Cognitive dysfunction in patients suffering minor head trauma.
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Adolescent↗
Biomedical subjects
M A Levitt
Publications and source records attributed to M A Levitt.
Delayed diagnosis of subdural hematoma following normal computed tomography scan.
We report the cases of three patients with subdural hematoma following minor closed-head trauma in whom the initial neurologic examinations and cranial computed tomography (CT) scans were normal. In each case, the patient was re-evaluated clinically several times (average of four times) due to persistence of post-traumatic symptoms. The development of focal neurologic signs, which eventually led to a correct diagnosis, was significantly delayed in all three cases (average of 47 days). All three patients had large subdural hematomas requiring surgical drainage. The timely diagnosis of subdural hematoma may be difficult despite the appropriate use of CT scan in the immediate post-traumatic period. Repeat CT scan may be indicated in patients suffering minor head trauma with persistent symptoms. These patients seem to recover without deficit following neurosurgical treatment despite a significant delay in diagnosis.
Adult↗
A prospective comparison of paramedic judgment and the trauma triage rule in the prehospital setting.
STUDY OBJECTIVE: To study paramedic judgment and the Trauma Triage Rule in prehospital trauma triage. DESIGN: Prospective. SETTING: A county emergency medical services system. PARTICIPANTS: Six hundred fifty-three trauma patients. RESULTS: Over a 3-month period, 653 trauma patients were evaluated in the prehospital setting. Paramedic judgment and the Trauma Triage Rule (TTR), as described by Baxt, were evaluated for accuracy in identifying patients requiring trauma center care. The TTR achieved a sensitivity of 88% and a specificity of 86%. Paramedic judgment had a sensitivity of 91% and a specificity of 60%. Combining the TTR and paramedic judgment achieved a sensitivity of 100% and a specificity of 75%. CONCLUSION: The TTR and paramedic judgment are effective in identifying patients who require trauma center care in the prehospital setting. The TTR and paramedic judgment combined have the greatest predictive value in identifying seriously injured patients.
Adolescent↗
Reduction of infarct size during myocardial ischemia and reperfusion by lazaroid U-74500A, a nonglucocorticoid 21-aminosteroid.
Lazaroid U-74500A, a 21-aminosteroid that inhibits iron-dependent lipid peroxidation, was previously shown to have protective effects on neuronal viability in animal models of ischemic neurologic injury. To test the hypothesis that lazaroid enhances myocardial salvage after ischemia/reperfusion, lazaroid-pretreated rats (2 mg/kg intravenously) (n = 26) and control rats pretreated with vehicle (n = 22) were subjected to 45-min left coronary (LCA) occlusion followed by 120 min of reflow. Lazaroid-pretreated rats and controls had similar ischemic risk areas (AR), as determined by phthalocyanine blue dye staining (47.2 +/- 2.3 vs. 48.2 +/- 3.0%, p = NS, mean +/- SEM). Infarct size, measured by triphenyltetrazolium staining, was markedly reduced in lazaroid-treated rats as compared with controls (6.0 +/- 1.5 vs. 22.2 +/- 3.9%, p = 0.001, infarct size/ischemic RA x 100). There were no differences in systolic blood pressure (SBP), heart rate (HR), rate-pressure product (RPP), or maximum rate of left ventricular systolic pressure development (LVdP/dt) between groups during ischemia or reperfusion. Lazaroid pretreatment enhances myocardial salvage after 45-min LCA occlusion and 2-h reflow in this animal model. This beneficial effect is independent of the hemodynamic determinants of myocardial oxygen demand.
Animals↗
Tough strategies for tough times.
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Cost Control↗
Intracranial injury following minor head trauma.
One hundred twelve patients presenting with a Glascow Coma Scale (GCS) score greater than or equal to 13 with a history of minor head trauma were prospectively studied to determine if certain historic or physical examination variables would predict which of these patients were at increased risk for intracranial injury. Patients either underwent cranial computed axial tomography (CT) or were followed up by phone at 4 weeks to determine major morbidity or mortality. Thirty-five patients underwent CT scanning of the head and eight demonstrated intracranial injury. Five patients were treated nonoperatively, and three patients had neurosurgical intervention. One patient died following surgery. At the 4-week follow-up no patient was found to have suffered any major morbidity or mortality. Stepwise logistic regression found age over 40 years (P = .05, odds ratio = 6.4, 95% confidence interval 1.0 to 38.8) and complaint of headache (P = .039, odds ratio 8.167, 95% confidence interval 1.074 to 62.09) to be significantly predictive of intracranial injury. All eight patients with positive CTs had a GCS score of 15. The authors conclude that intracranial injury does exist in patients suffering minor head trauma with a GCS score of 13 or above. Age over 40 years and complaint of headache are associated with an increased risk of intracranial injury.
