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We present the case of a 69 year-old gentleman with non-healing ulcers of the bilateral medial malleoli as a result of graft-versus-host disease (GvHD). The patient discussed was diagnosed with stage IV mantle cell lymphoma. Over the course of 4 years the patient was treated with autologous stem cell transplant, later reduced-intensity allogeneic stem cell transplant, and finally donor lymphocyte infusion due to recurrence. Following these therapies, the patient developed extensive GvHD that resulted in bilateral non-healing ulcers of the medial malleoli. The patient was seen in the wound care center, and his ulcers were treated with standard care that included off-loading, minor outpatient debridement, macrovascular assessment, and local moist wound healing. Despite this care, the ulcers failed to heal over a 6 month period. The patient underwent adjunctive hyperbaric oxygen therapy (HBO). He healed both ulcers within a month of completing HBO. It is our goal to discuss the pathophysiologic mechanism of non-healing wounds in the setting of GvHD and discuss the potential role of HBO in their treatment.

This clinical policy focuses on critical issues in the evaluation and management of patients with acute myocardial infarction or unstable angina. A MEDLINE search for articles published between January 1993 and December 1998 was performed using combinations of the key words chest pain, acute myocardial infarction, unstable angina, thrombolytics, primary angioplasty, 12-lead ECG, ST-segment monitoring, cardiac serum markers, and chest pain centers. Subcommittee members and expert peer reviewers also supplied articles with direct bearing on the policy. This policy focuses on 5 areas of current interest and/or controversy: (1) ECG eligibility criteria for fibrinolytic therapy, (2) role of primary angioplasty in patients with acute myocardial infarction, (3) use of serum markers to diagnose acute myocardial infarction, (4) serial 12-lead ECGs during the initial evaluation, and (5) chest pain evaluation units. Recommendations for patient management are provided for each of these 5 topics based on strength of evidence (Standards, Guidelines, Options). Standards represent patient management principles that reflect a high degree of clinical certainty; Guidelines represent patient management principles that reflect moderate clinical certainty; and Options represent other patient management strategies based on preliminary, inconclusive, or conflicting evidence, or based on panel consensus. This guideline is intended for physicians working in hospital-based emergency departments or chest pain evaluation units. [American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting with suspected acute myocardial infarction or unstable angina. Ann Emerg Med. May 2000;35:521-544.].

A rare complication of gastric decontamination occurred in a young woman undergoing treatment for tricyclic ingestion. After orogastric intubation and lavage, she developed an acute abdomen and underwent laparotomy. Charcoal was discovered throughout the peritoneum, but concurrent and subsequent efforts failed to localize a specific perforation site. Her hospital course was protracted and complicated by tenacious peritoneal charcoal deposition, persistent peritonitis, and adhesion and abscess formation. She underwent both percutaneous and open abscess drainage, oophorectomy, and small-bowel resection. She required total parenteral nutrition in addition to feeding jejunostomy. This present case constitutes the first report of the clinical consequences of charcoal peritoneum. Outright viscus perforation should be considered among potential complications of orogastric intubation and lavage in the poisoned patient. Methods to minimize risks of its occurrence are suggested.

The evolving relationship between emergency and palliative medicine is expected to benefit patients of each. Two collaborative care encounters involving home hospice patients are discussed. Portable bedside ultrasound was performed in the home to diagnose ascites and to guide palliative paracentesis. Specific interventions and outcomes are reported. The interface of emergency and palliative care and the use of paracentesis in cancer palliation are briefly reviewed. It is concluded that home-performed ultrasound and ultrasound-guided procedures are promising palliative modalities for care at the end of life.

