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The role of thoracic aortic occlusion for massive hemoperitoneum
f
Abstractsl
peter Rosen, M D - - e d i t o r
professor of Emergency Medicine and Director of the Division of Emergency Medicine, university of Chicago Hospitals and Clinics
Beverly Fauman,
MD -- assistant editor
Assistant Professor of Emergency Medicine and Psychiatry, University of Chicago Hospitals and Clinics current status of diagnosis and management of strangulation obstruction of the small bowel. Shatila AH, Chamberlain BE, Webb WR, Am J Surg (Sept) 1976. The presence of strangulated bowel increases by threefold the overall mortality of patients with intestinal obstruction, and increases the likelihood of shock (hypovolemic a n d septic), peritonitis and sepsis. However, a retrospective review of 103 cases of acute mechanical small bowel obstruction found no clinical sign or laboratory test t h a t differentiated simple (nonstrangulated) from strangulated obstruction. The classic signs of strangulation - - fever, tachycardia and leukocytosis - - were not predictive and were especially misleading in patients older t h a n 50 years. The abdominal examination, plain and contrast x-ray studies, and serum levels of lactic dehydrogenase (LDH), serum glutamic oxaloacetic transaminase (SGOT) and amylase were equally unhelpful. Although abdominal wall rigidity, hypothermia and occult rectal bleeding were only seen in patients with strangulation obstruction, they were late findings and not helpful in making an early diagnosis. In this series, most cases of strangulation were associated with femoral hernias; others were less commonly associated with internal and inguinal hernias and postoperative adhesions. Simple.obstruction was most often associated with postoperative adhesions, and less often with intra-abdominal m a l i g n a n c i e s (ovarian and colorectal) and femoral and inguinal hernias. The authors recommended early laparotomy for all patients with acute mechanical small bowel obstruction as the only therapy at present to decrease the mortality of this entity. (Editor's note: We have found a helpful clinical clue to be the change from intermittent to constant abdominal pain. In the older patient, a differential shift is often present without leukocytosis. This remains a difficult diagnostic entity for the emergency physician and far too often obstruction is fobbed off as gastroenteritis. We again emphasize the diagnostic triad of pain, nausea and vomiting, and prior surgery.)
Michael D. McGehee, MD
intestinal obstruction, strangulated bowel Cardiac complications in amitriptyline poisoning: successful treatment with physostigmine. Tobis J, Das BN, JAMA 235:1474-1476, (April) 1976. Physostigmine has been used successfully to treat the central nervous system effects of tricyclic antidepressants such as agitation, seizures and coma, as well as their peripheral effects such as tachycardia. Physostigmine (22 mg over 48 hours) was used to successfully treat some of the more severe cardiac complications induced by amitriptyline hydrochloride, such as abnormal Conduction pathways, A-V dissociation, and ventricular tachyCardia. Following one dose of physostigmine, the patient deloped a generalized tonic-clonic seizure reaffi1:ming the fact nat physostigmine itself is not an innocuous drug. (Editor's note: When faced with heart block, the natural tendency is to reach for atropine. This will be disastrous in the face o f this nd of anticholinergic poisoning. A m o n g drugs for overdos¢~,y e tricyclic antidepressants certainly provide a dangerou s choice ' for the depressed patient_) Vincent Markovchiclq MD
~
~
Physostigmine, amitriptyline poisoning
~]~)
6:3 (Mar) 1977
Bacteriologic diagnosis of acute pneumonia. Davidson M, Tempest B, Palmer DL, JAMA 235:158-163, (Jan) 1976. The authors compare the diagnostic value of sputum, blood, tracheal aspirate, and lung aspirate cultures in 25 patients with pneumonia. Although sputum showed the same isolates that were found in the lung aspirate in 68c~ of patients, it commonly contained additional organisms. Tracheal and lung aspirates demonstrated identical results 41% of the time. Lung aspirates yielded a single isolate in 69% of patients (more frequently Lhan other techniques), and only occasionally multiple organisms. Twenty-seven percent of tracheal aspirates grew multiple potential pathogens, and the data suggests contamination of tracheal aspirates from the upper respiratory tract. Complications for all techniques were few. Nevertheless, the authors feel that lung aspiration should be confined to critically ill but cooperative patients with "accessible roentgenographic infiltrates" and for whom a rapid and precise bacteriologic diagnosis is essential. (Editor's note: The complication rate of lung aspiration is indeed small in experienced hands. However, it is our opinion that this diagnostic maneuver is not indicated in the emergency department. I f sputum gram stain is not enough to give the proper clue for initial therapy, tracheal aspiration is much safer and almost as accurate.) d.B. Franaszek, MD
