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Diaphragmatic paralysis following supraclaviculan puncture of subclavian vein
prone to two types of arrhythmias. Paroxysmal atrial tachycardia (PAT) at a rate of 120 to 230 beats/minute constitutes 70% to 80% of all arrhythmias. Atrial flutter-fibrillation is the second most common arrhythmia and it may be life-threatening if 1:1 conduction occurs with a ventricular rate of 300. The therapy of PAT consists of the usual vagotonic maneuvers, followed by the usual drugs. However, if hemodynamic decompensation is imminent, synchronized cardioversion may be necessary. Digoxin should be avoided during atrial flutter-fibrillation_ Parenteral propranolol or procainamide may be used to treat this arrhythmia in an emergency. Quinidine and/or propranolol are the agents of choice for the long-term suppression of arrhythmias associated with this syndrome. Cardiac pacing and surgery are reserved for use in particularly difficult cases. (Editor's note:
This article warns of the danger of digitalis in treating atrial flutter-fibrillation when it is of W P W origin. Psychologically, this is the first drug people reach for when faced with these rhythms and thus it is especially important for the emergency physician to be aware of the danger of ventricular fibrillation following its use in this syndrome.) Vincent Markovchick. MD cardiovasology,
Wolff-Parkinson-White
syndrome,
ar-
rhythmias Pneumothorax complicating pulmonary emphysema. George RB, Herbert SJ, Shames JM, et al, JAMA 234:389-393, (Oct) 1975. The e t i o l o g y a n d clinical p r e s e n t a t i o n of s p o n t a n e o u s pneumothorax varies according to age. In young, healthy adults, it is usually due to rupture of pleural blebs that form as a result of defects in the walls of subpleura] alveoli. Chest pain is often one of the presenting symptoms in the young. In patients over 40, spontaneous pneumothorax is most often due to chronic bronchitis and emphysema and results from the rupture of intrapulmonary bullae through intact visceral pleura. Breathlessness and anxiety are the principal presenting symptoms with chest pain sometimes lacking. Physical signs of pneumothorax are unreliable due to the underlying lung disease, Therefore, in older patients who develop sudden or progressive breathlessness, anxiety, or an unexplained worsening of their respiratory status, it is imperative to obtain a chest roentgenogram. The degree of pneumothorax may be small in relation to symptomatology and full expiratory films may be necessary. In all ages, definitive therapy is insertion of a chest tube. Recurrence is more common in younger than older individuals. (Editor's note: Acute change
in respiratory status should always alert one to this possibility. It is also common to have tension pneumothorax develop with great rapidity in these patients without the helping classical physical signs of neck vein distention and deviated traches. This complication should also be considered in the acute asthmatic whose condition is worsening.) Vincent Markovchick, MD
respiratory disease, pneumothorax Prophylaxis against meningococcal disease. Finley RA, JAMA 236:459-461, 1976, Prophylactic t r e a t m e n t of people who have been in contact with meningococcal disease is still a controversial issue. In the past, s u l f o n a m i d e s were considered effective t r e a t m e n t for and prophylaxis against the disease. In 1974, the Communicable Disease Center (CDC) reported approximately 77% of meningococci were sensitive to sulfonamides. While both Minocin and rifampin have been shown effective in eradicating the carrier state, it is not accepted that either, alone or in combination, will reliably prevent meningococcal disease. The author recommends prophylactic t r e a t m e n t with sulfadiazine and rifampin of all those with household and day-care nurseries contacts. The dosages recommended are 1) for adults: sulfadiazine 1 gm twice a day for two days and rifampin 600 mg twice a day for two days; 2) for children (1 to 12 years of age): sulfadiazine 500 mg twice a day for two days, and rifampin 10 mg/kg twice a day for two days; 3) for infants (three months to 1 year): sulfadiazine 500 mg twice a day for two days and rifampin 5 mg/kg twice a day for
62/75
two days. (Editor's note: After every case of meningitis, there is Q
rash of visits to our emergency department of children who ha~e been "exposed." We have found these guidelines for prophylax~ for household or day-nursery contacts very useful.)
