Predictors of intracranial pathologic findings in patients who seek emergency care because of headache.

BACKGROUND: Clinical criteria to select patients with headache in whom structural diagnostic studies (computed tomography) have a high yield disclosing intracranial pathologic findings, independent of abnormal findings on neurologic examination, have not been defined. OBJECTIVE: To determine which clinical characteristics predict the presence of intracranial pathologic findings, independently of neurologic examination, in patients with headache. DESIGN: Case-control, consecutive sample. SETTING: Major metropolitan trauma center emergency department. PATIENTS AND MATERIALS: Hospital records of 139 hospitalized and 329 randomly selected patients from 1720 nonhospitalized adult patients, consecutively evaluated for headache in the emergency department, were reviewed. Demographic data, clinical characteristics of the headache, results of neurologic and physical examinations, and diagnostic radiologic and laboratory results were correlated with final diagnosis and outcome at 6 months after emergency department visit. DATA ANALYSIS: Nonparametric statistical analysis. RESULTS: Intracranial pathologic findings were found in 18 (3.8%) of 468 patients. Acute onset and occipitonuchal location of headache, presence of associated symptoms, and patient age of 55 years or older were significantly associated with the finding of intracranial pathology, independently of the findings from neurologic examination. Abnormal findings on neurologic examination alone, whether focal or nonfocal, had a highly significant association and a positive predictive value for intracranial pathology of 39%. CONCLUSIONS: Abnormal results from neurologic examination are the best clinical parameters to predict structural intracranial pathology; however, in patients 55 years or older with headache of acute onset located in the occipitonuchal region that has associated symptoms, computed tomographic scan of the head is justified as part of their clinical evaluation independently of the findings of the neurologic examination.

The prevalence of Neisseria gonorrhoeae and Chlamydia trachomatis in victims of sexual assault.

The prevalence of Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) in 232 sexual assault victims who presented for examinations between August 1, 1987, and July 31, 1988, was determined. Results are reported for cervical, rectal, and oropharyngeal NG cultures and for cervical and rectal CT smears. Results from a one-week follow-up are also reported. Cervical test results from the initial sexual assault examination were compared with cervical tests on 399 randomly selected female emergency department patients who presented for other gynecological conditions or lower abdominal pain. The victims of sexual assault had ten of 210 positive cervical NG cultures (4.76%), and 13 of 213 positive cervical CT smears (6.1%) at the first visit. These prevalence rates were not significantly different (P = .3058). There were none of 28 positive rectal NG cultures (0%) and one of 22 positive rectal CT smears (4.34%) (P = .451). None of the 43 oral NG cultures was positive. Seventy-three victims returned for follow-up examination. No follow-up cervical, rectal, or oral NG cultures were positive. However, one of 53 follow-up cervical smears for CT was positive, but this was not significantly different than for cervical NG (P = .461). Sexually assaulted patients had ten of 210 (4.76%) cervical NG cultures positive, and nonassaulted patients showed 53 of 393 positives (13.4%) (P less than .001). Assaulted patients had 13 of 213 (6.1%) cervical CT smears positive, and nonassaulted patients showed 33 of 352 (9.3%) positives (P = .11).(ABSTRACT TRUNCATED AT 250 WORDS)

Analyses of the relationship between blood alcohol and nasal breath alcohol concentrations: implications for assessment of trauma cases.

To prevent serious complications and facilitate efficient and effective management of patients admitted to the emergency department or intensive care settings, it is extremely important to differentiate, quickly, between elevated concentrations of alcohol in the blood and compromised neurological status due to brain injury or other pathology. This research analyzed the relationship between blood alcohol concentrations (BACs) estimated from venous blood samples and those estimated from breath samples that were obtained using the Alco-Sensor III device with an attached tube for passive nasal breath sampling. Blood and breath samples, as well as brief medical histories and demographic and environmental data, were obtained and recorded for 35 adult trauma patients admitted to two major urban emergency departments. Passively expired nasal breath provided an excellent estimate of BAC measured from venous blood (range, 0 to 0.32) as evidenced in the extremely high regression coefficient (r = 0.99; slope = 1.22; p less than 0.0001). BAC assessment and monitoring, through the application of passive nasal breath sampling, provides a means of rapidly estimating BAC, and thus can facilitate diagnosis and the initiation of appropriate management and treatment.

Methanol intoxication in multiple trauma.

Management of inflicted or self-inflicted trauma to accomplish homicide or suicide is no novelty in the practice of medicine. However, it takes an astute clinician to recognize serious poisoning in the midst of life-threatening injuries. We describe two cases where homicide and suicide attempts were accompanied with the ingestion of methanol. Both patients recovered with proper management of the injuries as well as early recognition and treatment of the methanol poisoning.

Emergency management of hand injuries. When to repair, when to refer.

The primary care physician can accurately diagnose hand injuries by obtaining a thorough patient history and performing a complete physical examination of the hand. When the severity of injury is doubtful, immobilization in a splint with next-day referral is appropriate. Immediate consultation should be obtained with nerve or vascular damage, fracture-dislocation injuries, open fractures, substantial skin loss, or flexor tendon injuries at or distal to the wrist.

Significance of symptoms and signs in patients with traumatic aortic rupture.