pneumonia, bacteriologic diagnosis Fetal heart rate patterns preceding death in utero. Cetrulo CL, Schifrin BS, Obstet Gynecol 48:521, (Nov) 1976. Four cases illustrate patterns of fetal heart rate during labor, as recorded by continuous monitoring, preceding the dehvery of stillborn infants. Normally, uterine contractions are associated with a transient deceleration of fetal heart rate. There is also a normal beat-to-beat variability of rate, reflected by rapid, small fluctuations in the baseline of the graph. The important point for the emergency physician is t h a t instantaneous or intermittent stethoscopic auscultation is of little value in assessing the well-being of the fetus, except in extreme cases. P e r s i s t e n t bradycardia, though certainly ominous, is a very late sign. Continuous electrode monitoring is the only means of early detection of fetal heart rate patterns now recognized as indicative of feLal distress in utero. (Editor's note: While few emergency depal"tments are set up to continuously monitor fetal heart ;ones, it is still an important responsibility to listen for them. A Doppler unquestionably can resolve some indistinct tones.)
Jeffrey S. Menkes, MD
heart failure, neonate, EKG The role of thoracic aortic occlusion for massive hemoperitoneum. Ledgerwood AM, Kazmers M, Lucas CE, J Trauma 16:610-615, 1976. In 40 patients with massive hemoperitoneum from abdominal trauma, laparotomy and left thoracotomy were performed in all to control abdominal bleeding (29 with thoracotomy first). Sud-
129/83
den cardiovascular collapse followed decompression of abdominal tension in 7 of 11 without primary thoracotomy. With primary thoracotomy, only seven patients had refractory hypotension. Advantages of primary thoracotomy include 1) restoration of brain and cardiac perfusion; 2) avoiding cardiovascular collapse from release of abdominal tamponade, and 3) proximal arterial control is gained, allowing better operative technique. Potential complications are 1) sudden left heart failure from overload; 2) ischemia of spinal cord or viscera from prolonged clamping, and 3) iatrogenic injury to thoracic aorta. Suggested management of the hypotensive, massive hemoperitoneum include 1) intubation; 2) at least two large intravenous lines with infusion of 2 to 3 liters of crystalloid plus two units type-specific blood, and 3) transportation to operating suite: if blood pressure (BP) is greater than 80 mm Hg two more units of blood are begun and as BP rises above 100 mm Hg, the abdomen is entered and aortic compression immediately established beneath the diaphragm. If h o w e v e r , p r e s s u r e r e m a i n s below m m Hg, left a n t e r i o r thoracotomy is performed with thoracic aortic clamping prior to opening the abdomen. As laparotomy proceeds, aortic compression is transferred to the previous method via placement of the compressor below the celic axis, and slow release of the thoracic clamp - - thus allowing adequate liver perfusion. BP must be carefully monitored during declamping and appropriate fluid therapy administered. Further, sodium bicarbonate must be given to offset the tissue acidosis from hypoperfused tissues_ (Editor's note. There is a role for thoracic aortic crossclamping in emergency medicine, but limited. Some of these patients will be better managed by Military Anti Shock Trouser suit compression unless an operating suite and surgical team are ready to intervene within minutes. There is no role for laparotomy in the emergency department.) Gary M. Sollars, MD
