James J. Cicero

Chest Roentgenographic Findings in 26 Patients with Traumatic Rupture of the Thoracic Aorta

The initial 100-cm anteroposterior (AP) supine chest roentgenograms of 26 patients with proven traumatic aortic rupture were reviewed. The 20 male patients and six female patients ranged in age from 12 to 75 years. Distortion of normal aortic contour or blurring of the aortic outline occurred in 23 cases. Opacification of the radiolucent space between the aorta and pulmonary artery was seen in 22 instances. The mean mediastinal width, measured at the superior border of the anterior fourth rib, was 9.4 cm. Obliteration of the medial aspect of the left upper lung field was observed on 13 films. Obliteration of the shadow of the descending aorta, hemopneumothorax, and tracheal shift to the right each occurred in 17, 14, and 12 cases, respectively. This study illustrates that distortion or blurring of the aortic arch contour, opacification of the clear space between the aorta and pulmonary artery, and increased mediastinal width (mean = 9.4 cm) are the most frequently occurring abnormalities on the initial AP supine chest films of patients with traumatic aortic rupture. Such findings should arouse the suspicion of aortic rupture, and warrant aortography.

The clinical diagnosis of ruptured subclavian artery following blunt thoracic trauma.

The clinical findings of nine patients who suffered disruption of the subclavian artery following blunt thoracic trauma were reviewed. Seven patients were men, two were women. Their ages ranged from 16 to 43 years. Five patients presented with shock at the time of admission. Five patients incurred a first rib fracture. The radial pulse was present in three patients, absent in three patients, and indeterminant in three patients due to their profound state of shock. Brachial plexus palsy was present in three patients. A palpable supraclavicular hematoma was present in two patients. The chest roentgenograms showed a localized hematoma over the area of the injured subclavian artery in two instances, a widened superior mediastinal shadow in one case, and both findings in another patient. Thus four of the seven patients who survived to undergo chest roentgenograms had films that suggested injury to the arch of the aorta or its branches. Seven patients survived long enough to undergo operative repair; one of these patients died (14%). The following five criteria should alert the physician to the possibility of subclavian arterial injury following blunt thoracic trauma: 1) fractured first rib; 2) diminished or absent radial pulse; 3) palpable supraclavicular hematoma; 4) chest film evidence of hematoma over the area of the subclavian artery or a widened superior mediastinum; and 5) brachial plexus palsy.

The prevalence of Neisseria Gonorrhoeae and Chlamydia Trachomatis in victims of sexual assault

The prevalence of Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) in 232 sexual assault victims who presented for examinations between August 1, 1987, and July 31, 1988, was determined. Results are reported for cervical, rectal, and oropharyngeal NG cultures and for cervical and rectal CT smears. Results from a one-week follow-up are also reported. Cervical test results from the initial sexual assault examination were compared with cervical tests on 399 randomly selected female emergency department patients who presented for other gynecological conditions or lower abdominal pain. The victims of sexual assault had ten of 210 positive cervical NG cultures (4.76%), and 13 of 213 positive cervical CT smears (6.1%) at the first visit. These prevalence rates were not significantly different (P = .3058). There were none of 28 positive rectal NG cultures (0%) and one of 22 positive rectal CT smears (4.34%) (P = .451). None of the 43 oral NG cultures was positive. Seventy-three victims returned for follow-up examination. No follow-up cervical, rectal, or oral NG cultures were positive. However, one of 53 follow-up cervical smears for CT was positive, but this was not significantly different than for cervical NG (P = .461). Sexually assaulted patients had ten of 210 (4.76%) cervical NG cultures positive, and nonassaulted patients showed 53 of 393 positives (13.4%) (P less than .001). Assaulted patients had 13 of 213 (6.1%) cervical CT smears positive, and nonassaulted patients showed 33 of 352 (9.3%) positives (P = .11).(ABSTRACT TRUNCATED AT 250 WORDS)

