Hydrogen sulfide is a potent lethal gas. Supportive care, nitrite therapy and hyperbaric oxygen are the treatment modalities reported in the literature in cases of hydrogen sulfide exposure. We describe an industrial exposure in which 6 workers inhaled high concentrations of hydrogen sulfide when they entered a closed spreader tank partially filled with liquid swine manure. Five of the 6 lost consciousness, and 2 were agitated and poorly responsive on arrival to the emergency department despite having already received high-flow oxygen for nearly 1 hour. These 2 patients received nitrite therapy followed by orotracheal intubation and hyperbaric oxygen. All patients were discharged home without sequelae after short stays in hospital. The emergency management of hydrogen sulfide exposure is briefly reviewed.

Succinylcholine is often used to facilitate neonatal and pediatric rapid sequence intubation in the emergency department, and most relevant literature recommends administering atropine prior to succinylcholine to reduce the risk of bradycardia. Given the potential complications associated with combining these medications, we searched the published literature for evidence supporting this practice. Most studies recommending atropine premedication were undertaken in the operating room setting and pertained to repeated succinylcholine dosing. Furthermore, there is little published evidence to indicate that succinylcholine-related bradycardia is a clinically important side effect. Several authors have called for the practice to cease, but, to date, these calls have gone unheeded. We found no evidence supporting atropine's use in pediatric patients prior to single-dose succinylcholine. Atropine premedication for emergency department rapid sequence intubation is unnecessary and should not be viewed as a “standard of care.”

Clinical question

Does the use of vasopressin for adult patients suffering a non-traumatic, out-of-hospital cardiac arrest improve the rates of survival to hospital admission (and discharge) better than epinephrine?

Wolff–Parkinson–White (WPW) syndrome with atrial fibrillation (AF) is a potentially life-threatening problem requiring rapid conversion to sinus rhythm. The most recent American Heart Association guidelines for the treatment of patients with WPW, published in conjunction with the 2000 Advanced Cardiac Life Support (ACLS) guidelines, suggests that intravenous amiodarone is a first-line therapy for AF–WPW; however the evidence suggests this is a potentially dangerous myth.

Blunt chest trauma causing coronary artery occlusion and myocardial infarction is a rare but potentially fatal condition. We present the case of a healthy 29-year-old man who developed a myocardial infarction due to complete occlusion of the proximal right coronary artery following blunt chest trauma. A review of the literature found 63 cases of previously healthy patients under 40 years of age who developed coronary artery occlusion following blunt chest trauma; diagnosis in all cases had been proven by angiography or during autopsy. The presentation, results of electrocardiography and echocardiography and laboratory findings of these patients are described.

Vaginal rupture leading to pneumoperitoneum is well documented to occur after hysterectomy or surgery. However, it is extremely rare in a young woman following conventional intercourse. We report one such case. A 16-year-old woman presented to the accident and emergency department with a clinical picture of an acute abdomen. Results of radiography showed gas under the diaphragm, suggesting the possibility of bowel perforation. A detailed sexual history pointed toward the possibility of vaginal trauma. Diagnosis was confirmed on examination under anesthesia, and the tear repaired. A concomitant laparoscopy ruled out any other intra-abdominal injury. This case reminds us that acute peritoneum can occur after sexual intercourse and also reiterates the importance of a detailed sexual history and vaginal examination in young women presenting with an acute abdomen.

High-pressure injection injuries to the hand are work-related injuries that can take a devastating toll on the functionality of the affected extremity. Chemical injections are a surgical emergency. Injuries involving only water injection are rarer and have variable management strategies. We report a case of high-pressure injection hand injury due to water only. The patient was managed non-operatively with parenteral antibiotics, narcotics and elevation, with good outcome. We present a review of the literature on high-pressure injection injury.

Neuroleptic malignant syndrome (NMS) is a potentially life-threatening condition that has been associated with antipsychotic use. Most diagnostic criteria include fever and muscle rigidity, although NMS may present without either. Diagnostic uncertainty in such cases may result in delays in diagnosis and management, leading to adverse consequences for these patients. The differential diagnosis of NMS is broad and includes a number of neurological, medical and psychiatric conditions as well as substance and medication-induced disorders. A case is described that illustrates an atypical presentation of NMS and demonstrates some of the challenges in its diagnosis. Limitations of current NMS criteria are also examined, and suggestions for future criteria are presented.

Thrombotic venous obstruction in patients with a tunnelled central venous catheter is a cause of superior vena cava syndrome that is not routinely encountered by emergency physicians. Diagnosis requires identifying patients at risk (e.g., those under treatment for cancer and those who have a tunnelled central venous catheter), recognizing the signs and symptoms of superior vena cava syndrome, usually dyspnea and dilated neck or thoracic veins, and imaging the venous obstruction using computer tomography or sonography. Management involves anticoagulation and local thrombolytic administration. We report the case of a 28-year-old woman who presented with a 2-day history of face, chest and bilateral arm swelling who had been receiving maintenance chemotherapy for acute lymphoblastic leukemia through a Hickman® catheter. This case demonstrates the need to be vigilant for thrombus formation in patients with long-term, indwelling central venous catheters.

Brugada syndrome is a potentially lethal and eminently treatable entity that may present with palpitations or syncope. This article presents the case of a young patient with Brugada syndrome and reviews key features in the epidemiology, pathophysiology, diagnosis, treatment and prognosis of this condition.