hemoperitoneum, laparotomy, thoracotomy Dementia induced by methyldopa with haloperidol. Thornton WE, N Engl J Med 294:1222, (May) 1976. Methyldopa, a frequently used antihypertensive agent, has well known central nervous system side effects. It is also known to potentiate the sedative effects of haloperidol in agitated and psychotic patients. Two patients are presented who were treated with methyldopa for more than one year. Within one week of being started on haloperidol for anxiety, both were observed to have a dementia syndrome. Mental symptoms cleared within 72 hours of discontinuing haloperidol. The interactions of these two commonly used drugs should be f a m i l i a r to the e m e r g e n c y physician. (Editor's note: Haldol is a common choice of sedative in the acutely agitated older patient who has an organic brain syndrome. Since this is the same population likely to be on Aldomet, the combination of these drugs is not rare. In determining the etiology of acute dementia, drugs and drug combinations should always be suspect.) Robert Rothstein, MD
Physiopathogenesis of subdural hematomas. Partinhibition of growth of experimental hematom~, t: dexamethasone. Glover D, Labadie EL, J Neu;nWiti 45:393-397, (Oct) 1976. user; Subdural hematomas were experimentally induced in 33 r°-. injecting 12 ml of autologous hemolyzed blood clotted i ~ ~ Seventeen animals served as controls (no treatmellt) ~hilS~tl~ were given daily intramuscular injections of dexamethas0,=L' beginning immediately after injection of blood. All animo~- '~ sacr]ficed after nine days, and two autopsy findings ~ e r e interest 1) the size of the subdural hematomas in the t-~'eat~ ~ rats averaged one fourth that of the controls and 2) n ~ brane formation, uniformly present in controls, was absent the treated group. The authors believe that the breakdo~l~lr[ J! blood products in the newly formed subdural hematoma stitch. lares an inflammatory reaction in surrounding tissues," which,,," turn, causes neovascularization with consequent further blee~. ing and/or plasma leakage. The authors believe that the ster~i4~ work by blocking the initial inflammatory reaction. (Editor'~ note: This interesting experiment may provide us with some ir~. sight into the mechanism of the effectiveness of steroids in t~ head injury patient.) Robert Hockberger, ~t(~
hematoma, subdural, steroids Pleural fluid pH in parapneumonic effusions. Potts DE, Levin DC, Sahn SA, Chest 70:328, (Sept) 1976. Pleura] effusions associated with bacterial pneumonia were classified into three categories: 1) empyemas, 2) loculated eff~. sions, and 3) benign (self-resolving) effusions. Samples of pleural fluid were obtained by thoracentesis from 24 patients who had bacteria] pneumonia associated with effusion. Ten patients had an empyema, four had loculated effusions, and ten had benign effusions. Within the first two groups, all of the pleural effusions fluid samples had a pH less t h a n 7.30, while all of the benign effusions had a pH of 7.32 or greater. Other fluid parameters measured were pCO2, total white blood cell count, neutrophil count, glucose content, and protein content. Among these, only the pH consistently differentiated benign effusions from the other two types. Since empyema and loculated effusion are both normally treated by tube thoracostomy, while benign effusions tend to resolve spontaneously, the pH of a sample of pleural fluid can be regarded as an early indicator of whether or not a patient with bacterial pneumonia is likely to require a chest tube. The test is simple to perform, and is valuable from the standpoint of avoiding unnecessary thoracostomy. (Editor's note: In the pediatric age group aggressive tube thoracostomy can be life-saving for a patient with empyema. Since some of these may be "benign" effusions in the adult, examining pH may avoid un. necessary thoracostomy.) Jeffrey S. Menkes, MD
pleural effusion, fluid pH
methyldopa, dementia; haloperidol; drug combinations First electrocardiogram in recent myocardial infarction. McGuiness JB, Begg TB, Semple T, Br Med J 2:449-450, (Aug) 1976. Of 898 patients admitted to a coronary care unit with suspected recent infarction, 449 had the diagnosis confirmed by all data obtained in the hospital. Of these 449, only 229 (51%) showed a definite infarct on the first electrocardiogram (EKG) and 120 (27%) showed a probable infarct. The mortality was almost twice as high in those with definite as opposed to doubtful or absent signs of infarction in the first tracing (24% versus 13%). The first EKG is therefore important, but in the early stages, the diagnosis should be based largely on clinical grounds. (Editor's note: Despite further documentation in this article that the EKG may not be helpful, emergency physicians are still reluctant to use the clinical setting to make the diagnosis. Perhaps isoenzyrhes and ultrasonography will increase laboratory support, but we believe the mainstay must be the clinical suspicion.)
