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allows freedom of movement for the patient and ease of patient transportation. It avoids the need to monitor IV fluid volume, and eliminates the possibility of inadvertent fluid overload. In addition, it provides easy access to the venous system for patients who require frequent blood sampling, thus avoiding the discomfort of multiple venipunctures. Finally, if the need for continuous infusion subsequently arises, it can easily be given through the existing heparin lock. It was apparent from our data that a large number of IV lines were established in patients who did not really require IV fluids. Although many of these may represent caution on the part of physicians, one must consider the influence of reflex and habituation in such physician behavior. The ready availability of a safe and simple alternative technique for access to the vascular system could serve to usefully alter such behavior. Previous studies have addressed concerns as to whether the heparin lock can reliably maintain patency, and whether there is a higher incidence of complications associated with its use.2s3 They concluded that the heparin lock is as reliable as the TKO line for providing a patent IV route, and that there was no significant difference in their complication rates. The question of whether the amount of heparin used to maintain patency would alter coagulation studies has also been addressed. It was found that a standard solution of 10 USP units of heparin in I mL normal saline reliably maintains patency and does not significantly alter systemic blood clotting factors including clotting time, prothrombin time, and activated partial thromboplastin time.6 More recently it was suggested that an injection of normal saline alone may be effective for maintaining heparin lock injection sites.7.8 This would avoid the possibility of heparin-related drug compatibility problems, and would also reduce both the cost of the flush solution, as well as the time necessary for routine maintenance of the system. In addition to the aforementioned benefits, the heparin lock offers an opportunity for substantial cost reduction to both patients and medical care providers. The hospital cost for intravenous cannulation equipment at our institution is detailed in Table 2. Over our 2-week study period, if heparin locks were ordered instead of fluid lines in all patients considered appropriate candidates, the savings in equipment alone would have been $651. Assuming these 2 weeks represent an average 2-week patient sample, the yearly savings on supplies would be approximately $17,000, a savings of 55%. Obviously these detailed figures are unique to both this study period and our institution. However, it is clear that in reducing the cost of supplies, not to mention costs involved in purchasing, inventory and storage, there is an opportunity for substantial cost reduction universally. The dollar savings to patients are proportionately much greater. Previously reported data comparing patient charges for IV cannulation equipment indicate a charge of $45.20 for a conventional IV D5W infusion, compared with $10.07 for a heparin lock.’ This results in a net decrease of $35.13, or 78% savings per patient. Other published cost-comparison data report a total cost of $14.80 for an IV DSRL infusion, compared with a cost of $2.99 for a heparin lock.’ This represents a difference of $11.81 per patient or an 80% savings. Clearly these numbers will vary geographically as both hosTABLE 2.

Cost of Supplies to Hospital

Angiocatheter (18 g) IV administration tubing IV solutions: Normal saline Dextrose 5% Ringers lactate D5 ‘/z NS Heparin lock adapter Heparin flush solution (10 U)

$0.45 1.14 0.60 0.55 0.74 0.71 0.45 0.08

pital costs and patient charges differ. At our medical center patients are not charged for specific medical supplies; however, it is easy to realize the potential for enormous reduction in charges at most hospitals where this does occur. In summary, the heparin lock has been demonstrated to be a safe, effective and reliable method for maintaining access to the venous system. It affords the advantages of enhanced patient comfort, increased freedom during transportation, minimal monitoring requirements, avoidance of inadvertent fluid administration and major cost reduction. It is therefore our recommendation that heparin locks replace IV fluid lines whenever appropriate in the emergency department . CLAUDIA R. GOLD, MD JOSEPHE. MORALES,MD LAC-USC Medical Center Los Angeles. California

