imately two hours after the original application of TAC. Her pupils were bilaterally dilated and she did not appear to recognize her parents. She was repetitively moving her arms, legs, and fingers in an agitated manner. She was not seizing. Her heart rate was 190. The child also was licking the sutured area just above the lip with her tongue repetitively. The wound was washed with soap and water and the child was observed closely. Within 30 minutes her agitation ended, her heart rate returned to normal, and she interacted normally. We tried to obtain a urine sample for cocaine analysis, but the child would not void. At the parent's insistence, after 90 minutes of observation with clinically normal behavior, she was discharged with a urine specimen container and a parental "promise" to return a sample of next voided urine to the hospital laboratory for analysis. Unfortunately, this did not occur. Telephone follow-up the next day revealed that the child slept normally after the second ED discharge and had behaved normally since her second return home. This experience reinforces previously expressed concerns regarding the use of TAC in the region of mucous membranes, particularly near the nose and oral cavity of children.i, 2 Dating back to 1983 there have been reports of children becoming agitated and disoriented when TAC contacted mucous membranes. 1-3 Dronen reported two children who had become agitated and disoriented following inadvertent contact with m u c o u s membranes. 3 There was a case report of a fatality secondary to misuse of TAC solution in a 7U2-month-old child. 1 The presumed route of absorption was a combination of nasal mucosa from "dripping into nose," and oral mucosa secondary to repetitive licking of the TAC cotton pledget. 1 Another report documented seizures in a 5-year-old after aspirating a pledget soaked in TAC. 2 In this patient the presumed route was direct absorption from oral and pharyngeal mucosa. 2 The presumed route of absorption in our child was through the mucosa of the tongue, secondary to 148/107

repetitive licking of the anesthetized wound site. We therefore suggest that whenever TAC solution is used to anesthetize a wound about the mouth, the a n e s t h e t i z e d area be t h o r o u g h l y washed with soap and water immediately after wound repair is completed, assuring that the soap/water solution does not enter the mouth or nostril. A l t h o u g h we have found TAC useful in the repair of superficial and n o n c o n t a m i n a t e d s k i n wounds in some children, it must be used with caution. Further investigation into the optimal concentrations of this topical anesthetic is warranted.

Mark Tripp, MD Daniel D Dowd, Jr, DO, FACEP David R Eitel, MD, FACEP Department of Emergency Medicine York Hospital York, Pennsylvania 1. Daily RH: Fatality secondary to the misuse of TAG solution. Ann Emerg Med 1988;17:159-169. 2. Days MR, Buton BT, Schiss MR, et al: Recurrent seizure s following mucosal application of TAG. A n n Emerg Med 1988;17:646-648. 3. Dronen SC: Complications of TAG (letter). A n n Emerg Med 1983;12:333.

Recommendations for Monitoring Intracranial Pressure To the Editor: We commend Dr Lehman for his article "Intracranial Pressure Monitoring and Treatment: A Contemporary View, [March 1990;19:295-303], but would like to take issue with a few of his recommendations, particularly, his choice of medications for the treatment of systemic hypertension, his recommendations concerning fluid management, and the use of steroids in patients with elevated intracranial pressure (ICP). We believe that systemic hypertension must be treated in the context of cerebral perfusion pressure (CPP). Too often compensatory hypertension, which is an attempt to maintain CPP in the presence of elevated ICP, is treated with drugs such as Annals of Emergency Medicine

s u b l i n g u a l n i f e d i p i n e . T h i s may cause a rapid drop in mean arterial pressure in those patients with disruption of autoregulation secondary to brain injury. In addition, the common use of methyl dopa in neurologically injured patients appears to arise more from tradition than from benefit (or lack of it) on cerebral blood flow and ICP. Of equal concern is that the effects of methyl dopa in some patients, such as sedation and somnolence, may confound the neurologic examination. We share Dr Lehman's concern for the administration of excess free water with DsW, but must add that hypotonic 50% saline may also contribute excess fluid; only isotonic fluids should be used. In brain-injured patients, the use of dextrose of any kind in IV solutions is of concern. Several studies have suggested that increased metabolism (increased injury) and central nervous system lactic acidosis may occur with increased glucose substrate.1, 2 Lastly, the "hope" that a special subset of patients will benefit from corticosteroids sounds very similar tO arguments made in the past for their use in both sepsis and adult respiratory distress syndrome. Not only have independent investigators shown no benefit of steroids in braininjured patients, 3 other studies have demonstrated increased morbidity resulting from their use. 4 Therefore, in contrast to the implied recommendation, it appears prudent not to use steroids until definite benefit can be shown. At present, only patients with intracranial tumors with edema appear to show a consistent advantage with the use of steroids.

DarelI E Heiselman, DO, FACP, FACC, FCCP, FCCM Northeastern Ohio Universities College of Medicine Akron General Medical Center Akron, Ohio 1. Myers RE: A unitary theory of causation of anoxic and hypoxic brain pathology, in Fahn S~ Davis JN, Rowland LP (eds): Advances in Neurolog~ Cerebral Hypoxia and its Consequences. N e w York, Raven Press, 1979, vol 26, p I95-213. 2. Ginsberg MD, Welsh £A, Budd WW: Deleterious effect of glucose pretreatment on recovery from diffuse cerebral ischemia in the cat. I. Local cerebral blood flow and glucose utilization. Stroke 1980;lh347-354.

