Efficacy of emergency room thoracotomy in pediatric trauma

gressive fever, rash, vomiting, diarrhea, hypotension, strawberry tongue, and subsequent desquamation, has been discovered to have a mimic syndrome produced by Streptococcus pyogenes. This group A beta-hemolytic bacterium is responsible for such infections as pharyngitis, impetigo, erysipelas, and necrotizing fasciitis. Two cases of systemic infections initially regarded as toxic shock syndrome and treated with oxacillin are presented. The patients had erythema over the forehead, cheeks, and chin with bulbar and palpebral conjunctivae injection. Both patients developed confusion and hypotension requiring aggressive pressor support. Neither patient had evidence of a strawberry tongue, and the one surviving patient demonstrated no subsequent desquamation with the resolution of her rash. During the course of their hospitalizations, both patients developed multiple flaccid, yellow, cutaneous bullae which, when aspirated and cultured, grew group A beta-hemolytic streptococci sensitive to ceftazidime. The authors emphasize the similarities between the entities of staphylococcal and streptococcal toxic shock in their clinical presentation with the only differences being the absence of strawberry tongue and desquamation as well as the presence of characteristic bullae in the latter cases. Staphlococcic toxic shock is treated with oxacillin or methaciblin; streptococcal toxic shock is treated with penicillin. Michael Hunt, MD antibiotics, wounds, penetrating, abdominal

Presumptive a n t i b i o t i c s for p e n e t r a t i n g abdominal w o u n d s Posner MC, Moore EE, Harris LA, et al

Surg Gynecol Obstet 165:29-32 Jul 1987

During a two-year period ending June 1985, 150 consecutive patients undergoing celiotomy for penetrating abdominal trauma were randomized prospectively to receive either 4 g q six hours of mezlocillin (Mz) or the combination of gentamicin (loading dose of 2 mg/kg then 1.5 mg/kg q eight hours) and 600 nag q six hours of clindamycin (G/C). Antibiotics were begun in the emergency department and continued for 24 hours to five days depending on the type of injury encountered at laparotomy. Aerobic and anaerobic cultures were taken intraoperatively and peritoneal irrigation did not include antimicrobial agents. Of the 150 patients entered into the study, 20 were excluded from analysis, ten due to death within 48 hours and ten due to breach in protocol. Sixty-nine patients received G/C and 61 received Mz. Groups were comparable for age, sex, ethanol intoxication, degree of shock on presentation, intraoperative blood requirement, and distribution of visceral injuries. The G/C group had 31 gunshot wounds and the Mz group only 18. The incidence of septic mortality was 2% for the Mz and 3% for the G/C group. The septic morbidity was 16% for the Mz and 13% for the G/C group. Bacterial culture analysis on re-laparotomy for intra-abdominal infection showed primarily Staphylococcus epiclermidis and Entero16:11November 1987

cocci isolates from the G/C grOup while the Mz group had predominantly bacteroides isolates. However, there was no significant difference in the outcome of these patients. It was concluded that there was no significant difference with respect to incidence of infection or mortality between the two groups once cost and toxicity were considered. Mz, a third-generation penicillin, is the optimal antimicrobial for penetrating abdominal injury. Cheryl Melick, MD ankle, sprain, meniscoid lesion

M e n i s c o i d lesion of the a n k l e in s o c c e r players McCarrol JR, Schrader JW, Shelbourne D, et al

Am J Sports Med t5:255-257 May/Jun 1987

The authors report four cases of athletes who presented with "meniscoid" lesions of the ankle. All athletes had initial inversion sprain to the ankle and experienced repeated ankle sprains during competition that were accompanied by persistent pain, swelling, and trapping. Physical examination revealed pain over the anterior aspect of the fibula in all five lesions. None of the patients exhibited lateral or anterior instability. Routine radiographs and bone scans were normal. After a period of at least six months of conservative treatment, the patients had the same complaints. Arthroscopic surgery was performed on the ankle, and a band of white fibrous, meniscus-like tissue found between the fibula and talus was removed through the arthroscope. A three-week rehabilitation program consisting of cryotherapy, and range of motion and strengthening exercises was implemented. Following this program, all patients had a return of 90% strength on Cybex testing and all passed functional progression tests. Only one of the athletes complained of pain on rare occasions during vigorous activity. The authors were unable to explain the true etiology of the condition because no pathology slides were reviewed as the lesions were excised with a power arthroscopic shaver. However, a meniscoid lesion of the ankle should be considered in an athlete who presents with a long history of repeated ankle sprains that are refractory to a reasonable period of conservative treatment. Jeffrey Schaider, MD thoracotomy, pediatric

Efficacy of e m e r g e n c y room t h o r a c o t o m y in p e d i a t r i c t r a u m a Beaver BL, Colombani PM, Buck JR, et al

J Pediatr Surg 22:19-23 Jan 1987

The authors report the reSults of emergency department t h o r a c o t o m y in children. Seventeen children, ages 15

Annals of Emergency Medicine

1308/157

ABSTRACTS

months to ! 4 years, who arrived in the ED of the Maryland Regional Pediatric Trauma Center between July 1980 and August 1985 were included in this study. Fifteen patients sustained blunt trauma, and two had isolated penetrating chest injuries. The initial Glascow Coma Scale (GCS) was 3 for all patients. The mean Modified Injury Severity Score (MISS) was 42. All patients arrived without vital signs or ECG activity. All ~underwent maximal conventional resuscitative therapy with intubation , military antishock trousers, rapid fluid administration, closed-chest massage, and cardiotonic medications for a mean time of 22 minutes prior to ED thoracotomy. In the absence of response to conventional therapy, a left thoracotomy was performed, the aorta cross-clamped, and open cardiac massage performed.

158/1309

Three of the patients initially responded with ECG activity. NO patient, however, survived the ED course. The cause of death was exsanguination in 13 cases and was multiple injuries in four. It was concluded that in children ED thoracotomy should be reserved for those with penetrating injuries, or blunt injuries associated with detectable vital signs and who then deteriorated despite maximal conventional therapy. [Editor's note: Both of the patients with isolated penetrating wounds to the chest sustained cardiac injuries; this is probably the one clear indication for an immediate ED thoracotorny Several large series have reaffirmed the very dismal outcome of patients who arrest secondary to blunt trauma.] Ronald P Ruffing, MD

Annals of Emergency Medicine

16:11 November 1987