Displaying 482-561 letters out of 803 published
DH and research agree on time definitions
I am delighted to see agreement between Taylor's article and the Dept of Health guidance on recording of arrival times. Taylor et al recommend that "the time the ambulance pulls up outside the department should no longer represent a patient’s arrival time. Instead the time at which the patient actually arrives in the clinical area should be accurately documented as the official arrival time" The existing Department of Health guidance actually states that "the time of arrival should be recorded by the clinician carrying out the initial triage/ assessment or A&E reception whichever is earlier". This may actually be later than physical arrival in the department and so may reduce the total time by a few more minutes! The only time when this does not occur is when the ambulance crew have not been able to hand over the patients within 15 minutes of arrival. This later is designed to prevent the patient getting lost in a gaming process between ambulance turnaround and A&E total time.
Conflict of interest: The author is also the DH advisor who contributed to the definition process.
1. Dept of Health SITREPS 2004-2005 Definitions and Guidance. London 2004.
Systemic manifestations of acute glaucoma in the elderly
We read with interest the case report published by Gandhewar RR and colleagues (1).
From September 05- November 05 we have seen three elderly female patients aged between 70 - 90 years presented to the emergency medicine department with sudden onset of unilateral headache, hypertension and profuse vomiting. They did not have any focal neurological deficit. The patients were examined by junior doctors initially and thought have been suffering from acute intracranial event and had requested CT scans.
What was interesting to note was that none of the patients complained of any visual disturbances unless particularly asked? They answered that the vision was hazy in that particular eye. None of the patients had a classical red eye; it was more of a mild conjunctival injection. The only consistent finding other than the systemic symptoms were that they all had a mid size pupil with minimal or no reaction to light and eye itself was hard to touch.
All three patients had a diagnosis of acute angle closure glaucoma (AACG) made in the emergency department. This was confirmed by ophthalmologists. All made complete recovery following treatment.
The systemic symptoms in these patients are said to arise from excessive vagal stimulation. Although the condition is more common in certain ethnic groups such as Asians and African Americans, in our group all three patients were Caucasian.
It is also important to note that the key to preventing visual loss from glaucoma is early diagnosis and treatment. Due to increased awareness created by this article, 3 patients in our hospital had just that.
Gandhewar RR, Kamath GG. Acute glaucoma presentations in the elderly. Emerg Med J 2005; 22: 306-307.
Painless aortic dissection in Marfan syndrome
Indeed we are indebted to Dr. Ayrik for his comments on one of the most dramatic cardiovascular emergencies: aortic dissection. He rightly points out, that acute aortic dissection may not always present with the classical cardinal symptoms, particularly the sudden, sharp and tearing pain. Moreover, the author states that 10 % of aortic dissections are painless and he warns that the diagnosis can be missed in the absence of the classic pattern, and that atypical presentation needs a high index of suspicion to make the right diagnosis.
From my personal experience in a huge cardiac centre I completely agree with all these statements. However, I should like to add that there is a group of patients who are at particular risk for such an atypical presentation: the patients with Marfan syndrome. Aortic dissection is the most endangering clinical finding in this particular patient group, typically occurring - with or without previous aortic root dilatation - after the second decade of life and only infrequently during childhood and adolescence. Precisely in Marfan patients, not infrequently symptoms from acute dissection may be atypical and severe pain may be completely missed. Therefore, any acute deterioration in Marfan patients necessitates the exclusion of an acute aortic dissection.
Harald Kaemmerer, MD, VMD, PhD
Address for correspondence:
Harald Kaemmerer, M.D., V.M.D., PhD, FESC
Deutsches Herzzentrum München
Klinik für Kinderkardiologie und angeborene Herzfehler
Lazarettstr. 36, 80636 München, Germany
Kaemmerer H, Oechslin E, Seidel H, Neuhann T, Neuhann IM, Mayer HM, Hess J. Marfan syndrome: what internists and pediatric or adult cardiologists need to know. Expert Rev Cardiovasc Ther. 2005 Sep; 3(5): 891-909.
Usefulness of MEDS score for risk stratification of severe sepsis medical patients
We read with interest the article by Chen et al which demonstrated that a MEDS score greater than 12 may be discriminant for Emergency Department (ED) triage, ICU placement (1). These results of importance are in accordance with those of our group. We prospectively evaluated the accuracy of the MEDS score in 286 patients with documented sepsis admitted into our medical ICU (10 beds) after an ED consultation and we compared it with the performance of the SAPS II score calculated with the worst values of physiologic variables during the first 24 hr of ICU admission. The median age (interquartile) was 69 yr (52.1-78.8), for a median MEDS value of 10 (8-12) and a SAPS II score of 51 (35.7-70). Community-acquired pneumonia was the main source of sepsis (58.6%). In our series, the two scores discriminate well between survivors and non- survivors (in-hospital mortality rate: 32.9%) if we consider the area under the ROC curve which was 0.771 [95% confidence interval (CI), 0.714-0.828) for the MEDS score and 0.830 (95%CI, 0.781-0.880) for the SAPS II score. Furthermore, severity of illness, age, and mortality increased when stratifying patients into the five risk groups defined by Shapiro et al (p<. 000.1) (see table) (2). Whereas, Chen et al reported an increased mortality in case of MEDS score > 12 [calculated odds ratio (OR): 4.51], in our population a cut-off value of 10 was already an important predictor of death: OR, 5.4(95%CI: 3.01-9.72), sensitivity 0.475, specificity 0.857, positive predictive value 0.809, negative predictive value 0.562. As in Chen et al cohort, the MEDS score performs well and then may be an appropriate tool in identification of ED patients at high risks of death from sepsis. However, its usefulness should be tested in surgical ICU patients and prospectively evaluated in the ED to decide ICU admission.
