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Recent eLetters

Displaying 207-231 letters out of 803 published

  1. The Rapid Emergency Medicine Score?

    I read with interest the Commentary by Roland and Coats with regard to early warning scores(1). The evidence base for the use of track and trigger systems (TTS)in the Emergency Department is not particularly strong and I agree that using a system that is designed for hospital inpatients will not be appropriate for our specific patient group.

    The rapid emergency medicine score(REMS) is a physiological scoring system that was derived in a non-surgical ED in Sweden (2) and subsequently validated in a study of almost 12,000 patients (3). Area under ROC curve for in-hospital mortality was 0.852 (Standard Error of the Mean 0.014). It has also been evaluated in a UK-based study by Goodacre et al (4).

    Clearly, TTS are here to stay and we need one which is appropriate to our patient population and helps to identify critically ill patients when they arrive in the ED. REMS was derived on ED patients, includes age as part of its scoring (itself an independent predictor of mortality) and studies involving it have much greater sample sizes than work on MEWS. It has its limitations, in that it has only (so far) been used on medical patients and it is a more complicated tool than MEWS. Also a recent survey of UK EDs (conducted by the author) revealed that whilst MEWS is in widespread use, REMS is not being used at all.

    However, if we are looking for a TTS to use in ED, should we not start with REMS, rather than modify a ward-based system?

    A postal survey of 254 UK EDs was undertaken. Responses were received from 145 departments giving a response rate of 57%. 87% of respondents are currently using early warning scores. Of those, 80% are using MEWS, 10% are using the Patient at Risk Score (PARS) and none are using REMS. 93% of respondents are in support of early warning scores in the ED.

    References:

    1. Roland D, Coats TJ. An early warning? Universal risk scoring in emergency medicine. Emerg Med J 2010;1.doi10.1136/emj.2010.106104

    2. Olsson T, Lind L. Comparison of the Rapid Emergency Medicine Score and APACHE II in nonsurgical emergency department patients. Acad Emerg Med 2003;10:1040-1048

    3. Olsson T, Terent A, Lind L. Rapid emergency medicine score: a new prognostic tool for in-hospital mortality in nonsurgical emergency department patients. Journal of Internal Medicine 2004;255:579-587

    4. Goodacre S, Turner J, Nicholl J. Prediction of mortality among emergency medical admissions. Emerg Med J 2006;23:372-375

    Conflict of Interest:

    None declared

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  2. Letter to the editor

    Sir,

    We congratulate Mueller et al. investigating the usefulness of serum protein S-100B to save cranial CT resources in the management of patients with minor head injury [1]. Although we definitely support their conclusions about the usefulness of protein S- 100B, two major concerns regarding the methodology of their study ought to be considered: Firstly, despite the well-described diagnostic time frame of S-100B as a screening tool in minor head injury [2, 3, 4], the authors interpreted the results of two patients false negative. However blood sampling of both patients was 11.5 and 48 hours subsequent to the incident far beyond recommended time frame to rule out traumatic brain injury, which was also mentioned by the authors themself in their discussion section. Therefore we completely agree with the authors' recommendation to ensure blood sampling for S-100 B as a screening tool within a maximum of 3 hours following the incident. If S-100B cannot be measured within 3 hours, it should not be considered to exclude traumatic brain injury [3]. Secondly, the authors found one patient with a skull fracture not been detected by serum S-100B. The patient was therefore interpreted as false negative as well. However protein S- 100B is a brain-specific serum protein to detect traumatic brain injury not skull fractures. Compared to missed or delayed diagnosis of traumatic brain injury, isolated asymptomatic skull fractures do not progress and rarely endanger patients' health. Acknowledging these circumstances, the sensitivity and the negative predictive value of serum-S100B would be 100%. Therefore the authors' conclusions may mislead clinicians considering the implementation of S- 100B to manage patients with minor head injury in the emergency department. Clinicians intending serum protein S-100B as a screening tool for decision making in adult mild traumatic brain injury in the acute setting should be familiar with its capabilities and limitations. If those are considered, S-100B is able to reduce the number of cranial CT by 30% [4].

    Yours sincerely,

    M. Zock, Chirurgische Klinik und Poliklinik, Campus Innenstadt, Klinikum der Universitaet Muenchen, Germany

    Dr. B.A. Leidel, MD, Interdisziplinaere Rettungsstelle und Notfallaufnahme, Campus Benjamin Franklin, Charite - Universitaetsmedizin Berlin, Germany

    References:

    1. Mueller B, Evangelopoulos DS, Bias K et al. (2010) Can S-100B serum protein help to save cranial CT resources in a peripheral trauma centre? A study and consensus paper. Emerg Med J. DOI:10.1136/emj.2010.095372

    2. Townend W, Dibble C, Abid K et al. (2006). Rapid elimination of protein S-100B from serum after minor head trauma. J Neurotrauma. 23(2): 149-155

    3. Jagoda AS, Bazarian JJ, Bruns JJ et al. from the American College of Emergency Physicians and Centers for Disease Control and Prevention (2008). Clinical Policy: Neuroimaging and decision making in adult mild traumatic brain injury in the acute setting. Ann Emerg Med. 52: 714-748

    4. Biberthaler P, Linsenmeier U, Pfeifer KJ et al. (2006). Serum S- 100B concentration provides additional information for the indication of computed tomography in patients after minor head injury: a prospective multicenter study. Shock. 25(5): 446-453

    Conflict of Interest:

    None declared

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  3. Patients still not taking analgesia before attending accident and emergency department

    Dear sir

    I was working at a A&E department in North West few years ago and had similar questions as to why patients not taking any analgesia before attending the department. I did a survey on this matter and this is the result of the survey.

