Self-poisoning with metaldehyde.

Metaldehyde poisoning is rare. This case report details the largest toxic dose of self-poisoning with metaldehyde ever recorded in the literature to the authors' knowledge, the aim being to emphasise the features of metaldehyde toxicity and the potential for good clinical outcome. The patient was admitted unconscious with features consistent with poisoning. Appropriate critical care was instituted early with correction of his acid-base disorder, ventilatory support, correction of haemodynamic instability, anticonvulsant therapy and early admission to the critical care unit. An almost complete recovery was seen over the following weeks, the only lasting deficit being to short-term memory, a finding common to other reported incidents of metaldehyde toxicity. This case is notable in that the patient took more than one and a half times what is considered to be a lethal dose of metaldehyde (the largest reported), but has had a remarkably good clinical outcome that is proposed to be due to methodical and timely interventions delivered according to basic principles irrespective of the absence of the early identification of the poison. The case demonstrates several of the key features of metaldehyde toxicity and the emergency management of such a situation. The published literature pertaining to metaldehyde overdose is reviewed.

The right place in the right space? Awareness of site for needle thoracocentesis.

BACKGROUND: Invasive practical procedures require identification of surface anatomical landmarks to reduce risk of damage to other structures. Needle thoracocentesis has specific complications, which have been previously documented. An observational study was performed among emergency physicians to name the landmark for needle thoracocentesis and identify this point on a human volunteer as per Advanced Trauma and Life Support (ATLS) guidelines. RESULTS: A cohort of 25 emergency physicians was studied, 21 (84%) of which were ATLS certified. The correct landmark was named by 22 (88%). Only 15 (60%) correctly identified the second intercostal space on the human volunteer, all placing the needle medial to the midclavicular line, with a range of 3 cm. Two (8%) named and identified the site of needle pericardiocentesis; one (4%) named and identified the fifth intercostal space in the anterior axillary line. DISCUSSION: These results demonstrate a low accuracy among emergency physicians in identifying correct landmarks for needle thoracocentesis under elective conditions. Should greater emphasis be placed on competency based training in ATLS?

Emergency department ultrasound (EDU): clinical adjunct or plaything?

BACKGROUND: Emergency department ultrasound (EDU) is a physician performed ultrasound service aimed at improving patient flow and diagnosis in the emergency department. METHODS: This paper describes the initial phase of the introduction of EDU with three illustrative case reports and a discussion on the pitfalls and benefits of EDU. RESULTS AND DISCUSSION: In three cases discussed here, the use of EDU facilitated treatment and reduced the need for formal radiological scanning. While there are drawbacks to EDU, we believe these are far outweighed by the advantages, and in a recent survey of emergency medicine consultants throughout Ireland, the vast majority were in favour of its introduction. CONCLUSION: EDU has become a routine part of our clinical practice, and although we are still on a learning curve with regard to its use, we have experienced significant benefits in patient care. With technological advances (such as improved image resolution and teleradiology) the potential for EDU will continue to expand, but training, practice, accreditation, and audit are essential.