y d i a m e t e r in an experimental model
J Trauma 29:1232-1239
Hale SL, Alker KJ, Rezkalla S, et al
Sep 1989
Peitzman AB, Shires GT, Teixidor HS, et al
Am J Heart 118:927-933
Nov 1989
This animal study evaluated the cardiac effects of large, rapidly administered doses of IV cocaine. The purpose was to recreate the rapidly peaking, high blood levels of cocaine that can occur with cocaine inhalation or IV administration. Eighteen pentobarbital-anesthetized dogs were randomized into three treatment groups - six received a cocaine bolus (10 mg/kg), six received a cocaine infusion (10 mg/kg) over ten minutes, and six received saline. Fifteen minutes after initiation of treatment, subepicardial 19:3 March 1990
Inhalation injury is seen frequently in burned patients, and pulmonary parenchymal damage secondary to smoke inhalation can be difficult to diagnose. Twenty-nine patients with severe burns (average percentage of body burns, 59 -+ 5% ) were studied. All underwent bronchoscopy or laryngoscopy on admission and 25 of 29 were intubated for endoscopic evidence of upper airway injury or clinical respiratory insufficiency. During the first five days of hospitalization, daily chest radiographs were graded: 0 (normal), 1 + (peribronchial cuffing or perivascular edema), 2 + (edema involving one third of the lung field), and 4 +
Annals of EmergencyMedicine
344/189
ABSTRACTS
(edema involving the entire lung field). Extravascular lung water volume was measured in vivo with the thermal/ green dye double indicator technique. Within 48 hours after injury, 84% showed some abnormality on chest radiograph. When chest radiograph abnormalities were present, pulmonary dysfunction (increased extravascular lung water volume, increased intrapulmonary shunt fraction, decreased compliance) was present in 92% of patients. It is suggested that this grading scale may be useful in reports of chest radiography findings in severe inhalation injuries.
Cynthia Elliott, MD
larynx, laryngeal fractures
Evaluation and treatment laryngeal fractures
John McGoldrick, MD
of a c u t e
Schild JA, Denneny EC Head Neck Surg 11:491-496 Nov/Dec 1989
superwarfarin, poisoning
Laryngeal trauma presents in many forms, and both the laryngeal mucosa and the underlying cartilagenous skeleton must be adequately evaluated and repaired when necessary. Fifteen consecutive cases of blunt and penetrating laryngeal trauma were reviewed during a five-year period to determine the value of computed tomography (CT) and photographic documentation. Three patients had penetrating injuries and 12 had blunt neck trauma. Symptoms ranged from mild neck discomfort to hoarseness and dyspnea. Injuries included soft tissue contusions or lacerations (11), fractures of the thyroid cartilage (seven), cricoid epiglottic ligament (one), and cricotracheal separation (one). Eight patients required surgery, were later extubated, and were talking at discharge. Endoscopic photographs were considered valuable in assessing patient's progress, especially in the more severe injuries. CT was found to be valuable in all cases because it enabled accurate evaluation of soft tissue trauma and delineation of the presence and displacement of any fractures. In evaluation of the cricoarytenoid area, the CT scans enabled better visualization than did plain films.
Cynthia Elliott, MD
Vibrio cholera
C h o l e r a in L o u i s i a n a Lowry PW, Pavia AT, McFarland LM, et al Arch Intern Med 149:2079-2084 Sep 1989
A retrospective analysis of the 1986 cholera outbreak in Louisiana, the largest cholera outbreak in the United States in more than a century, was performed. Eighteen
190/345
persons in 12 family clusters had stool culture or serologic evidence of infection with toxigenic W b r i o cholerae 0-group 1. All 18 patients survived; four required intensive care support. A case control study showed that case patients were more likely than neighborhood control subjects to have eaten cooked crabs or cooked or raw shrimp during the week before illness. A third vehicle from the Gulf waters, raw oysters, caused V cholerae 01 infection in two persons residing in Florida and Georgia. Stool isolates from the Louisiana case patients were genetically identical to other North American strains isolated since 1973, but differed from African and Asian isolates. It was concluded that a persisting reservoir of V cholerae 01 along the Gulf coast may continue to cause sporadic cases and outbreaks of cholera in Gulf states and in states importing Gulf seafood, particularly crabs, shrimp, and oysters.