Adolescent↗
Evaluation of the tilt test in an adult emergency medicine population.
STUDY OBJECTIVE: To evaluate the usefulness of the tilt test in identifying significantly dehydrated or occultly bleeding adult patients in an emergency department. DESIGN: Prospective. SETTING: Urban ED. TYPES OF PARTICIPANTS: Two hundred two ill adult patients with complaints suggestive of dehydration and/or occult blood loss and a control sample of 21 healthy individuals. INTERVENTION: Orthostatic measurements were taken from blood samples from the ill and healthy patients. The estimates of the degree of dehydration measured or calculated were total body water deficit percentage (based on measured serum osmolality), ratio of blood urea nitrogen to creatinine, creatinine, and hematocrit. Multiple historical and physical examination variables related to dehydration or occult bleeding were recorded. MEASUREMENTS AND MAIN RESULTS: Multiple analysis of variance testing of the historical and examination variables in the 166 dehydrated patients revealed the absence of syncope (P = .037) and the lack of axillary sweat (P = .026) to be significantly associated with an increased level of dehydration. Regression analysis of the orthostatic measurements and age with the estimates of dehydration found that orthostatic change in heart rate (P = .0165) and age (P = .0047) demonstrated a very small (r2 = .098) association with the level of dehydration. Orthostatic changes in systolic blood pressure and diastolic blood pressure demonstrated no statistically significant association with level of dehydration. There was wide variation in the tilt test measurements in samples from both the healthy and the ill patients: heart rate, 6.8 +/- 7.8 versus 13.2 +/- 10.5; systolic blood pressure, -2.5 +/- 8.0 versus -8.3 +/- 12.8 mm Hg; and diastolic blood pressure, 5.3 +/- 9.9 versus 0.6 +/- 8.6 mm Hg, respectively. The only parameter that attained statistical significance between the 36 blood-loss patients and the healthy patients was change in systolic blood pressure (P = .001); however, this was not clinically significant (-10.7 +/- 13.7 versus -2.5 +/- 8.0 mm Hg, respectively). CONCLUSION: It appears impossible to define a "positive" tilt test that would adequately identify patients with clinically significant dehydration or blood loss; this is due to the large variance in patients' orthostatic measurements both in a healthy and in an ill state and the lack of a significant correlation of orthostatic measurements to a level of dehydration. Lack of axillary sweat, no complaint of syncope, and younger age all indicate greater degrees of dehydration.
Adolescent↗
Evaluation of a prostacyclin analog, iloprost, and a thromboxane A2 receptor antagonist, daltroban, in experimental intimal hyperplasia.
This study evaluated the efficacy of a prostacyclin analog, iloprost, and a thromboxane A2 receptor antagonist, daltroban, as inhibitors of experimental intimal hyperplasia. The vascular injury model used is based on an endothelial injury induced by a brief infusion of air into an isolated segment of the common carotid artery in the rat. Iloprost and daltroban were administered by continuous IV infusion for two weeks. The infusion rates were 0.1 micrograms/kg/min for iloprost and 0.1 mg/kg/hr for daltroban; these dosing rates are associated with significant alterations in eicosanoid-related pharmacologic effects. The animals were sacrificed at two weeks and the carotid arteries fixed in situ for light microscopy. The myointimal thickening was measured as the intima to media area (I/M) ratio. The control animals developed marked intimal thickening, with an I/M ratio of 0.76 +/- 0.12 (mean +/- SEM; N = 7). There was no inhibition of intimal hyperplasia (P greater than 0.05) after either iloprost (I/M ratio: 1.04 +/- 0.13; N = 8) or daltroban (I/M ratio: 0.70 +/- 0.04; N = 6). It is concluded that neither of these two modulators of eicosanoid activity, iloprost and daltroban, inhibit intimal hyperplasia following experimental endothelial injury.
