in group 2 had cardiac penetration. The two groups were similar in terms of extent of cardiac injury (PCTI), total in- jury sustained and mean physiologic indices (PI and TS). There were a larger number of patients in group 2 arriving at the ED with signs of life. It is unclear if this resulted from faster transportation or differences in severity of inju- ry. Overall survival of patients with cardiac trauma was 13%, and eight of these nine survivors came from group 2 (P > .01). It is concluded that in an urban setting with short transport times, immediate transportation without at- tempts at infield stabilization is the optimal prehospital management of patients with penetrating thoracic trauma. [Edftor's note: A classic study of apples versus oranges. The best conclusion that can be reached is i f you're going to sustain thoracic penetrating trauma, have it near a hospi- tal, and get there fast.j

Katherirle Hurlbut, MD

urinary tract infection, norfloxacin, sutfamethoxazote/trimethoprim

A mult icenter comparat ive trial of three-day norfloxacin vs. ten-day sul famethoxazole and tr imethoprim for the t rea tment of uncompl icated urinary t r a c t infections Stein GE, Mummaw N, Goldstein E J, et al Arch Intern Med 147:1760-1762 Oct 1987

A multicenter, controlled clinical trial randomized 209 patients with acute, uncomplicated urinary tract infections (UTI} to treatment of three days of norfloxacin {400 mg, twice daily) or ten days of sulfamethoxazole (SMX) and tri- methoprim (TMP) (800 mg and 160 mg, respectively, twice daily). Patients with pyuria and frequency, dysuria, or ur- gency were eligible for the study, Patients with pyeloneph- ritis (flank pain, rigor or temperature more than 38 C), less than 18 years old, pregnant, with quinolone or sulfur allergy, or with structural functional urinary tract abnormalities were excluded. UTI was defined as 10,000 or more colony- forming units per milliliter in a midstream clean catch urine. Urine cultures sensitivities were performed five to nine days and four to six weeks after completion of therapy. Cure was defined as elimination of all pretherapy signs and symptoms, and the initial urinary pathogen. A treatment failure was the persistence of the initial urinary symptoms and the initial infecting organism. There were no significant differences between the treatment groups in number of pa- tients, sex, age, degree of pyuria at presentation, or kinds of bacterial isolates. Cures rates were 71 of 74 (96%) with nor- floxacin and 81 of 81 (100%) with SMX and TMP. Treatment failure rates were one of 74 (l.3%) with norfloxacin and zero of 81 with SMX and TMP. Side effects were similar between the groups. The authors concluded the two treatment reg- imens were equally efficacious.

Douglas Campbell, MD

CT scan, head trauma, pediatric

Poor predict ion of positive computed tomographic scans by clinical cr i ter ia in symptomat ic pediatr ic head t rauma Rivara F, Tanaguchi D, Parish RA, et al Pediatrics 80:579-584 Oct 1987

This retrospective study evaluated the accuracy of clinical signs in predicting the need for computed tomogra- phy (CT) scanning in 98 children scanned for acute head trauma. All children had symptomatic injury, history of loss of consciousness, abnormal level of consciousness, and/or focal neurologie signs observed in the field or the emergen- cy department. Forty-nine children had a normal CT. How- ever, 14 were neurologically abnormal. Of the abnormal scans, 16 (32%) had subdural hematomas, 12 (25%) had lin- ear, and 12 (25%) depressed skull fractures; 11 had cerebral contusions, seven had subarachnoid hemorrhages, and four had epidural hematomas. Of 51 patients with a Glascow Coma Scale score of 13 to 15, 16 (31%) had an abnormal CT scan. An abnormal CT scan was more likely with one of the following: loss of consciousness for five minutes, Glascow Coma Scale score of less than 12, unequal pupils, posturing, focal neurologic signs, and blood behind the tym- panic membrane or in the external canal. Seizures or vomit- ing did not predict an abnormal CT scan. No single clinical sign identified all abnormal scans, nor did any combination of clinical signs. The clinical examination failed to predict brain injury. Early use of the CT scan for symptomatic pedi- atric head trauma is recommended to prevent missed or de- layed diagnosis of significant intracranial injury.

Alexander Krivchenia, MD

gastrointestinal bleeding, varices, causes

Upper gastrointest inal bleeding in pat ients with esophageal var ices - - What is the most common cause? Sutton FM Am J Med 83:273-275 Aug 1987

For a number of years it has been taught that the source of hematemesis in patients with esophageal varices is usu- ally nonvaricea]. This study retrospectively reviewed the re- sults of endoscopic examinations performed within 24 hours of admission after hemodynamic stabilization. Vari- ces were considered the source of bleeding if they were seen actively bleeding or if no other source was identified. There were 222 patients with 299 episodes of upper gastroin- testinal (UGI) bleeding whose endoscopic findings in their first episode revealed varices as the only lesion in 145 (65%), esophagitis in ten (4.5%), Mallory-Weiss tear in seven

17:4 April 1988 Annals of Emergency Medicine 375/133