Antidysrhythmics. Emergent.

The emergent treatment of dysrhythmias in the ED continues to evolve. Classic medications such as bretylium and lidocaine are given with newer drugs like amiodarone, ibutilide, and sotalol. Studies in progress will examine their efficacy in the ED. The emergency physician must keep abreast of the growing body of literature.

The extremities and spine.

A variety of pearls, pitfalls, and updates related to the extremities and spine are discussed. Tricks of the trade regarding shoulder dislocations, easily missed fractures, radial head subluxation, and the approach to deep lacerations are discussed. In the pitfall section, potential difficulties in the evaluation of suspected nonaccidental trauma, compartment syndromes, partial cord syndromes, and hip pain in children are discussed. Finally, new information regarding cost-effective evaluation of knee and ankle injuries, as well as advances in ultrasound evaluation of shoulder and extremity injuries, is presented in the clinical updates section.

Injuries resulting from bungee-cord jumping.

A 19-year-old woman sustained a nonfatal hanging injury and a 28-year-old man sustained a unilateral locked facet with resultant quadriplegia as a result of bungee jumping. Injuries due to this sport have not been reported previously.

Blunt chest trauma.

The spectrum of injuries after blunt chest trauma presents a challenging problem to the emergency physician. The clinician must select among a number of diagnostic tests and therapeutic options after the initial history and physical examination has been performed. Nine clinical entities are discussed: sternal fracture, flail chest, pulmonary contusion, tracheobronchial injuries, myocardial contusion, myocardial rupture, aortic disruption, esophageal perforation, and diaphragm rupture. Emphasis is placed on newer diagnostic modalities available for these conditions.

Endotracheal tube whistle: an adjunct to blind nasotracheal intubation.

To perform blind nasotracheal intubation, the physician feels or listens for air movement through the endotracheal tube to facilitate the tube's passage into the trachea. The tube whistle is a device that attaches to the endotracheal tube adapter and produces whistle sounds of different pitches during inspiration and expiration, enhancing the detection of air movement and possibly allowing for easier intubation. This article describes the use of the whistle and presents information collected from a nine-month prospective study of the endotracheal tube whistle.

Cyclic antidepressants, lithium, and neuroleptic agents. Pharmacology and toxicology.

Cyclic antidepressants, lithium, and phenothiazines are frequently prescribed to psychiatric patients. Emergency department physicians must be familiar with these medications, and the pharmacologic and toxicologic characteristics of them are discussed. Cyclic antidepressants are the primary cause of drug-related death in the United States, with sodium bicarbonate recognized as the treatment of choice. Lithium toxicity may be subtle, and treatment is generally supportive in addition to volume replacement with normal saline and hemodialysis for significant intoxications. A neuroleptic overdose is managed primarily with supportive care. Neuroleptic malignant syndrome must be considered in any psychiatric patient presenting to the Emergency Department.

Thiopental-facilitated interview in respiratory Munchausen's syndrome.

We report an unintentional thiopental-facilitated interview in a patient presenting with apparent respiratory failure as a manifestation of Munchausen's syndrome. Unnecessary intubation was avoided and correct diagnosis was made using the thiopental interview. Patients with suspected Munchausen's syndrome represent a difficult dilemma for the emergency physician. Use of the barbiturate-facilitated interview in the emergency department may reveal the diagnosis and prevent unnecessary procedures and hospitalization.

Aspiration following a cave-in.

Reported is a case of massive aspiration of particulate matter after a cave-in. A 14-year-old boy was buried beneath 18 inches of dirt while playing at a construction site. After extrication he was breathing spontaneously and was transported to the emergency department on supplemental oxygen. Physical examination revealed cough, tachypnea, and diminished breath sounds of the right lung field. Chest radiographs showed multiple radiopaque densities filling the right mainstem bronchus and a left-to-right shift of the mediastinum. The patient was treated with bronchodilators followed by postural drainage and percussion. Chest radiographs and physical examination both returned to normal within 24 hours. Reports of massive aspiration of sand are scarce, and have emphasized the need for bronchoscopic removal of particles to restore ventilation. This case was managed with bronchodilators and postural drainage alone, with complete resolution of pulmonary abnormalities.

Diagnosis of ruptured ectopic pregnancy with peritoneal lavage.

A case of ruptured ectopic pregnancy with a nondiagnostic culdocentesis is presented. Diagnosis was made by using open diagnostic peritoneal lavage. The patient underwent laparotomy, left salpingectomy, and cornual resection, and had no postoperative complications. In selected patients with suspected ectopic pregnancy, peritoneal lavage may serve as a helpful diagnostic procedure.