Standard TAC (0.5% tetracaine, 0.05% epinephrine, and 11.8% cocaine) solution is finding increased use as a topical anesthetic for lacerations. The extent of systemic absorption of TAC components and their resultant physiologic effects are unclear. Absorption of cocaine or tetracaine may result in serious toxicity. The investigators hypothesized that there are no measurable plasma cocaine or tetracaine levels after application of TAC in a swine laceration model. After an overnight fast 10 domestic swine underwent tracheostomy, mechanical ventilation, femoral venous, and arterial cannulation. Maintenance anesthesia with intermittent thiopental and pancuronium was provided to maintain stage III anesthesia. Heart rate (HR), arterial pressure (BP), plasma cocaine, and tetracaine levels were measured at intervals for 180 minutes. Five milliters of TAC was applied for 15 minutes to a standardized facial laceration in experimental swine (n = 5). Randomly labeled plasma samples were placed in vials containing 2% sodium fluoride and 1% potassium oxalate, immediately refrigerated, and analyzed for cocaine and tetracaine using gas chromatography and mass spectroscopy. Significant changes in HR and mean BP, compared with baseline values, were analyzed using Dunnett's multiple range test. Plasma cocaine levels were measurable in all experimental swine after 10 minutes, while no tetracaine was detectable. No significant differences in HR or BP changes were observed between experimental and control subjects. Application of standard TAC solution results in measurable plasma cocaine levels, but not tetracaine. Further studies into anesthetic formulation, as well as timing and technique of application, are required before consensus on optimal emergency departmental use of topical anesthesia can be achieved.

Background: As emergency physicians perform bedside ultrasound with greater frequency, greater numbers of incidental and potentially unfamiliar sonographic findings will be encountered. Objectives: Illustrate, discuss, and briefly review literature regarding one such finding and diagnosis in right upper quadrant sonography. Case Report: A middle-aged woman was evaluated in the Emergency Department for abdominal pain. Limited bedside sonography of the gallbladder revealed mural thickening and comet-tailing. A diagnosis of adenomyomatosis was made. Conclusion: Gallbladder adenomyomatosis can produce ultrasound findings similar to those of more serious and emergent gallbladder diseases. Cognizance of the sonographic details and typical clinical characteristics will allow the emergency physician to appropriately assess and disposition patients with this condition.

Jena and colleagues confirm what most have long suspected—expensive medicine is less risky medicine.1 Greater expenditure correlates with reduced risk of subsequent medical malpractice claims. …

Use of new technology makes possible the outpatient management of conditions previously requiring inpatient treatment. With increased use of such modalities comes a greater chance that the emergency physician will encounter patients with device-related complications. We report a case of such a complication, a tension pneumothorax presenting to the emergency department following misguided manipulation of a modified Heimlich chest drainage system. It is recommended that physicians opting to utilize such out-patient technology refrain from improvised modifications that may be unfamiliar to subsequent providers.

Reported is the case of a 30-year-old male motorcycle accident victim who was found on plain cervical-spine radiography to have prevertebral soft-tissue swelling. Although subsequent computed tomography demonstrated no cervical-spine fracture, it did reveal a fracture of one occipital condyle. The mechanism, diagnosis, and treatment of occipital condyle fractures are reviewed, as is the ligamentous and fascial anatomy of the cervicocranium. Dissection of fracture hematoma inferiorly along vertically oriented tissue planes is hypothesized as the pathogenesis of our patient's retropharyngeal hematoma. In addition to being a sign of potential cervical-spine injury, post-traumatic prevertebral soft-tissue swelling may also indicate occipital condyle fracture. To avoid overlooking such fractures, computed tomography undertaken to investigate upper cervical-spine prevertebral soft-tissue swelling should always include slices up to the level of the basal skull so as to visualize the condyles.

[American College of Emergency Physicians: Clinical policy for procedural sedation and analgesia in the emergency department. Ann Emerg Med May 1998;31:663-677.].

