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.
5. Sharma N, Chauhan S, Faruqi S, et al. Snake envenomation in a north Indian hospital. Emerg Med J 2005;22:118-20.
6. Lewis RL, Gutmann L. Snake venoms and the neuromuscular junction. Semin Neurol 2004;24:175-9.
7. Warrell DA. Crisis in snake anti-venom supply for Africa. Lancet 2000;356:2104.
8. Warrell DA. Animal toxins. In: Cook GC, Zumla A, editors. Manson’s tropical diseases. London: WB Saunders; 2003. p. 581-618.

ED management of pediatric syncope./p>

To the Editor,

We read with interest the article by Goble and colleagues

[1] entitled “ED management of pediatric syncope: searching for a rationale.” The authors highlighted 2 findings: “the interpretation of ECGs by a pediatric cardiologist before planning admission may have adverted up to 5 of the 11 admissions”, and “a high rate of non cardiologic testing,” particularly head computed tomography (58% of patients, all with normal findings). We performed an observational cohort study that confirmed the first and original point and illustrated the second one with a very different pattern of procedures performed in a French multidisciplinary pediatric emergency department (ED) of a university hospital.

The aim of our study was to evaluate management of childhood syncope, focusing on diagnostic tests ordered, and the interest of cardiologist electrocardiogram (ECG) inter- pretation. Data of all consecutive children aged 2 to 15 years, who were referred for syncope or near-syncope, were prospectively collected during 1 year. Permanent medical supervision was provided by pediatricians. Standard ECG was the only compulsory investigation. The attending pediatrician decided if any other investigation was needed. One hundred fifty-nine children (mean age, 11 +- 4 years; sex ratio = 0.9) were included. Forty-eight percent had syncope, 52% had near-syncope. The most common cause was neurocardiogenic syncope (62%), followed by neurologic causes (seizure and migraine, 18%).

In the series of Goble and colleagues, 6 among the 11 hospital admissions were arranged because of equivocal ECGs. All but one of these ECGs (which showed Wolff- Parkinson-White syndrome) was later read as normal by a pediatric cardiologist. In our series, ECG was performed and blindly interpreted by a pediatric cardiologist in 149 cases (94%). There were discrepancies between cardiolo- gists’ and ED pediatricians’ ECG interpretations in 9% (n

= 13) of cases. The main significant discordant ECGs were the 5 long QT syndrome suspicions, all excluded by the cardiologist. The 8 other discordant ECGs were not clinically significant. The 2 studies cited by Goble and colleagues for reporting discrepancy rates from 13% to 24% for ECG interpretation in pediatric EDs concerned different clinical conditions: chest pain, arrhythmias, apparent life-threatening event, drug exposure, with only

11% and 18 % of “syncope and seizure” [2,3]. Our data clearly confirm the conclusion of Goble and colleagues that “ED interpretation of ECGs suspected of being abnormal should be verified if possible before planning admission based on that ECG” [1].

The second point is the very different pattern of procedures performed in our study. Like Goble and colleagues, we found a high rate for noncardiologic testing for pediatric syncope in the ED but with a lower rate of Head CT. The most commonly ordered tests except ECG in our study were electrolytes (44% vs 90% [1]), EEGs

(33%), urinary drug screen (18%), chest x-ray (17% vs

37% [1]), and head computed tomography (8% vs 58% [1]). The 2 other recent studies of pediatric syncope cited by Goble and colleagues reported a high rate of EEG (58% and 39%, respectively) and head CT (23% and 27%) [4,5]. In no case was disease-related syncope diagnosed by head CT in our study, as in the others [1,4]. In the study by Steinberg and Knilans, Neuroimaging studies diagnostic yield was not precisely described but was also low [5]. All these data are consistent with the recommendation that “patients with Prolonged LOSs of consciousness, Seizure activity, and a postictal phase be referred for neurologic evaluation and an electroencephalogram, but that a head CT is not indicated unless focal neurologic deficits are found” [1,4].

Our data confirm the value of the interpretation of all

ECGs suspected of being abnormal by a pediatric cardiol- ogist and the limited indications of neuroimaging for pediatric syncope.

Valerie Hue MD Odile Noizet-Yvernaux MD Guy Vaksmann MD Francois Dubos MD

Alain Martinot MD Department of Pediatric Emergency Care Salengro Hospital, CHRU Lille

59037 Lille cedex, France E-mail address: [email protected]

doi:10.1016/j.ajem.2008.05.019

References

1. Goble MM, Benitez C, Baumgardner M, et al. ED management of pediatric syncope: searching for a rationale. Am J Emerg Med 2008;26:66-70.
2. Wathen JE, Rewers AB, Yetman AT, et al. Accuracy of ECG interpretation in the pediatric emergency department. Ann Emerg Med 2005;46:507-11.
3. Horton LA, Mosee S, Brenner J. Use of the electrocardiogram in a pediatric emergency department. Arch Pediatr Adolesc Med 1994;148: 184-8.