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Emergency casebook traction caused by apical adhesions and a completely collapsed lung disrupting the sympathetic chain as it traverses the thoracic inlet. There was no evidence of tensioning, but this remains an additional mechanism leading to disruption of the sympathetic chain. In all cases cited, once the pneumothorax was relieved the Horner’s syndrome resolved. It is important medicolegally to recognise the presence of a Horner’s syndrome before an operation, as it is a rare but recognised complication of surgical pleurodesis. In conclusion, the presence of unequal pupils in a patient presenting to the A&E
department with a suspected spontaneous pneumothorax may represent an ipsilateral Horner’s syndrome. Further, this association, albeit rare, may reflect the severity of lung collapse and even the presence of a tensioning pneumothorax. Its identification may aid clinical diagnosis and appropriate further management in the emergency room. Harefield Hospital, Middlesex, UK Correspondence to: Mr I Hunt, Department of Thoracic Surgery, Harefield Hospital, Middlesex UB9 6JH, UK;
[email protected]
Competing interests: None. Informed consent obtained for publication. Emerg Med J 2008;25:119–120. doi:10.1136/emj.2007.055129
REFERENCES 1. 2. 3. 4.
Accepted: 19 October 2007
Sataline L, Kraus T. Horner’s syndrome occurring with spontaneous pneumothorax. N Engl J Med 1965;272:1227–8. Jaffe NS. Localization of lesions causing Horner’s syndrome. Arch Opthalmol 1950;44:710–28. Gutman I, Levartovski S, Goldhammer Y, et al. Sixth nerve palsy and unilateral Horner’s syndrome. Ophthalmology 1986;93:913–6. Cook T, Kietzman L, Leibold R. ‘‘Pneumo-ptosis’’ in the emergency department. Am J Emerg Med 1992;10:431–4.
Images in emergency medicine Laparotomy for treatment of seizures A 57-year-old man self-referred to the emergency department. Upon arrival he had a grand mal seizure followed by a cardiac arrest. Cardiac output was promptly restored. As seizures continued infusions of propofol, midazolam and phenytoin were started. Empirical aciclovir and ceftriaxone were also given. A head CT and lumbar puncture were non-diagnostic. An amylase of 795 IU/l precipitated an abdominal CT scan (figs 1A and B). The contrast-enhanced CT scan through the abdomen and pelvis showed multiple rounded opacities of slightly heterogeneous attenuation, each surrounded by a thin ring of low attenuation. They measured 1.8 cm in diameter. The density of the rings was similar to that of air. These opacities were seen in the stomach (fig 1A) with further opacities seen within the sigmoid colon and rectum (fig 1B). One of the opacities lying on its long axis in the sigmoid colon appears sausage-shaped, and more clearly shows
that external to the rim of air is a further enveloping rim of higher attenuation. These opacities are clearly not normal bowel residue, containing a central sausage-shaped density surrounded by a thin layer of trapped air and an outer membrane. These were found at laparotomy to be condoms packed with cocaine. This case exemplifies body packing or internal concealment of illicit substances in an attempt to elude customs. In uncomplicated cases conservative management with laxatives or bowel irrigation may be preferred. Rupture of the packet warrants surgical intervention. In this case at laparotomy, 32 packages (average weight 10 g) were removed (fig 2). One of them showed evidence of rupture. The contents were cocaine. Plain films identify up to 89% of drug packets ingested and CT may be a better investigation. Most body packers have no complications. Complications, including packet
Figure 2 Packages of cocaine found at laparotomy. rupture or intestinal obstruction, occur in 1.3–2.2% of cases.1 2 Cocaine toxicity is lethal if not treated, but otherwise the prognosis is good. Prompt surgery is life saving. In a large series of 2880 body packers, rupture of the packet occurred in 63 patients. Of those, 20 underwent a laparotomy and survived; the others died.2
P Szawarski,1 L Dvorkin,2 E Tam3 1
Department of Anaesthesia, Queen Elizabeth Hospital, London, UK; 2 Department of Surgery, North Middlesex University Hospital, London, UK; 3 Department of Radiology, Northwick Park Hospital, Harrow, UK Correspondence to: Dr P Szawarski, Department of Anaesthesia, Queen Elizabeth Hospital, Stadium Road, Woolwich, London SE18 4QH, UK; zmierzchowiec@aol. com Competing interests: None. Emerg Med J 2008;25:120. doi:10.1136/emj.2007.049221
REFERENCES 1. 2.
Figure 1 120
Abdominal slices of (A) the stomach and (B) the colon and rectum.
de Prost N, Lefebvre A, Questel F, et al. Prognosis of cocaine body-packers. Intensive Care Med 2005;31:955–8 Schaper A, Hofmann R, Ebbecke M, et al. Cocainebody-packing. Infrequent indication for laparotomy. Chirurg 2003;74:626–31
Emerg Med J February 2008 Vol 25 No 2
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Laparotomy for treatment of seizures P Szawarski, L Dvorkin and E Tam Emerg Med J 2008 25: 120
doi: 10.1136/emj.2007.049221
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