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Accidental hypothermia in the subtropics
CORRESPONDENCE
357
completely inadequate. Undergraduate medical school curricula devote, on average, less than 3% 2 of teaching to this subject, while musculoskeletal complaints represent 15% to 25% of visits. 3 A recent study published by Freedman 1 tested new medical school graduates with a standardized questionnaire of basic musculoskeletal knowledge. An impressive 82% of the new graduates failed this basic knowledge test. Despite an imperative for education, an organized approach to these problems has been lacking. Emergency medicine, pediatric, and family practice residents often rotate onto inpatient orthopedic services, but directed study of outpatient musculoskeletal problems ls notoriously lacking. Students and residents on these services are too often taught surgical techniques and inpatient care instead Of functional issues and the clinical examination. In the emergency department, this translates into an abdication of authority, where the attitude becomes "splint the patient and refer them on to the specialist." Too little time is devoted to the examination and education of these patients, partially because of time constraints, and partially because of out low level of comfort in examining and educating them. In this era of managed care, the primary care practitioner is increasingly going to be called on to treat the vast majority of nonoperative musculoskeletal injuries, and the specialty of emergency medicine has the opportunity to lead the way. Primary care sports medicine is a relatively new subspeciality of emergency medicine. One or two postgraduate fellowship years are devoted to the nonsurgical management of musculoskeletal injuries. A recent report by Veenema4 outlined the successful integration of primary care sports medicine into an emergency medicine training program. The addition of an expert on musculoskeletal injury to an academic faculty, similar to the addition of a toxicologist, an emergency medical services director, or a pediatric emergency medicine specialist, enhances the care delivered in the department, serves as a focal point for student and resident education, and has potential for revenue enhancement. The integration of such a program can help emergency medicine as a field take ownership of educating medical students, off-service residents, and our own trainees in sound musculoskeletal care, and the thought processes and skills that are essential in its practice.
may develop in persons exposed to a modestly cool climate for prolonged period. The condition has even been reported in tropical climates where average daily temperatures do not fall below 16°C. 2 We present a rare case of accidental hypothermia in the subtropics. An 86-year-old man was found lying unconscious in the padi field at 8:00 AM on May 4, 1998. The patient had gone out to pick wood 2 days earlier and did not return. He was found partially immersed in the half-foot flooded padi field after 1-day search. He was dressed light-weight clothing, He was unresponsive and with undetectable vital signs. The highest and lowest outdoor temperarare during those 2 days was reporting 33.8°C and 23.1°C respectively. He was given oxygen via a facial mask and was sent by ambulance to the emergency department at 8:30 AM. Physical examination on arrival revealed a skinny, suntanned man in his 80s. Vital signs were: temperature 29.3°C by tympanic thermometer; blood pressure 75/49 mm Hg; irregular pulse 68 beats/rain; and a barely detectable respiration. His eyes opened to pain stimulation, no verbal response, and could localized pain (Glasgow Coma Scale score of 8). Pupils were 2.5 rmn in size with sluggish light reflex. There was no evidence of trauma noted after full exposure. His breathing sounds revealed diffuse expiratory wheeze and coarse crackles over right lung and left lower lobes. Irregular heart beat was noted. Extremities were slightly rigid on passive flexion and extension, and his skin was cold, dry and muddy. The remainder of the physical examination was unremarkable. Initial laboratory studies showed: sodium, 146 mg/dL; potassium, 4.62 mg/dL; glucose, 43 mg/dL; blood urea nitrogen, 50 mg/dL; creatinine, 1.9 mg/dL; amylase, 38 mg/dL; and lipase, 33 mg/dL. Complete blood count revealed a white blood cell count of 5,150/gL with 36% segment, 34% band, and 7% metamyelocytes. The red cell count was 3 million/mL, the hemoglobin was 14.3 g/dL and the platelet count was 139,000/mL. An arterial blood gas analysis with FiO2 0.40 was obtained revealed pH 7.141; pCO2 45.3 mm Hg; pO2 37.9 mm Hg; HCO3 13.0 mEq/dL; and 69.9%
ANDREWD. PENNON,MD
Department of Emergency Medicine University of Virginia Charlottesville, VA
References 1. Freedman KB, Bernstein J: The adequacy of medical school education in musculoskeletal medicine. J Bone Joint Surg 1998;80: 1421-1427 2, Craton N, Matheson GO: Training and clinical competency in musculoskeletal medicine: Identifying the problem. Sports Med 1993; 15:328-337 3. Matheson GO: Musculoskeletal Medicine: How to strengthen training. Phys Sports Med 1999;27:147-148 4. Veenema KR: The integration of primary care sports medicine into an academic emergency medicine practice: Academic and revenue enhancement. Acad Emerg Med 1999;6:828-832
ACCIDENTAL HYPOTHERMIAIN THE SUBTROPICS To the Editor:--Accidental hypothermia is defined as unintentional decline in the core temperature below 35°C. 1 It is frequently associated with cold exposure in the frigid region. Hypothermia
Copyright © 2000 by W.B. Saunders Company doi:10.1053/JE.2000.6318
FIGURE 1. Chest radiograph on presentation revealed a large pneumonia patch over right lung and alveolar infiltration in the left lower lobe.