REFERENCES 1. Schwarzman P, Rottman S: Prehospital use of heparin locks: A cost-effective method for intravenous access. Am J Emerg tvled 1987;5:475-477 2. Hanson R: Heparin-lock or keep-open I.V.? Am J Nurs 1976;76:1102-1103 3. Hanson R: A Comparison of the rate of complications with heoarin-lock and keeo-ooen I.V.‘s. Comm Nurs Res 1977:8: . . 1S&200 4. Levitt D: Use of the heparin lock on an outpatient basis. Cancer Nurs 1981;4:115-119 5. Basil W: The use of heparin locks (PRN Adapters) vs. intravenous therapy in outpatient surgery. Insight 1988;13:13, 15 6. Hanson R, Grant A, Majors K: Heparin-lock maintenance with ten units of sodium heparin in one milliliter of normal saline solution. Surg Gynecol Obstet 1976;142:373-6 7. Lombardi T, Gunderson B, Zammet L, et al: Efficacy of 0.9% sodium chloride injection with or without heparin sodium for maintaining patency of intravenous catheters in children. Clin Pharm 1988;7:832-836 8. Epperson E: Efficacy of 0.9% sodium chloride injection with and without heparin for maintaining indwelling intermittent injection sites. Clin Pharm 1984;3:626-629

AN UNUSUAL DIAGNOSIS FOR ACUTE RIGHT-SIDED GROIN PAIN IN A 39-YEAR-OLD WOMAN To the Edifor;-Pelvic pain is a common presentation to the emergency department. When pelvic pain is associated with a pelvic mass, the emergency physician should take into consideration a specific differential diagnosis. Although extraskeletal Ewing’s sarcoma is an exceedingly rare cause of pelvic mass and pain, the possibility of a tumor must be considered in this setting. A 39-year-old gravida 1 para 1 Hispanic woman presented to the emergency department at 4 AM complaining of acute right-sided groin pain radiating to her knee. She stated that the pain had awakened her from sleep. She further denied any trauma, injury, previous episodes of similar pain as well as history of low back pain. She denied dysuria, urgency, frequency, vaginal discharge, hematuria, or anorexia. No recent history of fever, chills, nausea, vomiting, or diarrhea was elicited. Her last menstrual period was 6 days before the emergency department visit and was described as normal. Past medical history was significant for hypertension for which she was prescribed atenolol. Past surgical history was significant for an appendectomy as a child. On examination, the patient was noted to be resting comfortably and appeared to be in no acute distress. Blood pressure was 164/110 mm Hg, pulse rate, 68 be.ats/min; respiration rate, 18 breaths/min; oral temperature 36.5”C. Breath sounds were clear. Heart rate and rhythm were regular with no murmurs, rubs, or gallops. The abdomen was noted to be obese, soft and nontender to palpation. No

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guarding or rebound tenderness was evident. Normal bowel sounds were auscultated in ah quadrants, Examination of the right groin showed no palpable adenopathy or hernias. The patient had full and normal range of motion of her right hip. Neurovascular examination of the right lower extremity was completely normal. A pelvic examination showed normal external genitalia. The cervix was long and the OS was parous and closed. There was no cervical motion tenderness. The right adnexa was palpated and was felt to have a 5 by 5 centimeter mass that was mildly tender to touch. The left adnexa was normal. Laboratory data showed hemoglobin, 12.8 g/dL; hematocrit, 38.9%; white blood cells, 13,2OO/pL (86% neutrophils, 3% bands, 8% lymphocytes, and 3% monocytes); platelets, 340,0OO/t.~L;sodium, 134 mEq/L(mmol/L); potassium, 3.7 mEq/L(mmol/L); chloride, 104 mEq/L(mmol/L); bicarbonate, 19 mEq/L(mmol/L); blood urea nitrogen, 7 mg/dL; glucose, 153 mg/dL; creatinine, 0.9 mg/dL; amylase, 39 IU/L; and lipase, 16 IU/L. A serum pregnancy test performed was negative. Urinalysis revealed a pH of 5, and specific gravity of 1.009 with no ketones, glucose, protein, bacteria, or occult blood. A pelvic ultrasound obtained indicated a right adnexal mass of about 3 by 6 centimeters with solid echogenic characteristics. Subsequently, the patient was admitted to the hospital to undergo a diagnostic laparoscopy and possible laparotomy. During the laparoscopy the patient was found to have what appeared to be a right broad ligament mass, thought to be either fibroid or a Wolffian duct cyst. An intravenous pyelogram further revealed an extrinsic mass effect on the right lateral aspect of the bladder by a soft tissue density. The flow through the right ureter did not appear to be impaired by the mass. A computed tomography (CT) scan of the pelvis failed to elucidate the nature of the pelvic mass. A CT of the chest was unremarkable. Three days after the laparoscopy, the patient developed acute respiratory distress (respiratory rate, 35 breaths/min) with an evident left pleural effusion. Room air arterial blood gases revealed a pH of 7.33, Pco, of 29.5 mm Hg, PO, of 57 mm Hg with an 87% saturation. A ventilation-perfusion scan showed a low probability of a pulmonary embolus. At this time the patient was noted to have abdominal distension with generalized guarding and rebound tenderness. The clinical impression was that of an acute abdomen secondary to a necrosing broad ligament fibroid or a ruptured Wolfftan duct cyst and the patient was taken back to the operating room for an emergent laparotomy. Intraoperatively, a rent in the anterior dome of the bladder was discovered with approximately 1000 mL of urine in the peritoneal cavity. The bladder defect was repaired and was thought to be iat-

