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tion, The center offered the following recom- mendations for treating lionfish stings. (1) Irri- gate the wound with fresh water and remove any integumentary tissues. (2) Immerse the injured part in water as hot as the patient can tolerate (but less than 45 ° C) for 30 to 90 min- utes to inactivate the venom. (3) Administer an appropriate antitetanus agent. (4) Admin- ister antibiotics and analgesics as indicated. (5) Elevate the extremity until edema has sub- sided. {6) Monitor vital signs. (7) Use radiog- raphy to search for venom spine fragments in the wound. 1 We also believe regional anes- thesia with a long-acting agent such as bupi- vacaine should be emphasized, especially in cases involving digits.

Worldwide, 40,000 to 50,000 marine enven- omations are estimated to occur each year. 2 Scorpionfish, which are second only to sting- rays in fish-reLated envenomations, inhabit tropical seas and temperate waters, as weft as aquariums. 3.4 In fact, the lionfish--the most benign of the scorpionfish--is one of the top ten most common aquarium fish. 5 The 200 or so species of scorpienfish are divided into three subgroups according to the severity of their envenomation, from the lionfish (mild) to the scorpionfish (moderate to severe) to the stonefish (severe to life-threatening). In all cases, pain is immediate, intense, and radiat- ing. Untreated, the pain lasts 6 to 12 hours, with peak intensity 60 to 90 minutes after the sting. Wounds that bleed profusely are less likely to be associated with intense symp- toms. 6 The venom organs of the lionfish com- prise 12 to 13 dorsal, 2 pelvic, and 3 anal spines. The heat-labile toxin flows from paired glands at the base of each spine along grooves on either side of the anterolateral region of the spine. The venom is injected through a punc- ture wound created by the spine, which rips the integumentary sheath and may fracture the venom spine. 7 The deadly systemic cardiovas- cular effects seen with stonefish are rarely observed in cases of lionfish envenomation.

in the largest study to date on lionfish en- venomation, Kizer, McKinney, and Auerbach 8 found that 45 such stings were reported to the San Francisco Poison Control Center over 5 years. Forty-four (98%) of these envenoma- tions involved the hand or a finger. The most common activity preceding envenomation was cleaning of a tank containing live lionfish. All the victims experienced pain around the

wound site; 22% reported pain extending throughout the affected extremity; 13% com- plained of systemic symptoms such as nausea, diaphoresis, difficulty breathing, chest or ab- dominal pain, generalized weakness, hypoten- sion, and syncope. One individual sustained a second-degree burn after immersing his hand in overly hot water. 8 However, no mention is made of the use of long-lasting digital nerve blockade for the management of pain. A Medline search yielded no report of this method of pain control in lionfish envenoma- t/on. Two reports mentioned regional anesthe- sia as an option but provided no references. 4,9

Generally the use of bupivacaine in cases of fingertip injury in which the patient must re- sume activities requiring normal tactile sensa- tion is not recommended. However, in lionfish envenomatien the patient is in such extreme pain, which may last 4 to 6 hours, that most likely he or she would prefer the digital block. In our case, the patient went home to sleep and resumed normal activity the next day.

Maritime folklore attempted to reassure vic- tims of lionfish stings with the adage that the pain lessens with the turn of the tide. 6 How- ever, in today's modern, busy EDs, simple, quick, time-saving solutions to clinical prob- lems are constantly being sought. We suggest the digital nerve block with .25% bupivacaine as an early, routine intervention in lionfish envenomation.

Garyfallos T garyfal/ou, MD Rocky Mountain Poison Center Denver, Colorado John F Madden, MD Medical Center of Delaware Newark, Delaware

1. Russell FE, Dart RC, McNally J: Fish stings, in Poisindex Toxicologic Management, vo187. Denver: Micromedex, i974-1996.

2. Otten EJ: Venomous animal in)uries, in Rosen P, editor: Ernergency Medicine: Concepts and Clinical Practice, ed

3. St Louis: Mosby-Year Book, I992.

3. Wdsman P,5: Marine animals, in GoIdfrank LR, Flomenhaum NE, Le~vin NA, et aI (eds): Goldfrank's Toxicologic Emergencies, ed 5. Norwalk, Connecticut: Appleton & Lange, 1994.

