Abstracts in this issue were prepared by residents in the Denver General/St Anthony's/St Joseph Hospitals Emergency Medicine Residency Program.

ABSTRACTS Richard Dart, MD Co-Editor Section of Emergency Medicine University of Arizona College of Medicine Tucson, Arizona

Vincent J Markovchick, MD, FACEP Co-Editor Emergency Medical Services Denver General Hospital Denver, Colorado

William A Robinson, MD, FACEP Co-Editor Department of Emergency Medicine University of Missouri-Kansas City

School of Medicine Kansas City, Missouri

gunshot wound, head

Civilian gunshot wounds to the head: A prospect ive study Grahm TW, Williams FC, Harrington T, et al Neurosurgery 27:696-700 Nov 1990

The authors conducted a prospec- t ive s t u d y of c i v i l i a n g u n s h o t wounds to the head. One hundred consecutive patients admitted to a Level I trauma center during an 18- month period were studied, and all were treated aggressively. Resuscita- tion began in the field with rapid transportation to the hospital (overall mean transportation time, 23 min- utes). Seventy-nine patients were in- tubated, 62 (78%) at the scene and 17 (22%) in the emergency department. Sixty-three patients attempted sui- cide, 24 were assaulted, three were victims of accidental shootings, and in ten the cause was unclear. The caliber of handgun was documented in 61 cases (.22 to .45), and .22 caliber rifles were used in four cases. Full re- suscitative efforts failed with 16 pa- tients who died in the ED. Neuro- logic evaluation was conducted after resusci tat ion and revealed 58 pa- tients with a Glasgow Coma Score (GCS) of 3 to 5, eight with a GCS of 6 to 8, 12 with a GCS of 9 to 12, and 22 with a GCS of 13 to 15. Head com- puted tomography (CT) scans were performed in 76 patients on admis- sion. The 24 patients who did not undergo head CT were either clini- cally brain dead, had fewer than two intact neurological signs, or could not be resuscitated. Forty-three pa- tients underwent craniotomy, 49 did not. Patients were monitored for a mean of nine months after injury; 59 pat ients died, three were perma- nently vegetative, six were severely disabled, 19 were moderately dis- abled, and 13 had good outcomes. Of the 58 patients with a GCS of three

to five, none had a sa t i s f ac to ry outcome. Several recommendations were made based on the results of this study: l) all gunshot wounds to the head receive aggressive initial re- suscitat ion; 2) patients who have been resuscitated and evaluated by CT scan to rule out large hematomas and still have a GCS of 3 to 5 should be offered further therapy; 3) patients with GCS of 6 to 8 with large mass lesions (which usually respond well to rapid surgical evacuation) should receive aggressive surgical therapy; and 4) all patients with a GCS of more than 8 should receive aggres- sive surgical therapy. [Editor's note: The dismal prognosis of the subset of pa t ien t s who sus ta in gunsho t wounds to the head described in this paper is important information for the emergency physic ian because this poor prognosis should be com- municated to the family, perhaps in concert with a request for considera- tion of organ donation.]

Juliana Karp, MD

asthma; aerosolized glycopyrrolate; aerosolized metaproterenol

Compar ison of aeresol ized glycopyrrolate and metaproterenol in acute as thma Gilman M J, Meyer L, Carter J, et al Chest 98:1095-1098 Nov 1990

This double-blinded, randomized, prospective study compared the ef- fectiveness and side effects of nebu- lized glycopyrrolate versus nebulized metaproterenol in patients between the ages of 18 and 45 years with a clinical diagnosis of acute asthma ex- ac-erbation. Patients were assigned to receive, as sole therapy, either 2 mg glycopyrrolate (an ant icholinergic agent) or 15 mg metaproterenol (a

Annals of Emergency Medicine

f3-agonist) every two hours for three doses. A total of 46 patients (23 in each group) were entered into the study. Ten patients (five in each group) required additional medica- tion because of poor clinical response and did not complete the study. An- other patient (glycopyrrolate group) withdrew for personal reasons. Of the 35 patients completing the study, there was no statistical difference in pre t reatment pulmonary funct ion tests or percent change in FEV 1 with treatment between the group receiv- ing glycopyrrolate versus the group receiving metaproterenol. In contrast to the comparable bronchodilator ac- tivity, the side effects profiles of the two agents were remarkedly differ- ent. Subjective complaints of tremor, palpitations, nausea, and paresthesias were much more common in the metaproterenol group (eight of 18) versus the glycopyrrolate group (one of 17). In addition, a significant ta- chycardic response was seen after each dose of metaproterenol versus no evidence of tachycardic response to glycopyrrolate. The authors con- cluded that glycopyrrolate is an effec- tive bronchodilator in the treatment of acute asthma exacerbation with comparable bronchodilator activity to metaproterenol but with fewer side effects and that glycopyrrolate is a reasonable therapeutic alternative for acute asthma.

