Subramaniam Balasubramaniam

Pelvic Ultrasound Performed by Emergency Physicians for the Detection of Ectopic Pregnancy in Complicated First-Trimester Pregnancies

STUDY OBJECTIVE To determine the accuracy and application of pelvic ultrasound performed by emergency physicians in detecting ectopic pregnancy (EP) in complicated first-trimester pregnancies. METHODS We studied consecutive pelvic ultrasounds performed in all women who presented with abdominal pain or vaginal bleeding during the first trimester of pregnancy over a 6-month period. Patients with clinical evidence of incomplete abortion were not included. We compared ultrasound results with subsequent ultrasound findings by the radiology department and correlated them with follow-up diagnoses and outcomes. RESULTS Of the 136 eligible patients, a final diagnosis was rendered in 125; 11 were lost to follow-up. These ED ultrasound findings were recorded: established intrauterine pregnancy (IUP) with embryonic structures, 87 (70%); indeterminate scan revealing no distinct evidence of IUP or EP, 15 (12%); early intrauterine gestational sac of less than 6 weeks without embryonic structures, 12 (10%); EP, 8 (6%); blighted ovum, 2 (2%); and molar pregnancy, 1 (1%). The initial ED ultrasound determination was consistent with radiology department findings, final outcome, or both in 121 (96%) (95% confidence interval [CI], 91% to 97%). ED ultrasound accurately identified 87 pregnancies with intrauterine embryonic structures, including 5 patients with fetal demise (95% Cl, 97% to 100%). Diagnosis of pregnancy location in these 87 patients effectively ruled out EP, with a negative predictive value of 100%. The sensitivity and specificity of ED ultrasound in the detection of EP were 90% and 88%, respectively. CONCLUSION Pelvic ultrasonography performed by emergency physicians can be used to rule out EP and make an accurate diagnosis in most patients with complicated first-trimester pregnancies during the initial ED visit. The remaining patients at risk can be identified and a diagnosis made by means of follow-up ultrasound and serial hCG determinations.

110 Bullet Wounds to the Neck

Selective management of 110 patients with bullet wounds to the neck resulted in 31 explored and 79 observed. There was an overall mortality rate of 2.7%, well within that reported in the literature, which ranges from 2 to 6%. At our institution, it is believed that a substantial number of patients can be selectively managed, depending on the signs and symptoms, the site and direction of the trajectory, and whether the interval of time between injury and entrance to the hospital is longer than 6 hours. Patients who are stable and lack physical signs of obvious major neck injury are evaluated by diagnostic radiologic and endoscopic techniques. If no significant injury is found, they are admitted for observation. The efficacy of this mode of management is strengthened by savings in the costs of hospitalization, risks of undergoing an additional operation, overall negative exploration rate in the mandatory exploration studies, and our own results of selective management. We do not recommend this form of management for all institutions. It has been found that in this well-staffed teaching hospital with an extensive trauma service, experienced personnel doing careful and repeated physical examinations, in addition to 24-hour availability of radiologic and endoscopic modalities, the policy of selective management of bullet wounds to the neck can be adhered to. Further studies need to be done into the various mechanisms of penetrating neck trauma, separating each mechanism into morbidity, mortality, and treatment.

Base station prehospital care: Judgment errors and deviations from protocol

During a three-year period 5,944 paramedic runs were reviewed at the King/Drew Medical Center for deviations from prehospital management protocols established by the Los Angeles Paramedic Training Institute, and from standard medical practice. An overall compliance to the prehospital management protocols of 94% was found. Compliance to standard medical care was 97%. The most common deviations were failure to administer prophylactic lidocaine to patients having chest pain suggestive of myocardial ischemia and failure to apply cervical spine precautions in patients with suspected head trauma. Fifty percent of the radio operators who deviated from algorithms also were found to be making errors in judgment in standard medical care.

Myoglobinuric acute renal failure in phencyclidine overdose: Report of observations in eight cases

Eight cases of myoglobinuric acute renal failure that developed following exposure to phencyclidine were seen in the emergency department of the Martin Luther King Jr. General Hospital during a period of 36 months. All eight survived with complete recovery of renal function. Dialysis was necessary in three patients. Acute renal failure is an uncommon complication of phencyclidine abuse.

