Dangerous Form of Marijuana

CORRESPONDENCE used in their study, and we wonder If other readers also had these problems. We would like to clarify our use ofterms in our study. We used the term "retrospective" to describe the study by Hunt et alln the sense that the control data collected were not collected at the same time as the experimental data. Although not clearly explained In their study, it is suggested that their experimental data may have been collected dUring adifferent week With the only controls being Similarity in day of week and time of day We believe that by not collectIng the control data during the same time as the collection ofthe experimental data, any comparison made must be aretrospective process and subject to weaknesses I nherent to this type of methodology In addition, we perceived the experimental and control time Intervals collected by Hunt et al to not be well-defined. Although it is stated that the Investigators used acity map and stopwatch, it does not state when the stopwatch was started or stopped. Because of this, we are led to believe thatthe collected times might mimic the times on an ambulance run sheet and be subject to the well-known inaccuracies associated With this (Ie, did the timing stop when the driver announced on the radio that they were arriving at the hospital versus did the timing stop when the ambulance transmission selector was placed Into the "park" POSition versus did the timing stop when the patient was physica Ily removed from the ambulance?) We had no Intention of incorrectly citing the study by Hunt et al.ln fact. we concur with many of their conclUSions Like Dr Hunt and his colleagues, we also believe that further studies in other EMS systems are needed to determine the utility of light and SIren usage when weighed against the risks associated with their use We appreciate this chance to offer our comments

Jeffrey Ho, MD Department of Emergency Medicine Bnan Casey, EMT-P Department of EMS Education Hennepin County Medical Center Minneapolis, MN 47/8/98804

JULY 1999

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Determination of Elevated Jugular Venous Pressure by Real-Time Ultrasound To the Editor. Knowledge of jugularvenous pressure (JVP) in patients with cardiopulmonary complaints is clinically Important. but often not attainable from the phySical examination. ThiS letter describes apatient with increased JVP that was not obvious cl inically but was clearly demonstrated with ultrasound. A66-year-old Hispanic man With renal cell carcinoma metastatic to the lungs presented to the emergency department with increaSing dyspnea over several days The patient was afebrile With ablood pressure of 110/80 mm Hg, pulse rate of 108 beats/min, and respiratory rate of 26 breaths/min. The Jugular veins were not distended, the lungs were clear, and the heart sounds were normal Achest radiograph revealed multiple pulmonary nodules with an enlarged cardiac shadow Immediate transthoracic ultrasound (sonoline prima, Siemens Medical Systems, Issaquah, WAj performed by the author revealed alarge pericardlal effusion With the patient sitting upright. the neck was scanned in the transverse plane With a7.5MHz linear transducer, disclOSing an abnormally distended internal jugular vein The patient was admitted to the ICU and aformal echocardlogram confirmed the effUSion with evidence oftamponade An urgent pericardial window was performed with relief ofthe patient's symptoms An elevated JVP usually reflects an elevation ofthe central venous pressure (CVPj, as the internal jugular veins are considered a "manometer to the right atrium" 1 Several studies have questioned the accuracy of the phySical examination In the assessment of JVp.2.3 Occasionally the CVP may be so elevated that the venous pulsations may be too high In the neckto be Visualized Also, large patients with short, thick necks always present achallenge These obstacles pose no difficulty for real-time sonographic visualization Ultrasound performed by emergency physiCians forfocused examinations IS gaining acceptance It has been helpful in assistIng Internal jugular vein (IJV) catheterIZation In the ED 4.5

The technique for determining elevation of JVP is quite simple. The middle ofthe neck is scanned In the transverse plane With the patient In asemi upright position.lfthe vein is distended at end-expiration, then the JVP is elevated. Conversely, Ifthe vein IS collapsed, the JVP is normal or low. However, several caveats are important. Because the IJV is a superfiCial structure, it is best viewed with a higher-frequency transducer. Also, the IJV IS compressible, unlike the more posteromedial common carotid artery. Gentle application of the transducer is all that IS necessary, too much pressure will occlude the vein and may cause afalse-negative result Furthermore, forced expiratIOn and the Valsalva maneuver wi II transiently distend anormally collapsed IJV. All ofthese are easJlyvlsuallzed in real time and therefore are unlikely to present a problem Ibelieve thiS to be an extremely Simple, yet useful procedure that can be rapidly learned by emergency phySicians

