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The esophageal obturator airway, a clinical comparison to ventilation with a mask and oropharyngeal airway
patients (88%), 54 of whom were men, were in the first group. Only 29% had angina prior to the infarct, but 77% had postinfarction angina. Eighteen percent had late ventricular arrhythmias. The incidence of risk factors was high: 8(F/o were smokers, 21% had hypertension, and 52% had a positive family history. All but one of the nine patients with normal coronary arteries were men. Angina was frequent both before and after the infarct, as were ventricular arrhythmias. Risk factors were significant only for smokers (44%). Three patients had coronary artery anomalies: a single left, a single right, and a left coronary artery arising from the pulmonary trunk. The patients never had angina, but two of three developed ventricular arrhythmias. Risk factors were usually absent. The a v e r a g e age a t the time of infarct was 20. Myocardial infarction in young people differs from that in the elderly, for there is a more heterogeneous underlying coronary anatomy, overwhelmingly predominance of male patients, lower incidence of angina, and overall better prognosis. This study suggests that all myocardial infarction patients should be studied in the catheterization laboratory. (Editor's note: The significance for emergency medicine is the increasing numbers of young patients with life-threatening arrhythmias. Whether or not they have anatomical lesions is less important than the need for excellent prehospital care to improve salvage.) Ken Kulig, MD
diac rates. Other studies demonstrate a ventricular fibrillation threshold lowered by increased heart rate or a lower vagal tone. In addition, increased heart rates associated with myocardial ischemia were noted to increase refractory period disparity in contiguous areas of myocardium, resulting in establishment of multiple sites of reentrant activity. Myocardial infaction associated with mild bradycardia and hypotension without peripheral vasoconstriction has a relatively benign prognosis and the routine administration of atropine m a y r e s u l t in t h e e m e r g e n c y of l e t h a l v e n t r i c u l a r arrhythmias. (Editor's note: Although a direct causal relationship between atropine and lethal ventricular arrhythmias has not been demonstrated, the points of this article are well worth considering in patients with mild hypotension and bradycardia. Further research with animal models is necessary to det e r m i n e the f u l l effect of atropine on the ischemic myocardiumJ Steven Koenigsknecht, MD
myocardial infarction, young adults
The use of metronidazole (Flagyl) in a single 2-gm oral dose has recently been reported for the successful t h e r a p y of trichomonal vaginitis and urethritis. Because of the carcinogenicity and mutagenicity of metronidazole in laboratory animals and bacteria, the highest cure rate with the smallest possible dose is desirable. Three patient groups were treated w i t h 2.0 gm, 1.5 gm, or 1.0 gm single oral dose of metronidazole and were studied for effectiveness of eliminating infection and for the incidence of side effects. Cure rates were similar (91%) in all three groups, with fewer side effects in the 1.0 gm dosage group. (Editor's note: It should be remembered that metronidazole and alcohol may produce an antibuse-alcohol type reaction and therefore patients treated with metronidazole should avoid any alcoholic beverages for 24 hours after the last dose.) Brian Allen, MD
Clonazepam. Browne TR, N Engl J Med 299:812-815, (Oct) 1978. Clonazepam, a new antiepileptic drug of the benzodiazepine class, was approved in 1977. It is currently approved by the FDA for use in the following types of seizures: typical petit mal, infantile spasms, atypical petit mal, and myoclonic and atonic seizures. It is not approved for t r e a t m e n t of grand mal, psychomotor, or focal seizures. Intravenous clonazepam is effective for all types of status epilepticus. However it is probably no more effective than diazepam and has as its major toxicity sedation and cardiorespiratory depression. Most comm e n side effects are d r o w s i n e s s , a t a x i a , a n d b e h a v i o r changes. Tolerance with recurrence of seizures may occur after an initially good response. Overdosage can result in drowsiness, ataxia and cyclic coma. To date, all overdoses have recovered without sequelae. (Editor's note: We have seen a number of patients treated for grand mal epilepsy with this drug whose seizures are not well controlled. Perhaps this reflects their difficult seizure diathesis; perhaps a fad for a new drug improperly applied.) Hal Thomas, MD
epilepsy, drug treatment, clonazepam Atropine-induced ventricular fibrillation: case report and review of the literature. Cooper MJ, Abinader EG, Am Heart J 97:225-228, (Feb) 1979. This article presents a case report and review of the literature concerning bradycardia and hypotension in the early phases of myocardial infarction. The authors review a case of inferior diaphragmatic myocardial infarction in a patient with a pulse of 48 beats/min and a blood pressure of 95/70 mm Hg who was treated with 0.5 mg atropine intravenously. Over the following 5 min the pulse increased to a rate of 130 beats/min (sinus) and t h e n d e g e n e r a t e d into v e n t r i c u l a r tachycardia followed by ventricular fibrillation. Several similar case reports of ventricular dysrhythmias following the treatment of bradycardia with atropine are cited. They note t h a t bradycardia with myocardial infarction is associated w i t h a lower incidence of lethal ventricular d y s r h y t h m i a compared to patients with tachycardia or normal heart rates. In addition, recent reports do not demonstrate any increase in n u t r i e n t myocardial blood flow with atropine-induced rapid heart rates and diminished vagal tone. More than one third of patients given careful atropine titration in a Belfast coronary care unit demonstrated inappropriately rapid car-
96/116
atropine, ventricular fibrillation; myocardial infarction, atropine Single-dose metronidazole for trichomonal vaginitis: patient and consort. Dykers JR Jr, Am J Obstet Gyneco/ 129:579-580, (Nov) 1978.
