]Correspondence Crepitation: A Sign of Intraperitoneal Hemorrhage To the Editor: A recent case of n o n p e n e t r a t i n g , abdominal trauma ai the Moline Public Hospital E m e r g e n c y D e p a r t m e n t illu, trated t h a t crepitation over the hepatic area, in the al~ sence of rib fractures or s u b c u t a n e o u s emphysema, can b~ a sign of i n t r a p e r i t o n e a l hemorrhage. The p a t i e n t was an 18-year-old m a n admitted to the emergency d e p a r t m e n t 30 m i n u t e s after a motorcycle ac. c i d e n t . I n i t i a l e x a m i n a t i o n d i s c l o s e d a n a l e r t but a l c o h o l - i n t o x i c a t e d p e r s o n w i t h a b r a s i o n s on his forehead, compound fractures of left f e m u r and tibia, moderate bleeding and hypovolemia. I n t r a v e n o u s fluid resuscitation restored his vital signs to n o r m a l levels.
Anesthetic Bottle Holder To the Editor: Repair of m i n o r lacerations is one of the most common t a s k s of t h e e m e r g e n c y p h y s i c i a n . T r a d i t i o n a l l y the gloved physician aspirates local anesthetic from a bottle held inverted by a nurse or other personnel. Much nursing time can be saved by i n s t a l l a t i o n of this easily b u i l t bottle holder on s u t u r e room walls (Figure). The holder is made from one fourth inch thick Plexiglas, 11 cm wide, cut into 9 and 8 centimeter l e n g t h s b o n d e d t o g e t h e r at a n a n g l e of 60 ° _ The neck of the medicine bottle fits into notches 2.5 cm deep cut in the l e a d i n g edge of the plastic. The notches taper from 17 ml to 16 m l wide so t h a t the bottle will be gripped by the plastic. The clear plastic allows easy visibility of the level of anesthetic in each bottle. The bottles can be changed w i t h i n seconds_ As a m a t t e r of routine, the bottle tops are swabbed with a n antiseptic solution before each case. W h e n we s t a r t e d the system, we kept 1% lidocaine with e p i n e p h r i n e in one notch and 1% lidocaine p l a i n in the other.Because of the possible medication error, however, we now keep only p l a i n lidocaine in the holder.
He t h e n complained of t e n d e r n e s s on the right anterior thoracic wall, j u s t below the nipple, t h a t somewhat re. stricted his respiration_ Crepitation was found in the fiRh and sixth intercostal space at the anterior axillary line along with decreased b r e a t h sounds in the ipsilateral hemithorax. Thoracentesis with an 18 gauge needle did n o t d e m o n s t r a t e a h e m o t h o r a x . F r a c t u r e d ribs and p n e u m o t h o r a x - - a clinical diagnosis - - were ruled out by radiographic e x a m i n a t i o n . A right s u b c l a v i a n centr~ v e n o u s pressure (CVP) c a t h e t e r was i n s e r t e d withou difficulty. A chest x-ray film, to verify the catheter' position, did not show a n y abnormalities_ He was re-evaluated one hour later because of persis~ e n t t e n d e r n e s s . C r e p i t a t i o n was once more distinctl1 p r e s e n t in the same area. There was also slight guardint in the right upper q u a d r a n t of the abdomen, with nor. moactive borborygmi and no r e b o u n d tenderness. At th~ time his vital signs were u n s t a b l e with a CVP of zero, despite the i n t r a v e n o u s infusion of 2,000 cc of Ringef~ lactate solution. An abdominal paracentesis with nega. tive r e s u l t s was followed by p e r i t o n e a l l a v a g e that yielded free, unclotted blood. He received 2 u n i t s of whole blood. Laparotomy revealed a r u p t u r e d spleen and a su. perficial laceration of the right lobe of the liver.
D u r i n g the past year we have realized a savings of approximately $3,000 in local anesthetic costs compared to our previously wasteful system of p u t t i n g 20cc's of local anesthetic in a medicine cup on each tray. We have detected no increase in infection rate d u r i n g this time.
