Recent eLetters
Displaying 1-10 letters out of 650 published
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Mental Health Care neglected in the Emergency Department
Submit responseI enjoyed reading the paper by Da Cruz et al. On starting my ED job I asked our consultants what our role is in terms of a good outcome for patients presenting in Mental Health Crisis. The overwhelming response was 'make sure they're medically fit' and let the psychiatric worker look after that side. These patients are a group with unmet needs in most ED's when the NICE guidelines are reviewed, a group who leave without being seen, are in the department the longest and frequently attend. Better training is needed for both staff doing an initial triage risk assessment and doctors being proactive in recognising potential suicide risk of someone presenting with Self-Harm. The use of Clinical pathways has aided some departments has enabled the needs of the patient as per NICE guidelines to be met, however unfortunately not universal. The last place you would want to go if you were in Mental Health crisis is an ED
Conflict of Interest:
None declared
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Value of a rigid collar in- need to more research and better devices
Submit responseThe use of cervical collar, head blocks and tape on a stable surface (such as a long spine board or hospital trolley) has long been accepted as the standard of care for patients with potentially unstable spinal injury. holla raises important isues[1]. There is however scant evidence that supports their use and there are significant potential risks associated with their use, including aspiration of vomit, difficult airway access, pressure sores and raise in intracranial pressure [2]. The majority of studies relating to the clinical effectiveness of rigid collars and head blocks as a means of immobilisation have utilised healthy volunteers and measure gross movement of head in relation to the shoulders. The recently published study by Holla[1] utilises gross measurements in healthy volunteers, the combination of a rigid cervical collar and head blocks does not significantly improve the degree of immobilisation offered by head blocks alone, and the argues that the continued use of rigid cervical collars in combination with head blocks should be reconsidered. Although the results of the study by Holla1 do demonstrate that the addition of a rigid collar fails to reduce the gross movement of the head in relation to the shoulders it fails to report potential movements between adjacent vertebrae. We previously conducted a study similar to that of Holla1, however we utilised Magnetic Resonance Imaging [3] to quantify the degree movement between adjacent vertebral bodies, as opposed to measuring the overall degree of movement of the head in relation to the shoulders. We assessed the effectiveness of a rigid cervical collar alone, head blocks and tape alone, a rigid cervical collar with head blocks and tape compared with no immobilisation in restricting movement in the sagittal plane amongst healthy volunteers; we did not assess the degree of mouth opening in our subjects. Our findings demonstrated that while any form of immobilisation reduced motion compared with no immobilisation, no single method of immobilisation was shown to be optimal as the range of cervical spine movements both with and without a rigid collar varied considerably between individuals. By assessing movement of the head on the shoulders (overall movement), ignoring all movement within the neck, our results demonstrated that the performance of each immobilization device was estimated by measuring gross movement and differed from that when considering the summated movement (irrespective of direction) at each level from base of skull to T1. We believe this summated movement may reflect the movement that would occur in an unstable injury. In other words, a rigid collar and blocks prevented the most movement in 5/10 individuals when looking at movement of base of skull relative to T1, but blocks only prevented the most movement in 7/10 individuals across the cervical vertebral bodies; i.e. a 'snaking' type movement was more prevalent with a rigid collar and blocks. In another recent cadaver study Horodyski et al[4] demonstrate that, when immobilising the neck with a cervical collar, the presence of spinal instability is likely to result in a significantly greater degree of movement than seen in healthy volunteer studies. If rigid collars do not increase immobilisation and are associated with increased risk, then it questions their use as standard. There is an urgent need for a cervical immobilisation device to be developed that minimises the intervertebral movement that can occur with current devices and can also be easily applied in the field, be able to be used in confined spaces, and reduce the risks to airway, pressure areas and intracranial pressure. Subsequent to our findings we are developing a device that, we believe, addresses the risks associated with rigid cervical collars, can be readily applied by paramedics in the field and reduces the need for a rescuer to maintain manual in-line stabilisation during extrication. A clinical trial (funded by NIHR i4i) is underway to assess the safety and effectiveness of this device[5]. References 1. Holla M. Value of a rigid collar in addition to head blocks: a proof of principle study. Emerg Med J 2012;29:104-107. 2. Kwan I, Bunn F, Roberts IG. Spinal immobilisation for trauma patients. Cochrane Database of Systematic Reviews 2001, Issue 2. Art. No.: CD002803. DOI: 10.1002/14651858.CD002803. 3. Crane T, Cooke MW, Wellings R, Wayte S, Higgins J. MRI study of effectiveness of cervical spine immobilisation - a pilot study. Available at: http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/research/spinalimmobiliser/mri_study_of_neck_imobilisation_web_version.pdf [accessed 2rd3 January 2012]. 4. Horodyski M, Dipaola CP, Conrad BP, Rechtine GR 2nd. Cervical Collars are Insufficient for Immobilizing an Unstable Cervical Spine Injury. J Emerg Med. 2011 Nov;41(5):513-9. Epub 2011 Mar 12. 5. Cooke MW. Development of a new spinal immobiliser. Available at: http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/research/spinalimmobiliser [accessed 28th January 2012].Conflict of Interest:
MWC is the inventor of a spinal imobilisation device under development and University is the patent holder.