    Objectives

    To determine the percentage of patients attending the accident and emergency department with pain but without taking any analgesia prior to attendance and to find out the reasons for not taking analgesia.

    Methods

    A questionnaire was filled by 122 patients attended the minor unit of accident and emergency department.

    Results

    57% of patients had not taken any analgesia. Most of the patients (61%) were less than 45 years old and 64% of them had not taken any analgesia. Nearly 80% of patients presented with limb pain and 64% of them had not taken any analgesia. Main reasons for not taking analgesia were 'have not thought about taking it' (51.4%), 'did not think need any' (8.6%), 'did not have any' (7.2%) and 'did not like taking them' (5.7%). Nearly 94% of patients who had not taken analgesia were eventually discharged home with analgesia as the definite management. Out of 43% of patients who had taken analgesia, paracetamol was the main choice.

    Conclusion

    There was high proportion of patients attending the accident and emergency department without any analgesia. Most of these patients were eventually discharged home with analgesia. Improvement in patients awareness and education is recommended.

    Conflict of Interest:

    None declared

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  4. Re:Effects of bed height on the performance of chest compressions- Clinical application of results

    We are incredibly glad to hear that Dr. Sherren has taken an interest in our research (1). I concur with his position on this matter. I believe that cardiopulmonary resuscitation (CPR) issues in in-hospital cardiac arrest patients will be solved through near future technologies such as extracorporeal membrane oxygenators. However, if we divide cardiac arrests broadly into in-hospital and out-of-hospital, or on-site arrests, we must admit that, even in the future, on-site treatment will largely rely upon CPR administered by other persons who are on-hand. Therefore, it is necessary that resuscitation research on the often overlooked ergonomic aspects of CPR be revitalized and brought to greater focus. The starting point for an ergonomic approach to CRP research will have to begin with the effectiveness of chest compressions. Already, in the 2005 guidelines, the importance of chest compression was emphasized (2). Within such emphasis, our research group is especially interested in the influence the relative body positions of the patient in need of CPR and the rescuer have on the quality of CPR administered. Previous research in this area indicates that it is most effective to administer CPR from a kneeling position (CPRKP) on a patient who is on the floor (3). If this is true, there is a need to identify what factors cause CPR administered from a standing position (CPRSP) on a patient who lies on the bed to be less effective. Research such as this must look at the rescuer's changes in body positioning, as well as other factors, from an ergonomics perspective in order to be most effective. Under the assumption that making the conditions of performing CPRSP more similar to those of CPRKP would reduce the loss of effectiveness associated with CPRSP, our research team postulated the following hypotheses: 1) that if the bed on which the patient lies were to be lowered to the height of the rescuer's knees during CPRSP, the rescuer would be able to perform CPR in basically the same position as with CPRKP and 2) that rather than placing the patient on a mattress and then a backboard, removing the mattress altogether will improve the conditions of administering CPR. The current study that we are presenting is the first of several studies being conducted regarding these hypotheses. We feel that Dr. Sherren's suggestion of having the rescuer perform CPR while kneeling on the bed itself (CPRKOB) is also a valid hypothetical solution to solving the problem of loss of effectiveness associated with performing CPR on patients in beds. However, this too must undergo rigorous performance studies. While there are cases in which CPRKOB has been performed in clinical settings, most clinical beds are not very strong, and thus a level of instability is often a factor in such cases. This is especially true of smaller emergency-room gurneys. Indeed, it may be true that the simplest solution to preventing the loss of effectiveness in CPR performed on patients in beds is to remove the beds altogether. However, procedures such as endotracheal intubation and vascular access, as well as various monitors attached to a patient may make the act of removing a patient from a bed in order to perform CPR unrealistic; extensive performance studies would have to be performed in order to make any sort of a persuasive argument for such a procedure. As Dr. Sherren has pointed out, mannequin-based performance studies have not beed recognized as very important because they lack things as chest recoil and thoracic pump effects - therefore, making them less desirable than animal and clinical trials. However, considering that CPR is a procedure directly performed by persons, performance studies will give us the best evidence for the creation of guidelines for effective CPR. Again, we thank Dr. Sherren for his attention to our research and give him our regards.

    References

    1. PB Sherren. Effects of bed height on the performance of chest compressions - Clinical application of results. Emerg Med J 2010;eLetter

    2. International Liaison Committee on Resuscitation. International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Part 2. Adult basic life support. Resuscitation 2005;67:187-201.

    3. Perkins GD, Benny R, Giles S, Gao F, Tweed MJ. Do different mattresses affect the quality of cardiopulmonary resuscitation? Intensive Care Med 2003;29:2330-5.

