Letters to Editor
4.
Kakitsubata Y, Theodorou SJ, Theodorou DJ, Yuko M, Ito Y, Yuki Y, et al. Symptomatic epidural gas cyst associated with discal vacuum phenomenon. Spine (Phila Pa 1976) 2009;34:E784-9.
5.
Wang YX, Griffith JF, Zeng XJ, Deng M, Kwok AW, Leung JC, et al. Prevalence and sex difference of lumbar disc space narrowing in elderly chinese men and women: Osteoporotic fractures in men (Hong Kong) and osteoporotic fractures in women (Hong Kong) studies. Arthritis Rheum 2013;65:1004-10. Access this article online Quick Response Code: Website: www.onlinejets.org
DOI: 10.4103/0974-2700.155524
Figure 2: An image of a traumatic PAN-SCAN taken of case 2 on arrival. An 89-nine-year-old female sustained head contusional wounds and cervical central spinal cord syndrome manifesting as bilateral dysesthesia of the hands after falling from a 3 m height. The PAN-SCAN revealed pneumorrhachis at the lumbosacral level (black arrow)
of gas, principally nitrogen, from surrounding tissues, and accumulation within the cracks, clefts or crevices, which form in the disc as it degenerates with aging, usually in the lumbar region.[4] The discrepancy in the frequencies between the vacuum disc and pneumorrhachis may be because the vacuum disc was rigid, thus leading to the retention of gas.[4] The prevalence and severity of disc space narrowing, characterized by degenerative changes, are both higher in elderly females than elderly males.[5] Accordingly, our findings suggested that it may have been incidentally detected vacuum phenomenon by the traumatic PAN-SCAN. In conclusion, pneumorrhachis detected by traumatic PAN-SCANs tends to be found in elderly females at the lumbosacral region. If the patient does not have a direct open wound into the spinal canal, pneumocephalus, pneumomediastinum, or pneumothorax, the diagnostic significance is minimized.
Mariko Obinata, Kazuhiko Omori, Kouhei Ishikawa, Hiromichi Osaka, Yasumasa Oode, Youichi Yanagawa Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Izunokuni, Shizuoka, Japan. E-mail: [email protected]
REFERENCES 1.
Gautschi OP, Hermann C, Cadosch D. Spinal epidural air after severe pelvic and abdominal trauma. Am J Emerg Med 2008;26:740.e3-5.
2.
Nakmura H, Murase K, Noguchi Y, Tawara M, Sadamitsu T, Yamaguchi K, et al. A case of decompressive sickness after diving into cultured fishes swim. Nagasaki Igakkaizasshi 2013;88:181-6.
3.
Yanagawa Y, Takasu A, Sugiura T, Okada Y. A case of cervical pneumorrhachis induced by the combination of pneumomediastinum and root avulsion injuries. Eur Spine J 2007;16:573-4.
Journal of Emergencies, Trauma, and Shock I 8:2 I Apr - Jun 2015
Hints in electrocardiography for coming myocardial infarction Dear Editor, The electrocardiogram (ECG) is a simple and non-invasive bedside diagnostic tool. Inversion of the T wave is a common electrocardiographic abnormality and can be interpreted as non-specific. Knowing the early changes in ECG for ischemia is crucial for the timely diagnosis of myocardial ischemia. Here, we present a 54-year-old woman admitted to the emergency department (ED) who had a normal ECG initially, which progressed with T inversions in leads aVL and V2 and resulted in inferior ST-elevated myocardial infarction (STEMI). She was admitted to the ED with complaints of sweating, discomfort and palpitation for two hours. Her blood pressure was 130/80 mmHg and pulse was 98/min, with 98% saturation using a pulse oximeter; her physical examination was normal. The patient was monitored, an ECG was taken, intravenous access was established, and blood samples were obtained for hemogram and routine chemical tests. Her initial ECG was completely normal [Figure 1]. Twenty minutes after her admission, she described a new onset of pain in her left axillary region. A new ECG was obtained and showed T wave inversions at derivations aVL and V2, which were different from her initial ECG [Figure 2]. Fifteen minutes later, the patient started to sweat and described her pain spreading to her chest and left arm. A new ECG was obtained and ST-segment elevations at derivations D2, D3 and aVF, and reciprocal changes at aVL, V1 and V2 were present [Figure 3]. The patient was given intravenous thrombolytic therapy in the ED and was admitted to our cardiology intensive care unit. Coronary angiography was performed 24 hours 121