Traumatic aortic rupture: roentgenographic indications for angiography. March DG, Sturm JT, Ann Thorac Surg 21:337-340, (April) 1976. The presence or absence of 16 findings on 100 cm anterop0s" terior supine chest roentgenograms were noted and compared in 47 consecutive patients who underwent aortography following blunt thoracic trauma and in 100 patients without trauma. 0n the basis of these data, the authors propose six radiologic indications for thoracic aortography following chest trauma: medias" t i n u m g r e a t e r t h a n 8 cm on 100 cm AP supine chest film; tracheal shift to the right; blurring of the normally sharp out, line of the aorta; obliteration of the medial aspect of the apex e[ the left upper lobe; opacification of the clear space between the aorta and pulmonary artery, and depression of the left main bronchus below 40 °. (Editor's note: The difficulty of accurately assessing supine chest films is known to all. It is helpful to have these guidelines for supine films but, when the patient is stable, it is always preferable to have an upright film.)
Robert Rothstein, MD
Robert Rothstein, MD
myocardial infarction, EKG 8~130
aortic rupture, aortography 6:3 (Mar)1977 ~ P
Abstractsl
peter Rosen, M D - - e d i t o r
professor of Emergency Medicine and Director of the Division of Emergency Medicine, university of Chicago Hospitals and Clinics
Beverly Fauman,
MD -- assistant editor
Assistant Professor of Emergency Medicine and Psychiatry, University of Chicago Hospitals and Clinics current status of diagnosis and management of strangulation obstruction of the small bowel. Shatila AH, Chamberlain BE, Webb WR, Am J Surg (Sept) 1976. The presence of strangulated bowel increases by threefold the overall mortality of patients with intestinal obstruction, and increases the likelihood of shock (hypovolemic a n d septic), peritonitis and sepsis. However, a retrospective review of 103 cases of acute mechanical small bowel obstruction found no clinical sign or laboratory test t h a t differentiated simple (nonstrangulated) from strangulated obstruction. The classic signs of strangulation - - fever, tachycardia and leukocytosis - - were not predictive and were especially misleading in patients older t h a n 50 years. The abdominal examination, plain and contrast x-ray studies, and serum levels of lactic dehydrogenase (LDH), serum glutamic oxaloacetic transaminase (SGOT) and amylase were equally unhelpful. Although abdominal wall rigidity, hypothermia and occult rectal bleeding were only seen in patients with strangulation obstruction, they were late findings and not helpful in making an early diagnosis. In this series, most cases of strangulation were associated with femoral hernias; others were less commonly associated with internal and inguinal hernias and postoperative adhesions. Simple.obstruction was most often associated with postoperative adhesions, and less often with intra-abdominal m a l i g n a n c i e s (ovarian and colorectal) and femoral and inguinal hernias. The authors recommended early laparotomy for all patients with acute mechanical small bowel obstruction as the only therapy at present to decrease the mortality of this entity. (Editor's note: We have found a helpful clinical clue to be the change from intermittent to constant abdominal pain. In the older patient, a differential shift is often present without leukocytosis. This remains a difficult diagnostic entity for the emergency physician and far too often obstruction is fobbed off as gastroenteritis. We again emphasize the diagnostic triad of pain, nausea and vomiting, and prior surgery.)
