serious respiratory consequences of detergent ingestions in children: einhorn a, horton l, altieri...

ABSTRACTS

was three t imes higher than when no head injury was present (6.1%). Although head injury patients comprised only one third of the series (33.6%), they comprised nearly two thirds (60.4%) of the deaths. The mortality of head- injured patients was influenced little by the presence of extracranial injury unless the AIS index was high (4 to 6). Head injury is associated with more deaths (3,010 vs 1,972) than all other injuries and causes almost as many deaths (2,040 vs 2,170) as extracranial injuries. It was, therefore, concluded that head injury was the single largest contrib- utor to deaths due to trauma.

Cynthia Elliott, MD

catheter, subclavian venous, pediatric

P e r c u t a n e o u s inser t ion of subc lav ian venous c a t h e t e r s in in fants and ch i ldren Bonventre EV, Lally KP, Chwals W J, et al Surg Gynecol Obstet 169:203-205 Sep 1989

Presented is a prospective study of all attempts at sub- clavian venous catheterization on the surgical service dur- ing an 18-month period at Children's Hospital of Los An- geles. One hundred seven consecutive patients entered the study. Results were analyzed in terms of patient age and weight, number of punctures attempted, catheter size, and position of placement, with complications noted for both successful and unsuccessfu l a t tempts . Pa t ien ts ' ages ranged from 2 days to 23 years (mean, 10 years), with weights ranging from 2.2 to 70 kg (mean, 30 kg). Seldinger technique was a t t empted in 60% of a t tempted place- ments. Fluoroscopy was used in 65 a t tempts and was more likely to be used in older children; it resulted in an 86% success rate. Attending physicians attempted 26% of catheterizations, fellows 58% and junior residents 16%. There were 282 punctures, 187 on the right and 95 on the left. Canalization was successful 89 times (71%), 49 of 89 on the first attempt. The highest rate of success was in the 13 to 23 age group with the lowest rate in the 2 day to 6 year age. There were 29 complications with the major complications being arterial puncture (ten), pneumothorax (three), and abnormal position (sixteen), with the highest complication rate in the youngest age group and those of lower weight. The success rate for right-sided a t tempts was 72% and left 68%. The serious complication rate be- tween left- and right-sided attempts was similar, but more catheters were abnormally positioned with right-sided at- tempts. There were two pneumothoraces from right-sided attempts, one from left. It was concluded that in children percutaneous subclavian venous catheterization can be ac- complished with relatively low morbidity. Fluoroscopy can be useful to guide catheter position, and left subcla- vian vein cannulation had a similar success rate and a lower complication rate of malposition than right-sided placement.

Patricia L Johnson, MD

panic disorder; suicide

Suic ida l idea t ion and s u i c i d e a t t e m p t s in pan ic d isorder and a t t a c k s Weissman MM, Klerman GL, Markowitz JS, et al N Engl J Med 321:1209-1214 Nov 1989

The authors analyzed the risk of suicidal ideation or at- tempts given a history of panic attacks or panic disorder. Panic disorder is defined in Diagnostic and Statistical Manual of Mental Disorders (DSM-III) as occurrence of at least three panic attacks within a three-week period. In this study, 18,011 subjects were interviewed. Techniques controlling for standard demographic and coexisting psy- chiatric disorders were used. Overall, the prevalence rates of panic disorder, panic attack, and any other psychiatric disorder, were 1.5%, 3.6%, and 27%, respectively. Com- pared with persons with other psychiatric disorders, those with panic disorder had made more suicide attempts, with an adjusted odds ratio of 2.62 (95% confidence interval, 1.83 to 3.74). Compared with those with no psychiatric disorder, the adjusted odds ratio was 17.99 (95% confi- dence interval, 12.18 to 26.58). Because patients with panic symptoms are much more likely to present to the emer- gency depar tment for psychological manifes ta t ions of their disorder than other psychiatric patients and they ap- pear to be at higher risk for suicide, it is important that the physician make appropriate psychiatric referral, after having ruled out a medical basis for their symptoms.

Rodney Loeffler, MD

ingestion, detergent, respiratory complications

Ser ious resp i ra tory c o n s e q u e n c e s of d e t e r g e n t inges t ions in ch i ld ren Einhorn A, Horton L, Altieri M, et al Pediatrics 84:472-474 Sep 1989

Today's nonphosphate laundry detergents contain so- dium carbonate and are highly alkaline pHs between 10 and 12. Initially medical literature raised concern, about the potential of gastrointestinal injury if these products were ingested, but there has been no mention about respi- ratory damage. Eight cases of ingestion or inhalation ad- mitted during an eight-year period are reviewed. Patients were between 1 and 21/2 years old. All but one ingestion were thought to be a small amount, and five vomited after ingestion. Stridor and drooling were the most frequent signs, both occurring in 50%. Other signs included retrac- tions, hoarseness, and edematous lips. All but one pa- t ient 's symptoms occurred within two hours, and that child had no airway compromise. Six patients (75%) had edema or erythema of the epiglottis on endoscopy (five) or lateral neck radiograph (one), and four patients were intu-

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bated for airway protection. Patients were treated with steroids, racemic epinephrine, antibiotics, and IV fluids. All patients were asymptomatic at 72 hours. It was con- cluded that sodium carbonate-containing detergents can cause severe upper airway compromise, and signs seem to appear within two hours.