Letters to Editor
Figure 2: T wave inversions in leads aVL and V2 were present in the second electrocardiogram, which was obtained 20 minutes after the patient’s admission Figure 1: The first normal electrocardiogram of the patient
Figure 4: The stenosis in the proximal left main coronary artery and total occlusion in the left anterior descending artery are visible on coronary angiogram Figure 3: ST-segment elevations at derivations D2, D3 and aVF, and reciprocal changes at aVL, V1 and V2 were present in the third electrocardiogram, which was obtained 35 minutes after the patient’s admission
Emergent coronary artery bypass grafting operation was planned and she was transferred to the cardiovascular surgery clinic. In the setting of acute coronary syndrome, several ECG findings help to localize the occluded vessel and occlusion site.[1,2] Certain T wave abnormalities in precordial leads are early warnings for an MI. Either the positive-negative biphasic T waves or the deeply inverted T waves that often follow them, when occurring in the precordial leads, are nearly pathognomonic of very recent severe ischemia or injury in the distribution area of the LAD and characterize Wellens syndrome.[3] T wave inversion in aVL significantly predicts LAD lesions typically in the mid-segment.[4] This finding should alert the health care providers during ECG interpretation. ST elevation in V5 and V6 are associated with large-vessel occlusion, larger infarct size and ST depression, while flat T waves in these leads indicate the probability of three-vessel disease in inferior STEMI patients.[5]
Figure 5: The stenosis in the right coronary artery is visible on coronary angiogram
later. There was stenosis in the proximal left main coronary artery (70%) and right coronary artery (85% and 90%) and total occlusion in the left anterior descending artery (LAD) [Figures 4 and 5]. 122
Our case shows that T wave inversions in leads aVL and V2, which can be thought of as non-specific may be a predictor of the following inferior MI. Observation of the patient and obtaining serial ECGs are important for not overlooking a myocardial ischemia developing into infarction. Journal of Emergencies, Trauma, and Shock I 8:2 I Apr - Jun 2015
Letters to Editor
Erden Erol Ünlüer, Arif Karagöz1 Department of Emergency, Atatürk Research and Training Hospital, Izmir Katip Çelebi University, İzmir, 1Emergency, Karşıyaka State Hospital, İzmir, Turkey. E-mail: [email protected]
REFERENCES 1.
Tamura A, Kataoka H, Mikuriya Y, Nasu M. Inferior ST segment depression as a useful marker for identifying proximal left anterior descending artery occlusion during acute anterior myocardial infarction. Eur Heart J 1995;16:1795-9.
2.
Quyyumi AA, Crake T, Rubens MB, Levy RD, Rickards AF, Fox KM. Importance of "reciprocal" electrocardiographic changes during occlusion of left anterior descending coronary artery. Studies during percutaneous transluminal coronary angioplasty. Lancet 1986;15:347-50.
3.
de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J 1982;103:730-6.
4.
Farhan HL, Hassan KS, Al-Belushi A, Sallam M, Al-Zakwani I. Diagnostic value of electrocardiographic T wave inversion in lead aVL in diagnosing coronary artery disease in patients with chronic stable angina. Oman Med J 2010;25:124-7.
5.
