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PostScript...... Ondansetron and chest pain do with convenience and ease of approach LETTERS than for any scientific reason. Aspirating two I was interested to read the letter by Dodd litres may take considerable time, and using Emerg Med J: first published as on 20 December 2004. Downloaded from 1 and Doyle criticising routine paramedic use the 2ICS MCL it is generally easy to find the of cyclizine as an antiemetic for patients with intercostal space and the patient can be in If you have a burning desire to respond chest pain. They sensibly highlight the BNF pretty much any position that is comfortable to a paper published in EMJ, why not make statement citing cyclizine’s side effects of for them and convenient for the ‘‘aspirator’’. I use of our ‘‘rapid response’’ option? palpitations and as cause for would contrast this with the 5th intercostal Log on to our web site (www.emjonline. concern but they then go on to recommend space anterior axillary line approach, when it com), find the paper that interests you, and ondansetron as the antiemetic of choice for can be more difficult to identify the space and send your response via email by clicking on patients with chest pain based on its lack of awkward for both patient and doctor to keep the ‘‘eLetters option in the box at the top ‘‘serious’’ side effects. the arm in a convenient position. I tried this right hand corner. Several reports have implicated ondanse- approach for a while and admit to going back 2 Providing it isn’t libellous or obscene, it will tron in causing not just arrhythmias but to the 2ICS MCL approach, which I find 34 be posted within seven days. You can chest pain too. In fact, the BNF lists chest much easier. While tempting to blame the retrieve it by clicking on ‘‘Read eLetters’’ pain, arrhythmias, , and brady- anatomy and dangerous ‘‘big vessels’’ on on our homepage. cardia under ondansetron’s side effects, while each of the cases presented, in none of them the packaging insert for ondansetron The editors will decide as before whether to was a source of bleeding identified. It is there- (Zofran) lists ‘‘chest pain with or without also publish it in a futher print issue. fore not possible to conclude, as the authors ST depression’’ among associations with its seem to, that similar complications would not use. Angina is not specifically mentioned on occur if a different approach occurred. the UK insert (because of lack of proof of a I would also be interested to know what Fasciotomy in crush syndrome cause-effect relation) but has been on the technique was used for aspiration—with patients: debates continue insert for the US product since 1992. modern purpose designed seldinger technique Furthermore, clinical trials have shown ECG We read, with interest, the well written kits (or just an old fashioned single lumen changes after intravenous administration of cvp line kit) the needle used to puncture the articles on fasciotomy and crush by ondansetron and other 5-HT receptor Duman et al1 and Demirkiran et al.2 3 chest wall is of a comparatively small calibre. antagonists in healthy subjects. It would be a rare occurrence to cause a massive Demirkiran et al presented 18 cases of crush The method by which 5-HT receptor syndrome, seven of them underwent fasciot- 3 haemothorax even when deliberately punctur- antagonists might precipitate myocardial ing subclavian vessels for central venous access, omy, and six of them had in the ischaemia and arrhythmias is not clear. It has end.2 It is difficult for Demirkiran et al2 to so it does seem incredibly unlucky to have three been postulated that it results from inhibition cases in such a short period of time. recommend fasciotomy as the first choice of the Bezold-Jarisch reflex by 5-HT receptor treatment in crush syndrome patients. By 3 1 block on vagal afferent fibres and a complex F C Rae contrast, Duman et al presented 16 cases of pattern of coronary vasoconstriction and vaso- Accident and Emergency, Queen Alexandra Hospital, fasciotomy, 10 of them had no peripheral dilatation mediated via various cardiac 5-HT Portsmouth, UK; [email protected] pulses, four underwent amputation, four receptors. Other authors have explained ECG needed further physiotherapy, and eight http://emj.bmj.com/ changes on the basis of 5-HT3 antagonists Reference functionally recovered after 15 months. ability to block cardiac sodium channels Huang et al also reported high infection and and their affinity for the potassium channel, 1 Rawlins R,BrownKM,CarrCS,et al. Life threaten- ing haemorrhage after anterior needle aspiration of amputation rate from their fasciotomies which may delay repolarisation. 