A n x - r a y film by a portable u n i t confirmed a left-sided pneumothorax. A 14-gauge c a t h e t e r w a s i n s e r t e d intercostally a n d a rush of a i r escaped from the needle. His ven. t r i c u l a r t a c h y c a r d i a s u d d e n l y c o n v e r t e d to a sinus r h y t h m . A chest t u b e was i n s e r t e d and he was admit. t e d to the intensive care u n i t in s i n u s r h y t h m .
41/~ hours of dialysis. The p a t i e n t recovered uneventfully and was discharged the following day. Fred M. Reid, M D Department o f Emergency Medicine Charity Hospital o f Louisiana N e w Orleans, Louisiana 1. Martin EW (ed): Remington's Pharmaceutical Sciences, ed 13. Eaton, Pennsylvania, Mack Publishing Co, 1956, p 853854. 2. Phelan WJ III: Camphor poisoning: Over-the-counter dangers. Pediatrics 57:428-431, 1976. 3. Jacobziner H, Raybin HW: Camphor poisoning. Arch Pediatr 79:28-30, 1967. 4. Weiss J, Capalano P: Camphorated oil intoxication during pregnancy. Pediatrics 52:713-714, 1973. 5. Aronow R: Camphor poisoning. JAMA 235:1260, 1976. 6. Smith AG, Margolis G: Camphor poisoning; anatomical and pharmacological study; report of a fatal case; experimental investigation of protective action of barbiturate. A m J Pathol 30:857-869, 1954. 7. Vasey RH, Karayannopoulos SJ: Camphorated oil. Br Med J 1"112, 1972. 8. Bellman MH: Camphor poisoning in children. Br Med J
DISCUSSION A tension p n e u m o t h o r a x probably accounted for the p a t i e n t ' s r e s p i r a t o r y distress, d i m i n i s h e d breath sounds, and a r r h y t h m i a s . T h e e t i o l o g y for h i s i n t r a c t a b l e v e n t r i c u l a r t a c h y c a r d i a is speculative b u t probably was altered v e n t r i c u l a r r e p o l a r i z a t i o n f r o m hypoxia;1, 2 reflex s t i m u l i from p r e s s u r e receptors in the heart, great veins, p u l m o n a r y a r t e r y a n d lung; shift of the mediast i n a l structures; and d i m i n i s h e d c o r o n a r y perfusion and cardiac o u t p u t caused by decreased venous return. References to v e n t r i c u l a r a r r h y t h m i a associated w i t h tension p n e u m o t h o r a x in t h e l i t e r a t u r e are infrequent b u t t h e occurrence of a r r h y t h m i a s in chronic cor pulmonale and chronic obstructive p u l m o n a r y disease (COPD) are described more often2,2 The presence of a r r h y t h m i a s m a y a g g r a v a t e alr e a d y e x i s t i n g tissue hypoxia by c a u s i n g a reduction in cardiac output. 1 A r r h y t h m i a s can reduce the cardiac output by 80%. In acutely ill p a t i e n t s with COPD, v e n t r i c u l a r a r r h y t h m i a s indicate a grave prognosis. 3 In any event, in p a t i e n t s w i t h a p n e u m o t h o r a x , vent r i c u l a r t a c h y c a r d i a m a y respond only after insertion of a chest t u b e or needle.
2:177, 1973. 9. Riggs J, Hamilton R, Home] S, et al: Camphorated oil intoxication in pregnancy. Obstet Gynecol 25:255-258, 1965. 10. Robertson JS, Hussain M: Metabolism of camphors and related compounds. Biomed J 113:57-67, 1969. 11. Blackmon WP, Curry HB: Camphor poisoning: Report of a case occurring during pregnancy. J Fla Med Assoc 43:9991000, 1957.
Donald Forester, MD Queens Hospital Center Jamaica, N e w York 1. Halford FD, Mithoefer JC: Cardiac arrhythmias in hospitalized patients with COPD. Am Rev Resp Dis 109:879-885, 1973. 2. Corazza LJ, Pastor BH: Cardiac arrhythmias in chronic car pulmonale. N Engl J Med 259:862-865, 1958. 3. Senior RM, Lefrak SS, Kleiger RE: The heart in chronic obstructive pulmonary disease; arrhythmias. Chest 75:1-2, 1979.
