A n x - r a y film by a portable u n i t confirmed a left-sided pneumothorax. A 14-gauge c a t h e t e r w a s i n s e r t e d intercostally a n d a rush of a i r escaped from the needle. His ven. t r i c u l a r t a c h y c a r d i a s u d d e n l y c o n v e r t e d to a sinus r h y t h m . A chest t u b e was i n s e r t e d and he was admit. t e d to the intensive care u n i t in s i n u s r h y t h m .
41/~ hours of dialysis. The p a t i e n t recovered uneventfully and was discharged the following day. Fred M. Reid, M D Department o f Emergency Medicine Charity Hospital o f Louisiana N e w Orleans, Louisiana 1. Martin EW (ed): Remington's Pharmaceutical Sciences, ed 13. Eaton, Pennsylvania, Mack Publishing Co, 1956, p 853854. 2. Phelan WJ III: Camphor poisoning: Over-the-counter dangers. Pediatrics 57:428-431, 1976. 3. Jacobziner H, Raybin HW: Camphor poisoning. Arch Pediatr 79:28-30, 1967. 4. Weiss J, Capalano P: Camphorated oil intoxication during pregnancy. Pediatrics 52:713-714, 1973. 5. Aronow R: Camphor poisoning. JAMA 235:1260, 1976. 6. Smith AG, Margolis G: Camphor poisoning; anatomical and pharmacological study; report of a fatal case; experimental investigation of protective action of barbiturate. A m J Pathol 30:857-869, 1954. 7. Vasey RH, Karayannopoulos SJ: Camphorated oil. Br Med J 1"112, 1972. 8. Bellman MH: Camphor poisoning in children. Br Med J
DISCUSSION A tension p n e u m o t h o r a x probably accounted for the p a t i e n t ' s r e s p i r a t o r y distress, d i m i n i s h e d breath sounds, and a r r h y t h m i a s . T h e e t i o l o g y for h i s i n t r a c t a b l e v e n t r i c u l a r t a c h y c a r d i a is speculative b u t probably was altered v e n t r i c u l a r r e p o l a r i z a t i o n f r o m hypoxia;1, 2 reflex s t i m u l i from p r e s s u r e receptors in the heart, great veins, p u l m o n a r y a r t e r y a n d lung; shift of the mediast i n a l structures; and d i m i n i s h e d c o r o n a r y perfusion and cardiac o u t p u t caused by decreased venous return. References to v e n t r i c u l a r a r r h y t h m i a associated w i t h tension p n e u m o t h o r a x in t h e l i t e r a t u r e are infrequent b u t t h e occurrence of a r r h y t h m i a s in chronic cor pulmonale and chronic obstructive p u l m o n a r y disease (COPD) are described more often2,2 The presence of a r r h y t h m i a s m a y a g g r a v a t e alr e a d y e x i s t i n g tissue hypoxia by c a u s i n g a reduction in cardiac output. 1 A r r h y t h m i a s can reduce the cardiac output by 80%. In acutely ill p a t i e n t s with COPD, v e n t r i c u l a r a r r h y t h m i a s indicate a grave prognosis. 3 In any event, in p a t i e n t s w i t h a p n e u m o t h o r a x , vent r i c u l a r t a c h y c a r d i a m a y respond only after insertion of a chest t u b e or needle.
2:177, 1973. 9. Riggs J, Hamilton R, Home] S, et al: Camphorated oil intoxication in pregnancy. Obstet Gynecol 25:255-258, 1965. 10. Robertson JS, Hussain M: Metabolism of camphors and related compounds. Biomed J 113:57-67, 1969. 11. Blackmon WP, Curry HB: Camphor poisoning: Report of a case occurring during pregnancy. J Fla Med Assoc 43:9991000, 1957.
Donald Forester, MD Queens Hospital Center Jamaica, N e w York 1. Halford FD, Mithoefer JC: Cardiac arrhythmias in hospitalized patients with COPD. Am Rev Resp Dis 109:879-885, 1973. 2. Corazza LJ, Pastor BH: Cardiac arrhythmias in chronic car pulmonale. N Engl J Med 259:862-865, 1958. 3. Senior RM, Lefrak SS, Kleiger RE: The heart in chronic obstructive pulmonary disease; arrhythmias. Chest 75:1-2, 1979.
12. Ginn HE, Anderson KE, Mercier RK, et al: Camphor intoxication treated by lipid dialysis. JAMA 203:230-231, 1968. 13. Corby DC, Decker WJ: Management of acute poisoning with activated charcoal. Pediatrics 54:324-328, 1974.
