efficient order. For example, have the ? Quantitative test running before ultrasound, start treatment with intravenous fluids and an antiemetic before x-ray, and start laboratory tests and treatment before sending the patient to radiology. This eliminates compounded waits. If results are not back or in process in a reasonable amount of time, find out why. Situations arise frequently where we are waiting for a test but the sample was never drawn, sent, processed, or placed into the computer.

5. Step 5: determine disposition

After all of the information and results of treatment have been completed, determine a disposition on the patient. This sounds simple, but in a busy ED, the sense of urgency to see the next patient leads to many patients lacking final dispositions.

Unless there is a critical patient, a disposition should be made before moving on to the next patient. Not doing this will lead to a partially completed patient unnecessarily occupying a bed with no active plan in place. Having multiple patients “in limbo” increases the workload of the entire ED staff.

In conclusion, these basic steps can be used by any physician regardless of their practice style to safely and efficiently care for emergency patients.

Annie Sadosty MD Department of Emergency Medicine Mayo Clinic, Rochester, MN 55905, USA

Brian Kruse MD Tyler Vadeboncoeur MD Department of Emergency Medicine

Mayo Clinic, Jacksonville, FL 32224, USA E-mail address: [email protected]

doi:10.1016/j.ajem.2007.11.004

To shock or not to shock

In his review [1], Dr Stewart argues that the current prohibition on Shocking apparent asystole in adults is not evidence-based. The question remains, however, how to investigate the issue. Dr Stewart mentions that it is left to the judgment of various Automated external defibrillator manufacturers to distinguish fine ventricular fibrillation from apparent asystole based on amplitude and waveform. It might be an idea to study which brand of AEDs have the best survival rates. Do AEDs with a low amplitude threshold for shocking have more success? Although the answer to

this question does not fully solve the controversy, it would be a way to initiate research on this important matter.

Peter Hallas MD

Department of Anaesthesiology and Intensive Care

Naestved Hospital Naestved, Denmark

doi:10.1016/j.ajem.2008.06.006

Reference

[1] Stewart J. The prohibition on shocking apparent asystole: a history and critique of the argument. Am J Emerg Med 2008;26(5):618-22.

Is there an alternative to mouth-to-mouth breathing?

To the Editor,

Is there an alternative to mouth-to-mouth breathing? In view of the present-day state of cardiopulmonary resuscita- tion (CPR), we believe it is time to rethink CPR.

There is an increasing reluctance among untrained and trained rescuers, nurses, physicians, firemen, and police- men to perform mouth-to-mouth breathing if the victim is suspected of having an infectious disease [1-3].

In the poliomyelitis days of the 1950s, the iron lung and the cuirass provided ventilation for patents with respiratory paralysis. However, providing nursing care was difficult with the iron lung. It was less difficult with the cuirass respirator because the patient was in a wheelchair. However, an alternate method for ventilating polio patients was described by Eve [4] who used the rocking bed. artificial respiration [5,6] was produced by Rhythmic abdominal compression in polio patients by Adamson et al [7] and was later used by Miller et al [8] who described the device as the pneumobelt.

In a recent 12-pig study by Pargett et al [9], ventilatory aspects of only abdominal compression CPR (OAC-CPR)

[10] were determined. The ratio of tidal volume to respiratory dead space was 2.57 +- 0.4, indicating that the animals were well ventilated with only rhythmic abdominal compression, thereby eliminating the need for mouth-to-mouth breathing. In view of the fact that during ventricular fibrillation, OAC-CPR produces 1.60 +- 1.73 times more coronary perfusion than standard chest compression CPR in the same animals [10] and produces a tidal volume [9] 2.5 +-

0.4 times the respiratory dead space, it appears that this new CPR method merits further study [11,12]. Add to these benefits that OAC-CPR eliminates the need for

mouth-to-mouth breathing and eliminates the risk of rib fracture [13]. Note also that it requires only one rescuer.

Yours very truly,

Leslie A. Geddes ME, PhD, DSc

Ann E. Rundell PhD Weldon School of Biomedical Engineering Purdue University, West Lafayette

IN 47907-2032, USA

E-mail addresses: [email protected]

[email protected]

doi:10.1016/j.ajem.2008.05.017

References

1. Brenner BE, Kauffman J. Reluctance of internists and medical nurses to perform mouth-to-mouth resuscitation. Arch Intern Med 1993;153: 1763-9.
2. Lock CJ, Berg RA, Sanders AB, et al. Bystander cardiopulmonary resuscitation: concerns about mouth-to-mouth contact. Arch Intern Med 1995;155:938-43.
3. Ornato JP, Hallagan LF, McMahan SB, et al. Attitudes of BLS instructors about mouth-to-mouth resuscitation during the AIDS epidemic. Ann Emerg Med 1990;19:151-6.
4. Eve FC. Activation of the inert diaphragm by a gravity method. Lancet

1932;2:995-7.