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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 18, Number 3 • May 2000
FIGURE 2. Electrocardiograph recording of atrial fibrillation with a normal ventricular response, muscle tremor artifact and prominent Osborn (J) waves in precordial leads as well as leads I, II, and aVE
oxygen saturation. The chest radiograph was remarkable for alveolar infiltrates over right upper lung and left lower lobes (Fig 1). The electrocardiographic examination revealed atrial fibrillation with a normal ventricular response, muscle tremor artifact, and Osborn (J) wave (Fig 2). The patient was intubated with ventilatory support and was given intravenous dextrose supplement. Active external rewarming with heating blankets and radiant heat were initiated. At the same time, active core rewarming with warm (43°C) humidified oxygen via the endotracheal tube, and infusion of warmed (42°C) isotonic intravenous fluids was performed. An Unasyn (sulbactampotentiated ampicillin) plus an aminoglycoside was administered in view of aspiration pneumonia. The patient's core temperature rose gradually from 29.3°C to 37.2°C after 14 hours of rewarming. The return of sinus rhythm with resolution of Osborn (J) wave was obvious on electrocardiographic tracings. The patient's mental status improved substantially (Glasgow Coma Scale score of 11, intubated) and was hemodynamically stable. The patient developed acute respiratory distress syndrome (ARDS) soon after admission and resolved gradually with positive pressure ventilation and antimicrobial agents. Sputum culture revealed KIebsiella ozaenae and non-Group A, B, D [3-streptococcus but blood culture was negative. He was eventually required tracheostomy and was ventilator-dependent. Chest radiograph obtained 2 months later revealed chronic pneumonia patch over right upper lung. His mental status recovered fully and was transferred to a nursing home for total supportive care. MING-MINGSIM, MD Yow-CHII Kuo, MD Department of lnternal Medicine, Taiwan Li Shin Hospital Ping-Chen City, Tao-Yaun, Taiwan, R.O.C.
References 1. Danzl DF, Pozos RS: Accidental hypothermia. N Engl d Med 1994; 331:1756-1760 2. Lee-Chiong TL, Jr, Stitt JT: Accidental hypothermia. When thermoregulation is overwhelmed. Postgrad Med 1996;99:77-88
REVIVARANT (GAMMA-BUTYROLACTONE)POISONING To the Editor:--After the recent banning by the Food and Drug Administration (FDA) of the public sale of Gamma-hydroxybutarate (GHB), the use of the gamma-butyrolactone (GBL) has become very popular. GBL is the precursor for GHB, and GBL Copyright © 2000 by W.B. Saunders Company doi:10.1053/JE.2000.6411
taken orally is converted to GHB in the body. 1 Because of their chemical similarities, toxicity from GBL is expected to be very similar to that described for GHB.