Kosuge M, Ebina T, Hibi K, Iwahashi N, Morita S, Endo M, et al. Implications of ST-segment elevation in leads V5 and V6 in patients with reperfused inferior wall acute myocardial infarction. Am J Cardiol 2012;109:314-9. Access this article online Quick Response Code: Website: www.onlinejets.org
DOI: 10.4103/0974-2700.155526
Suicidal poisoning with cypermethrin: A clinical dilemma in the emergency department Sir, Cypermethrin, a pyrethroid compound is widely used due to its high insecticidal potential and slow resistance in pest. It is considered less toxic for human use, because of poor dermal absorption, rapid metabolism, less tissue accumulation, and environmental persistence. [1] Cases of accidental pyrethroid poisoning at work places have been reported[2], but poisoning with suicidal intention is extremely rare. [3] Increased overJournal of Emergencies, Trauma, and Shock I 8:2 I Apr - Jun 2015
the-counter availability of these insecticides is likely to increase the prevalence of their toxicity. Furthermore, resemblance of cypermethrin toxicity to organophosphate poisoning pose a diagnostic dilemma in the emergency department. [4,5] We report a case of 30-year old male who presented to our emergency department with complaints of recurrent vomiting, epigastric and throat pain, increased salivation, drooling, lacrimation, anxiety, cough, and dyspnea. There was no history of convulsion, diarrhea, frequent urination, chest pain, or fever. He gave a history of ingestion of about 300 mL of a liquid from a container 90 minutes before hospital presentation following a family dispute. There was no history suggestive of co-ingestion of any other toxin or drug. There were no relevant past medical or mental illness, or suicidal attempt. On clinical examination, patient was conscious, oriented, but anxious and restless. He had conjuctival congestion with normal pupillary size. The lips and buccal mucosa were swollen. The patient had tremors of hands but no fasciculation. His pulse was 80/min, blood pressure was 128/84 mm of Hg, Respiratory rate 20/min with SpO2 of 96% at room air. Systemic examinations were unremarkable except bilateral chest rhonchi. A diagnosis of organophosphate poisoning was made and patient was given oxygen and one intravenous dose of 1.8 mg of atropine. Meantime, the patient’s wife brought three containers of “Danger-10”, 100 ml each, [Figure 1] containing 10% of cypermethrin (equivalent to total of 33.6 g of cypermethrin). His hemogram, liver function, renal function, serum electrolytes, arterial blood gas, blood glucose, chest radiograph and electrocardiogram were within normal limit. Although he came more than one hour of ingestion, gastric lavage was performed. Activated charcoal was not given due to delayed hospital presentation and to prevent aspiration. Atropine was stopped after one dose and the patient was given symptomatic treatment in the form of hydrocortisone, chlorpheniramine maleate, ranitidine and nebulization with albuterol for bronchospasm. He improved significantly over the next 24 hours. On the second day, he developed hoarseness of voice. His indirect laryngoscopy was unremarkable and it
Figure 1: Containers of cypermethrin 10% ingested by the patient 123
Copyright of Journal of Emergencies, Trauma & Shock is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
4.
Kakitsubata Y, Theodorou SJ, Theodorou DJ, Yuko M, Ito Y, Yuki Y, et al. Symptomatic epidural gas cyst associated with discal vacuum phenomenon. Spine (Phila Pa 1976) 2009;34:E784-9.
5.
Wang YX, Griffith JF, Zeng XJ, Deng M, Kwok AW, Leung JC, et al. Prevalence and sex difference of lumbar disc space narrowing in elderly chinese men and women: Osteoporotic fractures in men (Hong Kong) and osteoporotic fractures in women (Hong Kong) studies. Arthritis Rheum 2013;65:1004-10. Access this article online Quick Response Code: Website: www.onlinejets.org
DOI: 10.4103/0974-2700.155524
Figure 2: An image of a traumatic PAN-SCAN taken of case 2 on arrival. An 89-nine-year-old female sustained head contusional wounds and cervical central spinal cord syndrome manifesting as bilateral dysesthesia of the hands after falling from a 3 m height. The PAN-SCAN revealed pneumorrhachis at the lumbosacral level (black arrow)
of gas, principally nitrogen, from surrounding tissues, and accumulation within the cracks, clefts or crevices, which form in the disc as it degenerates with aging, usually in the lumbar region.[4] The discrepancy in the frequencies between the vacuum disc and pneumorrhachis may be because the vacuum disc was rigid, thus leading to the retention of gas.[4] The prevalence and severity of disc space narrowing, characterized by degenerative changes, are both higher in elderly females than elderly males.[5] Accordingly, our findings suggested that it may have been incidentally detected vacuum phenomenon by the traumatic PAN-SCAN. In conclusion, pneumorrhachis detected by traumatic PAN-SCANs tends to be found in elderly females at the lumbosacral region. If the patient does not have a direct open wound into the spinal canal, pneumocephalus, pneumomediastinum, or pneumothorax, the diagnostic significance is minimized.
Mariko Obinata, Kazuhiko Omori, Kouhei Ishikawa, Hiromichi Osaka, Yasumasa Oode, Youichi Yanagawa Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Izunokuni, Shizuoka, Japan. E-mail: [email protected]
REFERENCES 1.
