supply accidentally during carotid, thyroid, or parathyroid surgery. The biochemical findings of hypoparathyroidism are hypocalcemia, hyperphosphatemia, and low PTH level. The clinical features are consistent with hypocalcemia and predominantly Neuromuscular dysfunction. Central nervous system presentations may include confusion, irritability, and focal or Generalized seizures. Peripheral nervous system presentation includes muscle weakness, cramps, positive Chvostek’s sign or Trousseau’s sign, and tetany [1].

Seizures in patients with hypoparathyroidism are often difficult to control with Anti-epileptic drugs only. Treatment of hypocalcemia with supplemental calcium and vitamin D preparations, however, can often achieve much better results [2]. Calcium levels should be checked regularly and kept at low normal levels to avoid the risk of urolithiasis. In our patient, the initial valproate level was within the therapeutic range, but seizures still occurred. We discontinued valproate since the diagnosis was established. Instead, intravenous calcium infusion, followed by oral calcium and vitamin D, was given. Although valproate levels declined, there were no more seizures during hospitalization. According to the clinic record, she got excellent seizure control and good drug compliance thereafter.

Hypoparathyroidism-induced epilepsy is frequently mis- diagnosed as idiopathic epilepsy, especially in children [3]. Although hypocalcemia-induced seizures are well docu- mented, many emergency physicians have not encountered this etiology. In facing a patient with presentation of suspected seizure, serum calcium levels should be routinely checked. Once hypocalcemia is noted, hyperphosphatemia and low PTH levels can implicate hypoparathyroidism pending a PTH level. Extensive bilateral symmetric calcifications (more impressive in the basal ganglia, cerebellum, and periventricular region in brain noncontrast CT than characteristic of Chronic hypoparathyroidism) should also alert physicians to the possibility of hypopara- thyroidism [4]. Once diagnosed, the proper treatment with calcium and vitamin D supplement can achieve much better seizure control, and the side effects are much less than with anti-epileptic drugs.

In conclusion, emergency physicians should be aware of hypoparathyroidism-induced epilepsy and its characteristic imaging findings in brain noncontrast CT. The serum calcium level should be routinely checked in patients presenting with seizure attack at the ED to rule out hypocalcemia-induced seizure.

Yung-Cheng Su MD Yu-Ming Lin MD Sheng-Wen Hou MD Chien-Chih Chen MD Emergency Department

Shin-Kong Wu Ho-Su Memorial Hospital

Taipei City 111, Taiwan E-mail address: [email protected]

Chee-Fah Chong MS, MD

Emergency Department Shin-Kong Wu Ho-Su Memorial Hospital

Taipei City 111, Taiwan School of Medicine

Fu Jen Catholic University Taipei 242, Taiwan

Tzong-Luen Wang MD, PhD

Emergency Department Shin-Kong Wu Ho-Su Memorial Hospital

Taipei City 111, Taiwan Department of Medicine Taipei Medical University Taipei 110, Taiwan

doi:10.1016/j.ajem.2005.12.010

References

1. Abe S, Tojo K, Ichida K, et al. A rare case of idiopathic hypoparathyroidism with varied neurological manifestations. Intern Med 1996;35:129 – 34.
2. Smits M, Gabreels F, Froeling P, et al. Autosomal dominant idiopathic hypoparathyroidism and nervous system dysfunction: report of three cases and review of literature. J Neurol 1982;228:113 – 22.
3. Anonymous. Clinical policy for the initial approach to patients presenting with a chief complaint of seizure who are not in status epilepticus. American College of Emergency Physicians. Ann Emerg Med 1997;29:706 – 24.
4. Jabr FI, Matari HM, Prempeh AL. Extensive intracranial Bilateral symmetrical calcification secondary to hypoparathyroidism. Arch Neurol 2004;61:281.

