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Toxic shock syndrome following diagnostic peritoneal lavage
CASE REPORT !avage, peritoneal, complications; syndrome, toxic shock, peritoneal lavage
Toxic Shock Syndrome Following Diagnostic Peritoneal Lavage We report the case of a 15-year-old girl who developed high fever, syncope, abdominal pain, nausea and vomiting, myalgia, pharyngitis, and a desquamating rash eight days after a diagnostic peritoneal lavage. The diagnostic peritoneal lavage wound was erythematous and tender. Incision of the site yielded 10 mL of exudate that cultured Staphylococcus aureus. The patient was treated with a first-generation cephalosporin and recovered without sequdae. To our knowledge, this is the first reported case of toxic shock syndrome following diagnostic peritoneal lavage. [Catapano M, Cwinn AA, Marx JA, Moore EE: Toxic shock syndrome following diagnostic peritoneal lavage. Ann Emerg Med July 1988;17:736-738.]
Michael Catapano, MD* A Adam Cwinn, MD* John A Marx*:l: Ernest E Mooret~ Denver, Colorado
INTRODUCTION Diagnostic peritoneal lavage (DPL) is widely used in the evaluation of abdominal trauma. Local wound infection is an infrequent complication and generally mild in severity. He Toxic shock syndrome (TSS) is a sequelae of Staphylococcus aureus infection or colonization.HA 2 It is usually associated with menses and tampon use18,14 but is recognized increasingly in clinical situations unrelated to menses, including abcesses and infected woundsJSd7 We rePort the first known case of TSS resulting from an infected DPL site.
Received for publication September 8, 1987. Revision received October 8, 1987. Accepted for publication March 23, 1988.
From the Departments of Emergency Medicine* and Trauma Surgery, t Denver General Hospital; and the University of Colorado Health Sciences Center,¢ Denver, Colorado.
Address for reprints: John A Marx, MD, Department of Emergency Medicine, Denver General Hospital, 777 Bannock Street, Denver, Colorado 80204-4507.
CASE REPORT A 15-year-old girl presented to the emergency department with a history of fever, weakness, sore throat, and abdominal pain for one day. Seven days before admission, she was an unrestrained front-seat passenger in a high-speed motor vehicle accident. The presence of left upper-quadrant abdominal pain and tachycardia prompted performance of DPL. This was accomplished with the semiopen technique at the infraumbilical ring. is The results were negative. The patient was observed in the hospital and discharged on the third day without complaints. The patient returned to the ED five days later with fever, weakness, sore throat, and midabd0minal pain as well as diffuse myalgias, diarrhea, and vomiting. Her last menstrual period was four weeks earlier, and she had not used tampons. She appeared in moderate distress and toxic. Vital signs were temperature, 39.4 C, orally; pulse, 140; respirations, 18; and blood pressure, 98/74 m m Hg. She b e c a m e s y n c o p a l on standing. The t o n g u e and oropharynx were beefy red. The DPL site was very tender but with minimal erythema. The abdomen was otherwise soft and nontender. Pelvic examination was normal. The patient had no rash or skin lesions. She was mildly lethargic, but the neurologic examination was otherwise normal. T h e hemoglobin was 13.5 g/dL; hematocrit, 41%; and WBC, 19,200 with 78% polymorphonuclear cells, 10% bands, 7% lymphocytes, 3% monocytes, and 2% eosinophils. The platelet count was normal. Electrolytes and BUN were normal; serUm CPK, liver enzymes, and calcium were not obtained. Urinalysis demonstrated 2 + proteinuria. Sutures from the DPL site were removed, and 10 mL of purulent material exuded freely from the wound, resulting in significant relief of abdominal pain. Gram's stain of the pus showed Gram-positive cocci in clusters and polymorphonuclear leukocytes. The patient received IV hydration with 3 L of nOrmal saline in the first two hours and was treated with IV cephapirin (1 17:7 July 1988
Annals of Emergency Medicine
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TOXIC SHOCK SYNDROME Catapano et al
Wound Complications Local wound infection1-3 Evisceration through the wound 2 Incisional hernia2 Wound dehiscence4 Sheared catheter5 Bowel Injury Small bowel laceration 1,5,19 Colon laceration1 Genitourinary Injury Bladder pe~foration6,7 Ovarian cyst laceration 2 Vascular Injury lilac artery 8 lilac veine Colic artery6 Epiploic vein 6 Mesenteric vein6,10 1 FIGURE 1. C o m p l i c a t i o n s o f DPL. FIGURE 2. Sources o f N M T S S . g every four hours) as well as wound cleansing. Wound cultures grew S aureus sensitive to cephalosporins. Blood cultures were negativ e. Approximately 24 hours later, the patient developed e r y t h e m a of the hands and feet. She defervesced with complete resolution of symptoms. She was discharged on the third hospital day on oral cephradine. At follow-up six days after discharge, she had des: quamation of the hands and feet but was well otherwise.
