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-

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