patients (88%), 54 of whom were men, were in the first group. Only 29% had angina prior to the infarct, but 77% had post- infarction angina. Eighteen percent had late ventricular ar- rhythmias. The incidence of risk factors was high: 8(F/o were smokers, 21% had hypertension, and 52% had a positive fam- ily history. All but one of the nine patients with normal coronary arteries were men. Angina was frequent both before and after the infarct, as were ventricular arrhythmias. Risk factors were significant only for smokers (44%). Three pa- t ients had coronary artery anomalies: a single left, a single right, and a left coronary artery arising from the pulmonary trunk. The patients never had angina, but two of three de- veloped ventricular arrhythmias. Risk factors were usually absent . The average age at the t ime of infarct was 20. Myocardial infarction in young people differs from that in the elderly, for there is a more heterogeneous underlying coro- nary anatomy, overwhelmingly predominance of male pa- tients, lower incidence of angina, and overall better prog- nosis. This study suggests that all myocardial infarction pa- t ients should be studied in the catheterization laboratory. (Editor's note: The significance for emergency medicine is the increasing numbers of young patients with life-threatening ar- rhythmias. Whether or not they have anatomical lesions is less important than the need for excellent prehospital care to im- prove salvage.) Ken Kulig, MD myocardial infarction, young adults

Clonazepam. Browne TR, N Engl J Med 299:812-815, (Oct) 1978. Clonazepam, a new antiepileptic drug of the benzodiazepine class, was approved in 1977. It is currently approved by the FDA for use in the following types of seizures: typical petit mal, infantile spasms, atypical petit mal, and myoclonic and atonic seizures. It is not approved for t rea tment of grand mal, psychomotor, or focal seizures. Intravenous clonazepam is ef- fective for all types of status epilepticus. However it is proba- bly no more effective than diazepam and has as its major to- xicity sedation and cardiorespiratory depression. Most com- men side effects are drowsiness , a tax ia , and behav io r changes. Tolerance with recurrence of seizures may occur after an initially good response. Overdosage can result in drowsiness, ataxia and cyclic coma. To date, all overdoses have recovered without sequelae. (Editor's note: We have seen a number of patients treated for grand mal epilepsy with this drug whose seizures are not well controlled. Perhaps this reflects their difficult seizure diathesis; perhaps a fad for a new drug improperly applied.) Hal Thomas, MD epilepsy, drug treatment, clonazepam

Atropine-induced ventricular fibrillation: case report and review of the literature. Cooper M J, Abinader EG, Am Heart J 97:225-228, (Feb) 1979. This article presents a case report and review of the litera- ture concerning bradycardia and hypotension in the early phases of myocardial infarction. The authors review a case of inferior diaphragmatic myocardial infarction in a pat ient with a pulse of 48 beats/min and a blood pressure of 95/70 mm Hg who was treated with 0.5 mg atropine intravenously. Over the following 5 min the pulse increased to a rate of 130 beats /min (sinus) and then degenerated into ventr icular tachycardia followed by ventricular fibrillation. Several simi- lar case reports of ventricular dysrhythmias following the t reatment of bradycardia with atropine are cited. They note tha t bradycardia with myocardial infarction is associated wi th a lower incidence of lethal ventr icular dysrhythmia compared to patients with tachycardia or normal heart rates. In addition, recent reports do not demonstrate any increase in nu t r i en t myocardial blood flow with atropine-induced rapid heart rates and diminished vagal tone. More than one third of patients given careful atropine ti tration in a Belfast coronary care unit demonstrated inappropriately rapid car-

diac rates. Other studies demonstrate a ventricular fibrilla- tion threshold lowered by increased heart rate or a lower vagal tone. In addition, increased heart rates associated with myocardial ischemia were noted to increase refractory period disparity in contiguous areas of myocardium, resulting in es- tabl ishment of multiple sites of reentrant activity. Myocar- dial infaction associated with mild bradycardia and hypoten- sion without peripheral vasoconstriction has a relatively be- nign prognosis and the routine administration of atropine may resu l t in the emergency of l e tha l ven t r i cu l a r ar- rhythmias. (Editor's note: Although a direct causal relation- ship between atropine and lethal ventricular arrhythmias has not been demonstrated, the points of this article are well worth considering in patients with mild hypotension and bradycar- dia. Further research with animal models is necessary to de- termine the fu l l effect of atropine on the ischemic myocardiumJ Steven Koenigsknecht, MD

atropine, ventricular fibrillation; myocardial infarction, atropine

Single-dose metronidazole for trichomonal vaginitis: patient and consort. Dykers JR Jr, Am J Obstet Gyneco/ 129:579-580, (Nov) 1978. The use of metronidazole (Flagyl) in a single 2-gm oral dose has recently been reported for the successful therapy of tr ichomonal vaginit is and urethri t is . Because of the car- cinogenicity and mutagenicity of metronidazole in laboratory animals and bacteria, the highest cure rate with the smallest possible dose is desirable. Three patient groups were treated wi th 2.0 gm, 1.5 gm, or 1.0 gm single oral dose of met- ronidazole and were studied for effectiveness of eliminating infection and for the incidence of side effects. Cure rates were similar (91%) in all three groups, with fewer side effects in the 1.0 gm dosage group. (Editor's note: It should be remem- bered that metronidazole and alcohol may produce an anti- buse-alcohol type reaction and therefore patients treated with metronidazole should avoid any alcoholic beverages for 24 hours after the last dose.) Brian Allen, MD vaginitis, trichomonal, drug treatment

The esophageal obturator airway, a clinical compari- son to ventilation with a mask and oropharyngeal airway. Bryson TK, Benumof JL, Ward CF, Chest 74:537-539, (Nov) 1978. Comparison of controlled ventilation with the esophageal ob- turator airway (EOA) to the conventional system of rubber mask and oropharyngeal a i rway was made in 10 anes- thetized patients scheduled for elective surgery under gen- eral anesthesia. Values for tidal volume were in all cases smaller with the EOA and in two cases were inadequate for survival. Leakage from the face mask was similar or greater in all cases with the EOA and in edentulous patients was marginal or unacceptable. Supraglottic obstruction was equal or greater in all cases with the EOA. Two of the 10 patients had accidental endotracheal intubation with the airway and required eventual direct laryngoscopic visualization. Place- merit of the EOA was cancelled in a third patient because of resistance to passage. Endotracheal intubation is the proce- dure of choice for resuscitative airway management. In situa- tions in which it cannot be used, the standard mask and oropharyngeal airway appears to be preferable to the EOA. (Editor's note: This article is intriguing because of the number of complications seen with the esophageal airway. One wonders i f the incidence was so high because of the pa- tients being anesthetized, or i f the lack of familiarity with the equipment played a role. We prefer endotracheal intubation when possible, but see a role for the EOA in the patient with potential neck injury in whom nasotracheal intubation cannot be achieved.) David H. Craig, MD esophageal obturator airway

96/116 Ann Emerg Med 9:2 (February) 1980