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The general public is ready for transparency about organ donation at the end of life
Submit responseThe general public is ready for transparency about organ donation at the end of life
Bruce et al conducted an opinion survey using a convenience sample in the emergency department (ED) and concluded that patients and relatives are not averse to organ donation being "discussed shortly after ED death" and that "organ preservation procedures [prior to donation consent] are acceptable to many" [1]. We outline 3 main concerns regarding the validity of the conclusions drawn by Bruce et al from the survey.
First, the medical criterion of death determination by the circulatory criterion (ie, mechanical asystole or cardiac arrest for 2- 10 minutes) without simultaneously confirming that brain death has occurred is scientifically flawed [2-4]. The use of a faulty "accepted medical standard" potentially leads to high error rates of determining donor death, which would then inevitably be underreported because of the terminality of surgical procurement. At least 6% of donors determined dead for organ donation purposes were successfully resuscitated and surgical procurement had to be aborted [5]. The public is uninformed of the scientific uncertainty of declaring death in donors in either planned (controlled) or unplanned (uncontrolled) cardiac arrest [4, 6-8]. Therefore, medical scholars from Canada and the United States have pleaded for "a call for a moratorium pending full public disclosure and fully informed consent" [3].
Bruce et al state that the survey results show that "organ preservation procedures are acceptable to many." However, none of the subjects prior to participating in the survey received information on the types of procedures involved, how and when they are performed on donors, and their potential risks. The authors state when consent to donation had yet to be obtained, "the majority [of survey participants] felt [that] commencement and continuation of these procedures would be acceptable if there was as little invasion to their relatives' bodies as possible" [1]. Practically, several highly invasive procedures are necessary to preserve organs for transplantation after unplanned cardiac arrest in eligible donors. They include but are not limited to:
1) Mechanical external cardiac compression, positive pressure ventilation through endotracheal tubes and administration of resuscitation drugs are continued until organs are surgically procured [5].
2) Catheters are inserted into the abdomen to irrigate the peritoneal cavity with ice-cold saline solution and cool rapidly internal organs. Rapid cooling preserves the internal organs for transplantation until donors are transported to medical facilities for surgical procurement [9].
3) Vascular catheters are inserted in the femoral vessels to recirculate oxygenated blood in the systemic circulation with heart-lung machines ie, extracorporeal membrane oxygenation (ECMO) [10, 11]. ECMO preserves organs until the surgical team can start organ removal. ECMO can resuscitate donors during organ procurement [2, 12]. ECMO is also performed at specialized centers to resuscitate patients after refractory cardiac arrest or failed traditional cardiopulmonary resuscitation. Survivors can recover fully with minimal neurological disabilities after ECMO-CPR intervention [13]. However, administering preservative fluids to donors is lethal and obliterates any possible chances of survival if they are successfully resuscitated on ECMO.
4) Surgical procurement is accomplished through midline laparotomy/sternotomy and enbloc removal of organs [14].
Second, the UK community consists of different ethnic groups and religious affiliations. The survey was not representative of these groups. Decision-making at the end of life is informed by personal values, beliefs, preferences, cultures and religious affiliations [15]. Sensitivity to and respect for cultural diversity in the care of dying in pluralistic societies is a basic human right that warrants respect. These considerations have been overlooked.
Finally, determining what ought to be considered ethical or morally acceptable in society should not be grounded in public opinion surveys [16]. As has been argued elsewhere:
"If ethics was determined by mere public opinion, our moral standards would be rendered hopelessly and unacceptably changeable, making it difficult to be certain about what is the morally right thing to do.... On a philosophical level, it violates a necessary requirement for sound moral judgements, notably the requirement for internal consistency.... On a more pragmatic level, there is also the troubling possibility that public opinion might be mistaken or wrong or misguided, particularly where it has been manipulated by pressure groups, politicians or by the media" [16].
This contention is pertinent to Bruce et al claims. What should a person expect as the minimal standard of disclosed information that is reasonable to ensure an informed decision/consent? Utilitarian bioethicists may justify certain life-ending medical practices to facilitate recovery of transplantable organs. For others, such life-ending medical practices constitute a violation of the moral obligation to preserve human life and dignity. In light of the cultural complexities at issue, deciding these issues requires a stronger moral foundation.
