Robert C. Jorden

Limitations of computed tomography in the evaluation of acute abdominal trauma: a prospective comparison with diagnostic peritoneal lavage.

There has been recent enthusiasm for computed tomography (CT) to supplant diagnostic peritoneal lavage (DPL) in the detection of abdominal injuries. We prospectively compared CT to DPL following acute blunt trauma or stab wound to the abdomen. Patients with hemodynamic instability or overt signs of intraperitoneal pathology underwent urgent laparotomy and were excluded from study. Those with indications for DPL had lavage catheter insertion via open technique and attempted aspiration for gross blood. This was followed by contrast CT of the abdomen with a Technicare 2010 scanner. Lavage fluid, when required, was then instilled, recovered, and analyzed. CT interpretations were made in a blind fashion by a single staff radiologist. Decision for laparotomy was based on clinical, DPL, and CT data. In blunt trauma (N = 65), DPL detected 5/5 (100%) injuries discovered at laparotomy and CT 2/5 (40%). Following stab wounds (N = 35), DPL was true positive in 7/7 (100%) and CT in 1/7 (14.3%), with one false positive CT leading to negative laparotomy and one false positive DPL which prompted unnecessary celiotomy. Overall, the sensitivity of DPL was 100% versus 25% for CT and specificity 98.9% for both DPL and CT. In particular, CT missed seven solid visceral (five liver, two spleen), five hollow visceral, one major vascular, and three diaphragmatic lesions requiring operative intervention. In our experience, CT demonstrated an alarming incidence of false-negative studies. Given the widespread variability of CT equipment and personnel we would argue strongly against the use of CT alone in the evaluation of acute abdominal trauma and continue to support DPL as the most accurate and reliable instrument of detection.

Airway management in patients with unstable cervical spine fractures

We conducted a retrospective study of traumatic, unstable cervical spine fractures requiring operative repair to determine the airway management technique and whether any neurologic complication resulted from the intubation. One hundred thirty-three patients with 140 fractures were reviewed relative to fracture site, oral versus nasal route of intubation, and location of intubation (surgery versus emergency department or field). Fracture site incidence was determined as follows: C-1, ten (7.1%); odontoid/C-2, 17 (12.1%); C-3, eight (5.7%); C-4, 21 (15.0%); C-5, 41 (29.2%); C-6, 38 (27.1%); and C-7, five (3.5%). Ten of the injuries resulted from blows to the neck or head, 25 from falls, seven from diving, and six from sports-related injuries. The remaining eighty-five patients were in motor vehicle accidents. Nine patients were nasally intubated in the ED, and one patient was orally intubated in the field. Ninety-four of the patients intubated in surgery were intubated nasally: 29 were intubated orally while in-line stabilization was maintained. No neurologic complications occurred in any patient. These data suggest that, under controlled circumstances, patients with unstable cervical spine fractures can be safely intubated with standard, nonsurgical approaches.

Airway management, penetrating neck trauma.

This study was performed to determine whether clinical presentation can accurately predict which victims of penetrating neck trauma require urgent airway management. An 8-year retrospective review of all patients with a diagnosis of penetrating neck trauma seen in the emergency department of an urban teaching hospital was conducted. Of the 114 patients reviewed, 69 (60%) were intubated at some point in their hospital course. Twenty-six (23%) met our predetermined criteria for urgent airway control; 25 of these patients were intubated in the emergency department. Forty-three patients (38%) did not meet the criteria and were electively intubated either in the operating room or in the emergency department. Forty-five patients (39%) were never intubated. None of the patients in this series developed complications as a result of their airway management.

A comparison of PTV and endotracheal ventilation in an acute trauma model.

Percutaneous transtracheal ventilation (PTV) is an active airway management technique that may be an alternative to cricothyroidotomy in critically injured patients. A canine trauma model was devised to compare the ventilatory capacity and hemodynamic effects of PTV to endotracheal intubation. Mongrel dogs (25-37 kg), splenectomized 14 days previously, were anesthetized with pentobarbital and bled to a mean arterial pressure (MAP) of 20 mm Hg. Animals were maintained at this MAP for 1 hour, then resuscitated with simultaneous: a) aortic crossclamping via left thoracotomy, b) Ringers lactate infusion, and c) active airway support. Control animals (N = 5), intubated with a cuffed endotracheal tube, were ventilated at a rate of 12 per minute, a tidal volume of 500 cc and an FIO2 of 60%. In study animals (N = 5), PTV, for a duration of 1 second, was instituted at the same rate and FIO2. There was no statistically significant difference between the two groups with regard to pO2, pCO2, pH, and hemodynamic parameters. PTV was also performed in the emergency department on four patients unresponsive to resuscitative thoracotomy for postinjury cardiac arrest. PTV rate was 12/minute; duration, 1 second; and FIO2, 100%. Mean values (+/- SEM) for pH, pO2, and pCO2 obtained after 15 minutes of PTV were 7.14 +/- 0.03, 322 +/- 49.5 torr, and 21.5 +/- 4.7 torr, respectively. PTV is comparable to endotracheal intubation with respect to oxygenation, ventilation and hemodynamic response (p greater than 0.05). Our preliminary clinical study corroborates its efficacy in the acute trauma setting and supports further clinical investigation.