Digital necrosis necessitating amputation after tube gauze dressing application in the ED

Applying a secure, safe, functional dressing to an injured digit can be a challenging aspect of emergency care. Tube gauze is a common dressing used for this clinical scenario in many EDs. The technique of tube gauze application is as

Fig. 1 The materials to apply a tube gauze dressing: metal cage and length of gauze.

Fig. 2 Knotted tube gauze loaded onto the cage and ready for application to the digit.

follows [1]. A length of tubular cotton gauze is loaded onto a cylindrical metal cage (Fig. 1). Often, a knot is placed in the end of the tube gauze (Figs. 2 and 3), and the cage is placed over the finger and moved proximally and distally as multiple layers of gauze are applied (Fig. 4A and B). Often, a twist is applied to the gauze at the distal end of the dressing before the cage is passed back over the finger (Fig. 5). The final dressing provides excellent coverage of the digit and limits range of motion (Fig. 6).

It is commonly understood that great caution must be used when applying any circumferential dressing to an appendage with end-arterial Blood supply to avoid iatrogenic ischemic complications. The tube gauze dressing is a form of circum- ferential dressing, but we are aware of no reported compli- cations related to its use. We report a case of digital necrosis after application of such a dressing in an Elderly woman.

A 74-year-old woman presented to the ED complaining of a 5-day history of pain in her left, nondominant, ring finger. She reported no fevers or chills. She had a history of hypertension, type II diabetes mellitus, and hyperlipidemia but was on no medications at the time of her visit. Her tetanus immunization status was up to date. She had a positive history of cigarette smoking (1 pack per day) and was a retired schoolteacher. Her vital signs on arrival were

Fig. 3 Beginning application of the dressing at the knotted end.

Fig. 4 The cage is passed proximally (A) and distally (B) over the finger as successive layers of gauze are added.

blood pressure of 169/115 mm Hg; pulse rate, 81 beats per minute; respirations, 16/min; and temperature, 36.58C orally. Examination revealed a paronychia of her ring finger. She underwent incision and drainage of the paronychia in the ED without the need for local or regional anesthesia. Approximately 3 mL of purulent material was removed. A tube gauze dressing was applied by a medical student in standard fashion to the finger. No tape or Coban

Fig. 5 A twist is applied to the gauze at the distal end of the dressing, before the cage is passed back over the finger.

Fig. 6 The completed tube gauze dressing.

(3M, St Paul, Minn) was used. She received 400 mg of oral ibuprofen in the ED and was discharged on oral cephalexin (500 mg 4 times daily for 10 days) and ibuprofen. She departed the ED before receiving her final computerized aftercare instructions for paronychia care.

The patient returned to the ED 5 days later with the dressing still in place. She complained of throbbing in the finger for the previous 3 days (pain rated at 6/10). She reported starting her cephalexin 2 days after her initial visit. Her vital signs were blood pressure of 138/76 mm Hg; pulse rate, 91 beats per minute; respirations, 16/min; and temper- ature, 36.48C orally. The dressing was noted by the triage nurse and the examining resident to be btight.Q After the dressing was removed, her finger was noted to be discolored (dark purple), with a hemorrhagic bleb distal to the proximal interphalangeal joint (Fig. 7) and with dusky indurated tissue more proximally. She had some range of motion at the distal interphalangeal joint but no sensation or capillary refill more distally. Her blood glucose was 266 mg/dL on bedside testing. The bleb was debrided, and a consultation with a hand specialist was obtained. After wound care, which included application of a Xeroform petrolatum gauze (Kendall Company, Mansfield, Mass) dressing, she was discharged with instructions to elevate her hand, to continue her antibiotics, to change her Xeroform dressing each day, and to follow up with the hand clinic in 3 days.

