Abstracts in this issue were prepared by residents in the University of Arizona Emergency Medicine Residency Program, Richard Dart, MD, on-site co-editor.

ABSTRACTS Harvey W Meislin, MD, FACEP Co-Editor Section of Emergency Medicine University of Arizona College of Medicine

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

abscess, peritonsillar, needle aspiration

Peritonsil lar abscess: A prospect ive evaluation of outpat ient management by needle aspirat ion Ophir D, Bawnik J, Poria Y, et al Arch Otolaryngol Head Neck Surg 114:661-663 Jun 1988

This prospective study explored needle aspiration and oral antibiotic therapy as an alternative to traditional inci- sion and drainage in 124 patients diagnosed with periton- sillar abscess. Nine patients were lost to follow-up, and 11 were excluded due to young age, noncooperation, or severe trismus. One hundred four patients underwent needle aspi- ration, culture, antibiotics, and follow-up for at least four months. Twenty-eight percent undergoing aspiration had no pus, were considered to have peritonsillar cellulitis, and were treated with IV antibiotics as inpatients (all resolved without repeat aspiration), l~s was recovered from 72% of the aspirates. Twelve percent of patients with a positive as- pirate required hospitalization for toxicity or odynophagia. Aspiration and oral antibiotics brought complete resolution of abscesses in 85% of patients with a positive aspirate. In 12 cases, a clinical impression of reaccumulat ion of pus prompted repeat aspiration. Abscesses persisted in 11% and recurred in 4% of the positive aspirate group; all underwent tonsillectomy. The authors point out that needle aspiration is diagnostic, provides symptomat ic relief, and decreases morbidity associated with surgery. They propose reconsider- ing the classic dogma of wide incision and drainage or ton- sillectomy as primary treatment.

Robin W Nicholson, MD

made. If the child was thought to have acute epiglottitis, a pediatric anesthesiologist was called for direct inspection of the epiglottis. Otherwise, the epiglottis was visualized by the pediatric resident or emergency department attending physician. The diagnosis of epiglottitis was based on inflam- mat ion and swell ing of the epiglottis. The diagnosis of laryngotracheitis was made based on acute stridor, lack of evidence for the presence of a foreign body, normal epiglot- tis on inspection, and no stridor at follow-up. The diagnosis assigned prior to inspection of the epiglottis was incorrect in two of six patients with epiglottitis and three of 149 pa- tients with laryngotracheitis. Minor complications of in- spection were seen in seven patients with laryngotracheitis. No complicat ions were experienced in patients with epi- glottitis. No findings present by history were predictive of the final diagnosis. Three findings on physical examination were predictive of a final diagnosis of epiglottitis: absence of spontaneous cough, presence of drooling, and presence of agitation. The authors conclude that drooling, agitation, and lack of spontaneous cough are predictors of epiglottitis (P < .0027). However, the occurrence of these findings is poorly est imated based on the small number of patients with epiglottitis. Due to the low incidence, the authors drew no conclusions concerning the safety of direct inspec- tion of the epiglottis in children with epiglottitis.

Carol Federiuk, MD

alcohol, trauma; marijuana, trauma

Mari juana and alcohol use among 1023 t rauma pat ients Soderstrom CA, Trifillis AL, Shankar BS, et al Arch Surg 123:733-737 Jun 1988

epiglottitis, laryngotracheitis

Differentiat ion of epiglott i t is from laryngotracheit is in the child with stridor Mauro RD, Poole SR, Lockhart CH Am J Dis Child 142:679-682 Jun 1988

The authors prospectively evaluated 155 children with stridor to identify clinical findings that differentiate acute epiglottitis from laryngotracheitis and to evaluate the effect of direct inspection o f the epiglottis. The presence or ab- sence of 19 findings on history and physical examination were recorded, and an initial diagnostic impression was

The authors prospectively investigated the use of mari- juana and alcohol among 1,023 vehicular and nonvehicular trauma patients. Of 1,023 samples tested for THC by radio- immunoassay, an activity of 2 ng/mL or more was detect- able in 34.7% of the subjects. RIA tests will detect THC up to four hours after marijuana use. Marijuana use was signifi- cantly greater in patients 30 years of age or younger and among men. There was no statistical difference in mari- juana use among vehicular and nonvehicular trauma vic- tims. Admitting blood alcohol levels were determined on 1,006 of the patients, with 32.6% positive. Over three-quar- ters of the blood alcohol levels were 100 mg/dL or higher. Alcohol use was significantly associated with being 30 years of age o r younger, a man, and injured in a vehicular crash. Of 1,006 patients tested for both, 16.1% had consumed only

