CORRESPONDENCE
never designed to replace objective diagnostic evaluations for abdominal injuries such as diagnostic peritoneal lavage or computed tamography scan. This analysis was performed to determine whether base deficit was a strong indicator of significant abdominal injury. The analysis done by Zafren and Purcell shows that base deficit is not a good screening instrument with poor sensitivity. A more important point that they do not address is the dependenceof the predictive value on the prevalence of the disease. Sensitivity and specificity are independent of prevalence, but the predictive value is highly dependent on prevalence. Thus, with the low overall prevalence of abdominal injury in the population of blunt trauma patients, the positive-predictive value of the test is expected to be poor, as is the case with base deficit. In this context, it would be equally valid (or invalid) to analyze the presence of admission hypotension for sensitivity; specificity, and positiveand negative-predictive values for abdominal injury. The fundamental point that we were trying to make was that just like the presence of a pelvic fracture or admission hypotension, the presence of a significant base deficit (ie, less than or equal te -6) should be considered an indicator of intra-abdominal injury and/or hemorrhage. The base deficit then should raise a clinician's index of suspicion for abdominal injury when it is significant and perhaps be considered an indication to perform objective abdominal evaluation with computed tomography scan or diagnostic peritoneal lavage. In this regard, the base deficit is a very strong indicator with 28% of the patients with a base deficit less than or equal to -6 having significant intra-abdominal injury requiring surgery.
James W Davis, MD, FACS Division of Trauma ValleyMedical Center UCSDMedical Center TroyL Holbrook,PhO Division of Familyand Community Medicine Division of Trauma UCSDMedical Center Fresno, California
154/1407
IV Adenosine in the Management of PSVT To the Editor. I write in regard to "Intravenous Adenosine in the Emergency Department Management of Paroxysmal Supraventricular Tachycardia" [July 1991;20:717-721] and "Intravenous Adenosine in the Prehospital Management of Paroxysmal Supraventricular Tachycardia" [April 1992;21:358-361]. Both studies reported excellent results with the drug, reflecting, I suspect, its proper administration. It should be noted, however, that in neither article was the recommended 1 protocol for administering adenosine presented in its entirety. The package insert recommends that IV adenosine be followed immediately by a "rapid saline flush" to ensure that the entire dose reaches the systemic circulation as a bolus. 1 This is in contrast to the articles, which refer to administering adenosine through a "free-flowing" infusion line. Our Fujisawa representatives have echoed the rapid flush recommendation, and our anecdotal experience with the drug corroborates its use. Our policy is to follow a dose of adenosine with 30 mL of normal saline by IV push with a syringe. We have noted at least two same-patient incidents in which injecting adenosine into a "wideopen'~ IV line did not convert paroxysmal supraventricular tachycardia, whereas the same dose followed by a syringe bolus of normal saline did convert the rhythm. As the use of this drug in emergency care settings continues to increase, it seems prudent to stress the manufacturer's recommended dosing protocol.
Charles VPoflack, Jr, MA, MD Departmentof EmergencyMedicine University of Mississippi Medical Center Jackson 1. Package insert, Adenocard® (adenosine). Deerfield, Illinois, Fujisawa USA, Inc, 1990.
Traumatic Uvulitis To the Editor. Traumatic uvulitis is an uncommon problem previously reported only in the anesthesia literature. TM Apparent causes include endotracheal intubation, nasal airway insertion, laryngeal masks, and high-pressuresuctioning. We would like to report the case of a 26-year-old man who developed traumatic edema of the uvula after passage of an orogastric tube. This patient was admitted to the emergency department after ingesting an unknown quantity of unidentified tablets in a suicide attempt 45 minutes before admission. Apart from substance abuse, the patient had no other medical problems er allergies. The patient had no complaints of discomfort in the mouth, throat, or chest and was fully oriented during his initial evaluation. On physical examination, he had blood pressure of 140/80 mm Hg; pulse, 85; respirations, 16; and temperature, 36.7 C. The oropharyngeal mucosa was noted to be clear without evidence of trauma. The neck was supple, the lungs were clear, and no stridor was noted. The remainder of the physical examination was within normal limits. Fifteen minutes after admission, several unsuccessful attempts at passing a 34F orogastric tube were made. Because the patient was uncooperative during this procedure, no further attempts were made, and ipecac and, later, activated charcoal were administered. Three hours after the attempts to pass the orogastric tube, the patient complained of a sore throat and was noted to have a markedly enlarged, edematous, ecchymotic uvula (Figure). He was in no respiratory
Figure. Patient with enlarged uvula
distress, and no specific treatment was required. After a short period of observation, he was admitted for inpatient psychiatric care. His throat discomfort and uvular edema resolved within 24 hours. A later toxicologic screen was positive for only cocaine. Recently, the efficacy of gastric lavage has been questioned. ~.6 Traumatic uvulitis has been reported in association with certain prolonged oropharyngeal and nasopharyngeal techniques, but we were unable to find any reports of this problem after orogastric tube placement. It also has been associated with infrequent complications, including aspiration of gastric contents, laryngeal spasm, cyanosis, and esophageal perforation. 7,8 Although no serious morbidity resulted in our case, it illustrates another potential iatrogenic complication that emergency physicians should consider before inserting the orogastric tube.