Surgical Wounds Exploratory laparotomy Spinal fusion Bladder suspension Mastectomy Tubal ligation Hysterectomy P!eurectomy Breast prosthesis Episi0tomy Varicose vein ligation Submucous resection and rhinoplasty Orchiectomy -. Herniorrhaphy Salpingo-oophorectomy Cholecystectomy Cesarean section Nonsurgical infections Buttock abscess Heel abscess Hand abscess Chest furuncle Axillary abscess Burns Traumatic skin wounds Pilonidal cyst Heroin injection sites Empyema Olecranon bursitis Purulent adenitis Septic arthritis Cellulitis Other Diaphragm use Vaginal contraceptive sponge Vaginal sea sponge Vaginal delivery
Ureterolithotomy Reduction mammoplasty Arthroscopy Shoulder repair Skin grafting Femoral osteotomy Hip osteoplasty Wrist arthrodesis Otoplasty Finger amputation Septorhinoplasty Septal reconstruction Cyst enucleation Lipoma removal Urethral suspension Lumbar sympathectomy Subtotal thyroidectomy Insect bite Abrasions Peri-rectal abscess Nasal pustule Hydradenitis suppurativa Breast abscess Chronic skin ulcer Subcutaneous insulin pump Varicella zoster Osteomyelitis Mastitis Bacteremia Thigh abscess Lung abscess Spontaneous abortion Nasal packing after epistaxis Septic abortion Vaginal infection
DISCUSSION DPL is a widely used modality to determine the need for laparotomy following blunt and penetrating trauma to the torso. H0 The wound complication rate after DPL~ including dehiscence, infection, and hematoma, has ranged from 0.3% to 6.0% (Figure 1). I"3 Incidence of local wound Infection has been sPecifically reported in one of 500 (0.2%), four of 796 (0.5%), and four of 1,465 (0.3%)Cases.2,19~z° TSS was first recognized as a clinical entity in 1978 when Todd described seven patients with high fever, rash followed by desquamation, confusion, vomiting, diarrhea , edema, renal abnormalities, and shock. 11 Subsequent reports further Characterized this syndrome (Figure 1) and n o t e d that it o c c u r r e d p r e d o m i nantly in young, menstruating women. 12-14,21~25 Most cases have been as-
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sociated with either colonization or infection with toxin-producing S aureus.ll,12,22-2s Epidemiologic studies suggested that use of certain high-absorbency tampons during menstruation led to a higher risk of contracting T S S . 13,14,26 T S S w a s i n i t i a l l y described as a serious illness with a mortality rate of 3% to 10%17 but subseq u e n t l y has been d o c u m e n t e d to include a broad clinical spectrum, with many mild cases.12,27 N o n m e n s t r u a l toxic s h o c k syndrome (NMTSS) has been reported since 1978,11 and recently has accounted for a higher percentage of reported cases of TSS.tS-W,28 NMTSS produces an illness indistinguishable from TSS associated with menses and tampon use.29,30 Infection with S aureus accounts for most cases. NMTSS is usually associated with abcesses, in-
Annals of Emergency Medicine
fected traumatic wounds, and infected surgical wounds but has also occurred with deep infections, with vaginal and nasal foreign bodies, and in the puerperium (Figure 2). Exploration of any recent wound is mandatory in a patient with an illness consistent with TSS. 29,30 Onset of manifestation s may occur as early as 12 hours after surgery or as late as 65 days, but most patients become ill within two days after soft tissue injury. Therapy of TSS is largely supportive; 12,2,$ the site of staphylococcal infection or colonization must be eliminated. Tampons, nasal packing, and other foreign objects should be removed, and infected wounds should be thoroughly cleansed. Hypotension warrants vigorous volume expansion and may necessitate inotropic phar macologic support. Invasive hemo-
