Hematuria after blunt trauma: When is pyelography useful?

Abstracts

of the anterior longitudinal ligament, detachment of the intervertebral disk from the caudal endplate, separation of the posterior longitudinal ligament from the body, and pinching of the spinal cord between the posterior inferior margin of the retroluxing vertebral body and the lamina of the subjacent vertebra. Following the initial hyperextension forces, the vertebrae may resume a normal anatomic position and the initial roentgenograms may appear normal or only show subtle signs of cervical injury. If disk space widening is evident on initial roentgenograms, immediate stabilization should be instituted. If the initial roentgenogram is normal but a neurologic deficit is present, a physician should carefully position the neck in limited extension, thereby confirming the hyperextension injury. If hyperextension injury is not diagnosed initially, follow-up roentgenograms may reveal accelerated degenerative disk disease indicative of the original injury. [J. P. Vellman, MD]

?? MUNCHAUSEN’S SYNDROME. Haddy RI, Weber RM, Joy Lekar AS. Am Fam Physician 1983; 27(2):193-197. This type of patient is characterized by traveling from hospital to hospital presenting with factitious and often self-inflicted illness. The disorder appears to be more common in men, with a mean age of 39 years, ranging from 19 to 62 years. They frequently permit painful and potentially dangerous diagnostic procedures during hospitalization and often have a history of multiple operations. Abdominal procedures are the most common but neurosurgical and chest procedures are also common. The patient may present with almost any type of illness. The spectrum of signs and symptoms is limited by the patient’s medical knowledge, as some have worked in medically related fields such as medical technology or nursing. The hospitalization of the patient is quite often associated with the administration of drugs. Drug dependence has been suspected in about 50% of these patients. A common characteristic of these patients is impersonation. This behavior may be a mechanism to deal with anxiety secondary to feelings of inferiority. They frequently impersonate anyone from a war hero to a university president. The psychodynamics of individuals with Munchausen syndrome has been extensively studied but the disorder has not yet been given an accurate diagnostic classification. Only occasionally are

291

patients of this type reported to respond to some form of treatment. Most authors believe that the patients should be cautiously confronted and psychiatric consultation recommended. A recently reported form of the disease is fabricated by a person other than the patient; the patient is often a child and the fabricator is the child’s [Esequiel C. Guevara, MD] parent. Editor’s Note: Clearly this can be a very difficult problem or series of problems to elaborate in the ED. Some of these patients are extraordinarily clever at the simulation of pain or other nonobjective findings. The only clue we have encountered is inappropriate rage at persistent questioning of unclear history of symptoms.

?H ?EMATURIA AFTER BLUNT TRAUMA: WHEN IS PYELOGRAPHY USEFUL? Guice K, Oldham K, Eide B, Johansen K. J Trauma 1983; 23:305-311. A retrospective review of all patients undergoing IVP following blunt trauma seen in the Harborview Medical Center emergency department during the l-year period of June 1980 through June 1981 was conducted to determine discriminating guidelines for IVP following blunt trauma. During this time, 156 patients were deemed at risk for urinary tract injury because of hematuria, either gross or microscopic. Thirty-seven patients had grossly bloody urine or 4 + hematuria on dipstick urinalysis. Only 13 (8.3%) of the patients had abnormal IVPs and all had gross blood or 4+ hematuria on urinalysis. Six patients requiring further diagnostic or therapeutic maneuvers were included in this group. If screening IVP had been utilized only in patients with gross 4+ hematuria, no significant renal injuries would have been missed, and 119 (75%) of the patients in the series would have been spared the expenditure of time and money, and the radiation and dye exposure resulting from negative studies. The authors conclude that (1) significant renal injuries from blunt trauma are uncommon, (2) the yield is low when IVP is performed for minimal amounts of hematuria, and (3) diagnostic yield may be iu creased significantly if IVP is reserved for blunt trauma patients with large amounts of blood in the urine. [Paul Lewis, MD] Editor’s Note: The argument still needs resolution with a prospective study. For the patient with microscopic hematuria but no major injury, it may well be more cost-effective to have

292

IVP and discharge, if normal, rather than admission and observation.