Robert Rothstein, I~[~ infectious disease, meningococcal, prophylaxis Antidiarrheal agents in the treatment of acute diarrhe~ in children. Portnoy B, Dupont HL, Pruitt D, et al, JAMA 236:844-846, 1976 To evaluate the efficacy of antidiarrheal agents, a study w~ c o n d u c t e d w i t h G u a t a m a l a n c h i l d r e n who h a d an acute diarrheal illness. Eighty patients, aged 3 to l l years, were hos~ pitalized and t r e a t e d for two days with one of five agents~ Kaolin-pectin suspension concentrate (Kao-Con), kaolin suspen~ sion, pectin suspension, diphenoxylateatropine liquid (Lomotil) or placebo. Although the patients receiving the kaolin-pecti~ produced stools that tended to be more formed than those of the placebo-treated group of patients, the study did not demonstrate any effect by any of the agents tested on the frequency of bowel movement, the water content of the stools, or their weight. Kaolin-pectin suspension and diphenoxylateatropine liquid d~ not appear to be useful in the relief of acute nonspecific diarrhea in children. (Editor's note: The major problem in diarrhea of
young children is massive fluid loss and electrolyte depletion, More attention should be paid to fluid balance than to stopping the diarrhea.) Robert Rothstein, Mb i n f e c t i o u s disease, diarrhea; antidiarrheal a g e n t s
Codeine intoxication in childhood. Yon Muhlendahl K[, Krienke EA, Scherf-Rahne B, et al, Lancet 7980:303, (Aug) 1976. Clinical reports on 430 children with acute codeine intoxication are evaluated. Of 234 children who had taken more than 5 mg/kg body weight, eight had respiratory arrest necessitating intubation and artificial ventilation; two died. In all other cases, t h e i n t o x i c a t i o n p r o d u c e d one or m o r e of t h e following symptoms: somnolence, ataxia, miosis, vomiting, rash, swelling and itching of the skin, but no life-threatening side effects. Close supervision of respiration is the main principle of managemenl when more than 2 mg/kg body weight of codeine has been ingested. Gastric voiding may be useful if done soon after inges. tion. Charcoal and purgatives should be given in all cases,
(Editor's note: A particularly lethal and confusing picture pre sents when aspirin-codeine combinations are ingested. Such in. gestions are increasingly common.) Robert Rothstein, MD
drug ingestion, codeine Diaphragmatic paralysis following supraclavicula~ puncture of subclavian vein. Epstein EJ, Quereshl MSA Wright JS, Br Med J 1:693-694, (Mar) 1976, The phrenic nerve is closely related to the subclavian vein an~ superior vena cava in the thoracic outlet and may be damage there by subclavian puncture. Two cases are described m whi~ paralysis of the ipsilateral hemidiaphragm occurred after right sided subclavian puncture for introduction of a pacing wire an, an intravenous catheter respectively. Diaphragmatic moveme~ remains abnormal after a follow-up period of two and thre years, respectively, but appears to cause no disability. The co~ plication occurred only twice in more than 500 punctures an! caused no disability, but failure to recognize that it may be d~ to the venipuncture may lead to a fruitless search for otbe causes of a raised hemidiaphragm. (Editor's note: Another in th
long list of complications of subclavian catheterization. The ternal jugular route is probably safer, but there will always indications for both procedures. Careful technique is the k~] rather than avoidance of a procedure because of its potential f~
serious complications.) Robert Rothstein, MI peripheral vascular injury, raised hemidiaphragm frol~ J subclavian puncture 6:2 (Feb) 1977 J ~ l
This article warns of the danger of digitalis in treating atrial flutter-fibrillation when it is of W P W origin. Psychologically, this is the first drug people reach for when faced with these rhythms and thus it is especially important for the emergency physician to be aware of the danger of ventricular fibrillation following its use in this syndrome.) Vincent Markovchick. MD cardiovasology,
Wolff-Parkinson-White
syndrome,
ar-
rhythmias Pneumothorax complicating pulmonary emphysema. George RB, Herbert SJ, Shames JM, et al, JAMA 234:389-393, (Oct) 1975. The e t i o l o g y a n d clinical p r e s e n t a t i o n of s p o n t a n e o u s pneumothorax varies according to age. In young, healthy adults, it is usually due to rupture of pleural blebs that form as a result of defects in the walls of subpleura] alveoli. Chest pain is often one of the presenting symptoms in the young. In patients over 40, spontaneous pneumothorax is most often due to chronic bronchitis and emphysema and results from the rupture of intrapulmonary bullae through intact visceral pleura. Breathlessness and anxiety are the principal presenting symptoms with chest pain sometimes lacking. Physical signs of pneumothorax are unreliable due to the underlying lung disease, Therefore, in older patients who develop sudden or progressive breathlessness, anxiety, or an unexplained worsening of their respiratory status, it is imperative to obtain a chest roentgenogram. The degree of pneumothorax may be small in relation to symptomatology and full expiratory films may be necessary. In all ages, definitive therapy is insertion of a chest tube. Recurrence is more common in younger than older individuals. (Editor's note: Acute change
in respiratory status should always alert one to this possibility. It is also common to have tension pneumothorax develop with great rapidity in these patients without the helping classical physical signs of neck vein distention and deviated traches. This complication should also be considered in the acute asthmatic whose condition is worsening.) Vincent Markovchick, MD
respiratory disease, pneumothorax Prophylaxis against meningococcal disease. Finley RA, JAMA 236:459-461, 1976, Prophylactic t r e a t m e n t of people who have been in contact with meningococcal disease is still a controversial issue. In the past, s u l f o n a m i d e s were considered effective t r e a t m e n t for and prophylaxis against the disease. In 1974, the Communicable Disease Center (CDC) reported approximately 77% of meningococci were sensitive to sulfonamides. While both Minocin and rifampin have been shown effective in eradicating the carrier state, it is not accepted that either, alone or in combination, will reliably prevent meningococcal disease. The author recommends prophylactic t r e a t m e n t with sulfadiazine and rifampin of all those with household and day-care nurseries contacts. The dosages recommended are 1) for adults: sulfadiazine 1 gm twice a day for two days and rifampin 600 mg twice a day for two days; 2) for children (1 to 12 years of age): sulfadiazine 500 mg twice a day for two days, and rifampin 10 mg/kg twice a day for two days; 3) for infants (three months to 1 year): sulfadiazine 500 mg twice a day for two days and rifampin 5 mg/kg twice a day for
62/75
two days. (Editor's note: After every case of meningitis, there is Q
rash of visits to our emergency department of children who ha~e been "exposed." We have found these guidelines for prophylax~ for household or day-nursery contacts very useful.)