Gautschi OP, Hermann C, Cadosch D. Spinal epidural air after severe pelvic and abdominal trauma. Am J Emerg Med 2008;26:740.e3-5.
2.
Nakmura H, Murase K, Noguchi Y, Tawara M, Sadamitsu T, Yamaguchi K, et al. A case of decompressive sickness after diving into cultured fishes swim. Nagasaki Igakkaizasshi 2013;88:181-6.
3.
Yanagawa Y, Takasu A, Sugiura T, Okada Y. A case of cervical pneumorrhachis induced by the combination of pneumomediastinum and root avulsion injuries. Eur Spine J 2007;16:573-4.
Journal of Emergencies, Trauma, and Shock I 8:2 I Apr - Jun 2015
Hints in electrocardiography for coming myocardial infarction Dear Editor, The electrocardiogram (ECG) is a simple and non-invasive bedside diagnostic tool. Inversion of the T wave is a common electrocardiographic abnormality and can be interpreted as non-specific. Knowing the early changes in ECG for ischemia is crucial for the timely diagnosis of myocardial ischemia. Here, we present a 54-year-old woman admitted to the emergency department (ED) who had a normal ECG initially, which progressed with T inversions in leads aVL and V2 and resulted in inferior ST-elevated myocardial infarction (STEMI). She was admitted to the ED with complaints of sweating, discomfort and palpitation for two hours. Her blood pressure was 130/80 mmHg and pulse was 98/min, with 98% saturation using a pulse oximeter; her physical examination was normal. The patient was monitored, an ECG was taken, intravenous access was established, and blood samples were obtained for hemogram and routine chemical tests. Her initial ECG was completely normal [Figure 1]. Twenty minutes after her admission, she described a new onset of pain in her left axillary region. A new ECG was obtained and showed T wave inversions at derivations aVL and V2, which were different from her initial ECG [Figure 2]. Fifteen minutes later, the patient started to sweat and described her pain spreading to her chest and left arm. A new ECG was obtained and ST-segment elevations at derivations D2, D3 and aVF, and reciprocal changes at aVL, V1 and V2 were present [Figure 3]. The patient was given intravenous thrombolytic therapy in the ED and was admitted to our cardiology intensive care unit. Coronary angiography was performed 24 hours 121
Letters to Editor
Figure 2: T wave inversions in leads aVL and V2 were present in the second electrocardiogram, which was obtained 20 minutes after the patient’s admission Figure 1: The first normal electrocardiogram of the patient
Figure 4: The stenosis in the proximal left main coronary artery and total occlusion in the left anterior descending artery are visible on coronary angiogram Figure 3: ST-segment elevations at derivations D2, D3 and aVF, and reciprocal changes at aVL, V1 and V2 were present in the third electrocardiogram, which was obtained 35 minutes after the patient’s admission
Emergent coronary artery bypass grafting operation was planned and she was transferred to the cardiovascular surgery clinic. In the setting of acute coronary syndrome, several ECG findings help to localize the occluded vessel and occlusion site.[1,2] Certain T wave abnormalities in precordial leads are early warnings for an MI. Either the positive-negative biphasic T waves or the deeply inverted T waves that often follow them, when occurring in the precordial leads, are nearly pathognomonic of very recent severe ischemia or injury in the distribution area of the LAD and characterize Wellens syndrome.[3] T wave inversion in aVL significantly predicts LAD lesions typically in the mid-segment.[4] This finding should alert the health care providers during ECG interpretation. ST elevation in V5 and V6 are associated with large-vessel occlusion, larger infarct size and ST depression, while flat T waves in these leads indicate the probability of three-vessel disease in inferior STEMI patients.[5]
Figure 5: The stenosis in the right coronary artery is visible on coronary angiogram
later. There was stenosis in the proximal left main coronary artery (70%) and right coronary artery (85% and 90%) and total occlusion in the left anterior descending artery (LAD) [Figures 4 and 5]. 122
Our case shows that T wave inversions in leads aVL and V2, which can be thought of as non-specific may be a predictor of the following inferior MI. Observation of the patient and obtaining serial ECGs are important for not overlooking a myocardial ischemia developing into infarction. Journal of Emergencies, Trauma, and Shock I 8:2 I Apr - Jun 2015
Letters to Editor
Erden Erol Ünlüer, Arif Karagöz1 Department of Emergency, Atatürk Research and Training Hospital, Izmir Katip Çelebi University, İzmir, 1Emergency, Karşıyaka State Hospital, İzmir, Turkey. E-mail: [email protected]
REFERENCES 1.
