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A case of spontaneous combustion
CORRESPONDENCE
6.8 has a long shelf life, it could be marketed at that pH and obviate the need for hospital personnel to perform this task.
Gregory Meyer, MD Department of Emergency Medicine Pioneer Hospital Artesia, California Philip L Henneman, MD Department of Emergency Medicine Paul Fu, PhD Department of Pathology Harbor- UCLA Medical Center Torrance, California 1. Stewart JH, Cole GW, Klein JA: Neutralized lidocaine with epinephrine for local anesthesia. J Dermatol Surg Oncol 1989;15:1081-1083.
C o n f i r m a t i o n of C e n t r a l Venous C a t h e t e r L o c a t i o n To the Editor: Arterial puncture during attempted placement of a central venous catheter (CVC) is a well-documented complication of this procedure. Identification of the problem is generally based on aspiration of bright red or pulsatile blood when advancing the placement needle. Minimal damage is produced when only this relatively small needle has punctured the arterial wall with removal of the needle, and application of direct pressure to the area is the only treatment required. Significant complications can occur, however, if the arterial puncture is not recognized and a larger 6to 9-F CVC or introducer is placed. To compound this problem, it is not always obvious at the time of the puncture just which vessel has been entered. We report a case of such confusion to highlight a technique to confirm access of the proper vessel. A 62-year-old man presented to the emergency department in a basic life support ambulance with a complaint of increasing lethargy. On arrival it was evident that the patient had agohal respirations with an extremely thready pulse. He was orally intu-
152/219
bated i m m e d i a t e l y and ventilated with 100% oxygen; attempts at vascular access were initiated. His cardiac monitor revealed a sinus tachyeardia of 110 with a palpable blood pressure of 80 m m Hg. The patient was moderately obese, and all attempts at peripheral vascular access were unsuccessful. After five minutes, a right-sided supraclavicular CVC was attempted. A nonpulsatile blood return was obtained easily on the first advancement of the needle. Although not bright red, the blood was much redder than expected and caused us to question the location of the needle. Pulse oximetry was not obtainable on the patient because of his low blood pressure and so we could not compare it with the oxygen saturation of the blood we obtained. Because we intended to introduce a 7-F triple-lumen catheter, we elected to confirm the needle's location prior to the CVC placement. The guide wire was inserted into the needle and the needle removed as per standard Seldinger technique. The wire was fixed in place with gauze and a sterile hemostat clamped on its end to prevent inadvertent embolism of the wire while a portable chest radiograph was obtained. The radiograph demonstrated placement of the wire in the superior vena cava. The hemostat was removed and the CVC was placed without difficulty. The entire process took approximately ten minutes from aspiration of the blood to confirmation of wire placement. Ultimately, it was discovered that the patient's arterial Po 2 was 400 m m Hg. The patient's low tissue perfusion, coupled with the high arterial oxygen content, resulted in the elevated mixed venous oxygen saturation and the arterial appearance of the blood. We have used this approach on a number of patients and find it a reliable method when proper needle location cannot be confirmed clinically. It is our belief that early disc o v e r y of an i n a d v e r t e n t arterial
Annals of Emergency Medicine
puncture when only a small 22- to 18-gauge hole has been placed in the artery is preferable to noticing a colu m n of pulsatile blood in the IV tubing of a recently introduced 9-F catheter.
Alfred Sacchetti, MD, FACEP Our Lady of Lourdes Medical Center Camden, New Jersey Cezar Tapnio, MD Jersey Shore Medical Center Neptune, New Jersey
A C a s e of S p o n t a n e o u s Combustion To the Editor: A 32-year-old man with a history of ethanol abuse made one of many visits to our emergency department for e v a l u a t i o n of a seizure. His clothes were removed, with the exception of his pants, and a cursory physical e x a m i n a t i o n revealed a postictal state. Standard therapy was begun. Forty-five minutes later, the patient developed a tonic-clonic seizure, but after a few seconds he arched his back into a position of opisthotonis and swung his arms through the air, striking his thighs. We were puzzled by the unusual nature of his seizure and stunned when smoke drifted up around his abdomen. We removed his pants and, in the b a c k p o c k e t , f o u n d t w o scorched books of matches interdigitared so that the match heads of one book opposed the striking surface of the other. The seizure activity had apparently rubbed the matchbooks together igniting the matches. Examination of his buttock skin showed only a mild erythema that did not progress. We believe this incident illustrates the importance of completely disrobing a seizure patient undergoing medical evaluation.
