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Teaching the recognition of odors
METHODS & TECHNIQUES odors, recognition of
Teaching the Recognition of Odors Odor recognition is a valuable skill for the emergency services provider, particularly when dealing with the poisoned patient. A simple "ten test-tube sniffing bar" emphasizing sensory recognition of common toxins in association with representative case histories is an effective emergency services teaching tool. The odor, toxdn, case history, and appropriate references are described for each component of the sniffing bar. [Goldfrank L, Weisman R, Flomenbaum N: Teaching the recognition of odors. Ann Emerg Med 11:684686, December 1982.]
INTRODUCTION Successful patient care in the emergency department may depend on astute first impressions and rapid assessments based on factual knowledge, technical skills, and correctly interpreted sensory input. Factual knowledge is classically imparted through textbooks, lectures, conferences, and audiovisual programs. Technical skills are taught at the bedside and, in "skill stations" or animal labs. Utilization of one's sensory skills for the most part is achieved only through exposure to sights, sounds, textures, colors, or odors in the presence of an instructor who can correctly interpret their significance. Nowhere, perhaps, is this more important than in the practice of clinical toxicology, where the recognition of a characteristic odor may enable a clinician to correctly identify and treat a potentially lethal ingestion long before the laboratory identification or confirmation.
Lewis Goldfrank, MD, FACEP* Richard Weisman, PharmD t Neal Flomenbaum, MD, FACEP* New York, New York From the Department of Emergency Medical Services, Bellevue Hospital Center,* and New York City Poison Control Centerd New York, New York. Address for reprints: Lewis Goldfrank, MD, FACER Director, Department of Emergency Services, Bellevue Hospital Center, First Avenue and 27th Street, New York, New York 10016.
TECHNIQUE To increase awareness of the odors of toxic products, we have prepared a simple and inexpensive "sniffing-bar" (Figure) complete with representative case histories. The toxic substance or substances with representative odors were placed in blood collecting tubes, numbered, and placed in a test tube rack for circulation among the staff. We have successfully utilized this "sniffing-bar" to supplement the case studies (Table 1) and table of diagnostic odors (Table 2) that we have utilized in the teaching of clinical toxicology. In preparing such a "sniffing-bar," the test tubes should be used in the order cited to avoid olfactory extinction. We have chosen ten tubes, but vary the presentation or emergency service display.
SUMMARY The "sniffing-bar" has been a most successful educational tool in an ignored area vital to rapid assessment of the poisoned patient in the emergency services. The clinical and practical nature of this model makes this device adaptable to any type of emergency service, and particularly important for the emergency department that is only infrequently called on to care for the toxic ingestion or drag overdose patient.
11:12 December 1982
Annals of Emergency Medicine
684/65
RECOGNITION OF ODORS Goldfrank, Weisman & Flomenbaum
TABLE 1. Case studies Tube 1 Case history: Odor: Toxin: Contents of tube: Tube 2 Case history: Odor: Toxin: Contents of tube: Tube 3 Case history: Odor: Toxin: Contents of tube: Tube 4 Case history: Odor: Toxin: Contents of tube: Tube 5 Case history: Odor: Toxin: Contents of tube: Tube 6 Case history: Odor: Toxin: Contents of tube: Tube 7 Case history: Odor: Toxin: Contents of tube: Tube 8 Case history: Odor: Toxin: Contents of tube: Tube 9 Case history: Odor: Toxin: Contents of tube: Tube 10 Case history: Odor: Toxin: Contents of tube: 66/685
