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higher alkaloid concentrations and severe clinical effects.In our patient, collapse occurred immediately after chewing apinang-wang and high concentrations of arecolin and arecaidinewere also noted. Those were decreased gradually and no morearrhythmia was noted thereafter. This suggests that arecolin andarecaidine may be related to the development of malignantarrhythmia. We treated the arrhythmia of the patient accordingto ventricular fibrillation algorithm initially, but in vain. Lateron, wide QRS tachycardia was noted and converted by theinjection of intravenous sodium bicarbonate. Therefore weassume that the constituents of pinang-wang may possesssodium channel blocker properties. In addition, coronary spasminduced by arecoline might be the cause of acute myocardialinfarction.4 The cause of prolonged ST-segment elevation inour patient may not be due to acute myocardial infarctionbecause of normal coronary angiogram. It may be related totransthoracic defibrillation.5
In conclusion, high arecoline and arecaidine concentrationsafter chewing pinang-wang may result in ventricular fibrillation.If this arrhythmia has no response to the standard algorithmtreatment, sodium bicarbonate may be used.
Chun-Jen Chou, MDDepartment of Emergency MedicineKaohsiung Municipal Hsiao-Kang HospitalKaohsiung Medical UniversityKaohsiung, Taiwan
Ho-Ming Su, MDDepartment of Internal MedicineKaohsiung Municipal Hsiao-Kang HospitalKaohsiung Medical UniversityKaohsiung, Taiwan
Hei-Hwa Lee, MSDepartment of Laboratory MedicineKaohsiung Medical University HospitalKaohsiung Medical UniversityKaohsiung, Taiwan
Ying-Chin Ko, MD, PhDDepartment of Public HealthFaculty of MedicineKaohsiung Medical UniversityKaohsiung, TaiwanDivision of Environmental Health and Occupational MedicineNational Health Research InstitutesKaohsiung, Taiwan
Ping-Ho Chen, PhDDivision of Environmental Health and Occupational MedicineNational Health Research Institutes
Kaohsiung, Taiwan758 Annals of Emergency Medicine
Bai-Hsiun Chen, MDDepartment of Laboratory MedicineKaohsiung Medical University HospitalKaohsiung Medical UniversityKaohsiung, TaiwanDepartment of Laboratory MedicineFaculty of MedicineKaohsiung Medical UniversityKaohsiung, TaiwanCenter of Excellence for Environmental MedicineKaohsiung Medical UniversityKaohsiung, Taiwan
doi:10.1016/j.annemergmed.2009.06.007
Funding and support: By Annals policy, all authors are required todisclose any and all commercial, financial, and other relationshipsin any way related to the subject of this article that might createany potential conflict of interest. The authors have stated that nosuch relationships exist. See the Manuscript Submission Agree-ment in this issue for examples of specific conflicts covered by thisstatement.
1. Raghavan V, Baruah HK. Arecanut, India’s popular masticatory:History, chemistry and utilization. Econ Botany. 1958;12:315-345.
2. Lin CF, Chen PH, Ko YC, et al. Predictors of betel quid chewingbehavior and cessation patterns in Taiwan aborigines. BMC PublicHealth. 2006;6:271.
3. Nelson BS, Heischober B. Betel nut: a common drug used bynaturalized citizens from India, Far East Asia, and the South PacificIslands. Ann Emerg Med. 1999;34:238-343.
4. Hung DZ, Deng JF. Acute myocardial infarction temporally relatedto betel nut chewing. Vet Hum Toxicol. 1998;40:25-28.
5. Ben-Dov IZ, Leibowitz D, Weiss AT. ST-segment elevation postcardioversion: a current of injury without injury. Int J Cardiol.2006;106:255-256.
Additional Information on Taser Safety
To the Editor:Controversy continues regarding the safety of conducted
electrical weapons, commonly known by the brand name Taser.This important discussion often pivots on the question ofcardiac safety: whether, and if so how often, conducted electricalweapons might produce a fatal cardiac dysrhythmia.
Recently released figures will be of particular note andinterest to the broad audience that is following this discussion.In May 2009 the British Home Office Scientific DevelopmentBranch presented a paper on conducted electrical weapon usesin England and Wales to the European Symposium on Non-Lethal Weapons.1 The UK has recorded 4,046 consecutiveTaser uses overall and 1330 cases in which conducted electricalweapons were discharged and an electrical shock was delivered.Clinical outcomes were assessed; in none of the cases was there adeath attributed to the conducted electrical weapon use and in
particular there were no sudden fatal collapses suggestive of aVolume , . : November
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cardiac dysrhythmia (personal communication, Graham Smith,Home Office Scientific Development Branch, May 20, 2009).