Harrison G Weed, MD Department of Emergency Medicine Boston City Hospital
20:2 February1991
6.8 has a long shelf life, it could be marketed at that pH and obviate the need for hospital personnel to perform this task.
Gregory Meyer, MD Department of Emergency Medicine Pioneer Hospital Artesia, California Philip L Henneman, MD Department of Emergency Medicine Paul Fu, PhD Department of Pathology Harbor- UCLA Medical Center Torrance, California 1. Stewart JH, Cole GW, Klein JA: Neutralized lidocaine with epinephrine for local anesthesia. J Dermatol Surg Oncol 1989;15:1081-1083.
C o n f i r m a t i o n of C e n t r a l Venous C a t h e t e r L o c a t i o n To the Editor: Arterial puncture during attempted placement of a central venous catheter (CVC) is a well-documented complication of this procedure. Identification of the problem is generally based on aspiration of bright red or pulsatile blood when advancing the placement needle. Minimal damage is produced when only this relatively small needle has punctured the arterial wall with removal of the needle, and application of direct pressure to the area is the only treatment required. Significant complications can occur, however, if the arterial puncture is not recognized and a larger 6to 9-F CVC or introducer is placed. To compound this problem, it is not always obvious at the time of the puncture just which vessel has been entered. We report a case of such confusion to highlight a technique to confirm access of the proper vessel. A 62-year-old man presented to the emergency department in a basic life support ambulance with a complaint of increasing lethargy. On arrival it was evident that the patient had agohal respirations with an extremely thready pulse. He was orally intu-
152/219
bated i m m e d i a t e l y and ventilated with 100% oxygen; attempts at vascular access were initiated. His cardiac monitor revealed a sinus tachyeardia of 110 with a palpable blood pressure of 80 m m Hg. The patient was moderately obese, and all attempts at peripheral vascular access were unsuccessful. After five minutes, a right-sided supraclavicular CVC was attempted. A nonpulsatile blood return was obtained easily on the first advancement of the needle. Although not bright red, the blood was much redder than expected and caused us to question the location of the needle. Pulse oximetry was not obtainable on the patient because of his low blood pressure and so we could not compare it with the oxygen saturation of the blood we obtained. Because we intended to introduce a 7-F triple-lumen catheter, we elected to confirm the needle's location prior to the CVC placement. The guide wire was inserted into the needle and the needle removed as per standard Seldinger technique. The wire was fixed in place with gauze and a sterile hemostat clamped on its end to prevent inadvertent embolism of the wire while a portable chest radiograph was obtained. The radiograph demonstrated placement of the wire in the superior vena cava. The hemostat was removed and the CVC was placed without difficulty. The entire process took approximately ten minutes from aspiration of the blood to confirmation of wire placement. Ultimately, it was discovered that the patient's arterial Po 2 was 400 m m Hg. The patient's low tissue perfusion, coupled with the high arterial oxygen content, resulted in the elevated mixed venous oxygen saturation and the arterial appearance of the blood. We have used this approach on a number of patients and find it a reliable method when proper needle location cannot be confirmed clinically. It is our belief that early disc o v e r y of an i n a d v e r t e n t arterial
Annals of Emergency Medicine
puncture when only a small 22- to 18-gauge hole has been placed in the artery is preferable to noticing a colu m n of pulsatile blood in the IV tubing of a recently introduced 9-F catheter.
Alfred Sacchetti, MD, FACEP Our Lady of Lourdes Medical Center Camden, New Jersey Cezar Tapnio, MD Jersey Shore Medical Center Neptune, New Jersey
A C a s e of S p o n t a n e o u s Combustion To the Editor: A 32-year-old man with a history of ethanol abuse made one of many visits to our emergency department for e v a l u a t i o n of a seizure. His clothes were removed, with the exception of his pants, and a cursory physical e x a m i n a t i o n revealed a postictal state. Standard therapy was begun. Forty-five minutes later, the patient developed a tonic-clonic seizure, but after a few seconds he arched his back into a position of opisthotonis and swung his arms through the air, striking his thighs. We were puzzled by the unusual nature of his seizure and stunned when smoke drifted up around his abdomen. We removed his pants and, in the b a c k p o c k e t , f o u n d t w o scorched books of matches interdigitared so that the match heads of one book opposed the striking surface of the other. The seizure activity had apparently rubbed the matchbooks together igniting the matches. Examination of his buttock skin showed only a mild erythema that did not progress. We believe this incident illustrates the importance of completely disrobing a seizure patient undergoing medical evaluation.
Harrison G Weed, MD Department of Emergency Medicine Boston City Hospital
20:2 February1991