Can J Emerg Med
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Lateral canthotomy and cantholysis is a simple procedure that can be performed by emergency physicians. It has the potential to save vision, particularly in cases of blunt ocular trauma. The case of a 37-year-old man with blunt ocular trauma, a retrobulbar hemorrhage and rapidly increasing orbital pressure requiring an urgent lateral canthotomy and cantholysis is presented. Pathophysiology, indications, contraindications, procedure and follow-up care are described.
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Poisoning is an uncommon but potentially fatal outcome of toxic alcohol ingestion. The toxic alcohols methanol, ethylene glycol and isopropyl alcohol are commonly found in household and commercial products. Because the toxic effects are caused by the metabolites of methanol and ethylene glycol rather than the agents themselves, there is often a substantial delay between ingestion and onset of clinical toxicity. ⋯ The pitfalls of using these tests to rule out alcohol ingestion are reviewed. Ethanol infusion is the traditional therapy for such overdoses. In addition to the pathophysiology and clinical findings in poisoning, recent evidence for the use of fomepizole and adjuvant therapies is reviewed.
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Most emergency departments (EDs) have deficiencies in the type and quantity of antidotes readily available to treat severely poisoned patients. Undue emphasis on the purchase price of several expensive antidotes such as anti-digoxin F(ab) fragments and fomepizole may contribute to this problem by creating the perception that comprehensive antidote stocking is too costly for smaller centres. For rarely used medications, however, purchase price alone is an insufficient estimate of cost. ⋯ While other factors (antidote efficacy, safety and available alternate therapy) need to be considered, the cost of maintaining antidote availability is not determined primarily by purchase price. A change in supplier policy to free replacement on expiry for fomepizole and cyanide antidotes would have a considerable effect on making these antidotes less costly for smaller Canadian EDs.
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Ethical issues can be more difficult to address in the emergency department than in other settings. We present two cases, with the goal of stimulating moral reflection and encouraging emergency physicians to gain a better understanding of two important ethical issues: advance directives and resource allocation decisions. ⋯ Although patients or substitute decision-makers define the value of a treatment goal, emergency physicians must ensure that this goal does indeed represent the patient's wishes, that it is achievable, and that competing claims for the same resource are considered. Learning from others' experiences and preparing for ethical problems in advance will help physicians feel more comfortable in dealing with ethical issues.