Elizabeth Tso

Abdominal injuries in restrained pediatric passengers

A statewide experience with pediatric abdominal visceral injury in restrained automobile passengers was compiled from the trauma registries of two academic institutions. Retrospective analysis of motor vehicle passenger injuries from 1987 to 1991 included age, sex, mechanism of injury, prehospital care, type of injury, therapeutic interventions, complications, and ultimate outcome. The records of over 2,000 patients evaluated for blunt trauma were reviewed, with 42 children fulfilling the following inclusion criteria: 15 years of age or younger, restrained in an automobile at the time of the accident, and diagnosed with an abdominal injury. Of the 42 patients studied, there were 20 boys and 22 girls; ages ranged from 2 months to 15 years (mean, 7.02 years). Six of 42 patients (14%) required extrication from the vehicle at the scene. Nineteen of 42 patients (45%) sustained belt-related abdominal wall bruising or erythema. The specific blunt visceral injuries noted were as follows: splenic 5, hepatic 5, bowel 6, renal 3, combined 6 (stomach, diaphragm, pancreas, or retroperitoneum). Twenty-three children (55%) had abdominal visceral injuries without external seat belt marks. Operative intervention was necessary in seven patients. A delay in diagnosing visceral injury occurred in 4 of 42 (10%) cases. One patient developed abdominal symptoms 72 hours after the accident. Length of hospital stay ranged from 1 to 45 days. Complications occurred in 4 (10%) of patients. There were two deaths due to injuries. Hollow and solid visceral injuries can occur in belted pediatric passengers during vehicular accidents. Both are a source of significant morbidity, and the patient should be evaluated carefully.(ABSTRACT TRUNCATED AT 250 WORDS)

The electrocardiographic features of hypothermia

Hypothermia results in the development of several characteristic electrocardiographic changes. As the core body temperature decreases, several changes in cardiac rhythm occur. Prolongation of the PR, QRS, and QT intervals are also seen. Muscle tremor artifact may be present, even in the absence of clinical shivering. A characteristic secondary deflection on the terminal portion of the QRS complex (Osborn wave) is usually found. All of these features are reversible with rewarming.

Unsuspected heterotopic pregnancy in a woman without risk factors

A 27-year-old woman presented to the emergency department with abdominal pain. One week prior to this she had had an ultrasound which revealed an intrauterine pregnancy (IUP). A second ultrasound performed at our institution revealed an intrauterine pregnancy along with a concomitant ectopic pregnancy which had ruptured. This case emphasizes that coincident pregnancies may occur in women who are without risk of ectopic pregnancy or multiple gestations. In addition, ultrasound must be evaluated fully for heterotopic pregnancy in all women.

Baseball bat assault injuries.

The baseball bat, according to Baltimore City police crime statistics, is a commonly used weapon. To assess the severity of injuries inflicted by this modern-day club, we retrospectively reviewed 75 charts of patients treated at the University of Maryland Medical Systems Hospital for baseball bat injuries from January 1990 through July 1991. Multisystem trauma was documented, with craniocerebral injury being the most frequent and the most frequent cause of death. Of the victims struck on the head, 26% sustained an intracranial hemorrhage. In our series, the history of loss of consciousness and the Glasgow Coma Scale score failed to reliably identify the patients with serious injuries. Seventeen percent of our patients with intracranial hemorrhages had both a negative or uncertain history of loss of consciousness and a normal Glasgow Coma Scale score on arrival.

Cranial computed tomography in the emergency department evaluation of HIV-infected patients with neurologic complaints

STUDY OBJECTIVE To demonstrate the usefulness of cranial computed tomography (CT) in the emergency department evaluation of HIV-infected patients and patients with risk factors for HIV infection who present with neurologic complaints. DESIGN Retrospective review of imaging reports and medical records of patients who visited the ED from March 1991 through March 1992. SETTING Urban university ED. PARTICIPANTS Patients with HIV infection or risk factors for infection who underwent emergency cranial CT after presenting to the ED with headache, altered mental status, focal deficits, or other neurologic signs or symptoms. RESULTS One hundred forty-six patients visited the ED 169 times. Of the 169 cranial CTs obtained, 85 (50%) were normal, 49 (29%) showed atrophy only, and 35 (21%) demonstrated focal lesions, with mass effect noted in ten (6%). Enhancing lesions were present in 13 scans. In 21 (12%) cases, CT revealed either an indication for admission, a contraindication to lumbar puncture, or both. In 25 instances, patients with lesions had nonfocal presentations and no papilledema. Two presentations--focal deficit and altered mental status--were each statistically significantly associated with lesions on CT. In seven patients with multiple ED visits, repeat CT showed new findings. Among patients who had risk factors but were of unknown HIV status, there was the same proportion of abnormal scans as in known HIV-infected patients. CONCLUSION CT detected clinically significant neuropathology among our study patients. Because lesions and mass effect were associated with nonfocal as well as focal presentations, CT is indicated in every neurologically symptomatic patient with HIV infection or risk factors for infection. Because HIV-related diseases can progress rapidly, repeat CT is recommended even in patients with recent scans.

Lithium intoxication: Manifestations and management

The clinical diagnosis of lithium intoxication can be elusive because of the slow onset and diversity of toxic manifestations. Mental status and neurologic symptoms often predominate. After the diagnosis is made, management depends on the clinical presentation and serum lithium level. Hemodialysis is the treatment of choice for severe lithium intoxication. Two cases of lithium intoxication are presented that demonstrate that predisposing factors and drug interactions play major roles. A review is given of the pathophysiology, presenting signs, symptoms, and approaches to treatment of lithium intoxication.

Late postpartum eclampsia

A case of new-onset seizures occurring 12 days postpartum is described. The patient presented with headache, hypertension, and proteinuria. Postpartum eclampsia was diagnosed and IV magnesium sulfate was administered. The patient had no further seizures and did not require long-term anticonvulsants. Medical and neurologic evaluations failed to reveal any other etiology for the seizures.

Esophageal spasm following propranolol overdose relieved by glucagon

A case of propranolol overdose complicated by esophageal spasm preventing extrication of an orogastric lavage tube and relieved by intravenous glucagon is presented. Esophageal spasm is an infrequent complication of beta-adrenergic over-dose. Possible mechanisms of esophageal spasm and its relief with glucagon are discussed.

Coronary artery spasm Part 1: Overview

The syndrome of coronary artery spasm is described. This phenomenon may occur in conjunction with, or in the absence of, fixed atherosclerotic coronary artery disease. ECG manifestations during an attack mimic those seen with acute myocardial injury, but normalization of the ECG following the resolution of the pain is usual. Intravenous ergonovine is a sensitive and specific test for confirmation of the diagnosis. Nitrates and calcium channel blockers are the mainstay of therapy, although other agents are of theoretical benefit. The role of surgery is unclear.

Coronary artery spasm. Part II.

Coronary artery spasm can occur in several settings, often combined with coronary artery disease and thrombosis. Calcium channel blockers and beta-blockers are primary treatment modalities. The role of alpha-blocking agents remains unconfirmed.