Correspondence o m m e n d e d for acute soft t i s s u e a n d bony injuries, l)i c h a r g e d p a t i e n t s s h o u l d be a d v i s e d t h a t cryothera~ should be episodic r a t h e r t h a n continual. •
Robert P. Proulx, ~ Burbank, Califor~i
Treatment of Acute Alcoholism To the E d i t o r :
The article on Intravenous Fructose for Acute Alcc
F i g . Swollen great toe, three days after injury, with vesicle formation and some weeping areas•
Southern California Frostbite To the Editor: F r o s t b i t e is an u n u s u a l diagnosis in s u n n y s o u t h e r n California b u t t h e r e is a t least one set of circumstances t h a t can l e a d to t h a t condition I'd like to s h a r e w i t h J A CEP readers. CASE REPORT A 79-year-old m a n c a m e to the e m e r g e n c y d e p a r t m e n t w i t h a c o m p l a i n t of p a i n in his left g r e a t toe after h a v i n g dropped a suitcase on it t h r e e days earlier. Examination revealed a swollen great toe with p u r p l i s h discoloration a n d vesicle formation. T h e r e were also some "weeping" a r e a s (Figure). S e n s a t i o n was i n t a c t and the toe was w a r m b u t refill t i m e a p p e a r e d delayed. On f u r t h e r q u e s t i o n i n g t h e p a t i e n t a d m i t t e d to a p p l y i n g ice packs u n r e m i t t i n g l y ever since the injury. X-ray films r e v e a l e d a n u n d i s p l a c e d fracture of the distal p h a l a n x . The p a t i e n t was diagnosed as h a v i n g frostbite as well as a f r a c t u r e d p h a l a n x . T e t a n u s toxoid, t e t a n u s i m m u n e globulin a n d antibiotics were given. The p a t i e n t was discharged w i t h instructions to s t a y off the foot and keep it e l e v a t e d . He was seen two d a y s l a t e r by his p r i v a t e p h y s i c i a n who debrided t h e wound. This was followed by an uneventful recovery except for the loss of the nail. DISCUSSION A l t h o u g h fracture blisters do occur w i t h a n y type of fracture, the discoloration did not a p p e a r typical of t h a t t y p e of problem. On r e p e a t e d q u e s t i o n i n g t h e p a t i e n t h i m s e l f recognized t h a t he h a d been too vigorous w i t h the use of ice. It is c e r t a i n l y worth k e e p i n g this diagnosis in m i n d w i t h p a t i e n t s who h a v e t r e a t e d t h e m s e l v e s w i t h ice packs prior to e x a m i n a t i o n . Ice packs are commonly rec-
Page 618 Volume 5 Number 8
holism - A Double Blind Study by P e t e r C. Amene, ~) (JACEP, A p r i l 1976) p r o m p t s me to r e p o r t on a meth~ of alcohol detoxification I h a v e used successfully. I have been using, as detoxification for acute alcoholis~ a double a p p r o a c h t h a t e n t a i l s first, t h e p a s s a g e of n a s o g a s t r i c t u b e to r e m o v e r e s i d u a l alcohol from t~ stomach a n d the i n s t a l l a t i o n of a double s t r e n g t h , caffeir a t e d coffee mixture. Then, a h e p a r i n well, or i n t r a v e n o u s infusion site, i placed in a n a n t i c u b i t a l fossa vein and 40 m g of furosemi~ (Lasix) is injected, followed by one a m p u l e of 50% gluc0s, (50 cc) a n d one a m p u l e of bicarbonate. The purpose ofth~ first step is to remove alcohol t h a t m u s t y e t be absorbe~ a n d increase corticol a c t i v i t y w i t h the caffeine. The put pose of~the second is to produce a diuresis to lower bl00c volume to counteract acidosis a n d to m a k e glucose avail able to liver a n d muscle for m e t a b o l i s m of circulatinl alcohol. I n my experience, over t h e p a s t year, t h i s h a s work~ a d m i r a b l y . Dr. A m e n e ' s article afforded a n e d i t o r i a l basi= for m y own experience. It will be i n t e r e s t i n g to kn0~ others' c o m m e n t s a n d experience t h a t m a y follow his pro vocative article.