To the Editor. —In their study of the influence of patient ethnicity on emergency department administration of analgesia, Todd et al 1 examined the potential influence of 17 other predictor variables (Table 2). Included among these were patient insurance status, occupation, and arrival time, as well as the ethnicity and gender of the treating physician. Conspicuous by its absence from the variables examined, however, is perhaps the single most important determinant of whether an individual patient in the emergency department ought to receive analgesia: his or her level of pain and distress as gauged by health providers. This would have been described in physicians' and nurses' notes and could have been reported and used to shed light on those questions of "cultural influences on the expression of pain" appropriately raised by the authors in the concluding paragraphs of the article. Is it the case that those study patients who received

Study objectives: To measure plasma cocaine and tetracaine levels in children after standardized application of a solution of tetracaine 0.5%, epinephrine 0.05%, and cocaine 11.8% (TAC) to lacerations requiring suture repair. Design: Nonrandomized, controlled trial over a five-month period. Setting: University hospital emergency department. Type of participants: Stable children less than 16 years of age with uncomplicated lacerations. Measurements and main results: Blood was obtained at either 15 or 20 minutes (early; 32) or 45 or 60 minutes (late; 45) for measurement of plasma cocaine and tetracaine levels. Analysis for cocaine and tetracaine concentrations was performed using gas chromatographymass spectroscopy with a limit of detection for both assays of 0.5 ng/mL. Serum cocaine levels were low but measurable at both times in 75% of children. No tetracaine was measurable. Median cocaine levels were 1 ng/mL (range, 0 to 112 ng/mL) for the early group and 2 ng/mL (range, 0 to 274 ng/mL) for the late group ( P = NS). Only two children had levels of more than 100 ng/mL. No significant correlation between patient or laceration characteristics and cocaine levels was detected. No significant change in heart rate or blood pressure was detected. Children who required additional local anesthesia had nonfacial lacerations and lower cocaine levels than children with facial lacerations. Conclusion: Application of 3 mL of standard TAC solution for 15 minutes results in low but measurable plasma cocaine levels in 75% of children.

To the Editor.— A 20-year-old gravida 1, para 0 woman in her sixth month of an uncomplicated pregnancy presented to the emergency department 1 hour after being awakened by rapid, regular palpitations. There were no associated symptoms. Approximately 1 year previously, she had experienced a similar episode, which terminated spontaneously after 2 minutes and did not compel her to seek medical attention. Further investigation of medical history and review of systems revealed no predisposition to tachyarrhythmia other than her taking oral theophylline and inhaled metaproterenol for asthma. Initial vital signs were as follows: blood pressure, 104/80 mm Hg; pulse rate, 178 beats per minute; respirations, 22/min; and temperature, 37.1°C. With the exception of mild apprehension and a rapid, regular heartbeat and pulse, the results of the physical examination were those of a normal pregnant woman. An intravenous line was started. Cardiac monitoring and an electrocardiogram revealed supraventricular tachycardia at a

The case is reported of a successful Foley catheter extraction of two superimposed coins from the esophagus of an 8-year-old girl. The presence of the second coin was suspected only on review of the lateral cervical radiograph. In a previous report, failure to initially diagnose the presence of an additional coin resulted in an endoscopic failure to clear the esophagus. The technical aspects of Foley extraction are reviewed along with the controversy surrounding the procedure. Series totaling 294 cases document a cumulative success rate of 85% without significant complications. The technique, when performed by airway experts, is concluded to be a viable alternative to endoscopic removal. Lateral films, fluoroscopic extraction, and barium studies in select cases are recommended as safeguards against missing nonobvious foreign bodies of the esophagus.

A case of the penile tourniquet syndrome is reported in a 5-year-old boy. Release of the constructing strands of hair was possible only after topical cocaine achieved adequate local anesthesia. The syndrome is briefly reviewed and emergency care recommendations are made.

The case of a young man in hypertensive emergency following the ingestion of 840 mg of pseudoephedrine is reported. The hypertension, which peaked at 200/160 mm Hg and was associated with severe headache and diaphoresis, responded expeditiously to two initial intravenous doses of labetalol. No rebound was observed following the administration of an additional dose in the intensive care unit, after which an uneventful one-day hospitalization ensued. The toxicity of pseudoephedrine is briefly reviewed along with the pharmacology and use of labetalol. On the basis of previous experimental studies and the present report, labetalol is suggested as a promising agent in the treatment of hyperadrenergic-induced hypertensive emergencies.