Operative versus nonoperative management of blunt abdominal trauma: Role of ultrasound-measured intraperitoneal fluid levels.

This study's objective was to analyze whether the quantity of free intraperitoneal fluid on ultrasonography, alone or in combination with unstable vital signs, is sensitive in determining the need for laparotomy in patients presenting with blunt trauma. Adult patients who presented with blunt abdominal trauma to 2 level I trauma centers were enrolled. Combined intraperitoneal fluid levels (anechoic stripe) of 5 intraperitoneal areas were measured and defined as small (< 1.0 cm), moderate (> 1.0 cm, < 3.0 cm), or large (> 3.0 cm). Unstable vital signs were defined as pulse > 100 bpm or systolic blood pressure < 90 mmHg. Exploratory laparotomy or computed tomography scan confirmed hemoperitoneum. Of 270 patients entered into the study, ultrasound detected free intraperitoneal fluid in 33 patients. Of the 18 patients with a large fluid accumulation, 16 underwent exploratory laparotomy (89% sensitivity), and all 8 patients with unstable vital signs underwent exploratory laparotomy (100% sensitivity). Of the 10 patients with a moderate fluid accumulation, 6 underwent exploratory laparotomy (60% sensitivity), and 4 of the 6 patients with unstable vital signs underwent exploratory laparotomy (67% sensitivity). A large intraperitoneal fluid accumulation on ultrasonography in combination with unstable vital signs, is sensitive for determining the need for exploratory laparotomy in patients presenting with blunt trauma.

Ultrasound detection of free intraperitoneal fluid associated with hepatic and splenic injuries.

BACKGROUND: The objective of this study was to compare the sensitivity and specificity of 5 abdominal views for detecting free intraperitoneal fluid in trauma patients later diagnosed with hepatic or splenic injuries. METHODS: This retrospective study conducted over a 17-month period enrolled patients with trauma. A Focused Abdominal Sonogram for Trauma (FAST) examination was done using 5 abdominal views. Exploratory laparotomy or computed tomography (CT) confirmed the presence of intraperitoneal fluid and associated injuries. The sensitivity and specificity were determined. RESULTS: Of the 245 study patients, 29 had injuries to the liver or spleen or both. The 5-view FAST examination's sensitivity for detecting free intraperitoneal fluid associated with hepatic, splenic, or combined injuries was 77%, 90%, and 100%, respectively. The sensitivity of the single Morison's pouch view in detecting free intraperitoneal fluid associated with hepatic, splenic, or combined injuries was 38%, 20%, and 67%, respectively. CONCLUSION: For identifying free intraperitoneal fluid associated with hepatic or splenic injuries, no single view of the FAST examination could match the sensitivity provided by the 5-view technique.

Electrocardiography in the patient with the Wolff-Parkinson-White syndrome: diagnostic and initial therapeutic issues.

The Wolff-Parkinson-White syndrome (WPW), estimated to occur in approximately 0.1% to 3% of the general population, is a form of ventricular preexcitation involving an accessory conduction pathway. The definition of WPW relies on the following electrocardiographic features: (1) a PR interval less than 0.12 seconds (2) with a slurring of the initial segment of the QRS complex, known as a delta wave, (3) a QRS complex widening with a total duration greater than 0.12 seconds, and (4) secondary repolarization changes reflected in ST segment-T wave changes that are generally directed opposite (discordant) to the major delta wave and QRS complex changes. The accessory pathway bypasses the atrioventricular (AV) node, creating a direct electrical connection between the atria and ventricles. The majority of patients with preexcitation syndromes remain asymptomatic throughout their lives. When symptoms do occur they are usually secondary to tachyarrhythmias; the importance of recognizing this syndrome is that these patients may be at risk to develop a variety of supraventricular tachyarrhythmias which cause disabling symptoms and, in the extreme, sudden cardiac death. The tachyarrhythmias encountered in the WPW patient include paroxysmal supraventricular tachycardia (both the narrow QRS and wide QRS complex varieties), atrial fibrillation, atrial flutter, and ventricular fibrillation. Diagnostic and urgent, initial therapeutic issues based on initial electrocardiographic information are presented via 5 illustrative cases.

Outcome analysis of a protocol including bedside endovaginal sonography in patients at risk for ectopic pregnancy.

STUDY OBJECTIVES: To determine whether bedside endovaginal sonography (EVS) performed by emergency physicians reduces complications associated with ectopic pregnancy (EP) including missed EP and EP rupture. METHODS: Our setting was an urban trauma center emergency department. We assembled a prospective convenience sample (n=314) with a historical EP control group (n=56) of women 18 years or older with a positive pregnancy test and any signs, symptoms, or risk factors for EP. Bedside EVS for all subjects and immediate quantitative serum human chorionic gonadotropin determination for patients with no definite intrauterine pregnancy by EVS. RESULTS: Retrospective chart review identified 56 EP patients in the historical control group who had had no bedside EVS. Twenty-four of these patients (43%; 95% confidence interval [CI], 30% to 56%) were discharged from the ED, 12 of whom (50%; 95% CI, 30% to 70%) were later categorized as having ruptured EP. During the prospective study period, 40 patients were diagnosed as having EP; 11 (28%; 95% CI, 14% to 42%) were discharged from the ED (P=NS), and only 1 (9%; 95% CI, 0% to 26%) of the discharged patients was later determined to have a ruptured EP (P<.05). CONCLUSION: An EP protocol incorporating bedside EVS performed by emergency physicians significantly reduced the incidence of discharged patients with subsequent EP rupture, compared with historical controls.

