Howard S. Snyder

Neonatal fever: Utility of the Rochester criteria in determining low risk for serious bacterial infections

The purpose of this study was to test the utility of the Rochester criteria in determining which febrile neonates are at low risk for serious bacterial infections (SBI). This was a retrospective study over a 5-year period of 134 patients younger than 29 days old with fever without a source evaluated in the emergency department. Results of urinalysis, lumbar puncture, peripheral white blood cell count, and cultures of blood, urine, cerebrospinal fluid, and stool were recorded. Of the 134 neonates, 71 were high-risk, 48 low-risk, and 15 were not classifiable by the available data. Nineteen of the 71 high-risk patients (26.8%) had SBI (2 patients had 2 SBI). Three of the 48 low-risk neonates (6.3%) had SBI (1 patient had 2 SBI). None of the 15 nonclassifiable patients had SBI. Employing the Rochester criteria to the fully cultured neonates who could be risk-stratified, the sensitivity, specificity, positive predictive value, and negative predictive value were 86.4%, 46.4%, 26.8%, and 93.8%, respectively. Although outpatient management of febrile neonates may be feasible, a small percentage of neonates meeting low-risk criteria will have a SBI.

Signs and symptoms of patients with brain tumors presenting to the emergency department.

This retrospective chart review was conducted to determine the presenting signs and symptoms of patients with primary brain tumors diagnosed in the emergency department. There were 101 patients (65 males and 36 females) identified with a hospital discharge diagnosis of primary brain tumor who were admitted through the emergency department. The presenting symptoms included headache (56 patients), altered mental status (51 patients), ataxia (41 patients), nausea or vomiting (37 patients), weakness (27 patients), speech deficits (21 patients), and sensory abnormalities (18 patients). The presenting signs included motor weakness (37 patients), ataxia (37 patients), papilledema (28 patients), cranial nerve palsies (26 patients), visual deficits (20 patients), and speech deficits (12 patients). The average age was 42.8 years, with a range of 3 days to 88 years. The majority of tumors were malignant astrocytomas. Tumor location was cortical in 68 patients, subcortical in 9 patients, and brainstem or cerebellum in 24 patients. In conclusion, patients of all ages may present to the emergency department with a variety of symptoms resulting from a primary brain tumor. Headache and altered mental status were common in our series of patients, but symptoms will depend on the size, location, and type of tumor. A complete neurologic examination is essential, including evaluation for papilledema.

Lack of a tachycardic response to hypotension with ruptured ectopic pregnancy

The concept that tachycardia is a reliable indicator of shock has recently been challenged in patients with hemoperitoneum. The purpose of this study was to document whether patients with ruptured ectopic pregnancy manifest a tachycardic response to hypotension and to define the relationship between hemodynamic response and blood loss resulting from hemoperitoneum. A retrospective chart review of 154 patients with documented ectopic pregnancy identified 20 (13.0%) hypotensive patients (systolic blood pressure less than or equal to 90 mm Hg). Eleven (55%) patients were not tachycardic (pulse rate less than 100 beats/min) and nine (45%) patients were tachycardic. The quantity of hemoperitoneum varied widely in each group and did not correlate with the hemodynamic response. These results support the proposed theory that hemoperitoneum may trigger a parasympathetic reflex, resulting in a pulse rate inappropriate for the degree of hypotension. A vasovagal reflex may play a role in those patients without significant hemoperitoneum. The diagnosis of hypovolemic shock must be considered when hypotension is present without tachycardia.

Significance of the initial spun hematocrit in trauma patients

This study was designed to determine whether the initial spun hematocrit (HCT) value correlated with blood loss requiring operative intervention (OR). A spun HCT was performed on the first available blood sample from 524 admitted patients 12 years of age or older with traumatic injuries (86% blunt, 14% penetrating). Patients in the OR (n = 66) group had a lower mean HCT (35 v 41, P < .001) when compared with the non-OR group. The 81 patients with an HCT of < or = 35 required OR more frequently (41% v 7%, P < .001). An HCT of < or = 35 had a sensitivity of 50%, specificity of 90%, positive predictive value of 41%, and negative predictive value of 93% for identifying the OR group. The effect of hemodilution from intravenous fluid is difficult to assess in a retrospective clinical study.

Lingual artery hematoma resulting in upper airway obstruction

A case of upper airway obstruction from a lingual artery hematoma after suturing of a puncture wound to the tongue is reported. The anatomy of the tongue and upper airway is reviewed to better understand the mechanism of obstruction. The emergency physician should be aware of this rare and potentially lethal complication to what might initially seem to be a trivial injury.

