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Synchronous intrauterine and ectopic pregnancy associated with clomiphene citrate
Abstracts in this issue were prepared by residents in the DenverGeneral/St Anthony's/St Joseph Hospitals Emergency Medicine Residency Program.
ABSTRACTS Vincent J Markovchick, MD, FACEP Co-Editor Emergency Medical Services Denver General Hospital
Harvey W Meislin, MD, FACEP Section Co-Editor Section of Emergency Medicine University of Arizona College of Medicine
'myocardial infarction, ECG
Electrocardiographic m a n i f e s t a t i o n s of right ventricular infarction Robalino BD, Whitlow PL, Underwood DA, et al Am Heart J 118:138-144
Ju11989
This collective review with 37 references studied electrocardiographic signs of right ventricular infarction (RVI). Several large autopsy studies of patients with myocardial infarctions report the incidence of isolated RVI to be 1.7% to 2.4%; however, RVI accompanying left ventricular infarction occurs in 3% to 43%. While early recognition of RVI may be subtle, it is important as RVI diagnosis can have both therapeutic and prognostic implications. Standard ECG findings suspicious for RVI include acute transmural inferior infarction, ST elevation in lead V] without other explanation, and right bundle branch or complete heart block in the setting of an inferior myocardial infarction. If RVI is suspected, then right-sided precordial leads are of great diagnostic value. The most important findings were ST elevations in the right precordial leads. V4R has the most diagnostic sensitivity, between 76% and 100%, specificity between 40% and 100%, and predictive value between 56% and 100% depending on the study. Therefore, obtaining right-sided precordial leads is recommended in all patients with standard ECG findings suspicious for RVI.
James Bodenhamer, MD
in six patients with fractures. Eight patients presented with complete paraplegia, one with incomplete motor loss, and four with no deficit. Four cases of cervical spine fractures and only two cases of lumbar spine fracture were identified in this study population. Of the 13 patients with thoracic spine injury, witnesses or the patient described catapulting over the handlebars as the mechanism of injury. Thoracic spine immobilization of all motorcycle accident victims should be performed in the field. Careful evaluation of the entire spine, especially the thoracic spine, should be performed in the emergency department. In those motorcycle accident victims who have catapulted over the handlebars or in whom a reliable history or clinical examination cannot be obtained, a full thoracic radiographic examination is recommended. [Edftor's n o t e :
Cervical spine is very routine in the evaluation of multiple trauma patients. This study highlights the relatively high incidence of thoracic spine injury in comparison with cervical and lumbar spine injury in motorcycle accident victims and the need to consider thoracic spine films as well as the routine cervical spine series.] Cynthia Elliott, MD
ectopic pregnancy, clomiphene citrate, pelvic ultrasound
Synchronous intrauterine and ec t o p ic p r e g n a n c y a s s o c i a t e d with c l o m i p h e n e citrate Raccuia JS, Neckles S, Butler D, et al Surg Gynecol Obstet 168:417-420
May 1989 motorcycles, spinal injuries
Thoracic spine injuries in vi ct i ms of motorcycle a c c i d e n t s J Trauma 29:593-596
May 1989
A retrospective review of motorcycle accident victims admitted during a 42-month period revealed 266 admissions with 164 of these requiring admission to the trauma intensive care unit (TICU). During this time period, 13 cases of thoracic spine injury were identified corresponding to 5% of all motorcycle accident admissions and 8% of those admitted to TICU. Single-level thoracic fractures were seen in seven and multiple levels were seen in six patients. T-7 was the most frequently involved level, seen 18:11 November1989
Although the simultaneous presence of both intrauterine and ectopic pregnancies is very rare, the incidence associated with the use of clomiphene citrate for infertility is probably much higher. In a 12-month period, four w o m e n treated with clomiphene citrate for infertility were diagnosed as having concomitant intra- and extrauterine pregnancies at one institution. In three, pelvic ultrasound, with visualization of a viable intrauterine pregnancy, was used to rule out ectopic gestation. One woman was diagnosed clinically without immediate preoperative sonogram. All women had peritoneal signs and symptoms suggestive of possible ruptured ectopic pregnancy and were operated on within a short time of presentation. In all cases, the products of the ectopic gestation were evacuated with three women delivering normal infants at full term and the fourth spontaneously aborting the intra-
Annals of Emergency Medicine
1251/169
ABSTRACTS
uterine pregnancy. It is concluded that the possibility of a false-negative ultrasound for ectopic gestation is more than previously believed and a viable intrauterine pregnancy associated with the use of clomiphene citrate may no longer be sufficient to rule out ectopic gestation.
