Diagnosis of myocardial contusion.

From July 1988 to July 1990, 159 consecutive cases of major blunt chest injury were evaluated prospectively for myocardial contusion with serial electrocardiographic monitoring, cardiac isoenzyme studies, and two-dimensional echocardiography. One hundred and forty-seven cases in the series were assessable; 97 of the patients were male, and 50 were female. They ranged in age from 2 to 97 years (average, 38.5 years). There were five deaths, none of cardiac origin. Total lactate dehydrogenase (LDH) values were elevated in 115 patients (78%); total creatine phosphokinase (CPK) values were elevated in 100 (68%). Cardiac isoenzyme patterns were consistent with myocardial contusion in 18 patients (12%). Seventy-five patients had abnormal electrocardiograms, and 10 of these had ectopic rhythms. Two-dimensional echocardiograms were completed in 58 cases; 12 of these (21%) were abnormal. Nineteen patients (25%) with abnormal rhythms had elevated LDH values, and 26 (35%) had elevated CPK values. One patient (10%) with ectopy had an abnormal echocardiogram. Two patients (11%) with abnormal isoenzyme patterns experienced dysrhythmias. Costs for hospitalization and studies amounted to $1,886 per patient. Given the poor predictive value of laboratory testing in patients with significant (ie, symptomatic) cardiac contusion, observation alone with electrocardiographic monitoring and treatment of symptomatic dysrhythmias is an adequate and cost-conscious treatment.

Outpatient open cholecystectomy.

A prospective study to evaluate discharge of patients from the hospital the day of open cholecystectomy was performed. Patients were selected for outpatient operation if they were less than 55 years of age, did not undergo exploration of the common bile duct and had no significant co-morbidity. During a six month period, 94 consecutive patients underwent cholecystectomy. Forty-four of 64 eligible patients were discharged the day of operation. Patients were walking and receiving oral liquids soon after operation. Marcaine (bupivacaine hydrochloride) was injected subfascially in all patients and vertical incisions were used in 34 of 44. One patient required readmission for 12 hours, three days after operation. The satisfaction rate was high and the patients returned to their usual activity in seven to 21 days. Outpatient open cholecystectomy is safe, and appropriate therapy and the data established a standard with which to compare that of laparoscopic cholecystectomy.

Twenty-four hour hospitalization after cholecystectomy.

To evaluate the likelihood that patients can be discharged from the hospital the day after open cholecystectomy, a prospective study of 500 consecutive patients undergoing cholecystectomy was undertaken. The study group included patients with associated acute and gangrenous cholecystitis, biliary pancreatitis and choledocholithiasis as well as those with diabetes, hypertension and obesity. Approximately one-fourth of the total group were discharged within 24 hours and over one-half in 48 hours. There was a significant correlation between advancing age and increasing length of stay. Almost one-half of the patients less than 35 years of age without acute or complicated disease were discharged within 24 hours, more than 80 per cent within 48 hours, and the mean length of postoperative stay (MLS) for these patients was 1.9 days. The presence of choledocholithiasis and fever greater than 101 degrees F. increased MLS, while acute cholecystitis, hyperamylasemia and leukocytosis did not. Early discharge from the hospital after open cholecystectomy, even in sick patients, is safe and cost-effective.

Perforated or gangrenous appendicitis treated with aminoglycosides. How do bacterial cultures influence management?

To study the influence of bacterial culture data on the clinical management of gangrenous or perforated appendicitis, we reviewed records of 104 patients who had been treated empirically with aminoglycoside antibiotics. Culture results appeared to influence antibiotic therapy in only 7 patients (7%). The routine cultures obtained at appendectomy affected therapy in only 2 patients. Discriminant analysis identified postoperative infectious complications and related factors as the principal determinants of culture utility. We conclude that, in patients with perforated appendicitis treated empirically with aminoglycoside combination regimens, culture results were seldom used for clinical management except in instances of postoperative infectious complication. Routine cultures and Gram's stains of perforated appendicitis, however, should still be obtained (1) to allow epidemiologic tracking in the hospital; (2) to identify organisms that are recovered infrequently but may cause serious disease (eg, Clostridium); and (3) because newer antibiotics are replacing aminoglycosides in the treatment of perforated appendicitis.