20:1 January 1991

CORRESPONDENCE

3. Braakman R, Shouten H, Dishoeck MB, et al: Megadose steroids in severe head injury. 7 Neurosurg i983; 58:326-330. 4. Poungvarin N, Bhoopat W, Viriyavejaku] A, et al: Effects of dexamethasone in primary supratentorial intracerebral hemorrhage. N Engl J Med 1987;316:1229-1233.

In Reply: I t h a n k Dr H e i s e l m a n for his thoughtful and interesting comments about my article. I have few if any disagreements with his valuable remarks; however, I will address them as each is quite important. I am in agreement that systemic hypertension in the head-injured patient should be treated in the context of cerebral perfusion pressure. Frequently, systemic pressure is elevated on a systemic basis (eg, essential hypertension, volume overload after resuscitation) and not as the result of the "Cushing phenomenon," which is usually seen as a preterminal event. The control of systemic hypertension is quite important in the acute care of head-injured patients, particularly those with parenchymal contusions that are at risk of expansion and further hemorrhaging. The ideal IV solution for brain-injured patients does not exist. My recommendations regarding use of D2. s 1/2 NS and other fluids come largely from monitoring, the need to avoid hypoglycemia, and anecdotal reports from others. Dr Heiselman is quite perceptive and correct in his criticism of my statements about the possible beneficial role of corticosteroids. The medical literature remains unclear about the benefit of these drugs in a variety of clinical settings, and the results achieved in the laboratory do not always translate well to the bedside. However, reports can be found describing a beneficial effect to the use of steroids in some groups of head-injured patients.1 Other reports, including one cited by Dr H e i s e l m a n , 2 seem to show a favorable outcome in terms of overall mortality in a steroid-treated group of patients treated with steroids. I am sure, however, that with the recent publicity regarding the benefit of very high-dose steroids in acute spinal trauma, 3 20:1 January 1991

more attention and study will be redirected at these agents and their role in head injury.

LB Lehman, MD Division of Neurosurgery Coney Island Hospital Brooklyn, New York 1. Fraupel G, Reulen HJ, Muller D, et al: Double-blind study on the effects of steroids on severe closed head injury, in Pappius HM, Feidel W (eds): Dynamics of Brain Edema. Berlin, Springer-Verlag, i976, p 337-343. 2. Poungvarin N, Bhoopat W, Viriyavejakul A, et al: Effects of dexamethasone in primary supratentoria] intracerebral hemorrhage. N EngI J Med 1984;316:1229-1233. 3. Bracken MB, Shepard MJ, Collins WE, et al: A randomized, controlled trial of methyl prednisolone or naIoxone in the treatment of acute spinal-cord injury. N Engl J Med 1990;322:1405 1411.

Stat RPRs To the Editor: We were pleased to read the letter "Testing for Syphilis" [July 1989; 18:802-803] and applaud Drs Kim, Shesser, and Smiths' urging stat reporting of RPRs in emergency department patients. We too found a dramatic increase in reactive FTA-ABSs in our study, in which we tested for syphilis in patients with any suspected sexually transmitted disease (presented at the Society for A c a d e m i c E m e r g e n c y Medicine A n n u a l Meeting in San Diego, May 1989). However, the authors seem to mistakenly conclude that because some of their sexually transmitted disease patients had painful genital ulcers and reactive RPRs that chancres could be painful. They might be, but the patients in their department who had painful ulcers or urethral discharges and reactive RPRs probably had herpetic ulcers and gonorrhea (or Chlamydia), respectively, and syphilis. These diseases can and do coexist. We found seven reactive FTAABSs in 118 patients with positive gonococci cultures and six reactive FTA-ABSs in 28 patients with positive Chlamydia antibody tests in 260 ED patients tested. The point about not treating syphilis patients on their first visit because the RPR result does not come back in time is especially important Annals of Emergency Medicine

in an urban setting. Many of our patients do not return for recommended follow-up visits or give us incorrect addresses and phone numbers. 8tat RPRs would allow for a much higher treatment percentage and reduce the spread of disease. In addition to considering syphilis in patients with any sexually transmitted disease, emergency physicians should be alert to the high incidence of syphilis in pregnant women in endemic areas. Stat RPRs should be performed on pregnant patients who have had no prenatal care, when presenting to the ED with any complaint, in the hopes of reducing the incidence of congenital syphilis as well.

Jesse Samuels, MD, FACEP Amy Ernst, MD Department of Emergency Medicine Saint Francis Hospital and Medical Center Hartford, Connecticut

In Reply: We thank Drs Samuels and Ernst for their observations. We did not wish to imply that patients infected with T pallidum could not be simultaneously infected with other organisms such as Herpes simplex or He-

mophilus ducrei. Furthermore, even w i t h o u t any specific lesions, our finding that patients with urethral discharge (presumably secondary to N gonococcus or Chlamydia trachomatis) but without genital ulceration or rash often had positive serologic tests indicating T pallidum infection supports the "classic" textbook recommendation that syphilis serologies be obtained in men with acute urethritis. Because specific bedside microbiologic diagnosis is very difficult, the emergency physician is faced with the choice of either obtaining cultures and serologies that take several days for results to become available or of empirically treating the patient for two or three different clinical conditions, with the attendant unnecessary costs and toxicities. The HIV epidemic has complicated 108/149