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Value of “inconclusive lavage” in abdominal trauma management
ABSTRACTS Peter Rosen,MD
--
editor
Director of the Division of Emergency Medicine, Denver General Hospital
Frank
J. B a k e r ,
II, MD
--
assistant editor
Associate Professor and Director, Department of Emergency Medicine, University of Chicago Hospitals and Clinics
Handcuffs and cheiralgia paresthetica. Massey EW, Pleet AB, Neurology 28:1312-1313, (Dec) 1978. Two cases of neuritis of the superficial branch of the radial nerve produced by handcuffs are presented. Cheiralgia paresthetica (hand pain) is a mononeuropathy of the superficial branch of the radial nerve. Both cases presented with numbness over the ulnar aspect of the dorsum of the h a n d with an area of h y p e r p a t h i a along with the u l n a r aspect of the thumb. Both cases presented within 24 hours of the injury and at least one was permanent. The superficial branch of the radial nerve is purely sensory to the dorsal of the hand; it runs parallel to the radial artery on the lateral side until it crosses the pronator teres, where it turns posterior and crosses the dorsal carpal ligament where it divides to its terminal branches. (Editor's note: This syndrome may be more common than we are aware. A contributor may be the struggling drunk who ends up with very tight cuffs both because of swelling and a punitive desire to cause pain by the restrainer. We also tend tooverlook minor complaints in prisoners as part of their desire to get out of jail.) Hal Thomas, MD neuritis, hand; cheiralgia paresthetica
Bystander-initiated cardiopulmonary resuscitation in the management of ventricular fibrillation, Thompson R, Hallstrom A, Cobb L, Ann Intern Med 90:737-740, (May) 1979. More t h a n 200,000 residents of Seattle have been trained in basic CPR. Three hundred sixteen patients were analyzed retrospectively to assess the difference between bystanderinitiated CPR (BICPR) and CPR begun when firemen or paramedics arrived (PICPR). Of the 316, 28% were ultimately discharged home; 34% were initally resuscitated but eventually died in a medical facility. Of significance is the difference in survival and eventual neurologic status of survivors in the two groups. BICPR resulted in a 43% survival r a t e with 50% conscious by hospital arrival; only one of 27 was disoriented and three of the 38 survivors were comatose. Also reduced were intractable shock and neurologic sequelae. Education of all community members in basic CPR would significantly improve survival in cardiac arrest situations and is an important part of a total emergency medical system. (Editor's note: We think CPR should be taught in the school system. The best efforts in the ED are totally dependent on the prehospital care.) Ben Honigman, MD
cardiopulmonary resuscitation, bystander-initiated Lidocaine prophylaxis in acute myocardial infarction, Noneman JW, Rogers JF, Medicine 57:501-515, 1978. The use of lidocaine in the setting of acute myocardial infarction (AMI) is reviewed. Lown in 1967 advocated the use of lidocaine prophylaxis to prevent ventricular fibrillation (VF) in AMI patients in a critical care unit (CCU) who manifested premonitory or warning arrhythmias, specifically: (1) PVCs occurring early in the cycle with interruption of T wave (R' on T phenomenon); (2) two or more consecutive PVCs; (3) multifocal PVCs; (4) more than five PVCs per minute. Although this approach has been essentially standard therapy in most CCUs and in the field and emergency department more recently, investigations have raised the question of the reliability of warning arrhythmias as consistent predictors of VF or patients at risk, and actually failing to warn of impending primary VF in up to 80% of patients with AMI. The incidence of PVF in AMI is 3% to 10% or more, with 60% to 80% of all episodes occurring in the first six hours after onset of symptoms. For effective lidocaine therapy to be used, constant therapeutic blood levels of lidocaine must be achieved; the pharmacokinetics of lidocaine dictate that a loading dose and a constant infusion with monitoring of blood levels are n e c e s s a r y to p r o m p t l y a c h i e v e a n d m a i n t a i n a d e q u a t e therapy. The authors conclude from their review of the literature that lidocaine prophylaxis in all AMI patients, presumably from onset of symptoms, is indicated until more definitive data are available. (Editor's note: Other unanswered questions are the prophylactic use in the field and multiple bolus therapy versus bolus and drip. Our own practice is bolus and drip, but our ambulance runs are short. A higher incidence of lidocaine complications may well occur with longer runs.) Frederick K. Seydel, MD