14. National Clearinghouse of Poison Control Centers Bulletin. US Dept HEW, Bethesda, MD, July-August, 1975, p 1-2.
Ventricular Tachycardia with Tension Pneumothorax To the Editor:
Asthmatic Evaluation by Spirometry
Tension p n e u m o t h o r a x not only causes ST a n d T wave changes, as r e p o r t e d by Slay et al in ~ T r a n s i e n t ST E l e v a t i o n s A s s o c i a t e d w i t h T e n s i o n P n e u m o thorax" (8:16-18, 1979), b u t m a y also be responsible for i n t r a c t a b l e v e n t r i c u l a r t a c h y c a r d i a as in the following brief case report.
To the Editor: The article by N o w a k et al, ~Spirometrie Evaluat i o n of A c u t e B r o n c h i a l A s t h m a " (8:9-15, 1979), f u r t h e r confirms t h e need and usefulness of puhnon a r y function t e s t i n g of a s t h m a t i c s in t h e emergency d e p a r t m e n t , b u t I m u s t t a k e issue w i t h two key points not a d e q u a t e l y discussed in t h e study. F i r s t of all, the a u t h o r s have a r b i t r a r i l y divided t h e i r a s t h m a t i c p a t i e n t s into t h r e e groups based on t h e i r FEVI.o on p r e s e n t a t i o n and the change in FEV1.0 p o s t t r e a t m e n t , w i t h o u t r e g a r d to age, h e i g h t , or weight. In short, t h e y d i s r e g a r d predicted FE¥1.o values according to accepted s t a n d a r d s . I believe ~his is an i n h e r e n t inaccuracy in t h e i r m e t h o d of evaluation. For example, a 6 ' 2 " 20-year-old m a n would have a predicted FEV1.0 of 4.81, while a 5' 40-year-old woman would have a predicted v a l u e of less t h a n h a l f of that, or 2.22. Thus to place such p a t i e n t s in the same clinical group based solely on absolute FEVI.o would be at-
CASE REPORT A 55-year-old m a n was b r o u g h t into the emergency d e p a r t m e n t in r e s p i r a t o r y distress. He h a d a h i s t o r y of s e v e r a l p n e u m o t h o r a c e s from c o n g e n i t a l blebs. D u r i n g t h e e x a m i n a t i o n he h a d a r e s p i r a t o r y arrest, followed by a g r a n d m a l seizure and ventricul a r tachycardia. He was i n t u b a t e d a n d given assisted v e n t i l a t i o n and i n t r a v e n o u s lidocaine. On a u s c u l t a tion of his lungs, d i m i n i s h e d b r e a t h sounds were noted in the left chest. His v e n t r i c u l a r t a c h y c a r d i a persisted d e s p i t e a t t e m p t s to c o n v e r t h i m e l e c t r i c a l l y a n d p h a r m a c o l o g i c a l l y (lidocaine, procainamide, b r e t y l i u m tosylate, and propranolol). The endotracheal tube was pulled back b u t din~inished b r e a t h sounds persisted.
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41/~ hours of dialysis. The p a t i e n t recovered uneventfully and was discharged the following day. Fred M. Reid, M D Department o f Emergency Medicine Charity Hospital o f Louisiana N e w Orleans, Louisiana 1. Martin EW (ed): Remington's Pharmaceutical Sciences, ed 13. Eaton, Pennsylvania, Mack Publishing Co, 1956, p 853854. 2. Phelan WJ III: Camphor poisoning: Over-the-counter dangers. Pediatrics 57:428-431, 1976. 3. Jacobziner H, Raybin HW: Camphor poisoning. Arch Pediatr 79:28-30, 1967. 4. Weiss J, Capalano P: Camphorated oil intoxication during pregnancy. Pediatrics 52:713-714, 1973. 5. Aronow R: Camphor poisoning. JAMA 235:1260, 1976. 6. Smith AG, Margolis G: Camphor poisoning; anatomical and pharmacological study; report of a fatal case; experimental investigation of protective action of barbiturate. A m J Pathol 30:857-869, 1954. 7. Vasey RH, Karayannopoulos SJ: Camphorated oil. Br Med J 1"112, 1972. 8. Bellman MH: Camphor poisoning in children. Br Med J
DISCUSSION A tension p n e u m o t h o r a x probably accounted for the p a t i e n t ' s r e s p i r a t o r y distress, d i m i n i s h e d breath sounds, and a r r h y t h m i a s . T h e e t i o l o g y for h i s i n t r a c t a b l e v e n t r i c u l a r t a c h y c a r d i a is speculative b u t probably was altered v e n t r i c u l a r r e p o l a r i z a t i o n f r o m hypoxia;1, 2 reflex s t i m u l i from p r e s s u r e receptors in the heart, great veins, p u l m o n a r y a r t e r y a n d lung; shift of the mediast i n a l structures; and d i m i n i s h e d c o r o n a r y perfusion and cardiac o u t p u t caused by decreased venous return. References to v e n t r i c u l a r a r r h y t h m i a associated w i t h tension p n e u m o t h o r a x in t h e l i t e r a t u r e are infrequent b u t t h e occurrence of a r r h y t h m i a s in chronic cor pulmonale and chronic obstructive p u l m o n a r y disease (COPD) are described more often2,2 The presence of a r r h y t h m i a s m a y a g g r a v a t e alr e a d y e x i s t i n g tissue hypoxia by c a u s i n g a reduction in cardiac output. 1 A r r h y t h m i a s can reduce the cardiac output by 80%. In acutely ill p a t i e n t s with COPD, v e n t r i c u l a r a r r h y t h m i a s indicate a grave prognosis. 3 In any event, in p a t i e n t s w i t h a p n e u m o t h o r a x , vent r i c u l a r t a c h y c a r d i a m a y respond only after insertion of a chest t u b e or needle.