12. Ginn HE, Anderson KE, Mercier RK, et al: Camphor intoxication treated by lipid dialysis. JAMA 203:230-231, 1968. 13. Corby DC, Decker WJ: Management of acute poisoning with activated charcoal. Pediatrics 54:324-328, 1974.
14. National Clearinghouse of Poison Control Centers Bulletin. US Dept HEW, Bethesda, MD, July-August, 1975, p 1-2.
Ventricular Tachycardia with Tension Pneumothorax To the Editor:
Asthmatic Evaluation by Spirometry
Tension p n e u m o t h o r a x not only causes ST a n d T wave changes, as r e p o r t e d by Slay et al in ~ T r a n s i e n t ST E l e v a t i o n s A s s o c i a t e d w i t h T e n s i o n P n e u m o thorax" (8:16-18, 1979), b u t m a y also be responsible for i n t r a c t a b l e v e n t r i c u l a r t a c h y c a r d i a as in the following brief case report.
To the Editor: The article by N o w a k et al, ~Spirometrie Evaluat i o n of A c u t e B r o n c h i a l A s t h m a " (8:9-15, 1979), f u r t h e r confirms t h e need and usefulness of puhnon a r y function t e s t i n g of a s t h m a t i c s in t h e emergency d e p a r t m e n t , b u t I m u s t t a k e issue w i t h two key points not a d e q u a t e l y discussed in t h e study. F i r s t of all, the a u t h o r s have a r b i t r a r i l y divided t h e i r a s t h m a t i c p a t i e n t s into t h r e e groups based on t h e i r FEVI.o on p r e s e n t a t i o n and the change in FEV1.0 p o s t t r e a t m e n t , w i t h o u t r e g a r d to age, h e i g h t , or weight. In short, t h e y d i s r e g a r d predicted FE¥1.o values according to accepted s t a n d a r d s . I believe ~his is an i n h e r e n t inaccuracy in t h e i r m e t h o d of evaluation. For example, a 6 ' 2 " 20-year-old m a n would have a predicted FEV1.0 of 4.81, while a 5' 40-year-old woman would have a predicted v a l u e of less t h a n h a l f of that, or 2.22. Thus to place such p a t i e n t s in the same clinical group based solely on absolute FEVI.o would be at-
CASE REPORT A 55-year-old m a n was b r o u g h t into the emergency d e p a r t m e n t in r e s p i r a t o r y distress. He h a d a h i s t o r y of s e v e r a l p n e u m o t h o r a c e s from c o n g e n i t a l blebs. D u r i n g t h e e x a m i n a t i o n he h a d a r e s p i r a t o r y arrest, followed by a g r a n d m a l seizure and ventricul a r tachycardia. He was i n t u b a t e d a n d given assisted v e n t i l a t i o n and i n t r a v e n o u s lidocaine. On a u s c u l t a tion of his lungs, d i m i n i s h e d b r e a t h sounds were noted in the left chest. His v e n t r i c u l a r t a c h y c a r d i a persisted d e s p i t e a t t e m p t s to c o n v e r t h i m e l e c t r i c a l l y a n d p h a r m a c o l o g i c a l l y (lidocaine, procainamide, b r e t y l i u m tosylate, and propranolol). The endotracheal tube was pulled back b u t din~inished b r e a t h sounds persisted.