REPORT OF A CASE A 21-year-old woman was transported to the ED by EMS after being found unresponsive in a bar. During transport, the paramedics infused 50 gm of dextrose IV without determining the blood sugar level. The patient remained unresponsive. Her brother confirmed that just previously she had ingested approximately 90 mL of a nonprescription sleep aid called Revivarant. The brother later provided the bottle of Revivarant for examination. Other than modest alcohol drinking, she had no significant past medical history. On physical examination, she was unresponsive but healthyappearing, with a blood pressure of 100/70 mm/Hg, a regular heart rate of 46 beats/rain, respiratory rate of 16 breaths/min, temperature 99°F, and a room air pulse oximetry of 98%. There were no signs of trauma. Oropharyngeal examination was normal including a strong gag reflex. Neck was supple and without crepitus on midline posterior palpation. The abdominal cardiorespiratory examinations were normal. The skin examination was normal and without evidence of tract marks. Neurological examination revealed an initial Glascow Coma Scale of 6 (E 1, V 1, M 4 as the patient withdrew from pain). The pupils were 3 mm bilaterally and reactive. The deep tendon reflexes were intact; there was no Babinski reflex bilaterally. Laboratory values included a normal complete blood count, electrolytes, blood urea nitrogen, and creatinine. The elevated blood glucose (362 mg/dL) was attributed to the dextrose given by the paramedics. The alcohol level was 59 mg/dL. The urine pregnancy test was negative. The urine drug screen was negative for the presence of opioids, cocaine, cannabinoids, benzodiazepines, and barbiturates. Four mg of 1V Naloxone produced no change in her mental status. After 5 mg of atropine intravenously, her heart rate rose to approximately 100 beats/rain with a PR interval of 184 ms, QRS interval of 76 ms, QTc of 469 ms, and no evidence of ischemic changes. The physical condition and vital signs remained the same during a 3-hour observation period. When she awoke spontaneously she was alert, oriented, and ambulatory without difficulty. She confirmed the ingestion of Revivarant, and was discharged to the care of her 25-year-old brother. Revivarant, is a dietary supplement that claims to help add to the user's "quality of life." Some advertised benefits of Revivarant include deep sleep rejuvenation, relieving stress and depression, increase in athletic performance, prosexual effects, and anecdotal
357
completely inadequate. Undergraduate medical school curricula devote, on average, less than 3% 2 of teaching to this subject, while musculoskeletal complaints represent 15% to 25% of visits. 3 A recent study published by Freedman 1 tested new medical school graduates with a standardized questionnaire of basic musculoskeletal knowledge. An impressive 82% of the new graduates failed this basic knowledge test. Despite an imperative for education, an organized approach to these problems has been lacking. Emergency medicine, pediatric, and family practice residents often rotate onto inpatient orthopedic services, but directed study of outpatient musculoskeletal problems ls notoriously lacking. Students and residents on these services are too often taught surgical techniques and inpatient care instead Of functional issues and the clinical examination. In the emergency department, this translates into an abdication of authority, where the attitude becomes "splint the patient and refer them on to the specialist." Too little time is devoted to the examination and education of these patients, partially because of time constraints, and partially because of out low level of comfort in examining and educating them. In this era of managed care, the primary care practitioner is increasingly going to be called on to treat the vast majority of nonoperative musculoskeletal injuries, and the specialty of emergency medicine has the opportunity to lead the way. Primary care sports medicine is a relatively new subspeciality of emergency medicine. One or two postgraduate fellowship years are devoted to the nonsurgical management of musculoskeletal injuries. A recent report by Veenema4 outlined the successful integration of primary care sports medicine into an emergency medicine training program. The addition of an expert on musculoskeletal injury to an academic faculty, similar to the addition of a toxicologist, an emergency medical services director, or a pediatric emergency medicine specialist, enhances the care delivered in the department, serves as a focal point for student and resident education, and has potential for revenue enhancement. The integration of such a program can help emergency medicine as a field take ownership of educating medical students, off-service residents, and our own trainees in sound musculoskeletal care, and the thought processes and skills that are essential in its practice.