MEDS score Patients (n) Age (yr) SAPSII Hospital mortality (%) 0-4 19 44.6 ± 16 31.8 ± 16.7 5.3 5-7 44 50 ± 14.4 36.9 ± 16.2 9.1 8-11 137 65.4 ± 18.6 52 ± 20 27.7 12-15 56 75.8 ± 10.6 65.8 ± 21 50.8 >15 30 78.3 ± 10.9 77.5 ± 22.6 76.7
1 Chen CC, Chong CF, Liu YL, et al. Risk stratification of severe sepsis patients in the emergency department. Emerg Med J 2006; 23: 281-5
2 Shapiro NI, Wolfe RE, Moore RB, et al. Mortality in Emergency Department Sepsis (MEDS) score: a prospectively derivated and validated clinical prediction rule. Crit Care Med 2003; 31:670-5
Amputation, can it wait for CPR: authors' response
Mr Gella raises some interesting questions. Before responding to the specifics we wish to make two general observations.
Firstly, this case illustrates real-time emergency decision-making. We had a patient in cardiac arrest due to hyperkalaemia. Seconds counted. We had to restore circulation as quickly as possible.
Second, such decisions are always made collaboratively. The role of the Emergency Medicine consultant (NR) was to initiate and enable rapid decision-making. This was achieved by consensus between emergency medicine, critical care and the vascular surgeons who had already assessed the patient. Such clinical scenarios are thankfully rare. We believe that good teamwork and decisive leadership were essential to the success achieved.
In response to Mr Gella’s questions:
1. It is true that there are many causes of hyperkalaemia. However, in healthy young individuals the list of acute causes is much smaller. He had no apparent cause of decreased potassium excretion and no reason to believe he had taken a potassium overdose, thus leaving potassium shifts and laboratory errors as the only possible reasons. He had a normal pH prior to his arrest (ruling out metabolic acidosis), had received no medication that could alter his potassium, and had no internal bleeding or signs of infection. He did, however, have an ischaemic leg – clearly the most likely cause.
2. The patient received the correct medical treatment for hyperkalaemia and the variety of arrhythmias encountered. Despite this, he remained unstable. Dialysis could not occur until circulation was restored. This was unlikely until the continuing hyperkalaemia was reversed. The source of potassium had to be isolated, and we observed a dramatic clinical improvement once the amputation had been completed.
3. We included the results available at the time of the arrest.
4. A tourniquet was suggested at the time, but no suitable device was immediately available. It would have taken as much time to fetch a tourniquet from the orthopaedic theatre in our large hospital as to perform a below knee amputation (which took a matter of minutes once started).
5. The final level of amputation was not determined in the resuscitation room. Our approach was to remove the clearly non-viable tissue. The stump was then bandaged and later revised in an operating theatre.
We hope this addresses all the points raised.
Alternative Approach to Evaluation
I would like to view this type of study as one about resource allocation and process changes: we allocate additional manpower resource to the system and make some changes.
Why don't we model this using computer simulation -- discrete event simulation? We will not have Hawthorne effect or have sample size problem. A very objective way of evaluation and we can run with different scenarios.
We can compare having the additional resource assigned to 'See & Treat', or keep it within the 'traditional' triage and treat system (i.e. increasing the number of physicians at the consult/treatment room).
The performance measures can be anything: wait time to first contact with physician, discharge time etc.
Is “Ischemia Modified Albumin” an early diagnostic indicator of myocardial infarction?
I would like to thank Dr Collinson (1) for his article about the utility of ischemia modified albumin (IMA) in chest pain patients. However the results may be overstated regarding IMA in patients with chest pain, particularly in patients with acute myocardial infarction (AMI).
First of all excluding ST segment elevation MI patients could create a selection bias. Because some of these patients have normal cardiac troponin (cTn) levels initially although they have a diagnostic ECG for ST segment elevation myocardial infarction.
The second point to emphasize is the negative predictive value of both a negative cardiac troponin and IMA was stated as %100. However the contribution of IMA to this rate is minimal because IMA was positive in only two acute myocardial infarction patients with a negative cTn (2/37). So it seems that cTn was able to exclude the great majority of AMI patients. And also a negative test might not be able to allow exclude AMI because 19 patients had a positive cTn without a positive IMA (19/37). And also the suggestion in the discussion section that a positive IMA alone will need a follow up to confirm AMI may be controversial. Because of the 342 study participants with a positive IMA, only two of them were AMI as well as a negative cTn (2/342). It seems IMA contributes little to cTn in diagnosing AMI.
As it is known, cardiac troponins have a high sensitivity and specificity in diagnosing AMI, however these high sensitivity and specificity decline in the early hours of the symptoms onset. The critical question here is “How much IMA adds in diagnosing AMI in the early hours of symptoms onset to cTn, ECG, likelihood or risk stratifications made by different societies and the coagulation and inflammation markers studied so far like d-dimer, C-reactive protein and IL-6?”. As it was mentioned in the manuscript, the median time of symptoms onset was 6 hours in the study population. These findings do not inform us about the utility of IMA in the early hours of AMI which was the most critical challenge. Furthermore 37 AMI patients as a pathologic group may be too small to make suggestions for the diagnosing power of IMA in AMI.
1. Collinson PO, Gaze DC, Bainbridge K, et al. Utility of admission cardiac troponin and ‘Ischemia Modified Albumin’ measurements for rapid evaluation and rule out of suspected acute myocardial infarction in the emergency department. Emerg Med J. 2006;23:256-261.
Triage: Evolution or extinction
Geoff Hughes' editorial (1) makes a good case for retaining triage in emergency departments but he omits to mention two further aspects - postponement and redirection.
Emergency departments experience peaks and troughs of workload and resources are used most efficiently if these variations can be ironed out. Postponement, by which during busy periods patients who can wait are made comfortable and brought back at a quieter time, is therefore another useful function of the triage nurse.
There are also large numbers of emergency department attenders who are best treated elsewhere eg those with general practice or dental problems. The redirection of such patients by the triage nurse prevents the emergency department being misused and allows it to concentrate on those things which it does best.
(1) Hughes G. Triage; evolution or extinction.Emerg Med J 2006;23:88.