70/340
JACEP
8:8 (August) 1979
Authors' Reply
b i t r a r y a n d i n a c c u r a t e . L i k e w i s e , t h e c h a n g e in FEV1.0 in a large m a n after t r e a t m e n t (ie, of 0.49, the mean change of group II) would necessarily reflect a smaller i m p r o v e m e n t t h a n in a small woman. Secondly, the authors give no figures as to length of t r e a t m e n t of each group, a variable t h a t seems to be taking on a n i n c r e a s i n g significance. Kelsen et al 1 have studied 127 emergency d e p a r t m e n t visits of 102 patients and likewise measured FEVI.o and change in FEV~.0 b u t have recorded t r e a t m e n t times. In their series, patients treated for a n average of two hours u n d e r a s t a n d a r d protocol had a m e a n AFEVI.o of 0.485 with a relapse rate of 55.6%, while those treated for an average of 31/2 hours had a AFEV~.o of 1.313 and a relapse rate of only 4%, regardless of clinical status or FEVI.o at the time of presentation. It has become increasingly e v i d e n t t h a t an objective clinical test for e v a l u a t i n g the asthmatic p a t i e n t is n e c e s s a r y , e s p e c i a l l y for use by the e m e r g e n c y physician. D i s a p p e a r a n c e of wheezing a n d d y s p n e a has not correlated well with i m p r o v e m e n t in pulmonary function, a l t h o u g h sternocleidomastoid muscle retraction has. 2 Additionally pO2 has a c t u a l l y been found to decrease i n a s t h m a t i c s g i v e n i n h a l e d isoproterenol, p r e s u m a b l y due to vasodilation of hypoxia-constricted vessels to poorly profused areas. 3 The FEV1.0 has been widely accepted as a reliable .indicator of the degree of obstructive airway disease. The test requires a minim,um of portable e q u i p m e n t which is easy to use and v a l u a b l e i n d e t e r m i n i n g adequacy of t r e a t m e n t . Nowak et al have used this method effectively b u t I feel a modification of their approach u s i n g predicted FEVLo values and a more standardized absolute time of t r e a t m e n t , regardless of clinical status, is required for proper use of p u l m o n a r y function t e s t i n g in the emergency department.
Dr. Kulig has misread our report with regard to the method for grouping patients. This was done according to their clinical a s s e s s m e n t (admissions, discharged patients who had s u b s e q u e n t problems, and discharged patients who did well). The spirometric results were analyzed later. We a g r e e t h a t a b s o l u t e s p i r o m e t r i c v a l u e s (FEVI.o) have different levels of clinical significance according to the age, sex, and height of the patient. However, these demographic differences require reference to tables of predicted n o r m a l values or nomograms that c u r r e n t l y are not kept in most emergency departments. It is i n t e r e s t i n g t h a t Dr. Kulig refers to the paper by Kelsen et al. These authors, like us, also analyzed patients p r i m a r i l y according to their absolute FEVI.o values. Moreover, the m e a n p o s t t r e a t m e n t FEVI.o in Kelsen's patients with relapse was 1,563 + 108 ml. Our group II p a t i e n t s h a d a m e a n posttreatm e n t FEVLo of 1.54 + 0.47 liter. The m e a n FEV1.0 in Kelsen's patients w i t h o u t relapse was 1,879 + 110 ml compared to our group III m e a n value of 1.9 + 0.68 liter. Our data analysis was a n a t t e m p t to identify one or two absolute n u m b e r s ( p r e t r e a t m e n t FEV~.o = 0.6 liter, p o s t t r e a t m e n t FEV1.0= 1.6 liter) that m i g h t be remembered to serve as a simple reference point in guiding clinical decisions about m a n a g e m e n t . We also agree with Dr. Kulig that a longer course of intensive t r e a t m e n t in the emergency d e p a r t m e n t is likely to produce a greater degree of reversal of airway o b s t r u c t i o n . H o w e v e r , 'all of us h a v e faced t h e d i l e m m a of the a s t h m a t i c p a t i e n t who continues to "look bad" even after t r e a t m e n t . At that point, the t r e a t i n g physician either prolongs the emergency dep a r t m e n t t r e a t m e n t or decides to admit or release the patient. Our study was a n a t t e m p t to develop simple objective criteria by which such decisions can be made promptly.
Ken Kulig, MD Presbyterian Medical Center Denver, Colorado
Richard M. Nowak, MD Paul A. Kvalel MD Michael C. Tomlanovich, MD Divisions of Emergency Medicine and Pulmonary Medicine Henry Ford Hospital Detroit, Michigan
1. Kelsen SG, Kelsen DP, Fleegler BF, et ah Emergency room assessment and treatment of patients with acute asthma. Am J Med 64:622-628, 1978. 2. McFadden ER Jr, Kiser R, Degroot WJ: Acute bronchial asthma: relations between clinical and physiologic manifestations. N Engl J Med 288:221-225, 1973. 3. Gazioglu K, Condemi JJ, Hyde RW, et al: Effect of isoproterenol on gas exchange during air and oxygen breathing in patients with asthma. Am J Med 50:185-190, 1971.