Cefamandole versus cefoxitin prophylaxis in patients undergoing cholecystectomy.

A prospective, randomized, double-blind study of three different antibiotic prophylaxis regimens in 150 patients undergoing cholecystectomy was conducted. Group I patients received a 1-gram preoperative dose of cefamandole followed by 4 additional postoperative doses at 6-hour intervals. Group II received a similar regimen except that 2-gram doses of cefamandole were used. Group III received a comparable cefoxitin regimen in 2-gram doses. The patients were deemed to be at high risk for postoperative infection by virtue of the fact that most (almost 70%) were obese and all had had a recent attack of cholecystitis. There were no significant differences among the 3 groups with respect to postoperative infectious complications. It is concluded that perioperative cefamandole and cefoxitin are both effective in reducing the postoperative infectious complications of cholecystectomy. A 5-gram course of cefamandole is as effective as either a 10-gram course of cefamandole or a 10-gram course of cefoxitin and could provide a substantial savings in cost.

Rapid resolution of high level hyperamylasemia as a guide to clinical diagnosis and timing of surgical treatment in patients with gallstones.

We reviewed the charts of 78 patients with acute hyperamylasemia (25 with gallstones, 38 alcoholic patients and 15 other), looking for early patterns of serum amylase flux that could distinguish gallstone associated disease. Patients with gallstones had average serum amylase levels of 1,848 +/- 289 International units per liter and 911 +/- 233 International units per liter at hospital admission and on hospital day 2, respectively; these levels were significantly greater than those in either the alcoholic or other patients. In the group of patients with gallstones, there were also dramatic decreases in serum levels of amylase at 24 hours (1,425 +/- 286 International units) after hospital admission; these decreases were not seen in the other groups of patients. At operation, the patients with gallstones had mild or no pancreatitis. All of them underwent uneventful cholecystectomy within 48 hours of hospitalization; only three patients required exploration of the common duct, and only one patient had ampullary obstruction. We conclude that rapid resolution of high level hyperamylasemia within 24 hours of hospitalization in symptomatic patients with gallstones can help to identify patients whose amylase fluctuations are indeed gallstone related, who have either mild pancreatitis or none at all, are good candidates for early cholecystectomy and are not likely to have common duct stones.

Rapid diagnosis of group A strep pharyngitis in the emergency department.

Two ten-minute rapid tests for diagnosing Group A streptococcal pharyngitis in 147 emergency department patients with a complaint of sore throat were evaluated using positive throat cultures as the marker for disease. Treatment was initiated solely on the basis of clinical judgment. Sensitivity and specificity were 78% and 93%, respectively, for the rapid test and 69% and 56%, respectively, for clinical judgment. The rapid test was significantly better than clinical judgment alone in determining the presence of disease (P less than .05). The predictive values of the positive and negative and were 78% and 93%, respectively, for the rapid test and 38% and 85%, respectively, for clinical judgment. In the ED setting in which adequate followup is difficult, the rapid test can identify more accurately than can clinical judgment alone those patients who need therapy.

Medical reliability of advanced prehospital cardiac life support.

Records of 263 consecutive patients receiving prehospital advanced cardiac life support for dysrhythmias associated with clinical cardiac arrest were reviewed to determine 1) accuracy of diagnosis of presenting rhythm by the paramedic in the field and the medical control physician at the telemetry base station; and 2) whether the treatment rendered was appropriate. The initial rhythm was misinterpreted by the paramedic in 41 patients (16%) and by the medical control physician in 22 patients (11%). In 16 patients (8%) both paramedic and physician misinterpreted the initial rhythm. Treatment errors occurred in 120 patients (46%). Forty-seven errors (18%) resulted from failure to establish an intravenous line, 17 (6%) resulted from failure to secure a controlled airway, and 38 (14%) were medication errors from failure to adhere to protocol. We conclude that errors in management of prehospital cardiac arrest victims in our emergency medical services system result most often from mistakes in specific therapy rather than from failure to identify the precipitating dysrhythmia.

Early surgery for biliary pancreatitis.