Physiologic amputation for crush syndrome induced cardiac arrest
Wise et al are to be commended for an excellent “save” as we like to say in the USA.1 I wonder, however, if the very midst of CPR is the best timing for a surgical amputation. Surgery, even the life saving maneuver described, invariably stresses the body. If at all possible, it should be delayed until medical resuscitation is complete because surgical mortality in cases such as the authors describe can exceed 40%.2
We wholeheartedly agree that the only way to control the massive rhabdomyolysis and hyperkalemia in their patient was to quickly eliminate the intracellular toxin leak from the leg. The authors briefly mention tourniquet application, but they do not state whether they considered it at the time. There is some fairly good experience with “physiologic amputation” or “cryoamputation” and we believe that the strategy deserves some elaboration for the readers.2-4
To perform, firmly apply 1-2 tourniquets to the extremity above the level of injury or entrapment and then apply dry ice distal to the tourniquet. Combat surgery hospitals from World War II through current conflicts have performed the procedure not infrequently.5 Physiologic amputation rapidly reduces myoglobin and other intracellular toxins due to crushed, ischemic or septic extremities.2, 3 One center reported a dramatic reduction in myoglobinuria within 24 hours of tourniquet application and the physiologic tourniquets have allowed definitive surgery to be delayed for up to 32 days.3
Physiologic amputation of the nonviable extremity should be considered for similar clinical scenarios as described by the authors.
1. Wise R, Higginson I, Benger J, Rawlinson N. Lower limb amputation with CPR in progress: recovery following prolonged cardiac arrest. Emergency Medicine Journal 2006;23(3):e20.
2. Hunsaker RH, Schwartz JA, Keagy BA, Kotb M, Burnham SJ, Johnson G, Jr. Dry ice cryoamputation: a twelve-year experience. Journal of Vascular Surgery 1985;2(6):812-6.
3. Winburn GB, Hawkins ML, Wood MC. Physiologic amputation prevents myoglobinuria from lower extremity myonecrosis. Southern Medical Journal 1993;86(10):1101-5.
4. Winburn GB, Wood MC, Hawkins ML, Wynn JJ, Nesbit RR, Wray CH, et al. Current role of cryoamputation. American Journal of Surgery 1991;162(6):647-50; discussion 650-1.
5. First United States Army Report of Operations: 1 August 1944-22 February 1945. Medical Section Report Annex 11. Government Printing Office 1946:131-196.
NIV in acute asthma: why not ?
We read with interest the case report recently published by Agarwal R and colleagues(1). The authors concluded, "a trial of NIV in acute asthma may be justified in carefully selected and monitored patients who do not respond to initial medical therapy. However, as it role is not clear and as the condition of an asthmatic patient may deteriorate abruptly, extreme caution is advisable to recognize failure of NIV... Facilities for immediate endotracheal intubation and next level of treatment should be readily available.” We approved these conclusions and we proposed several comments on this case and on this management approach in accordance with our local experience and with current state of knowledge (2-4). In the case presented, patient was initially more hypoxemic (PaO2 8.4 kPa) as hypercapnic (PaCO2 4.9 kPa) with a grade I of severity in first arterial blood gas measurement. An initial chest X-ray was not described in this case. We can postulated that NIV failed because patient was also in acute respiratory failure secondary to a added complication (atelectasia, pneumonia).
In our experience, NIV for patients with severe status asthmaticus not improving under conventional medical therapy and on the edge of intubation is the only possibility of decreasing morbidity and mortality of this acute illness. We will try in this letter to explain our opinion. The severity of an acute asthmatic exacerbation may be assessed using a variety of signs like major dyspnea, tachypnea, the use of accessory respiratory muscles, the presence of a pulsus paradoxus, a quiet chest on auscultation and the decrease of the PEFR below 120 L/min. The appearance of these signs and the increase of the dead space lead to an acute respiratory failure with respiratory acidosis. This clinical condition is not a priory an absolute indication for intubation and mechanical ventilation. Indeed, only 8% of this population of patients needs in fine endotracheal intubation (5). The absence of response to the optimal medical treatment and especially the alteration of conscience are the absolute indications of intubation. Patients with status asthmaticus have a significant increase in both inspiratory and expiratory indexes of airways obstruction. They have also a considerable dynamic hyperinflation.
Inspiratory muscle fatigue and increased physiologic dead space lead to ventilatory failure and respiratory acidosis. In fact, hypercapnia does not occur, however, unless the FEV1 is less than 25 % of predicted. The pathophysiology of status asthmaticus includes airflow obstruction of both large and small airways, inhomogeneous lung inflation, dynamic hyperinflation, ventilation/perfusion mismatch and respiratory muscle fatigue. Airway wall inflammation, smooth muscle-mediated bronchoconstriction and intraluminal mucus explain airway obstruction. Lung hyperinflation is primarily related to the fact that the highly increased airway expiratory resistance, the high ventilatory needs, the relative short expiratory time and the increased post-inspiratory activity of inspiratory muscles do not permit the respiratory system to reach static equilibrium volume at the end of expiration. Therefore, inspiration begins at a volume in which the respiratory system exhibits a positive recoil pressure. This pressure is called intrinsic positive-end expiratory pressure (PEEPI) or auto-PEEP. At each respiratory cycle, this inflation can increase and compromise the respiratory function. This phenomenon is called dynamic hyperinflation and is directly proportional to minute ventilation and to the degree of airflow obstruction. This phenomenon causes substantial shortening of the diaphragm and the inspiratory intercostal and accessory muscles, thereby reducing their mechanical efficiency and endurance and increasing the risk for fatigue. As airway obstruction becomes more serious and the work of breathing becomes excessive, carbon dioxide production is greater than what can be eliminated by alveolar ventilation. Therefore, PaCO2 increases and a respiratory acidosis appears. Moreover, in asthma, large negative swings in intrapleural pressure can significantly impair right ventricular function.