8:8 (August)t 979
JACEP
341/71
41/~ hours of dialysis. The p a t i e n t recovered uneventfully and was discharged the following day. Fred M. Reid, M D Department o f Emergency Medicine Charity Hospital o f Louisiana N e w Orleans, Louisiana 1. Martin EW (ed): Remington's Pharmaceutical Sciences, ed 13. Eaton, Pennsylvania, Mack Publishing Co, 1956, p 853854. 2. Phelan WJ III: Camphor poisoning: Over-the-counter dangers. Pediatrics 57:428-431, 1976. 3. Jacobziner H, Raybin HW: Camphor poisoning. Arch Pediatr 79:28-30, 1967. 4. Weiss J, Capalano P: Camphorated oil intoxication during pregnancy. Pediatrics 52:713-714, 1973. 5. Aronow R: Camphor poisoning. JAMA 235:1260, 1976. 6. Smith AG, Margolis G: Camphor poisoning; anatomical and pharmacological study; report of a fatal case; experimental investigation of protective action of barbiturate. A m J Pathol 30:857-869, 1954. 7. Vasey RH, Karayannopoulos SJ: Camphorated oil. Br Med J 1"112, 1972. 8. Bellman MH: Camphor poisoning in children. Br Med J
DISCUSSION A tension p n e u m o t h o r a x probably accounted for the p a t i e n t ' s r e s p i r a t o r y distress, d i m i n i s h e d breath sounds, and a r r h y t h m i a s . T h e e t i o l o g y for h i s i n t r a c t a b l e v e n t r i c u l a r t a c h y c a r d i a is speculative b u t probably was altered v e n t r i c u l a r r e p o l a r i z a t i o n f r o m hypoxia;1, 2 reflex s t i m u l i from p r e s s u r e receptors in the heart, great veins, p u l m o n a r y a r t e r y a n d lung; shift of the mediast i n a l structures; and d i m i n i s h e d c o r o n a r y perfusion and cardiac o u t p u t caused by decreased venous return. References to v e n t r i c u l a r a r r h y t h m i a associated w i t h tension p n e u m o t h o r a x in t h e l i t e r a t u r e are infrequent b u t t h e occurrence of a r r h y t h m i a s in chronic cor pulmonale and chronic obstructive p u l m o n a r y disease (COPD) are described more often2,2 The presence of a r r h y t h m i a s m a y a g g r a v a t e alr e a d y e x i s t i n g tissue hypoxia by c a u s i n g a reduction in cardiac output. 1 A r r h y t h m i a s can reduce the cardiac output by 80%. In acutely ill p a t i e n t s with COPD, v e n t r i c u l a r a r r h y t h m i a s indicate a grave prognosis. 3 In any event, in p a t i e n t s w i t h a p n e u m o t h o r a x , vent r i c u l a r t a c h y c a r d i a m a y respond only after insertion of a chest t u b e or needle.
2:177, 1973. 9. Riggs J, Hamilton R, Home] S, et al: Camphorated oil intoxication in pregnancy. Obstet Gynecol 25:255-258, 1965. 10. Robertson JS, Hussain M: Metabolism of camphors and related compounds. Biomed J 113:57-67, 1969. 11. Blackmon WP, Curry HB: Camphor poisoning: Report of a case occurring during pregnancy. J Fla Med Assoc 43:9991000, 1957.
Donald Forester, MD Queens Hospital Center Jamaica, N e w York 1. Halford FD, Mithoefer JC: Cardiac arrhythmias in hospitalized patients with COPD. Am Rev Resp Dis 109:879-885, 1973. 2. Corazza LJ, Pastor BH: Cardiac arrhythmias in chronic car pulmonale. N Engl J Med 259:862-865, 1958. 3. Senior RM, Lefrak SS, Kleiger RE: The heart in chronic obstructive pulmonary disease; arrhythmias. Chest 75:1-2, 1979.
