Treatment of cat bite injuries of the hand

Treatment of cat bite injuries of the hand

in 15 (83%). Opacification of the clear space between the aorta and pulmonary artery was noted in 11 cases (60%). Less common and therefore less helpf...

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in 15 (83%). Opacification of the clear space between the aorta and pulmonary artery was noted in 11 cases (60%). Less common and therefore less helpful findings were obliteration of the shadow of the distal aorta, tracheal shift to the right, and depression of the angle of the left main stem bronchus below 40 degrees. It is important to note t h a t all the findings were found on 100 cm supine A P chest films and not s t a n d a r d PA u p r i g h t films. Confirmation was obtained in every case by retrograde femoral aortogram with soft-tipped flexible catheters. No complications a t t r i b u t a b l e to t h i s method occurred. (Editor's note: Realistically the supine film is the one available in a critical, unstable patient. These findings should be looked for but a high_index of suspicion in decelerating trauma a n d an aggressive willingness to pursue aortography is the key to early diagnosis and repair.)

Frank Purdie, MD thoracic aorta, rupture, radiography; trauma, blunt chest, complications Abuse of nitrous oxide. Rosenberg H, Orkin FK, Springstead J, Anesth Ana/g 48:104-106 (Mar/Apr) 1979. Anonymous questionnaires of 524 medical and dental students of three different classes (1980, 1981, 1982) revealed t h a t up to 20% have used nitrous oxide in a social setting to produce a 'thigh." Sources of n i t r o u s oxide v a r i e d from whipped cream aerosol cans to cartridges of nitrous oxide from " h e a d shops." No personal injury was reported, alt h o u g h a few respondents reported nausea, cyanosis, a n d syncope. The authors feel that, because of its potential dangers, more effective control of the distribution of this drug should be instituted. (Editor's note: While I see no reason to sell this drug over the counter, the dangers are probably miniscule compared to those we can produce i f we allow the narcotics bureau to become involved.) Larry Proano, MD

drug abuse, nitrous oxide Treatment of cat bite injuries of the hand. Veitch JM, Omer GE, J Trauma 19:201-202, (Mar) 1979. The authors report six cases of cat bites to the h a n d resulting in infection requiring hospitalization. Several of these were mixed infections, with Staphylococcus aureus requiring more t h a n penicillin for adequate treatment. Pasteurella multocida, commonly seen in dog bites, is also seen in cat bites. The authors point out t h a t cat teeth are sharp and narrow and tend to penetrate deep into soft tissue and joints, setting the stage for infection. The authors recommend the following t r e a t m e n t protocol. Cleanse the wound with a n antiseptic soap and c u l t u r e t h e wound w i t h a special note to t h e laboratory to look for PasteureUa, since this organism is often difficult to culture. The patient should be placed on penicillin or erythromycin for 7 to 10 days. The need for close follow-up is stressed; patients are brought back in 24 hours for wound check. (Editor's note: I see little need to take a culture o f these wounds. The only debate in my m i n d is whether staphicidal drugs should be used, for P multocida is sensitive to penicillin. The real danger from the cat is the puncture wound, for these have the highest incidence of infection.)

Robert Jorden, MD injury, hand, cat bite; bites, cat, hand injury Rapid diagnosis of meningitis with use of selected clinical data and gas-liquid chromatographic deter-

9:3 (March) 1980

Ann

mination of lactate concentration in cerebrospinal fluid. Gastria B, Briem H, Rombo L, J Infect Dis 139: 529-533, (May) 1979. The cerebrospinal fluid (CSF) of 98 patients was sampled to determine lactate concentrations in various types of meningitis. Assay was by gas-liquid chromatography. In 29 control subjects with suspected meningitis, CSF studies were normal with lactate levels of 1.3 - 0.54 mmol/liter. Seventeen patients with serous meningitis having predominant mononuclear cells in the CSF h a d lactate levels of 2.3 -+ 1.26 mmol/ liter. Thirty-eight patiezlts with culture positive bacterial meningitis h a d lactate concentrations of 14.7 - 8.50 mmol] liter with levels slightly lower in five patients with probable bacterial meningitis. Other pathologic CNS conditions had lactate levels of 4.5 + 2.24 mmol/liter. Comparison of bacteriologic agents showed S. pneumonial (16.9 - 9.14 mmol! liter) and N. meningitis (16.5 -+ 8.2 mmol/liter) with higher l e v e l s t h a n H. i n f l u e n z a l (8.1 - 3.3 m m o l / l i t e r ) or 1 monocytogens (10.6 - 8.0 mmol/liter). Using lactate levels a l o n e i t could be m i s l e a d i n g to d i f f e r e n t i a t e serous a n d bacterial meningitis due to some overlapping of concentrations. However, combined with clinical and other laboratory data lactate levels can be diagnostically helpful for bacterial meningitis. (Editor's note: Even i f this test should prove to be of reproducible value, its effectiveness will depend on the alertness and aggressive willingness to do LPs in the febrile patient.) Larry Weil, MD

meningitis, CSF, lactate concentrations

Complications of artificial heart valves. Kloster FE, JAMA 241:2201-2203, (May) 1979. Artificia~ h e a r t valves are becoming more common amongst the general population. The authors discuss the diagnosis a n d m a n a g e m e n t of t h e four most common problems: endocarditis, thromboembolism, prosthesis dysfunction, a n d hemolysis. Regarding the former, the authors state, "The importance of immediately suspecting infectious endocarditis in any p a t i e n t with a prosthetic valve who has i n t e r m i t t e n t or persistent fever cannot be over emphasized." Confirmation of the diagnosis is made with blood cultures and t r e a t m e n t requires antibiotics for six weeks. Approximately 50% to 70% will require reoperation due to failure of medical therapy. F u r t h e r m o r e , they advocate large dose prophylaxis in all prosthetic-valve patients prior to dental, skin, gastrointestinal, or g e n i t o u r i n a r y surgery or endoscopy. Thromboembolism, more common in mitral valve replacements, is often a result of inadequate anticoagulation. Recurrent thromboembolism in the face of good anticoagulant control may benefit from insertion of a newer model prosthesis. Valve dysfunction usually occurs due to thrombotic obstruction or regurgitation and is associated with increasing congestive failure; occasionally, a paravalvular leak occurs due to disruption of a suture line. In either case, if there is substantial dysfunction, r e o p e r a t i o n is u s u a l l y required. Hemolysis due to mechanical t r a u m a to erythrocytes is diagnosed by a low hemoglobin and elevated LDH. It can usually be managed by oral iron therapy but, on occasion, the hemolytic anemia is a sign of valve dysfunction and further investigation, such as angiography, is required. (Editor's note: There is great reluctance to diagnose endocarditis in the ED. We feel that any patient with a predisposing condition [eg, artificial valve or drug abuse] who is febrile should be considered as having the disease until it can be disproven.) Frank Purdie, MD h e a r t valves, artificial, c o m p l i c a t i o n s

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