The pathophysiologic condition of acute respiratory failure in asthma is in many ways similar to that of acute respiratory failure in patients with COPD. Although a large body of literature has clearly proved the efficacy and advantages of NPPV in patients with COPD with ARF, only a few reports had described this modality in patients with status asthmaticus. In our experience, we found NIV simple to implement and well tolerated by our patients with severe clinical conditions. Since many years, we known that application of CPAP causes bronchodilatation and decreases airway resistances, reexpands atelectasis and promotes elimination of secretions, rests the diaphragm and inspiratory muscles and may offset PEEPI, and also decreases the adverse hemodynamic effects of large peak and mean inspiratory pleural pressures. CPAP is also available for reexpanding atelectasis by increasing collateral flow (through collateral channels " Kohn channels") to obstructed lung region. But in patients with acute respiratory failure secondary to COPD, similar to patients with asthma, short-term application of CPAP does not improve gas exchange. However, when IPPV is added to CPAP, minute ventilation and gas exchange improve in proportion to the amount of pressure applied. In our clinical experience, when NPPV was used, the respiratory muscles appeared to be rapidly unloaded, dyspnea was resolved and respiratory rate was reduced. The effect on gases exchange was also rapidly observed. In our experience, the mechanical effect of an early application of NPPV seems faster than the pharmacological action. Currently, many experts find that there is insufficient evidence to recommend NIV in acute asthma. For these reasons, in our opinion, NIV for patients with severe status asthmaticus not improving under conventional medical therapy and on the edge of intubation is the only possibility of decreasing morbidity and mortality of this acute situation. However, it is mandatory to comply with the rules of maximal security in term of staff, rapid access to endotracheal intubation and monitoring.
1. Agarwal R, Malhotra P, Gupta D. Failure of NIV in acute asthma : case report and a word of caution. Emerg. Med. J. 2006;23: 9-10.
2.Thys F, Roeseler J, Marion E, El Gariani A, Meert P, Danse E et al. Non invasive ventilation in severe status asthmaticus, a new therapeutic approach ? Two case reports. Réan Urg 1998; 7: 423-6.
3. Thys F, Roeseler J, Reynaert M.S, Liistro G, Rodenstein D.O. Non invasive ventilation for acute respiratory failure: a prospective randomized placebo-controlled trial. Eur Respir J 2002; 20: 545-555.
4. Ram FS, Wellington S, Rowe B, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database Syst Rev 2005; 1: CD004360.
5. Finfer SR, Garrard CS. Ventilatory support in asthma. Br J Hosp Med 1993; 49:357-60
Amputation, can it wait for CPR
Article named Lower limb amputation with CPR in progress: recovery following prolonged cardiac arrest(Ref1) is very interesting as well as thought provoking. Such clinical scenario is not only rare but needs a good team effort to come to a clinical judgement. Amputation in acute scenario in the absence of obvious vascular injury is definitely a brave decision.
I would be grateful for the authors if my doubts can be clarified
1) There are many causes of hyperkalemia and how the team treating could come to a conclusion that the hyperkalemia was caused by the rhabdomyolysis of foot.
2) Drugs like cocaine, heroine can cause rhabdomyolysis (of any muscle), disseminated intra vascular coagulation, hyperkalemia and arrythmias which can be made worse by naloxone (Ref2). In the presented clinical situation these possibilities cannot be ruled out.
3) Arterial blood gas values of this patient would be very interesting to see as well, with particular emphasis on acidosis and anion gap.
4) If limb ischaemia and reprfusion of the ischaemic limb are considered as the cause of hyperkalemia, application of tourniquet or clamping of the vessels can act as diagnostic test rather than going for an amputation.
5) What are the parameters that the teams used to determine the level of initial amputation and what was the initial level of amputation.
Mr Sreenadh Gella
Calderdale Royal Hospital
1. R Wise1, I Higginson2, J Benger2 and N Rawlinson1 Lower limb amputation with CPR in progress: recovery following prolonged cardiac arrest, Emergency Medicine Journal 2006;23:e20; doi:10.1136/emj.2005.
2. McCann B, Hunter R, McCann J. Cocaine/heroin induced rhabdomyolysis and ventricular fibrillation.Emerg Med J. 2002 May;19(3):264-5.
ED workload: Who does what?
In response to Drs Gilligan and Campbell, a study carried out in our ED has shown some interesting findings.
We examined SHO workload on cohorts of ED SHOs in our department, (paediatric ED in a major tertiary centre), between February 2000 and February 2005. SHOs from February 2000 to February 2001 (2 cohorts), saw 22798 patients, 62.52% of total attendances. SHOs from February 2004 to February 2005 saw 23627 patients, 62.2% of total patients. There were 8 full time ED SHOs in each cohort, each working a full shift rota, which was unchanged through the study period. The rota is fully European Working Time Directive compliant.
By comparison, ED middle grades saw 5577 patients between Feruary 2000 and February 2001 (15.29%)and 5585 patients between February 2004 and February 2005 (14.7%). ED consultants showed the biggest change, seeing 597 patients between February 2000 and February 2001 (1.64%), and 1152 patients between February 2004 and February 2005 (3.03%). Nurse Practitioners saw 464 patients from February 2000 to February 2001 (1.27%), and 1157 patients from February 2004 to February 2005 (3.04%). The total number of new patient episodes was 36463 from February 2000 to 2001 and 37986 from February 2004 to 2005.
It can be seen that the number of patients seen by ED SHOs has not varied significantly over this 5 year period. In both absolute and percentage terms, the figure remains constant. Similarly, middle grade workload remains essentially unchanged. The major point of note is the increased input of consultants and nurse practitioners. This represents a considerable change in the delivery of emergency care provision.
The impact of the European Working Time Directive and Modernising Medical Careers will almost certainly have a further significant effect on working patterns and hence service delivery and EM training. The delivery of patient care is anecdotally shifting away from an SHO delivered service to utilising other grades of medical staff, or other health care professionals altogether (ENPs/ECPs). Although this trend is borne out of necessity, caution is needed to prevent detrimental impact on the training of Emergency Medicine doctors and, ultimately, patient care.
Baron DominiqueJean LArrey
Re: Dr. Robertson-Steel.