vaginitis, trichomonal, drug treatment The esophageal obturator airway, a clinical comparison to ventilation with a mask and oropharyngeal airway. Bryson TK, Benumof JL, Ward CF, Chest 74:537-539, (Nov) 1978. Comparison of controlled ventilation with the esophageal obturator airway (EOA) to the conventional system of rubber m a s k and o r o p h a r y n g e a l a i r w a y was m a d e in 10 anesthetized patients scheduled for elective surgery under general anesthesia. Values for tidal volume were in all cases smaller with the EOA and in two cases were inadequate for survival. Leakage from the face mask was similar or greater in all cases with the EOA and in edentulous patients was marginal or unacceptable. Supraglottic obstruction was equal or greater in all cases with the EOA. Two of the 10 patients had accidental endotracheal intubation with the airway and required eventual direct laryngoscopic visualization. Placemerit of the EOA was cancelled in a third patient because of resistance to passage. Endotracheal intubation is the procedure of choice for resuscitative airway management. In situations in which it cannot be used, the standard mask and oropharyngeal airway appears to be preferable to the EOA. (Editor's note: This article is intriguing because of the number of complications seen with the esophageal airway. One wonders i f the incidence was so high because of the patients being anesthetized, or i f the lack of familiarity with the equipment played a role. We prefer endotracheal intubation when possible, but see a role for the EOA in the patient with potential neck injury in whom nasotracheal intubation cannot be achieved.) David H. Craig, MD
esophageal obturator airway
Ann Emerg Med
9:2 (February) 1980
diac rates. Other studies demonstrate a ventricular fibrillation threshold lowered by increased heart rate or a lower vagal tone. In addition, increased heart rates associated with myocardial ischemia were noted to increase refractory period disparity in contiguous areas of myocardium, resulting in establishment of multiple sites of reentrant activity. Myocardial infaction associated with mild bradycardia and hypotension without peripheral vasoconstriction has a relatively benign prognosis and the routine administration of atropine m a y r e s u l t in t h e e m e r g e n c y of l e t h a l v e n t r i c u l a r arrhythmias. (Editor's note: Although a direct causal relationship between atropine and lethal ventricular arrhythmias has not been demonstrated, the points of this article are well worth considering in patients with mild hypotension and bradycardia. Further research with animal models is necessary to det e r m i n e the f u l l effect of atropine on the ischemic myocardiumJ Steven Koenigsknecht, MD
myocardial infarction, young adults
The use of metronidazole (Flagyl) in a single 2-gm oral dose has recently been reported for the successful t h e r a p y of trichomonal vaginitis and urethritis. Because of the carcinogenicity and mutagenicity of metronidazole in laboratory animals and bacteria, the highest cure rate with the smallest possible dose is desirable. Three patient groups were treated w i t h 2.0 gm, 1.5 gm, or 1.0 gm single oral dose of metronidazole and were studied for effectiveness of eliminating infection and for the incidence of side effects. Cure rates were similar (91%) in all three groups, with fewer side effects in the 1.0 gm dosage group. (Editor's note: It should be remembered that metronidazole and alcohol may produce an antibuse-alcohol type reaction and therefore patients treated with metronidazole should avoid any alcoholic beverages for 24 hours after the last dose.) Brian Allen, MD