    Conflict of Interest:

    None declared

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  5. Intravenous lipid emulsion for calcium channel blocker overdose: fattening up the treatment

    We read with interest the case report by Abeysinghe and colleagues reporting hyperinsulinaemic euglycaemic therapy (HIET) in the treatment of a patient presenting with persistent hypotension following an overdose of the lipophilic calcium channel blocker diltiazem.[1]

    Diltiazem is extremely lipophilic with a log P value of 4.53 (a measure of lipid solubility). Thus we consider that it would have been amenable to treatment with intravenous lipid emulsion (ILE). This new and emerging addition to the treatment arsenal of lipophilic drug overdoses is supported by a rapidly expanding body of experimental work and clinical cases. The effectiveness of ILE in reversing local anaesthetic induced cardiovascular collapse has been unequivocally demonstrated in animal studies, and recent attention has turned to non-local anaesthetic applications.[2] The role of ILE has extended to include suppression of the toxic effects of verapamil and recently the first case report describing a successful outcome with the use of ILE combined with HIET for the treatment of diltiazem overdose has been published.[3]

    Abeysinghe and colleagues astutely noted that in calcium channel blocker overdose 'myocardial extraction of free fatty acids is decreased despite maintained plasma levels'. ILE is believed to have several beneficial effects with enhancement of myocardial fatty acid transport appearing to be one of the ways in which physiological and metabolic integrity might be restored. Secondly, ILE binds lipophilic drugs within an expanded intravascular lipid phase (the 'lipid sink' effect), thereby reducing the amount of drug available to exert its toxic effects. Finally, ILE may act via a direct inotropic action by increasing cardiac intracellular calcium concentration.[2] With evidence for the effectiveness of ILE in lipophilic drug overdoses increasing we believe it may become a standard intervention in the treatment of calcium channel blocker overdose either as monotherapy or possibly alongside HIET.

    Dr Theophilus Luke Samuels

    Dr David R Uncles

    Dr Johann W Willers

    Dr Aikaterini Papadopoulou

    References

    1 Abeysinghe N, Aston J, Polouse S. Diltiazem overdose: a role for high-dose insulin. Emerg Med J 2010;27:802-3.

    2 Cave G, Harvey M. Intravenous Lipid Emulsion as Antidote Beyond Local Anaesthetic Toxicity: A Systematic Review. Acad Emerg Med 2009;16:815-24.

    3 Montiel V, Gougnard T, Hantson P. Diltiazem poisoning treated with hyperinsulinemic euglycemia therapy and intravenous lipid emulsion. Eur J Emerg Med Published Online First: 17 November 2010. doi: 10.1097/MEJ.0b013e32834130ab.

    Conflict of Interest:

    None declared

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  6. Triage system and adherence of nurses

    We would like to thank van Veen et al. for their evaluation of the Manchester Triage System (MTS) in children. This study was based on simulated case scenario to investigate the repeatability of triage, with a total compliance of nurses with the MTS. We would like to highlight that in real life experience, strict adherence of nurses to triage protocol is rare. Wacher et al. (evaluating the implementation of a set of standardized pediatric telephone triage protocols) have found that 58% of nurses felt confined to the protocols, and 42% admitted intentional deviation from them, when they believed that optimal patient care mandated that they do so .1 Correlation among dispositions determined by triage providers was poor, despite instructions to follow protocols as closely as possible. Although it is a basic assumption that protocols operate by standardization, these results indicate that nurses did not reliably choose the same protocol in a given case and did not reach the same triage endpoint even when they followed the same protocol. As suggested by Poole et al., nurses may decide under some circumstances to follow their intuition rather than the recommendations. 2 Piccotti et al. evaluated the percentage of consistency with the triage process drawn up at the level of pediatric emergency department (ED), and concluded that they were a need for further efforts to improve compliance with the protocol and pursue a higher degree of uniformity in evaluation by triage personnel. 3 The triage in ED relies on two key factors: accurate triage tools for identifying major cases, and compliance of medical staff with the triage protocols. The MTS must be studied rigorously in daily practice before it can be safely disseminated for general use, as far as many bias linked with poor adherence can make it less seducing in practice.

    1. Wacher DA, Brillman JC, Lewis J, Sapien RE. Pediatric Telephone triage protocols: standardized decisionmaking or false sense of security? Ann Emerg Med 1999; 33: 388- 94.

    2. Poole SR, Schmitt BD, Carruth T et al: After-hours telephone coverage: The application of an area-wide telephone triage and advice system for pediatric practices. Pediatrics 1993; 92: 670-79.

    3. Picotti E, Magnani M, Tubino B et al. Assessment of the triage system in a pediatric emergency department. A pilot study of critical codes. J Prev Med Hyg 2008; 49: 120-23.

    Conflict of Interest:

    None declared

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  7. Normalization of ischemia modified albumin results for serum albumin.

    Ischemia modified albumin (IMA) has recently been proposed for the early detection of myocardial ischemia without infarction [1]. We read with interest the article of Ming-Hui Lin, who evaluated this marker as an early negative predictor of acute coronary syndrome (ACS) in different time to presentation groups and different cardiac risk groups [2]. The authors asserted that IMA is a relatively new test, performed on different instruments and with no universal standardisation, so that different laboratories are likely to produce different test results. This is however only partially true. In a previous study we have comprehensively addressed this issue, highlighting that the diagnostic performances of IMA are influenced by some analytical drawbacks. In particular, there is a significant inverse association between IMA and serum albumin, so that the "raw" IMA serum values in patients with extremely low or high serum albumin levels (i.e., <20 or >55 g/L) may be unreliable and lacking in clinically informative value. To overcome this limitation, we have thereby proposed the use of a corrective formula, as follows: [(individual serum albumin concentration/median albumin concentration of the population) x IMA value] [3]. The major advantage of this equation is the normalization of test results for the concentration of serum albumin in the samples. We have also demonstrated that this approach is effective to (i) substantially reduce the otherwise heterogeneous distribution of values in heath and disease while maintaining the median IMA concentration substantially unchanged, and (ii) overcome the bias arising from various methods and instrumentation, thus contributing to harmonize results among different laboratories and techniques. Although we agree that IMA might not be a reliable negative predictor for ACS using the manufacturer cut-off, it might be advisable to re-evaluate the results of Ming-Hui Lin normalizing results for serum albumin by using our corrective formula.