Mohamed Y Rady, BChir, MB (Cantab), MA, MD (Cantab), FRCS (Edin. & Eng.), FRCP (UK), FCCM
Professor, College of Medicine, Mayo Clinic
Consultant, Department of Critical Care Medicine, Hospital, Mayo Clinic, Phoenix, Arizona, USA
Joseph Verheijde, MBA, PhD, PT
Associate Professor, Department of Physical Medicine and Rehabilitation, Mayo Clinic, Phoenix, Arizona, USA
Megan-Jane Johnstone, RN, PhD, FRCNA, FCN
Professor, Chair in Nursing and Associate Head of School (Research), School of Nursing and Midwifery, Faculty of Health, Deakin University, Melbourne, Victoria 3125, Australia
References
1. Bruce CM, Reed MJ, MacDougall M. Are the public ready for organ donation after out of hospital cardiac arrest? Em Med J. 2012:Published Online First: 13 April 2012 doi:2010.1136/emermed-2012-201135.
2. Rady MY, Verheijde JL, McGregor JL. Scientific, legal, and ethical challenges of end-of-life organ procurement in emergency medicine. Resuscitation. 2010;81(9):1069-1078.
3. Joffe A, Carcillo J, Anton N, et al. Donation after cardiocirculatory death: a call for a moratorium pending full public disclosure and fully informed consent. Philos Ethics Humanit Med. 2011;6(1):17. http://www.peh-med.com/content/6/1/17.
4. Rady MY, Verheijde JL. Autoresuscitation and determining circulatory-respiratory death in clinical practice for organ donation. Crit Care Med. 2012;40(5):1665-1656.
5. Mateos-Rodriguez A, Pardillos-Ferrer L, Navalpotro-Pascual JM, Barba-Alonso C, Martin-Maldonado ME, Andr?s-Belmonte A. Kidney transplant function using organs from non-heart-beating donors maintained by mechanical chest compressions.Resuscitation. 2010;81(7):904-907.
6. Dhanani S, Ward R, Hornby L, et al. Survey of determination of death after cardiac arrest by intensive care physicians. Crit Care Med. 2012;40(5):1449-1455.
7. Stiegler P, Sereinigg M, Puntschart A, et al. A 10 min "no-touch" time - is it enough in DCD? A DCD Animal Study. Transpl Int. 2012;25(4):481-492.
8. Rodriguez-Arias D, Tortosa J, Burant C, Aubert P, Aulisio M, Youngner S. One or two types of death? Attitudes of health professionals towards brain death and donation after circulatory death in three countries. Med Health Care Philos. 2011:Online First, 2 December 2011.DOI: 2010.1007/s11019-11011-19369-11011.
9. DuBois JM, Waterman AD, Iltis A, Anderson J. Is Rapid Organ Recovery a Good Idea? An Exploratory Study of the Public's Knowledge and Attitudes. Am J Transplant. 2009;9(10): 2392 - 2399.
10. Rodriguez-Arias D, Deballon IO. Protocols for uncontrolled donation after circulatory death. Lancet. 2012;379(9823):1275-1276.
11. Fondevila C, Hessheimer AJ, Flores E, et al. Applicability and Results of Maastricht Type 2 Donation After Cardiac Death Liver Transplantation. Am J Transplant. 2012;12(1):162-170.
12. Dejohn C, Zwischenberger JB. Ethical implications of extracorporeal interval support for organ retrieval (EISOR). ASAIO J. 2006;52(2):119-122.
13. Shin TG, Choi J-H, Jo IJ, et al. Extracorporeal cardiopulmonary resuscitation in patients with inhospital cardiac arrest: A comparison with conventional cardiopulmonary resuscitation. Crit Care Med. 2011;39(1):1-7.
14. Perera MTPR. The super-rapid technique in Maastricht category III donors: has it developed enough for marginal liver grafts from donors after cardiac death? Current Opinion in Organ Transplantation. 2012;17(2):131-136.
15. Johnstone M-J, Kanitsaki O. Ethics and Advance Care Planning in a Culturally Diverse Society. J. Transcult. Nurs. 2009;20(4):405-416.