Bruce M Lipton, MD, RDMS Department of Emergency MediCine Kaiser Permanente Medical Center Anaheim, CA

47/8/98723 1 Cook D], Sund DL Doe' thIS pattent have ab,wrmal venous pressure" ]AMA 1996,275630-634 2 EconomIdes E, Stevenson LIV The Jugular vems KnOWIng enougk to look Am Heart] 1998,1366-9 3 McGee SR PhYSIcal o.ammatwn oj venous pressure A en tIcal reVIew Am Heart] 1998,13610-18

4 Hudson PA. Ro,c]S Real-tIme ultrasound gUIded mternal Jugular veIn cathetcn,:atwn In the emergency department Am] Emerg Med 1991,1579-82 5 Hnls p. WIlber S, Blanda MP, et "I Ultrasound-asSisted Internal veIn cathetcn,:atwn In the ED Am] Emerg Med 19 Q8,16401-403

Dangerous Form of Marijuana To the Editor. Marijuana is Widely used by adolescents and adults for ItS pleasurable effects.' Although users typically experience euphoria, dysphoria may also occasionally occur. Recently the occurrence of severe dysphOria associated With marijuana smoking appears to be riSing This trend is speCifically associated With the use of marijuana cigarettes that are allegedly treated with" embalming flUid" to enhance their euphoriC effects 2 Although undisclosed to most users, these cigarettes

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are adulterated with phencyclidine (PCP) Marijuana adulteration is not new, but the manner In which this agent IS marketed IS of great public health concern. The prerolled marijuana cigarettes are illicitly sold under regionally varYing names including "Illy" In Connectlcut,3 "Hydro" In New York City, "Wet" in Philadelphia, and "Fry" In Texas 2 Intoxication from these adulterated cigarettes produces disorganized thoughts, diminished attention, psychomotor agitation, and stimulation ofthe sympathetic nervous system, all of which are expected findings after PCP use Patients are often sedate on presentation and become increasingly agitated during observation Although several authors have attributed these findings to formaldehyde intoxlcatlon 4 or an interaction between tetrahydrocannabinol and formaldehyde, they have also noted their slmilarityto PCP intoxication 4 However, no laboratory analySIs of patient's body fl ulds or the drug specimen for phencyclidine has been reported to date USing gas chromatography/mass spectrometry analysIs ofthe urine of arecent user, aswell as that ofthe original "embalming flUid" preparation, we Identified PCP and several of its congenerssuch as 1-plperldlnocyclohexa ne ca rbonltrile (PCC) and phenylcyclohexane (PCH) Many of these PCP analogs are phySiOlogically active, and the low sensitivity ofthe screening assay toward these agents may explain the high frequency of negative drug screen results In patients who are clinically Intoxicated Given the IlliCit nature of the product, It is not surprising that starting products for the synthesIs of PCP (eg, bromobenzene and cyclohexanone) were also found Embalming flUid, which contains the volatile solvent formalin (ie, formaldehyde in methanol). IS merely avehicle to aid in the uniform distribution of PCP Although typically allowed to dry, smoking the cigarette while stili wet may account for one appellation The epidemiology ofthe adulterated marIJuana use IS currently unclear, and It IS not known whether this mixture IS purchased intentionally or distributed surreptitiously Despite the problems associated with concealed use of PCP In the 1970s, the drug has until recently been of limited Importance The rise In popularity may be related to the ease