The persistence of crepitation - - found by two different observers - - in the absence of rib fractures, lacerated skin or subcutaneous e m p h y s e m a was certainly intrigU' ing in this patient. Through the infallible retrospe¢~ scope, it appears reasonable to postulate t h a t compr~' sion and apposition of the d i a p h r a g m a n d the liver dur' ing the palpatory e x a m i n a t i o n produced the fragments' tion of free blood clots in the subphrenic space, which produced crepitation.
Bruce D. Janiak, MD Department of Emergency Medicine The Toledo Hospital
Although the hypovolemic syndrome prompted us perform the peritoneal lavage to clinch the diagnosis i~ this patient, crepitation per se, in the circumstances de
Page 382 Volume 5 Number 5
May 1976
edited by Judith E. Tintinalli, Figure 4 is mislabeled, I believe. It is the right lung which is hyperaerated and the mediastinum is shifted to the left, which is consistent with an endobronchial foreign body on the right.
scribed here, should alert the clinician to early diagnosis of intra-abdominal hemorrhage in trauma patients before a full-blown picture of hypovolemic shock develops. Miguel A. Flores, MD Moline, Illinots
Except for this minor oversight, the article was superb! David Lewin, MD Vestal, New York (Editor's Note: Dr. Lewin is correct that there is a problem with Figure 4. However, rather than an incorrect caption, Figure 4, along with Figure 3, were inadvertently flopped when reproduced. The captions for both illustrations are correct. The x-rays appear below correctly.)
Respiratory Stridor in the Young Child To the Editor."
In the article which appeared in the March, 1976 issue of the J A C E P "Respiratory Stridor in the Young Child," !
Fig. 3. Chest radiograph taken during full inspiration.
Organization of Emergency Medical Care The Soviet Experience
edited by L. B. Shapiro and I. A. Ostrovskii Preface by Patrick B. Storey
Fig. 4. Chest radiograph taken during full expiration. The left hemithorax is hyperinflated, and the mediastinum is deviated to the right. This is consistent with an endobronchial foreign body on the left.
The Soviet system of emergency medical care with its use of diseasespecific emergency teams is perhaps the most sophisticated of any country in the world. For the first time a full description is made available in translation. Special chapters are devoted to emergency medical care for traumatic injuries, cardiovascular and cerebrovascular attacks and acute poisoning. $10.00
The J o h n s Hopkins University Press, Baltimore, Maryland 21218
J • PMay 1976
Volume 5 Number 5 Page 383
Anesthetic Bottle Holder To the Editor: Repair of m i n o r lacerations is one of the most common t a s k s of t h e e m e r g e n c y p h y s i c i a n . T r a d i t i o n a l l y the gloved physician aspirates local anesthetic from a bottle held inverted by a nurse or other personnel. Much nursing time can be saved by i n s t a l l a t i o n of this easily b u i l t bottle holder on s u t u r e room walls (Figure). The holder is made from one fourth inch thick Plexiglas, 11 cm wide, cut into 9 and 8 centimeter l e n g t h s b o n d e d t o g e t h e r at a n a n g l e of 60 ° _ The neck of the medicine bottle fits into notches 2.5 cm deep cut in the l e a d i n g edge of the plastic. The notches taper from 17 ml to 16 m l wide so t h a t the bottle will be gripped by the plastic. The clear plastic allows easy visibility of the level of anesthetic in each bottle. The bottles can be changed w i t h i n seconds_ As a m a t t e r of routine, the bottle tops are swabbed with a n antiseptic solution before each case. W h e n we s t a r t e d the system, we kept 1% lidocaine with e p i n e p h r i n e in one notch and 1% lidocaine p l a i n in the other.Because of the possible medication error, however, we now keep only p l a i n lidocaine in the holder.