may develop in persons exposed to a modestly cool climate for prolonged period. The condition has even been reported in tropical climates where average daily temperatures do not fall below 16°C. 2 We present a rare case of accidental hypothermia in the subtropics. An 86-year-old man was found lying unconscious in the padi field at 8:00 AM on May 4, 1998. The patient had gone out to pick wood 2 days earlier and did not return. He was found partially immersed in the half-foot flooded padi field after 1-day search. He was dressed light-weight clothing, He was unresponsive and with undetectable vital signs. The highest and lowest outdoor temperarare during those 2 days was reporting 33.8°C and 23.1°C respectively. He was given oxygen via a facial mask and was sent by ambulance to the emergency department at 8:30 AM. Physical examination on arrival revealed a skinny, suntanned man in his 80s. Vital signs were: temperature 29.3°C by tympanic thermometer; blood pressure 75/49 mm Hg; irregular pulse 68 beats/rain; and a barely detectable respiration. His eyes opened to pain stimulation, no verbal response, and could localized pain (Glasgow Coma Scale score of 8). Pupils were 2.5 rmn in size with sluggish light reflex. There was no evidence of trauma noted after full exposure. His breathing sounds revealed diffuse expiratory wheeze and coarse crackles over right lung and left lower lobes. Irregular heart beat was noted. Extremities were slightly rigid on passive flexion and extension, and his skin was cold, dry and muddy. The remainder of the physical examination was unremarkable. Initial laboratory studies showed: sodium, 146 mg/dL; potassium, 4.62 mg/dL; glucose, 43 mg/dL; blood urea nitrogen, 50 mg/dL; creatinine, 1.9 mg/dL; amylase, 38 mg/dL; and lipase, 33 mg/dL. Complete blood count revealed a white blood cell count of 5,150/gL with 36% segment, 34% band, and 7% metamyelocytes. The red cell count was 3 million/mL, the hemoglobin was 14.3 g/dL and the platelet count was 139,000/mL. An arterial blood gas analysis with FiO2 0.40 was obtained revealed pH 7.141; pCO2 45.3 mm Hg; pO2 37.9 mm Hg; HCO3 13.0 mEq/dL; and 69.9%
ANDREWD. PENNON,MD
Department of Emergency Medicine University of Virginia Charlottesville, VA
References 1. Freedman KB, Bernstein J: The adequacy of medical school education in musculoskeletal medicine. J Bone Joint Surg 1998;80: 1421-1427 2, Craton N, Matheson GO: Training and clinical competency in musculoskeletal medicine: Identifying the problem. Sports Med 1993; 15:328-337 3. Matheson GO: Musculoskeletal Medicine: How to strengthen training. Phys Sports Med 1999;27:147-148 4. Veenema KR: The integration of primary care sports medicine into an academic emergency medicine practice: Academic and revenue enhancement. Acad Emerg Med 1999;6:828-832
ACCIDENTAL HYPOTHERMIAIN THE SUBTROPICS To the Editor:--Accidental hypothermia is defined as unintentional decline in the core temperature below 35°C. 1 It is frequently associated with cold exposure in the frigid region. Hypothermia
Copyright © 2000 by W.B. Saunders Company doi:10.1053/JE.2000.6318
FIGURE 1. Chest radiograph on presentation revealed a large pneumonia patch over right lung and alveolar infiltration in the left lower lobe.