Thank you for a very interesting and informative article. It may be of interest to readers that a book on Larrey provides fascinating further reading about this remarkable man. The book is difficult to get hold of, and I am afraid that I have forgotten the source by which I acquired my two copies several years ago. The details are as follows:
Author: Dr. Robert Richardson
Title: Larrey: Surgeon to Napoleon's Imperial Guard
Publisher: Quiller Press, London
Published: 1974 with a revised edition in 2000
I do often wonder how many of us involved in the application of the principles of triage, (be it in the pre-hospital field or otherwise), know of its origins. I unfortunately had cause to ponder on this whilst I was collecting my thoughts preparatory to explaining to the press the use of triage and Triage Labels following the 7/7 bombings, during which I was triaging patients at Russell Square Tube Station.
In the book Dr. Richardson relates the tale of an episode during the battle of Waterloo. Although not medical in nature as such, I think it might be of interest:
"Who is that bold fellow?" asked the Duke of Wellington. "It's Larrey," someone answered. "Tell them not to fire in that direction; at least let us give the brave man time to gather up the wounded." And so saying he doffed his hat. "Who are you saluting?" enquired the Duke of Cambridge. "I salute the courage and devotion of an age that is no longer ours," said Wellington, pointing at Larrey with his sword.
As a further point of interest the author has also written extensively on other medical matters.
Manoeuvres affecting central venous cannulation
Clenaghan et al  have demonstrated that Trendelenberg tilt increases the diameter of the internal jugular vein (IJV) in healthy volunteers. This confirms the results of previous studies.
While the benefits of Trendelenburg tilt are well known, the negative effects of other commonly performed manoeuvres are less well appreciated. Gentle palpation of the carotid artery and neck extension cause significant decreases in IJV size. Textbooks describe the IJV as lying lateral to the carotid artery but ultrasound studies show that it overlies the carotid artery to some degree in 54% of subjects. The degree of overlap increases with head rotation , which may increase the risk of carotid artery puncture, especially if the needle passes through the posterior wall of the IJV.
Carotid artery palpation, neck extension and head rotation are often used during IJV cannulation. These manoeuvres decrease the target size and potentially increase the risk of failure or complications, and should be avoided during IJV cannulation using a landmark technique.
1. Clenaghan S, McLaughlin RE, Martyn C et al. Relationship between Trendelenberg tilt and internal jugular vein diameter. Emerg Med J 2005;22:867-8.
2. Armstrong PJ, Sutherland R, Scott DHT. The effect of position and different manoeuvres on internal jugular vein diameter size. Acta Anaesthesiol Scand 1994;38:229-31.
3. Sulek CA, Gravenstein N, Blackshear RH et al. Head rotation during internal jugular vein cannulation and the risk of carotid artery puncture. Anesth Analg 1996;82:125-8.
Two wrongs don’t make a right
To “shoot the messenger” is to reply to an argument by attacking the person presenting the argument rather than the argument itself. It is a time-honoured way of dealing with unpleasant messages. The underlying sentiment is perhaps best expressed by Sophocles: “How dreadful knowledge of the truth can be when there is no help in the truth” (1).
Dr Mason suggests that the criticism of Sen and Nichani’s BET is motivated by a dislike of the message itself rather than a deep and genuine concern about the strength and reliability of the underpinning evidence (2). As a co-author of the letter by French et al.(3), I would like to emphasise that the criticism of the BET was, as is reflected in the title, on methodological and clinical grounds. It was not a personal reaction to the ‘distress generated by uncertainty and the realization of the limits of our knowledge’ (4).
In promoting the ILMA as an alternative to tracheal intubation in the pre-hospital setting, Dr Mason has, I fear, misunderstood the two main criticisms of the BET. The first was that the ‘clinical bottom line’ (prehospital endotracheal intubation is associated with increased mortality in patients with moderate to severe traumatic brain injury) could not be reliably concluded from the literature reviewed in the BET. It is, as Dr Mason acknowledges, “somewhat over-simplistic”. This seems a perfectly fair and reasonable criticism to make of an article published in a major emergency medicine journal.
The second was that the BETS process seems to ignore a key principle of evidence based practice: the combination of the best available evidence with clinical experience. Those of us with extensive pre-hospital experience do not question the clinical need for pre-hospital emergency anaesthesia, intubation, ventilation and retrieval to the most appropriate hospital for selected patients. We question how we might target this intervention more appropriately, how we might train paramedic practitioners to undertake it and how we might properly and thoroughly evaluate its safety and effectiveness compared to alternatives. The example given by French et al. was intended to highlight, to use Dr Mason’s words, another of the “ongoing absurdities in emergency medicine” – the historical acceptance of a standard of critical care in the pre- hospital phase which would be completely unacceptable in any hospital setting.
Neither the BET or the letter by French et al. concerned the role of the ILMA (or any other supraglottic airway device) or the role of professional paramedics in provision of pre-hospital critical care. The subject under discussion was the BET. Dr Mason's comments therefore seem a little unfair. Even if we can be accused of shooting the messenger, then two wrongs certainly don’t make a right. As a messenger who has been shot many times, I would ask Dr Mason to holster his gun, critically appraise the BET in question and re-read the correspondence related to it.
PhD MRCP FFAEM
Conflict of interest
Dr Mason and I have previously drawn pistols at dawn regarding the use of the ILMA in pre-hospital care (5,6).
1. Lloyd-Jones H (ed.) Sophocles. Ajax. Electra. Oedipus Tyrannus, Harvard University Press 1994.
2. Mason AM. Please don't shoot the messengers! EMJ Electronic Letter, 16 January 2006.
3. French J, Steel A, Clements R, et al., Best Bets. A call for scrutiny. EMJ Electronic Letter, 13 December 2005.
4. Choi PTL, Jadad AR. Systematic reviews in anesthesia: should we embrace them or shoot the messenger? Canadian Journal of Anesthesia 2000;47:486-493.
5. Mason AM, Use of the intubating laryngeal mask airway in pre- hospital care: a case report. Resuscitation, 2001;51:91-5.
