Displaying 1-10 letters out of 713 published
Tranexamic acid generates thrombin via contact activation
A bleeding stop within 10 min this can only be explained by the action of tranexamic acid on intrinsic coagulation. Kaolin would have stopped the bleeding within 1 minute. Fibrinolysis is usually not a system that acts within minutes, it acts within hours or days.
Conflict of Interest:
Department of Emergency: on the Frontlines Against H7N9 Virus
Haijiang Zhou,1Chunsheng Li,1 Yong Yan2 1Department of Emergency, Beijing Chao-yang Hospital, Capital Medical University NO.8 of Gongti South Street, Chao-yang District, Beijing, 100020, China firstname.lastname@example.org 2Department of Urology, Beijing Shijitan Hospital, Capital Medical University NO.10 of Tieyi Road, Hai-dian District, Beijing, 100038, China
To the editor, As more cases of patients infected by a novel influenza A (H7N9) virus are identified, public health concerns have been raised and emergency responses have been launched in China. Meanwhile, swift actions by the government are implemented through relevant departments, among which the emergency departments in hospitals are on the frontlines. The infection of novel H7N9 virus, characterized by high fever and severe respiratory symptoms as reported by Gao and colleagues , poses a potential threat to public health. Fortunately, official statistics so far show no sustained human-to-human transmission. However, we should not relax our vigilance. The SARS crisis in 2003, with severe morbidity and mortality , has taught us a profound lesson. As the source and mode of transmission have not been confirmed, rigid surveillance and appropriate protection measures should be taken in the emergency department. Throat- swab specimens are required to be collected from all high-risk patients presented with flu-like symptoms. Gauze masks are distributed and reporting forms covering the patients' history of recent exposure to poultry and other animals, recent travel to epidemic area etc. are collected. Highly suspicious patients need to be isolated and under observation. Moreover, in order to reduce mortality, great attention should be paid to establishing a sound and timely-respond system in case of outbreak of pandemic.
Competing Interest:None. References 1 Gao RB, Cao B, Hu YW, et al. Human infection with a novel avian-origin influenza A (H7N9) virus. New Eng J Med Published Online First: 4 April 2013. doi: 10.1056/NEJMoa 1304459 2 Lee N, Hui D, Wu A, et al. A major outbreak of severe acute respiratory syndrome in HongKong. New Eng J Med 2003; 348(20):1986-94.
Conflict of Interest:
The elephant in the room
Professor Hughes' article is certaininly an eloquent summary of the current staffing crisis in UK emergency medicine. Furthermore it is encouraging to know that the taskforce has a grip on the challenges facing the speciality and an awareness of some of the strategies that could, indeed already have, been tried to address the problem of staffing emergency departements. However, insightful the Professor's commentary may be, I feel compelled to address the elephant(s) in the room.
First, the use of nurses (by any other name) is simply robbing Peter to pay Paul; emergency nursing has a staffing crisis of its own to address. Furthermore, the presence of ENPs often denies junior doctors experience of dealing with (for example) minor injuries, which they are subsequently expected to deal with at night (when supervision is less available), as ENPs often do not work the full range of antosocial hours. This has a clear deleterious effect on their training and possibly even job satisfaction. To expand nurses' roles even further risks an ever diminishing range of conditions in which the emergency doctor is proficient.
Secondly, Professor Hughes quites rightly points out that recruitment to the speciality is unproblematic, even competitive. However, the point that retention within the speciality, particularly retention to higher speciality training, is not given fuller consideration. Given that alternative strategies to staff the speciality at this level, even by recruitment from abroad, have failed, the answer to the crisis must surely be to assiduously retain the trainees who so enthusiastically competed to join the speciality? The silence on this point was resounding.
Yours faithfully etc
Conflict of Interest:
I am an ex ED sister and the irony of my remarks re nurses taking on the role of doctors is not entirely lost on me.
Facebook pages about junior doctors in the UK.
Lulic and Kovic are to be congratulated for an innovative and captivating article exploring the use of Twitter in emergency physicians1.