Animals↗
An evaluation of electrocardiograms before and after nitroglycerin therapy.
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Coronary Disease↗
An evaluation of physiological parameters of stress in the emergency department.
Seven physiological parameters previously used in stress research were studied to determine which would be able to quantitate levels of stress and study interventions in the emergency department setting. Eighteen emergency medicine personnel were prospectively studied. Sequential measurements of heart rate, respiratory rate, systolic blood pressure, diastolic blood pressure, skin temperature, serum norepinephrine, and serum epinephrine were recorded during multiple shifts in the emergency department. These parameters were assessed in repeated measures analysis of variance models with the subject's stress score of the shift and a calculated stress score of the shift. Respiratory rate demonstrated a significant association with the score of the shift over time within subjects (P = .0228). Skin temperature showed a significant trend over time (P = .0001) and in relation to how stressful the subject perceived the shift to be (P = .0006). A significant association was detected between epinephrine change over the shift and the subject's perception of the stress of the shift (P = .0217), and the stress score of the shift (P = .0009). Sequential serum epinephrine appears to be an objective measure of both perceived stressfulness of a shift and objective stress scoring of the shift. Respiratory rate changes and skin temperature changes over a shift may also be useful to measure stress in individuals in this setting.
Blood Pressure↗
Diagnostic capabilities of magnetic resonance imaging and computed tomography in acute cervical spinal column injury.
The present study was conducted to evaluate the imaging capabilities of magnetic resonance imaging (MRI) in evaluating acute cervical spinal column injury and compare these results to that of computed tomographic (CT) imaging. Forty-nine patients undergoing MRI at a Level I and regional spinal cord trauma center to evaluate cervical spinal column injury were studied. Seventy-one injuries were identified by MRI. These injuries were classified as osseous (fracture/dislocation) (n = 21), disc herniation (n = 29), and spinal cord injury (edema/contusion/transection) (n = 21). Diagnostic imaging results in 33 of the 49 patients undergoing both MRI and CT were compared. CT demonstrated 22 fracture/dislocations compared to 10 on MRI. MRI demonstrated 19 disc protrusions compared to 7 on CT. Additionally, MR imaged 13 cord injuries as compared to 0 by CT. MR imaging proved superior in demonstrating spinal cord pathology and intervertebral disc herniation. CT was superior to MRI in demonstrating osseous injury. CT and MRI may be useful together in determining presence and extent of spinal column injury.
Adult↗
An evaluation of clinical variables in determining the need for pelvic examination in the emergency department.
STUDY OBJECTIVE: To evaluate the ability of multiple clinical variables to predict an increased or decreased probability of pelvic pathology, therefore determining when a pelvic examination is needed. DESIGN: Cross-sectional. SETTING: An urban emergency department. TYPE OF PARTICIPANTS: 246 female patients presenting with abdominal pain and undergoing pelvic examination. MEASUREMENTS AND MAIN RESULTS: The patients were divided into two groups. Group 1 consisted of 99 patients without pelvic pathology (40%) and group 2 consisted of 147 patients with pelvic pathology (60%). Pelvic pathology was defined as presence of infective discharge (with confirmation on wet mount/potassium hydroxide smear), presence of adnexal mass and/or tenderness, cervical motion tenderness, uterine enlargement and/or tenderness, blood in the vaginal vault, and culture report positive for Neisseria gonorrhea. The following variables achieved statistical significance (P less than .05) using a logistic regression model: history of vaginal discharge (odds ratio, 2.30 [95% confidence interval, 1.23 to 4.32]); history of dysmenorrhea/menorrhagia (4.35 [1.52 to 12.40]); right upper quadrant pain on physical examination (0.33 [0.13 to 0.85]); and left lower quadrant pain on physical examination or history (1.73 [0.94 to 3.19]). CONCLUSION: History of vaginal discharge, history of dysmenorrhea/menorrhagia, and left lower quadrant pain on physical examination act as risk variables predicting presence of pelvic disease. Right upper quadrant pain on physical examination acts as a protective variable to predict absence of pelvic disease. This information may aid the emergency physician in determining the need for a pelvic examination in women with abdominal pain.