17:7 July 1988
Hypotension or orthostatic syncope Fever more than 38.9 C Rash with desquamation Multisystem i n v o l v e m e n t three or more of the following: Gastrointestinal Mucous membranes Renal Muscular Hepatic Central nervous system Hematologic Cardiopulmonary Modified from Fisher et al.25
d y n a m i c m o n i t o r i n g m a y b e u s e f u l if t h e c l i n i c a l c o u r s e is c o m p l i c a t e d b y adult respiratory distress syndrome or acute renal failure. Parenteral antistaphylococcal antibiotics probably h a v e ~ittle e f f e c t o n t h e c l i n i c a l c o u r s e b u t m a y p r e v e n t r e c u r r e n c e , z2 O u r p a t i e n t e x h i b i t e d all f o u r c r i t e ria n e c e s s a r y t o e s t a b l i s h a d e f i n i t i v e d i a g n o s i s o f T S S ( F i g u r e 3}. S h e responded quickly to the appropriate therapy and recovered. While the maj o r i t y of D P L c o m p l i c a t i o n s a r e i n s i g nificant and the incidence of local w o u n d i n f e c t i o n s is low, w e r e p o r t a p o t e n t i a l l y l i f e - t h r e a t e n i n g s e q u e l a e of this procedure.
REFERENCES 1. Fischer RP, Beverlin BC, Engrav LH, et al: Diagnostic peritoneal lavage: Fourteen years and 2,856 patients later. A m J Surg 1978;136: 701-704. 2. Engrav LH, Benjamin CI, Strate RG, et ah
17:7 Jijly 1988
F I G U R E 3. C r i t e r i a f o r t h e d e f i n i t i v e d i a g n o s i s o f TSS. Diagnostic peritoneal lavage in blunt abdominal trauma. J Trauma 1975;15:854-859. 3. Parvin S, Smith DE, Asher WM, et ah Effectiveness of peritoneal lavage in blunt abdominal trauma. Ann Surg 1976;181:255-261. 4. Soderstrom CA, DuPriest RW, Cowley RA: Pitfalls of peritoneal lavage in blunt abdominal trauma. Surg Gynecol Obstet 1980;151:513-518. 5. Caffee HH, Benfield JR: Is peritoneal lavage for the diagnosis of hemopcritoneum safe? Arch Surg 1971;103:4. 6. Thai ER, Shires GT: Peritoneal lavage in blunt abdominal trauma. A m J Surg 1973;125: 64-69. 7. Sachatello CR, Bivins BA: Technique for peritoneal dialysis and diagnostic peritoneal lavage. A m J Surg 1976;131:637-640. 8. Olsen WR, Hildreth DH: Abdominal paracentesis and peritoneal Iavage in blunt abdominal trauma. J 7)auma 1971;1i:824-829. 9. Thal ER: Evaluatio n of peritoneal lavage and local exploration in lower chest and abdominil Stab wounds, f Trauma 1977~17:642-648. 10. Breen PC, Rudolph LE: Potential sources of error in the use of peritoneal ]avage as a diagnostic tool. JACEP 1974;3:401-403. 11. Todd J, Fishaut M, Kapral F, et al: Toxic shock syndrome associated with phage-group I staphylococci. Lancet 1978;2:1116-1118. 12. McKenna UG, Meadows JA, Brewer NS, et aI: Toxic shock syndrome, a newly recognized disease entity. Mayo Clin Proc 1980;55:663-672. 13. Follow-up on toxic shock syndrome-United States. MMWR 1980;29:297-299. 14. Toxic shock s y n d r o m e - U n i t e d States. MMWR 1980;29:229-230. 15. Toxic shock s y n d r o m e - U n i t e d States, 1970-1980. MMWR 198I;30:25-33. 16. Toxic shock s y n d r o m e - U n i t e d States, 1970-1982. MMWR 1982;31:201-204. 17. Update: Toxic shock s y n d r o m e - U n i t e d States. MMWR 1983;32:298-400.