    The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, an exclusive licence (or non exclusive for government employees) on a worldwide basis to the BMJ Publishing Group Ltd and its Licensees to permit this article (if accepted) to be published in EMJ editions and any other BMJPGL products to exploit all subsidiary rights, as set out in our licence(http://group.bmj.com/products/journals/instructions-for- authors/licence-forms)."

    Competing Interest: None to declare.

    References.

    1. Lippi G, Montagnana M, Salvagno GL, Guidi GC. Potential value for new diagnostic markers in the early recognition of acute coronary syndromes. CJEM 2006;8:27-31.

    2. Lin RM, Fatovich DM, Grasko JM, Vasikaran SD. Ischaemia modified albumin cannot be used for rapid exclusion of acute coronary syndrome. Emerg Med J. 2010;27:668-71

    3. Lippi G, Montagnana M, Salvagno GL, Guidi GC. Standardization of ischemia-modified albumin testing: adjustment for serum albumin. Clin Chem Lab Med 2007;45:261-2.

    Conflict of Interest:

    None declared

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  8. Nail polish and pulse oximetry

    To the Editor!

    We have read the original contribution by Sutcu Cicek et al. [1] with high interest regarding the effect of nail polish and henna on pulse oximetry readings. In their study, these authors report on the influence of both factors in 33 normoxic healthy females. Although the study is interesting, it has significant limitations, which must be addressed.

    To our surprise, the authors state, it is not proven that nail polish effects the accuracy of pulse oximeters [1]. However, several randomized, controlled trials with both healthy persons and critically ill patients report on the effect of nail polish on oxygen saturation measured by pulse oximetry [2, 3, 4]. Interestingly, some of these studies have been cited by the authors themselves.

    Sample size calculation prior to beginning of a trial is obligate to determine the significance of results. Unfortunately, in this trial an adequate mathematical sample size calculation was obviously waived. Therefore, results of the present study cannot be interpreted regarding both the statistical significance and the clinical relevance.

    To determine pulse oximetry accuracy, intermittent arterial blood gas analyses (ABGA) are essential [3]. However, accuracy in the present study was only determined by consecutive pulse oximeter measurements over a specific duration, which may alter pulse oximetry readings. A major limitation of the present study is that accuracy is not analyzed in the present study although it is most important in patients who have nail polish applied, e.g. to identify hypoxia. The authors only report on mean values (given in percent) but omit to verify their measurements, e.g. with ABGA.

    Additionally, the presented results also lack standard deviation (SD). Independently, one may assume that the presented differences (max. 1,25%) are not clinically relevant, which is in congruency to other publications [2, 3, 4]. In the present trial one may therefore speculate the differences identified might be due to slightly alternating oxygen saturation values in spontaneously breathing persons.

    In conclusion, the present study does not add significant new data for nail polish to the present knowledge.

    References:

    [1] Sutcu Cicek H, Gumus S, Deniz O, Yildiz S, Acikel CH, Cakir E, Tozkoparan E, Ucar E, Bilgic H. Effect of nail polish and henna on oxygen saturation determined by pulse oximetry in healthy young adult females. Emerg Med J. 2010 Oct 5. [Epub ahead of print]

    [2] Cote CJ, Goldstein EA, Fuchsman WH, et al. The effect of nail polish on pulse oximetry. Anesth Analg 1988;67:683

    [3] Hinkelbein J, Genzwuerker HV, Sogl R, Fiedler F. Effect of nail polish on oxygen saturation determined by pulse oximetry in critically ill patients. Resuscitation. 2007 Jan;72(1):82-91

    [4] Rodden AM, Spicer L, Diaz VA, Steyer TE. Does fingernail polish affect pulse oximeter readings? Intensive Crit Care Nurs. 2007 Feb;23(1):51-5.

    Conflict of Interest:

    None declared

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  9. Is S100-B better then rolling a die?

    Muller et al report that S-100B had a specificity of 12.2% and a sensitivity of 86.4% and conclude that use of serum S-100B as a biomarker for CCT triage may improve patient screening and decrease the number of CCT scans performed. However, if we were to roll a 6-sided die and call the number 6 negative and the numbers 1 to 5 positive we would expect to have a test with similar parameters: 83.3% sensitivity (i.e. positive 5/6 times in those with the disease) and 16.6% specificity (i.e. negative 1/6 times in those without the disease). This illustrates how adopting a low threshold for positivity can produce and apparently high sensitivity at the expense of specificity for an essentially worthless test (like rolling a die). Reporting likelihood ratios overcomes this problem. The likelihood ratios for a positive and negative test based on the estimates of sensitivity and specificity reported by Muller are 0.98 and 1.11 respectively.

    In fact, the performance of S-100B may not be quite as bad as their reported estimates suggest. Based on the data reported in Table 2 the sensitivity is indeed 86.4% (19/22) but the specificity is actually 31.8% (67/211), giving positive and negative likelihood ratios of 1.27 and 0.43 respectively. This is still not much help for decision-making but probably better than rolling a die.