1. Geddes LA. The history of artificial respiration. IEEE, EMBS Magazine 2007:38-41 Retrospectroscope. Nov/Dec.
2. Schafer EA. Harvey Society Lectures, London. 1907-8. Simple and affective methods of performing artificial respiration on human subjects, especially in drowning. Proc Royal Med Chir Soc 1903-4;87:609.
3. Adamson JP, Stern JD. Application of abdominal pressure for artificial

respiration. JAMA 1959;169(14):153-7.

1. Miller HJ, Thomas E, Wilmot CB. Pneumobelt use among high quadriplegic population. Arch Phys Med Rehab 1988;69:369-72.
2. Pargett M, Otlewski M, Geddes LA, Rundell A. Only rhythmic abdominal compression CPR provides effective blood circulation and ventilation without breaths. Resuscitation 2008 (in press).
3. Geddes LA, Rundell AE, Lottes AE, Kemeny A, Otlewski M. A new CPR method employing only abdominal compression. Am J Emerg Med 2007;25.7:786-90.
4. Sylvester HR. A new method for resuscitating stillborn children and of restoring apparently drowned or dead. Br Med J 1858;2:576-9.
5. Sylvester HR. General correspondence. Med Times Gaz (London) 1859;16:301.
6. Lederer W, Main D, Ralston S, et al. Rib and sternal fractures associated with out-of-hospital CPR. Resuscitation 2004;60:156-62.

Efficacy of low-dose snake antivenom in severe neurotoxic snake envenoming

To the Editor,

I read with interest the recent article by Acikalin et al [1], wherein the authors have shown that low-dose snake antivenom (SAV) treatment is effective in treating patients with Venomous snakebite injuries in their region. I would

like to share our departmental experience of treating patients with severe neurotoxic snake envenoming with low dose of SAV [2].

Snake envenoming is a common medical emergency encountered in our country, and an estimated 35 000 to 50 000 people die of snakebite every year in India [3]. The incidence of bites by elapid snakes is common than vipers in Northern India [4,5]. The bites of elapid snakes cause predominantly neurotoxicity, which manifests as paralysis of ocular, bulbar, limb, and respiratory muscles [5].

In our departmental study of 55 patients with elapid snakebite, 27 patients were randomized to receive high dose and 28 to low dose antivenom. All the patients had ptosis, dysphagia, diplopia, dysphonia, and evidence of hypercapnic respiratory failure (PaO2, 60 mmHg; PaCO2, 45 mmHg). The median dose of SAV in the high-dose group was 600 mL (range, 300-1600 mL); all patients in the low-dose group received 150 mL. The median time to extubation in the high- dose and low-dose SAV groups was 44 and 47.5 hours, respectively, and there was no significant different in the mean duration of Intensive care unit stay [2].

The economic significance of using low doses of SAV is obvious. Each 10-mL vial of antivenom in India costs 400 rupees (approximately $9), and use of lower dosages could translate into huge savings to the patient and the community. In addition, there is an increasing shortage of SAV in several Developing countries [6,7], and an important incentive for a regulated dosing protocol would be to prevent crisis of SAV availability and supply. Finally, the incidence of early anaphylaxis and late serum sickness-type reactions, which is related to the dose of SAV [8], can be decreased.

Akashdeep Singh MD Christian Medical College and Hospital Ludhiana, Punjab 141008, India

E-mail address: [email protected]

Ritesh Agarwal MD

PGIMER

Chandigarh, India

doi:10.1016/j.ajem.2008.05.018

References

1. Acikalin A, Gokel Y, Kuvandik G, Duru M, Koseoglu Z, Satar S. The efficacy of low-dose antivenom therapy on morbidity and mortality in snakebite cases. Am J Emerg Med 2008;26(4):402-7.
2. Agarwal R, Aggarwal AN, Gupta D, Behera D, Jindal SK. Low dose of anti-snake venom is as effective as high dose in patients with severe neurotoxic snake envenoming. Emerg Med J 2005;22:397-9.
3. Warrell DA, International Panel of Experts. WHO/SEARO Guidelines for the clinical management of Snake bites in the Southeast Asian region. Southeast Asian J Trop Med Public Health 1999;30(suppl 1):1-85.
4. Punde DP. Management of snakebite in rural Maharashtra: a 10-year experience. Natl Med J India 2005;18:71-5.