Lethargic 28-year-old woman brought to emergency services with altered mental status. Vinyblike smell.1 Ethchlorvynol. Liquid contents of Placidyl® capsule. 34-year-old man in cardiopulmonary arrest found in chemical plant near several gas cylinders. Bitter almonds.2 Cyanide. Macerated seeds from inside of peach pit. 5-year-old child ingested unknown rodenticide, presented to emergency services with orthostatic hypotension, hyperglycemia, ketoacidosis. A small sample of rodenticide had this odor. Peanuts.3 Vacor®. (Odor is from a flavoring agent used in commercially available products.) Macerated peanuts. 27-year-old man brought to emergency services with necrotic burns on oral mucosa after gargling with unknown liquid germicide. Patient stated he thought it would help his sore throat. Emergency physician surprised to find that pH of germicide was 5. White paste. Phenol (liquefied). Phenol. Comatose 35-year-old man employed as sanitary engineer pulled out of sewer by fellow worker. CPR initiated. Brought to emergency services smelling like rotten eggs. Rotten eggs. 4 Hydrogen sulfide. Sulfurated potash. Photographer brought to emergency services after accidentally ingesting chemical used in developing film. On presentation, patient was drooling and grasping his throat in considerable distress. On examination, patient's mouth and throat were erythematous and he smelled "like a salad." Vinegar. Glacial acetic acid. Vinegar. Crop duster brought to emergency services in acute respiratory distress. Patient had hypersalivation, coarse rhonchi in both lung fields. Patient had miotic pupils (2 mm) and very unpleasant odor. Garlic.5 Organophosphate insecticide. Garlic. 4-year-old child brought to emergency services with temperature of 39.7 C, respiratory rate of 32/rain, and markedly altered mental status. Laboratory tests on admission showed high anion gap metabolic acidosis. Patient smelled like "wintergreen Lifesaver®.'' Oil of wintergreen. Methyl salicylate. Oil of wintergreen. 3-year-old brought to emergency services in considerable pain. On examination, child exhibited dysphagia and dysphonia, oral mucosa appeared blistered and erythematous. Child's mother-stated that he must have gotten into cleaning supplies while she was talking on telephone. Ammonia. Ammonia. Ammonia. 2-year-old child brought to emergency services after vomiting and having what was described as a grand mal seizure. Child had been playing several minutes earlier in a storage closet. Moth balls. Camphor. Camphor. Annals of Emergency Medicine
11:12 December 1982
Fig. Red-top tubes containing substances with characteristic odors that m a y be detected on or about poisoned patients.
TABLE 2. Diagnostic odors Odor Acetone (sweet, like Russet apples) Acrid (pear-like) Alcohols (fruit-like) Ammoniacal Bitter almonds Carrots Coal gas (stove gas) Disinfectants Eggs (rotten) Fish or raw liver (musty) Fruit-like Garlic Halitosis Mothballs Peanuts Pungent, aromatic Shoe polish Tobacco (stale) Violets Wintergreen
Toxin Lacquer, alcohol, isopropyl alcohol, chloroform; ketoacidosis Paraldehyde, chloral hydrate Alcohol, isopropyl alcohol Uremia Cyanide (in choke cherry, apricot pits) Circutoxin Carbon monoxide (odorless but associated with coal gas) Phenol, creosote Hydrogen sulfide, mercaptans, disulfuram (Antabuse®) Hepatic failure, zinc phosphide Amyl nitrite, alcohol, isopropyl alcohol Phosphorus, tellurium, arsenic (breath and perspiration), parathion, malathion, selenium, dimethyl sulfoxide (DMSO), thallium Acute illness, poor oral hygiene Camphor-containing products RH-787 (Vacor®) Ethchlorvynol (Placidyl®) Nitrobenzene Nicotine Urinary turpentine Methyl salicylate
REFERENCES 1. Schuhz JC, Crowder DG, Medart WS: Excretion studies in ethchlorvynol intoxication. Arch Intern Med 117:409-411, 1966.
2. Sayre JW, Kaymakcalan S: Cyanide poisoning from apricot seeds among children in Central Turkey. N Engl J Med 270:1113-1115, 1964. 3. Gallanosa AG, Spyker DA, Curnow RT: Diabetes mellitus associated with autonomic and peripheral neuropathy after
11:12 December 1982
Vacor ® rodenticide poisoning: A review. Clin Toxicol 18:441-449, 1981. 4. Gafafer WM (ed): Occupational Diseases: A Guide to Their Recognition. Washington, DC, US Government Printing Office, 1964. 5. Namba T, Nolte CT, Jackrel J, et ah Poisoning due to organophosphate insecticides. Am J Med 50:475-492, 1971. 6. Goldffank L (ed): Toxicologic Emergencies: A Comprehensive Handbook in Problem Solving, ed 2. New York, AppletonCentury-Crofts, 1982, p 253.