RobertA Partridge, MD RobertM McNamara,MD, FACEP Departmentof EmergencyMedicine Medical Collegeof Pennsylvania Philadelphia 1. Raavindran, R, Priddy S: Uvular edema: A rare complication of endotraeheal intabation. Anesthesiology 1978;48:374. 2. Schulman MS: Uvular edema without endotracheal iutubation (letter). Anesthesioloffy1981;55:82-83. 3. Seigne TD: Uvular edema (letter). Anesthesiology 1978;49:375-376. 4. Bogetz MS, Tupper B J, et al: Too much of a good thing: Uvular edema caused by overzealous suctioning. Anesth Analg 1991 ;72:125-126. 5. Tenenbein M, Cohen S, et al: Efficacy of ipecac4nduced emesis, orogastrie lavage and activated charcoal for acute drug overdose. Ann Emerg Med 1987;16:838-841. 6. Kulig I(, Bar-Or D, et al: Management qf acntely poisoned patients without gastric emptying. Ann Emerg Med 1985;14:562-567. 7. Easom JM, Lovejoy EF: Efficacy and safety of gastrointestinal decontamination in the treatment of oral poisoning. Pediatr Clin North Am 1979;26:827-835. 8. Askenasi R, Abramowicz M, et al: Esophageal perforation: An unusual complication of gastric lavage (letter). Ann Emerg Med 1984;13:146.
ANNALSOF EMERGENCY MEDICINE 21:11 NOVEMBER1992
never designed to replace objective diagnostic evaluations for abdominal injuries such as diagnostic peritoneal lavage or computed tamography scan. This analysis was performed to determine whether base deficit was a strong indicator of significant abdominal injury. The analysis done by Zafren and Purcell shows that base deficit is not a good screening instrument with poor sensitivity. A more important point that they do not address is the dependenceof the predictive value on the prevalence of the disease. Sensitivity and specificity are independent of prevalence, but the predictive value is highly dependent on prevalence. Thus, with the low overall prevalence of abdominal injury in the population of blunt trauma patients, the positive-predictive value of the test is expected to be poor, as is the case with base deficit. In this context, it would be equally valid (or invalid) to analyze the presence of admission hypotension for sensitivity; specificity, and positiveand negative-predictive values for abdominal injury. The fundamental point that we were trying to make was that just like the presence of a pelvic fracture or admission hypotension, the presence of a significant base deficit (ie, less than or equal te -6) should be considered an indicator of intra-abdominal injury and/or hemorrhage. The base deficit then should raise a clinician's index of suspicion for abdominal injury when it is significant and perhaps be considered an indication to perform objective abdominal evaluation with computed tomography scan or diagnostic peritoneal lavage. In this regard, the base deficit is a very strong indicator with 28% of the patients with a base deficit less than or equal to -6 having significant intra-abdominal injury requiring surgery.
James W Davis, MD, FACS Division of Trauma ValleyMedical Center UCSDMedical Center TroyL Holbrook,PhO Division of Familyand Community Medicine Division of Trauma UCSDMedical Center Fresno, California
154/1407
IV Adenosine in the Management of PSVT To the Editor. I write in regard to "Intravenous Adenosine in the Emergency Department Management of Paroxysmal Supraventricular Tachycardia" [July 1991;20:717-721] and "Intravenous Adenosine in the Prehospital Management of Paroxysmal Supraventricular Tachycardia" [April 1992;21:358-361]. Both studies reported excellent results with the drug, reflecting, I suspect, its proper administration. It should be noted, however, that in neither article was the recommended 1 protocol for administering adenosine presented in its entirety. The package insert recommends that IV adenosine be followed immediately by a "rapid saline flush" to ensure that the entire dose reaches the systemic circulation as a bolus. 1 This is in contrast to the articles, which refer to administering adenosine through a "free-flowing" infusion line. Our Fujisawa representatives have echoed the rapid flush recommendation, and our anecdotal experience with the drug corroborates its use. Our policy is to follow a dose of adenosine with 30 mL of normal saline by IV push with a syringe. We have noted at least two same-patient incidents in which injecting adenosine into a "wideopen'~ IV line did not convert paroxysmal supraventricular tachycardia, whereas the same dose followed by a syringe bolus of normal saline did convert the rhythm. As the use of this drug in emergency care settings continues to increase, it seems prudent to stress the manufacturer's recommended dosing protocol.