Robert Rothstein, I~[~ infectious disease, meningococcal, prophylaxis Antidiarrheal agents in the treatment of acute diarrhe~ in children. Portnoy B, Dupont HL, Pruitt D, et al, JAMA 236:844-846, 1976 To evaluate the efficacy of antidiarrheal agents, a study w~ c o n d u c t e d w i t h G u a t a m a l a n c h i l d r e n who h a d an acute diarrheal illness. Eighty patients, aged 3 to l l years, were hos~ pitalized and t r e a t e d for two days with one of five agents~ Kaolin-pectin suspension concentrate (Kao-Con), kaolin suspen~ sion, pectin suspension, diphenoxylateatropine liquid (Lomotil) or placebo. Although the patients receiving the kaolin-pecti~ produced stools that tended to be more formed than those of the placebo-treated group of patients, the study did not demonstrate any effect by any of the agents tested on the frequency of bowel movement, the water content of the stools, or their weight. Kaolin-pectin suspension and diphenoxylateatropine liquid d~ not appear to be useful in the relief of acute nonspecific diarrhea in children. (Editor's note: The major problem in diarrhea of
young children is massive fluid loss and electrolyte depletion, More attention should be paid to fluid balance than to stopping the diarrhea.) Robert Rothstein, Mb i n f e c t i o u s disease, diarrhea; antidiarrheal a g e n t s
Codeine intoxication in childhood. Yon Muhlendahl K[, Krienke EA, Scherf-Rahne B, et al, Lancet 7980:303, (Aug) 1976. Clinical reports on 430 children with acute codeine intoxication are evaluated. Of 234 children who had taken more than 5 mg/kg body weight, eight had respiratory arrest necessitating intubation and artificial ventilation; two died. In all other cases, t h e i n t o x i c a t i o n p r o d u c e d one or m o r e of t h e following symptoms: somnolence, ataxia, miosis, vomiting, rash, swelling and itching of the skin, but no life-threatening side effects. Close supervision of respiration is the main principle of managemenl when more than 2 mg/kg body weight of codeine has been ingested. Gastric voiding may be useful if done soon after inges. tion. Charcoal and purgatives should be given in all cases,
(Editor's note: A particularly lethal and confusing picture pre sents when aspirin-codeine combinations are ingested. Such in. gestions are increasingly common.) Robert Rothstein, MD
drug ingestion, codeine Diaphragmatic paralysis following supraclavicula~ puncture of subclavian vein. Epstein EJ, Quereshl MSA Wright JS, Br Med J 1:693-694, (Mar) 1976, The phrenic nerve is closely related to the subclavian vein an~ superior vena cava in the thoracic outlet and may be damage there by subclavian puncture. Two cases are described m whi~ paralysis of the ipsilateral hemidiaphragm occurred after right sided subclavian puncture for introduction of a pacing wire an, an intravenous catheter respectively. Diaphragmatic moveme~ remains abnormal after a follow-up period of two and thre years, respectively, but appears to cause no disability. The co~ plication occurred only twice in more than 500 punctures an! caused no disability, but failure to recognize that it may be d~ to the venipuncture may lead to a fruitless search for otbe causes of a raised hemidiaphragm. (Editor's note: Another in th
long list of complications of subclavian catheterization. The ternal jugular route is probably safer, but there will always indications for both procedures. Careful technique is the k~] rather than avoidance of a procedure because of its potential f~
serious complications.) Robert Rothstein, MI peripheral vascular injury, raised hemidiaphragm frol~ J subclavian puncture 6:2 (Feb) 1977 J ~ l