Brooks F. Bock

Controversial issues in clinical management of the simple wound

The primary goals of the practitioner managing a simple wound are to encourage primary healing and avoid infection. We conclude from this analysis that the four basic aspects of wound management we have reviewed, the timing of wound repair, the preparation of the wound, local anesthetic management, and antimicrobial therapy, will continue to be fertile topics for investigation and debate.

Prehospital on-site triaging.

Objective. To estimate the proportion of patients transported by emergency medical services (EMS) who do not need immediate emergency medical care. Secondary objectives were: 1) to evaluate the ability of paramedics to determine which patients need immediate ambulance transport, and 2) to evaluate on-scene patient characteristics that may aid in developing an EMS transport protocol. Methods. A prospective cross-sectional study design was utilized to estimate the percentage of low-risk patients eligible for non-ambulance transport among 277 patients transported to an emergency department via ambulance. The EMS personnel prospectively rated each patient as to need for immediate ambulance transport. Physician raters, using predefined criteria, determined eligibility for non-ambulance transport. Results. There were 116 patients (59.2%, 95% CI = 53.4%–65.0%) who were not in need of immediate emergency medical care. Comparison of the EMS personnels rating with the criterion-standard need for emergency treatment transport yielded a sensitivity of 22.1% (95% CI = 13.9%–30.2%) and a specificity of 80.5% (95% CI = 72.5%–88.3%). Chief complaints of abdominal pain (OR = 2.94, 95% CI = 1.31–6.60) and administration of oxygen (OR = 2.13, 95% CI = 1.06–4.29) were independently associated with the need for ambulance transport, while young age (OR = 0.28, 95% CI = 0.09–0.90) was negatively associated. Conclusions. The majority of patients triaged as low-risk were not in need of immediate ambulance transport for emergency medical care. However, EMS personnel, unaided by triage protocols or specific training, could not reliably identify those patients in need of emergency medical treatment, and few factors were identified to assist that decision.

Acute suppurative salpingitis with concomitant intrauterine pregnancy

A 20-year-old woman presented to the emergency department with a history of lower abdominal pain and recent loss of consciousness. She was admitted with a primary diagnosis of abdominal pain; ectopic pregnancy was ruled out. The culture of the endocervix was positive for Neisseria gonorrhoeae. Surgical exploration of the pelvis was performed, and histological analysis of the specimen showed an acute suppurative salpingitis and an intrauterine pregnancy. The patient was placed on intravenous antibiotics. Postoperative course was unremarkable, and the patient was discharged on oral antibiotics. Although a rare entity acute suppurative salpingitis with concomitant intrauterine pregnancy are not mutually exclusive. Ectopic pregnancy should be the presumptive diagnosis when clinical presentation is consistent with pelvic inflammatory disease and pregnancy especially in the first trimester. Patients who are pregnant and exhibit clinical signs and symptoms that are consistent with salpingitis should be admitted for aggressive management of their high-risk pregnancy. Fetal wastage seems to be significant in spite of aggressive management. Endocervical culture for N gonorrhoeae should be obtained from all pregnant patients with follow-up treatment pending culture results. The following is a case presentation along with a review of the existing cases in the English literature and discussion of the possible pathogenesis and clinical outcome of this entity.

Phenytoin loading in chronic alcoholic patients

Controversy exists concerning the appropriate loading dose of phenytoin in chronic alcoholic patients. Chronic alcoholics are frequently assumed to have low albumin levels secondary to malnutrition and liver disease. Phenytoin is bound to albumin, and therefore the usual loading dose of phenytoin might result in a higher percentage of unbound drug and increased toxicity in these patients. Thirty-six chronic alcoholic patients were given a 15-mg/kg loading dose of phenytoin by constant intravenous infusion. After the infusion, patients were evaluated for clinical signs of phenytoin toxicity. At 1 hour after infusion, blood was sent for determination of total phenytoin, free phenytoin, and albumin levels. Fifteen patients were hypoalbuminemic (mean, 3.4 g/dL); 21 patients had albumin levels within the normal range (mean, 4.3 g/dL). In the hypoalbuminemic group, the mean free phenytoin level was 1.1 micrograms/mL, and the mean total phenytoin level was 13.6 micrograms/mL. In patients with normal albumin levels, the mean free phenytoin level was 1.3 micrograms/mL, and the mean total phenytoin level was 15.7 micrograms/mL. There were no statistically significant differences in total phenytoin or free phenytoin levels between either groups. No patient had a postinfusion phenytoin level (either free or total) within the toxic range. Although our sample size was small, our results suggest that a 15-mg/kg loading dose of phenytoin does not produce toxic levels in chronic alcoholics.