16. Johnstone M-J. Public opinion and ethics. Aust Nurs J. 2011;19(1):25-25.
Conflict of Interest:
None declared
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Re:Assessment of Respiratory Status in the Hot Zone
Submit responseI would like to thank N Abeysinghe, K Laver and F Mason for their e- letter response to my reflective article. One of the aims of the reflection was to stimulate debate around this difficult subject and indeed the proposal of using a piece of equipment that has a dual purpose of triaging and supplying oxygen therapy has its merits. I welcome the opportunity to explain why I favour the use of the disposable End Tidal Carbon Dioxide (ETCO2) detector for responders in difficult and dangerous incidents over the Respi-check mask. With regard to the susceptibility of the disposable ETCO2 detector to atmospheric contaminants, it was acknowledged in the reflection that this is an area that requires investigation, but if the disposable ETCO2 detector were to react with contaminants, this may be useful. It should be remembered that during a multiple casualty Chemical Biological Radiological Nuclear (CBRN) or HAZMAT incident, not all of the responders may have access to portable Detection Identification and Monitoring (DIM) equipment such as the Gas Alert Quattro, which in itself only detects 4 gases without a Ph value. If a responder was to use the disposable ETCO2 and noted any changes to the colour before or during its use, this could help identify the contaminant or at least some of its characteristics. Any changes noted (or absent of changes) could assist in Personal Protection Equipment (PPE) choice, treatment of casualties (or expectant decision if there is an indication of the casualty has been exposed a contaminant at the extremes of Ph), possible 'scouting' Hot Zone treatment or collection areas. The ETCO2 apnoea detector may not only be used in large single site multiple casualty incidents but also at a chemical suicide to perform Recognition Of Life Extinct (ROLE) or the 'front door' of a NHS hospital away from the incident site where there may have been gross contamination. As for emesis and excessive secretions, it may not be advisable to use any mask as it may fill up rapidly and block any vents and increasing the risk of aspiration. It may be best to position the casualty in the recovery position allowing drainage and visualising evidence of respiratory effort from fluid movement from the mouth and/or bubbling. If any aerosolised fluids make it as far as the disposable ETCO2 detector during use, this may be seen as evidence of breathing. Also the Respi-check masks we currently use in my local ambulance service caution against getting moisture in the indicator tube as this may stop it from working. If I may take this opportunity to expand further on the ETCO2 apnoea detector use. It is envisaged that if possible and appropriate the casualty will be rolled into the supine position and apply the mask/ETCO2 detector combination. Whilst holding and applying the mask the responder may be able to open the airway by tilting the head back with the responder crouching and without directly touching the casualty's face. With the Respi-check mask there is a danger of crushing the mask, covering the indicator tube and blocking vents with the large PPE gloves and kneeling on the ground. Whereas it may be easier to get a good seal, without crushing the mask and clearly seeing if the casualty is breathing with the ETCO2 detector. Additions to the original ETCO2 set-up could include adding an in-line filter which may help protect the responder from any possible exhalation contamination, but of course increasing air resistance and dead air space. The addition of a catheter mount allowing the ETCO2 detector to be positioned to enable viewing may be used in trapped or difficult to reach casualties where their head is reachable. To assess the respiratory status of casualties wearing negative pressure respiratory protection (such as the Avon S10 respirator with the exhalation valve at the front) the same method may be deployed but replacing the adult translucent mask with a paediatric mask/ETCO2 monitor combination over the exhalation valve. In summary I feel that there are advantages of using the ETCO2 set-up over the Respi-check mask, with the ETCO2 possible susceptibility to contaminants may be an advantage.
Conflict of Interest:
None declared
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Emergency Medicine Can!
Submit responseLetter to the Editor
RE: Coats, Timothy J.: Future research in emergency medicine: explanation or pragmatism? Large or small? Simple or complex? Emerg Med J. 2011 Dec;28(12):1004-7.
Coats highlights the potential role of emergency medicine in conducting large pragmatic trials and the shortcomings of the more traditional complex randomized controlled trials. He correctly points out that traditional phase III trials are difficult to run, extremely expensive, and restricted by highly competitive funding mechanisms. While many of the points made in the article are valid, the premise that emergency medicine researchers are not capable, or competitive in an arena of rigorously conducted clinical trials is disconcerting and inaccurate. Emergency physicians can compete, create niches, and succeed! The trial design is irrelevant.
Over the last 10 years, the number of emergency physicians conducting high quality RCTs has risen steadily1,2. These include both industry- sponsored and federally funded trials. As the specialty matures, it is only logical that emergency medicine expands its research footprint and relevance.
The concept that traditional clinical trials or research are restricted only to specialties that have narrowed their scope to a particular disease state, organ system, technical skill, or type of research is unsound. Emergency Medicine's uniqueness is that there are diverse interests and a broad base of expertise. Science in general, and clinical trials is particular, is a TEAM sport. The emergency physician is ideally poised to take the reins of the RCT team, since emergency medicine holds the key to the door (literally) and is the entry point for many diseases and conditions into the system. Indeed, emergency medicine's recent success in high-quality research has garnered substantial attention at NIH. Just in the past 3 years, a number of requests for proposals (RFPs) are targeted at emergency medicine researchers3. The Neurological Emergencies Treatment Trials (NETT) network4,5 is constructed primarily of emergency physicians as principal investigators. The NETT is being heralded as one of the most successful acute trials networks in the history of the NIH, and it has proven that emergency physicians not only can run complicated RCT's, but that they excel at it. Fortunately for other specialties, emergency medicine is collaborative by nature and seeks out the participation and expertise of its colleagues. Non-EM researchers now actively engage emergency physicians in acute trials because they realize EM's critical role (e.g. Stroke Hyperglycemia Insulin Network Effort (SHINE) Trial, Albumin in Acute Ischemic Stroke (ALIAS) Trial6).