Michael D. McGehee, MD
intestinal obstruction, strangulated bowel Cardiac complications in amitriptyline poisoning: successful treatment with physostigmine. Tobis J, Das BN, JAMA 235:1474-1476, (April) 1976. Physostigmine has been used successfully to treat the central nervous system effects of tricyclic antidepressants such as agitation, seizures and coma, as well as their peripheral effects such as tachycardia. Physostigmine (22 mg over 48 hours) was used to successfully treat some of the more severe cardiac complications induced by amitriptyline hydrochloride, such as abnormal Conduction pathways, A-V dissociation, and ventricular tachyCardia. Following one dose of physostigmine, the patient deloped a generalized tonic-clonic seizure reaffi1:ming the fact nat physostigmine itself is not an innocuous drug. (Editor's note: When faced with heart block, the natural tendency is to reach for atropine. This will be disastrous in the face o f this nd of anticholinergic poisoning. A m o n g drugs for overdos¢~,y e tricyclic antidepressants certainly provide a dangerou s choice ' for the depressed patient_) Vincent Markovchiclq MD
~
~
Physostigmine, amitriptyline poisoning
~]~)
6:3 (Mar) 1977
Bacteriologic diagnosis of acute pneumonia. Davidson M, Tempest B, Palmer DL, JAMA 235:158-163, (Jan) 1976. The authors compare the diagnostic value of sputum, blood, tracheal aspirate, and lung aspirate cultures in 25 patients with pneumonia. Although sputum showed the same isolates that were found in the lung aspirate in 68c~ of patients, it commonly contained additional organisms. Tracheal and lung aspirates demonstrated identical results 41% of the time. Lung aspirates yielded a single isolate in 69% of patients (more frequently Lhan other techniques), and only occasionally multiple organisms. Twenty-seven percent of tracheal aspirates grew multiple potential pathogens, and the data suggests contamination of tracheal aspirates from the upper respiratory tract. Complications for all techniques were few. Nevertheless, the authors feel that lung aspiration should be confined to critically ill but cooperative patients with "accessible roentgenographic infiltrates" and for whom a rapid and precise bacteriologic diagnosis is essential. (Editor's note: The complication rate of lung aspiration is indeed small in experienced hands. However, it is our opinion that this diagnostic maneuver is not indicated in the emergency department. I f sputum gram stain is not enough to give the proper clue for initial therapy, tracheal aspiration is much safer and almost as accurate.) d.B. Franaszek, MD
pneumonia, bacteriologic diagnosis Fetal heart rate patterns preceding death in utero. Cetrulo CL, Schifrin BS, Obstet Gynecol 48:521, (Nov) 1976. Four cases illustrate patterns of fetal heart rate during labor, as recorded by continuous monitoring, preceding the dehvery of stillborn infants. Normally, uterine contractions are associated with a transient deceleration of fetal heart rate. There is also a normal beat-to-beat variability of rate, reflected by rapid, small fluctuations in the baseline of the graph. The important point for the emergency physician is t h a t instantaneous or intermittent stethoscopic auscultation is of little value in assessing the well-being of the fetus, except in extreme cases. P e r s i s t e n t bradycardia, though certainly ominous, is a very late sign. Continuous electrode monitoring is the only means of early detection of fetal heart rate patterns now recognized as indicative of feLal distress in utero. (Editor's note: While few emergency depal"tments are set up to continuously monitor fetal heart ;ones, it is still an important responsibility to listen for them. A Doppler unquestionably can resolve some indistinct tones.)