12. Ginn HE, Anderson KE, Mercier RK, et al: Camphor intoxication treated by lipid dialysis. JAMA 203:230-231, 1968. 13. Corby DC, Decker WJ: Management of acute poisoning with activated charcoal. Pediatrics 54:324-328, 1974.
14. National Clearinghouse of Poison Control Centers Bulletin. US Dept HEW, Bethesda, MD, July-August, 1975, p 1-2.
Ventricular Tachycardia with Tension Pneumothorax To the Editor:
Asthmatic Evaluation by Spirometry
Tension p n e u m o t h o r a x not only causes ST a n d T wave changes, as r e p o r t e d by Slay et al in ~ T r a n s i e n t ST E l e v a t i o n s A s s o c i a t e d w i t h T e n s i o n P n e u m o thorax" (8:16-18, 1979), b u t m a y also be responsible for i n t r a c t a b l e v e n t r i c u l a r t a c h y c a r d i a as in the following brief case report.
To the Editor: The article by N o w a k et al, ~Spirometrie Evaluat i o n of A c u t e B r o n c h i a l A s t h m a " (8:9-15, 1979), f u r t h e r confirms t h e need and usefulness of puhnon a r y function t e s t i n g of a s t h m a t i c s in t h e emergency d e p a r t m e n t , b u t I m u s t t a k e issue w i t h two key points not a d e q u a t e l y discussed in t h e study. F i r s t of all, the a u t h o r s have a r b i t r a r i l y divided t h e i r a s t h m a t i c p a t i e n t s into t h r e e groups based on t h e i r FEVI.o on p r e s e n t a t i o n and the change in FEV1.0 p o s t t r e a t m e n t , w i t h o u t r e g a r d to age, h e i g h t , or weight. In short, t h e y d i s r e g a r d predicted FE¥1.o values according to accepted s t a n d a r d s . I believe ~his is an i n h e r e n t inaccuracy in t h e i r m e t h o d of evaluation. For example, a 6 ' 2 " 20-year-old m a n would have a predicted FEV1.0 of 4.81, while a 5' 40-year-old woman would have a predicted v a l u e of less t h a n h a l f of that, or 2.22. Thus to place such p a t i e n t s in the same clinical group based solely on absolute FEVI.o would be at-
CASE REPORT A 55-year-old m a n was b r o u g h t into the emergency d e p a r t m e n t in r e s p i r a t o r y distress. He h a d a h i s t o r y of s e v e r a l p n e u m o t h o r a c e s from c o n g e n i t a l blebs. D u r i n g t h e e x a m i n a t i o n he h a d a r e s p i r a t o r y arrest, followed by a g r a n d m a l seizure and ventricul a r tachycardia. He was i n t u b a t e d a n d given assisted v e n t i l a t i o n and i n t r a v e n o u s lidocaine. On a u s c u l t a tion of his lungs, d i m i n i s h e d b r e a t h sounds were noted in the left chest. His v e n t r i c u l a r t a c h y c a r d i a persisted d e s p i t e a t t e m p t s to c o n v e r t h i m e l e c t r i c a l l y a n d p h a r m a c o l o g i c a l l y (lidocaine, procainamide, b r e t y l i u m tosylate, and propranolol). The endotracheal tube was pulled back b u t din~inished b r e a t h sounds persisted.