Robert Schmidt, MD

acid-base imbalance, cardiac arrest

Myocard ia l acidosis associated wi th CO 2 product ion during card iac arrest and resusci ta t ion Planta MV, Weil MH, Gzamuri R J, et al Circulation 80:684-692 Sep 1989

This study investigated the acid-base status of the myo- cardium during cardiac arrest. Domestic pigs were anes- thetized, intubated, and mechanically ventilated. Ven- tricular fibrillation was induced electronically. Three min- utes later mechanical compressions were begun with DC cardioversion eight minutes later. The investigators found that during CPR profound myocardial acidosis developed with a myocardial pH decrease of 7.27 + 0.04 to 6.88 + 0.20 pH units; great cardiac vein Pco2 increased from 57 _+ 2 to 158 + 12 mm Hg with associated increased produc- tion of myocardial lactate. However, cardiac vein bicar- bonate concentrations only decreased from 31 + 1 to 23 + 1 mmol/L. These acid-base changes almost completely re- versed 60 minutes after DC cardioversion. The Pco z of cardiac vein blood was also significantly greater than that of mixed venous blood, demonstrating disproportionate myocardial production of CO 2 during CPR. It was con- cluded that it is predominately CO 2 production during is- chemia that accounts for the decrease in myocardial pH and that administration of a bicarbonate buffer that in- creases CO z may be counterproductive.

Robert Van Hare, MD

wound, stab, chest

Prospect ive trial of the six hour rule in stab wounds of the chest Kerr TM, Sood R, Buckman RE et al Surg Gynecol Obstet 169:223-225 Sep 1989

This prospective study tested the validity of the hypoth- esis that asymptomatic victims of stab wounds to the chest with normal chest radiograph and physical examina- tions, who remain asymptomatic with normal chest radio- graph after six hours, will not have delayed complications.

Over a three-year period, 170 patients with stab wounds to the chest presented to the emergency department. Those with evidence of intrathoracic injury, precordial wounds, or wounds within 2 cm Of the clavicle had further studies or procedures and were excluded. Those with wounds be- low the nipple or scapula underwent diagnostic peritoneal lavage but were included if this was negative. One hun- dred five patients (69.%) met inclusion criteria and were admitted to the hospital for a minimum of 24 hours. All patients had a chest radiograph on admission, at six hours and at 24 hours. Four patients developed hemothorax or pneumothorax during the first six hours. There were no complications from six to 24 hours. It was concluded that, excluding patients with signs or symptoms of serious in- jury, precordial wounds, or wounds close to major vessels, and using diagnostic peritoneal tavage for low chest wounds, a six-hour observation period is sufficient to de- tect intrathoracic injury. [Editor's note: A very cost-effec- tive way of managing this group of patients with isolated stab wounds of the chest is to admit them to a short-term ED or inhospital observation unit. In our institution, such patients are discharged from the ED observation unit if they have a normal chest radiograph four hours after ad- mission.]

Laurie Vande Krol, MD

caustics, ingestion

Ingest ion of corrosive acids: Spect rum of injury to upper gastro intest inal t ract and natural history Zargar SA, Kochar R, Nagi B, et al Gastroenterology 97:702-707 Sep 1989

In this prospective study 41 patients who ingested corro- sive acids were studied by endoscopy, surgery, or autopsy for location, extent, severity, and outcome of the injury to the upper gastrointestinal tract. All acids were ingested in liquid form and included hydrochloric, sulfuric, nitric, carbolic, glacial acetic, formic, and aqua regia. All patients were assessed within 36 hours of ingestion. Dysphagia and oropharyngeal pain were the two most frequent com- plaints. Hematemesis or melena occurred in eight pa- tients, and only four required transfusion. The esophagus and stomach were damaged in 81 and the duodenum in only 34. Symptoms of dysphagia or odynophagia, or both, were associated with esophagitis in 26 of 27 patients. In contrast, only 17 of the 35 patients with gastric burns had epigastric pain or tenderness or both. Five patients had ev- idence of perforation at the time of admission, and in one patient it developed eight days later. Plain radiographs showed pneumomediastinum in both patients with esoph- ageal perforation and in three of four patients with gastric perforation. Esophageal injury occurred in 88% and subse- quent stricture formation in 38%. Sixteen of the 41 had.

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