    Conflict of Interest:

    None declared

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  10. Nail polish and pulse oximetry

    To the Editor!

    We have read the original contribution by Sutcu Cicek et al. [1] with high interest regarding the effect of nail polish and henna on pulse oximetry readings. In their study, these authors report on the influence of both factors in 33 normoxic healthy females. Although the study is interesting, it has significant limitations, which must be addressed. To our surprise, the authors state, it is not proven that nail polish effects the accuracy of pulse oximeters [1]. However, several randomized, controlled trials with both healthy persons and critically ill patients report on the effect of nail polish on oxygen saturation measured by pulse oximetry [2, 3, 4]. Interestingly, some of these studies have been cited by the authors themselves. Sample size calculation prior to beginning of a trial is obligate to determine the significance of results. Unfortunately, in this trial an adequate mathematical sample size calculation was obviously waived. Therefore, results of the present study cannot be interpreted regarding both the statistical significance and the clinical relevance. To determine pulse oximetry accuracy, intermittent arterial blood gas analyses (ABGA) are essential [3]. However, accuracy in the present study was only determined by consecutive pulse oximeter measurements over a specific duration, which may alter pulse oximetry readings. A major limitation of the present study is that accuracy is not analyzed in the present study although it is most important in patients who have nail polish applied, e.g. to identify hypoxia. The authors only report on mean values (given in percent) but omit to verify their measurements, e.g. with ABGA. Additionally, the presented results also lack standard deviation (SD). Independently, one may assume that the presented differences (max. 1,25%) are not clinically relevant, which is in congruency to other publications [2, 3, 4]. In the present trial one may therefore speculate the differences identified might be due to slightly alternating oxygen saturation values in spontaneously breathing persons. In conclusion, the present study does not add significant new data for nail polish to the present knowledge.

    References:

    [1] Sutcu Cicek H, Gumus S, Deniz O, Yildiz S, Acikel CH, Cakir E, Tozkoparan E, Ucar E, Bilgic H. Effect of nail polish and henna on oxygen saturation determined by pulse oximetry in healthy young adult females. Emerg Med J. 2010 Oct 5. [Epub ahead of print]

    [2] Cote CJ, Goldstein EA, Fuchsman WH, et al. The effect of nail polish on pulse oximetry. Anesth Analg 1988;67:683

    [3] Hinkelbein J, Genzwuerker HV, Sogl R, Fiedler F. Effect of nail polish on oxygen saturation determined by pulse oximetry in critically ill patients. Resuscitation. 2007 Jan;72(1):82-91

    [4] Rodden AM, Spicer L, Diaz VA, Steyer TE. Does fingernail polish affect pulse oximeter readings? Intensive Crit Care Nurs. 2007 Feb;23(1):51-5.

    Conflict of Interest:

    None declared

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  11. Response to: Survival after cardiac arrest and severe lactic acidosis (pH 6.61) due to haemorrhage.

    Dear Sirs

    I read, with considerable interest, your case history of a 21 year old man who was stabbed in his buttock and went on to suffer a hypovolaemic cardiac arrest whilst on the emergency unit ward awaiting transfusion and exploration of the wound under general anaesthesia.

    A pH of 6.61 is undeniably low and had he presented at such extremes of physiology to your Emergency Department his outcome would have been worthy of a case report. However, it appears that he presented with no more than cryptogenic shock (Hb 7.1) at worst (though there is no mention of a FAST and IVC assessment being carried out) and one might argue that prompt and aggressive damage control resuscitation with urgent surgery would have avoided a cardiac arrest, rhabdomyolysis, ionotropic support, hospital acquired pneumonia and a prolonged ITU stay.

    Quite why the patient was moved to the emergency unit ward is not clear but you do document that after two hours whilst still awaiting transfusion he arrested and promptly went on to receive a hypothermia inducing 4 litres of gelofusin to compound his already dysfunctional clotting mechanism.

    His age and physiological reserve saved his life - this phenomenon is nothing new.

    I am stunned that in these days of centralisation of trauma services post the damning NCEPOD and NAO reports1 2 as well as the emphasis being placed placed on trauma care nationally, cases such as these still occur in our Emergency Departments. More concerning is that 'our' journal sees fit to publish such horrors that would constitute a SUI in many establishments.

    The case highlights that the human body does have the ability to survive critical physiological insult - it does not mean we should allow our patients to reach these limits if there is no requirement to do so.

    Major HJ Pynn RAMC ST5 Emergency Medicine

    1 Trauma. Who Cares? National Confidential Enquiry into Patient Outcome and Death 2007.

    2 Major Trauma Care in England. National Audit Office. Feb 2010.

    Conflict of Interest:

    None declared

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  12. The good and the harm.

    The principle of 'primum non nocere' stems from the ancient world of Plato. In the 'real' world it is immpossible to act without doing harm. An examination or treatment takes always some time and money from the patient. Taking time and money is the minimum harm that is done. In many cases ther is additional harm.

    Therefore the principle 'doing more good than harm' seems at first sight a better and more realistic principle but unfortunately what is 'more good than harm' cannot be easily defined. Indeed, what is considered as more good than harm differs from individual to individual, from time to time, from society to society.