myocardial infarction, fidocaine 9:2 (February) 1980
Ann
Value of "inconclusive lavage" in abdominal trauma management. Hornyak S, Shafton G, J Trauma 19:329333, (May) 1979. Peritoneal lavage is an important adjunct to physical examination in evaluating the need for exploratory laparotomy in a patient with blunt or penetrating abdominal trauma. Traditionally a red blood count of greater t h a n 100,000 RBC/cu m m of lavage fluid has been the threshold mandating exploration in an otherwise stable patient. The authors of this prospective study evaluated the results of 685 peritoneal lavages with subsequent laparotomy. Through a protocol mandating exploration for RBC counts greater than 5,000 RBC/cu mm they found serious injury in 23% of patients with cell counts from 0 to 20,000, 67% with cell counts from 20,000 to 50,000, 86% with cell counts from 50,000 to 100,000, and finally 95% with cell counts above 100,000. In a group of 398 patients with crystal clear lavage fluid, two patients were explored based on physical examination. Both were found to have serious intraperitoneal injury. John Hurst, MD
injury, abdominal, peritoneal iavage Historic and angiographic features of young adults surviving myocardial infarction. Warren SE, Thompson Sl, Vieweg VR, Chest 75:667-670, (Jun) 1979. Selective coronary cinearteriograms were performed on 68 survivors of myocardial infarction who were under 36 years of age. T h r e e g r o u p s of p a t i e n t s e m e r g e d : t h o s e w i t h atherosclerotic coronary arteries, those with normal coronary arteries, and those with coronary artery anomalies. Fifty-six
Emerg Med
115/95
--
editor
Director of the Division of Emergency Medicine, Denver General Hospital
Frank
J. B a k e r ,
II, MD
--
assistant editor
Associate Professor and Director, Department of Emergency Medicine, University of Chicago Hospitals and Clinics
Handcuffs and cheiralgia paresthetica. Massey EW, Pleet AB, Neurology 28:1312-1313, (Dec) 1978. Two cases of neuritis of the superficial branch of the radial nerve produced by handcuffs are presented. Cheiralgia paresthetica (hand pain) is a mononeuropathy of the superficial branch of the radial nerve. Both cases presented with numbness over the ulnar aspect of the dorsum of the h a n d with an area of h y p e r p a t h i a along with the u l n a r aspect of the thumb. Both cases presented within 24 hours of the injury and at least one was permanent. The superficial branch of the radial nerve is purely sensory to the dorsal of the hand; it runs parallel to the radial artery on the lateral side until it crosses the pronator teres, where it turns posterior and crosses the dorsal carpal ligament where it divides to its terminal branches. (Editor's note: This syndrome may be more common than we are aware. A contributor may be the struggling drunk who ends up with very tight cuffs both because of swelling and a punitive desire to cause pain by the restrainer. We also tend tooverlook minor complaints in prisoners as part of their desire to get out of jail.) Hal Thomas, MD neuritis, hand; cheiralgia paresthetica