Despite the specialty's relative young age and limited research infrastructure, EM researchers are leading the pack in many fields of research including traumatic brain injury, stroke, status epilepticus, asthma and others. The ProTECT III trial is one of the highest funded NINDS clinical trial ever awarded for TBI research, and the PI is an emergency physician. The RAMPART study was multimillion-dollar clinical trial for status epilepticus that recruited patients so fast and efficiently that, even with an expanded sample size, it was completed 2 years ahead of schedule...and the PI was an EM researcher7. There are numerous other examples. Clinical specialization based on a particular organ system does not inherently confer any unique talents or exclusive skills. Emergency medicine can compete with good science, training, and a passion to succeed.
The type of trial design that one chooses depends on the question to be answered. The distinction between efficacy and effectiveness is clearly an important one (treatments may be efficacious, but when employed to the broader population are not effective), but there are many reasons for why this may occur; not all are encompassed in the term generalizability. The small sample size in RCTs is more a function of poor trial design than a fundamental flaw in any particular trial methodology.
Even though the apparent underlying intent of Coates' article is to justify large simple trials, the argument is lost on the contention that emergency medicine is not competitive in disease-based sciences and therefore should become "known" for a particular methodology. There is no doubt that substantial inequalities in funding with our non-EM colleagues exist8 and numerous challenges abound for EM researchers. But, emergency medicine is making significant strides as the specialty matures. Furthermore, trial design does not trump good science. Both types of trials have merit, and emergency physicians can be great at and compete for both!
REFERENCES
1. Rosenzweig JS, Van Deusen SK, Okpara O, Datillo PA, Briggs WM, Birkhahn RH. Authorship, collaboration, and predictors of extramural funding in the emergency medicine literature. Am J Emerg Med. Jan 2008;26(1):5-9. 2. Birkhahn RH, Van Deusen SK, Okpara OI, Datillo PA, Briggs WM, Gaeta TJ. Funding and publishing trends of original research by emergency medicine investigators over the past decade. Acad Emerg Med. Jan 2006;13(1):95-101. 3. Funding Opportunities. 2011; http://search2.google.cit.nih.gov/search?q=Emergency+Medicine&Search.x=22&Search.y=1&site=GRANTS_ALL&client=GRANTS_ALL_frontend&proxystylesheet=GRANTS_ALL_frontend&output=xml_no_dtd&filter=0&getfields=*, 2012. 4. Hill MD, Martin RH, Palesch YY, et al. The Albumin in Acute Stroke Part 1 Trial: an exploratory efficacy analysis. Stroke; a journal of cerebral circulation. Jun 2011;42(6):1621-1625. 5. Silbergleit R. Response to Food and Drug Administration draft guidance statement on research into the treatment of life-threatening emergency conditions using exception from informed consent: testimony of the neurological emergencies treatment trials. Acad Emerg Med. Apr 2007;14(4):e63-68. 6. Ginsberg MD, Hill MD, Palesch YY, Ryckborst KJ, Tamariz D. The ALIAS Pilot Trial: a dose-escalation and safety study of albumin therapy for acute ischemic stroke--I: Physiological responses and safety results. Stroke. Vol 372006:2100-2106. 7. Silbergleit R, Lowenstein D, Durkalski V, Conwit R. RAMPART (Rapid Anticonvulsant Medication Prior to Arrival Trial): a double-blind randomized clinical trial of the efficacy of intramuscular midazolam versus intravenous lorazepam in the prehospital treatment of status epilepticus by paramedics. Epilepsia. Oct 2011;52 Suppl 8:45-47. 8. Bessman SC, Agada NO, Ding R, Chiang W, Bernstein SL, McCarthy ML. Comparing National Institutes of Health funding of emergency medicine to four medical specialties. Acad Emerg Med. Sep 2011;18(9):1001-1004.
Acknowledgements: The author thanks the members of the editorial board of Academic Emergency Medicine who participated in an email discussion of the source paper; particularly Drs. David Cone, Jill Baren, Clifton Callaway, Don Yealy, Christopher Moore, Lowell Gerson, Michelle Biros, and Gary Gaddis.
David W. Wright, MD
Conflict of Interest:
None declared
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Migration of endotracheal tubes in children
Submit responseWe read with interest Dr Durge's suggestion with regards recognition of a migrating endotracheal tube (ETT). Whilst this simple idea looks like a very effective way of monitoring the position of an ETT in an adult, we would urge extreme caution when treating paediatric patients.