Annals of Emergency Medicine
686/67
Teaching the Recognition of Odors Odor recognition is a valuable skill for the emergency services provider, particularly when dealing with the poisoned patient. A simple "ten test-tube sniffing bar" emphasizing sensory recognition of common toxins in association with representative case histories is an effective emergency services teaching tool. The odor, toxdn, case history, and appropriate references are described for each component of the sniffing bar. [Goldfrank L, Weisman R, Flomenbaum N: Teaching the recognition of odors. Ann Emerg Med 11:684686, December 1982.]
INTRODUCTION Successful patient care in the emergency department may depend on astute first impressions and rapid assessments based on factual knowledge, technical skills, and correctly interpreted sensory input. Factual knowledge is classically imparted through textbooks, lectures, conferences, and audiovisual programs. Technical skills are taught at the bedside and, in "skill stations" or animal labs. Utilization of one's sensory skills for the most part is achieved only through exposure to sights, sounds, textures, colors, or odors in the presence of an instructor who can correctly interpret their significance. Nowhere, perhaps, is this more important than in the practice of clinical toxicology, where the recognition of a characteristic odor may enable a clinician to correctly identify and treat a potentially lethal ingestion long before the laboratory identification or confirmation.
Lewis Goldfrank, MD, FACEP* Richard Weisman, PharmD t Neal Flomenbaum, MD, FACEP* New York, New York From the Department of Emergency Medical Services, Bellevue Hospital Center,* and New York City Poison Control Centerd New York, New York. Address for reprints: Lewis Goldfrank, MD, FACER Director, Department of Emergency Services, Bellevue Hospital Center, First Avenue and 27th Street, New York, New York 10016.
TECHNIQUE To increase awareness of the odors of toxic products, we have prepared a simple and inexpensive "sniffing-bar" (Figure) complete with representative case histories. The toxic substance or substances with representative odors were placed in blood collecting tubes, numbered, and placed in a test tube rack for circulation among the staff. We have successfully utilized this "sniffing-bar" to supplement the case studies (Table 1) and table of diagnostic odors (Table 2) that we have utilized in the teaching of clinical toxicology. In preparing such a "sniffing-bar," the test tubes should be used in the order cited to avoid olfactory extinction. We have chosen ten tubes, but vary the presentation or emergency service display.
SUMMARY The "sniffing-bar" has been a most successful educational tool in an ignored area vital to rapid assessment of the poisoned patient in the emergency services. The clinical and practical nature of this model makes this device adaptable to any type of emergency service, and particularly important for the emergency department that is only infrequently called on to care for the toxic ingestion or drag overdose patient.
11:12 December 1982
Annals of Emergency Medicine
684/65
RECOGNITION OF ODORS Goldfrank, Weisman & Flomenbaum
TABLE 1. Case studies Tube 1 Case history: Odor: Toxin: Contents of tube: Tube 2 Case history: Odor: Toxin: Contents of tube: Tube 3 Case history: Odor: Toxin: Contents of tube: Tube 4 Case history: Odor: Toxin: Contents of tube: Tube 5 Case history: Odor: Toxin: Contents of tube: Tube 6 Case history: Odor: Toxin: Contents of tube: Tube 7 Case history: Odor: Toxin: Contents of tube: Tube 8 Case history: Odor: Toxin: Contents of tube: Tube 9 Case history: Odor: Toxin: Contents of tube: Tube 10 Case history: Odor: Toxin: Contents of tube: 66/685