As they mention, Facebook is another popular social media site that highly engages all members of the public, including doctors. A number of pages have emerged on the site that represent quintessential figures in UK hospitals. Popular pages include 'The Medical Registrar', 'The Anaesthetic Registrar' and 'The A&E Registrar'. These pages reflect on the typical stresses of being a trainee doctor and comment on topical issues, mixing light-hearted humour, witty satire and hard-hitting observations. Their growing popularity highlights the potential benefits of doctors sharing experiences and interacting fruitfully on social media.
However, despite the obvious proviso of patient anonymity being maintained, there remain complex issues related to professional conduct2, with these pages being available openly to the public and not just clinicians. Indeed, the digital behaviour of doctors has been the topic of recent guidance by the UK General Medical Council3. The full implications of this guidance are still to be seen. For now, junior doctors continue to benefit from these amusing and often informative pages.
1. Lulic I, Kovic I. Analysis of emergency physicians' Twitter accounts. Emerg Med J. 2013;30(5):371-6. 2. Farnan JM, Paro JAM, Higa JT, Reddy ST, Humphrey HJ, Arora VM. The relationship status of digital media and professionalism: It's complicated. Acad Med. 2009;84:1479-1481. 3. General Medical Council. Doctors' use of social media. Available at: http://www.gmc-uk.org/Doctors__use_of_social_media.pdf_51448306.pdf (Accessed April 2013)
Conflict of Interest:
Improper Use of Troponin Assay
The publication authored by Macdonald, et al. focused on the accuracy of a 2 hour serial multiple biomarker protocol for exclusion of myocardial infarction in the Emergency Department1. Correct use of biomarkers to exclude MI is essential.
I recently observed a case in the emergency department which demonstrated improper use of the troponin assay.
The patient, a man in his 60's with history of diabetes mellitus, hypertension and hyperlipidemia, presented to the emergency department with complaints of 5 days of upper abdominal burning radiating to the chest. EKG revealed a STEMI.
Despite the clinical picture and positive electrocardiogram, the physician incorrectly delayed consulting cardiology until the point of care troponin results were available.
Evidence of STEMI in a patient with multiple risk factors and correlating clinical picture should prompt immediate cardiac intervention. About 5% of patients with acute chest pain present with STEMI2.
The newest generation of highly-sensitive cardiac troponins holds great promise for early identification of myocardial infarction (MI), better risk stratification and rapid effective coronary interventions2. The challenge remains for doctors to accurately diagnose those presenting with non-specific ECG changes and without a straightforward clinical picture. The cardiac troponin values play a significant role in identifying patients with non-STEMI and acute coronary syndrome at high risk, thus enabling rapid non-invasive and invasive treatment2.
Elevation of troponin may occur in multiple conditions other than acute myocardial infarction. It may occur in patients with temporary coronary artery vasospasm, severe but stable congestive heart failure, mechanical trauma of the heart, pulmonary embolism, post- cardiac surgery and in patients with pericarditis/myocarditis. Other causes of increased troponin levels include sepsis, end stage renal disease, tachyarrythmias and acute cerbrovascular events2- 4. Patients with carbon monoxide toxicity and adriamycin cardiotoxicity may also exhibit elevated levels2.
Patients with elevated levels will include those with myocardial infarctions as well as those with myocardial injury from other causes. It is therefore important to consider the clinical picture, the absolute level and change of cTn early after presentation4.
1. Macdonald SP, et al. Serial multiple biomarkers in the assessment of suspected acute coronary syndrome: multiple infarct markers in chest pain (MIMIC) study Emerg Med J emermed-2011-200667Published Online First: 21 March 2012 doi:10.1136/emermed-2011-200667
2. Twerenbold R, Jaffe A, Reichlin T, et al. High-sensitive troponin T measurements: what do we gain and what are the challenges? Eur Heart J.2012;33(5): 579-586.
3. Giannitsis E, Katus HA. Current Recommendations for Interpretation of the Highly Sensitive Troponin T Assay for Diagnostic, Therapeutic and Prognostic Purposes in Patients with a Non-ST-elevation Acute Coronary Syndrome. Eur Cardiology Journal.2009;33:44-47.