358
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 18, Number 3 • May 2000
FIGURE 2. Electrocardiograph recording of atrial fibrillation with a normal ventricular response, muscle tremor artifact and prominent Osborn (J) waves in precordial leads as well as leads I, II, and aVE
oxygen saturation. The chest radiograph was remarkable for alveolar infiltrates over right upper lung and left lower lobes (Fig 1). The electrocardiographic examination revealed atrial fibrillation with a normal ventricular response, muscle tremor artifact, and Osborn (J) wave (Fig 2). The patient was intubated with ventilatory support and was given intravenous dextrose supplement. Active external rewarming with heating blankets and radiant heat were initiated. At the same time, active core rewarming with warm (43°C) humidified oxygen via the endotracheal tube, and infusion of warmed (42°C) isotonic intravenous fluids was performed. An Unasyn (sulbactampotentiated ampicillin) plus an aminoglycoside was administered in view of aspiration pneumonia. The patient's core temperature rose gradually from 29.3°C to 37.2°C after 14 hours of rewarming. The return of sinus rhythm with resolution of Osborn (J) wave was obvious on electrocardiographic tracings. The patient's mental status improved substantially (Glasgow Coma Scale score of 11, intubated) and was hemodynamically stable. The patient developed acute respiratory distress syndrome (ARDS) soon after admission and resolved gradually with positive pressure ventilation and antimicrobial agents. Sputum culture revealed KIebsiella ozaenae and non-Group A, B, D [3-streptococcus but blood culture was negative. He was eventually required tracheostomy and was ventilator-dependent. Chest radiograph obtained 2 months later revealed chronic pneumonia patch over right upper lung. His mental status recovered fully and was transferred to a nursing home for total supportive care. MING-MINGSIM, MD Yow-CHII Kuo, MD Department of lnternal Medicine, Taiwan Li Shin Hospital Ping-Chen City, Tao-Yaun, Taiwan, R.O.C.
References 1. Danzl DF, Pozos RS: Accidental hypothermia. N Engl d Med 1994; 331:1756-1760 2. Lee-Chiong TL, Jr, Stitt JT: Accidental hypothermia. When thermoregulation is overwhelmed. Postgrad Med 1996;99:77-88
REVIVARANT (GAMMA-BUTYROLACTONE)POISONING To the Editor:--After the recent banning by the Food and Drug Administration (FDA) of the public sale of Gamma-hydroxybutarate (GHB), the use of the gamma-butyrolactone (GBL) has become very popular. GBL is the precursor for GHB, and GBL Copyright © 2000 by W.B. Saunders Company doi:10.1053/JE.2000.6411
taken orally is converted to GHB in the body. 1 Because of their chemical similarities, toxicity from GBL is expected to be very similar to that described for GHB.
REPORT OF A CASE A 21-year-old woman was transported to the ED by EMS after being found unresponsive in a bar. During transport, the paramedics infused 50 gm of dextrose IV without determining the blood sugar level. The patient remained unresponsive. Her brother confirmed that just previously she had ingested approximately 90 mL of a nonprescription sleep aid called Revivarant. The brother later provided the bottle of Revivarant for examination. Other than modest alcohol drinking, she had no significant past medical history. On physical examination, she was unresponsive but healthyappearing, with a blood pressure of 100/70 mm/Hg, a regular heart rate of 46 beats/rain, respiratory rate of 16 breaths/min, temperature 99°F, and a room air pulse oximetry of 98%. There were no signs of trauma. Oropharyngeal examination was normal including a strong gag reflex. Neck was supple and without crepitus on midline posterior palpation. The abdominal cardiorespiratory examinations were normal. The skin examination was normal and without evidence of tract marks. Neurological examination revealed an initial Glascow Coma Scale of 6 (E 1, V 1, M 4 as the patient withdrew from pain). The pupils were 3 mm bilaterally and reactive. The deep tendon reflexes were intact; there was no Babinski reflex bilaterally. Laboratory values included a normal complete blood count, electrolytes, blood urea nitrogen, and creatinine. The elevated blood glucose (362 mg/dL) was attributed to the dextrose given by the paramedics. The alcohol level was 59 mg/dL. The urine pregnancy test was negative. The urine drug screen was negative for the presence of opioids, cocaine, cannabinoids, benzodiazepines, and barbiturates. Four mg of 1V Naloxone produced no change in her mental status. After 5 mg of atropine intravenously, her heart rate rose to approximately 100 beats/rain with a PR interval of 184 ms, QRS interval of 76 ms, QTc of 469 ms, and no evidence of ischemic changes. The physical condition and vital signs remained the same during a 3-hour observation period. When she awoke spontaneously she was alert, oriented, and ambulatory without difficulty. She confirmed the ingestion of Revivarant, and was discharged to the care of her 25-year-old brother. Revivarant, is a dietary supplement that claims to help add to the user's "quality of life." Some advertised benefits of Revivarant include deep sleep rejuvenation, relieving stress and depression, increase in athletic performance, prosexual effects, and anecdotal