    A diagnosis is not only a matter of knowing. The more that is known the more correct diagnoses will be made, but for an individual diagnosis it is ultimately a decision based on less or more firm knowledge, not on certainty. Who has the right (or the duty) to decide where uncertainty is the rule? Perhaps it is (partly) dependent on the circumstances. For many it will seem to be the first right of the well informed patient since he/she will suffer from the potential harms or profit from the potential benefits of the treatment. But even if this principle should be generally accepted there is often lack of time in urgent situations to inform the patient or the patient is not in the possibility to understand the information. Moreover the government and/or insurance companies too will influence the decision by less or more or no reimbursement for examinations and treatments.

    Since it can be assumed that diagnoses are more often accurate with increasing knowledge it can perhaps be stated that doing more good than harm can be defined by the duty of making efforts by the individual as well as by the society to increase knowlegde.

    Conflict of Interest:

    None declared

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  13. What Price 90 Seconds; is "Call Connect" a disservice to 999 users?

    Woollard et al reiterate the view that many of us have for some time, there is no evidence that an 8 minute response target is worthwhile in itself, that it should be replaced with more clinically orientated priorities and that it has had unfortunate consequences. It is interesting to reflect that most other health organisations (whether primary or secondary care) have significantly increased both the breadth and depth of the skill mix of clinical staff over recent years and that ambulance trust policies of employing large numbers of emergency care practitioners with three weeks clinical training runs counter to the approach of other parts of the health economy and most importantly makes little or no sense. By design such personnel are not in a position to be able to make an overall clinical assessment and take responsibility for decisions with the consequence that patients in virtually all cases are transported to a hospital emergency department. At a time when the NHS is struggling to meet demand and contain financial pressures and where the solution is to guide patients (where appropriate) to more suitable and cost effective community health services (including general practice), ambulance trusts need to be concentrating on increasing significantly the breadth and depth of clinical decision making (likely to include nursing and medical disciplines) rather than employing personnel with limited training and rushing to "stop the clock".

    As many colleagues have said to me (once they have understood the level of training of an emergency care assistant), if they became unwell, they would prefer to be seen by a health professional who had undergone significant training and who could undertake relevant treatments at 8 minutes and one second than an individual with a very limited skill mix at 7 minutes 59 seconds! Probably just as important is that those who develop policy, is to consider the effects upon the overall health economy as there are large interdependencies between organisations with the risk that there are unexpected and often expensive clinical and financial consequences.

    Conflict of Interest:

    NHS Worcestershire is involved with commissioning ambulance services in the West Midlands. The author responds in a voluntary capacity for West Midlands Ambulance Service

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  14. GP Co-op and ED Dept Colocation

    I thank the authors for an interesting article. The article states that none of the other 13 GP co-ops are located on hospital grounds close to an ED. This is factually incorrect. The North East Doctor on call service has 2 co-located sites on hospital grounds, Cavan and Navan. In the case of the Cavan centre the GPs are located in the hospital building. In Navan, the site is on the hospital grounds. In both cases, unlike DubDoc, the service extends from 6pm to 8am and both day and night at weekends and public holidays.

    Conflict of Interest:

    None declared

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  15. Posterior reversible encephalopathy syndrome

    Moratalla describes a case of posterior reversible encephalopathy syndrome (PRES) in a female patient after delivery.1 We feel concerned about the accuracy of his diagnosis. PRES (also termed reversible posterior leukoencephalopathy syndrome) represents a clinical and radiological disease entity characterized by reversible vasogenic oedema in the brain, which primarily results from autoregulation failure and endothelial dysfunction.2 The reversibility of vasogenic oedema, as most specifically and sensitively detected by diffusion-weighted imaging (DWI), especially ADC map, preferably involving posterior white matter can unambiguously differentiate typical PRES from differential diagnoses including metabolic encephalopathy, inflammatory demyelinating diseases, etc. Although atypical cases are not uncommon,2 they should be diagnosed with caution, after prudential exclusion of other confounding disorders. However, reversibility, not only clinical but radiological, and vasogenic oedema, as revealed by DWI ADC map, as well as well-acknowledged risk factors that may predispose to hypertension, such as phaeochromocytoma, glomerulonephritis, eclampsia and with cytotoxic and immunosuppressant drugs,2 were not confirmed by clinical and neuroimaging findings to categorize this case into a typical PRES. In summary, PRES represents a clinicoradiological syndrome, the diagnosis of which relies on typical clinical manifestations and neuroimaging findings.

    References 1. Moratalla MB. Posterior reversible encephalopathy syndrome. Emerg Med J 2010;27:547. 2. Sharma M, Kupferman JC, Brosgol Y, et al. The effects of hypertension on the paediatric brain: a justifiable concern. Lancet Neurol DOI:10.1016/S1474-4422(10)70167-8

    Conflict of Interest:

    None declared

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  16. prevalence of sudden death in asthma

    The case Dr. Alzetta describes is similar to the ones I described. Although these cases are rare in any one location and undocumented especially after death I believe that taken nationally they are of significant numbers. The evidence lies in a paper written to discover the cause of the dramatic increase in asthma deaths in the sixties by Speizer, Doll et al. They studied all the deaths in England and Wales for six consecutive months using Death Certificates from the Registrar General from 1st Oct. 1966-31st March 1967 in which asthma was the underlying cause. They wrote to the doctors and hospitals concerned for full details of the cases. Most of the cases surprisingly occurred in persons with mild asthma only 59% had ever been admitted to hospital. Death was sudden and unexpected in 80% of cases. In 25% death occurred in less than one hour and only 29% survived more than 24 hrs. That death was commonly sudden is confirmed by the fact that 59% of deaths (109 out of 184) were certified by coroners. In 39% of cases (67 out of 171) the practitioner had not regarded the patient as suffering from severe asthma in the terminal episode. This paper is very important as : 1) it demonstrates the only way that one can collect and study these cases in any number. 2) It is the only record we have of the numbers of deaths due to asthma in that era and the dramatic increase at that time. The reason being that asthma deaths were included with all other types of respiratory diseases until several years late. It is very important that this work is repeated today to discover the prevelance today.

