[Correspondence Insect Sting Reactions To the Editor: In all p a r t s of the country, with the a r r i v a l of w a r m w e a t h e r comes the ubiquitous bee sting victim. B u t in the South, for most of t h e y e a r these p a t i e n t s a p p e a r in such large n u m b e r s t h a t the t r e a t m e n t becomes routine: fluids i n t r a v e n o u s l y , a d r e n a l i n , B e n a d r y l and steroids. Occasionally, though, t h e victim is not l u c k y e n o u g h to a r r i v e in t h e e m e r g e n c y d e p a r t m e n t in a stable condition. For example, a y o u n g m a n was s t u n g by a bee while w o r k i n g in his y a r d on an unus-~ally w a r m F e b r u a r y day. S h o r t l y after b e i n g stung, he passed out. His wife called the rescue squad which a r r i v e d about t e n m i n u t e s later. The EMTs could not feel a pulse and b e g a n cardiopulmon a r y r e s u s c i t a t i o n (CPR). The p a t i e n t a r r i v e d a t t h e e m e r g e n c y d e p a r t m e n t t e n m i n u t e s l a t e r w h e r e int r a v e n o u s fluids were started, i n t u b a t i o n was performed and CPR was continued. D u r i n g the n e x t h a l f h o u r he received four a m p u l e s of s o d i u m b i c a r b o n a t e a n d two a m p u l e s of a d r e n a l i n i n t r a c a r d i a l l y . The cardiac m o n i t o r showed a flat line t h r o u g h o u t and the p a t i e n t was pronounced dead. Insects can kill. This case d r a m a t i z e s the need for i m p r o v i n g the mana g e m e n t of m i l d insect sting reactions in the e m e r g e n c y d e p a r t m e n t . It is the e m e r g e n c y physician's responsibility to w a r n t h e p a t i e n t of the d a n g e r of f u r t h e r insect stings. It is also his r e s p o n s i b i l i t y to provide the p a t i e n t w i t h some form of p r o t e c t i o n - - such as an i n h a l a n t c o n t a i n i n g a d r e n a l i n . P e r h a p s not every p a t i e n t t r e a t e d for a n insect sting reaction should be a r m e d w i t h such a d a n g e r o u s invention, b u t p a t i e n t s who w o r k outside in wooded a r e a s c e r t a i n l y need some form of r a p i d t r e a t m e n t . I e n c o u r a g e e m e r g e n c y p h y s i c i a n s to c o n s i d e r this in m a n a g e m e n t of insect sting reactions.
Selwyn T. Hartley, MD College Park, Georgia
Cold Injury From Skin Refrigerants To the Editor: We would like to d r a w your a t t e n t i o n to the deleterious effects of a skin r e f r i g e r a n t widely a v a i l a b l e in emergency d e p a r t m e n t s . F r i g i d e r m (Dichlorotetrafluoroethane [Freon]) is m a r k e t e d as "an a g e n t to quickly o b t a i n t e m p o r a r y a n e s t h e s i a by freezing, for m i n o r s u r g e r y , surgical p l a n i n g . . . " The directions a r e to "hold t h e s p r a y tip two to five inches from the surface to be frozen. A l l o w s p r a y to act for t h r e e to five seconds for localized m i n o r surgical procedures and for 20-30 seconds for s u r g i c a l p l a n i n g (dermabrasion). Do not exceed 45 seconds. L a r g e r a r e a s to be s p r a y e d from two cans simul-
Page 814 Volume 5 Number 10
taneously." This r e a g e n t is less toxic a n d nonflammable c o m p a r e d to ethyl chloride a n d h a s s u p p l a n t e d t h e latter as the e v a p o r a t i v e r e f r i g e r a n t a n e s t h e t i c of choice. However, it h a s a lower boiling point (3.6 C, [38.5 F]) t h a a e t h y l chloride (12 C, [53.6 F]) a n d would a p p e a r more l i k e l y to cause cold injury. Curiosity led us to e x p e r i m e n t w i t h t h i s product on iat a c t n o r m a l skin. We followed t h e m a n u f a c t u r e r ' s instructions, holding the s p r a y tip t h r e e inches from the dorsum of the h a n d and s p r a y e d the a r e a for less than five seconds. All four subjects who took p a r t in the test experienced a b u r n i n g s e n s a t i o n followed by t e m p o r a r y a n e s t h e s i a of the skin. Once the frost effect disappeared, the sprayed areas became progressively erythematous a n d painful. Twenty-four to 48 hours later, these areas showed signs typical of superficial frost bite. Over the n e x t seven days t h e y u n d e r w e n t b r a w n y discoloration and finally desquamation, leaving hypopigmented patches. In routine use, these effects are p r o b a b l y masked, since t h e a r e a to be a n e s t h e t i s e d is a l r e a d y the seat of inflammation. If t h e s k i n is b r e a c h e d d u r i n g the surgical procedure, the r e s u l t a n t cold i n j u r y m a y be m i s i n t e r p r e t e d as t h e tissue r e a c t i o n to t r a u m a . However, considering the frost bite injury suffered by t h e subjects after application on i n t a c t skin, we are even more concerned about using this r e a g e n t on inflamed, devitalized skin. We r e c o m m e n d t h a t these skin r e f r i g e r a n t s be used w i t h caution in e m e r g e n c y d e p a r t m e n t s . The manufact u r e r s should be r e q u i r e d to include a w a r n i n g on the aerosol cans o u t l i n i n g the possible d a n g e r of cold injury.