He t h e n complained of t e n d e r n e s s on the right anterior thoracic wall, j u s t below the nipple, t h a t somewhat re. stricted his respiration_ Crepitation was found in the fiRh and sixth intercostal space at the anterior axillary line along with decreased b r e a t h sounds in the ipsilateral hemithorax. Thoracentesis with an 18 gauge needle did n o t d e m o n s t r a t e a h e m o t h o r a x . F r a c t u r e d ribs and p n e u m o t h o r a x - - a clinical diagnosis - - were ruled out by radiographic e x a m i n a t i o n . A right s u b c l a v i a n centr~ v e n o u s pressure (CVP) c a t h e t e r was i n s e r t e d withou difficulty. A chest x-ray film, to verify the catheter' position, did not show a n y abnormalities_ He was re-evaluated one hour later because of persis~ e n t t e n d e r n e s s . C r e p i t a t i o n was once more distinctl1 p r e s e n t in the same area. There was also slight guardint in the right upper q u a d r a n t of the abdomen, with nor. moactive borborygmi and no r e b o u n d tenderness. At th~ time his vital signs were u n s t a b l e with a CVP of zero, despite the i n t r a v e n o u s infusion of 2,000 cc of Ringef~ lactate solution. An abdominal paracentesis with nega. tive r e s u l t s was followed by p e r i t o n e a l l a v a g e that yielded free, unclotted blood. He received 2 u n i t s of whole blood. Laparotomy revealed a r u p t u r e d spleen and a su. perficial laceration of the right lobe of the liver.
D u r i n g the past year we have realized a savings of approximately $3,000 in local anesthetic costs compared to our previously wasteful system of p u t t i n g 20cc's of local anesthetic in a medicine cup on each tray. We have detected no increase in infection rate d u r i n g this time.
The persistence of crepitation - - found by two different observers - - in the absence of rib fractures, lacerated skin or subcutaneous e m p h y s e m a was certainly intrigU' ing in this patient. Through the infallible retrospe¢~ scope, it appears reasonable to postulate t h a t compr~' sion and apposition of the d i a p h r a g m a n d the liver dur' ing the palpatory e x a m i n a t i o n produced the fragments' tion of free blood clots in the subphrenic space, which produced crepitation.
Bruce D. Janiak, MD Department of Emergency Medicine The Toledo Hospital
Although the hypovolemic syndrome prompted us perform the peritoneal lavage to clinch the diagnosis i~ this patient, crepitation per se, in the circumstances de
Page 382 Volume 5 Number 5
May 1976
edited by Judith E. Tintinalli, Figure 4 is mislabeled, I believe. It is the right lung which is hyperaerated and the mediastinum is shifted to the left, which is consistent with an endobronchial foreign body on the right.
scribed here, should alert the clinician to early diagnosis of intra-abdominal hemorrhage in trauma patients before a full-blown picture of hypovolemic shock develops. Miguel A. Flores, MD Moline, Illinots
Except for this minor oversight, the article was superb! David Lewin, MD Vestal, New York (Editor's Note: Dr. Lewin is correct that there is a problem with Figure 4. However, rather than an incorrect caption, Figure 4, along with Figure 3, were inadvertently flopped when reproduced. The captions for both illustrations are correct. The x-rays appear below correctly.)
Respiratory Stridor in the Young Child To the Editor."
In the article which appeared in the March, 1976 issue of the J A C E P "Respiratory Stridor in the Young Child," !
Fig. 3. Chest radiograph taken during full inspiration.
Organization of Emergency Medical Care The Soviet Experience
edited by L. B. Shapiro and I. A. Ostrovskii Preface by Patrick B. Storey
Fig. 4. Chest radiograph taken during full expiration. The left hemithorax is hyperinflated, and the mediastinum is deviated to the right. This is consistent with an endobronchial foreign body on the left.
The Soviet system of emergency medical care with its use of diseasespecific emergency teams is perhaps the most sophisticated of any country in the world. For the first time a full description is made available in translation. Special chapters are devoted to emergency medical care for traumatic injuries, cardiovascular and cerebrovascular attacks and acute poisoning. $10.00
The J o h n s Hopkins University Press, Baltimore, Maryland 21218
J • PMay 1976
Volume 5 Number 5 Page 383
