Abstracts in this issue were prepared by residents in the University of Arizona Emergency Medicine Residency Program,

ABSTRACTS Harvey W, Meislin, MD, FACEP Co-Editor Chief, Section of Emergency Medicine University of Arizona College of Medicine

Vincent J, Markovchick, MD, FACEP Co-Editor Emergency Medical Services Denver General Hospital

MYOCARDIAL CONTUSION

Myocardial contusion: Implications for patients with multiple traumatic injuries Snow N, Richardson JD, Flint LM, Jr Surgery 92:744-749 Oct 1982

agnosed as having contusion and absence of significant cardiac problems in patients with both normal ECG and CPK-MBs suggest that the criteria suggested in this study may serve us well until a better early method of diagnosing cardiac contusion is available.]

Keith Kaback, MD

During an 18-month period, 300 patients with suspected blunt chest trauma were prospectively evaluated in order to better evaluate diagnostic aids and management of cardiac contusion. All patients with suspected blunt chest trauma were admitted. Serial ECGs and CPK-MB analysis were per- formed for 72 hours. Criteria for the diagnosis of cardiac contusion consisted of a clinical picture consistent with cardiac trauma and either an abnormal ECG or CPK-MB levels that were 5% or more of the total CPK activity. Of the 300 suspected cases, 4! met the criteria for cardiac con- tusion. Twenty patients (49%) complained of nonspecific chest pain. Thirty patients (73%) demonstrated external evi- dence of thoracic trauma. Of the 41, 34 (83%) had abnormal initial ECGs, with such findings as sinus tachycardia, nonspecific ST-T waves changes, prematuri t ies, heart blocks, and ischemic pattems. Of the 41, 34 (83%) had CPK- MB fractions greater than or equal to 5%. Twenty-seven of 41 (66%) had both abnormal initial ECGs and positive CPK- MB. Seven patients had normal initial ECGs but positive CPK-MB levels. Seven patients had normal enzyme levels but ECG evidence of cardiac injury. CPK-MB levels tended to peak within the first 1 to 2 days in the majority of pa- tients. Emergency sttrgery was necessary in 27 of the 41 pa- tients. Despite their increased risk due to cardiac contusion, little morbidity was seen and none died during surgery. Car- diac complications occurred in 28 (68%) of the 41 patients with cardiac contusion, including arrhythmias, CHF, car- diac ischemia, pericarditis, and cardiogenic shock. Treat- ment interventions were necessary in 16 of the 28 with complications, including inotropic drags and electroshock. Three pa t ien ts died, one f rom sepsis and two f rom cardiogenic shock. No patient with both negative ECG and CPK-MB levels had a clinical course consistent with signifi- cant cardiac injury. The authors suggest that: 1) available clinical methods can adequately diagnose significant cardiac contusion; 2) cardiac monitoring is advisable prior to di- agnosis and in cases of confirmed contusion due to the high rate of associated cardiac morbidity; and 3) surgical pro- cedures with general anesthesia can be safely performed in patients with cardiac contusion. [Editor's note: Autopsy studies have shown that both ECG changes and enzyme elevations correlated poorly with actual cardiac contusion. The high rate of cardiac complications in patients di-

PEDIATRIC VISITS

Ostensible versus actual reasons for seeking pediatr ic a t tent ion: Another look at the parenta l t i cke t of admiss ion Bass LW, Cohen RL Pediatrics 70:870-874 Dec 1982

Many times the anxiety expressed by the parent is in ex- cess of that which seems warranted from the demeanor and physical findings of the pediatric patient. Frequently reas- surance or an appropriate prescription may not satisfy the parent, and the parental anxiety remains. The authors note that many times ostensible reasons for medical visits mask actual reasons for seeking medical help. The study reviews 370 sick-patient visits in a pediatric office practice over a 3-month period. Each parent was asked, "What are you con- cemed about?" Regardless of the answer (eg "the fever," "the ear infection," etc) a follow-up question was asked: "Is there anything special about the fever, the ear infection, etc, that causes you concern?" The further questioning revealed a hidden, underlying reason for the visit in 125 (33.8%) of these visits. In 39 instances the parents tended tO link the child's current symptoms with a serious disease in another family member or friend, or the child might have had a serious illness in the past which the parents thought was recurring. The authors go on to describe parental fears of leukemia, an authority figure raising doubt in the parent's mind, perceptions that the illness has lasted too long, or death of another family member as potent underlying rea- sons for parents to seek pediatric attention. Recent travel, moving, or an absent parent also often prompted such visits. Is the additional time needed to determine the un- derlying, "actual" reason for the visit worthwhile? The authors conclude that discussing the actual reasons for coming versus the ostensible reason appears to give a more satisfactory resolution of parental anxiety, eliminates un- necessary prescriptions, and leads to gratification and satis- faction for a job well done by the pediatrician. [Editor's note" The one to three minutes of further questioning re-

98/521 Annals of Emergency Medicine t2:8 August 1983

quired may prove to be worthwhile for the emergency phy- sician in reducing parental anxiety or uncovering an under- lying problem that needs the followup of a pediatric, psy- chiatric or social service referral.]

