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Unrecognized human immunodeficiency virus infection in emergency department patients
alcohol, 18.3% were positive for THC only, and 16.5% had used both. The number of patients using both marijuana and alcohol is significantly larger than the expected number if their use were unassociated. No correlation was found between injury severity and consumption of alcohol or serum detection of THC. This study did not consider the possibility of false-positive results in long-term heavy users of marijuana or the possibility of detecting T H C leyels in passive nonusers in the vicinity of marijuana smokers. In many cases serum was not tested on patients who were dead on arrival or pronounced dead within one hour of admission. Also, this was not a controlled study, and nonvehicular trauma was not clearly defined. Regardless, it is interesting to note the slightly higher use of marijuana than alcohol among these trauma patients. Mark Murphy, MD acute chotecystitis, Curtis-Fitz-Hugh syndrome
Clinical a c u t e ch o l ecyst i t i s and t h e Curtis-Fitz.Hugh syn d r o me Shanahan D, Lord PH, Grogono J, et al Ann R Coil Surg Engl 70:44-48 Jun 1988
The Curtis-Fitz-Hugh s y n d r o m e is an anterior perihepatitis associated with a genitourinary tract infection. Presenting signs and symptoms of this syndrome clinically resemble acute cholecystitis, and diagnosis is usually made by exclusion of biliary or other abdominal pathology. In a preliminary study the authors reviewed records of 105 patients admitted with the clinical diagnosis of cholecystitis. Biliary pathology was proven in 61% of these patients, while 22% had definite other abdominal causes for their pain. The remaining 17% had right upper quadrant pain of unknown etiology, a situation found to be more common in women and in the 15 to 35 age group. A prospective study was then undertaken in which 18 patients who were admitted with the clinical diagnosis of acute cholecystitis were studied. Clinical criteria for admission were any of the signs and symptoms of the right upper quadrant pain syndrome with or without peritoneal inflammatory signs and any abnormalities in the hemoglobin, white cell count, amylase, renal, and liver function tests. The patients were further investigated with plain radiographs of the chest or oral cholecystograms. Of these patients, 28% were found to actually have acute cholecystitis as etiology of their pain, while 33% suffered from other abdominal pathology. The remaining 39% of undiagnosed right upper quadrant pain were screened for Chlamydia trachomatis. Serologies were examined with complement fixation. Tests for gonococcal infection were negative. All were then treated for C trachomatis, after which repeat genitourinary screens were negative. Six of seven patients with undiagnosed pain had complete resolution. Curtis-Fitz-Hugh syndrome may be more common than previously thought, especially in sexually active women in the 15 to 35 age group. The authors suggest that all
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sexually active patients with suspected acute cholecystitis and a normal ultrasound be screened for C trachomads.
Riemke M Brakema, MD infection, hand
Hand infections: B a c t e r i o l o g y and t r e a t m e n t : A prospecti ve study Dellinger EP, Wertz MJ, Miller SD, et al Arch Surg 123:745-750 Jun 1988
A prospective, double-blind study involving 193 patients with established hand infections requiring admission compared methicillin and cefamandole. Patients were given either cefamandole or methicillin IV for the initial 48 hours followed by cephaloxin or dicloxicillin orally. There were 67 cases of human bites, nine animal bites, 39 lacerations, 60 puncture wounds, abrasions, or burns, and 18 unknown causes. A single organism grew in culture in 16% and multiple organisms grew in 84%. Twenty-eight percent of wounds required operating room debridement, 46% emergency department debridement, and 26% no debridement. Human bites required the most operating room and ED procedures, as well as the longest mean duration of therapy. When all patients were grouped together, there was no significant difference between the methicillin- (94% satisfactory) and cefamandole- (93% satisfactory) treated infections. This study shows that drainage is the key to controlling most hand infections and that either cefamandole or methicillin is an adequate choice of initial therapy. Cefamandole, because Of the greater spectrum of activity, might be advisable in human bite wounds, but this study did not prove that empiric observation. Duncan Saue~MD
HIV, emergency department
Unrecognized human immunodeficiency virus infection in e m e r g e n c y d e p a r t m e n t patients Kelen GD, Fritz S, Qaqish B, et al N Er}gl J Med 318:1645-1650 Jun 1988
"-.