    Conflict of Interest:

    None declared

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  17. Over-bedding or de-bunking

    The paper by Harris and Sharma [1] confirms what many emergency physicians think they know : no beds means no admissions. An automatic plea for more beds needs to be regarded sceptically.

    The authors rightly conclude that "the availability of fully staffed beds is a major determinant of ED overcrowding".

    It is crucial for clinicians as well as planners to realise that availability does not equate simply with numbers. Less could mean more in terms of effect!

    Effective bed capacity is a function of length of patient stay as well as crude bed numbers.

    In turn, length of stay can be a function of three major factors, two active at strategic and the third at operational level.

    At strategic level, the configuration of resources in community settings has an arguable impact on their capacity to 'pull' patients out of in-patient wards. Funders' and planners'distribution of resources and attention , towards elective versus emergency 'activity', is a second strategic factor.

    The operational factor relates to the intensity with which resources downstream from the ED are actually utilised. The 5 day/40 hour pattern of diagnostic sessions, theatre sessions and consultant ward rounds, characteristic of historical UK practice has fitted ill with the 7 day/168 hour pattern of illness.

    The authors' message may be that fewer in-patient beds, more intensively used, could release resources for more effective deployment : in our own Emergency Departments if nowhere else.

    Nicholas Harrop, Consultant in Emergency Medicine, Victoria Hospital, Blackpool, UK.

    Reference

    1 Harris A, Sharma A. "Access Block and Overcrowding in emergency departments: an empirical analysis". Emerg Med J 2010;27:508-511

    Conflict of Interest:

    None declared

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  18. diagnosis of swine flu: wieghting between false positive and false negative

    Editor, I read the recent publication by Mann et al. with a great interest. Mann et al. concluded that " There is a significant risk of harm with false-positive diagnoses and potential delays in appropriate treatment [1]." I agree that there are several problem in diagnosis of swine flu. Several problems can lead to the failure of using any scoring system or algorithm for diagnosis [2-3]. On the other hands, although several new diagnostic tools can be availble, the problem of false positive can be seen. How to manage and weight for risk and benefit on using simple method with possible false negative and new modern tools with possible high cost and false positive should be the topic to be discussed.

    References

    1. Mann C, Wood D, Davies P. An evaluation of the UK National Pandemic Flu Service swine flu algorithm in hospitalised children, and comparison with the UK National Institute for Health and Clinical Excellence fever guideline. Emerg Med J. 2010 Sep 3. [Epub ahead of print]

    2. Wiwanitkit V. Scoring system for diagnosis of swine flu. Heart Lung. 2010 Jul-Aug;39(4):345-6.

    3. Wiwanitkit V.Swine flu: the present pandemic infectious disease. Kulak Burun Bogaz Ihtis Derg. 2009 Mar-Apr;19(2):57-61.

    Conflict of Interest:

    no

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  19. The benefit of intravenous magnesium sulphate is not proven in adults with acute severe asthma

    The correct answer to question 2a in the EMQs on magnesium is false, at least with regard to adults. For children it is probably true. The evidence cited to support the answer provided is ten years old [1]. Avid EMJ readers will know that a more recent meta-analysis [2] showed that in adults there was only weak evidence that intravenous magnesium sulphate had an effect upon respiratory function (standardised mean difference 0.25, 95% confidence interval (CI) -0.01 to 0.51; p=0.05) and no significant evidence of an effect on hospital admission (relative risk 0.87, 95% CI 0.70 to 1.08; p=0.22). However, even this latest meta- analysis is effectively out of date. The 3Mg Trial [3] has so far recruited over 400 patients and is now the largest trial of magnesium sulphate in acute asthma. When the 3Mg trial is completed and the results analysed we will have a definitive answer to this tricky EMQ.

    Steve Goodacre

    1. Rowe BH, Bretzlaff J, Bourdon C, et al. Magnesium sulphate for treating exacerbations of acute asthma in the emergency department. Cochrane Database Syst Rev 2000;(1):CD001490. doi:10.1002/14651858.CD001490. 2. Mohammed S & Goodacre S. Intravenous and nebulised magnesium sulphate for acute asthma: systematic review and meta-analysis. Emerg Med J 2007;24:823-830. 3. The 3Mg Trial, ISRCTN 04417063, http://www.hta.ac.uk/project/1619.asp

    Conflict of Interest:

    Chief Investigator for the 3Mg Trial

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  20. Re:'Unstable' buckle fractures

    In reply to Dr Kennedy's comments Salter Harris IV and displaced Salter Harris II fractures are seen in this population, these may be initially interpreted as stable fractures but may require manipulation or observation to avoid long term disability. Misdiagnosis may also occur where a fracture is diagnosed in the absence of any bony injury.

    Conflict of Interest:

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  21. Trauma care in England: Londons Trauma System goes live

    We were encouraged by Hughes editorial on Trauma Care in England (1), which highlighted the key points from the National Audit Office publication Major Trauma Care in England (2).