Accuracy of blood ethanol determination using serum osmolality

A retrospective review of 81 emergency department patients was performed to determine the accuracy of blood ethanol levels (BEL) calculated from serum osmolality. The osmolar gap (measured-calculated serum osmolality) was used to determine the calculated BEL. The mean difference between calculated and measured BEL was 49.2 mg/dL. Calculated BEL overestimated measured BEL in 83% of patients. Adding a correction factor for unmeasured osmoles to the equation for calculated serum osmolality will reduce this error.

Uncommon complications of odontogenic infections

The emergency physician is familiar with the presentation of dental abscesses and periodontal disease. The majority of these cases are easily managed with analgesia, antibiotics, and appropriate follow-up with the dentist or oralmaxillofacial surgeon. The emergency physician, however, must be aware of several unusual complications arising from odontogenic infections. Among these complications are dentocutaneous fistula, osteomyelitis, cavernous sinus thrombosis, and Ludwigs angina. The first two sequelae are not associated with mortality, but morbidity and cosmesis are significantly affected. Cavernous sinus thrombosis and Ludwigs angina have been associated with significant morbidity and mortality, although mortality rates have declined significantly with Ludwigs angina since the advent of effective antibiotics and aggressive airway management. Awareness of these potentially serious complications and a high index of suspicion in the early stages of the disease process may prevent unnecessary treatment regimens, as well as significant morbidity and mortality.

Hysterical stridor: A benign cause of upper airway obstruction

We present the cases of three patients with stridor that resolved spontaneously. Paradoxical vocal cord motion was documented in one patient. Normal vocal cord motion was present in the other two patients, but stridor had resolved in both cases. Many different terms have been used to describe this entity in the literature. Emergency physicians must recognize the subtle signs of hysterical stridor. Once more serious etiologies are ruled out, sedation and reassurance instead of aggressive airway intervention are required for this benign condition.

Radiographic changes with radial head subluxation in children

Radial head subluxation (RHS) produces no radiographic abnormalities according to most experts. However, recent anecdotal case reports have identified displacement of the radiocapitellar line (RCL) in pediatric patients with RHS. To verify this finding, we retrospectively reviewed all patients less than 5 years of age who received elbow and forearm radiographs in our emergency department. From January 1988 through April 1989, we identified 20 cases of RHS. Of the 20 radiographs, 5 (25%) were read by the attending radiologist as abnormal due to RCL displacement indicating subluxation of the radiocapitellar articulation. All 5 of these radiographs had RCL displacement greater than 3 mm. The remaining normal radiographs had RCL displacement less than or equal to 3 mm. The presence of RCL displacement without disruption of the radiocapitellar articulation confirms the diagnosis of RHS, but does not appear to change treatment or outcome in this subset of patients. In addition, radiographs may not be mandatory when the diagnosis of RHS is certain. We suggest obtaining radiographs if the history (i.e., fall) or physical examination is atypical or if reduction is unsuccessful to rule out more serious injuries such as radial head dislocation or fracture.

A retrospective review of positive chlamydial cultures in emergency department patients

This study evaluated the accuracy of diagnosis and treatment of chlamydial infection based solely on clinical presentation in the emergency department (ED). The signs and symptoms of women with chlamydial infection confirmed by cervical culture were identified and compared between appropriately treated and nontreated groups to determine which clinical features tended to lead to the correct or incorrect diagnosis. The study also determined which signs and symptoms were consistently present in the entire study group. Two hundred thirty-three charts of female ED patients with positive cervical chlamydial cultures were obtained via computerized records from the microbiology lab and reviewed retrospectively. Only 20% of the patients were correctly diagnosed as having a sexually transmitted disease and only 24% were properly treated during their initial ED visit. Although abdominal pain and vaginal discharge were the most frequent symptom and sign, only 70% and 54% of all patients had these clinical manifestations, respectively. Patients with vaginal discharge and cervical motion tenderness were significantly (P < .01) more likely to be treated in the ED. Patients with urinary tract symptoms and pregnancy were significantly (P < .01) less likely to be treated in the ED. Cervical cultures should be performed during all pelvic examinations because of the variability in the clinical presentation of chlamydial infection. A follow-up system must be in place to identify positive cultures and locate patients to ensure appropriate treatment.