Jeffrey S. Menkes, MD
heart failure, neonate, EKG The role of thoracic aortic occlusion for massive hemoperitoneum. Ledgerwood AM, Kazmers M, Lucas CE, J Trauma 16:610-615, 1976. In 40 patients with massive hemoperitoneum from abdominal trauma, laparotomy and left thoracotomy were performed in all to control abdominal bleeding (29 with thoracotomy first). Sud-
129/83
den cardiovascular collapse followed decompression of abdominal tension in 7 of 11 without primary thoracotomy. With primary thoracotomy, only seven patients had refractory hypotension. Advantages of primary thoracotomy include 1) restoration of brain and cardiac perfusion; 2) avoiding cardiovascular collapse from release of abdominal tamponade, and 3) proximal arterial control is gained, allowing better operative technique. Potential complications are 1) sudden left heart failure from overload; 2) ischemia of spinal cord or viscera from prolonged clamping, and 3) iatrogenic injury to thoracic aorta. Suggested management of the hypotensive, massive hemoperitoneum include 1) intubation; 2) at least two large intravenous lines with infusion of 2 to 3 liters of crystalloid plus two units type-specific blood, and 3) transportation to operating suite: if blood pressure (BP) is greater than 80 mm Hg two more units of blood are begun and as BP rises above 100 mm Hg, the abdomen is entered and aortic compression immediately established beneath the diaphragm. If h o w e v e r , p r e s s u r e r e m a i n s below m m Hg, left a n t e r i o r thoracotomy is performed with thoracic aortic clamping prior to opening the abdomen. As laparotomy proceeds, aortic compression is transferred to the previous method via placement of the compressor below the celic axis, and slow release of the thoracic clamp - - thus allowing adequate liver perfusion. BP must be carefully monitored during declamping and appropriate fluid therapy administered. Further, sodium bicarbonate must be given to offset the tissue acidosis from hypoperfused tissues_ (Editor's note. There is a role for thoracic aortic crossclamping in emergency medicine, but limited. Some of these patients will be better managed by Military Anti Shock Trouser suit compression unless an operating suite and surgical team are ready to intervene within minutes. There is no role for laparotomy in the emergency department.) Gary M. Sollars, MD
hemoperitoneum, laparotomy, thoracotomy Dementia induced by methyldopa with haloperidol. Thornton WE, N Engl J Med 294:1222, (May) 1976. Methyldopa, a frequently used antihypertensive agent, has well known central nervous system side effects. It is also known to potentiate the sedative effects of haloperidol in agitated and psychotic patients. Two patients are presented who were treated with methyldopa for more than one year. Within one week of being started on haloperidol for anxiety, both were observed to have a dementia syndrome. Mental symptoms cleared within 72 hours of discontinuing haloperidol. The interactions of these two commonly used drugs should be f a m i l i a r to the e m e r g e n c y physician. (Editor's note: Haldol is a common choice of sedative in the acutely agitated older patient who has an organic brain syndrome. Since this is the same population likely to be on Aldomet, the combination of these drugs is not rare. In determining the etiology of acute dementia, drugs and drug combinations should always be suspect.) Robert Rothstein, MD
Physiopathogenesis of subdural hematomas. Partinhibition of growth of experimental hematom~, t: dexamethasone. Glover D, Labadie EL, J Neu;nWiti 45:393-397, (Oct) 1976. user; Subdural hematomas were experimentally induced in 33 r°-. injecting 12 ml of autologous hemolyzed blood clotted i ~ ~ Seventeen animals served as controls (no treatmellt) ~hilS~tl~ were given daily intramuscular injections of dexamethas0,=L' beginning immediately after injection of blood. All animo~- '~ sacr]ficed after nine days, and two autopsy findings ~ e r e interest 1) the size of the subdural hematomas in the t-~'eat~ ~ rats averaged one fourth that of the controls and 2) n ~ brane formation, uniformly present in controls, was absent the treated group. The authors believe that the breakdo~l~lr[ J! blood products in the newly formed subdural hematoma stitch. lares an inflammatory reaction in surrounding tissues," which,,," turn, causes neovascularization with consequent further blee~. ing and/or plasma leakage. The authors believe that the ster~i4~ work by blocking the initial inflammatory reaction. (Editor'~ note: This interesting experiment may provide us with some ir~. sight into the mechanism of the effectiveness of steroids in t~ head injury patient.) Robert Hockberger, ~t(~