Mark Copeland, MD

trauma, fetal

Fetal t rauma: Relat ion to materna l injury Farmer DL, Adzick NS, Crombleholme WR, et al J Pediatr Surg 25:711-714 Jul 1990

A retrospective review of 32 cases of blunt trauma to pregnant women who either sustained a fracture (ex-

20:3 March 1991 326/165

ABSTRACTS

cluding hands and feet) or were ad- mitted to a Level I trauma center over a ten-year period was performed. None of the women died, but three fetuses died. Two fetal deaths were associated with severe maternal inju- ries, including pelvic fractures. In contrast, the third fetal death in- volved a 31-year-old woman with a 30-week pregnancy who was kicked in the abdomen but sustained no ap- parent injuries. All three cases of fe- tal death had evidence of placental abruption by pathological and/or ul- trasonographic criteria but no evi- dence of direct fetal injury. Three other patients were severely injured but had successful pregnancies. The remaining 27 patients had insignifi- cant injuries and successful pregnan- cies. Based on these results and a re- view of the literature, the authors concluded that fetal death from trauma can occur in the absence of severe maternal trauma and severely injured women can have successful pregnancies. It is recommended that pregnant trauma patients be admit- ted for fetal monitoring for at least 24 hours and that ultrasonography be performed to diagnose placental and fetal injuries.

Michael Kohn, MD

motorcycle accidents, head injury

Head in ju ry .assoc ia ted dea ths f rom m o t o r c y c l e crashes: Re la t ionsh ip to h e l m e t - u s e laws Sosin DM, Sacks J J, Holmgreen P JAMA 264:2395-2399 Nov 1990

This study examined the US mor- tality data of head injury-associated deaths from motorcycle accidents to report the descriptive epidemiology, national time trends, and association between such deaths and motorcycle helmet-use laws. From 1979 to 1986, 15,194 deaths and approximate ly 600,000 years of potential life lost be- fore the age of 65 were associated with head injuries from motorcycle crashes. Sixty-nine percent of deaths were white males aged 15 to 34 years. Loss of control of the motorcycle was

cited for 40% of motorcyclist deaths associated with head injury, and col- lision with another motor vehicle ac- counted for 52% of such deaths. The age-, sex-, and race-adjusted annu- alized death rate for all motorcycle fatalities was 11.7 per million resi- dents in states with full helmet-use laws, 19.5 in states with partial laws, and 17.6 in states with no law. Death rates associated with head injuries were nearly half in states with full h e l m e t - u s e laws compared wi th those having partial or no laws. Two states weakened their helmet-use laws from comprehensive to partial during the study period with a subse- quent increase in motorcycle-related head injury death rates (184% and 73%). One state strengthened its law from partial to comprehensive, and noted a decline of 44% in its death rate. It was recommended that be- cause helmets reduce the severity of nonfatal head injuries in addition to lowering the rate of fatal injuries, leg- islation and enforcement of compre- hens ive m o t o r c y c l e h e l m e t - u s e should be promoted. [Editor's n o t e : This is another s tudy documenting the obvious, ie, that motorcycle hel- mets save lives. It does not address the significant morbidity and dis- ability that occurs from nonuse of helmets. The uniform use of helmets, which realistically will come about only through mandatory legislation, will significantly reduce the great emotional and financial cost to both families and society that results from these preventable head and facial in- juries.]

James Bodenhamer, MD

thrombolytic therapy

Ef fect of in t ravenous s t r e p t o k i n a s e on the re la t ion b e t w e e n ini t ia l ST-pred ic ted size and f inal Q R S . e s t i m a t e d size of a c u t e m y o c a r d i a l in farc ts Clemmensen P, Grande P, Saunamaki K, et at J Am Col~ Cardiol 16:1252-1257 Nov 1990

Thromboly t ic therapy has been

shown to reduce final infarct size in patients with acute myocardial in- farct (AMI). Thrombolytic therapy is now administered routinely to pa- tients wth AMI and there is a need for noninvasive methods to evaluate its effectiveness. The effect of IV streptokinase on the relationship be- tween acute myocardial infarct size p red ic ted by in i t ia l ST segment changes and the final QRS estimated size was studied in 73 patients from the second International Study of In- farct Survival (ISIS-2). A control group of 40 patients was compared with 33 patients who received strep- tokinase, and both groups were clas- sified by infarct location (anterior vs inferior). Patients were excluded if there was ECG evidence of earlier AMI, bundle branch or fascicular block, ventricular hypertrophy, or a ventricular paced rhythm. Final myo- cardial infarct size was predicted from the admission ECG by previ- ously validated formulas based on ST elevation and was compared with the QRS estimated infarct size using the Selvester QRS score on the discharge ECG. The value identifying the per- cent difference in infarct size for the lowest quartile of control patients was designated as the threshold value below which salvage could be considered to have occurred. In the control group there was no signifi- cant change from ST-predicted to fi- nal QRS-estimated infarct size. In the streptokinase group there was a 26% decrease from the predicted to the fi- nal infarct size (P < .0002). Patients with inferior infarcts had a 45% de- crease in final infarct size compared with an 18% decrease for those with anterior infarcts. Multiple regression analyses correcting for the distribu- tion of patients with large initial ST- predicted infarct size confirmed the treatment effect of streptokinase but indicated that infarct location was not significant. A threshold decrease in infarct size of 20% or more (seen in lowest quartile of control group) was present in 20 of 33 patients (63%) in the streptokinase group as compared with ten of 40 patients (25%) in the control group, indicat- ing significant myocardial salvage after streptokinase. This study sug-

166/327 Annals of Emergency Medicine 20:3 March 1991