FIGURE 1. Characteristic microscopic picture consisting of solidly packed round or ovoid tumor cells having an ill-defined cytoplasm and pale staining nuclei.

TABLE1. Reported Sites of Extra-Skeletal Ewing’s Sarcoma Site

Reference

Neck Broad ligament Seminal vesicle Scalp Digits of hand and feet Hip Scrotum

2 3 4 5 697 7 6

rogenic secondary to the diagnostic laparoscopy. On further evahration of the right pelvic mass it became evident that the mass was completely free of the broad ligament and seemed to extend from the obturator fossa in the area of the right ureter and obturator nerve. Neurosurgical and gynecological consultations were obtained intraoperatively. It was believed that definitive surgery should be deferred until after the patient had recovered from her pleural effusion and peritoneal contamination. The patient was subsequently discharged with an indwelling Foley catheter. Approximately 3 months later, the patient was admitted for elective right retroperitoneal dissection with removal of the obturator mass. The mass was noted to be arising from the obturator fossa and the pubic ramus up to the posterior aspect of the rectus fascia. There was also one large pelvic lymph node that was dissected and whose frozen section was negative for a malignancy. Frozen section of the tumor mass was initially reported as undifferentiated carcinoma, probable lymphoma (Figure 1). However further evaluation by permanent sections, PAS stains, and electron microscopy evaluation revealed features consistent with a Ewing’s sarcoma. The cell marker studies were negative for a lymphoma. Therefore, the final diagnosis was extraskeletal Ewing’s sarcoma. A bone scan and chest CT done postoperatively were negative for any metastases. Extraskeletal Ewing’s sarcoma was first described by Tefft et al in 1969 when they reported their experience with four paravertebral round cell tumors that arose from soft tissues and that were morphologically similar to Ewing’s sarcoma of the bone.’ In 1975 it was further characterized by Angervall and Enzinger who reviewed 39 soft tissue tumors sent to the Armed Forces Institute of Pathology during a period ranging from 1957 to 1969 that were coded under a number of different diagnoses. They reviewed the history, histology, radiographic findings and treatment of these 39 patients and noted a uniform histologic picture indistinguishable from that of Ewing’s sarcoma of bone. It does, however, differ from Ewing’s sarcoma in three main clinical features: (1) it does not show the distinct male predilection shown in bony Ewing’s sarcoma, being equally distributed among both sexes; (2) patients with extraskeletal Ewing’s sarcoma are approximately 20 years old, which is 10 years older than those with Ewing’s sarcoma of bone; (3) extraskeletal Ewing’s sarcoma differs in its anatomic predilection. Ewing’s sarcoma most commonly involves the lower extremities, while extraskeletal Ewing’s sarcoma occurs predominately in the paravertebral region, with the lower extremity and chest wall being the next in frequency.* Cases of extraskeletal Ewing’s sarcoma arising in other parts of the body have also been reported (Table 1). A review of the literature by Stuart-Harris et al in 1986 found only 136 cases reported in the literature world-wide. The cells of origin of this rare tumor have been the subject of great debate over the years. Some believe that it is merely a soft tissue expression of an osseous Ewing’s sarcoma and others closely associate it with rhabdomyosarcomas.’ Pathologically these extraskeletal tumors, can resemble malignant lymphomas, neuroblastoma, hemangiopericytoma, and other undifferentiated small cell carcinomas.6*‘D’4 Extraskeletal Ewing’s sarcoma has been shown to metastasize