Seven days later, she returned to the ED complaining of pain (7/10) in the finger. She had not followed up as instructed because of btransportation problems.Q She was no longer on antibiotics. Her vital signs were blood pressure of 141/60 mm Hg; pulse rate, 87 beats per minute; respirations, 18/min; and temperature, 37.18C orally. Her ring finger was now black at the tip, with redness and a green tinge more proximally and with redness and swelling at the base that spread to the bases of her index, long, and little fingers. The ring finger was foul smelling. A complete blood

count and metabolic panel revealed a white blood cell count of 5000/lL; hematocrit, 41.2%; platelets, 166000/lL; glucose, 408 mg/dL; sodium, 134 mmol/L; potassium, 4.1 mmol/L; chloride, 98 mmol/L; carbon dioxide, 29 mmol/L; blood

urea nitrogen, 7 mg/dL; creatinine, 0.7 mg/dL; and calcium,

9.3 mg/dL. Blood cultures were drawn (ultimately revealing no growth). Radiographs of her ring finger revealed decreased Soft tissues adjacent to her distal phalanx with no boney defect or gas. She received 2 intravenous doses of regular insulin (5 U each), 1500 mL of intravenous isotonic sodium chloride solution, and 800 mg of oral ibuprofen. At discharge, her blood glucose was 293 mg/dL. Plans were made for her to return for surgery in 2 days, and she was discharged on ciprofloxacin (500 mg orally twice each day) and ibuprofen for pain.

Four days later, she underwent scheduled guillotine amputation of her ring finger at the proximal phalanx. She tolerated the procedure well and was discharged on the first postoperative day. She was discharged with prescriptions for hydrocodone/acetaminophen, clindamycin, metformin, metoprolol, docusate sodium, and aspirin and was instructed to follow up in the hand clinic in 6 days.

The patient was next seen again in the ED on postoperative day 7. She denied pain or fevers and admitted that she had not taken any of her medications. The digital stump was well healing. Her blood glucose was 320 mg/dL, and she received 6 U of subcutaneous regular insulin. She was instructed to perform daily Xeroform dressing changes; to begin her metformin, metoprolol, and aspirin; and to follow up in the hand clinic in 2 weeks. She was thereafter lost to follow up. There have been other published cases of digital ischemia and gangrene after the use of tube gauze [2-4]. As this is a commonly used dressing for Finger injuries in emergency departments and clinics, it is important to be aware of this possible complication. Our patient’s clinical course was complicated by her history of diabetes, hypertension (both

poorly controlled), smoking, and noncompliance.

Fig. 7 Severe ischemia with necrosis of the ring finger after removal of tube gauze.

Tube gauze is commonly used to dress injuries of the digits. Its ease of application makes it popular as a dressing material. When tube gauze is applied to the entire length of a digit, it prevents visualization of the distal appendage, making assessment of capillary refill and vascular integrity impossible. This case points out the need to use special caution when applying tube gauze, to warn patients to elevate the injured extremity, and to instruct them to return imme- diately if they have significant increasing pain in the digit.

Similar precautions should be used in applying any form of circumferential dressing such as Coban to an appendage with end-arterial flow. Hart et al [5] have pointed out the risks for using circumferential Coban to dress digits, particularly in children. Use of tape to secure any form of dressing to a finger must also be done cautiously. Wrapping the tape circumferentially may produce a tourniquet-like effect, especially if secondary swelling develops in the digit. Special care is needed when applying circumferential dressings to digits that have been anesthetized using regional techniques with long-acting anesthetics because several hours of ischemia could pass before such patients develop significant pain. Care is also needed when applying such dressing to young children, elderly patients, patients with altered mental status, and patients with possible neurovascular compromise (due to trauma or long-standing

hypertension, diabetes, or peripheral vascular disease).

