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Ultralight aircraft accidents
1985 through December 1986 included a total of 117 responses for trauma. Our average ground time was only 16.2 minutes. Five patients were pronounced dead at the scene of the accident, and 15 more died in the ED, for an initial mortality rate of 17% (NS, P > .05). Again, although it is difficult to compare different patient populations, the similarity between our results and those of Anderson suggests that the "benefit" of having a physician aboard the helicopter is extremely difficult to demonstrate. We believe that the primary contribution of the physician to the care of the patient with AMI or severe multiple trauma is in the ED and the operating room. Moreover, this comparison tends to support our clinical
suspicion that most physicians spend inappropriately long periods in the field. Dr Anderson's program (with physicians) spent twice as long at each scene as did our program (with physicians on only 5% of flights) with no difference in outcome.
Thomas J Poulton, MD, FAAP, FCCP, FACP Pamela J Gutierrez, RN, CCRN, CEN, NREMT-P Daniel J Schwabe, RN, NREMT-P Life Flight Saint Joseph Hospital Omaha, Nebraska
Remember the Physical Examination To the Editor: The article "Differentiation of Ventricular Tachycardia from Supraventricular Tachycardia with Aberration: Value of the Clinical History" [January 1987; 16:40-43] by Baerman et al raises several interesting points but fails to mention one very important one: examination of the patient. In a time when medicine is becoming increasingly sophisticated it behooves us to remember the physical examination. As mentioned by the authors, atrial-ventricular dissociation is highly suggestive that a wide-complex tachycardia is ventricular in origin. One important clue in determining atrial-ventricular dissociation is the pattern of the jugular venous pulse. The "a" wave in the venous pulse is caused by venous distension secondary to right atrial systole. While it is often not readily distinguishable, the "a" wave can be recognized when it is abnormally prominent. It occurs just before the first heart sound and is marked by a rapid rise and fall. Prominent "a" waves occur in patients with a sinus rhythm and tricuspid stenosis and right ventricular hypertension. Cannon (very large) "a" waves are seen in patients with atrial-ventricular dissociation when the right atrium contracts against a closed tricuspid valve. It would be interesting to know if Baerman et al specifically looked for cannon waves. One additional point is w o r t h n o t i n g : a l t h o u g h atrial-ventricular d i s s o c i a t i o n strongly supports ventricular tachycardia, retrograde ventricular-atrial conduction m a y occur, and the ventricular tachycardia may therefore not exhibit atrial-ventricnlar dis-
sociation. 1 Conversely atrial-ventricular dissociation can rarely occur in supraventricular tachycardia. 2
Marc Nelson, MD Department of Emergency Services Stanford University Hospital Stanford, California 1. Kirsten AD: Retrograde conduction to the atria in ventricular tachycardia. Circulation 1961;24:236. 2. Brunwald E: Heart Disease: A Textbook of Cardiovascular Medicine. Philadelphia, WB Saunders Co, 1984, p 637.
In ~eply: Our article was not meant to be a general review on the differentiation of ventricular from supraventricular tachycardia. This is w h y it did not discuss the value of the jugular venous pulse. In our study, which was retrospective, reliable data on the jugular venous pulse were not available. There is no question that an irregular pattern of cannon waves indicates atrioventricular dissociation and a high likelihood that a tachycardia is ventricular in origin. 1
Fred Morady, MD University of Michigan Medical Center Ann Arbor 1. Morady F: Ventricular tachycardia, in Callaham ML {ed): Current Therapy in EmergencyMedicine. Toronto, BC Decker, Inc, 1987, p 436-440.
Ultralight Aircraft Accidents To the Editor: During the past ten years, ultralight aircraft, which are essentially m o t o r i z e d versions of hang gliders, have increased in popularity as a recreational aircraft. The increase in the use of ultralight aircraft has led to an increase in the number of crashes. Only three cases involving injuries associated with ultralight aircraft accidents have been presented in the English literature, as indicated by Zwimpfer and Gertzbein; 1 all involve fractures of the t h o r a c o l u m b a r spine. One fracture was a burst fracture of T-10 that resulted 16:12 December 1987
in no neurological deficit. The second fracture was a bilateral facet dislocation of Tll-T12. The third case was a L-1 burst fracture with displacement of bony fragments into the spinal canal that resulted in an incomplete neurological lesion. We saw a 57-year-old m a n who presented to the emergency department with neck and mid-back pain after crash landing his ultralight aircraft. Physical examination found that the patient was tender over the posterior region of C-2
Annals of Emergency Medicine
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CORRESPONDENCE
only. Radiographs and CT scanning revealed a fracture involving the posterior aspect of the lamina of C-2. The patient demonstrated no neurological deficit and was treated with bed rest and a Philadelphia collar. In communications with the Experimental Aircraft Association (EAA), we have received preliminary information pertaining to injuries associated with ultralight accidents from voluntary accident reports filed with the EAA. In the 3.5-year voluntary study of ultralight accidents that ended in January 1982, the EAA reported 101 accidents with 20 fatalities and 31 injuries. 2 Injuries sustained in the ultralight crashes included spinal fractures, fractures of the legs and ankles, lacerations, severe internal injuries, and massive trauma that resulted in death. With the increasing number of ultralight accidents, there must be more reporting on the
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injuries associated with these accidents in order to elicit characteristic injuries that m a y be specifically associated with this type of aircraft. William Masius, MS Thomas Knight, MD Department of Emergency Medicine East Carolina University School of Medicine Greenville, North Carolina "1. ZwimpferT], GertzbeinSG: Ultralight aircraft crashes: Tl~eirincreasing incidence and associated fractures of the thoracolumbar spine, f Trauma 1987;27:431-436. 2. Mosely HS: Ultralight aircraft safety and regulation. Aviat Space Environ 1983;54:944-948.