It has long been recognised that ETTs in small children and infants are prone to migration, even when securely strapped(1,2). Whilst working in neonatal and paediatric intensive care units we have witnessed a number of accidental extubations, either through coughing or movement of the patient. This has been without any movement of the ETT at the mouth / nose. Therefore, Dr Durge's suggestion for recognition of a migrated ETT would not be effective.
As the trachea is relatively short, small moments of the ETT can easily result in either endobronchial intubation or extubation. Flexion of the neck causes the ETT to move caudally whilst extension causes cranial migration. This displacement can be seen in paediatric patients of all ages(3).
We would suggest that "Melbourne Strapping" is the only way to safely secure the ETT of an infant or small child who is being transferred. In addition we would strongly consider the use of a muscle relaxant during any transfer and have a high index of suspicion about displacement of paediatric ETTs.
1. Endotracheal tube position in infants. Kuhn LR, Poznanski AK. J Pediatr (1971); 78: 991-6
2. Instability of the tracheal tube in neonates. A postmortem study. Roopchand R, Roopnarinesingh S, Ramsewak S. Anaesthesia (1989);44: 107-9
3. Tracheal tube-tip displacement in children during head-neck movement--a radiological assessment. M. Weiss Et al. Br. J. Anaesth. (2006);96 (4): 486-491. doi: 10.1093/bja/ael014
Conflict of Interest:
None declared
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Nose and vein, speed and pain: comparing the use of intranasal diamorphine and intravenous morphine in a Scottish paediatric emergency department
Submit responseRe: Nose and vein, speed and pain: comparing the use of intranasal diamorphine and intravenous morphine in a Scottish paediatric emergency department
The conclusions of the study by Regan et al 1, that intranasal diamorphine (IND) compares favourably over the use of intravenous morphine (IVM) would suggest a potential prehospital utility.
There are however some concerns regarding the audit that produced this conclusion. Whilst it is suggested that the prospective 'intranasal diamorphine' and the retrospective 'intravenous morphine' groups are comparable there is no data presented to support this. Likewise with a mixed prospective / retrospective audit there is always a risk that a confounding change in departmental practice may have influenced the results.
There is no clear indication of how 'time to analgesia' was assessed, how often pain scores were measured or what was considered 'analgesed' or 'not analgesed', rather 'need for co-analgesics' appears based on 'did the child receive co-analgesiacs' rather than any specific indication for this. If indeed all the cases met the College of Emergency Medicine criteria for severe pain 3 it is likely that most will have been seen by paramedics prehospital although no comparison between groups is given
Regan et al 1 state that a number of children already had intravenous (IV) access on arrival in the emergency department (ED) established by paramedics and suggests that this would reduce the time taken by the ED to administer morphine IV. Prehospital pain relief guidelines 2 view morphine as the gold standard in pain relief in children but comment that IV access in children is a last resort. Non-pharmacological methods are advocated as starting points in children proceeding to oral analgesia and entonox.
It would be reasonable to assume that a proportion of those children arriving with IV access in place would have already received some analgesia which may include IV morphine. It is not clear if these patients were then excluded from the study?
The study highlights the issues in providing pain relief in children and encourages the use of the less invasive intranasal route. Given that the intranasal route is less stressful for the child it would be interesting to consider the potential role of intranasal diamorphine prehospital but the practicalities of calculating drug dosage and carrying diamorphine may preclude this.
References
1 Regan, L, Chapman, A, Celnik, A et al, 'Nose and Vein, speed and pain: comparing the use of intranasal diamorphine and intravenous morphine in a Scottish paediatric emergency department' Emerg Med J (2012) doi:10.1136/emergmed-2011-200970 2 JRCALC 'Management of pain in children guidelines' (accessed 3rd April, 2012) 3 College of Emergency Medicine Clinical Effectiveness Committee. 'Guideline for the Management of Pain in Children'. 2010. (accessed 3rd April, 2012)
Conflict of Interest:
None declared
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Increasing evidence of inadequacy of traditional spinal immobilisation
Submit responseThe use of cervical collar, head blocks and tape on a stable surface (such as a long spine board or hospital trolley) has long been accepted as the standard of care for patients with potentially unstable spinal injury. There is however scant evidence that supports their use and there are significant potential risks associated with their use, including aspiration of vomit, difficult airway access, pressure sores and raise in intracranial pressure. 