Merton J. Alexander, MI Arcadia, Californll
Splint the Patients, not the Fractures, Where They Lie To the Editor: I r e a d w i t h i n t e r e s t '~Contra-indications to the Rep0Si t i o n i n g of F r a c t u r e d or Dislocated Limbs in the Field," bl J o h n E. Gustafson, MD, (JACEP M a r c h 1976) and fl~! t h a t I cannot t o t a l l y agree w i t h its conclusions. Dr. Gu~ tafson seems to advocate rigid i n t e r p r e t a t i o n of the 0J axiom, % p l i n t t h e m where they-lie." He i n t e r p r e t s this tl m e a n t h a t no fractures or dislocations should be rep0S! tioned b u t r a t h e r splinted in e x a c t l y the position they ~ found by the first aider. Actually, this a x i o m does not s~l t h a t fractures should not be repositioned b u t r a t h e r tl~$ the fracture should be s p l i n t e d w h e r e t h e p a t i e n t li$
August 1976 , ~ ! J
Robert P. Proulx, ~ Burbank, Califor~i
Treatment of Acute Alcoholism To the E d i t o r :
The article on Intravenous Fructose for Acute Alcc
F i g . Swollen great toe, three days after injury, with vesicle formation and some weeping areas•
Southern California Frostbite To the Editor: F r o s t b i t e is an u n u s u a l diagnosis in s u n n y s o u t h e r n California b u t t h e r e is a t least one set of circumstances t h a t can l e a d to t h a t condition I'd like to s h a r e w i t h J A CEP readers. CASE REPORT A 79-year-old m a n c a m e to the e m e r g e n c y d e p a r t m e n t w i t h a c o m p l a i n t of p a i n in his left g r e a t toe after h a v i n g dropped a suitcase on it t h r e e days earlier. Examination revealed a swollen great toe with p u r p l i s h discoloration a n d vesicle formation. T h e r e were also some "weeping" a r e a s (Figure). S e n s a t i o n was i n t a c t and the toe was w a r m b u t refill t i m e a p p e a r e d delayed. On f u r t h e r q u e s t i o n i n g t h e p a t i e n t a d m i t t e d to a p p l y i n g ice packs u n r e m i t t i n g l y ever since the injury. X-ray films r e v e a l e d a n u n d i s p l a c e d fracture of the distal p h a l a n x . The p a t i e n t was diagnosed as h a v i n g frostbite as well as a f r a c t u r e d p h a l a n x . T e t a n u s toxoid, t e t a n u s i m m u n e globulin a n d antibiotics were given. The p a t i e n t was discharged w i t h instructions to s t a y off the foot and keep it e l e v a t e d . He was seen two d a y s l a t e r by his p r i v a t e p h y s i c i a n who debrided t h e wound. This was followed by an uneventful recovery except for the loss of the nail. DISCUSSION A l t h o u g h fracture blisters do occur w i t h a n y type of fracture, the discoloration did not a p p e a r typical of t h a t t y p e of problem. On r e p e a t e d q u e s t i o n i n g t h e p a t i e n t h i m s e l f recognized t h a t he h a d been too vigorous w i t h the use of ice. It is c e r t a i n l y worth k e e p i n g this diagnosis in m i n d w i t h p a t i e n t s who h a v e t r e a t e d t h e m s e l v e s w i t h ice packs prior to e x a m i n a t i o n . Ice packs are commonly rec-
Page 618 Volume 5 Number 8
holism - A Double Blind Study by P e t e r C. Amene, ~) (JACEP, A p r i l 1976) p r o m p t s me to r e p o r t on a meth~ of alcohol detoxification I h a v e used successfully. I have been using, as detoxification for acute alcoholis~ a double a p p r o a c h t h a t e n t a i l s first, t h e p a s s a g e of n a s o g a s t r i c t u b e to r e m o v e r e s i d u a l alcohol from t~ stomach a n d the i n s t a l l a t i o n of a double s t r e n g t h , caffeir a t e d coffee mixture. Then, a h e p a r i n well, or i n t r a v e n o u s infusion site, i placed in a n a n t i c u b i t a l fossa vein and 40 m g of furosemi~ (Lasix) is injected, followed by one a m p u l e of 50% gluc0s, (50 cc) a n d one a m p u l e of bicarbonate. The purpose ofth~ first step is to remove alcohol t h a t m u s t y e t be absorbe~ a n d increase corticol a c t i v i t y w i t h the caffeine. The put pose of~the second is to produce a diuresis to lower bl00c volume to counteract acidosis a n d to m a k e glucose avail able to liver a n d muscle for m e t a b o l i s m of circulatinl alcohol. I n my experience, over t h e p a s t year, t h i s h a s work~ a d m i r a b l y . Dr. A m e n e ' s article afforded a n e d i t o r i a l basi= for m y own experience. It will be i n t e r e s t i n g to kn0~ others' c o m m e n t s a n d experience t h a t m a y follow his pro vocative article.
Merton J. Alexander, MI Arcadia, Californll
Splint the Patients, not the Fractures, Where They Lie To the Editor: I r e a d w i t h i n t e r e s t '~Contra-indications to the Rep0Si t i o n i n g of F r a c t u r e d or Dislocated Limbs in the Field," bl J o h n E. Gustafson, MD, (JACEP M a r c h 1976) and fl~! t h a t I cannot t o t a l l y agree w i t h its conclusions. Dr. Gu~ tafson seems to advocate rigid i n t e r p r e t a t i o n of the 0J axiom, % p l i n t t h e m where they-lie." He i n t e r p r e t s this tl m e a n t h a t no fractures or dislocations should be rep0S! tioned b u t r a t h e r splinted in e x a c t l y the position they ~ found by the first aider. Actually, this a x i o m does not s~l t h a t fractures should not be repositioned b u t r a t h e r tl~$ the fracture should be s p l i n t e d w h e r e t h e p a t i e n t li$
August 1976 , ~ ! J