6. Mackenzie R, The ILMA in pre-hospital care. Resuscitation, 2002;53:227.
Apparant incompatibility between the flow chart provided and Medicines for Children
I must congratulate the authors for coming up with such a simple flow chart which is very clear regarding how should the junior doctors manage Paracetamol overdose. However,if I go by this flow chart then SHOs in Paediatrics prescribe potentially hepatotoxic dose of Paracetamol to probably all the " high risk groups". Consider the case of a child with cystic fibrosis (or say epilepsy on carbamazepine)who is reviewed for a viral fever and is prescribed Paracetamol ( which in accordance with " Medicines for Children" would be ) 15 mg/kg/dose, 4-6 hourly ( max 90mg/kg/day for kids >3 months ). If we go by this flow chart ,then, if the child recieves 5 0r 6 doses over 24 hours then he is at risk of hepatotoxicity ( Iatrogenic !!!). This apparant incompatibility between guidelines issued on behalf of NPIS and " Medicines for Children" needs sorting out or further clarification.
1)Wallace CI, Dargan PI, Jones AL. Paracetamol overdose : an evidence based flow chart to guide management. Emerg Med J 2002;19:202-5.
2)The Medicines Committee of The Royal College of Paediatrics and Child Health and Neonatal and Paediatric Pharmacists Group. Medicines for Children 2003, page 470.London : Royal College of Paediatrics and Child Health Publications 2003.
Letter to the editor
The article by Dr N S Demiryoguran "on painless aortic dissection with bilateral carotid involvement" is of great interest for emergency physicians, reminding us of atypical presentations.
I would like to emphysis the fact that the patient had vertigo, the dissection was likely to involve the posterior circulation also (vertebral arteries). A collegue of mine, Dr Michel Garner, has published a very good article on that subject (MedActuel FMC May 2003)
Thank you for your kind attention.
Dr Luc Simoncelli
Please don't shoot the messengers!
Sen and Nichani should be congratulated for drawing our attention to one of the ongoing absurdities in emergency medicine; namely, that UK paramedics are provided with tracheal tubes, but are not given the drugs or monitoring equipment which enable their safe and effective use in salvageable trauma patients. The ability to intubate a trauma patient without the benefit of drugs is known to be an extremely grave sign, yet we don’t seem to be able to pluck up courage either to withdraw them from use, or to offer a viable alternative. Part of the problem comes from within the Ambulance Service itself, with many paramedics regarding the tracheal tube as the touchstone of their status.
The authors certainly don’t deserve to have their conclusions rubbished. Steel et al. challenge them by asking if a potentially combative and physiologically compromised patient should preferentially undergo bag-valve-mask ventilation (BVMV) with an unsecured airway for a prolonged period, as if there were only two solutions to this problem; full-blown rapid-sequence intubation (RSI) or BVMV in the unsedated patient. Clearly, there is a third way that they omitted to mention, and that is the use of a supraglottic device in conjunction with appropriate sedation. They themselves had the opportunity to put forward evidence to convince us of the potential value and safety of endotracheal intubation in the hands of paramedics with or without drugs, but simply chose to take pot-shots at the messengers instead. Sen and Nichani’s bottom line may have been somewhat over-simplistic, but it has to be met with good evidence for the efficacy and safety of tracheal intubation in prehospital care before it can simply be dismissed.
1. Sen A, Nichani R. Prehospital endotracheal intubation in adult major trauma patients with head injury Emerg Med J 2005; 22.
2. Lockey D, Davies G, Coats T. Survival of trauma patients who have prehospital tracheal intubation without anaesthesia or muscle relaxants: observational study. Brit Med J 2001;323:141.
3. French J, Steel A, Clements R, Lewis S, Wilson M, Teasdale B, Mackenzie R, Black J. Best BETS. A call for scrutiny. EMJ Electronic Letter, 13 December 2005.
CONFLICT OF INTEREST STATEMENT: AMM is Adviser in Prehospital Care to Intavent Orthofix Ltd, distributor of the LMA in the UK. This is an unsalaried position, but AMM has received occasional payment from the company for advisory work in connection with use of the LMA and iLMA in the prehospital environment.
S-100b protein levels as a predictor for long-term disability after head injury
Lomas and Dunning have shown that serum S-100B concentration, measured at initial assessement, relates to outcome after head injury. The potential role of a blood test for head injury severity must be evaluated against what can be inferred from clinical parameters that we already record routinely.
In one of the studies the authors reviewed, of 148 patients in three UK Emergency departments, S-100B was the only independent predictor of one month Glasgow Outcome Score, compared with clinical indices of severity such as conscious level, post traumatic amnesia and head injury symptoms.
It is also likely that CT is a relatively insensitive tool for predicting high risk patient for neuropsychological sequelae, if the rates of scan abnormality (around 6%) and disablility (around 18%) are compared. (The relationship between CT findings and neuropsychological outcome has yet to be reported in a large cohort of mild head injury patients.)
It may be necessary, therefore, for biomarkers to be included in large scale studies of head injury outcome prediction if a useful decision tool is to be derived.
(1)Townend WJ, Guy MJ, Pani MA. et al. Head injury outcome prediction in the emergency department: a role for protein S-100B? Journal of Neurology, Neurosurgery & Psychiatry 2002;73:542–6.
(2)Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med. 2000 Jul 13;343(2):100-5.
(3)van der Naalt J, van Zomeren AH, Sluiter WJ, Minderhoud JM. One year outcome in mild to moderate head injury: the predictive value of acute injury characteristics related to complaints and return to work.J Neurol Neurosurg Psychiatry. 1999 Feb;66(2):207-13.
Use of intravenous cyclizine in cardiac chest pain
The quoted aim of best evidence topic reviews (BETs) is to produce a clinical bottom line which indicates, in the light of the evidence found, what the reporting clinician would do if faced with the same scenario again. Such an objective is only achieved if the recommendation of the BET accurately reflects the results of the evidence review. May and Kumar conclude that “cyclizine should be avoided in patients with acute coronary events”, although we note with interest and concern that this conclusion differs from the on-line version on the BEST Bets website, which is that “There appears to be no firm evidence that cyclizine increases morbidity and mortality in patients with myocardial ischaemia”.