Patricia L Johnson, MD
ultrasound, first-trimester pregnancy
Ultrasound changes way doctors view pregnancy Flisak ME
Diagn Imag 7:104-107 Jul 1989
In this collective review, the use of ultrasound in firsttrimester pregnancy in the evaluation of threatened abortion and ectopic pregnancy is reviewed. Gestational sacs 5 to 10 m m in diameter are easily seen with modern ultrasound equipment, using both transabdominal and transvaginal scanning techniques. This corresponds to about five to six weeks gestation by menstrual dates. The presence of a double decidual sac appearance differentiates the early gestational sac from the pseudosac of ectopic pregnancy. An intrauterine gestationa] sac should always be seen when the quantitative h u m a n chorianic gonadotropin (hCG) level is greater than 1,800 mIU/mL. Highresolution transabdomina] equipment has advanced the recognition of structure by one to two weeks and demonstrates cardiac activity by the sixth gestational week. Transvaginal equipment has shown that cardiac activity is almost always present at the time the embryonic disk can be identified as a focal area of thickening adjacent to the yolk sac, between the fourth and fifth gestational weeks. If an intrauterine gestational sac is detected by sonography, the risk of harboring an ectopic pregnancy is negligible. The quoted estimate for coincidental intra- and extrauterine pregnancies is 1:30,000 cases and may be 1:7,000 in the high-risk population undergoing ovulation induction.
John McGoldrick, MD
olecranon bursitis, surface temperature
Septic and nonseptic olecranon bursitis Smith DL, McAfee JH, Lucas LM, et al Arch Intern Med 149:1581-1585 Jul 1989
A prospective study of 46 consecutive patients presenting with olecranon bursitis during a one-year period was performed. Eleven cases were septic and 35 cases were nonseptic as determined by positive or negative cultures.
170/1252
In addition to bursal fluid analysis, the surface temperature over the involved olecranon bursa and the contralateral (control) oleeranon process was measured with a surface temperature probe. In nonseptic cases, the mean surface temperature difference was 0.7 C versus 3.7 C in septic cases (P = .0001). In all cases, the temperature dif- i ference was 2.2 C or more. The use of the surface probe i; temperature difference was 100% sensitive and 94% spe-': cific in discriminating septic from nonseptic cases. In fact, it was more accurate than the bursal fluid leukocyte count, the predominant cell type, or Gram's stain in the early differentiation of septic and nonseptic olecranon bursitis. It is recommended that all patients with a surface temperature difference of more than 2.2 C be started on antibiotics pending culture results regardless of Gram's stain or cell count results. [Editor's note: This is a poten-
tially useful diagnostic tool in differentiating septic from nonseptic bursitis, which perhaps may be helpful in differentiating septic from nonseptic joints and other bursitis. However, most emergency departments do not have the equipment necessary to accurately measure surface skin temperatures.] John McGoldrick, MD cardiac ischemia
S t u d i e s on p r o l o n g e d a c u t e r e g i o n a l i s c h e m i a . I. E v i d e n c e for p r e s e r v e d c e l l u l a r v i a b i l i t y a f t e r 6 h o u r s of c o r o n a r y o c c l u s i o n Beyersdorf F, Alen BS, Buckberg GD, et al
J Thorac Cardiovasc Surg 98:112-126 Jul 1989
Six hours has been considered the duration of coronary occlusion that prodffces such extensive transmural necrosis that muscle salvage by reperfusion is unlikely. Presented is a study of 20 open-chest anesthetized dogs who underwent severe regional ischemia produced by proximal ligation of the left anterior descending coronary artery for six hours. Eight of the 20 did not undergo ischemia and served as controls. Transmural biopsy specimens were analyzed. Coronary occlusion resulted in decreased regional blood flow to less than i0 mL/100 g/min, and dyskinesia persisted in the area at risk for six hours. Myocardial highenergy phosphates (adenosine triphosphate and creatine phosphate) decreased to negligible levels in both the epicardial and endocardial muscle layers. There was nearcomplete loss of tissue adenosine triphosphate. Histochemical damage, as evidenced with triphenyhetrazolium chloride nonstaining, occurred in 49%. Mitochondrial calcium content was increased and there was a marked depletion of tissue glutamate, alphaketoglutarate, and oxaloacetic acid. Despite these predictable changes associated with severe ischemia, the cardiac uhrastructure demonstrated only mild impairment of structural integrity. The myofibrils were intact and the sarcoplasmic reticulum and sarcolemma did not differ from nonischemic
Annals of EmergencyMedicine
18:11 November 1989