4. Guenin DG, Auerbach PS: Trauma and envenomations from marine fauna, in Ttntinallt JE, Raiz E, Krome RL (eds): Emergency Medicine: A Comprehensive Study Guide, ed 4. New York: McGraw-Hill, i996. 5. HolIiday L: Coral Reefs. London: Salamander, 198&127.

6. Edmonds C: Marine animal injuries, in Bore AA, DavisJC (eds): Diving Medicine, ed 2. Philadelphia: Saunders, i990. 7. Auerbach PS: Marine envenomations. N Engl J Med 1991;325:486-493.

8. Kizer KV,/, McKinney HE, Auerbach PS: Scoq)aenidae envenomation: Alive-year poison center experience. JAMA 1985;253:807-810. 9. Auerbach PS: Marine envenomation, in A~.terbach PS (ed): Wilderness Medicine: Management of Wilderness and Environmental Emergencies, ed 3. St Louis: Mosby- Year BooTe, i995.

"Hole-in-One" Sudden Death To the Editor,

Sudden death resulting from complete occlu- sion of mitral inflow by a mass, the so-called hole-in-one sudden death, is rare. We report the case of a patient in whom hole-in-one sudden death was confirmed on transesoph- ageal echocardiography during CPR. Our report includes echocardiographic findings and a proposed mechanism of the hole-in-one phenomenon.

A 59-year-old man was brought to the emergency department after collapsing sud- denly. He had been healthy until the preced- ing 15 days, when he began experiencing frequent episodes of paroxysmal dyspnea. The patient had been referred to a cardiology clinic for evaluation of the dyspnea.

On the day of presentation, the patient com- plained of an episode of severe dizziness and lost consciousness suddenly. His wife wit- nessed the collapse. In the ED the patient was apneic and pulseless, and electrocardiographic monitoring revealed asystole. The only medical history given by the victim's family was of valvular heart disease. Resuscitation efforts were conducted. While these efforts were con- tinued, biplane transesophageal echocardiog- raphy was performed to determine whether the arrest was reversible. It revealed a 2.5x4.2- cm mass that occluded mitral inflow complete- ly. The mass had an irregular, ragged margin and did not move during precordial compres- sion. The left ventricle was very small, and the left atrium was dilated. Color Doppler imaging revealed no evidence of blood flow across the mitral valve during external chest compression. We ceased resuscitation efforts, with the fam- ily's consent, when circulation did not return.

According to cardiology clinic records, trans- thoracic and transesophageal echocardiogra- phy had been performed earlier for evaluation of a diastolic rumbling murmur. Echocardi- ography revealed rheumatic mitral stenosis and a ball-shaped 4x5-cm mass on the postero-

OCTOBER 1996 28:4 ANNALS OF EMERGENCY MEDICINE 4 5 7

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basal wall of the left atrium. The mass demon- strated inhomogenous echodensity but a smooth margin. It did not move on posture change. Surgery had been scheduled.

Reporting a case of a patient who died after the stenotic mitral orifice was occluded by a ball thrombus, Lie and Entman ~ used the term "hole-in-one sudden death" because of the similarity to a golf ball in a hole cup. Be- fore the echocardiography era, the ball-valve mass as a cause of sudden death was diag- nosed at autopsy. Behavior of ball-valve masses during cardiac cycles has been well document- ed with two-dimensional echocardiography, z During diastolic filling of the left ventricle, the mass moves along the direction of blood flow and occludes the mitral orifice. At the onset of the ventrieular systole, the mass re- bounds and floats freely into the left atrium. This transient occlusion might cause episodes of syncope or paroxysmal dyspnea.