Annals of Emergency Medicine
i8. Moore JB, Moore EE; Markovchick VJ, et ah Diagnostic peritoneal lavage for abdominal trauma: Superiority of the open technique at the infraumbilical ring. J Trauma 1981;21:570-572. 19. Feliciano DV, Bitodo CG, Steed G, et al: Five hundred open taps Or lavages in patients with abdominal stab wounds. A m J Surg 1984; 148:772-777. 20. Gruenberg JC, Brown RS, Talbert JG, et ah The diagnostic usefulness of peritoneal lavage in penetrating trauma: A prospective comparison and evaluation with blunt trauma. A m Surg 1982~48:402-407. 21. Schrock CG: Disease alert (news). lAMA I980;243:1231. 22. Davis JP, chesney PJ, Wand PJ, et ah Toxic shock syndrome-epidemiologic features, recurrence, risk factors and prevention. N Engl J Med 1980;303:1429-1435. 23. Shands KN, Schmid GP, Dan BB, et ah Toxic shock syndrome in menstruating women. Association with tampon use and Staphylococcus aureus and clinical features in 52 cases. N Engl f Med I980~303:1436-1442. 24. Torte RW,, Williams DN: Toxic shock syndrome: Clinical and laboratory features in 15 patients. Ann lntern Med 1981;94:149-156. 25. Fisher RE Goodpasture HC, Peterie JD, et ah Toxic shock syndrome in m e n s t r u a t i n g women. Ann Intern Med 1981;94:156-163. 26. Davis JP, Osterholm MT, Helms CM, et ah Tri-state toxic shock s y n d r o m e study. II. Clinical and laboratory findings. J Infect Dis 1982; 145:441-448. 27. Tofte RW, Williams DN: Toxic shock syndrome. Evidence of a broad clinical spectrum. JAMA 198I;246:2163-2167. 28. Toxic shock syndrome-annual summary i983. MMWR 1984;32:59-60. 29. Reingold AL, Dan BB, Shands KN, et ah Toxic shock syndrome not associated with menstruation. A review of 54 cases. Lancet 1982;1:1-4. 30. Reingold AL, Hirgrett NT, Dan BB, et al: Nonmenstrual toxic shock syndrome. A review of I30 cases. Ann Intern Med 1982;96:871-874.
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Toxic Shock Syndrome Following Diagnostic Peritoneal Lavage We report the case of a 15-year-old girl who developed high fever, syncope, abdominal pain, nausea and vomiting, myalgia, pharyngitis, and a desquamating rash eight days after a diagnostic peritoneal lavage. The diagnostic peritoneal lavage wound was erythematous and tender. Incision of the site yielded 10 mL of exudate that cultured Staphylococcus aureus. The patient was treated with a first-generation cephalosporin and recovered without sequdae. To our knowledge, this is the first reported case of toxic shock syndrome following diagnostic peritoneal lavage. [Catapano M, Cwinn AA, Marx JA, Moore EE: Toxic shock syndrome following diagnostic peritoneal lavage. Ann Emerg Med July 1988;17:736-738.]
Michael Catapano, MD* A Adam Cwinn, MD* John A Marx*:l: Ernest E Mooret~ Denver, Colorado
INTRODUCTION Diagnostic peritoneal lavage (DPL) is widely used in the evaluation of abdominal trauma. Local wound infection is an infrequent complication and generally mild in severity. He Toxic shock syndrome (TSS) is a sequelae of Staphylococcus aureus infection or colonization.HA 2 It is usually associated with menses and tampon use18,14 but is recognized increasingly in clinical situations unrelated to menses, including abcesses and infected woundsJSd7 We rePort the first known case of TSS resulting from an infected DPL site.
Received for publication September 8, 1987. Revision received October 8, 1987. Accepted for publication March 23, 1988.
From the Departments of Emergency Medicine* and Trauma Surgery, t Denver General Hospital; and the University of Colorado Health Sciences Center,¢ Denver, Colorado.
Address for reprints: John A Marx, MD, Department of Emergency Medicine, Denver General Hospital, 777 Bannock Street, Denver, Colorado 80204-4507.