ABSTRACTS Vincent J Markovchick, MD, FACEP Co-Editor Emergency Medical Services Denver General Hospital
Harvey W Meislin, MD, FACEP Section Co-Editor Section of Emergency Medicine University of Arizona College of Medicine
'myocardial infarction, ECG
Electrocardiographic m a n i f e s t a t i o n s of right ventricular infarction Robalino BD, Whitlow PL, Underwood DA, et al Am Heart J 118:138-144
Ju11989
This collective review with 37 references studied electrocardiographic signs of right ventricular infarction (RVI). Several large autopsy studies of patients with myocardial infarctions report the incidence of isolated RVI to be 1.7% to 2.4%; however, RVI accompanying left ventricular infarction occurs in 3% to 43%. While early recognition of RVI may be subtle, it is important as RVI diagnosis can have both therapeutic and prognostic implications. Standard ECG findings suspicious for RVI include acute transmural inferior infarction, ST elevation in lead V] without other explanation, and right bundle branch or complete heart block in the setting of an inferior myocardial infarction. If RVI is suspected, then right-sided precordial leads are of great diagnostic value. The most important findings were ST elevations in the right precordial leads. V4R has the most diagnostic sensitivity, between 76% and 100%, specificity between 40% and 100%, and predictive value between 56% and 100% depending on the study. Therefore, obtaining right-sided precordial leads is recommended in all patients with standard ECG findings suspicious for RVI.
James Bodenhamer, MD
in six patients with fractures. Eight patients presented with complete paraplegia, one with incomplete motor loss, and four with no deficit. Four cases of cervical spine fractures and only two cases of lumbar spine fracture were identified in this study population. Of the 13 patients with thoracic spine injury, witnesses or the patient described catapulting over the handlebars as the mechanism of injury. Thoracic spine immobilization of all motorcycle accident victims should be performed in the field. Careful evaluation of the entire spine, especially the thoracic spine, should be performed in the emergency department. In those motorcycle accident victims who have catapulted over the handlebars or in whom a reliable history or clinical examination cannot be obtained, a full thoracic radiographic examination is recommended. [Edftor's n o t e :
Cervical spine is very routine in the evaluation of multiple trauma patients. This study highlights the relatively high incidence of thoracic spine injury in comparison with cervical and lumbar spine injury in motorcycle accident victims and the need to consider thoracic spine films as well as the routine cervical spine series.] Cynthia Elliott, MD
ectopic pregnancy, clomiphene citrate, pelvic ultrasound
Synchronous intrauterine and ec t o p ic p r e g n a n c y a s s o c i a t e d with c l o m i p h e n e citrate Raccuia JS, Neckles S, Butler D, et al Surg Gynecol Obstet 168:417-420
May 1989 motorcycles, spinal injuries
Thoracic spine injuries in vi ct i ms of motorcycle a c c i d e n t s J Trauma 29:593-596
May 1989
A retrospective review of motorcycle accident victims admitted during a 42-month period revealed 266 admissions with 164 of these requiring admission to the trauma intensive care unit (TICU). During this time period, 13 cases of thoracic spine injury were identified corresponding to 5% of all motorcycle accident admissions and 8% of those admitted to TICU. Single-level thoracic fractures were seen in seven and multiple levels were seen in six patients. T-7 was the most frequently involved level, seen 18:11 November1989
Although the simultaneous presence of both intrauterine and ectopic pregnancies is very rare, the incidence associated with the use of clomiphene citrate for infertility is probably much higher. In a 12-month period, four w o m e n treated with clomiphene citrate for infertility were diagnosed as having concomitant intra- and extrauterine pregnancies at one institution. In three, pelvic ultrasound, with visualization of a viable intrauterine pregnancy, was used to rule out ectopic gestation. One woman was diagnosed clinically without immediate preoperative sonogram. All women had peritoneal signs and symptoms suggestive of possible ruptured ectopic pregnancy and were operated on within a short time of presentation. In all cases, the products of the ectopic gestation were evacuated with three women delivering normal infants at full term and the fourth spontaneously aborting the intra-
Annals of Emergency Medicine
1251/169
ABSTRACTS
uterine pregnancy. It is concluded that the possibility of a false-negative ultrasound for ectopic gestation is more than previously believed and a viable intrauterine pregnancy associated with the use of clomiphene citrate may no longer be sufficient to rule out ectopic gestation.