Don W. D. Collure, MD Steven B. Lanse E. J. Meyer Memorial Hospital Buffalo, New York
Nongrammar-of Pseudoscientific Language To the Editor: D u r i n g the w e e k of M a y 9 to 16, 1976, three meetings r e l a t e d to e m e r g e n c y m e d i c a l services took place in our b i c e n t e n n i a l East. The A m e r i c a n T r a u m a Society and t h e F i r s t I n t e r n a t i o n a l S y m p o s i u m of T r a u m a t o l o g y and E m e r g e n c y Medical Services met in B a l t i m o r e followed by the U n i v e r s i t y A s s o c i a t i o n for E m e r g e n c y Medical Services A n n u a l Meeting, d u r i n g which a F o r u m for the Society of T e a c h e r s of E m e r g e n c y Medicine was held, in P h i l a d e l p h i a . A t a b u l a t i o n of t h e words u t t e r e d during these seven days causes one to challenge the declension a n d conjugation, or even the derivation, of words used in medicine's unique form of communication. T r a d i t i o n a l errors include the use of the verb "to bleed"
•October 1976 J : ~ P
Selwyn T. Hartley, MD College Park, Georgia
Cold Injury From Skin Refrigerants To the Editor: We would like to d r a w your a t t e n t i o n to the deleterious effects of a skin r e f r i g e r a n t widely a v a i l a b l e in emergency d e p a r t m e n t s . F r i g i d e r m (Dichlorotetrafluoroethane [Freon]) is m a r k e t e d as "an a g e n t to quickly o b t a i n t e m p o r a r y a n e s t h e s i a by freezing, for m i n o r s u r g e r y , surgical p l a n i n g . . . " The directions a r e to "hold t h e s p r a y tip two to five inches from the surface to be frozen. A l l o w s p r a y to act for t h r e e to five seconds for localized m i n o r surgical procedures and for 20-30 seconds for s u r g i c a l p l a n i n g (dermabrasion). Do not exceed 45 seconds. L a r g e r a r e a s to be s p r a y e d from two cans simul-
Page 814 Volume 5 Number 10
taneously." This r e a g e n t is less toxic a n d nonflammable c o m p a r e d to ethyl chloride a n d h a s s u p p l a n t e d t h e latter as the e v a p o r a t i v e r e f r i g e r a n t a n e s t h e t i c of choice. However, it h a s a lower boiling point (3.6 C, [38.5 F]) t h a a e t h y l chloride (12 C, [53.6 F]) a n d would a p p e a r more l i k e l y to cause cold injury. Curiosity led us to e x p e r i m e n t w i t h t h i s product on iat a c t n o r m a l skin. We followed t h e m a n u f a c t u r e r ' s instructions, holding the s p r a y tip t h r e e inches from the dorsum of the h a n d and s p r a y e d the a r e a for less than five seconds. All four subjects who took p a r t in the test experienced a b u r n i n g s e n s a t i o n followed by t e m p o r a r y a n e s t h e s i a of the skin. Once the frost effect disappeared, the sprayed areas became progressively erythematous a n d painful. Twenty-four to 48 hours later, these areas showed signs typical of superficial frost bite. Over the n e x t seven days t h e y u n d e r w e n t b r a w n y discoloration and finally desquamation, leaving hypopigmented patches. In routine use, these effects are p r o b a b l y masked, since t h e a r e a to be a n e s t h e t i s e d is a l r e a d y the seat of inflammation. If t h e s k i n is b r e a c h e d d u r i n g the surgical procedure, the r e s u l t a n t cold i n j u r y m a y be m i s i n t e r p r e t e d as t h e tissue r e a c t i o n to t r a u m a . However, considering the frost bite injury suffered by t h e subjects after application on i n t a c t skin, we are even more concerned about using this r e a g e n t on inflamed, devitalized skin. We r e c o m m e n d t h a t these skin r e f r i g e r a n t s be used w i t h caution in e m e r g e n c y d e p a r t m e n t s . The manufact u r e r s should be r e q u i r e d to include a w a r n i n g on the aerosol cans o u t l i n i n g the possible d a n g e r of cold injury.
Don W. D. Collure, MD Steven B. Lanse E. J. Meyer Memorial Hospital Buffalo, New York
Nongrammar-of Pseudoscientific Language To the Editor: D u r i n g the w e e k of M a y 9 to 16, 1976, three meetings r e l a t e d to e m e r g e n c y m e d i c a l services took place in our b i c e n t e n n i a l East. The A m e r i c a n T r a u m a Society and t h e F i r s t I n t e r n a t i o n a l S y m p o s i u m of T r a u m a t o l o g y and E m e r g e n c y Medical Services met in B a l t i m o r e followed by the U n i v e r s i t y A s s o c i a t i o n for E m e r g e n c y Medical Services A n n u a l Meeting, d u r i n g which a F o r u m for the Society of T e a c h e r s of E m e r g e n c y Medicine was held, in P h i l a d e l p h i a . A t a b u l a t i o n of t h e words u t t e r e d during these seven days causes one to challenge the declension a n d conjugation, or even the derivation, of words used in medicine's unique form of communication. T r a d i t i o n a l errors include the use of the verb "to bleed"
•October 1976 J : ~ P