This study was undertaken in an inner-city emergency department to determine the prevalence of HIV-positive clients who seek treatment in the ED. Excess blood samples for HIV testing were obtained from any patient who required blood drawing for other medical purposes during a six-week period of t987. Demographic data on the study subjects were obtained by chart review and interviewing of clinicians by independent investigators who had no contact with the patients. Significant results included an overall
Annals of EmergencyMedicine
17:12 December 1988
positive rate of 4.0% of patients in whom HIV status was unknown prior to presentation. Age, sex, and race were important factors, but on multivariate relative-risk regression, seropositivity was independently associated with age under 45, black or "other" nonwhite race, history of homosexuality (presumably male), and history of IV drug use. Penetrating trauma also was independently associated with positivity, but overdose of IV drug and "gynecologic presentation other than vaginal bleeding" were found to be statistically significant on univariate analysis. Previous blood transfusion did not correlate statistically with positivity. The hospital location in this study is "a primary source of emergency care for indigent patients from the surrounding predominantly black community." The author's discussion centered on the high number of patients who are HIV positive in the emergency setting and bemoans the lack of appropriate precautions taken by emergency personnel. The authors call for the use of universal precautions for all patients in the emergency setting. ]Editor's note: Inner-city emergency physicians are at high risk for exposure to the H I V virus; precaution m u s t be taken.] Jim Vayda, M D
left bundle branch block, ECG
E l e c t r o c a r d i o g r a p h i c c r i t e r i a for v e n t r i c u l a r t a c h y c a r d i a in w i d e c o m p l e x left b u n d l e branch block morphology tachycardias Kindwall KE, Brown J, Josephson ME Am J Cardiol 61:1279-1283 Jun 1988
Few morphologic criteria have been established to aid in the differentiation of supraventricular tachycardia (SVT) from ventricular tachycardia (VT) when the pattern of left bundle branch block is present. In a retrospective analysis, the 12-lead ECGs of 118 patients with wide-complex tachycardia exhibiting the left bundle branch block pattern were examined. One hundred thirteen of these subjects underwent electrophysiologic evaluation that proved 91 cases to be VT and 27 to be SVT. Four criteria were identified that appeared to distinguish the underlying mechanism as VT rather than SVT: an R wave in V 1 or V2 of more than 30 ms duration; any Q wave in V6; a duration of more than 60 ms from QRS onset to S wave nadir in V 1 or V2; and any notching of the downstroke of the S wave in V 1 or V~. The results showed each of these criteria to have specificities and predictive accuracies of more than 95%, with sensitivities of 36% to 63%. When the criteria were used such that criteria 1, 2, 3, or 4 was present, the sensitivity was 100% with a specificity of 89% and predictive accuracy of 96%. The fact that a large percentage of the study population actually had VT and that, of those patients with SVT, none were taking medications that could have prolonged their conduction times could possibly have skewed the results. Bruce Spears, M D 17:12 December 1988
Annals
calcium, ionized; CPR
C a r d i a c a r r e s t and blood ionized c a l c i u m levels Urban P, Scheidegger D, Buchmann B, et al Ann Intern Med 110-113 Jul 15,1988
The value of calcium administration during cardiac arrest is controversial, and the American Heart Association does not currently recommend its routine use. In this study, blood ionized calcium levels and pH values in 12 out-ofhospital cardiac arrests were compared with those of nine patients who suffered cardiac arrest in an intensive care unit or during surgery. Ionized calcium is the biologically active form. Hypocalcemia leads to decreased ventricular performance, peripheral vasodilatation, and decreased hemodynamic response to catecholamines. In the 12 out-ofhospital arrests, all were given CPR, and only two received IV drugs and were intubated. Blood samples were taken at least ten minutes after the arrest. In this group there was significant ionized hypocalcemia (mean ionized calcium levels of .67 -+ .22 mmol/L), but normal total calcium levels. There was a positive correlation between pH and ionized calcium levels. In the nine of the in-hospital arrest group, all were given full resuscitation and blood samples were taken within the first three minutes. Ionized and total calcium levels were normal in this group. There was no significant difference in ionized calcium levels when comparing survivors with those who died. This study documents moderate to severe ionized hypocalcemia in out-of-hospital cardiac arrests. The hypocalcemia is time dependent and correlates to metabolic acidosis. Possible mechanisms for this include the binding of free calcium to lactate because this has been shown to occur in vitro. Further studies are needed to determine if out-of-hospital and prolonged cardiac arrests will benefit from calcium administration. [Editor's note: These are important data on the use of calcium. Outc o m e studies would be a logical next step.] Tim Hutchison, M D