4. Inbar R, Shoenfeld Y. Elevated Cardiac Troponins: the Ultimate Marker for Myocardial Necrosis, but Not Without a differential diagnosis. Isr Med Assoc J. 2009;11:50-53.
Conflict of Interest:
Re:Pre-intervention data and paramedic intubation
Mr Mallinson makes three pertinent points. A doctor-paramedic team attends all patients. Each member of the team has a specific role to play and while some of these skills are theoretically interchangeable, it is local policy that the doctor performs the intubation. This is because we recognise that these patients are a high-risk group who should have intubation carried out with the maximum chance of success at the first attempt. Recent evidence has confirmed that more experienced intubators have better intubation success in pre-hospital care (1), and that even highly trained paramedics performing rapid sequence induction have considerably higher failed intubation rates than doctors (2). This is important because multiple attempts at intubation are far from benign and have been clearly associated with dramatically increased rates of adverse events (3).
This service evaluation was not designed to look at specific anaesthetic or intubation-related adverse events. Nevertheless, it is identified as an important area for future prospective study within our service.
The quality of data recording is central to any retrospective review of performance. With the re-designed clinical service the registry capability is continuing to develop, with a step change occurring on introduction of a full-time doctor-paramedic team on both of the aircraft operated by EAAA. Historical data prior to the introduction of the database that was interrogated for this study unfortunately lacks the robustness for reliable direct comparison with that collected to assess performance against the new SOP. Recognising this constraint, the continuing development of a sophisticated quality assurance system that optimally exploits our clinical data is a main effort to underpin our commitment to evidence-based improvements in care.
References 1. Breckwoldt J, Klemstein S, Brunne B, Schnitzer L, Arntz H, Mochmann H. Expertise in prehospital endotracheal intubation by emergency medicine physicians - comparing 'proficient perfromers' and 'experts'. Resuscitation. 2012 Apr; 83(4): p. 434-439. 2. Lossius H, Roislien J, Lockey D. Patient safety in pre-hospital emergency tracheal intubation: a comprehensive meta-analysis of the intubation success rates of EMS providers. Critical Care. 2012; 16(1): p. R24. 3. Sakles J, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing orptracheal intubation in the emergency department. Ac Emerg Med. 2013; 20: p. 71-78.
Conflict of Interest:
Re:Out-of- hospital non-invasive mechanical ventilation: discovering a new setting.
We thank Antonio Esquinas for his response to our article. Our rationale for NIV in the prehospital setting is based on the pathophysiology of acute respiratory failure. In acute hypoxic respiratory failure shunt is the primary underlying problem. While the application of Oxygen (+ specific medication, e.g. diuretics) may improve SpO2, the paO2/FiO2- Index will not improve, as there is no alveolar recruitment. NIV immediately leads to alveolar recruitment and therefore improved oxygenation. In acute hypercapnic respiratory failure fatigue of the respiratory muscles causes hypercapnia. NIV (PEEP + pressure support) unloads respiratory muscles at least partially while a sufficient tidal volume is generated. The benefits of NIV are well documented . Furthermore, since out-of-hospital intubation is associated with an increased risk for airway management problems, morbidity and mortality may already be reduced by avoiding endotracheal intubation . In this study the number of patients with COPD (n=18, 11 SMT group + 7 NIV group) was lower and not higher than the number of patients with ACPE (n=25, 13 SMT group +12 NIV group). Only in those patients where ACPE respectively COPD has been the leading cause for ARF and has been combined with another respiratory affection, the number of patients with COPD was - statistically not significant - higher (COPD n= 11, ACPE n =6). We therefore think that it is hypothetical that this did influence the results of this study. According the methodology we understand the considerations of Esquinas. It is correct that we used patients comfort as one of the parameters to adapt the NIV settings and we are aware that this parameter does not allow quantification. But dyspnoe scores often also quantify only the subjective perception of the patient. We agree that tidal volume should be observed. But it must be recognized that this parameter may be incorrect if the mask seals not tightly and there is a leakage. Furthermore some systems - especially pure CPAP-systems - do not allow to measure tidal volume. In the methods section, we have listed the physiological parameters that defined the need for an ICU therapy in patients with ARF. We did not list all possible causes that my lead to an ICU admission. We could have excluded the patients mentioned. But they were treated in the prehospital phase either with SMT or with NIV due to ARF despite the fact that further diagnoses were found. Since the same number of patients has been affected in each group we do not think that this biased our results. Unfortunately we do not understand the final point adressed by Esquinas, that patients with oxygen therapy (we guess standard medical therapy [SMT] is meant) had a worse clinical course but were not admitted to ICU. Patients with SMT stayed longer in the hospital, were more often and longer in an ICU and had more ventilator days and hours. We agree that it would be worth to discuss and explain the different evolution. But the primary purpose of this study has been to evaluate whether OOH NIV is safe, feasible and more effective when compared with SMT. This question has been answered positively for NIV and we attribute the better in- hospital course to the more effective therapy of ARF with NIV. Adressing this issue as well would have busted both, intention and length of our publication.