Abdominal Pain↗
A comparative rewarming trial of gastric versus peritoneal lavage in a hypothermic model.
A comparison of gastric lavage versus peritoneal lavage rewarming was studied in a hypothermic rabbit model. The gastric lavage group (n = 5) had a mean rewarming time of 136 +/- 25.1 minutes versus the peritoneal lavage group (n = 6) mean rewarming time of 131.7 +/- 27.9 minutes (p = .795). Good correlation was found between tympanic membrane temperature readings and both rectal temperature readings (r = .69) in the gastric lavage group and esophageal temperature readings (r = .90) in the peritoneal lavage group. Gastric lavage and peritoneal lavage have the same rewarming rates in the present hypothermic model.
Animals↗
An evaluation of clinical predictors to determine need for rectal temperature measurement in the emergency department.
A cross-sectional study was conducted in an urban emergency department to determine if predictive variables existed that would identify a patient who would be afebrile by oral temperature measurement and febrile by rectal temperature measurement. This study included 366 patients. Five variables studied achieved statistical significance by univariant analysis: mouth breathing (P = .002), respiratory rate (P = .001), supplemental oxygen (P = .009), pulse (P = .0001), and supplemental oxygen via mask (P = .01). Placing these variables in a logistic regression model left two variables that significantly explained the variance of the model: pulse (odds-risk ratio, 1.032/increase in pulse of 1 from 0; 95% confidence interval, 1.020 to 1.039) and mouth breathing (odds-risk ratio, 2.113; 95% confidence interval, 1.41 to 3.43). There was poor linear correlation between oral and rectal temperatures (r = 0.2). If a patient has an unexplained tachycardia and/or is breathing by mouth and is afebrile orally, a rectal temperature measurement should be obtained to determine if fever exists. The results of this study suggest that good linear correlation does not exist between oral and rectal temperature measurements.
Adult↗
Spontaneous rupture of the spleen: a case report and literature review.
Traumatic rupture of the spleen has been well described in the medical literature and is found in approximately 30% of patients undergoing surgery for blunt abdominal injury. Atraumatic splenic rupture is described much less often. A case of atraumatic rupture of an enlarged spleen is described. The etiology of spontaneous rupture of the spleen in this case could not be determined. The patient was seen and discharged twice from the emergency department; the diagnosis was made at emergency laparotomy three days after subsequent admission. This case should remind the emergency physician that nontraumatic splenic rupture should be considered in the differential diagnosis of unexplained acute left upper quadrant abdominal pain.
Adult↗
Efficacy of a combination thromboxane receptor antagonist and lipoxygenase inhibitor in traumatic shock.
The effects of a thromboxane receptor antagonist having lipoxygenase inhibitory activity, L-655,240 (3-[1-(4-chlorobenzyl)-5-fluoro-3-methyl-indol-2-yl]2,2-dimethylpropa noic acid) (1 mg/kg per h) were studied in a standardized model of traumatic shock. Pentobarbital (35 mg/kg) anesthetized rats subjected to Noble-Collip drum trauma were characterized by a 82 +/- 12 min survival time, a 20-fold increase in plasma cathepsin D activity, and a 6-fold increase in plasma myocardial depressant factor (MDF) activity. L-655,240 significantly attenuated the accumulation of MDF activity in the plasma (74 +/- 3 vs. 46 +/- 4 units/ml), vehicle vs. drug, respectively, and significantly (P less than 0.01) prolonged survival time to 206 +/- 26 min. However, plasma cathepsin D was not significantly altered with L-655,240 administration during traumatic shock. L-655,240 at 20 micrograms/ml markedly attenuated minced rat lung fragments from producing LTC4 and LTD4.L-655,240 exhibited significant anti-proteolytic activity in pancreatic homogenates. Therefore, L-655,2340 does not stabilize lysosomal membranes directly, but exerts an anti-proteolytic action which appears to curtail the production of a myocardial depressant factor by the ischemic pancreas, thus protecting during traumatic shock. A combination anti-eicosanoid drug such as L-655,240 may therefore prove to be an important therapeutic agent in acute ischemic disorders including traumatic shock.
Animals↗
Supraventricular tachycardia with aberrant conduction versus ventricular tachycardia: differentiation and diagnosis.
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Diagnosis, Differential↗