Intravenous prochlorperazine for the rapid control of vomiting in the emergency department

In this study, 40 patients whose active vomiting stemmed from various causes were given 2.5 mg of prochlorperazine by slow intravenous push. If no response was observed within 20 minutes, the dosage was repeated. Of 35 patients, 32 responded to doses of 2.5 to 5.0 mg. Three patients experienced no relief of vomiting while in the emergency department, after a total of 5 mg each, in divided doses. These three patients had received morphine sulphate for acute myocardial infarctions. The mean time to cessation of vomiting was 8.5 minutes, versus 35 minutes for a similar group receiving intramuscular prochlorperazine. This difference was statistically significant using analysis of variance (P less than .05). None experienced extrapyramidal reactions, or developed hypotension. We concluded that 2.5 mg of intravenous prochlorperazine given over one minute is an effective, safe treatment for the control of vomiting in the emergency department, until the etiology of the nausea and vomiting is determined and treated specifically. Further double-blind, controlled studies are warranted.

Iatrogenic pulmonary overpressure accident.

An unconscious victim of an overdose was intubated with an endotracheal tube to prevent aspiration. The respiratory therapist deflated the cuff of the endotracheal tube to allow for a retrograde oral air leak and then tightly attached the oxygen tube directly to the endotracheal tube. Seconds later there was a loud pop as the oxygen tube blew off the end of the endotracheal tube. The patient sustained both a hemodynamic and a neurologic decompensation as the result of marked pulmonary overinflation, with bilateral pneumothoraces and probable cerebral and coronary artery air emboli. We present the case in the hope that it will help avoid any such future occurrences.

Effect of heparin on arterial blood gases

To evaluate changes in arterial blood gas samples caused by the addition of liquid heparin, 50 patients had three simultaneous blood samples drawn, each with one of three amounts of heparin. The liquid heparin decreased statistically the PCO2, PO2, HCO3, and base excess, while the pH remained unchanged. By using a 2-cc blood sample with a 5-cc glass syringe and a 11/2-inch, 18-gauge needle to draw the heparin solution up to the 2-cc mark, and then completely evacuating it, we found that 0.025 cc of solution remained to coat the syringe. Although this remaining solution would cause a 1.25% error in the blood gas results, the error would be acceptable because it is generally less than the standard deviation of the laboratory results. Excess liquid heparin statistically exaggerated or produced false results consistent with a metabolic acidosis with respiratory compensation. We recommend that the complete evacuation of liquid heparin from the sampling syringe be included when performing an arterial blood gas analysis.

Tension gastrothorax complicating post-traumatic rupture of the diaphragm.

Traumatic diaphragmatic rupture or herniation has been reported, in addition to many cases of delayed rupture of the diaphragm, as long as several years after the initial trauma. Recognition of traumatic diaphragmatic herniation has been described to occur in three phases: acute, latent, and late. The diagnostic triad of mediastinal shift, dullness or tympany to percussion over the chest, and bowel sounds audible over the thorax strongly suggests atraumatic or post-traumatic diaphragmatic herniation. A review of the literature revealed no case study of a patient with the classical triad of post-traumatic rupture of the diaphragm. This paper describes the case history of such a patient and a simple but life-saving procedure performed to temporarily decompress the patient’s tension gastrothorax.

Efficacy of absorption of sublingual and intravenous cardio-green

To simulate the effect of sublingual injections on pediatric patients, open-chested kid goats were injected sublingually or peripherally with Cardio-Green while being supported by internal cardiac massage. Our study demonstrates that there is statistically a ten-fold lower central blood level after sublingual injection compared to that after use of the peripheral intravenous route. Our experiment casts doubt on whether absorption through the sublingual route is adequate, and shows that if a peripheral intravenous line cannot be started, vigorous attempts should be made to obtain a central line rather than taking valuable time to inject sublingual drugs. Further studies must be done before these results can be applied to clinical situations.

Toxic shock syndrome due to an infected human bite

We report a case of nonmenstrual toxic shock syndrome. A 21-year-old man presented with severe pain in the right hand after an altercation in which he sustained a bite from a person. Physical examination revealed a small abscess on the right proximal interphalangeal joint with edema in the fourth and fifth digits and tenderness of the flexor sheath. The patient was hypotensive with diffuse macular erythematous skin. He responded to surgical drainage and antibiotics.