These data are important because they provide a carefullymonitored denominator of consecutive conducted electricalweapon uses, against which a numerator of adverse events canbe compared. When this experience is combined with previousreports of medical outcomes after consecutive field use ofconducted electrical weapons, including Eastman et al (n�426),Bozeman et al (n�1201), and a recent abstract by Angelidis etal (n�1101), there is a combined experience of 4,058consecutively monitored conducted electrical weapon uses withan electrical shock delivered.2-4 Serious injuries are clearly rare,and there are no cases in any of the reports suggesting suddencardiac death related to the Taser. While these findings of zeroobserved fatalities neither fully exclude the possibility ofconducted electrical weapons having cardiac effects nordiminish the importance of that possibility, they do allowcalculation of a 97.5% confidence interval that the risk of animmediate fatal event due to conducted electrical weapon use isnot greater than 0.09%.
The accumulating safety evidence from carefully monitoredfield experience clarifies the potential risks of conductedelectrical weapons and continues to support their overall safety.This is particularly evident when safety information isconsidered in the context of the known benefits of conductedelectrical weapons including their effectiveness as a police tool,reductions in injuries among both officers and suspects, andreductions in the use of lethal force.
From a public health/epidemiologic perspective the use ofconducted electrical weapons is similar to that of automobile airbags, which are also known to pose a small risk of serious injuryand even death in rare cases, but are clearly responsible for
marked overall reductions in injuries and fatalities. WhileVolume , . : November
investigations to clarify the risks and optimize the safety of thesedevices must continue, the overall balance of risks versusbenefits in terms of injuries prevented and lives saved weighsheavily in favor of the use of both.
William P. Bozeman, MDWake Forest UniversityDepartment of Emergency MedicineWinston Salem, NC
doi:10.1016/j.annemergmed.2009.06.015
Funding and support: By Annals policy, all authors are required todisclose any and all commercial, financial, and other relationshipsin any way related to the subject of this article that might createany potential conflict of interest. The author has stated that nosuch relationships exist. See the Manuscript Submission Agree-ment in this issue for examples of specific conflicts covered by thisstatement.
1. Home Office Scientific Development BranchFigures on the reported and recorded uses of Taser by policeforces in England and Wales. 05 May 2009. Available at:http://scienceandresearch.homeoffice.gov.uk/images/106966/Taserfigs_Sep-Dec_08_.pdf. Accessed May 16, 2009.
2. Eastman AL, Metzger JC, Pepe PE, et al. Conductive electricaldevices: a prospective, population-based study of the medicalsafety of law enforcement use. J Trauma. 2008;64:1567-172.
3. Bozeman WP, Hauda WE 2nd, Heck JJ, et al. Safety and injuryprofile of conducted electrical weapons used by law enforcementofficers against criminal suspects. Ann Emerg Med. 2009;53:480-489.
4. Angelidis M, Basta A, Walsh M, et al. injuries associated with lawenforcement use of conducted electrical weapons. Acad Emerg
Med. 2009;16(suppl. 1):S229.IMAGES IN EMERGENCY MEDICINE(continued from p. 756)
DIAGNOSIS:Life-threatening psychotropic drug–induced gastrointestinal hypomotility. Antipsychotics can affect the entire
gastrointestinal system, from esophagus to rectum, and may cause bowel obstruction, colonic distension, ischemia,perforation, and aspiration. The mechanism is likely to be anticholinergic and antiserotonergic. The fatality rate ofacute colonic pseudo-obstruction is high, especially if surgery is delayed and in cases of abdominal compartmentsyndrome associated with multiple organ failure.1 Althought many cases of fatal neuroleptic-induced constipationhave been previously reported, this life-threatening adverse effect of psychotropic drugs remains unknown by mostemergency care practitioners who may be in charge of such psychotic patients in the medical-surgical setting.2,3
REFERENCES1. Oudemans-van Straaten HM. Acute megacolon in critically ill patients. In: Fink MP, Abraham E, Vincent JL, et al, eds.
Textbook of Critical Care Medicine.5thed. Philadelphia, PA: Elsevier Saunders; 2005:1055-1060.2. Palmer SE, McLean RM, Ellis PM, et al. Life-threatening clozapine-induced gastrointestinal hypomotility: an analysis of 102
cases. J Clin Psychiatry. 2008;69:759-768.3. Gollock JM, Thomson JP. Ischaemic colitis associated with psychotropic drugs. Postgrad Med J. 1984;60:564-565.
Annals of Emergency Medicine 759
