Safety first - sedate and shock/The authors respond by ProQuest


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									                                              LETTERS • CORRESPONDANCE

Safety first — sedate and                       this is VT. Although not polymorphic,        has grave risks associated with its use.
shock                                           the addition of sotalol would increase the   We suggest that when an article is pub-
                                                pretest likelihood of VT as well.            lished one should concern themselves
To the editor: Mitchell and Lazarenko              If indeed the authors’ logic is correct   with the message that is delivered to
recently authored a diagnostic challenge        and the remaining differential includes      the typical emergency physician, and
in the November 2008 issue of CJEM.1            supraventricular tachycardia (SVT)           therefore should project a message that
We thank the authors for providing this         with aberrancy by way of an accessory        is safe and effective.
worthy topic for discussion and con-            pathway, one still ought to avoid aden-         In this case, no one should close the
gratulate them on their publication.            osine in these instances. There are sev-     journal thinking that through cannon
However, with due respect, we take              eral reports of ventricular fibrillation     atrial waves associated with beat-to-
considerable issue with several of the          associated with adenosine therapy,           beat systolic variability and Brugada
conclusions reached in this article and         in both Wolff–Parkinson–White syn-           criteria that they can differentiate these
ultimately with the answer to the diag-         drome2–4 and in the treatment of VT.5        2 entities in the chaos of the emergency
nostic challenge. Although it is alluded        The safest approach in this setting          department. Let us put the safety of our
to as a possible treatment twice in the         would be electrical cardioversion or, in     patients first and the vanity of superior
discussion, we assert that the safest ap-       a stable patient, procainamide.6             academic skills second.
proach for the emergency physician is              We thank the authors for their com-          Sedate and shock this rhythm — be
to treat all wide complex tachycardia as        ments regarding the application of the       safe.
ventricular tachycardia (VT).                   Brugada criteria. The originally re-
   As with many situations in emer-             ported sensitivity and specificity were      Andrew Healey, MD
gency medicine, when a patient pre-             95.7% and 96.5%,7 which have never           PGY5, Emergency Medicine/Critical
                                                                                             Care Resident, McMaster University,
sents with an unstable wide complex             been externally reproduced. Two re-
                                                                                             Hamilton, Ont.
dysrhythmia, we are forced to make de-          ports have failed to replicate these
                                                                                             Mark Mensour, MD, FCFP
cisions without the benefit of much of          numbers in the hands of cardiologists        Assistant Professor, Emergency
the information referenced within the           or emergency physicians, suggesting          Medicine, Northern Ontario School
article. The assessment for the presence        even less broad applicability in the         of Medicine, Huntsville, Ont.
of cannon atrial waves or variability of        emergency setting.8,9 These numbers          Thomas Marshall, MD
the first heart sound requires clinical         are not sufficient to exclude VT, partic-    Staff Emergency Physician,
acumen well beyond even the expert              ularly when considering verapamil or         St. Joseph’s Healthcare, Hamilton, Ont.
emergency physician. In fact, the addi-         diltiazem as a potential therapy.
tional criterion of variability in beat-to-        Even if these numbers were accept-        References
beat systolic blood pressure requires           able to some practitioners (which is         1. Mitchell J, Lazarenko G. Wide QRS
the placement of an arterial catheter,          where our concerns lie), life-threaten-         complex tachycardia. CJEM 2008;6:
which is impractical and unnecessary in         ing consequences of misdiagnosing
                                                                                             2. Gupta AK, Shah CP, Maheshwari A,
many instances.                                 VT as SVT with aberrancy are unac-              et al. Adenosine induced ventricular
   Electrolytes are rarely available and        ceptable when the therapy of choice             fibrillation in Wolff-Parkinson-White
toxicology screens are rarely helpful.          for VT works equally well for SVT               syndrome. Pacing Clin Electrophysiol
The authors state that the toxicology           with aberrancy with very little added        3. Gallagher JJ, Sealy WC, Kasell J, et al.
screen was negative, which we believe           potential for harm. The authors cor-            Multiple accessory pathways in patients
to be relatively un
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