Tamura A, Kataoka H, Mikuriya Y, Nasu M. Inferior ST segment depression as a useful marker for identifying proximal left anterior descending artery occlusion during acute anterior myocardial infarction. Eur Heart J 1995;16:1795-9.
2.
Quyyumi AA, Crake T, Rubens MB, Levy RD, Rickards AF, Fox KM. Importance of "reciprocal" electrocardiographic changes during occlusion of left anterior descending coronary artery. Studies during percutaneous transluminal coronary angioplasty. Lancet 1986;15:347-50.
3.
de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J 1982;103:730-6.
4.
Farhan HL, Hassan KS, Al-Belushi A, Sallam M, Al-Zakwani I. Diagnostic value of electrocardiographic T wave inversion in lead aVL in diagnosing coronary artery disease in patients with chronic stable angina. Oman Med J 2010;25:124-7.
5.
Kosuge M, Ebina T, Hibi K, Iwahashi N, Morita S, Endo M, et al. Implications of ST-segment elevation in leads V5 and V6 in patients with reperfused inferior wall acute myocardial infarction. Am J Cardiol 2012;109:314-9. Access this article online Quick Response Code: Website: www.onlinejets.org
DOI: 10.4103/0974-2700.155526
Suicidal poisoning with cypermethrin: A clinical dilemma in the emergency department Sir, Cypermethrin, a pyrethroid compound is widely used due to its high insecticidal potential and slow resistance in pest. It is considered less toxic for human use, because of poor dermal absorption, rapid metabolism, less tissue accumulation, and environmental persistence. [1] Cases of accidental pyrethroid poisoning at work places have been reported[2], but poisoning with suicidal intention is extremely rare. [3] Increased overJournal of Emergencies, Trauma, and Shock I 8:2 I Apr - Jun 2015
the-counter availability of these insecticides is likely to increase the prevalence of their toxicity. Furthermore, resemblance of cypermethrin toxicity to organophosphate poisoning pose a diagnostic dilemma in the emergency department. [4,5] We report a case of 30-year old male who presented to our emergency department with complaints of recurrent vomiting, epigastric and throat pain, increased salivation, drooling, lacrimation, anxiety, cough, and dyspnea. There was no history of convulsion, diarrhea, frequent urination, chest pain, or fever. He gave a history of ingestion of about 300 mL of a liquid from a container 90 minutes before hospital presentation following a family dispute. There was no history suggestive of co-ingestion of any other toxin or drug. There were no relevant past medical or mental illness, or suicidal attempt. On clinical examination, patient was conscious, oriented, but anxious and restless. He had conjuctival congestion with normal pupillary size. The lips and buccal mucosa were swollen. The patient had tremors of hands but no fasciculation. His pulse was 80/min, blood pressure was 128/84 mm of Hg, Respiratory rate 20/min with SpO2 of 96% at room air. Systemic examinations were unremarkable except bilateral chest rhonchi. A diagnosis of organophosphate poisoning was made and patient was given oxygen and one intravenous dose of 1.8 mg of atropine. Meantime, the patient’s wife brought three containers of “Danger-10”, 100 ml each, [Figure 1] containing 10% of cypermethrin (equivalent to total of 33.6 g of cypermethrin). His hemogram, liver function, renal function, serum electrolytes, arterial blood gas, blood glucose, chest radiograph and electrocardiogram were within normal limit. Although he came more than one hour of ingestion, gastric lavage was performed. Activated charcoal was not given due to delayed hospital presentation and to prevent aspiration. Atropine was stopped after one dose and the patient was given symptomatic treatment in the form of hydrocortisone, chlorpheniramine maleate, ranitidine and nebulization with albuterol for bronchospasm. He improved significantly over the next 24 hours. On the second day, he developed hoarseness of voice. His indirect laryngoscopy was unremarkable and it
Figure 1: Containers of cypermethrin 10% ingested by the patient 123
Copyright of Journal of Emergencies, Trauma & Shock is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
