Massive strychnine intoxication: serial blood levels in a fatal case.

A fatal case of strychnine intoxication is reported. The patient expired despite early aggressive management and prevention of metabolic complications. Serial blood levels are reported. In contrast to a previous report describing first order elimination kinetics, our data suggest that strychnine follows Michaelis-Menton elimination kinetics. The case illustrates the rapid, dramatic course of severe strychnine ingestions. A review of the toxicokinetics, mechanism of action and treatment of strychnine intoxication follows.

Analysis of base station morphine orders: assessment of supervising physician consistency.

Paramedic contact with a base station should gemerate consistent recommendations reflecting a consensus of base station physician care. In our urban EMS system, paramedics must contact a single base station to provide morphine sulfate (MS) for a patient with chest pain. We performed a retrospective cohort analysis of all prehospital MS requests for chest pain to determine the consistency of the circumstances for which the paramedic team was refused MS. These MS requests represented 123 of the 1,715 (7%) on-line physician consultations during the 6-month study. Only 15 of the 123 (12%) MS requests were refused. Neither the mean patient age, sex distribution, or presenting vital signs correlated with MS refusal. A maximum estimate of transport time to the hospital of less than or equal to 5 minutes was noted for 7 of 15 (47%) medication refusals compared to only 11 of 96 (11%) approvals with documented estimated transport times (P less than or equal to 0.005). A simultaneous request for nitroglycerin (NTG) was noted for 6 of the 15 (40%) medication refusals and 15 of the 108 (14%) approvals (P less than 0.05). We found refusal of MS administration to be uncommon. Supervising physicians tended to refuse MS when the transport time was short and when NTG was requested for concomitant administration. We also noted physician inconsistencies in refusal scenarios. These findings can guide physician consensus development to avoid sending mixed messages to paramedics.

Functional airway obstruction presenting as stridor: a case report and literature review.

We report the case of a young man who presented to 3 emergency departments with apparent upper airway obstruction and was intubated each time before being diagnosed with paradoxical vocal cord motion. His previous discharge diagnoses were laryngeal edema secondary to anaphylaxis, even though he had no other objective findings of IgE-mediated disease. Flexible fiberoptic laryngoscopy demonstrated tight apposition of the vocal cords during inspiration while symptomatic, but normal movement when asymptomatic. Psychiatric evaluation revealed severe posttraumatic stress disorder. Of the approximately 41 reported cases of functional airway obstruction in the medical literature, only two have been adult males and none have been associated with posttraumatic stress disorder. The current literature is reviewed, and an approach to evaluation and management of such patients is provided.

Fractures of the hip in children: a review of forty cases.

In a series of children's hip fracture seen over a 27-year-period, there were 39 patients (40 fractures) with a mean age of 8.9 years followed for an average 7 years. After an initial period of traction, 50% of the fractures were treated in a spica cast, 40% by internal fixation, and 10% by bed rest. Overall, there were 65% good results, 25% fair and 10% poor. All nondisplaced fractures were found to have a good result, while only one-half of displaced fractures were considered a good result. The complications were premature epiphyseal closure 23%, avascular necrosis 17%, coxa vara 12.5%, and nonunion 7.5%. Intertrochanteric fractures should be treated in traction followed by a spica cast. All other displaced fractures should be reduced and internally fixed. The hip joint capsule is opened in those transepiphyseal and transcervical fractures for which closed reduction has been unsuccessful. Spica casts are used to protect the fixation until roentgenograms show healing. Nondisplaced fractures may be treated non-operatively but must be watched closely for varus angulation. Threaded pins or lag screws are the devices of choice except in transepiphyseal fractures where smooth pins can be used to cross the physis. Nail-plates should be avoided.