CASE REPORT A 15-year-old girl presented to the emergency department with a history of fever, weakness, sore throat, and abdominal pain for one day. Seven days before admission, she was an unrestrained front-seat passenger in a high-speed motor vehicle accident. The presence of left upper-quadrant abdominal pain and tachycardia prompted performance of DPL. This was accomplished with the semiopen technique at the infraumbilical ring. is The results were negative. The patient was observed in the hospital and discharged on the third day without complaints. The patient returned to the ED five days later with fever, weakness, sore throat, and midabd0minal pain as well as diffuse myalgias, diarrhea, and vomiting. Her last menstrual period was four weeks earlier, and she had not used tampons. She appeared in moderate distress and toxic. Vital signs were temperature, 39.4 C, orally; pulse, 140; respirations, 18; and blood pressure, 98/74 m m Hg. She b e c a m e s y n c o p a l on standing. The t o n g u e and oropharynx were beefy red. The DPL site was very tender but with minimal erythema. The abdomen was otherwise soft and nontender. Pelvic examination was normal. The patient had no rash or skin lesions. She was mildly lethargic, but the neurologic examination was otherwise normal. T h e hemoglobin was 13.5 g/dL; hematocrit, 41%; and WBC, 19,200 with 78% polymorphonuclear cells, 10% bands, 7% lymphocytes, 3% monocytes, and 2% eosinophils. The platelet count was normal. Electrolytes and BUN were normal; serUm CPK, liver enzymes, and calcium were not obtained. Urinalysis demonstrated 2 + proteinuria. Sutures from the DPL site were removed, and 10 mL of purulent material exuded freely from the wound, resulting in significant relief of abdominal pain. Gram's stain of the pus showed Gram-positive cocci in clusters and polymorphonuclear leukocytes. The patient received IV hydration with 3 L of nOrmal saline in the first two hours and was treated with IV cephapirin (1 17:7 July 1988
Annals of Emergency Medicine
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TOXIC SHOCK SYNDROME Catapano et al
Wound Complications Local wound infection1-3 Evisceration through the wound 2 Incisional hernia2 Wound dehiscence4 Sheared catheter5 Bowel Injury Small bowel laceration 1,5,19 Colon laceration1 Genitourinary Injury Bladder pe~foration6,7 Ovarian cyst laceration 2 Vascular Injury lilac artery 8 lilac veine Colic artery6 Epiploic vein 6 Mesenteric vein6,10 1 FIGURE 1. C o m p l i c a t i o n s o f DPL. FIGURE 2. Sources o f N M T S S . g every four hours) as well as wound cleansing. Wound cultures grew S aureus sensitive to cephalosporins. Blood cultures were negativ e. Approximately 24 hours later, the patient developed e r y t h e m a of the hands and feet. She defervesced with complete resolution of symptoms. She was discharged on the third hospital day on oral cephradine. At follow-up six days after discharge, she had des: quamation of the hands and feet but was well otherwise.
Surgical Wounds Exploratory laparotomy Spinal fusion Bladder suspension Mastectomy Tubal ligation Hysterectomy P!eurectomy Breast prosthesis Episi0tomy Varicose vein ligation Submucous resection and rhinoplasty Orchiectomy -. Herniorrhaphy Salpingo-oophorectomy Cholecystectomy Cesarean section Nonsurgical infections Buttock abscess Heel abscess Hand abscess Chest furuncle Axillary abscess Burns Traumatic skin wounds Pilonidal cyst Heroin injection sites Empyema Olecranon bursitis Purulent adenitis Septic arthritis Cellulitis Other Diaphragm use Vaginal contraceptive sponge Vaginal sea sponge Vaginal delivery