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of obtaining information about PCP syntheSIS on the Internet or part ofthe continuing search for unique drugs of abuse Patients presenting with acute psychOSIS in relation to drug abuse should be questioned about the use ofthls substance Screening for PCP may not be uniformly helpful because the relative concentration of PCP versus congener may vary by region and between syntheses. Awareness ofthls relatively new phenomenon IS Importantto permit rapid Identification of Intoxicated patients, administration of appropriate therapy, and aVOidence of unnecessary or costly investigations Lewis SNelson, MD Divlson of Emergency Medicine New York University and Bellevue Hospital Center New York City Poison Control Center New York, NY Julie A Holland, MD ComprehenSIVe Psychiatric Emergency Program, Bellevue Hospital New York. NY PR Ravlkumar, PhD DiVISIOn of EnV/(onmental Science and Toxicology New York City Department of Health New York, NY

47/8/98722 I Drug Abuse Warmng Network Year-end Prehmmdl} Estimates from the 1996 Drug Abuse Wammg Network WashIngton DC Substance Abuse and Mental

Health So VIces Admlmstratl,m. Department of Health and Human ServIces. November 1997 2 Holland JA, Nclson L. RaVlkuml1r PR, et ell EmbalmIng flUId-soaked manJuana New hIgh or new gUIse Jor PCP) J Psychoactive Drugs 1998,30215-219 J

Swart~

MK Monarty AL What's "new" In street drugs

"lIIv" J Pedlatr Health Care 1996,10 -+1--+3

-+ Spector 1 AMP A new Jorm PsychIatry 19H5, -+6 -+98--+09

01 m,m,uana J Clm

5 Re'nf"'" CL. I.bsmgo TA Street drug analvslS An cleven year pospcctlVC on illiCIt dnlg alteratIOn Serom AJolesc Med 1985.12-+1-257

Tissue Adhesives To the Editor' Iread With Interest the study on tissue adhesives In the December 1998 Issue of Annals' (article#94302) Whatwas leftoutofthat article and the others like It in recent months IS the cost Each unit dose package of Dermabond (Closure Medical Corp, Raleigh, NC) costs $27.09 when purchased In apack-

age of 12 units. Apackage of suture costs an average of $6.75 in our office. Even adding In the minimal costs of autoclave wrap, gauze, and any other nonreuseable Items In asurgical pack, thiS new technology IS 3to 4times as costly as suturing. In the current managed care enVironment, where reimbursementfor asimple laceration repair averages about $30 to $45, It is difficult to Justify the added cost of Dermabond As It is considered asupply Integral to the repair, It IS not separately reimbursable As we evaluate the wonderful new technological and pharmaceutical advances that are coming ourway, we need to be cognizant ofthe costs that are being Incurred and plan for away to pay for them. Joanne Berkowitz, MD The Doctors Center Medical Group Fair Oaks, CA

47/8/98720 1 QUInn]. Weill G. Sutcliffe T. et al TIssue adheSIve 1'0suture wound reparr at 1 year RandomIzed clmlwl tnal correlatmg early. 3-month, and 1-year cosmetIC Olltcome, Ann Emerg Med 1998,32 6-+5-6-+9

SliS

In reply Dr BerkOWitz makes an important point regarding the cost of new drugs and medical deVices She IS correctthat physicians need to manage patients In the most cost-effective and effiCient manner The costs of new drugs and deVices need to be considered along with their efficacy, and Ihave tried to do this whenever possible 1,2 One should realize, however, thatthe timIng of studies and dates of publication can prohibltthe authors from performing acost companson Our study was performed 2 years before the product came to market, and the manuscnptwas submitted and accepted before the Food and Drug Administration approval was granted forthe product In late August 1998 3 Information regarding priCing ofthe product was unavailable to us at the time of publication I, too, was somewhat disappointed at the high cost of Dermabond when It came to market Although octylcyanoacrylate has phySIcal properties that make it more deSirable than the current butylcyanoacrylates, one can debate whether its efficacy justifies the cost differential as these products generally cost $3 to $5 per application in othercountries such as Canada 1

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34 1 JULY 1999