Unusual cause of hypotension associated with penetrating trauma.

In a hypotensive patient who has sustained a penetrating injury, the hypotension is usually due to acute blood loss. We present a patient who was stabbed in the subxiphoid region found to have an unusual cause of hypotension.

Evaluation of hemoperitoneum using a single- vs multiple-view ultrasonographic examination.

OBJECTIVE: To compare the sensitivities, specificities, and accuracies between a single-view ultrasonography (US) technique and a multiple-view technique for identifying hemoperitoneum in multiple-trauma patients. METHODS: Data from a prior prospective study of US for trauma diagnosis at a level I trauma center were retrospectively analyzed. A convenience sample of adult patients (> or = 18 years of age) who had presented with major blunt or penetrating torso trauma and had undergone rapid trauma US examinations to detect hemoperitoneum were reviewed. The US interpretations by emergency physicians had been recorded prior to obtaining other diagnostic tests. Five views were evaluated, including the right intercostal oblique view examining Morison's pouch. Evidence of free intraperitoneal fluid by exploratory laparotomy, CT, or diagnostic peritoneal lavage (DPL) was used as the criterion standard. RESULTS: Of the 245 patients entered into the study, 37 had free intraperitoneal fluid, confirmed by CT, DPL, or exploratory laparotomy. With the multiple-view technique, US was 87% (95% CI = 71%, 96%) sensitive, 100% (95% CI = 97%, 100%) specific, and 98% (95% CI = 95%, 100%) accurate. The single-view technique, evaluating only Morison's pouch, was 51% (95% CI = 34%, 68%) sensitive, 100% (95% CI = 98%, 100%) specific, and 93% (95% CI = 89%, 96%) accurate. CONCLUSIONS: An initial trauma US examination using a multiple-view technique is more sensitive than that using a single-view technique for detecting hemoperitoneum in trauma patients.

Prospective analysis of a rapid trauma ultrasound examination performed by emergency physicians.

The objective of this prospective study was to determine the sensitivity, specificity, and accuracy of the rapid trauma ultrasound examination, performed by emergency physicians, for detecting free peritoneal and thoracic fluid in patients presenting to a level I trauma center with major blunt or penetrating torso trauma. Emergency medicine residents and faculty were trained to perform an ultrasound examination of the torso evaluating for free intraperitoneal, retroperitoneal, pleural, and pericardial fluid. In the 245 study patients, emergency physicians examined 975 intracavitary spaces and demonstrated 64 positive findings for free fluid as documented by computed tomography scan, diagnostic peritoneal lavage, exploratory laparotomy, chest radiography, tube thoracostomy, or formal two-dimensional echocardiography. The rapid trauma ultrasound examination was 90% sensitive, 99% specific, and 99% accurate. Ultrasonography can serve as an accurate diagnostic adjunct in detecting free peritoneal and thoracic fluid in trauma patients. Appropriately trained emergency physicians can accurately perform and interpret these trauma ultrasound examinations.

Death after discharge from the emergency department.

STUDY OBJECTIVE: To determine the rate and cause of death of patients who were evaluated in the emergency department and discharged and how the cause of death related to the ED visit. DESIGN: Retrospective chart review of medical examiner cases from July 1, 1990, to June 30, 1991. SETTING: Urban county served by 13 hospital EDs with 383,416 visits in 1991. Eighty-five percent of these patients were discharged. PARTICIPANTS: Medical examiner cases of patients who had been evaluated and released from an ED within 8 days prior to death. RESULTS: Forty-two of the 2,665 medical examiner cases met inclusion criteria. Death was classified as expected or unexpected based on the patient's clinical status at the time of discharge, and directly related or not directly related to the ED visit, based on review of all records and the cause of death as listed on the death certificate. Six deaths (14%) were considered expected and directly related. Three deaths (7%) were considered expected and not directly related. Twenty-four deaths (57%) were considered unexpected and not directly related. Nine deaths (21%) were considered unexpected and directly related; the most common cause was ruptured aortic aneurysm, occurring in three of these nine cases. The death rate was 13 per 100,000 discharged patients. CONCLUSION: Death after discharge from the ED is uncommon. The most common cause of unexpected, directly related death is ruptured aortic aneurysm.

Tetanus.

Tetanus is a preventable disease with proper immunization. The marked decline in the incidence over the past several decades has resulted from widespread use of tetanus prophylaxis and improved wound management in the emergency department. Emergency physicians are among the most frequent providers of tetanus vaccination. We can stress the importance of proper immunization and encourage patients to keep accurate immunization records. This can maximize protection of patients from tetanus, and minimize adverse reactions from excessive administration of booster. Tetanus can be fatal even with proper treatment. Vital treatment measures can easily be completed in the emergency department.