Ureterolithotomy Reduction mammoplasty Arthroscopy Shoulder repair Skin grafting Femoral osteotomy Hip osteoplasty Wrist arthrodesis Otoplasty Finger amputation Septorhinoplasty Septal reconstruction Cyst enucleation Lipoma removal Urethral suspension Lumbar sympathectomy Subtotal thyroidectomy Insect bite Abrasions Peri-rectal abscess Nasal pustule Hydradenitis suppurativa Breast abscess Chronic skin ulcer Subcutaneous insulin pump Varicella zoster Osteomyelitis Mastitis Bacteremia Thigh abscess Lung abscess Spontaneous abortion Nasal packing after epistaxis Septic abortion Vaginal infection
DISCUSSION DPL is a widely used modality to determine the need for laparotomy following blunt and penetrating trauma to the torso. H0 The wound complication rate after DPL~ including dehiscence, infection, and hematoma, has ranged from 0.3% to 6.0% (Figure 1). I"3 Incidence of local wound Infection has been sPecifically reported in one of 500 (0.2%), four of 796 (0.5%), and four of 1,465 (0.3%)Cases.2,19~z° TSS was first recognized as a clinical entity in 1978 when Todd described seven patients with high fever, rash followed by desquamation, confusion, vomiting, diarrhea , edema, renal abnormalities, and shock. 11 Subsequent reports further Characterized this syndrome (Figure 1) and n o t e d that it o c c u r r e d p r e d o m i nantly in young, menstruating women. 12-14,21~25 Most cases have been as-
132/737
sociated with either colonization or infection with toxin-producing S aureus.ll,12,22-2s Epidemiologic studies suggested that use of certain high-absorbency tampons during menstruation led to a higher risk of contracting T S S . 13,14,26 T S S w a s i n i t i a l l y described as a serious illness with a mortality rate of 3% to 10%17 but subseq u e n t l y has been d o c u m e n t e d to include a broad clinical spectrum, with many mild cases.12,27 N o n m e n s t r u a l toxic s h o c k syndrome (NMTSS) has been reported since 1978,11 and recently has accounted for a higher percentage of reported cases of TSS.tS-W,28 NMTSS produces an illness indistinguishable from TSS associated with menses and tampon use.29,30 Infection with S aureus accounts for most cases. NMTSS is usually associated with abcesses, in-
Annals of Emergency Medicine
fected traumatic wounds, and infected surgical wounds but has also occurred with deep infections, with vaginal and nasal foreign bodies, and in the puerperium (Figure 2). Exploration of any recent wound is mandatory in a patient with an illness consistent with TSS. 29,30 Onset of manifestation s may occur as early as 12 hours after surgery or as late as 65 days, but most patients become ill within two days after soft tissue injury. Therapy of TSS is largely supportive; 12,2,$ the site of staphylococcal infection or colonization must be eliminated. Tampons, nasal packing, and other foreign objects should be removed, and infected wounds should be thoroughly cleansed. Hypotension warrants vigorous volume expansion and may necessitate inotropic phar macologic support. Invasive hemo-
17:7 July 1988
Hypotension or orthostatic syncope Fever more than 38.9 C Rash with desquamation Multisystem i n v o l v e m e n t three or more of the following: Gastrointestinal Mucous membranes Renal Muscular Hepatic Central nervous system Hematologic Cardiopulmonary Modified from Fisher et al.25
d y n a m i c m o n i t o r i n g m a y b e u s e f u l if t h e c l i n i c a l c o u r s e is c o m p l i c a t e d b y adult respiratory distress syndrome or acute renal failure. Parenteral antistaphylococcal antibiotics probably h a v e ~ittle e f f e c t o n t h e c l i n i c a l c o u r s e b u t m a y p r e v e n t r e c u r r e n c e , z2 O u r p a t i e n t e x h i b i t e d all f o u r c r i t e ria n e c e s s a r y t o e s t a b l i s h a d e f i n i t i v e d i a g n o s i s o f T S S ( F i g u r e 3}. S h e responded quickly to the appropriate therapy and recovered. While the maj o r i t y of D P L c o m p l i c a t i o n s a r e i n s i g nificant and the incidence of local w o u n d i n f e c t i o n s is low, w e r e p o r t a p o t e n t i a l l y l i f e - t h r e a t e n i n g s e q u e l a e of this procedure.