ceftriaxone, gonorrhea
C e f t r i a x o n e for t r e a t m e n t of u n c o m p l i c a t e d gonorrhea: Routine use of a single 1 2 5 - m g dose in a s e x u a l l y t r a n s m i t t e d d i s e a s e clinic Handsfield HH, Hook EW Sexually Transmitted Diseases 14:227-230 Oct-Dec 1987
A single 250-rag dose of ceftriaxone is a treatment of choice for uncomplicated gonococcal infections, including those caused by ~-lactamase-producing strains and those with chromosomally mediated antibiotic resistance. With
of EmergencyMedicine
1359/153
Clinical a c u t e ch o l ecyst i t i s and t h e Curtis-Fitz.Hugh syn d r o me Shanahan D, Lord PH, Grogono J, et al Ann R Coil Surg Engl 70:44-48 Jun 1988
The Curtis-Fitz-Hugh s y n d r o m e is an anterior perihepatitis associated with a genitourinary tract infection. Presenting signs and symptoms of this syndrome clinically resemble acute cholecystitis, and diagnosis is usually made by exclusion of biliary or other abdominal pathology. In a preliminary study the authors reviewed records of 105 patients admitted with the clinical diagnosis of cholecystitis. Biliary pathology was proven in 61% of these patients, while 22% had definite other abdominal causes for their pain. The remaining 17% had right upper quadrant pain of unknown etiology, a situation found to be more common in women and in the 15 to 35 age group. A prospective study was then undertaken in which 18 patients who were admitted with the clinical diagnosis of acute cholecystitis were studied. Clinical criteria for admission were any of the signs and symptoms of the right upper quadrant pain syndrome with or without peritoneal inflammatory signs and any abnormalities in the hemoglobin, white cell count, amylase, renal, and liver function tests. The patients were further investigated with plain radiographs of the chest or oral cholecystograms. Of these patients, 28% were found to actually have acute cholecystitis as etiology of their pain, while 33% suffered from other abdominal pathology. The remaining 39% of undiagnosed right upper quadrant pain were screened for Chlamydia trachomatis. Serologies were examined with complement fixation. Tests for gonococcal infection were negative. All were then treated for C trachomatis, after which repeat genitourinary screens were negative. Six of seven patients with undiagnosed pain had complete resolution. Curtis-Fitz-Hugh syndrome may be more common than previously thought, especially in sexually active women in the 15 to 35 age group. The authors suggest that all
152/1358
sexually active patients with suspected acute cholecystitis and a normal ultrasound be screened for C trachomads.
Riemke M Brakema, MD infection, hand
Hand infections: B a c t e r i o l o g y and t r e a t m e n t : A prospecti ve study Dellinger EP, Wertz MJ, Miller SD, et al Arch Surg 123:745-750 Jun 1988
A prospective, double-blind study involving 193 patients with established hand infections requiring admission compared methicillin and cefamandole. Patients were given either cefamandole or methicillin IV for the initial 48 hours followed by cephaloxin or dicloxicillin orally. There were 67 cases of human bites, nine animal bites, 39 lacerations, 60 puncture wounds, abrasions, or burns, and 18 unknown causes. A single organism grew in culture in 16% and multiple organisms grew in 84%. Twenty-eight percent of wounds required operating room debridement, 46% emergency department debridement, and 26% no debridement. Human bites required the most operating room and ED procedures, as well as the longest mean duration of therapy. When all patients were grouped together, there was no significant difference between the methicillin- (94% satisfactory) and cefamandole- (93% satisfactory) treated infections. This study shows that drainage is the key to controlling most hand infections and that either cefamandole or methicillin is an adequate choice of initial therapy. Cefamandole, because Of the greater spectrum of activity, might be advisable in human bite wounds, but this study did not prove that empiric observation. Duncan Saue~MD
HIV, emergency department
Unrecognized human immunodeficiency virus infection in e m e r g e n c y d e p a r t m e n t patients Kelen GD, Fritz S, Qaqish B, et al N Er}gl J Med 318:1645-1650 Jun 1988
"-.