Simultaneous bilateral anterior and posterior shoulder dislocations

Shoulder dislocations, a common injury, are usually unilateral and secondary to trauma. In addition, 95% are anterior, and the remainder are posterior. Simultaneous bilateral anterior shoulder dislocations occur rarely.lm3 The cause of injury in these cases is almost always trauma. Honnefi reported 21 cases of bilateral posterior dislocations, of which 13 were sustained as a result of electroshock treatment, electrocution, or epilepsy. An unusual case is described of simultaneous bilateral shoulder dislocations in a 44-year-old man who awoke with one anterior and one posterior dislocation. The probable cause of this injury is also examined. CASE REPORT A 44-year-old man presented to the emergency department at 3:00 AM after being awakened from a sound sleep by severe bilateral shoulder pain. He had retired for the evening in his usual state of health and had been feeling well. He denied having fecal and urinary incontinence, tongue biting, or a history of seizure disorder. The past medical history showed a clinical diagnosis of mild arthritis in the right shoulder for which he took aspirin occasionally. The patient denied having had prior trauma or dislocation of either shoulder. He claimed alcohol consumption of two to three beers per day and admitted to occasional self-medication with 5 mg of diazepam during stressful situations. He denied any history of alcohol withdrawal in the past. The physical examination revealed an alert and oriented man in moderate distress with obvious lack of normal contour of both shoulders. Any movement of the upper extremities caused severe pain. Results of the neurological examination were normal. There was no evidence of external trauma.

Methanol intoxication in multiple trauma

Management of inflicted or self-inflicted trauma to accomplish homicide or suicide is no novelty in the practice of medicine. However, it takes an astute clinician to recognize serious poisoning in the midst of life-threatening injuries. We describe two cases where homicide and suicide attempts were accompanied with the ingestion of methanol. Both patients recovered with proper management of the injuries as well as early recognition and treatment of the methanol poisoning.

Peritoneal lavage for the diagnosis of abdominal visceral injury

Peritoneal lavage has become standard for the diagnosis of abdominal visceral injury following trauma. Peritoneal lavage is indicated after blunt trauma when a patient presents with abdominal symptoms or signs and the integrity of the abdominal viscera is in doubt. Immediate laparotomy may be indicated following penetrating abdominal wounds when symptoms, signs, or hypotension are present. However, peritoneal lavage may be indicated if the patient is asymptomatic. Lavage is also indicated after penetrating extra-abdominal wounds when the path of the wounding agent suggests that the peritoneal cavity might have been entered. Peritoneal lavage is 98% accurate in determining the presence or absence of abdominal visceral injury following blunt trauma (100,000 red blood cells [RBCs]/mm3 or 500 white blood cells [WBCs]/mm3). The diagnostic accuracy of peritoneal lavage in penetrating abdominal injuries is more controversial than in blunt trauma, but recent retrospective data suggest that peritoneal lavage has the potential of giving 98% accurate results following penetrating abdominal injury when the threshold for a positive result of lavage is lowered to 50,000 RBCs/mm3 or 500 WBCs/mm3.

Emergency management of hand injuries. When to repair, when to refer.

The primary care physician can accurately diagnose hand injuries by obtaining a thorough patient history and performing a complete physical examination of the hand. When the severity of injury is doubtful, immobilization in a splint with next-day referral is appropriate. Immediate consultation should be obtained with nerve or vascular damage, fracture-dislocation injuries, open fractures, substantial skin loss, or flexor tendon injuries at or distal to the wrist.

Ovarian ectopic pregnancy

We present the case of a 27-year-old woman with left lower quadrant pain, tenderness, and rebound tenderness. Culdocentesis demonstrated non-clotting blood, and exploratory laparotomy showed an ovarian ectopic pregnancy. A wedge resection of the ovary was accomplished and the patient recovered completely. Ovarian ectopic pregnancy is an uncommon presentation of ectopic pregnancy.