17:12 December 1988 Annals of Emergency Medicine 1357/151

alcohol, 18.3% were positive for THC only, and 16.5% had used both. The number of patients using both marijuana and alcohol is significantly larger than the expected number if their use were unassociated. No correlation was found between injury severity and consumption of alcohol or serum detection of THC. This study did not consider the possibility of false-positive results in long-term heavy users of marijuana or the possibility of detecting THC leyels in passive nonusers in the vicinity of marijuana smokers. In many cases serum was not tested on patients who were dead on arrival or pronounced dead within one hour of ad- mission. Also, this was not a controlled study, and non- vehicular trauma was not clearly defined. Regardless, it is interesting to note the slightly higher use of marijuana than alcohol among these trauma patients.

Mark Murphy, MD

acute chotecystitis, Curtis-Fitz-Hugh syndrome

Clinical acute cholecyst i t is and the Curt is-Fi tz .Hugh syndrome Shanahan D, Lord PH, Grogono J, et al Ann R Coil Surg Engl 70:44-48 Jun 1988

The Cur t i s -Fi tz-Hugh syndrome is an anter ior peri- hepatitis associated with a genitourinary tract infection. Presenting signs and symptoms of this syndrome clinically resemble acute cholecystitis, and diagnosis is usually made by exclusion of biliary or other abdominal pathology. In a preliminary study the authors reviewed records of 105 pa- tients admitted with the clinical diagnosis of cholecystitis. Biliary pathology was proven in 61% of these patients, while 22% had definite other abdominal causes for their pain. The remaining 17% had right upper quadrant pain of unknown etiology, a situation found to be more common in women and in the 15 to 35 age group. A prospective study was then undertaken in which 18 patients who were admit- ted with the clinical diagnosis of acute cholecystitis were studied. Clinical criteria for admission were any of the signs and symptoms of the right upper quadrant pain syndrome with or without peritoneal inflammatory signs and any ab- normalities in the hemoglobin, white cell count, amylase, renal, and liver function tests. The patients were further in- vestigated with plain radiographs of the chest or oral cho- lecystograms. Of these patients, 28% were found to actually have acute cholecystitis as etiology of their pain, while 33% suffered from other abdominal pathology. The remaining 39% of undiagnosed right upper quadrant pain were screened for Chlamydia trachomatis. Serologies were exam- ined with complement fixation. Tests for gonococcal infec- tion were negative. All were then treated for C trachomatis, after which repeat genitourinary screens were negative. Six of seven patients with undiagnosed pain had complete reso- lution. Curtis-Fitz-Hugh syndrome may be more common than previously thought, especially in sexually active wom- en in the 15 to 35 age group. The authors suggest that all

sexually active patients with suspected acute cholecystitis and a normal ultrasound be screened for C trachomads.

Riemke M Brakema, MD

infection, hand

Hand infections: Bacter io logy and t rea tment : A prospect ive study Dellinger EP, Wertz M J, Miller SD, et al Arch Surg 123:745-750 Jun 1988

A prospective, double-blind study involving 193 patients with established hand infections requiring admission com- pared methici l l in and cefamandole. Patients were given either cefamandole or methicillin IV for the initial 48 hours followed by cephaloxin or dicloxicillin orally. There were 67 cases of human bites, nine animal bites, 39 lacerations, 60 puncture wounds, abrasions, or burns, and 18 unknown causes. A single organism grew in culture in 16% and mul- tiple organisms grew in 84%. Twenty-eight percent of wounds required operating room debridement, 46% emer- gency department debridement, and 26% no debridement. Human bites required the most operating room and ED pro- cedures, as well as the longest mean duration of therapy. When all patients were grouped together, there was no sig- nificant difference between the methicillin- (94% satisfacto- ry) and cefamandole- (93% satisfactory) treated infections. This study shows that drainage is the key to controlling most hand infections and that either cefamandole or meth- icillin is an adequate choice of initial therapy. Cefamandole, because Of the greater spectrum of activity, might be advis- able in human bite wounds, but this study did not prove that empiric observation.

Duncan Saue~MD

HIV, emergency department

Unrecognized human immunodef ic iency virus infect ion in emergency depar tment pat ients Kelen GD, Fritz S, Qaqish B, et al N Er}gl J Med 318:1645-1650 Jun 1988 "-.

This study was undertaken in an inner-city emergency department to determine the prevalence of HIV-positive clients who seek treatment in the ED. Excess blood samples for HIV testing were obtained from any patient who re- quired blood drawing for other medical purposes during a six-week period of t987. Demographic data on the study subjects were obtained by chart review and interviewing of clinicians by independent investigators who had no contact with the patients. Significant results included an overall

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