Clonazepam. Browne TR, N Engl J Med 299:812-815, (Oct) 1978. Clonazepam, a new antiepileptic drug of the benzodiazepine class, was approved in 1977. It is currently approved by the FDA for use in the following types of seizures: typical petit mal, infantile spasms, atypical petit mal, and myoclonic and atonic seizures. It is not approved for t r e a t m e n t of grand mal, psychomotor, or focal seizures. Intravenous clonazepam is effective for all types of status epilepticus. However it is probably no more effective than diazepam and has as its major toxicity sedation and cardiorespiratory depression. Most comm e n side effects are d r o w s i n e s s , a t a x i a , a n d b e h a v i o r changes. Tolerance with recurrence of seizures may occur after an initially good response. Overdosage can result in drowsiness, ataxia and cyclic coma. To date, all overdoses have recovered without sequelae. (Editor's note: We have seen a number of patients treated for grand mal epilepsy with this drug whose seizures are not well controlled. Perhaps this reflects their difficult seizure diathesis; perhaps a fad for a new drug improperly applied.) Hal Thomas, MD
epilepsy, drug treatment, clonazepam Atropine-induced ventricular fibrillation: case report and review of the literature. Cooper MJ, Abinader EG, Am Heart J 97:225-228, (Feb) 1979. This article presents a case report and review of the literature concerning bradycardia and hypotension in the early phases of myocardial infarction. The authors review a case of inferior diaphragmatic myocardial infarction in a patient with a pulse of 48 beats/min and a blood pressure of 95/70 mm Hg who was treated with 0.5 mg atropine intravenously. Over the following 5 min the pulse increased to a rate of 130 beats/min (sinus) and t h e n d e g e n e r a t e d into v e n t r i c u l a r tachycardia followed by ventricular fibrillation. Several similar case reports of ventricular dysrhythmias following the treatment of bradycardia with atropine are cited. They note t h a t bradycardia with myocardial infarction is associated w i t h a lower incidence of lethal ventricular d y s r h y t h m i a compared to patients with tachycardia or normal heart rates. In addition, recent reports do not demonstrate any increase in n u t r i e n t myocardial blood flow with atropine-induced rapid heart rates and diminished vagal tone. More than one third of patients given careful atropine titration in a Belfast coronary care unit demonstrated inappropriately rapid car-
96/116
atropine, ventricular fibrillation; myocardial infarction, atropine Single-dose metronidazole for trichomonal vaginitis: patient and consort. Dykers JR Jr, Am J Obstet Gyneco/ 129:579-580, (Nov) 1978.
vaginitis, trichomonal, drug treatment The esophageal obturator airway, a clinical comparison to ventilation with a mask and oropharyngeal airway. Bryson TK, Benumof JL, Ward CF, Chest 74:537-539, (Nov) 1978. Comparison of controlled ventilation with the esophageal obturator airway (EOA) to the conventional system of rubber m a s k and o r o p h a r y n g e a l a i r w a y was m a d e in 10 anesthetized patients scheduled for elective surgery under general anesthesia. Values for tidal volume were in all cases smaller with the EOA and in two cases were inadequate for survival. Leakage from the face mask was similar or greater in all cases with the EOA and in edentulous patients was marginal or unacceptable. Supraglottic obstruction was equal or greater in all cases with the EOA. Two of the 10 patients had accidental endotracheal intubation with the airway and required eventual direct laryngoscopic visualization. Placemerit of the EOA was cancelled in a third patient because of resistance to passage. Endotracheal intubation is the procedure of choice for resuscitative airway management. In situations in which it cannot be used, the standard mask and oropharyngeal airway appears to be preferable to the EOA. (Editor's note: This article is intriguing because of the number of complications seen with the esophageal airway. One wonders i f the incidence was so high because of the patients being anesthetized, or i f the lack of familiarity with the equipment played a role. We prefer endotracheal intubation when possible, but see a role for the EOA in the patient with potential neck injury in whom nasotracheal intubation cannot be achieved.) David H. Craig, MD
esophageal obturator airway
Ann Emerg Med
9:2 (February) 1980