We have further concerns about the conclusion in the paper edition of the journal. The paper reviews a single 16 year old study, which looked at a small number of patients suffering from heart failure. To their credit May and Kumar observe that it was a small study in a very specific group of patients. Unfortunately the published clinical bottom line appears to draw conclusions that are not limited to treatment of patients suffering from heart failure.
The study by Tan, Bryant and Murray, which was reviewed, contained measurement data when cyclizine was given 30 minutes before diamorphine. While cyclizine significantly increased heart rate, right atrial, pulmonary arterial, pulmonary artery wedge and systemic arterial pressures, the subsequent diamorphine tended to change those variables toward the basal values, although right atrial and pulmonary arterial pressures remained significantly above basal values. Tan et al quoted work that concluded that cyclizine may be useful if avoidance or prompt reversal of the hypotensive effect of opiate is required,which potential benefit does not appear to have been considered by May and Kumar.
It is also relevant to observe that no data is given for simultaneous administration of cyclizine with opiate, for cyclizine administered after the opiate and the study excluded use of any other drugs.. Since cyclizine may be administered simultaneously with, or shortly after the opiate in the clinical situation, considerable caution is required if the conclusions of this study are to be translated into advice about clinical care.
The clinical bottom line has the disadvantage of being a negative recommendation, which begs the question "if not cyclizine what should I use?" The authors have noted that the effects of other antiemetics have not been studied, and do not therefore exclude the possibility that other anti-emetics may have more frequent or more severe adverse effects than cyclizine. We repeated their search strategy but replacing the cyclizine search with metoclopramide or stemetil/prochlorperazine, revealing no studies of the effects of these two commonly used drugs. A Cochrane study is being undertaken to review other anti-emetics, and recommendations regarding use of cyclizine or other anti-emetics in acute coronary events must surely await a broader review of this type.
In summary, the clinical bottom line propounded by May and Kumar does not accurately reflect the findings of the single study review; we would suggest that it would have been more appropriate to conclude that "There is the possibility of adverse homodynamic effects of cyclizine in patients with heart failure, and of beneficial effects in patients with opiate induced hypotension; the effects of other known anti-emetics are unknown."
1. Carley SD ed Towards evidence based emergency medicine: best BETs from Manchester Royal Infirmary Emerg Med J 2006; 61-66.
2. May G, Kumar R Use of intravenous cyclizine in cardiac chest pain Emerg Med J 2006; 61-62.
3. Tan LB, Bryant S, Murray RG detrimental Haemodynamic effects of cyclizine in heart failure Lancet 1988; 1: 560-1.
4. Christie G, Gershon S, Gray R, Shaw FH, McCance I, Bruce DW Treatment of certain effects of morphine Br Med J 1968; I: 675-678.
5. Smith E, Wasiak J, Boyle M. Prophylactic antiemetic therapy in the emergency and ambulance setting for preventing opioid induced nausea and vomiting. (Protocol) The Cochrane Database of Systematic Reviews 2004, Issue 3.
Is the patient brain-dead?
The UK criteria for the diagnosis of brain death would prevent the diagnostic confusion encountered by Agarwal et al. Included in the preconditions, before brainstem testing can proceed, is that the patient’s condition should be due to irremediable brain damage of known aetiology. Whilst this may be immediately apparent such as in massive head injury or intracerebral haemorrhage, for patients with possible global hypoxic damage it may take days to establish that the injury is irremediable.
The authors do not mention which agents were used to facilitate endotracheal intubation in their case. The UK criteria stipulate that there should be no evidence that the patient’s clinical state is due to depressant drugs or the effects of neuromuscular blocking agents. Use of a nerve stimulator to exclude neuromuscular blockade may have aided diagnosis in this patient.
The ‘locked-in’ syndrome consists of quadriplegia and anarthria with preservation of consciousness. Vertical eye movements are retained. The syndrome is usually caused by damage affecting the ventral pons or more rarely by destruction of corticobulbar and corticospinal tracts. Whilst extremely rare, the condition should be considered as ten-year survival for these patients has been reported to be as high as 80%. Non-verbal communication may be established using the preserved vertical eye movements.
Guidance for the performance of brain death tests varies worldwide. The UK criteria recommend the use of ancillary tests such as cerebral angiography, transcranial doppler or EEG in situations where testing is clinically difficult such as local trauma that precludes full assessment of cranial nerve function. In other countries, the use of such tests is mandatory. Reassuringly, a follow-up survey of over 1300 patients diagnosed as brain dead on the basis of the UK criteria, found that all patients suffered cardiorespiratory death even if full supportive measures were continued.
Published reports have identified a number of other conditions that may mimic brain death.6 To these should be added envenomation with neuroparalytic agents such as that descibed by Agarwal et al.
1.Health Departments of Great Britain and Northern Ireland. A code of practice for the diagnosis of brain stem death including guidelines for the identification and management of potential organ and tissue donors. London: HMSO,1998.
2.Agarwal R, Singh N, Gupta D. Is the patient brain-dead? Emerg Med J 2006;23:e5. 3.Smith E, Delargy M. Locked-in syndrome. BMJ 2005;330:406-409
4.Wijdicks EFM. Brain death worldwide; accepted fact but no global consensus in diagnostic criteria. Neurology 2002;58:20-25.
5.Pallis C. Brain stem death – the evolution of a concept. Med Leg J. 1987;2:84-104.
6.Powner DJ, Hernandez M, Rives TE. Variability among hospital policies for determining brain death in adults. Crit Care Med 2004;32:1284-1288.
Prehospital Intubation – Delving deeper into the evidence
May I thank Ayan Sen and Raj Nichani for their recent “Best Bet” on prehospital intubation in head injury. It was a pity however, that they neglected to look deeper into the reasons why their conclusion, at least at this point in time, was that there is insufficient evidence to support its use. The very topic of prehospital rapid sequence induction (RSI), was the subject of a panel discussion and presentation at the National Association of Emergency Medical Service Physicians annual meeting in Arizona in 2004. They, fortunately, delved deeper into the issues surrounding RSI in head injured patients. One of the most important findings from this discussion was that most of the ambulance services involved in studies surrounding RSI / sedation assisted intubation, did so without the benefit of End-Tidal Carbon Dioxide (ETCo2) or even oxygen saturation monitoring. This, coupled with the widespread use of hyperventilation and inadequate preoxygenation went some way to explain the adverse findings found.