The records of 50 patients with traumatic aortic rupture (Group I) and 50 patients with blunt chest trauma but negative aortograms (Group II) were reviewed retrospectively. Symptoms and signs referable to the chest and thoracic aorta were recorded and compared in Group I and Group II patients. Each patient's chart was evaluated for chest pain, respiratory distress, thoracic back pain, hypotension, hypertension, and decreased femoral pulses. None of the symptoms or signs attained statistical significance between Group I and Group II patients. The only significant difference between Group I and Group II patients was in the injury severity score (ISS). The mean ISS for aortic rupture patients was 42.1 +/- 11.6 (SD), but was only 19.9 +/- 11.4 (SD) (P less than .001) for patients without aortic rupture. We conclude that the diagnosis of aortic rupture in patients sustaining blunt chest trauma cannot be accurately predicted or excluded on the basis of the patients' presenting complaints or physical findings.

Ovarian ectopic pregnancy.

We present the case of a 27-year-old woman with left lower quadrant pain, tenderness, and rebound tenderness. Culdocentesis demonstrated non-clotting blood, and exploratory laparotomy showed an ovarian ectopic pregnancy. A wedge resection of the ovary was accomplished and the patient recovered completely. Ovarian ectopic pregnancy is an uncommon presentation of ectopic pregnancy.

Peritoneal lavage for the diagnosis of abdominal visceral injury.

Peritoneal lavage has become standard for the diagnosis of abdominal visceral injury following trauma. Peritoneal lavage is indicated after blunt trauma when a patient presents with abdominal symptoms or signs and the integrity of the abdominal viscera is in doubt. Immediate laparotomy may be indicated following penetrating abdominal wounds when symptoms, signs, or hypotension are present. However, peritoneal lavage may be indicated if the patient is asymptomatic. Lavage is also indicated after penetrating extra-abdominal wounds when the path of the wounding agent suggests that the peritoneal cavity might have been entered. Peritoneal lavage is 98% accurate in determining the presence or absence of abdominal visceral injury following blunt trauma (100,000 red blood cells [RBCs]/mm3 or 500 white blood cells [WBCs]/mm3). The diagnostic accuracy of peritoneal lavage in penetrating abdominal injuries is more controversial than in blunt trauma, but recent retrospective data suggest that peritoneal lavage has the potential of giving 98% accurate results following penetrating abdominal injury when the threshold for a positive result of lavage is lowered to 50,000 RBCs/mm3 or 500 WBCs/mm3.

Chest roentgenographic findings in 26 patients with traumatic rupture of the thoracic aorta.

The initial 100-cm anteroposterior (AP) supine chest roentgenograms of 26 patients with proven traumatic aortic rupture were reviewed. The 20 male patients and six female patients ranged in age from 12 to 75 years. Distortion of normal aortic contour or blurring of the aortic outline occurred in 23 cases. Opacification of the radiolucent space between the aorta and pulmonary artery was seen in 22 instances. The mean mediastinal width, measured at the superior border of the anterior fourth rib, was 9.4 cm. Obliteration of the medial aspect of the left upper lung field was observed on 13 films. Obliteration of the shadow of the descending aorta, hemopneumothorax, and tracheal shift to the right each occurred in 17, 14, and 12 cases, respectively. This study illustrates that distortion or blurring of the aortic arch contour, opacification of the clear space between the aorta and pulmonary artery, and increased mediastinal width (mean = 9.4 cm) are the most frequently occurring abnormalities on the initial AP supine chest films of patients with traumatic aortic rupture. Such findings should arouse the suspicion of aortic rupture, and warrant aortography.

Open treatment of fingertip amputations.

Twenty-five patients with fingertip injuries at or distal to the distal interphalangeal joint were treated with a thorough cleansing of the wound with application of bacitracin and a sterile dressing. Warm soaks were begun 48 hours after injury. Crush injury was the most common type of trauma, followed by cutting injuries. Bone involvement was present in six cases. The average healing time was 29 days. At the time of complete healing, sensation was normal in 22 patients (88%). Systemic antibiotics were not administered routinely. No patient developed a wound infection. Our study documents that fingertip amputations can be successfully treated by nonoperative methods that result in preservation of finger length and contour, retention of sensation, and healing without infection.

The clinical diagnosis of ruptured subclavian artery following blunt thoracic trauma.

The clinical findings of nine patients who suffered disruption of the subclavian artery following blunt thoracic trauma were reviewed. Seven patients were men, two were women. Their ages ranged from 16 to 43 years. Five patients presented with shock at the time of admission. Five patients incurred a first rib fracture. The radial pulse was present in three patients, absent in three patients, and indeterminant in three patients due to their profound state of shock. Brachial plexus palsy was present in three patients. A palpable supraclavicular hematoma was present in two patients. The chest roentgenograms showed a localized hematoma over the area of the injured subclavian artery in two instances, a widened superior mediastinal shadow in one case, and both findings in another patient. Thus four of the seven patients who survived to undergo chest roentgenograms had films that suggested injury to the arch of the aorta or its branches. Seven patients survived long enough to undergo operative repair; one of these patients died (14%). The following five criteria should alert the physician to the possibility of subclavian arterial injury following blunt thoracic trauma: 1) fractured first rib; 2) diminished or absent radial pulse; 3) palpable supraclavicular hematoma; 4) chest film evidence of hematoma over the area of the subclavian artery or a widened superior mediastinum; and 5) brachial plexus palsy.