hematoma, subdural, steroids Pleural fluid pH in parapneumonic effusions. Potts DE, Levin DC, Sahn SA, Chest 70:328, (Sept) 1976. Pleura] effusions associated with bacterial pneumonia were classified into three categories: 1) empyemas, 2) loculated eff~. sions, and 3) benign (self-resolving) effusions. Samples of pleural fluid were obtained by thoracentesis from 24 patients who had bacteria] pneumonia associated with effusion. Ten patients had an empyema, four had loculated effusions, and ten had benign effusions. Within the first two groups, all of the pleural effusions fluid samples had a pH less t h a n 7.30, while all of the benign effusions had a pH of 7.32 or greater. Other fluid parameters measured were pCO2, total white blood cell count, neutrophil count, glucose content, and protein content. Among these, only the pH consistently differentiated benign effusions from the other two types. Since empyema and loculated effusion are both normally treated by tube thoracostomy, while benign effusions tend to resolve spontaneously, the pH of a sample of pleural fluid can be regarded as an early indicator of whether or not a patient with bacterial pneumonia is likely to require a chest tube. The test is simple to perform, and is valuable from the standpoint of avoiding unnecessary thoracostomy. (Editor's note: In the pediatric age group aggressive tube thoracostomy can be life-saving for a patient with empyema. Since some of these may be "benign" effusions in the adult, examining pH may avoid un. necessary thoracostomy.) Jeffrey S. Menkes, MD
pleural effusion, fluid pH
methyldopa, dementia; haloperidol; drug combinations First electrocardiogram in recent myocardial infarction. McGuiness JB, Begg TB, Semple T, Br Med J 2:449-450, (Aug) 1976. Of 898 patients admitted to a coronary care unit with suspected recent infarction, 449 had the diagnosis confirmed by all data obtained in the hospital. Of these 449, only 229 (51%) showed a definite infarct on the first electrocardiogram (EKG) and 120 (27%) showed a probable infarct. The mortality was almost twice as high in those with definite as opposed to doubtful or absent signs of infarction in the first tracing (24% versus 13%). The first EKG is therefore important, but in the early stages, the diagnosis should be based largely on clinical grounds. (Editor's note: Despite further documentation in this article that the EKG may not be helpful, emergency physicians are still reluctant to use the clinical setting to make the diagnosis. Perhaps isoenzyrhes and ultrasonography will increase laboratory support, but we believe the mainstay must be the clinical suspicion.)
Traumatic aortic rupture: roentgenographic indications for angiography. March DG, Sturm JT, Ann Thorac Surg 21:337-340, (April) 1976. The presence or absence of 16 findings on 100 cm anterop0s" terior supine chest roentgenograms were noted and compared in 47 consecutive patients who underwent aortography following blunt thoracic trauma and in 100 patients without trauma. 0n the basis of these data, the authors propose six radiologic indications for thoracic aortography following chest trauma: medias" t i n u m g r e a t e r t h a n 8 cm on 100 cm AP supine chest film; tracheal shift to the right; blurring of the normally sharp out, line of the aorta; obliteration of the medial aspect of the apex e[ the left upper lobe; opacification of the clear space between the aorta and pulmonary artery, and depression of the left main bronchus below 40 °. (Editor's note: The difficulty of accurately assessing supine chest films is known to all. It is helpful to have these guidelines for supine films but, when the patient is stable, it is always preferable to have an upright film.)
Robert Rothstein, MD
Robert Rothstein, MD
myocardial infarction, EKG 8~130
aortic rupture, aortography 6:3 (Mar)1977 ~ P