?L ?ACK OF EFFICACY OF A DECONGESTANT-ANTIHISTAMINE COMBINATION FOR OTITIS MEDIA WITH EFFUSION (“SECRETORY” OTITIS MEDIA) IN CHILDREN. Cantekin EI, Mandel EM, Bluestone CD, et al. N Engl J Med 1983; 308:297-301. The authors present a 3-year double-blind randomized trial in 553 infants and children who had otitis media with effusion, comparing the efficacy of a 4-week course of an oral decongestant-antihistamine combination with that of placebo. The medication used was pseudoephedrine hydrochloride, 4 mg/kg of body weight per day, and chlorpheniramine maleate, 0.35 mg/kg/ day. Otitis media with effusion, otherwise known as “serous,” “secretory,” or “nonsuppurative” otitis media was defined by the independent findings of a “validated otoscopist,” tvmpanometry, and of middle-ear reflex muse testing. A large list of exclusions for entry as used and included suppurative otitis media, Jngenital malformations, and chronic illnesses. imong patients with initially unilateral disease, esolution of middle-ear effusion occurred at 4 veeks in 38% of those treated with placebo and n 34070of those treated with drug @ = 0.74). In hose patients with initially bilateral disease, 19% of placebo-treated patients had resolution In 4 weeks as opposed to 21% of the drugtreated group @ = 0.67). Side effects were more common in the drug-treated group and included mild sedation, restlessness, irritability, anorexia, nausea, and vomiting. The authors conclude that decongestant-antihistamine combinations do not appear to be indicated for the treatment of otitis media with effusion in infants and children. [James Berner, MD] Editor’s Note: For some time, it has been puzzling as to which drugs to treat these children with. The advantage to this knowledge is that now only a single drug need be prescribed, which will not only be cheaper for the patient but should measureably improve compliance.

The Journal of Emergency Medicine

?A ?IR TRANSPORT OF PEDIATRIC EMERGENCY CASES. Black RE, Mayer T, Walker ML, Christison EL, Johnson DG, et al. N Engl JMed 1982; 307:1465-1468. The authors, from Primary Childrens Medical Center, Salt Lake City, Utah, present their data on 752 pediatric patients transported mainly by air over a 32-month period (April 1979 to December 1981). The transport personnel consisted of highly skilled nurses and physicians. Air transport was accomplished by helicopter in 448 cases (6007o)and fixed wing aircraft in 265 cases (35%). Approximately 5% of cases (39) were transported by ground ambulance because of inclement weather precluding safe air transport. Patient ages ranged from 3 weeks to 16 years. Thirtythree percent of patients (249) were under 1 year of age, 47% (356) were between 1 and 6 years of age, and 20% (147) were over 6 years old. Nineteen percent of total transports were made for head injuries or multiple trauma. Neurologic illness and need for computed tomography of the head accounted for 32% of cases. Nineteen percent had infectious diseases (other than central nervous system infections). General pediatric and pediatric surgical emergencies accounted for 22% of cases. An additional 7% had miscellaneous diagnoses and 1% had orthopedic problems. Only 1% of patients required major resuscitative measures during flights. Ninety-nine percent of transports were accomplished without ill-effect to the patient or flight crew. Costs for air transportation were within 1% of the charges for similar ground transportation for distances from 25 to 200 miles. Charges for air transportation were substantially less than for ground transportation for distances over 200 miles. The hospital recovered 90% of all charges billed by the system. The authors suggest that aeromedical transportation can be delivered without exorbitant cost to either the patient or the hospital when justified by geography, time, and the need for regionalization of specialized care. In their experience, aeromedical transportation resulted in efficient care and suitable outcomes for critically ill [James Berner, MD] patients.