Bystander-initiated cardiopulmonary resuscitation in the management of ventricular fibrillation, Thompson R, Hallstrom A, Cobb L, Ann Intern Med 90:737-740, (May) 1979. More t h a n 200,000 residents of Seattle have been trained in basic CPR. Three hundred sixteen patients were analyzed retrospectively to assess the difference between bystanderinitiated CPR (BICPR) and CPR begun when firemen or paramedics arrived (PICPR). Of the 316, 28% were ultimately discharged home; 34% were initally resuscitated but eventually died in a medical facility. Of significance is the difference in survival and eventual neurologic status of survivors in the two groups. BICPR resulted in a 43% survival r a t e with 50% conscious by hospital arrival; only one of 27 was disoriented and three of the 38 survivors were comatose. Also reduced were intractable shock and neurologic sequelae. Education of all community members in basic CPR would significantly improve survival in cardiac arrest situations and is an important part of a total emergency medical system. (Editor's note: We think CPR should be taught in the school system. The best efforts in the ED are totally dependent on the prehospital care.) Ben Honigman, MD
cardiopulmonary resuscitation, bystander-initiated Lidocaine prophylaxis in acute myocardial infarction, Noneman JW, Rogers JF, Medicine 57:501-515, 1978. The use of lidocaine in the setting of acute myocardial infarction (AMI) is reviewed. Lown in 1967 advocated the use of lidocaine prophylaxis to prevent ventricular fibrillation (VF) in AMI patients in a critical care unit (CCU) who manifested premonitory or warning arrhythmias, specifically: (1) PVCs occurring early in the cycle with interruption of T wave (R' on T phenomenon); (2) two or more consecutive PVCs; (3) multifocal PVCs; (4) more than five PVCs per minute. Although this approach has been essentially standard therapy in most CCUs and in the field and emergency department more recently, investigations have raised the question of the reliability of warning arrhythmias as consistent predictors of VF or patients at risk, and actually failing to warn of impending primary VF in up to 80% of patients with AMI. The incidence of PVF in AMI is 3% to 10% or more, with 60% to 80% of all episodes occurring in the first six hours after onset of symptoms. For effective lidocaine therapy to be used, constant therapeutic blood levels of lidocaine must be achieved; the pharmacokinetics of lidocaine dictate that a loading dose and a constant infusion with monitoring of blood levels are n e c e s s a r y to p r o m p t l y a c h i e v e a n d m a i n t a i n a d e q u a t e therapy. The authors conclude from their review of the literature that lidocaine prophylaxis in all AMI patients, presumably from onset of symptoms, is indicated until more definitive data are available. (Editor's note: Other unanswered questions are the prophylactic use in the field and multiple bolus therapy versus bolus and drip. Our own practice is bolus and drip, but our ambulance runs are short. A higher incidence of lidocaine complications may well occur with longer runs.) Frederick K. Seydel, MD
myocardial infarction, fidocaine 9:2 (February) 1980
Ann
Value of "inconclusive lavage" in abdominal trauma management. Hornyak S, Shafton G, J Trauma 19:329333, (May) 1979. Peritoneal lavage is an important adjunct to physical examination in evaluating the need for exploratory laparotomy in a patient with blunt or penetrating abdominal trauma. Traditionally a red blood count of greater t h a n 100,000 RBC/cu m m of lavage fluid has been the threshold mandating exploration in an otherwise stable patient. The authors of this prospective study evaluated the results of 685 peritoneal lavages with subsequent laparotomy. Through a protocol mandating exploration for RBC counts greater than 5,000 RBC/cu mm they found serious injury in 23% of patients with cell counts from 0 to 20,000, 67% with cell counts from 20,000 to 50,000, 86% with cell counts from 50,000 to 100,000, and finally 95% with cell counts above 100,000. In a group of 398 patients with crystal clear lavage fluid, two patients were explored based on physical examination. Both were found to have serious intraperitoneal injury. John Hurst, MD
injury, abdominal, peritoneal iavage Historic and angiographic features of young adults surviving myocardial infarction. Warren SE, Thompson Sl, Vieweg VR, Chest 75:667-670, (Jun) 1979. Selective coronary cinearteriograms were performed on 68 survivors of myocardial infarction who were under 36 years of age. T h r e e g r o u p s of p a t i e n t s e m e r g e d : t h o s e w i t h atherosclerotic coronary arteries, those with normal coronary arteries, and those with coronary artery anomalies. Fifty-six
Emerg Med
115/95