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early in its course, with the two most frequent sites being the lung and the skeleton2 The most widely recommended treatment at this time appears to be aggressive surgical excision combined with chemotherapy and/or local radiation. Kinsella and associates report treating 11 patients with surgical excision and high-dose radiation combined with chemotherapy (vincristine, dactinomycin, and cyclophosphamide). He reports that 64% of the patients with no evidence of distant metastasis remained disease free with follow-up from 3 to 7 years.15 Many challenges are presented to the emergency physician by a female patient presenting with lower abdominal and pelvic pain. Although extraskeletal Ewing’s sarcoma is a rare diagnosis for a patient with pelvic pain, pain secondary to a tumor mass must be considered in a differential diagnosis that should include, among other things, torsion of either a fallopian tube and/or ovary, ovarian cysts, endometriosis, adenomyosis, leiomyomas, appendicitis, pyelonephritis, and of course, ectopic pregnancy. Pain from pelvic organs is known to radiate to the lower abdomen, lower back, perineum and thighs. It was believed that this patient’s groin pain radiating to her knee was secondary to the tumor mass’s impinging on the obturator nerve within the obturator fossa. Thorough history and physical examination are essential for early detection and diagnosis of such soft tissue tumors as extraskeletal Ewing’s sarcoma. It is this early diagnosis and subsequent definitive treatment that allows for a better prognosis. NEIL JASANI, MD ROBERTE. O’CONNOR, MD JAMESK. BOUZOLJKIS, MD

Medical Center of Delaware Wilmington, DE

REFERENCES 1. Gustafson R, Maragos N, Reiman H: Extraskeletal Ewing’s sarcoma occurring as a mass in the neck. Otolaryngol Head Neck Surg 1982;90:491-493 2. Angervall L, Enzinger F: Extraskeletal neoplasm resembling Ewing’s sarcoma. Cancer 1975;36:240-251 3. Longway S, Lind H, Haghighi P: Extraskeletal Ewing’s sarcoma arising in the broad ligament. Arch Pathol Lab Med 1986;110:1058-1061 4. Johansen T, Huseby A, Steuwig J: Extraskeletal Ewing’s sarcoma contiguous with the seminal vesicle. Stand J Urol Nephrol 1988;22:237-239 5. Suster S, Ronnen M, Huszar M: Extraskeletal Ewing’s sarcoma of the scalp. J Pediat Dermatol 1988;5:123-126 8. Peters M, Reiman H, Muller S: Cutaneous extraskeletal Ewina’s sarcoma. Cutaneous Pathol 1985:12:476485 7. Huntrakoon M: Extraskeletal Ewing’ssarcoma. Ultrastructural Pathology 1987;11:41 l-419 8. Stuart-Harris R, Wills E, Langlands A, et al: Extraskeletal Ewing’s sarcoma: A clinical, morphological, and ultrastructural analysis of five cases with a review of literature. Eur J Cancer Clin Oncol 1986;22:393-400 9. Brehaut L, Anderson L, Taylor D: Extraskeletal Ewing’s sarcoma: Diagnosis of a case by fine needle aspiration cytology. Acta Cytologica 1986;30:883-687 10. Berthold F, Knacht J, Lampert F, et al: Ultrastructural, biochemical and cell-culture studies of a presumed extraskeletal Ewing’s sarcoma with specific reference to differential diagnosis from neuroblastoma. J Cancer Res Clin Oncol 1982;103:293-304 11. Wigger H, Salazer G, Blanc W: Extraskeletal Ewing’s sarcoma-An ultrastructural study. Arch Pathol Lab Mad 1977; 101:446-449 12. Hashimoto H, Tsuneyoshi M, Daimani Y, et al: Extraskeletal Ewing’s sarcoma. A clinico-pathologic and electron microscopic analysis of eight cases. Acta Pathol Jpn 1985;35:1087-1098 13. Gillespie J, Roth L, Wills E, et al: Extraskeletal Ewing’s sarcoma. Histological and ultrastructural observations in three cases. Am J Surg Pathol 1979;3:99-108