Herein, we documented our successful experience in performing definitive biliary tract surgery on patients with biliary pancreatitis as soon as the diagnosis was made and within 48 hours of admission. Early surgery reduced the length of hospital stay and did not result in associated morbidity, death, or complications of acute pancreatitis. The results of the study support the concept that removing obstruction of the pancreatic duct prevents progression of edematous pancreatitis to hemorrhagic pancreatitis. We conclude that patients with acute pancreatitis should be evaluated urgently for the presence of biliary tract stone disease and should be operated on as soon as the diagnosis of biliary pancreatitis is made, that early definitive surgery can be performed safely on patients with biliary pancreatitis, that cholecystectomy with intraoperative cholangiography and common duct exploration as necessary should be performed in all patients, and that length of stay for patients with biliary pancreatitis is reduced and morbidity and mortality possibly may be reduced by early surgery as compared with delayed surgery.

Traumatic hernia of the anterior abdominal wall.

Despite an increase in incidence of blunt abdominal trauma and despite the variations in compressive forces that occur, very few cases of traumatic hernia of the anterior abdominal wall have been recorded. Two recently treated cases of traumatic disruption of the musculature and fascia of the anterior abdominal wall with herniation of intestine into the subcutaneous space are herein reported. The occurrence of blunt abdominal trauma associated with an extra-abdominal mass believed to contain intestine signifies a severe compressive force and probable extensive associated injury. It represents an acute emergency and requires prompt resuscitative measures and surgical intervention.

Splenic abscess caused by Shigella flexneri and Bacteroides fragilis.

We report a case of splenic abscess from which only Shigella flexneri (serotype 1a) and Bacteroides fragilis were isolated. The patient was a 59-year-old diabetic female who displayed minimal gastrointestinal symptoms. The S. flexneri isolate was resistant to chloramphenicol and tetracycline. The possible synergistic relationship between the two organisms is discussed.

Amebic liver abscess. Differential diagnosis of cholecystitis.

Among patients presenting with pain and tenderness in the right upper quadrant were 75 with cholelithiasis (13 male, 2 under age 50) and 9 with amebic hepatic abscess (6 male, all under age 45). The differential diagnosis of cholelithiasis versus liver abscess was accurately made by prompt sonography and hepatobiliary scintigraphy. Amebic abscess was confirmed by positive serum ameba titers. Presenting symptoms and results of laboratory studies of patients with amebic abscess were indistinguishable from those of patients with cholecystitis. It is concluded that an accurate diagnosis of amebic liver abscess in the differential diagnosis of cholecystitis can be made by sonography and hepatobiliary imaging. Also, in endemic areas of the southwestern United States, amebic abscess should be strongly considered in the differential diagnosis of patients presenting with pain and tenderness in the right upper quadrant and is more common than cholecystitis in young men.

Early operation for acute biliary tract stone disease.

A prospective study to evaluate the accuracy of early diagnosis and the efficacy of early operation for biliary tract stone disease was performed. One hundred fifty-two consecutive patients with signs and symptoms compatible with biliary colic or acute cholecystitis were admitted to the hospital and promptly evaluated with ultrasonography and hepatobiliary (Pipida) scanning. Patients with demonstrable stones or a nonvisualized gallbladder underwent operation within 48 hours of admission. Of 75 patients who underwent operation, 64 had acute and/or severe chronic cholecystitis. Associated biliary pancreatitis was present in 14 of 75 patients. Cholecystectomy with intraoperative cholangiography was performed for 73 of the 75 patients. One patient underwent cholecystectomy only and one patient underwent cholecystostomy. There were 18 common duct explorations. No transfusions were required and there were no deaths. The average duration of hospital stay for all patients who underwent operation was 6.5 days. The results indicate that an accurate diagnosis of acute biliary tract stone disease can be made rapidly with use of sonography and hepatobiliary scanning, that cholecystectomy with intraoperative cholangiography and common duct exploration as necessary can be performed safely (including cases of biliary pancreatitis) in the acute setting, and that with early operation the duration of stay is decreased and morbidity and mortality rates compare favorably with those of elective cholecystectomy. It is concluded that operation performed within at least 48 hours of admission is the treatment of choice for acute biliary tract stone disease.