    As an update, the London Trauma System was launched on 6th April 2010. The system is composed of four trauma networks, each with a major trauma centre providing care for the most seriously injured patients, linked in with a number of local trauma units for those patients with less serious injury.

    Each major trauma centres delivers consultant-led care 24 hours a day, seven days a week. It houses all the specialties required to treat serious injuries on-site, access to rapid diagnostics and operating theatres. Ambulance crews use an agreed triage protocol to determine which patients require transfer to the major trauma centres.

    Hospitals within the networks are required to submit data to Trauma Audit & Research Network. A structured clinical governance system, overseen by the London Trauma Board, operates to ensure the highest quality of care is delivered to patients. Within this, the rehabilitation workstream operates to improve the rehabilitation pathway and identify future priorities for development.

    There are plans to roll out trauma networks outside London in the near future.

    References

    1.http://www.nao.org.uk/publications/0910/major_trauma_care.aspx (accessed 14 May 2010)

    2.Hughes G. Trauma care in England. Emerg Med J 2010;27:338

    Conflict of Interest:

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  22. To complete the question...

    I read with great interest the Best Evidence Topic by N. Naheed and R. Jenner about the place of rectal examination in paediatric constipation.

    The current NICE guidelines concur with the conclusions worded in the BET and do not advocate a digital examination unless one is a healthcare professional with experience in the specific aspect.

    Whilst I would not suggest that emergency physicians should undertake rectal digital examination on all children attending EDs, I feel there is a place for a formal anal and gluteal inspection.

    This should be undertaken to exclude trivial pathologies, which could lie in the background of a constipation like anal fissures, prolapse, fistulas, displaced anal passage, hairy patch etc.

    There is another very important feature, which should be checked in the very young child and I feel emergency physicians often fail on this point too.

    The anorectal reflex (often called anal wink) should be examined if any suspicion of neurological or locomotor deficit is suspected to exclude involvement of the lower sacral segments of any aetiology.

    As recommended by NICE, the above should be undertaken after explanations had been given and informed consent gained from the patient or parent and in the presence of a chaperone.

    Conflict of Interest:

    None declared

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  23. Be wary of premature extrapolations!

    I read with great interest the Sophia section of the EMJ this month.

    A few lines draw our attention to a multi-centre prospective randomised study, which compared preoperative cleansing of the patients 'skin with chlorhexidine-alcohol to povidone-iodine for preventing surgical site infection (Darouiche et al).

    The EMJ editors wondered if there would be some useful implications for ED practice.

    The immediate reaction of any ED practitioner reading these lines would be to think we should advocate the use of chlorhexidine in skin/wound cleansing in the emergency setting.

    I feel this would be a premature extrapolation from a study, which appears flawed to me.

    First of all, despite being a multi-centre study, the selection of the involved institutions was performed by one of the authors, which undoubtedly could have led to some recruitment bias.

    The operating surgeon could technically not be blinded to the study, as the povidone solution is well recognisable from its brownish colour. Some further bias could have been introduced at this particular stage too.

    When the authors looked at the results, they found a statistically significant difference between the cleansing agents overall in favour of chlorhexidine.

    It is well known that statistical and clinical significance are two completely different entities and one should be very cautious when trying to extrapolate from the results of a study that included a different population subgroup than ours.

    This study was performed in an operative setting recruiting patients who were undergoing clean-contaminated surgery; not the typical ED population!

    The type of wounds we see and manage in the ED is usually the superficial, minimally contaminated type; any other type usually requiring surgical referral.

    A recently published and later updated review of the current medical literature even suggests the use of tap water over normal saline or povidone for cleansing of minor wounds in the ED (Thompson and Lecky).

    After the above thoughts, I wondered if we can extrapolate any valuable clinical implication useful for the ED physician at all.

    References: Darouiche O.R., Wall M. J., Itani K.M.F., Otterson M.F., Chlorhexidine- alcohol versus povidone-iodine for surgical site anti-sepsis, New England Journal of Medicine 2010;362:18-26

    Thompson S, Lecky F: Tap water is an adequate cleansing for minor wounds, www.bestbets.org, http://bestbets.org/bets/bet.php?id=24

    Conflict of Interest:

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  24. 'Unstable' buckle fractures

    Hamilton et al in commenting about use of removable splints in childhood wrist fractures mention that there may be misdiagnoses in these 'unstable' fractures. How on earth can a barely visible Taurus or greenstick fracture of a child's wrist be anything but stable??

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  25. generalists cannot afford the luxury of being ignorant

    The luxury of being relatively ignorant of the latest developments outside the "comfort zone" of one's highly specialised field of expertise is one which can be indulged only by specialists in highly esteemed disciplines such as cardiology (the heart being a highly emotive organ), and neurology (neurology being the equivalent of "brainy"). Generalists, such as frontliners in emergency medicine, have to make do with encyclopaedic knowledge because that is the only kind of knowledge which matters when you are the first port of call for undifferentiated life and death emergencies, hence the need for 24/7 services of an emergency librarian

    Conflict of Interest:

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Poll

Among patients with minor TBI (GCS 13-15) getting CT scans ≥ 24 hours after injury, what proportion have a traumatic finding?

Results

0.5% - 43% response rate
3% - 41% response rate
10% - 16% response rate

Related original article: PCT head imaging in patients with head injury who present after 24 h of injury: a retrospective cohort study