This study was undertaken in an inner-city emergency department to determine the prevalence of HIV-positive clients who seek treatment in the ED. Excess blood samples for HIV testing were obtained from any patient who required blood drawing for other medical purposes during a six-week period of t987. Demographic data on the study subjects were obtained by chart review and interviewing of clinicians by independent investigators who had no contact with the patients. Significant results included an overall
Annals of EmergencyMedicine
17:12 December 1988
positive rate of 4.0% of patients in whom HIV status was unknown prior to presentation. Age, sex, and race were important factors, but on multivariate relative-risk regression, seropositivity was independently associated with age under 45, black or "other" nonwhite race, history of homosexuality (presumably male), and history of IV drug use. Penetrating trauma also was independently associated with positivity, but overdose of IV drug and "gynecologic presentation other than vaginal bleeding" were found to be statistically significant on univariate analysis. Previous blood transfusion did not correlate statistically with positivity. The hospital location in this study is "a primary source of emergency care for indigent patients from the surrounding predominantly black community." The author's discussion centered on the high number of patients who are HIV positive in the emergency setting and bemoans the lack of appropriate precautions taken by emergency personnel. The authors call for the use of universal precautions for all patients in the emergency setting. ]Editor's note: Inner-city emergency physicians are at high risk for exposure to the H I V virus; precaution m u s t be taken.] Jim Vayda, M D
left bundle branch block, ECG
E l e c t r o c a r d i o g r a p h i c c r i t e r i a for v e n t r i c u l a r t a c h y c a r d i a in w i d e c o m p l e x left b u n d l e branch block morphology tachycardias Kindwall KE, Brown J, Josephson ME Am J Cardiol 61:1279-1283 Jun 1988
Few morphologic criteria have been established to aid in the differentiation of supraventricular tachycardia (SVT) from ventricular tachycardia (VT) when the pattern of left bundle branch block is present. In a retrospective analysis, the 12-lead ECGs of 118 patients with wide-complex tachycardia exhibiting the left bundle branch block pattern were examined. One hundred thirteen of these subjects underwent electrophysiologic evaluation that proved 91 cases to be VT and 27 to be SVT. Four criteria were identified that appeared to distinguish the underlying mechanism as VT rather than SVT: an R wave in V 1 or V2 of more than 30 ms duration; any Q wave in V6; a duration of more than 60 ms from QRS onset to S wave nadir in V 1 or V2; and any notching of the downstroke of the S wave in V 1 or V~. The results showed each of these criteria to have specificities and predictive accuracies of more than 95%, with sensitivities of 36% to 63%. When the criteria were used such that criteria 1, 2, 3, or 4 was present, the sensitivity was 100% with a specificity of 89% and predictive accuracy of 96%. The fact that a large percentage of the study population actually had VT and that, of those patients with SVT, none were taking medications that could have prolonged their conduction times could possibly have skewed the results. Bruce Spears, M D 17:12 December 1988
Annals
calcium, ionized; CPR
C a r d i a c a r r e s t and blood ionized c a l c i u m levels Urban P, Scheidegger D, Buchmann B, et al Ann Intern Med 110-113 Jul 15,1988
The value of calcium administration during cardiac arrest is controversial, and the American Heart Association does not currently recommend its routine use. In this study, blood ionized calcium levels and pH values in 12 out-ofhospital cardiac arrests were compared with those of nine patients who suffered cardiac arrest in an intensive care unit or during surgery. Ionized calcium is the biologically active form. Hypocalcemia leads to decreased ventricular performance, peripheral vasodilatation, and decreased hemodynamic response to catecholamines. In the 12 out-ofhospital arrests, all were given CPR, and only two received IV drugs and were intubated. Blood samples were taken at least ten minutes after the arrest. In this group there was significant ionized hypocalcemia (mean ionized calcium levels of .67 -+ .22 mmol/L), but normal total calcium levels. There was a positive correlation between pH and ionized calcium levels. In the nine of the in-hospital arrest group, all were given full resuscitation and blood samples were taken within the first three minutes. Ionized and total calcium levels were normal in this group. There was no significant difference in ionized calcium levels when comparing survivors with those who died. This study documents moderate to severe ionized hypocalcemia in out-of-hospital cardiac arrests. The hypocalcemia is time dependent and correlates to metabolic acidosis. Possible mechanisms for this include the binding of free calcium to lactate because this has been shown to occur in vitro. Further studies are needed to determine if out-of-hospital and prolonged cardiac arrests will benefit from calcium administration. [Editor's note: These are important data on the use of calcium. Outc o m e studies would be a logical next step.] Tim Hutchison, M D
ceftriaxone, gonorrhea
C e f t r i a x o n e for t r e a t m e n t of u n c o m p l i c a t e d gonorrhea: Routine use of a single 1 2 5 - m g dose in a s e x u a l l y t r a n s m i t t e d d i s e a s e clinic Handsfield HH, Hook EW Sexually Transmitted Diseases 14:227-230 Oct-Dec 1987
A single 250-rag dose of ceftriaxone is a treatment of choice for uncomplicated gonococcal infections, including those caused by ~-lactamase-producing strains and those with chromosomally mediated antibiotic resistance. With
of EmergencyMedicine
1359/153