Annals of Emergency Medicine
16:12 December 1987
suspicion that most physicians spend inappropriately long periods in the field. Dr Anderson's program (with physicians) spent twice as long at each scene as did our program (with physicians on only 5% of flights) with no difference in outcome.
Thomas J Poulton, MD, FAAP, FCCP, FACP Pamela J Gutierrez, RN, CCRN, CEN, NREMT-P Daniel J Schwabe, RN, NREMT-P Life Flight Saint Joseph Hospital Omaha, Nebraska
Remember the Physical Examination To the Editor: The article "Differentiation of Ventricular Tachycardia from Supraventricular Tachycardia with Aberration: Value of the Clinical History" [January 1987; 16:40-43] by Baerman et al raises several interesting points but fails to mention one very important one: examination of the patient. In a time when medicine is becoming increasingly sophisticated it behooves us to remember the physical examination. As mentioned by the authors, atrial-ventricular dissociation is highly suggestive that a wide-complex tachycardia is ventricular in origin. One important clue in determining atrial-ventricular dissociation is the pattern of the jugular venous pulse. The "a" wave in the venous pulse is caused by venous distension secondary to right atrial systole. While it is often not readily distinguishable, the "a" wave can be recognized when it is abnormally prominent. It occurs just before the first heart sound and is marked by a rapid rise and fall. Prominent "a" waves occur in patients with a sinus rhythm and tricuspid stenosis and right ventricular hypertension. Cannon (very large) "a" waves are seen in patients with atrial-ventricular dissociation when the right atrium contracts against a closed tricuspid valve. It would be interesting to know if Baerman et al specifically looked for cannon waves. One additional point is w o r t h n o t i n g : a l t h o u g h atrial-ventricular d i s s o c i a t i o n strongly supports ventricular tachycardia, retrograde ventricular-atrial conduction m a y occur, and the ventricular tachycardia may therefore not exhibit atrial-ventricnlar dis-
sociation. 1 Conversely atrial-ventricular dissociation can rarely occur in supraventricular tachycardia. 2
Marc Nelson, MD Department of Emergency Services Stanford University Hospital Stanford, California 1. Kirsten AD: Retrograde conduction to the atria in ventricular tachycardia. Circulation 1961;24:236. 2. Brunwald E: Heart Disease: A Textbook of Cardiovascular Medicine. Philadelphia, WB Saunders Co, 1984, p 637.
In ~eply: Our article was not meant to be a general review on the differentiation of ventricular from supraventricular tachycardia. This is w h y it did not discuss the value of the jugular venous pulse. In our study, which was retrospective, reliable data on the jugular venous pulse were not available. There is no question that an irregular pattern of cannon waves indicates atrioventricular dissociation and a high likelihood that a tachycardia is ventricular in origin. 1
Fred Morady, MD University of Michigan Medical Center Ann Arbor 1. Morady F: Ventricular tachycardia, in Callaham ML {ed): Current Therapy in EmergencyMedicine. Toronto, BC Decker, Inc, 1987, p 436-440.
Ultralight Aircraft Accidents To the Editor: During the past ten years, ultralight aircraft, which are essentially m o t o r i z e d versions of hang gliders, have increased in popularity as a recreational aircraft. The increase in the use of ultralight aircraft has led to an increase in the number of crashes. Only three cases involving injuries associated with ultralight aircraft accidents have been presented in the English literature, as indicated by Zwimpfer and Gertzbein; 1 all involve fractures of the t h o r a c o l u m b a r spine. One fracture was a burst fracture of T-10 that resulted 16:12 December 1987
in no neurological deficit. The second fracture was a bilateral facet dislocation of Tll-T12. The third case was a L-1 burst fracture with displacement of bony fragments into the spinal canal that resulted in an incomplete neurological lesion. We saw a 57-year-old m a n who presented to the emergency department with neck and mid-back pain after crash landing his ultralight aircraft. Physical examination found that the patient was tender over the posterior region of C-2
Annals of Emergency Medicine
1413/139
CORRESPONDENCE
only. Radiographs and CT scanning revealed a fracture involving the posterior aspect of the lamina of C-2. The patient demonstrated no neurological deficit and was treated with bed rest and a Philadelphia collar. In communications with the Experimental Aircraft Association (EAA), we have received preliminary information pertaining to injuries associated with ultralight accidents from voluntary accident reports filed with the EAA. In the 3.5-year voluntary study of ultralight accidents that ended in January 1982, the EAA reported 101 accidents with 20 fatalities and 31 injuries. 2 Injuries sustained in the ultralight crashes included spinal fractures, fractures of the legs and ankles, lacerations, severe internal injuries, and massive trauma that resulted in death. With the increasing number of ultralight accidents, there must be more reporting on the
140/1414
injuries associated with these accidents in order to elicit characteristic injuries that m a y be specifically associated with this type of aircraft. William Masius, MS Thomas Knight, MD Department of Emergency Medicine East Carolina University School of Medicine Greenville, North Carolina "1. ZwimpferT], GertzbeinSG: Ultralight aircraft crashes: Tl~eirincreasing incidence and associated fractures of the thoracolumbar spine, f Trauma 1987;27:431-436. 2. Mosely HS: Ultralight aircraft safety and regulation. Aviat Space Environ 1983;54:944-948.
Annals of Emergency Medicine
16:12 December 1987