3 pneumothoraces. A role for lateral needle aspiration series. During an earthquake disaster Overall, ondansetron has a better side because of increased patient overload and in emergency decompression of spontaneous effect profile than many antiemetics but it . Emerg Med J 2003;20:383–4. the chaotic situation, fasciotomies carry a is the side effect of chest pain, specifically, higher risk of infection and can result in that may cloud the clinical picture the most. improper wound care and and mortal- It would seem prudent to exercise caution Needle handling should be ity. Sever et al reported findings that support when using ondansetron in the treatment of avoided while suturing on October 1, 2021 by guest. Protected copyright. the attitude not to undertake fasciotomy suspected acute coronary syndromes. unless clear objective indications are present I read the instructive and informative article by Gandham and Menon. However, I was such as increased intracompartmental pres- J Lee 4 concerned to note that in figure 1 the suture sure. Sever et al also suggested that the Accident and Emergency Department, Leeds General practice they followed during this disaster Infirmary, Leeds LS1 3EX, UK; needle appears to be held by the thumb and regarding fasciotomy was not correct.4 [email protected] index finger of the operator. Needle handling However, this dispute regarding fasciotomy has been linked to glove perforation that can is still not settled, and there is a need for be significantly reduced if the suture needle is References 2 prospective studies on intracompartmental held only with instruments. This forms a key pressure in crush syndrome patients.3 1 Dodd T, Doyle T. Cyclizine. Emerg Med J part of a non-touch suture technique as 2003;20:302. taught on the Basic Surgical Skills course.3 Y-M Lin, T-S Lee 2 Kasinath N, Malak O, Tetzlaff J. Atrial fibrillation Do the authors feel that needle handling is a after ondansetron for prevention of postoperative Department of Orthopaedics, Taichung Veterans low risk practice? nausea and vomiting. Can J Anaesth General Hospital, Taichung, Taiwan; 2003;50:215–20. [email protected] R E McLaughlin 3 Ballard H, Bottino G, Bottino J. Ondansetron and Emergency Department, Ulster Hospital, Belfast BT16 chest pain. Lancet 1992;340:1107. 1RH, UK; [email protected] References 4 Bosek V, Hu P, Robinson L. Acute myocardial ischaemia after administration of ondansetron 1 Duman H, Kulahci Y, Sengezer M. Fasciotomy in hydrochloride. Anesthesiology 2000;92:885–7. References resulting from prolonged pressure in an earthquake in Turkey. Emerg Med J 1 Gandham S, Menon D. Prospective randomised 2003;20:251–2. Haemorrhage after trial comparing traditional suture technique with 2 Demirkiran O, Dikmen Y, Utku T, et al. Crush the dynamic sliding loop suture technique in the syndrome patients after the Marmara earthquake. pneumothorax aspiration closure of skin laceration. Emerg Med J Emerg Med J 2003;20:247–50. I read with interest the case reports on 2003;20:33–6. 3 Huang KC,LeeTS,LinYM,et al. Clinical features and haemorrhage after aspiration for sponta- 2 McAdam T, McLaughlin R, McNicholl B. The outcome of crush syndrome caused by the Chi-Chi neous pneumothorax.1 influence of the BSS course on needlestick . earthquake. J Formos Med Assoc 2002;101:249–56. Ann R Coll Surg Engl 2002;84(suppl):310–11. 4 Sever MS, Erek E, Vanholder R, et al. Clinical It has always been my understanding that 3 The Royal College of Surgeons of England. Basic findings in the renal victims of a catastrophic the reason for continuing to use the second surgical skills: participant handbook. 1st ed. disaster: the Marmara earthquake. Nephrol Dial intercostal space, mid-clavicular line (2ICS London: Royal College of Surgeons of England, Transplant 2002;17:1942–9. MCL) approach for these patients is more to 1996:12.

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