S u p e r w a r f a r i n p o i s o n i n g in c h i l d r e n : A prospective study Smolinske SC, Sherger DL, Kearns PS, et al Pediatr 84:490-494 Sep 1989
Anticoagulant rodenticides act like long-acting, superpotent coumadin. Intentional adult ingestions ranging from three to 36 bait packets have been reported with prolonged prothrombin times and clinical evidence of bleeding. Accidental ingestions in children are not uncommon but have not been reported previously. This prospective study looked at incidence, severity, time of onset, and duration of coagulopathy in acute superwarfarin ingestions in the pediatric population. All cases reported to the Rocky Mountain Poison Center over an eight-month period in children 12 years or younger were entered in the study. Data on 121 children included age, weight, product type, amount of ingestion if known, presence of blue/ green dye in or around mouth, prothrombin time (PT), symptoms, and any treatment. Eleven patients were excluded for lack of PT values or lack of short-term followup. One hundred ten patients were included in the study, ranging in age from 7 months to 4 years. All patients had at least one PT value, 26 had two values, and three had three values. An abnormal value was considered 1.2 or more patient to control. Eight patients (7.3%) had one or more abnormal values. A P T value at 48 hours was significantly more likely to be abnormal than a 24-hour value (17.6% vs 1.9%). No short-term clinical sequelae were noted in any patient. Long-term follow-up was lost in four of the eight patients with abnormal PTs. No long-term sequelae were noted in the four patients who were followed. Rodenticide ingestions are a serious and not uncommon problem in pediatrics. It is important that PT values be determined at both 24- and 48-hour intervals in any his-
Annals of EmergencyMedicine
19:3 March 1990
ABSTRACTS Harvey W Meislin, MD, FACEP Section 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
deep venous thrombosis, cellulitis
O e d e m a protein c o n c e n t r a t i o n s for d i f f e r e n t i a t i o n of cellulitis and d e e p venous thrombosis Berlyne GM, Li J, Kwan T, et al Lancet 728-729
Sep 1989
Edema fluid from 15 inpatients with previously known diagnoses of cellulitis (five) or deep venous thrombosis (nine), with an acutely swollen, hot leg was obtained to determine if the tissue-fluid protein concentration could help differentiate between deep venous thrombosis and cellulitis. The mean tissue-fluid protein concentration in deep venous thrombosis was 5.5 g/L compared with 19.8 g/L in cellulitis (P < .001). There was no overlap between the high tissue-fluid protein concentrations in cellulitis and the much lower levels in deep venous thrombosis. Tissue-fluid was obtained from the swollen leg by aspiration through a 25-gauge needle, and protein levels were measured with colorimetry. The diagnosis of deep venous thrombosis was confirmed by venography or Doppler ultrasound. [Editor's note: This simple, accurate technique m a y be a useful screening test when venography or Doppler ultrasound is not readily available.]
blood flow was significantly reduced in both the cocaine bolus and infusion groups (26% and 38%, respectively) but unchanged in the control group. Cocaine caused significant reduction in heart rate (17% with bolus protocol, 14% with infusion protocol, no change in saline protocol). Left ventrieular dP/dt was decreased in all groups (bolus, 34%; infusion, 41%; saline, 8%). While cocaine had no effect on systemic arterial pressure or left ventricular pressure, left ventricular end-diastolic pressure was increased. No ECG changes were noted in the control group but PR and QT intervals were significantly lengthened with cocaine administration. Echocardiograms revealed dilation of the left ventricle in both cocaine-treated groups. A second protocol was performed to determine if cocaine causes vasoconstriction of coronary arteries. Seven dogs received a cocaine bolus (10 mg/kg), and two control dogs received a saline bolus. Coronary angiogram was performed prior to treatment and repeated three to five minutes after injection. Circumflex artery diameter did not change in the control group; however, in cocaine-treated dogs, the circumflex artery diameter was reduced 15 -+ 4% (P < .04) with a range of 2% to 29%. It was concluded that in this study model rapidly administered cocaine depresses left ventricular function, causes left ventricular dilation, and is associated with coronary artery vasoconstriction and reduced myocardial blood flow.
James Bodenhamer, MD
Marc A Davis, MD smoke inhalation cocaine, cardiovascular effects
S m o k e i n h a l a t i o n injury: Evaluation of r a d i o g r a p h i c m a n i f e s t a t i o n s and p u l m o n a r y dysfunction
A d v e r s e e f f e c t s of c o c a i n e on c a r d i o v a s c u l a r d y n a m i c s , m y o c a r d i a l blood flow, and c o r o n a r y a r t e r y d i a m e t e r in an experimental model
J Trauma 29:1232-1239
Hale SL, Alker KJ, Rezkalla S, et al
Sep 1989
Peitzman AB, Shires GT, Teixidor HS, et al
Am J Heart 118:927-933
Nov 1989
This animal study evaluated the cardiac effects of large, rapidly administered doses of IV cocaine. The purpose was to recreate the rapidly peaking, high blood levels of cocaine that can occur with cocaine inhalation or IV administration. Eighteen pentobarbital-anesthetized dogs were randomized into three treatment groups - six received a cocaine bolus (10 mg/kg), six received a cocaine infusion (10 mg/kg) over ten minutes, and six received saline. Fifteen minutes after initiation of treatment, subepicardial 19:3 March 1990
Inhalation injury is seen frequently in burned patients, and pulmonary parenchymal damage secondary to smoke inhalation can be difficult to diagnose. Twenty-nine patients with severe burns (average percentage of body burns, 59 -+ 5% ) were studied. All underwent bronchoscopy or laryngoscopy on admission and 25 of 29 were intubated for endoscopic evidence of upper airway injury or clinical respiratory insufficiency. During the first five days of hospitalization, daily chest radiographs were graded: 0 (normal), 1 + (peribronchial cuffing or perivascular edema), 2 + (edema involving one third of the lung field), and 4 +
Annals of EmergencyMedicine
344/189
ABSTRACTS
(edema involving the entire lung field). Extravascular lung water volume was measured in vivo with the thermal/ green dye double indicator technique. Within 48 hours after injury, 84% showed some abnormality on chest radiograph. When chest radiograph abnormalities were present, pulmonary dysfunction (increased extravascular lung water volume, increased intrapulmonary shunt fraction, decreased compliance) was present in 92% of patients. It is suggested that this grading scale may be useful in reports of chest radiography findings in severe inhalation injuries.
