Pediatric myocardial infarction after racemic epinephrine administration.

Myocardial infarction is a previously unreported complication of treatment with racemic epinephrine that is used commonly in the emergency department for severe respiratory distress in bronchiolitis or croup syndrome. We describe a pediatric patient who presented with the croup syndrome and severe respiratory distress that required multiple doses of nebulized racemic epinephrine in the emergency department. The patient developed ventricular tachycardia and mild chest discomfort during one treatment, which resolved spontaneously on discontinuation of the nebulization. Persistently abnormal electrocardiograms and elevated creatine phosphokinase MB isoenzyme (CPK-MB) levels suggested a myocardial infarction had occurred. Subsequent echocardiography, cardiac catheterization, and angiography revealed an anatomically normal heart with normal coronary circulation; however, a stress nuclear study showed a small myocardial infarct. The significance of this previously unreported complication of racemic epinephrine is discussed, along with recommendations for proper use in the emergency department.

Arrow wound management in Papua New Guinea.

Arrow injuries sustained during tribal fighting are a common reason for admission to the hospitals of Southern Highlands Province in Papua New Guinea (P.N.G.). The authors, Canadian and American family physicians with an aggregate 12 years' general practice experience in the P.N.G. Highlands, present the findings of a 1-year retrospective study of arrow wound victims admitted to two hospitals. Arrow wound injuries are a consequence of a variety of sociocultural factors that continue to result in their high incidence despite many decades of contact with the outside world. We present the details of the presentation and management of 90 cases including a preponderence of soft-tissue as well as intracranial, thoracic, and abdominal injuries. Illustrative case histories of the more challenging or unusual cases provide insight into the unique opportunity afforded the general practitioner/surgeon in managing a type of injury which has become virtually extinct in North American practice over the last 200 years.