Abstracts in this issue were prepared by residents in the Denver General/St Anthony's/St Joseph Hospitals Emergency Medicine Residency Program.

ABSTRACTS Harvey W Meislin, MD, FACEP Co-Editor Section of Emergency Medic ine University of Ar izona Col lege of Medic ine

Vincent J Markovchick, MD, FACEP Co-Editor Emergency Medical Services Denver General Hospital

acute myocardial infarction, coronary thrombolysis, prehospital; streptokinase, acute myocardial infarction

Prehospital coronary thrombolysis: A new strategy in acute myocardial infarction Weiss AT, Fine DG, Gotsman MS, et al Chest 92:124-128 Jul 1987

Prehospital IV streptokinase t rea tment of 29 patients with first-time acute myocardial infarction was compared to a similar group of 84 in-hospital patients treated with IV streptokinase in this prospective study. A 24-hour, physi- cian-operated mobile intensive care unit (MICU) ambulance responded to emergency calls and established the diagnosis of transmural ischemia from the history and 12-lead ECG after sublingual isorbide dinitrate and nifedipine. If no con- traindications to streptokinase were present, pretreatment with IV bolus of hydrocortisone was followed by strepto- kinase infusion of 750,000 IU over 20 to 30 minutes. Serum creatine phosphokinase levels were drawn hourly for 24 hours. ECGs were obtained hourly until ST segment resolu- tion and daily thereafter. Coronary angiography and left ventriculography were performed on day six and global left ventricular ejection fraction was calculated. Myocardial in- farction size also was estimated from an EGG obtained at the time of catherization using a quantitative QRS scoring system. The mean time to streptokinase administration was 1.9 + 0.9 hours in the hospital group, compared to 1.0 + 0.4 hours in the prehospital group. It was concluded that patients receiving streptokinase in the prehospital phase of acute myocardial infarction had smaller infarcts and better residual myocardial function than did the in-hospital group. In the prehospital-treated group one patient had a major hemorrhage. There were no allergic reactions or life-threat- ening reperfusion arrhythmias. It also was concluded that the use of streptokinase in the prehospital setting is both safe and effective. [Editor's note: Although not explicitly stated, this appears to be a physician-staffed MICU am- bulance capable of performing a 12-lead ECG bases at Hadassah Hospital in Jerusalem. With the relatively short transit times in most prehospital care systems and the gen- eral inability to perform 12qead ECG, it would seem that the field use of thomolytic agents is both impractical and unnecessary. Continued efforts at educating the public re- garding the symptoms of ischemic cardiac pain so that they can access the emergency medical services system earlier will reap far greater dividends in terms of potential myocardial salvage.]

David K Anderson, MD

acute abdomen, laparotomy in mentally retarded

Acute abdomen in severely mental ly retarded adults Voitk AJ Can J Surg 30:195-196 May 1987

The diagnosis of an acute abdomen is difficult to make in the severely retarded patient secondary to difficulty in ob- taining a medical history and inconclusive results on phys- ical examination. This dilemma was examined by retro- spective review of 25 patients who underwent emergency laparotomy from a chronic care facility housing the men- tally retarded between 1979 and 1983. These 25 patients ac- counted for 29 admissions. One patient died en route to the operating room. Of the remaining 28 laparotomies, three (l I%) were classified as negative (no acute condition found at laparotomy), t5% (54%) as appropriate (acute, surgically correctable condition found at laparotomy), and ten (36%) as late (patients who died perioperatively with gangrene or peritonitis). Of the 25 patients, four I14%) died. Pica Ide- prayed appetite) was documented in 14 of the 29 admissions (48%) and accounted for three (75%) of the deaths. It was concluded that the severely mentally retarded are prone to serious abdominal processes and poor outcome due to diffi- culty in assessment and to the high incidence of pica.

Greg Bennett, MD

thrombotic coronary occlusion, thrombolytic therapy

Thrombolysis in myocardial infarction (TIMI) trial, phase h A comparison between IV t issue plasminogen act ivator and IV streptokinase Chesebro JH, Knatterud G, Roberts R, et al Circulation 76:142-154 Jul 1987

This randomized, double-blind trial compared the throm- bolytic efficacy of IV streptokinase and recombinant tissue plasminogen activator (rt-PA) in the setting of acute trans- mural myocardia l infarct ion with p re t rea tment anglo- graphic proof of occlusion in the infarct-related artery in a total of 290 patients. Patients participating in the trial had chest pain thought to be due to myocardial ischemia lasting from 30 minutes to seven hours and at least 0.1 mV (ST)

154/1305 Annals of Emergency Medicine 16:11 November 1987