Lethargic 28-year-old woman brought to emergency services with altered mental status. Vinyblike smell.1 Ethchlorvynol. Liquid contents of Placidyl® capsule. 34-year-old man in cardiopulmonary arrest found in chemical plant near several gas cylinders. Bitter almonds.2 Cyanide. Macerated seeds from inside of peach pit. 5-year-old child ingested unknown rodenticide, presented to emergency services with orthostatic hypotension, hyperglycemia, ketoacidosis. A small sample of rodenticide had this odor. Peanuts.3 Vacor®. (Odor is from a flavoring agent used in commercially available products.) Macerated peanuts. 27-year-old man brought to emergency services with necrotic burns on oral mucosa after gargling with unknown liquid germicide. Patient stated he thought it would help his sore throat. Emergency physician surprised to find that pH of germicide was 5. White paste. Phenol (liquefied). Phenol. Comatose 35-year-old man employed as sanitary engineer pulled out of sewer by fellow worker. CPR initiated. Brought to emergency services smelling like rotten eggs. Rotten eggs. 4 Hydrogen sulfide. Sulfurated potash. Photographer brought to emergency services after accidentally ingesting chemical used in developing film. On presentation, patient was drooling and grasping his throat in considerable distress. On examination, patient's mouth and throat were erythematous and he smelled "like a salad." Vinegar. Glacial acetic acid. Vinegar. Crop duster brought to emergency services in acute respiratory distress. Patient had hypersalivation, coarse rhonchi in both lung fields. Patient had miotic pupils (2 mm) and very unpleasant odor. Garlic.5 Organophosphate insecticide. Garlic. 4-year-old child brought to emergency services with temperature of 39.7 C, respiratory rate of 32/rain, and markedly altered mental status. Laboratory tests on admission showed high anion gap metabolic acidosis. Patient smelled like "wintergreen Lifesaver®.'' Oil of wintergreen. Methyl salicylate. Oil of wintergreen. 3-year-old brought to emergency services in considerable pain. On examination, child exhibited dysphagia and dysphonia, oral mucosa appeared blistered and erythematous. Child's mother-stated that he must have gotten into cleaning supplies while she was talking on telephone. Ammonia. Ammonia. Ammonia. 2-year-old child brought to emergency services after vomiting and having what was described as a grand mal seizure. Child had been playing several minutes earlier in a storage closet. Moth balls. Camphor. Camphor. Annals of Emergency Medicine
11:12 December 1982
Fig. Red-top tubes containing substances with characteristic odors that m a y be detected on or about poisoned patients.
TABLE 2. Diagnostic odors Odor Acetone (sweet, like Russet apples) Acrid (pear-like) Alcohols (fruit-like) Ammoniacal Bitter almonds Carrots Coal gas (stove gas) Disinfectants Eggs (rotten) Fish or raw liver (musty) Fruit-like Garlic Halitosis Mothballs Peanuts Pungent, aromatic Shoe polish Tobacco (stale) Violets Wintergreen
Toxin Lacquer, alcohol, isopropyl alcohol, chloroform; ketoacidosis Paraldehyde, chloral hydrate Alcohol, isopropyl alcohol Uremia Cyanide (in choke cherry, apricot pits) Circutoxin Carbon monoxide (odorless but associated with coal gas) Phenol, creosote Hydrogen sulfide, mercaptans, disulfuram (Antabuse®) Hepatic failure, zinc phosphide Amyl nitrite, alcohol, isopropyl alcohol Phosphorus, tellurium, arsenic (breath and perspiration), parathion, malathion, selenium, dimethyl sulfoxide (DMSO), thallium Acute illness, poor oral hygiene Camphor-containing products RH-787 (Vacor®) Ethchlorvynol (Placidyl®) Nitrobenzene Nicotine Urinary turpentine Methyl salicylate
REFERENCES 1. Schuhz JC, Crowder DG, Medart WS: Excretion studies in ethchlorvynol intoxication. Arch Intern Med 117:409-411, 1966.
2. Sayre JW, Kaymakcalan S: Cyanide poisoning from apricot seeds among children in Central Turkey. N Engl J Med 270:1113-1115, 1964. 3. Gallanosa AG, Spyker DA, Curnow RT: Diabetes mellitus associated with autonomic and peripheral neuropathy after
11:12 December 1982
Vacor ® rodenticide poisoning: A review. Clin Toxicol 18:441-449, 1981. 4. Gafafer WM (ed): Occupational Diseases: A Guide to Their Recognition. Washington, DC, US Government Printing Office, 1964. 5. Namba T, Nolte CT, Jackrel J, et ah Poisoning due to organophosphate insecticides. Am J Med 50:475-492, 1971. 6. Goldffank L (ed): Toxicologic Emergencies: A Comprehensive Handbook in Problem Solving, ed 2. New York, AppletonCentury-Crofts, 1982, p 253.
Annals of Emergency Medicine
686/67