Mark Rubin, MD

EPIGLOTTITIS; PEDIATRIC EPIGLOTTITIS

Respiratory status of children with epiglottitis with and without an artificial airway Costigan DC, Newth CJL Am J Dis Child 137:139-141 Feb 1983

In an attempt to evaluate the respiratory status of pa- tients with epiglottitis, the authors reviewed the charts of 170 patients (mean age, 3 to 4 years) with the diagnosis of acute epiglottitis confirmed by direct laryngoscopy or later- al airway radiography. Twenty-two of these patients had arterial blood gases performed after admission, and com- prised the study group. The arterial/alveolar (a/A) oxygen tension ratios were calculated from these data (normal, 0.75 to 1.00). Additionally, chest radiographs from the study group were reviewed. The mean a/A ratio for the entire group was 0.59, with 17 of 22 (77%) with ratios less than 0.75, indicating abnormal gas exchange. Overall 33% of the chest radiographs were abnormal, with atelectasis and/or consolidation as the major abnormality. Of the patients with decreased a/A ratios, 10 of 17 (58%) had abnormal chest films. The authors point out the high incidence of chest radiograph abnormality (33%) and the 77% incidence of abnormal gas exchange in patients with epiglottitis, regardless of the relief of airway obstruction. The patho- genesis of these findings is presumed to be related to ele- vated negative pleural pressure generated f rom increased in- spiratory efforts resulting in an increase in interstitial lung fluid. The authors suggest 30% humidified oxygen for pa- tients with epiglottitis both before and after an artificial air- way is placed.

Martin E. Ogle, MD

HEAD TRAUMA, MYOCARDIAL INJURY

Biochemical evidence of myocardial injury after severe head trauma Hackenberry LE, Miner ME; Garry LR, et al Crit Care Med 10:641-643 Oct 1982

The authors investigated whether myocardial injury, as evidenced by CK-MB liberation and ECG aberration, occurs in severe traumatic head injury. Thirty adult patients were studied (average age, 27 years). None of the patients had sus-

tained chest or spinal injuries. All patients were evaluated within two hours post injury, all were comatose, all were endotracheally intubated, and all were treated in the ICU. Eight of 10 patients requiring immediate craniotomy died. Two additional patients died as well. Total CK and CK-MB fractions were assayed 6 to 96 hours post injury. Serial ECGs were recorded for the first five days of hospitalization. Only two patients had consistently normal heart rate. Nonspecific ST-T wave changes were noted in 16 of 30 pa- tients. Twenty-seven of 30 had increased Q-Tc intervals. Based on serial ECGs, seven patients had acute MIs. However, no distinct correlation between Q-Tc, ST-T changes, CK-MB, and survival could be found. All patients had elevated CK levels in one or more samples. Ninety- three percent had elevated CK-MB. Patterns of enzyme elevation were variable but did not follow typical post- infarction courses, for the CK-MB often was elevated for several days. This prolongation of elevated CK-MB favors an ongoing process of myocardial injury. The authors suggest that excessive release of catecholamines from a hyperactive sympathetic nervous system may be a factor in this phe- nomenon.

William Blahd, MD

ABDOMINAL TRAUMA; AORTIC TRAUMA; TRAUMA, BLUNT

Treatment priorities in combined blunt abdominal and aortic trauma Borman KR, Aurbakken CM, Weigelt JA Am J Surg 144:728-731 Dec 1982

This retrospective study addressed treatment priorities in patients with combined blunt abdominal and aortic trauma. Charts of 16 patients with both thoracic aortic transection and intra-abdominal injuries were reviewed. The patients were divided into 2 groups. The 11 patients in Group I had laparotomies prior to thoracotomy. The 5 patients in Group II had thoracotomy prior to laparotomy. Multiple organ inju- ries and postoperative complications were common in both groups. Ten of the l l patients in Group I underwent lapa- rotomy prior to angiography. All 5 patients in Group II un- derwent angiography prior to thoracotomy. Angiography was performed prior to surgery only on patients who were hemodynamically stable after fluid resuscitation. Nine of the 11 patients in Group I and 3 of the 5 patients in Group II had active intra-abdominal bleeding. Five of the patients in Group I and 3 of the patients in Group II ultimately recov- ered and were discharged from the hospital. In summary, all 16 patients had contained thoracic aortic hematomas, while 12 of the 16 patients had active intra-abdominal or retroperi- toneal bleeding. The authors state that in combined injury, hyp0tension is due to intra~abdominal, not aortic, hemor- rhage. Delayed thoracotomy did not result in free rupture of the aortic hematoma. The authors, therefore, recommend laparotomy prior to thoracotomy in patients suffering both abdominal injury and thoracic aortic transection.

William B. White, MD

12:8 August 1983 Annals of Emergency Medicine 522/99