14. Enjoji M, Hashimoto H: Diagnosis of soft tissue sarcomas. Path Res Pratt 1984;178:215-226 15. Kinsella J, Triche J, Dickman P, et al: Extraskeletal Ewing’s sarcoma: Results of combined modality treatment. J Clin Oncol 1983;1:489-495

IMMOBlLlZATlON AND EXTRICATION OF TRAUMA PATIENTS BY UNTRAINED PERSONNEL To the Editor:-Trauma is a multibillion dollar health care problem in the United States, accounting for over 100,000 deaths annually.‘,’ The leading cause of death among persons 1 to 37 years of age, and the fourth leading cause of death at all ages, an estimated one in four Americans has an accident each year.3*4 Acute treatment of the injured patient is usually initiated at the accident scene and continued through hospitalization. Evaluation, resuscitation, immobilization, extrication and transportation are principal prehospital objectives, with continued resuscitation and physiologic stabilization the goals of hospital care.5 Recent emphasis and improvements in prehospital immobilization and extrication techniques are credited with greatly reducing morbidity and mortality of the trauma patient. ‘5y Such patients, however, may present to the hospital emergency department (ED) without soliciting assistance from ambulance personnel. not having the benefit of appropriate prehospital care and transportation. The following cases illustrate this problem. A 76-year-old woman slipped and fell, twisting her right ankle. Gross deformity of the ankle was immediately noted. Rather than request an ambulance, her husband transported her to the hospital ED by private automobile. Upon arrival, the patient was unable to exit the vehicle as it was painful for her to bear weight on the injured joint. As no hospital protocols for patient management in such situations existed, the patient was lifted from the car, set into a wheelchair and wheeled into the ED by hospital security guards. untrained in proper extrication techniques. No attempt was made to immobilize or examine the patient’s ankle during these proceedings. Physical and radiographic findings in the ED revealed gross deformity. dislocation and fracture of the right ankle. Neurologic and vascular integrity were intact. The subsequent course of hospitalization was uneventful. A 47-year-old woman was the unrestrained front seat passenger in a car, driven by her husband, which was struck from behind by another automobile. Upon collision, the patient lost all sensory and motor functions in her lower extremities. Complaining of head, neck and low back pain, the patient denied a loss of consciousness. Their car still driveable, her husband declined waiting for paramedics. and sped to the hospital with his wife unmoved. Upon arrival. injuries rendered the patient incapable of exiting the vehicle. ED personnel learned of the situation when approached by a hospital security guard, untrained in proper extrication techniques. He requested assistance in lifting the woman from the car. having tried unsuccessfully to do so himself. The emergency physician immediately realized the danger of the situation and had to discourage two passing police officers. and the security guard, from helping. ED personnel applied a cervical collar to the patient and called fire department paramedics for assistance. Paramedics arrived, and assessed. immobilized, extricated, reassessed and brought the patient into the ED in accordance with accepted paramedic protocols, using a KED and backboard. Radiographs of the chest, pelvis. cervical. lumbosacral and dorsal spine, and CT of the cervical spine (Cl-W. were unremarkable. Fifty milligrams Decadron was administered intravenously and a Foley catheter and nasogastric tube were inserted. The patient was transferred to a tertiary care spinal cord center, where her condition reportedly resolved. These two patients presented to the ED in private automobiles, accompanied by family members. Neither solicited assistance from ambulance personnel, thus neither had the benefit of appropriate prehospital care and transportation.

An unusual diagnosis for acute right-sided groin pain in a 39-year-old woman.

AMERICAN JOURNAL OF EMERGENCY MEDICINE l Volume 9, Number 1 n January 1991 96 allows freedom of movement for the patient and ease of patient transpo...
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