2 The majority of studies relating to the clinical effectiveness of rigid collars and head blocks as a means of immobilisation have utilised healthy volunteers and measure gross movement of head in relation to the shoulders. The recently published study by Holla1 utilises gross measurements in healthy volunteers, the combination of a rigid cervical collar and head blocks does not significantly improve the degree of immobilisation offered by head blocks alone, and the argues that the continued use of rigid cervical collars in combination with head blocks should be reconsidered. Although the results of the study by Holla1 do demonstrate that the addition of a rigid collar fails to reduce the gross movement of the head in relation to the shoulders it fails to report potential movements between adjacent vertebrae. We previously conducted a study similar to that of Holla1, however we utilised Magnetic Resonance Imaging3 to quantify the degree movement between adjacent vertebral bodies, as opposed to measuring the overall degree of movement of the head in relation to the shoulders. We assessed the effectiveness of a rigid cervical collar alone, head blocks and tape alone, a rigid cervical collar with head blocks and tape compared with no immobilisation in restricting movement in the sagittal plane amongst healthy volunteers; we did not assess the degree of mouth opening in our subjects. Our findings demonstrated that while any form of immobilisation reduced motion compared with no immobilisation, no single method of immobilisation was shown to be optimal as the range of cervical spine movements both with and without a rigid collar varied considerably between individuals. By assessing movement of the head on the shoulders (overall movement), ignoring all movement within the neck, our results demonstrated that the performance of each immobilization device was estimated by measuring gross movement and differed from that when considering the summated movement (irrespective of direction) at each level from base of skull to T1. We believe this summated movement may reflect the movement that would occur in an unstable injury. In other words, a rigid collar and blocks prevented the most movement in 5/10 individuals when looking at movement of base of skull relative to T1, but blocks only prevented the most movement in 7/10 individuals across the cervical vertebral bodies; i.e. a 'snaking' type movement was more prevalent with a rigid collar and blocks. In another recent cadaver study Horodyski4 et al demonstrate that, when immobilising the neck with a cervical collar, the presence of spinal instability is likely to result in a significantly greater degree of movement than seen in healthy volunteer studies. If rigid collars do not increase immobilisation and are associated with increased risk, then it questions their use as standard. There is an urgent need for a cervical immobilisation device to be developed that minimises the intervertebral movement that can occur with current devices and can also be easily applied in the field, be able to be used in confined spaces, and reduce the risks to airway, pressure areas and intracranial pressure. Subsequent to our findings we are developing a device that, we believe, addresses the risks associated with rigid cervical collars, can be readily applied by paramedics in the field and reduces the need for a rescuer to maintain manual in-line stabilisation during extrication. A clinical trial (funded by NIHR i4i) is underway to assess the safety and effectiveness of this device5. References 1. Holla M. Value of a rigid collar in addition to head blocks: a proof of principle study. Emerg Med J 2012;29:104-107. 2. Kwan I, Bunn F, Roberts IG. Spinal immobilisation for trauma patients. Cochrane Database of Systematic Reviews 2001, Issue 2. Art. No.: CD002803. DOI: 10.1002/14651858.CD002803. 3. Crane T, Cooke MW, Wellings R, Wayte S, Higgins J. MRI study of effectiveness of cervical spine immobilisation - a pilot study. Available at: http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/research/spinalimmobiliser/mri_study_of_neck_imobilisation_web_version.pdf [accessed 2rd3 January 2012]. 4. Horodyski M, Dipaola CP, Conrad BP, Rechtine GR 2nd. Cervical Collars are Insufficient for Immobilizing an Unstable Cervical Spine Injury. J Emerg Med. 2011 Nov;41(5):513-9. Epub 2011 Mar 12. 5. Cooke MW. Development of a new spinal immobiliser. Available at: http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/research/spinalimmobiliser [accessed 28th January 2012].Conflict of Interest:
MWC is the inventor of the new device mentioned and the patent is held by Warwick University.
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The iLMA vs the Airtraq for prehospital airway management
Submit responseI was interested to read the study by Grosomanidis et al., which compared intubation of a manikin using the intubating laryngeal mask airway (iLMA) and Airtraq optical laryngoscope in various non-conventional patient positions [1]. The authors report that those anaesthetists who participated in the study required a significantly greater number of attempts (and time) to achieve intubation via the iLMA when the operator was facing the manikin lying in the lateral decubitus position, compared with the three other positions under investigation.
Aware that Komatsu et al. had demonstrated comparable success rates for intubations via the iLMA in supine and lateral positions [2], the authors suggest that the problems they encountered could have been due to a greater difficulty in manipulating the airway of the manikin, compared to that of the human. However, in Figure 3 (Image D), the operator can be seen attempting intubation of the manikin in the lateral position without any manipulation of the handle of the iLMA.
Early experience with the iLMA suggested that a learning curve of approximately twenty cases existed for proficiency in tracheal intubation via the device [3]. However, subsequent refinements to the recommended insertion technique managed to produce significant improvements in first- time intubation success rates [4]. The technique currently recommended is called the 'Chandy manoeuvre', which can be expected to improve first-time intubation rates via the iLMA to levels approaching 100%. If the anaesthetists who participated in the study did not all utilise the formal Chandy manoeuvre during attempts to intubate the manikin in the lateral position, then this could explain the findings.