Cynthia Elliott, MD
larynx, laryngeal fractures
Evaluation and treatment laryngeal fractures
John McGoldrick, MD
of a c u t e
Schild JA, Denneny EC Head Neck Surg 11:491-496 Nov/Dec 1989
superwarfarin, poisoning
Laryngeal trauma presents in many forms, and both the laryngeal mucosa and the underlying cartilagenous skeleton must be adequately evaluated and repaired when necessary. Fifteen consecutive cases of blunt and penetrating laryngeal trauma were reviewed during a five-year period to determine the value of computed tomography (CT) and photographic documentation. Three patients had penetrating injuries and 12 had blunt neck trauma. Symptoms ranged from mild neck discomfort to hoarseness and dyspnea. Injuries included soft tissue contusions or lacerations (11), fractures of the thyroid cartilage (seven), cricoid epiglottic ligament (one), and cricotracheal separation (one). Eight patients required surgery, were later extubated, and were talking at discharge. Endoscopic photographs were considered valuable in assessing patient's progress, especially in the more severe injuries. CT was found to be valuable in all cases because it enabled accurate evaluation of soft tissue trauma and delineation of the presence and displacement of any fractures. In evaluation of the cricoarytenoid area, the CT scans enabled better visualization than did plain films.
Cynthia Elliott, MD
Vibrio cholera
C h o l e r a in L o u i s i a n a Lowry PW, Pavia AT, McFarland LM, et al Arch Intern Med 149:2079-2084 Sep 1989
A retrospective analysis of the 1986 cholera outbreak in Louisiana, the largest cholera outbreak in the United States in more than a century, was performed. Eighteen
190/345
persons in 12 family clusters had stool culture or serologic evidence of infection with toxigenic W b r i o cholerae 0-group 1. All 18 patients survived; four required intensive care support. A case control study showed that case patients were more likely than neighborhood control subjects to have eaten cooked crabs or cooked or raw shrimp during the week before illness. A third vehicle from the Gulf waters, raw oysters, caused V cholerae 01 infection in two persons residing in Florida and Georgia. Stool isolates from the Louisiana case patients were genetically identical to other North American strains isolated since 1973, but differed from African and Asian isolates. It was concluded that a persisting reservoir of V cholerae 01 along the Gulf coast may continue to cause sporadic cases and outbreaks of cholera in Gulf states and in states importing Gulf seafood, particularly crabs, shrimp, and oysters.
S u p e r w a r f a r i n p o i s o n i n g in c h i l d r e n : A prospective study Smolinske SC, Sherger DL, Kearns PS, et al Pediatr 84:490-494 Sep 1989
Anticoagulant rodenticides act like long-acting, superpotent coumadin. Intentional adult ingestions ranging from three to 36 bait packets have been reported with prolonged prothrombin times and clinical evidence of bleeding. Accidental ingestions in children are not uncommon but have not been reported previously. This prospective study looked at incidence, severity, time of onset, and duration of coagulopathy in acute superwarfarin ingestions in the pediatric population. All cases reported to the Rocky Mountain Poison Center over an eight-month period in children 12 years or younger were entered in the study. Data on 121 children included age, weight, product type, amount of ingestion if known, presence of blue/ green dye in or around mouth, prothrombin time (PT), symptoms, and any treatment. Eleven patients were excluded for lack of PT values or lack of short-term followup. One hundred ten patients were included in the study, ranging in age from 7 months to 4 years. All patients had at least one PT value, 26 had two values, and three had three values. An abnormal value was considered 1.2 or more patient to control. Eight patients (7.3%) had one or more abnormal values. A P T value at 48 hours was significantly more likely to be abnormal than a 24-hour value (17.6% vs 1.9%). No short-term clinical sequelae were noted in any patient. Long-term follow-up was lost in four of the eight patients with abnormal PTs. No long-term sequelae were noted in the four patients who were followed. Rodenticide ingestions are a serious and not uncommon problem in pediatrics. It is important that PT values be determined at both 24- and 48-hour intervals in any his-
Annals of EmergencyMedicine
19:3 March 1990