AMERICAN JOURNAL OF EMERGENCY MEDICINE n Volume 10, Number 4 n July 1992

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tionable efficacy in the ED, we urge clinicians to avoid routine use of aminophylline in the ED.

1. Stewart RD: Tactile Med 1984;13(3):175-178

TIMOTHYSELF, PHARMD RONALD JOE, PHARMD ARTHUR KELLERMANN, MD, MPH The University of Tennessee Health Science Memphis, TN

Center

1. Duke T, Kellermann A, Ellis R, et al: Asthma in the emergency department: Impact of a protocol on optimizing therapy. Am J Emerg Med 1991;9:432-435 2. Walker FB, Kaiser DL, Kowal MB, et al: Prolonged inhaled glycopyrrolate in asthma. Chest 1987;91:49-51

effect of

3. Gilman MJ, Meyer L, Carter J, et al: Comparison of aerosolized glycopyrrolate and metaproterenol in acute asthma. Chest 1990;98:1095-1098 4. O’Driscoll BR, Taylor RJ, Horsley MG, et al: Nebulized salbutamol with and without ipratropium bromide in acute airflow obstruction. Lancet 1989;1:1418-1420 5. Rebuck AS, Chapman KR, Abbovd R, et al: Nebulized anticholinergic and sympathomimetic treatment of asthma and chronic obstructive pulmonary disease in the emergency room. Am J Med 1987;82:59-64 6. Wrenn K, Slovis CM, Murphy F, et al: Aminophylline therapy for acute bronchospastic disease in the emergency room. Ann Intern Med 1991;115:241-247 7. Joe RH, Kellermann tocol in the emergency 1992;26:472-476

Reference

A, Ellis R, et al: Asthma treatment prodepartment. Ann Pharmacotherapy

DIGITAL ENDOTRACHEAL INTUBATION To the Editor:-In an article published in 1984, Dr Ronald Stewart revived the concepts of digital intubation. ’ Though not embraced by all residency training programs, and commonly met with intubator complaints of inadequate finger length or overabundant hand size, this method of controlling the airway is used at appropriate times by emergency physicians. I wish to share an addendum to this technique. In the article Dr Stewart offers, “The tube is then placed against the epiglottis anteriorly with the middle and index fingers posteriorly. The fingers then provide firm anteriorly directed pressure to guide the tube through the glottis.” In an elaboration of this step of this technique which I have found to be useful, the intubator initially places the hand in the hypopharynx and uses the extended second and third fingers to “flip up” the floppy epiglottis. Then the intubator pushes his hand farther forward such that the linger tips are actually in the hypopharynx, posterior to the posterior aspect of the larynx. As the endotracheal tube is passed into the pharynx with the opposite hand, the index and middle lingers of the “intraoral hand” serve in the role of a “basketball backstop.” As the tube approaches the lower pharynx, the distal end of the tube hits the volar surface of these fingers and, given that they are approximated to the posterior aspect of the larynx, the tube slides down these fingers, and in most cases, slides through the glottis, as it has no other place to go. The index finger may be flexed to help guide the tube into this position. The tube is advanced by the extraoral hand. The choice of which specific technique to use for guiding through the glottis may be determined by the anatomy of the intubator or the patient. I offer here an alternate technique to this step of digital intubation which may be useful in some of these anatomic situations. RICHARDT. COOK, JR, MD Pennsylvania State University College of Medicine Hershey, PA

orotracheal

intubation:

Ann

Emerg

TRAUMATIC CARDTIDEAL DISSECTION AFTER BLUNT CERVICAL INJURY: AN ELUSIVE CLINICAL ENTITY To the Editor:-In spite of the high incidence of head trauma and/or blunt cervical lesions, injuries of the internal carotid artery are extremely unusual,’ and the clinical picture can be altered by the presence of temporary encephalitic injuries. The existence of traumatic injuries in other organs and the need to resort immediately to “life-saving” surgical procedures are elements which can further delay diagnosis. The following is a report of our own experience in a case of posttraumatic dissection of the internal carotid artery. A white 17-year-old male was hospitalized as a consequence of a road accident (a fall from his bicycle). In the accident he broke his right shoulder bone and lost consciousness for a few moments, but recovered it by the time the hospital was reached. The patient was hospitalized on the orthopedic ward, and at the time of hospitalization had a negative neurologic assessment. Four hours later, a right hemiparesis with ingravescent behavior began to appear together with a reduction of consciousness. A cranial computed tomographic scan was performed; its result was negative. Digital angiography of the left internal carotid artery highlighted the presence of an obstruction 3 cm from the bifurcation up to the carotideal siphon (Figure I). Rehabilitation of left anterior cerebral artery was accomplished through the anterior communication artery. Thereafter the patient underwent surgical treatment, during which was detected the existence of a thrombus above a wide intimal dissection. After the removal of the thrombus, a tract of inverted saphena was grafted. Administration of heparine and nimodipine began. A control angiography, which was done the following day, revealed a thrombosis of the venous bypass. A computed tomographic scan of the skull, taken 4 days after the surgical repair of the carotideal dissection, revealed the existence of a wide right parietal hypodensity (Figure 2). compatible with a recent vascular ischemic injury. After I month’s stay in our intensive care unit, the patient was moved to the rehabilitation department: by then he was able to move his left lower limb quite spontaneously, while the upper limb was still paralyzed. Injuries of internal carotid artery following a blunt cranial-cervical injury are unusual, but by no means exceptional, and can often be overlooked because of concomitant encephalic injuries.’ The internal carotid artery. in its extracranial course, can be damaged by a direct injury. or by the combination of hyperextension and rotation of the head and the neck with subsequent stretching of the carotid artery against the first and the second cervical vertebras, or the transversal process against the third vertebra can occur. Injuries of the oral cavity and basal or skull fractures can damage the intrapetrous part of the artery.’ From the anatomic pathologic point of view, blunt traumatic carotideal injuries can be divided into stenosis or intraluminal obstructions of a thrombotic nature. pseudoaneurisms, and arteriovenous listulas.4 The thrombus generally originates in correspondence of a solution of continuity of the intimal wall which can lead to its dissection by allowing the inflow of blood in the vessel wall, as in our case study, or lead to the formation of a pseudoaneurism.’ The clinical picture determined by traumatic carotid artery injuries is quite unstable, both as far as the appearance of the injury is concerned and the symptomatology recorded. Despite the fact that the symptoms can appear up to 10 years later, they usually do so within 12 hours of the traumatic event.‘.5 The clinical picture can change from the appearance of focal signals of varying gravity to hemiparesis. These signals can be associated with alteration of consciousness. The clinical picture is also influenced by the overall

Digital endotracheal intubation.

AMERICAN JOURNAL OF EMERGENCY MEDICINE n Volume 10, Number 4 n July 1992 396 tionable efficacy in the ED, we urge clinicians to avoid routine use of...
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