Patricia L Johnson, MD
ultrasound, first-trimester pregnancy
Ultrasound changes way doctors view pregnancy Flisak ME
Diagn Imag 7:104-107 Jul 1989
In this collective review, the use of ultrasound in firsttrimester pregnancy in the evaluation of threatened abortion and ectopic pregnancy is reviewed. Gestational sacs 5 to 10 m m in diameter are easily seen with modern ultrasound equipment, using both transabdominal and transvaginal scanning techniques. This corresponds to about five to six weeks gestation by menstrual dates. The presence of a double decidual sac appearance differentiates the early gestational sac from the pseudosac of ectopic pregnancy. An intrauterine gestationa] sac should always be seen when the quantitative h u m a n chorianic gonadotropin (hCG) level is greater than 1,800 mIU/mL. Highresolution transabdomina] equipment has advanced the recognition of structure by one to two weeks and demonstrates cardiac activity by the sixth gestational week. Transvaginal equipment has shown that cardiac activity is almost always present at the time the embryonic disk can be identified as a focal area of thickening adjacent to the yolk sac, between the fourth and fifth gestational weeks. If an intrauterine gestational sac is detected by sonography, the risk of harboring an ectopic pregnancy is negligible. The quoted estimate for coincidental intra- and extrauterine pregnancies is 1:30,000 cases and may be 1:7,000 in the high-risk population undergoing ovulation induction.
John McGoldrick, MD
olecranon bursitis, surface temperature
Septic and nonseptic olecranon bursitis Smith DL, McAfee JH, Lucas LM, et al Arch Intern Med 149:1581-1585 Jul 1989
A prospective study of 46 consecutive patients presenting with olecranon bursitis during a one-year period was performed. Eleven cases were septic and 35 cases were nonseptic as determined by positive or negative cultures.
170/1252
In addition to bursal fluid analysis, the surface temperature over the involved olecranon bursa and the contralateral (control) oleeranon process was measured with a surface temperature probe. In nonseptic cases, the mean surface temperature difference was 0.7 C versus 3.7 C in septic cases (P = .0001). In all cases, the temperature dif- i ference was 2.2 C or more. The use of the surface probe i; temperature difference was 100% sensitive and 94% spe-': cific in discriminating septic from nonseptic cases. In fact, it was more accurate than the bursal fluid leukocyte count, the predominant cell type, or Gram's stain in the early differentiation of septic and nonseptic olecranon bursitis. It is recommended that all patients with a surface temperature difference of more than 2.2 C be started on antibiotics pending culture results regardless of Gram's stain or cell count results. [Editor's note: This is a poten-
tially useful diagnostic tool in differentiating septic from nonseptic bursitis, which perhaps may be helpful in differentiating septic from nonseptic joints and other bursitis. However, most emergency departments do not have the equipment necessary to accurately measure surface skin temperatures.] John McGoldrick, MD cardiac ischemia
S t u d i e s on p r o l o n g e d a c u t e r e g i o n a l i s c h e m i a . I. E v i d e n c e for p r e s e r v e d c e l l u l a r v i a b i l i t y a f t e r 6 h o u r s of c o r o n a r y o c c l u s i o n Beyersdorf F, Alen BS, Buckberg GD, et al
J Thorac Cardiovasc Surg 98:112-126 Jul 1989
Six hours has been considered the duration of coronary occlusion that prodffces such extensive transmural necrosis that muscle salvage by reperfusion is unlikely. Presented is a study of 20 open-chest anesthetized dogs who underwent severe regional ischemia produced by proximal ligation of the left anterior descending coronary artery for six hours. Eight of the 20 did not undergo ischemia and served as controls. Transmural biopsy specimens were analyzed. Coronary occlusion resulted in decreased regional blood flow to less than i0 mL/100 g/min, and dyskinesia persisted in the area at risk for six hours. Myocardial highenergy phosphates (adenosine triphosphate and creatine phosphate) decreased to negligible levels in both the epicardial and endocardial muscle layers. There was nearcomplete loss of tissue adenosine triphosphate. Histochemical damage, as evidenced with triphenyhetrazolium chloride nonstaining, occurred in 49%. Mitochondrial calcium content was increased and there was a marked depletion of tissue glutamate, alphaketoglutarate, and oxaloacetic acid. Despite these predictable changes associated with severe ischemia, the cardiac uhrastructure demonstrated only mild impairment of structural integrity. The myofibrils were intact and the sarcoplasmic reticulum and sarcolemma did not differ from nonischemic
Annals of EmergencyMedicine
18:11 November 1989