2:177, 1973. 9. Riggs J, Hamilton R, Home] S, et al: Camphorated oil intoxication in pregnancy. Obstet Gynecol 25:255-258, 1965. 10. Robertson JS, Hussain M: Metabolism of camphors and related compounds. Biomed J 113:57-67, 1969. 11. Blackmon WP, Curry HB: Camphor poisoning: Report of a case occurring during pregnancy. J Fla Med Assoc 43:9991000, 1957.
Donald Forester, MD Queens Hospital Center Jamaica, N e w York 1. Halford FD, Mithoefer JC: Cardiac arrhythmias in hospitalized patients with COPD. Am Rev Resp Dis 109:879-885, 1973. 2. Corazza LJ, Pastor BH: Cardiac arrhythmias in chronic car pulmonale. N Engl J Med 259:862-865, 1958. 3. Senior RM, Lefrak SS, Kleiger RE: The heart in chronic obstructive pulmonary disease; arrhythmias. Chest 75:1-2, 1979.
12. Ginn HE, Anderson KE, Mercier RK, et al: Camphor intoxication treated by lipid dialysis. JAMA 203:230-231, 1968. 13. Corby DC, Decker WJ: Management of acute poisoning with activated charcoal. Pediatrics 54:324-328, 1974.
14. National Clearinghouse of Poison Control Centers Bulletin. US Dept HEW, Bethesda, MD, July-August, 1975, p 1-2.
Ventricular Tachycardia with Tension Pneumothorax To the Editor:
Asthmatic Evaluation by Spirometry
Tension p n e u m o t h o r a x not only causes ST a n d T wave changes, as r e p o r t e d by Slay et al in ~ T r a n s i e n t ST E l e v a t i o n s A s s o c i a t e d w i t h T e n s i o n P n e u m o thorax" (8:16-18, 1979), b u t m a y also be responsible for i n t r a c t a b l e v e n t r i c u l a r t a c h y c a r d i a as in the following brief case report.
To the Editor: The article by N o w a k et al, ~Spirometrie Evaluat i o n of A c u t e B r o n c h i a l A s t h m a " (8:9-15, 1979), f u r t h e r confirms t h e need and usefulness of puhnon a r y function t e s t i n g of a s t h m a t i c s in t h e emergency d e p a r t m e n t , b u t I m u s t t a k e issue w i t h two key points not a d e q u a t e l y discussed in t h e study. F i r s t of all, the a u t h o r s have a r b i t r a r i l y divided t h e i r a s t h m a t i c p a t i e n t s into t h r e e groups based on t h e i r FEVI.o on p r e s e n t a t i o n and the change in FEV1.0 p o s t t r e a t m e n t , w i t h o u t r e g a r d to age, h e i g h t , or weight. In short, t h e y d i s r e g a r d predicted FE¥1.o values according to accepted s t a n d a r d s . I believe ~his is an i n h e r e n t inaccuracy in t h e i r m e t h o d of evaluation. For example, a 6 ' 2 " 20-year-old m a n would have a predicted FEV1.0 of 4.81, while a 5' 40-year-old woman would have a predicted v a l u e of less t h a n h a l f of that, or 2.22. Thus to place such p a t i e n t s in the same clinical group based solely on absolute FEVI.o would be at-
CASE REPORT A 55-year-old m a n was b r o u g h t into the emergency d e p a r t m e n t in r e s p i r a t o r y distress. He h a d a h i s t o r y of s e v e r a l p n e u m o t h o r a c e s from c o n g e n i t a l blebs. D u r i n g t h e e x a m i n a t i o n he h a d a r e s p i r a t o r y arrest, followed by a g r a n d m a l seizure and ventricul a r tachycardia. He was i n t u b a t e d a n d given assisted v e n t i l a t i o n and i n t r a v e n o u s lidocaine. On a u s c u l t a tion of his lungs, d i m i n i s h e d b r e a t h sounds were noted in the left chest. His v e n t r i c u l a r t a c h y c a r d i a persisted d e s p i t e a t t e m p t s to c o n v e r t h i m e l e c t r i c a l l y a n d p h a r m a c o l o g i c a l l y (lidocaine, procainamide, b r e t y l i u m tosylate, and propranolol). The endotracheal tube was pulled back b u t din~inished b r e a t h sounds persisted.
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