Aberrant Conduction vs. Tachycardia

~o the Editor~

I wish to br ing a t tent ion to a probable error in the ar t i - cle by Levy (JACEP, March, 1977), <<Arrhythmias Fol- lowing Physos t igmine Admin i s t r a t ion in J imson Weed £oisoning."

The r h y t h m str ip (Figure) is repor ted to show <'atrial fibrillation and short run of ven t r icu la r tachycardia ." In my opinion, the t achycard ia is more l ikely to be a b e r r a n t conduction in the presence of a t r i a l f ibr i l la t ion.

to be a safe drug, provided a r t e r i a l blood gases are moni- tored." I wonder if Diamond would spare a thought for those blood-gasless regions where pa t ien t s wi th acute pulmonary edema are s t i l l t r ea t ed successfully wi th oxy- gen, furosemide and morphine-wi th-care . Would he con- sider such heresy as a t r i a l of gases versus no gases in pu lmonary edema?

Cyril T.M. Cameron, MD, FRCS, FACS Director, Emergency Department

Samaritan Hospital Troy, New York

~ ~J_u ~i~I1

! "~ ~ ; ~' ,'." ,' ~' ; l ; ,, ,, .'; ,, ,,; ,, . . . . . . ~

d + ~ ~ 4 ~ : 1 l itt le,., ÷d t t ~

Fig. Rhythm strip showing atrial fibrillation and short run of ventricular tachycardia.

The following factors favor aberrancy:

1) the lengthened preceding cycle

2) the cycle length va r i ab i l i ty of as much as 0.07 sec- onds, unusua l in vent r icu la r t achycard ia

3) a s suming a V1 lead (I suspect it is) the in i t ia l bea t has a RBBB contour.

It is possible t ha t the authors have other r h y t h m s t r ips more suggest ive of vent r icu la r tachycardia . The differ- entiat ion of vent r icu lar t achycard ia from aber rancy in atrial f ibr i l la t ion is difficult, bu t for the above reasons, I believe the a r r h y t h m i a is more l ikely to be abe r r an t con- duction.

Robert Grundy, MD Emergency Department, Providence Medical Center

Seattle, Washington

Blood Gases in Pulmonary Edema

Wound Cleansing

To the Editor:

The Stevenson et al ar t ic le on wound c leans ing wi th syr inge/needle versus <'Asepto" bulb-syr inge i r r iga t ion was most i n t e r e s t i n g (JACEP, J a n u a r y 1976). I ap- preciate the i r efforts in demons t r a t i ng what, up to this point, had seemed to me in tu i t ive ly t rue but unproven.

However, I t h ink it is fair to point out t ha t the specific type of exper imen ta l wounds inflicted on the rabbi t , ie, s t r a igh t edged surgical incisions, are l ikely to respond bes t to h igh p r e s s u r e sy r inge /need l e i r r i g a t i o n s ince there is no s ignif icant sk in or t issue avuls ion or macera- tion. More impor tan t ly , there was no subcutaneous ex- tens ion of the wound ex t end ing per iphera l ly from the wound edges. These l a t t e r type wounds, typica l ly seen in tear ing, crush injur ies or closed head t rauma, often have bac ter ia and physical debr is h id ing under sk in folds and in the subcutaneous t issue ex tend ing c i rcumferen t ia l ly from the wound edges. These a reas are not accessible to the syr inge/needle i r r iga t ion - type c leans ing and I feel use of the bulb syr inge to copiously i r r igate these wounds with large volumes of i r r igan t , often grea ter t han one li- ter , is the in i t i a l t r e a t m e n t of choice pr ior to needle/ syringe i r r igat ion.

Gordon W. Josephson, MD Director of Emergency Services

The Memorial Hospital Worcester, Massachusetts

To the Editor:

I r ead wi th considerable in te res t Diamond 's ar t ic le on acute pu lmonary edema (JACEP, Ju ly 1976). I am sur- prised t h a t a l though 55% of the pa t ien ts were orthopneic, only 43% showed t a c h y c a r d i a . Al l of the m o r p h i n e - treated pat ients , each wi th the one exception, showed very neatly rounded-to-zero blood pressures , pulse ra tes and respira tory rates . It is unusua l for pa t ien ts wi th acute pulmonary edema to have appa ren t ly normal pulse ra tes , much less such nea t resp i ra tory ra tes as 20, 30 or 40.

Diamond notes tha t "use "of oxygen and morphine t q ~ t reat pu lmonary edema has been replaced by oxygen and furosemide." He adds, which he ce r t a in ly knew long before farosemide or blood gases, t ha t <<morphine sulfate seems

Author's Reply

The expe r imen ta l model repor ted in our paper simu- la tes lacera t ions caused by sharp wounding ins t rumen t s (knives, glass) which comprise approximate ly 90% of the wounds t rea ted in our Emergency Medical Service. These wounds are very suscept ible to wound c leans ing by high pressure i r r igat ion.

In the r e m a i n i n g wounds resu l t ing from compressive forces r a t h e r t h a n shear forces, the lacera t ions are stel- la te in con f igu ra t ion e x t e n d i n g occas iona l ly into ser- p ig inous cav i t i e s . In these wounds , unroof ing of the cavi t ies followed by met iculous debridement of the wound is essent ia l to remove devi ta l ized tissue and debris. The

~ P 6:11 ('Nov)1977'" 519/67

exposed wound is then subjected to high pressure irriga- tion. We do not employ low pressure i r r igat ion with an Asepto syringe since it is ineffective in removing bacteria or soil infection potent ia t ing factors from the wound.

Thomas Stevenson, MD

Rolando 's or a C o m m i n u t e d Bennet t 's

To the Editor:

In reference to the article, ~'Fractures of the Phalanges and Metacarpals: An Analysis of 555 Fractures," by Go1- den et al (JACEP, March 1977), I should like to point out for the sake of historical accuracy tha t the fracture pic- tured in Figure 5 is actually a Rolando's fracture, 1 not a Bennet t ' s fracture as stated.

Green and Rowland, 2 however, have pointed out tha t this ent i ty can be thought of as a comminuted Bennet t ' s fracture with the implication tha t it is more difficult to treat and has a poorer prognosis than the classic Ben- net t 's fracture.

Lawrence M. Rubens, MD Henry Ford Hospital Dearborn, Michigan

REFERENCES 1. Rolando S: Fracture de la base premier metacarpien: et princi- palemente sur une variete non encore decrite. Pressmed 33:303, 1910.

2. Green DP, Rowland SA, in Rockwood and Green: Fractures. Philadelphia, J. B. Lippincott Company, 1975, pp 307-308.

Fig. 5. Bennett's fracture dislocation of the thumb meta- carpophalangeal joint. This fracture is unstable because of the pull of the abductor pollicus longus on the distal fragments. The thumb must be held in wide abduction to maintain reduction. Although this is occasionally possible by splinting alone, most cases require maintenance with Kirschner wire fixation.

68/520 6:11 (Nov)1977 ' ~ P