Preoperative bilirubin, alkaline phosphatase and amylase levels as predictors of common duct stones.

The predictive value of the preoperative level of bilirubin, alkaline phosphatase and amylase as indicators of choledocholithiasis was determined by prospectively evaluating 304 consecutive patients undergoing cholecystectomy. Elevated levels of bilirubin and alkaline phosphatase are associated with an increased incidence of common duct stones, and the percentage incidence of stones increases with rising bilirubin and alkaline phosphatase levels. Alkaline phosphatase levels as great as 200 are associated with common duct stones in a low percentage of instances, being equivalent to that for unsuspected stones. Levels of 200 or greater are associated with a marked increase in the incidence of common duct stones. An elevated serum or urine amylase level, or both, is of little, if any, value as a predictor of common duct stones. Alkaline phosphatase appears to be a better indicator of common duct stones than does bilirubin, but neither bilirubin nor alkaline phosphatase in themselves are statistically significant indicators. Bilirubin and alkaline phosphatase in combination is a statistically significant predictor of common duct stones at all levels. The combination of a bilirubin level of greater than 3.0 and an alkaline phosphatase level of greater than 250 has a 76.2 per cent probability of an associated common duct stone. The quite important role of operative cholangiography in demonstrating unsuspected stones and in preventing unnecessary common duct explorations is reinforced.

Frequency analysis of commercially available vibrators.

The tonic vibration reflex -- elicitation of a muscle contraction by mechanical vibration -- is a well documented physiological phenomenon of particular relevance to physiotherapy. Among the critical features pertaining to the effectiveness of its use in clinical practice are the mechanical attributes of the vibrator used to elicit the reflex. Because physiological responses differ with vibrations of varying frequency and amplitude, it is necessary to measure these characteristics before a commercial vibrator is used therapeutically: Facilities and equipment for performing such tests are, however, not readily available to physiotherapists. The purpose of this study, therefore, was to measure and compare frequencies of a variety of commercially available vibrators under varying load conditions and over time. Vibrators from major Canadian retail outlets and manufacturers were obtained and, through the use of both mechanical and optical methods, a total of 19 models were frequency-calibrated. The results of the study permit discussion related to the suitability and reliability of each model and provide specific guidance to physiotherapy departments in the selection of appropriate therapeutic vibrators. The results also indicate that the mode of application, such as strapping the apparatus to the patient rather than having the operator hold it in her hand, affects the frequency in some models. The data related to frequency measurements, gained through this study, should enable therapists to make more effective use of commercially available vibrators in motor reeducation.

Emergent or elective operation for symptomatic abdominal aortic aneurysm.

The patient with the symptomatic abdominal aortic aneurysm (AAA) presents a management dilemma, ie, emergent, urgent, or elective operation. The mortality for 38 patients with a ruptured AAA prior to 1972 was 61%. That year, a policy of immediate operation was instituted for patients with symptoms that might be referable to a ruptured AAA. It is concluded that an immediate operation on the patient with a symptomatic but intact AAA resulted in an excessively high mortality. Thus, the indications for an immediate operation on these patients should be based on clinical judgment; attempting to differentiate between the patient with the ruptured and the patient with the intact aneurysm. Hemodynamic data (blood pressure hematocrit reading) suggesting a decrease in blood volume dictate an immediate operation. An urgent operation on the well-prepared patient should be performed on all patients with a symptomatic aneurysm in which the clinical and hemodynamic findings do not suggest that it has ruptured.

Pancreatic and duodenal injuries: morbidity and mortality of surgical management.

A retrospective review of pancreatic injury is presented. Twenty-five cases in which the pancreatic injury was either the sole or major injury were selected from over 100 cases of pancreatic injury admitted during the period 1970 to 1977. Eight pancreatic injuries resulted from blunt trauma and 17 from penetrating trauma. Two methods of treatment were compared, drainage alone versus duodenal diverticularization and/or distal resection. There were no deaths. Of the 15 patients treated by drainage alone, 14 (93%) developed postoperative complications, as compared to 20% (two of ten patients) treated by diverticularization and/or distal resection.