CJEM Articles: Lance Brown

Objective: There are few reports in the medical literature describing removal of a coin from the upper esophageal tract of a child by an emergency physician. However, given the nature of their training and practice, emergency physicians are well suited to perform this common procedure. We describe our experience with this procedure.

Methods: This was a retrospective review of a continuous quality improvement data set from a university-based tertiary care pediatric emergency department between Nov. 1, 2003, and Mar. 31, 2004.

Results: Thirteen children, with a median age of 20 months, underwent rapid sequence intubation and had coins successfully removed from their upper esophageal tract by emergency physicians. In 10 cases, the coin was visible at laryngoscopy and removed with Magill forceps. In 3 cases this approach failed and a Foley catheter was used to remove the coin. One child suffered a tonsillar abrasion and two sustained minor lip trauma, but all were extubated and discharged home from the emergency department with no significant complications. Eleven of the 13 patients were successfully followed up, and the parents reported no problems.

Conclusions: This pilot study suggests that the removal of a coin from the upper esophageal tract by an emergency physician can be both safe and effective. A larger study is needed before this procedure can be generally recommended.

Objectives: Obtaining prompt vascular access in young children presenting to the emergency department (ED) is frequently both necessary and technically challenging. The objective of our study was to describe our experience using intramuscular (IM) ketamine to facilitate the placement of central venous catheters in children presenting to our ED needing vascular access in a timely fashion.

Methods: We performed a retrospective medical record review of all pediatric patients

<18 years of age who presented to our tertiary care pediatric ED between May 1, 1998, and August 7, 2003, and underwent the placement of a central venous catheter facilitated by the use of IM ketamine.

Results: Eleven children met our inclusion criteria. Most of the children were young and medically complicated. The children ranged in age from 6 months to 8 years. The only complication identified was vomiting experienced by an 8-year-old boy. Emergency physicians successfully obtained central venous access in all subjects in the case series.

Conclusions: The use of IM ketamine to facilitate the placement of central venous catheters in children who do not have peripheral venous access appears to be helpful. Emergency physicians may find it useful to be familiar with this use of IM ketamine.

We report a case of an 8-year-old boy who presented to the emergency department with small jewelry magnets adherent across his nasal septum. Prompt removal of these foreign bodies is important to avoid septal necrosis and perforation. We report our success in using the metal handle of bayonet forceps to break the attraction between the magnets. The magnets were removed painlessly and without trauma to the nasal septum.

We report a case of a 53-year-old man whose first manifestation of coronary artery disease was an acute isolated posterior myocardial infarction (IPMI). Acute IPMI is relatively uncommon and predominantly due to occlusion of the left circumflex coronary artery. IPMI is challenging to diagnose due to the absence of ST segment elevation on a standard 12-lead electrocardiogram (ECG) even in the setting of total coronary artery occlusion and transmural (Q-wave) infarct. We discuss the diagnostic implications of the absence of tall R waves in leads V1 and V2 on this patient's ECG. The utility of posterior leads (V7 through V9) is demonstrated. The controversy surrounding the use of thrombolytic therapy or primary angioplasty in the setting of acute IPMI without ST segment elevation on a standard 12-lead ECG is reviewed.