Robert L. Norris MD Gregory H. Gilbert MD Division of Emergency Medicine

Stanford University School of Medicine

Stanford, CA, USA E-mail address: [email protected]

doi:10.1016/j.ajem.2005.12.009

References

1. Greene A. Tube gauze. Handy finger bandages. Kevin Kelly cool tools. Available at: http://www.kk.org/cooltools/archives/000264.php [Accessed November 11, 2005].
2. Miller TA, Haftel AJ. Iatrogenic digital ischemia. West J Med 1975;122:183 – 4.
3. Neal JM. Iatrogenic digital ischemia. Am Emerg Med 1986;15:382 – 3.
4. Giandoni MB, Vinson RP, Grabski WJ. Ischemic complications of tubular gauze dressings. Dermatol Surg 1995;21:716 – 8.
5. Hart RG, Wolff TW, O’Neil WL. Preventing tourniquet effect when dressing finger wounds in children. Am J Emerg Med 2004;22:594 – 5.

A fatal case of Vibrio vulnificus septicemia from a nongulf state: a public health alert for patients with Chronic liver disease

A 50-year-old man presented to the ED of New York Presbyterian Hospital, Weill Cornell Medical Center, after

We would like to acknowledge Lynne Strasfeld, M.D. Department of Medicine, Division of Infectious Disease, Weill Medical College of Cornell University for providing the photographs.

1 day of fever, rigors, diarrhea, and bilateral Lower extremity pain. He had a history of hypertension and cirrhosis secondary to Hepatitis C, and his maintenance medications were pantoprazole, furosemide, spironolac- tone, nadolol, and iron supplements. He denied tobacco, alcohol, or illicit drug use.

The afternoon before presentation, the patient consumed raw clams for lunch at a local restaurant. At 5:00 pm, he developed watery diarrhea, fever to 1018F, and shaking chills. Throughout the evening, his symptoms intensified, and he began to experience severe pain accompanied by redness and swelling in both calves.

The next morning on ED presentation, the patient had a temperature of 37.58C, a blood pressure of 130/70 mm Hg, a pulse rate of 99/min, and a respiratory rate of 18/min and was in no apparent distress. His examination was remark- able for bilateral erythematous, maculopapular, blanching rashes on his lower extremities, extending from his ankles to the inferior margins of his knees. His calves were tender to palpation with 1+ Pitting edema. He had 2+ posterior tibial and dorsalis pedis pulses bilaterally.

Within 1 hour, the patient’s lower extremity pain had become significantly more severe with markedly increased edema. Lower extremity color flow Doppler ultrasounds showed no evidence of deep vein thrombosis. Orthopedics was consulted, but compartment pressures were not measured because they did not believe the patient’s examination was consistent with compartment syndrome.

laboratory investigations revealed white blood cell count of 3.1/lL with 52% polymorphonuclear neutrophils and 42% band neutrophils; hemoglobin, 14.3 g/dL; platelet count, 46 x 10³/lL; prothrombin time, 17.8 seconds; and partial thromboplastin time, 33.1 seconds. Abnormal chem- istries included a bicarbonate of 14 mEq with an anion gap of 19, and an arterial lactate of 7.7 mg/dL. Blood cultures, urine cultures, and a chest radiograph were obtained.

Intravenous vancomycin, piperacillin/tazobactam, and gentamicin were initiated. Intravenous aqueous colloid vitamin K and fresh frozen plasma were administered to treat disseminated intravascular coagulation. Within 6 hours of the patient’s ED arrival, his blood pressure dropped to 80/60 mm Hg. The blood pressure did not improve with rapid infusion of 3 L of isotonic sodium chloride solution, and a norepinephrine infusion was initiated. Arterial blood gas values were of pH 7.11; Paco₂, 48 mm Hg; and Pao₂,

216 mm Hg, while the patient was on a 100% non- rebreather facemask.

Because of the patient’s deteriorating mental status, hypoxemia, and severe metabolic and respiratory acidosis, endotracheal intubation was performed using a standard rapid sequence protocol. Intravenous ceftazidime and doxycycline were added to cover for possible Vibrio vulnificus infection.

Concomitantly, the lower extremity skin lesions pro- gressed at an alarming rate. The initially described erythematous maculopapular lesions evolved into circum-