Echocardiographic findings in this patient help us understand the possible mechanism of this type of death. During resuscitation, the left ventricle was very small compared with the left atrium, and the mass did not move or dislodge from the mitral orifice despite con- tinuing precordial compression. Sudden death in our patient followed this sequence: When the mass did not rebound into the left atrium after several ventricular systoles, left ventric- ular filling volume and pressure decreased rapidly. Meanwhile, continuous blood flow from the pulmonary vein resulted in a pro- gressive increase in left atrial pressure. Con- sequently, pressure gradient between the left atrium and left ventricle increased further as the cardiac cycle continued. The increased transmitral pressure gradient made it impos- sible for the mass to escape the mitral orifice. Continuous contraction of the left ventricle without cardiac output resulted in electrome- chanical dissociation and, ultimately, death.

Sung Oh Hwang, MB /(young Sac Lira, MD Department of Emergency Medicine Wonju College of Medicine Yonsei University Wonju, Republic of Korea

I. Lie.JT, Entman ML: "Hole-in-one" sudden death: Mitral valve stenosis and left atrial ball thrombus. Am Heart J 1976;9i:798-804. 2. Wrisley D, Giambartolomei A, Levy" I, et aI: Left atrial bail thrombaa: Apparent detachment following initiation of anticoagulant therapy. Am Heart J I988;116:1351-i352.

"Bean Bag" Pelvic Stabilization To the Editor.

Severe hemorrhage is a well-known and com- mon complication of major pelvic fracture. Management priorities have been suggested but remain controversial. It is, however, gen- erally agreed that some form of stabilization of the pelvis often significantly slows the rate of hemorrhage and allows time for patient transport and definitive pelvic fixation or anglo- graphic vessel embolization.

The pneumatic antishock garment is a de- vice frequently used for temporary pelvic sta- bilization during interhospital and intrahospital transport. The garment is believed to reduce pelvic retroperitoneal hemorrhage by reap- proximating and tamponading disrupted can- cellous bone and associated vasculature 1, reducing the volume of the retroperitoneum 2, and decreasing blood flow through compres- sion. 3 However, use of the pneumatic anti- shock garment has been associated with complications including limb loss and myo- globinuric kidney failure resulting in death. 4

We recently encountered a patent with an unstable pelvic fracture that we managed with the use ef a "bean bag" positioning device before definitive pelvic fixation.

Figure, Falcone. Bean bag pelvic stabilization.

The device is commonly used in the operating room for positioning of patients. It consists of a bag filled with synthetic "beans." When suction is applied to the bag's air valve, the bag becomes rigid.

In this same manner the device may be wrapped about a patient's pelvis; on removal of the air in the bag the device will conform to the contours of the individual's pelvis while forming a rigid stabilizing structure around the circumference of the pelvic girdle (Figure),

We have also experimented with bean bag pelvic stabilization in the normal human model. Subjectively, the bag seems to render the pelvis quite immobile when the adjustable straps are used as shown in the Figure. The device affords both anteroposterior and later- al compression and stabilization.

Although one should be alert to the theoretic possibility of pressure ulceration over a bony prominence, the relatively malleable nature of the device makes it unlikely to cause the adverse circulatory changes sometimes seen with the pneumatic antishock garment.

We believe this technique of pelvic stabi- lization may be a helpful temporary measure in the care of patients with pelvic fracture.

We must emphasize, however, that the ad- justable straps shown in the figure are neces- sary for successful stabilization of the device about the pelvis.

Robert E Falcon& RID Bruce W Thomas, DO Grant Medical Center Regional Trauma Services Columbus, Ohio

I. Moreno C, Moor~ EE, Rosenberoer A, et al: Hemorrhage associated with major pelvic fracture: A maltispeciaIty challenge• J Trauma 1986;26:987-994. 2. Kellam JR: The role of external fixation in pelvic discap- tions. Clin Orthop 1989;24]:66-82. 3. Ludewig RM, Wangeisteen SL: Effect of external counter- pressure on venous bleeding. Surgery i969;56:515-520. 4. Chdstensen KS: Pneumatic antishock garments: Do they precipitate lower extremity compartment syndromes? j Trauma 1985;25:1102-2105.

False-Positive End-Tidal C O 2

To the Editor."

The following case demonstrates a problem with end-tidal carbon dioxide detection that may be of interest to your readers.

45 8 ANNALS OF EMERGENCY MEDICINE 28:4 OCTOBER 1986