Charles VPoflack, Jr, MA, MD Departmentof EmergencyMedicine University of Mississippi Medical Center Jackson 1. Package insert, Adenocard® (adenosine). Deerfield, Illinois, Fujisawa USA, Inc, 1990.
Traumatic Uvulitis To the Editor. Traumatic uvulitis is an uncommon problem previously reported only in the anesthesia literature. TM Apparent causes include endotracheal intubation, nasal airway insertion, laryngeal masks, and high-pressuresuctioning. We would like to report the case of a 26-year-old man who developed traumatic edema of the uvula after passage of an orogastric tube. This patient was admitted to the emergency department after ingesting an unknown quantity of unidentified tablets in a suicide attempt 45 minutes before admission. Apart from substance abuse, the patient had no other medical problems er allergies. The patient had no complaints of discomfort in the mouth, throat, or chest and was fully oriented during his initial evaluation. On physical examination, he had blood pressure of 140/80 mm Hg; pulse, 85; respirations, 16; and temperature, 36.7 C. The oropharyngeal mucosa was noted to be clear without evidence of trauma. The neck was supple, the lungs were clear, and no stridor was noted. The remainder of the physical examination was within normal limits. Fifteen minutes after admission, several unsuccessful attempts at passing a 34F orogastric tube were made. Because the patient was uncooperative during this procedure, no further attempts were made, and ipecac and, later, activated charcoal were administered. Three hours after the attempts to pass the orogastric tube, the patient complained of a sore throat and was noted to have a markedly enlarged, edematous, ecchymotic uvula (Figure). He was in no respiratory
Figure. Patient with enlarged uvula
distress, and no specific treatment was required. After a short period of observation, he was admitted for inpatient psychiatric care. His throat discomfort and uvular edema resolved within 24 hours. A later toxicologic screen was positive for only cocaine. Recently, the efficacy of gastric lavage has been questioned. ~.6 Traumatic uvulitis has been reported in association with certain prolonged oropharyngeal and nasopharyngeal techniques, but we were unable to find any reports of this problem after orogastric tube placement. It also has been associated with infrequent complications, including aspiration of gastric contents, laryngeal spasm, cyanosis, and esophageal perforation. 7,8 Although no serious morbidity resulted in our case, it illustrates another potential iatrogenic complication that emergency physicians should consider before inserting the orogastric tube.
RobertA Partridge, MD RobertM McNamara,MD, FACEP Departmentof EmergencyMedicine Medical Collegeof Pennsylvania Philadelphia 1. Raavindran, R, Priddy S: Uvular edema: A rare complication of endotraeheal intabation. Anesthesiology 1978;48:374. 2. Schulman MS: Uvular edema without endotracheal iutubation (letter). Anesthesioloffy1981;55:82-83. 3. Seigne TD: Uvular edema (letter). Anesthesiology 1978;49:375-376. 4. Bogetz MS, Tupper B J, et al: Too much of a good thing: Uvular edema caused by overzealous suctioning. Anesth Analg 1991 ;72:125-126. 5. Tenenbein M, Cohen S, et al: Efficacy of ipecac4nduced emesis, orogastrie lavage and activated charcoal for acute drug overdose. Ann Emerg Med 1987;16:838-841. 6. Kulig I(, Bar-Or D, et al: Management qf acntely poisoned patients without gastric emptying. Ann Emerg Med 1985;14:562-567. 7. Easom JM, Lovejoy EF: Efficacy and safety of gastrointestinal decontamination in the treatment of oral poisoning. Pediatr Clin North Am 1979;26:827-835. 8. Askenasi R, Abramowicz M, et al: Esophageal perforation: An unusual complication of gastric lavage (letter). Ann Emerg Med 1984;13:146.
ANNALSOF EMERGENCY MEDICINE 21:11 NOVEMBER1992