ACUTE ABDOMINAL AORTIC OCCLUSION

Acute occlusion of the infrarenal abdominal aorta is a catastrophic event requiring early recognition and intervention if permanent disability is to be decreased or avoided. While traditional causes of occlusion (saddle embolus and thrombosis) are the most frequent, vasculitis and hypercoagulable states have recently been suggested as etiologies. This article presents three cases of acute abdominal aortic occlusion from different mechanisms and reviews the literature concerning presentation and management.

Benign cystic mesothelioma presenting as acute abdominal pain in a young woman

Benign cystic mesothelioma is a rare tumor that, due to compressive effects, presents with abdominal pain and distention and other mass symptoms such as early satiety. Although diagnostic modalities such as plain radiography, ultrasonography, and computed tomography (CT) scan can suggest the diagnosis, confirmation can be accomplished only at surgery. The differential diagnosis includes any benign or malignant cystic abdominal or pelvic tumor. Management consists of surgical excision, which unfortunately is not always curative, since there is a recurrence rate of 50%. The clinical features, work-up, and course of a 15-year-old female with benign cystic mesothelioma are presented, followed by a brief review of the literature.

Usefulness of empiric chest radiography and urinalysis testing in adults with acute sickle cell pain crisis

STUDY OBJECTIVE To determine the usefulness of obtaining routine chest radiographs and urinalyses on adults presenting to the emergency department in acute sickle cell pain crisis. The hypothesis tested is that in some adult sickle cell patients, sickle cell pain crises are precipitated or accompanied by acute infection that may be clinically occult and that routine screening for pulmonary or urinary tract infection would identify some of these precipitating illnesses. DESIGN Prospective clinical study. SETTING A university hospital ED. PATIENTS All patients more than 14 years old with S-S, S-C, or S-beta-thalassemia sickle hemoglobinopathies who presented to the ED with acute nontraumatic painful complaints during a six-month period. INTERVENTIONS All patients underwent posteroanterior and lateral chest radiography, routine urinalysis, and CBC count with reticulocyte count. A standard questionnaire for localizing symptoms of systemic, pulmonary, and urinary tract infection was completed for each patient. Urine cultures were ordered on all patients with voiding symptoms, flank pain, and/or more than 5 WBCs or RBCs per high-power field on urinalysis. Physical examination for evidence of pulmonary and urinary tract infection was carefully performed and recorded for subsequent analysis. RESULTS Seventy-one patients with 134 ED presentations were studied over a six-month period. Eight diagnoses of acute pneumonia were made. Four of these patients complained of chest pain (50% vs 48% overall) and three had shortness of breath (38% vs 21%). None of these patients complained of fever or symptoms of upper respiratory illness. Ten diagnoses of urinary tract infection were made. Four of these patients complained of dysuria and frequency; three complained of flank pain. Eleven of the 18 infections (61.1%) did not have a typical history for or suggestive physical or laboratory findings of bacterial infection. CONCLUSION In sickle cell disease patients with pain crisis, routine chest radiography and urinalysis may be clinically useful and cost effective in the early diagnosis of crisis-related infection.

Case report: Common femoral artery occlusion following blunt trauma in a child

Vascular injury from blunt trauma is infrequently seen in children unless associated with major trauma. This case report is an example of a significant vascular injury in the setting of minor trauma. The consequences of missing such an injury as well as some of the difficulties encountered in establishing the diagnosis are discussed.

Percutaneous transtracheal ventilation in a canine shock model with an open thorax

This study evaluates the effectiveness of percutaneous transtracheal ventilation (PTV) in a canine shock model. Five mongrel dogs (25 to 35 kg), splenectomized two weeks prior to study, were anesthetized (pentobarbital, 22 mg/kg) and bled to and sustained at a mean arterial pressure (MAP) of 20 mm Hg for 60 minutes. Ringers lactate was infused and the descending thoracic aorta was cross-clamped. Simultaneously, PTV was begun with 60% O2 through the cricothyroid membrane. Hemodynamic measurements and arterial blood gases were obtained at 0, 5, 15, and 30 minutes following the initiation of PTV. Orotracheal ventilation was then instituted in place of PTV and continued for 30 minutes, and measurements were repeated. Auto-transfusion was also begun at this time. During PTV, PO2 and PCO2 were adequate in all dogs at each interval. We conclude that PTV provides effective oxygenation and ventilation in dogs subjected to profound shock, thoractomy, and thoracic aortic cross-clamp.

Gastric emptying in the acutely inebriated patient

Fifty inebriated emergency department (ED) patients underwent evacuation of gastric contents via a nasogastric tube, in order to determine if a significant amount of ingested ethanol can be removed prior to absorption. Such a result could potentially reduce additional intoxicating effect. The gastric contents were assayed for total ethanol concentration, and a potential (postabsorption) additive blood alcohol level (PABAL) was projected and compared to the actual BAL on arrival. The type of beverage ingested and the time since last drink were recorded. BAL ranged from 108 to 637 mg/dL (mean +/- SD, 290 +/- 104.7). Gastric aspirate volume ranged from 50 to 700 mL (190 +/- 134), and contained alcohol in a range of 87 to 2271 mg/dL (475 +/- 479). Based on the distribution volume for alcohol calculated according to the patients weight, this corresponded to a PABAL of 3 to 167 mg/dL (mean, 24.3 +/- 29.3). There was no significant correlation between the volume or concentration of gastric aspirate and the patients stated drinking history. The authors conclude that a significant amount of ingested alcohol may occasionally be removed from absorption by the routine evacuation of gastric contents in intoxicated patients. These patients cannot be identified upon presentation, however, and these data cannot support routine use of gastric emptying in the detoxification of inebriated patients.