The authors go on to state that few cases have appeared in the literature where the iLMA has been used in the sitting position for prehospital trauma care. They reference my paper from 2000, but I would draw their attention to a paper I published in 2009 detailing prehospital use of the iLMA in five patients with severe polytrauma [5]. In this study, three of the patients were trapped in a sitting position and all three were successfully treated using the iLMA and went on to survive to discharge from hospital. For those who are interested, a full description of the Chandy manoeuvre appears in this paper.
In addressing the suitability of the iLMA and Airtraq for prehospital airway management, the authors fail to point out one crucial difference between the two devices, viz., that the Airtraq has no inherent ability to oxygenate patients, except by facilitating tracheal intubation. In contrast, the iLMA functions as a rescue ventilation device in its own right, permitting rapid re-oxygenation of the hypoxaemic patient prior to any intubation attempt. Furthermore, in order to facilitate intubation, the Airtraq user relies upon a satisfactory view of the larynx. But what often defeats rescuers in prehospital trauma situations is the presence of blood and secretions in the airway obscuring the laryngeal inlet. In the case of the iLMA, no view of the larynx is required since the device is specifically intended to facilitate blind intubation of the trachea.
Andrew M Mason
(Accredited Basics Immediate Care Physician, Suffolk Accident Rescue Service, Ipswich, UK, & Honorary Physician, East of England Ambulance Service NHS Trust)
REFERENCES:
[1] Grosomanidis V, Amaniti E, Pourzitaki Ch, Fyntanidou V, Mouratidis K, Vasilakos D. Comparison between intubation through ILMA and Airtraq in different non-conventional patient positions: a manikin study. Emergencey Medicine Journal 2012; 29: 32-36. doi:10.1136/emj.2010.100933.
[2] Komatsu R, Nagata O, Sessler DI, et al. The intubating laryngeal mask airway facilitates tracheal intubation in the lateral position. Anesthesia & Analgesia 2004; 98: 858-61.
[3] Baskett PJF, Parr MJ, Nolan JP. The intubating laryngeal mask. Results of a multicentre trial with experience of 500 cases. Anaesthesia 1998; 53(12): 1174-9.
[4] Ferson DZ, Rosenblatt WH, Johansen MJ, Osborn I, Ovassapian A. Use of the intubating LMA-Fastrach in 254 patients with difficult-to- manage airways. Anesthesiology 2001; 95(5): 1175-1181.
[5] Mason AM. Prehospital use of the intubating laryngeal mask airway in patients with severe polytrauma: a case series. Case Reports in Medicine 2009; doi:10.1155/2009/938531. Available for free download at: http://www.hindawi.com/journals/crim/2009/938531/
Conflict of Interest:
None declared
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Assessment of Respiratory Status in the Hot Zone
Submit responseEditor, We read with interest the article by M.Malpas [1] which cites the difficulty of assessing respiratory status in triaging those involved in a mass casualty chemical incident resulting from the use of personal protective equipment. However, we are concerned that the use of a calorimetric device to aid this assessment in a mass casualty CBRN incident will prove impractical. It is often difficult to ascertain early identification of the contaminant [2] which may result in false negative readings of the calorimetric device from acidic atmospheric agents. It is also well established that the effects of noxious chemical agents are highly variable but include emesis; itself of an acidic nature, and excessive secretions, which may impair the performance of the calorimetric device. We believe that a simpler device may have been overlooked. The Respi-check mask? is a high-flow reservoir oxygen mask with an adjustable clear plastic tube housing a highly-visible coloured ball, which moves with respiratory effort [3]. This gives a clear visual indication of a patient's respiratory status. Whilst we feel it unlikely that this device's performance will fail due to atmospheric contaminants, we acknowledge that patients will need to generate sufficient tidal volumes in order for the ball sensor to move. However, in a mass casualty triage incident this may help identify those which may be assigned to the 'expectant' category. Discussion with HART operatives has confirmed that oxygen can be delivered via these masks to patients within the hot zone. Whilst identification of a patient's respiratory effort does not require the mask to be connected to an oxygen supply, this could be attached later. The application of these masks whilst wearing a chemical protection suit has also been confirmed to be straightforward and practical. We suggest that this simple device offers the most convenient and practical method of determining respiratory status.
References 1. Malpas M. Prehospital reflections: diagnosing apnoea at a multiple casualty chemical, biological, radiological and nuclear incident. Emerg Med J 2011;28:1061-2. 2. Byers M, Russell M, Lockey DJ. Clinical care in the ''Hot Zone''. Emerg Med J 2008;25:108-12. 3. Breakell A, Townsend-Rose C. The clinical evaluation of the Respi-check mask: a new oxygen mask incorporating a breathing indicator Emerg Med J 2001;18:366-9
Conflict of Interest:
None declared
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