REFERENCES 1. Fischer RP, Beverlin BC, Engrav LH, et al: Diagnostic peritoneal lavage: Fourteen years and 2,856 patients later. A m J Surg 1978;136: 701-704. 2. Engrav LH, Benjamin CI, Strate RG, et ah
17:7 Jijly 1988
F I G U R E 3. C r i t e r i a f o r t h e d e f i n i t i v e d i a g n o s i s o f TSS. Diagnostic peritoneal lavage in blunt abdominal trauma. J Trauma 1975;15:854-859. 3. Parvin S, Smith DE, Asher WM, et ah Effectiveness of peritoneal lavage in blunt abdominal trauma. Ann Surg 1976;181:255-261. 4. Soderstrom CA, DuPriest RW, Cowley RA: Pitfalls of peritoneal lavage in blunt abdominal trauma. Surg Gynecol Obstet 1980;151:513-518. 5. Caffee HH, Benfield JR: Is peritoneal lavage for the diagnosis of hemopcritoneum safe? Arch Surg 1971;103:4. 6. Thai ER, Shires GT: Peritoneal lavage in blunt abdominal trauma. A m J Surg 1973;125: 64-69. 7. Sachatello CR, Bivins BA: Technique for peritoneal dialysis and diagnostic peritoneal lavage. A m J Surg 1976;131:637-640. 8. Olsen WR, Hildreth DH: Abdominal paracentesis and peritoneal Iavage in blunt abdominal trauma. J 7)auma 1971;1i:824-829. 9. Thal ER: Evaluatio n of peritoneal lavage and local exploration in lower chest and abdominil Stab wounds, f Trauma 1977~17:642-648. 10. Breen PC, Rudolph LE: Potential sources of error in the use of peritoneal ]avage as a diagnostic tool. JACEP 1974;3:401-403. 11. Todd J, Fishaut M, Kapral F, et al: Toxic shock syndrome associated with phage-group I staphylococci. Lancet 1978;2:1116-1118. 12. McKenna UG, Meadows JA, Brewer NS, et aI: Toxic shock syndrome, a newly recognized disease entity. Mayo Clin Proc 1980;55:663-672. 13. Follow-up on toxic shock syndrome-United States. MMWR 1980;29:297-299. 14. Toxic shock s y n d r o m e - U n i t e d States. MMWR 1980;29:229-230. 15. Toxic shock s y n d r o m e - U n i t e d States, 1970-1980. MMWR 198I;30:25-33. 16. Toxic shock s y n d r o m e - U n i t e d States, 1970-1982. MMWR 1982;31:201-204. 17. Update: Toxic shock s y n d r o m e - U n i t e d States. MMWR 1983;32:298-400.
Annals of Emergency Medicine
i8. Moore JB, Moore EE; Markovchick VJ, et ah Diagnostic peritoneal lavage for abdominal trauma: Superiority of the open technique at the infraumbilical ring. J Trauma 1981;21:570-572. 19. Feliciano DV, Bitodo CG, Steed G, et al: Five hundred open taps Or lavages in patients with abdominal stab wounds. A m J Surg 1984; 148:772-777. 20. Gruenberg JC, Brown RS, Talbert JG, et ah The diagnostic usefulness of peritoneal lavage in penetrating trauma: A prospective comparison and evaluation with blunt trauma. A m Surg 1982~48:402-407. 21. Schrock CG: Disease alert (news). lAMA I980;243:1231. 22. Davis JP, chesney PJ, Wand PJ, et ah Toxic shock syndrome-epidemiologic features, recurrence, risk factors and prevention. N Engl J Med 1980;303:1429-1435. 23. Shands KN, Schmid GP, Dan BB, et ah Toxic shock syndrome in menstruating women. Association with tampon use and Staphylococcus aureus and clinical features in 52 cases. N Engl f Med I980~303:1436-1442. 24. Torte RW,, Williams DN: Toxic shock syndrome: Clinical and laboratory features in 15 patients. Ann lntern Med 1981;94:149-156. 25. Fisher RE Goodpasture HC, Peterie JD, et ah Toxic shock syndrome in m e n s t r u a t i n g women. Ann Intern Med 1981;94:156-163. 26. Davis JP, Osterholm MT, Helms CM, et ah Tri-state toxic shock s y n d r o m e study. II. Clinical and laboratory findings. J Infect Dis 1982; 145:441-448. 27. Tofte RW, Williams DN: Toxic shock syndrome. Evidence of a broad clinical spectrum. JAMA 198I;246:2163-2167. 28. Toxic shock syndrome-annual summary i983. MMWR 1984;32:59-60. 29. Reingold AL, Dan BB, Shands KN, et ah Toxic shock syndrome not associated with menstruation. A review of 54 cases. Lancet 1982;1:1-4. 30. Reingold AL, Hirgrett NT, Dan BB, et al: Nonmenstrual toxic shock syndrome. A review of I30 cases. Ann Intern Med 1982;96:871-874.
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