70/340
JACEP
8:8 (August) 1979
Authors' Reply
b i t r a r y a n d i n a c c u r a t e . L i k e w i s e , t h e c h a n g e in FEV1.0 in a large m a n after t r e a t m e n t (ie, of 0.49, the mean change of group II) would necessarily reflect a smaller i m p r o v e m e n t t h a n in a small woman. Secondly, the authors give no figures as to length of t r e a t m e n t of each group, a variable t h a t seems to be taking on a n i n c r e a s i n g significance. Kelsen et al 1 have studied 127 emergency d e p a r t m e n t visits of 102 patients and likewise measured FEVI.o and change in FEV~.0 b u t have recorded t r e a t m e n t times. In their series, patients treated for a n average of two hours u n d e r a s t a n d a r d protocol had a m e a n AFEVI.o of 0.485 with a relapse rate of 55.6%, while those treated for an average of 31/2 hours had a AFEV~.o of 1.313 and a relapse rate of only 4%, regardless of clinical status or FEVI.o at the time of presentation. It has become increasingly e v i d e n t t h a t an objective clinical test for e v a l u a t i n g the asthmatic p a t i e n t is n e c e s s a r y , e s p e c i a l l y for use by the e m e r g e n c y physician. D i s a p p e a r a n c e of wheezing a n d d y s p n e a has not correlated well with i m p r o v e m e n t in pulmonary function, a l t h o u g h sternocleidomastoid muscle retraction has. 2 Additionally pO2 has a c t u a l l y been found to decrease i n a s t h m a t i c s g i v e n i n h a l e d isoproterenol, p r e s u m a b l y due to vasodilation of hypoxia-constricted vessels to poorly profused areas. 3 The FEV1.0 has been widely accepted as a reliable .indicator of the degree of obstructive airway disease. The test requires a minim,um of portable e q u i p m e n t which is easy to use and v a l u a b l e i n d e t e r m i n i n g adequacy of t r e a t m e n t . Nowak et al have used this method effectively b u t I feel a modification of their approach u s i n g predicted FEVLo values and a more standardized absolute time of t r e a t m e n t , regardless of clinical status, is required for proper use of p u l m o n a r y function t e s t i n g in the emergency department.
Dr. Kulig has misread our report with regard to the method for grouping patients. This was done according to their clinical a s s e s s m e n t (admissions, discharged patients who had s u b s e q u e n t problems, and discharged patients who did well). The spirometric results were analyzed later. We a g r e e t h a t a b s o l u t e s p i r o m e t r i c v a l u e s (FEVI.o) have different levels of clinical significance according to the age, sex, and height of the patient. However, these demographic differences require reference to tables of predicted n o r m a l values or nomograms that c u r r e n t l y are not kept in most emergency departments. It is i n t e r e s t i n g t h a t Dr. Kulig refers to the paper by Kelsen et al. These authors, like us, also analyzed patients p r i m a r i l y according to their absolute FEVI.o values. Moreover, the m e a n p o s t t r e a t m e n t FEVI.o in Kelsen's patients with relapse was 1,563 + 108 ml. Our group II p a t i e n t s h a d a m e a n posttreatm e n t FEVLo of 1.54 + 0.47 liter. The m e a n FEV1.0 in Kelsen's patients w i t h o u t relapse was 1,879 + 110 ml compared to our group III m e a n value of 1.9 + 0.68 liter. Our data analysis was a n a t t e m p t to identify one or two absolute n u m b e r s ( p r e t r e a t m e n t FEV~.o = 0.6 liter, p o s t t r e a t m e n t FEV1.0= 1.6 liter) that m i g h t be remembered to serve as a simple reference point in guiding clinical decisions about m a n a g e m e n t . We also agree with Dr. Kulig that a longer course of intensive t r e a t m e n t in the emergency d e p a r t m e n t is likely to produce a greater degree of reversal of airway o b s t r u c t i o n . H o w e v e r , 'all of us h a v e faced t h e d i l e m m a of the a s t h m a t i c p a t i e n t who continues to "look bad" even after t r e a t m e n t . At that point, the t r e a t i n g physician either prolongs the emergency dep a r t m e n t t r e a t m e n t or decides to admit or release the patient. Our study was a n a t t e m p t to develop simple objective criteria by which such decisions can be made promptly.
Ken Kulig, MD Presbyterian Medical Center Denver, Colorado
Richard M. Nowak, MD Paul A. Kvalel MD Michael C. Tomlanovich, MD Divisions of Emergency Medicine and Pulmonary Medicine Henry Ford Hospital Detroit, Michigan
1. Kelsen SG, Kelsen DP, Fleegler BF, et ah Emergency room assessment and treatment of patients with acute asthma. Am J Med 64:622-628, 1978. 2. McFadden ER Jr, Kiser R, Degroot WJ: Acute bronchial asthma: relations between clinical and physiologic manifestations. N Engl J Med 288:221-225, 1973. 3. Gazioglu K, Condemi JJ, Hyde RW, et al: Effect of isoproterenol on gas exchange during air and oxygen breathing in patients with asthma. Am J Med 50:185-190, 1971.
8:8 (August)t 979
JACEP
341/71
