Electrocardiographical case. A man found unconscious.

A 25-year-old man was brought to the emergency room after being found unconscious. Electrocardiography (ECG) showed changes classical of tricyclic antidepressant (TCA) poisoning. These included sinus tachycardia, QTc prolongation, QRS complex widening, right axis deviation and positive R waves in lead aVR. This unique ECG highlights the importance of lead aVR, which often tends to be ignored. Treatment is started based on ECG findings.

Emergency physician versus cardiologist-initiated thrombolysis for acute myocardial infarction: a Singapore experience.

INTRODUCTION: To compare the door-to-needle time between thrombolysis administration for patients with ST elevation myocardial infarction (STEMI) in the emergency department (EMD) by emergency physicians and those administered in the coronary care unit (CCU) by cardiologists. METHODS: The data was collected prospectively for all patients with STEMI who received thrombolysis in the emergency department over a one-year period from January 2001 to December 2001. We recorded the time of arrival in the EMD as well as the time thrombolytic therapy was commenced. This data was compared to those from the previous year, obtained retrospectively, where the patients received thrombolysis in the CCU. RESULTS: 118 patients were thrombolysed in the CCU and 78 patients were thrombolysed in the EMD. The median door-to-needle time was significantly shorter in patients who are thrombolysed in the emergency department by emergency physicians than in the coronary care unit by cardiologists (29 minutes versus 60 minutes, p value is less than 0.001). There was no incident of inappropriate thrombolysis nor was there intracranial or gastrointestinal bleed in the patients who were thrombolysed in the EMD. There was one case of medication dose error but it was of no consequence to the patient. CONCLUSION: Emergency physicians can administer thrombolytic treatment appropriately, quickly and safely in patients with STEMI.

A review of 2,517 childhood injuries seen in a Singapore emergency department in 1999--mechanisms and injury prevention suggestions.

BACKGROUND: Childhood injuries cause significant mortality and morbidity in Singapore. With injury surveillance, patterns of repeated injury can be identified and injury prevention strategies devised. METHODS: We conducted a retrospective study of all children aged 12 and below seen for trauma in an Emergency Department over one year. Data captured in the real-time computer system was studied with regards to patient profile, mechanism of injury and patient disposition. Clinical summaries were extracted with follow-up telephone interviews done. RESULTS: Two thousand five hundred and seventeen children aged 12 and below were seen for accidental trauma in 1999, accounting for 37.1% of the total attendance for that age. Mean age was 7.7 years with males making up 62.7%. Home injuries (56.4%) were the most common, followed by road-related (14.4%), sports (8.2%) and playground injuries (7.4%). 48.5% sustained head and face injuries. Pre-school children (age <5) were more likely to sustain home injuries (p<0.0001), a higher proportion of head injuries (p<0.0001), foreign bodies, burns and poisoning compared to school-going children (age 6-12), who were more likely to sustain injuries in road accidents, sports, at playgrounds or schools, with more limb, trunk and multi-trauma. We highlight drownings, falls from height, rollover falls from beds, slamming door injuries, the low use of child car restraints, bicycle injuries and playground falls as areas of concern. CONCLUSION: Several injury prevention strategies have been suggested and it is hoped these may contribute to addressing preventable childhood injuries in Singapore. We also advocate the establishment of a national childhood injury surveillance database.

Fulminant refractory Lyme disease.

Lyme Disease, which is carried by ticks, has not been widely reported in Iowa but does occur here. The author discusses a case which involved most of the classic landmarks of the various stages of the disease.