 Sch?nhofer B, Kuhlen R, Neumann P, Westhoff M, Berndt C, Sitter H. Non-invasive ventilation as treatment for acute respiratory insufficiency. Essentials from the new S3 guidelines. Anaesthesist 2008 Nov;57(11):1091-102.
 Timmermann A, Russo SG, Eich C, Roessler M, Braun U, Rosenblatt WH, Quintel M. The out-of-hospital esophageal and endobronchial intubations performed by emergency physicians. Anesth Analg. 2007;104:619- 623.
Conflict of Interest:
Re:The importance of accurate identification of drugs of abuse in emergency departments
We thank Polesel and colleagues for raising some important points regarding the accurate identification of ecstasy and related drugs (ERDs) in emergency departments. While testing of biological samples to accurately identify what drugs have been consumed is ideal, these resources may not always be available and, given the time required to conduct analysis and obtain test results, decisions regarding patient management may need to be made in the absence of this information. In these circumstances, self-report data may be the only source of information available, and thus must be relied upon to inform clinical decisions. In addition, in the emergency department setting, we emphasise the role of symptomatic management of ERD presentations. Gahlinger (2004) proposes an algorithm for the management of 'club drug' presentations which focuses on cardiac and respiratory maintenance and prevention of seizures, followed by treatment of psychological symptoms such as anxiety and agitation .
References 1. Gahlinger PM. Club drugs: MDMA, gamma-hydroxybutyrate (GHB), Rohypnol, and ketamine. Am Fam Physician. 2004;69:2619-26.
Conflict of Interest:
electrocardiographic differential diagnosis of ST segment depression
Case examples were succinct and very user friendly to follow.
Thanks, Linda O'Connor RN
Conflict of Interest:
Driver obesity and the risk of fatal injury during traffic collisions - the view from Europe
The excellent article by Rice and Zhu on driver obesity and the risk of fatal injury during traffic collisions attracted our attention. We represent a collaborative research group which is involved in similar research in Europe. As part of our work, we are currently analyzing the data of over 20,000 passengers collected in the largest German accident register across a range of variables, including weight.
Rice and Zhu state in their paper that "driver pairs were included only if the two vehicles were of similar type and size". Perhaps the authors would consider a follow-up manuscript which includes the vehicle year of construction as a matched pair variable? We suggest this because our research has indicated that due to technological advances, cars built in the year 2000 and earlier are less safe than newer vehicles. We are intrigued to see if the American experience matches the European one.
In addition, given society's focus on the negative effects of obesity, it was very interesting to read that underweight males are more likely to suffer a fatal car accident than males who are overweight or from any of the three WHO classes of obesity (RR of 1.78 vs. 0.83 - 1.75).
Based upon previous work we have conducted, we echo the authors' concerns that overweight or obese drivers and passengers in modern vehicles may be poorly served by current designs.
Thank you for publishing this thought-provoking paper. We believe that further research will help both surgeons and car manufacturers to lessen the damaging effects of automobile accidents.
Yours sincerely, A Ernstberger, M Nerlich (Universitaetsklinikum Regensburg) M Kiss (Audi Accident Research Unit) B Hanson, D De Faoite (AO Clinical Investigation and Documentation)
Conflict of Interest:
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