In one of the largest studies, the San Diego Paramedic RSI study, when one ambulance service introduced the use of ETCo2 monitoring, further analysis found hyperventilation (<30mmhg) occurred in 79% and severe hyperventilation (<25mmhg) occurred in 59% of intubated patients. Post introduction of ETCo2 monitoring, the incidence of inadvertent hyperventilation was significantly reduced. The only RSI subgroup without increased mortality were in those patients who underwent paramedic RSI but were then transported by air medical crews who had substantial experience using ETCo2 to guide ventilation.
The San Diego trial uncovered many adverse findings, but in a positive light, many important lessons were learned. First, advanced monitoring including pulse oximetry and ETCo2 should be mandatory when performing ETI with or without RSI. Second, adequate preoxygenation prior to RSI and close oxygen saturation monitoring during laryngoscopy should be routine. Third, hyperventilation should be avoided. In stark contrast to the San Diego study, the Whatcom Medic One program in Washington has experienced none of the desaturation/bradycardia issues and has an intubation success rate of 96.6%. All failed intubations were successfully managed. This successful RSI program is as a result of rigorous training, clinical governance, medical oversight, continuous quality assurance and of course the investment in adequate monitoring including ETCo2.
The most startling contrast between the USA and the UK, is that only physicians here undertake RSI. The monitoring described above is now mandatory in the emergency department (ED) and the anaesthetic room after a position statement by both the Royal College of Anaesthetists and our own faculty. In my scheme (Hampshire) and many others, we fully extend this to the prehospital theatre. In conclusion, if we are to accept that RSI in traumatic brain injury is a valid and meaningful intervention in the ED, then would it not follow that this is also true prehospital?
Dr Rob Dawes BM MFAEM DipIMC RCSed REMT-P
1. Ayan Sen and Raj Nichani: Prehospital endotracheal intubation in adult major trauma patients with head injury Emerg Med J 2005; 22.
2. Wang HE et al. Prehospital Rapid Sequence Intubation – What does the evidence show?: Proceedings from the 2004 national association of EMS physicians annual meeting: Prehospital Emergency Care Volume 8 No 4.
3. Position Statement 1: Confirmation of endotracheal tube placement with end tidal CO2 detection: March 2001 Emerg Med J 2001; 18:329.
Treatment for acute paronychia: Author's response
I read with interest the comments regarding the Best Evidence Topic Report (BET) entitled “Incision and drainage preferable to oral antibiotics in acute paronychial nail infection?” and would be delighted to provide justification for the conclusion. Acute paronychia is one of the most common infections of the hand. Far from being a simple digital abscess, acute paronychia represents a dynamic and evolving condition. The patient initially complains of pain and tenderness in the paronychial fold, which appears erythematous and inflamed. If the infection persists, a collection of pus may develop, forming an abscess around the paronychium. Left untreated, this may spread under the nail sulcus to the opposite side, creating a “run-around abscess”[2-4].
In clinical practice within the Emergency Department, patients present at different stages along this continuum of infection. Although it is widely held that acute paronychia mandates surgical management, many paronychiae are treated conservatively by general practitioners, using oral antibiotics. Indeed, this approach has been advocated for early infections in the literature, as have warm-water soaks.
BETs are designed to summarise the best available evidence to answer a specific and well-defined clinical problem. The BET in question describes the clinical scenario of a patient who has neither obvious fluctuance and abscess formation nor trivial erythema. In the experience of the two authors, this presentation is not uncommon and presents a dilemma for the Emergency physician. If surgical management confers no benefit over the conservative approach, avoidance of an unpleasant and unnecessary surgical procedure may be beneficial for the patient.
Following independent exhaustive literature searches and review at the Manchester Royal Infirmary Emergency Medicine Journal Club, we were unable to identify any relevant comparative trials to answer the three-part question. As such, our conclusion that there is no evidence that a surgical approach is either better or worse than conservative treatment in this situation is justified.
In the absence of relevant evidence in the literature we do not, however, state that either approach is of equal benefit. We clearly state that if pus is present in acute paronychial nail infection, our current practice is to incise and drain the abscess. Further, we highlight an interesting area for potential future research.
1. Shaw J, Body R. Incision and drainage preferable to oral antibiotics in acute paronychial nail infection? Emergency Medicine Journal 2005; 22: 813-814.
2. Rockwell PG. Acute and chronic paronychia. American Family Physician 2001; 63: 1113-1116.
3. Jebson PJL. Infections of the fingertip: Paronychias and felons. Hand Clinics 1998; 14: 547-555.
4. Canales FL, Newmeyer WL 3rd, Kilgore ES. The treatment of felons and paronychias. Hand Clinics 1989; 5: 515-523.
IMA - any further benefit?
I read with great interest this article. I believe IMA did not add any benefit over myoglobin in terms of early ruling-out Acute Myocardial Infarction, as the negative predictive value of myoglobin is about 99% in the first 1-3 hours. Moreover, both of them are not specific for Acute MI. Troponins are sensitive in 6-12 hours post symptoms, specific for the heart, especially cardiac troponin I, but both, troponin I and T, are not specific for Acute MI.
I believe what we really are in need of is a biomarker that is both sensitive and specific for Acute MI. Until that time, thorough history including risk stratification, meticulous physical examination, EKG and TIMI score for Unstable Angina/Non-ST-Elevation MI, are the pearls we have to diagnose ACS.
Re: Simple technique for paronychia management: aspiration by wide bore needle
The technique used by us is quite useful for the superficial collection of pus at any other site as well. This requires simple aspiration. This aspiration technique can be used for hematoma collection also. The simplicity of aspirating rather than incising is readily acceptable to patients and can be easily performed as an OPD procedure.
Psychoactive substance misuse in emergency medical care: lessons from psychiatry
We note with interest findings by Binks et al. that almost 50% of emergency department presenters with direct consequences of “illegal drug” (psychoactive substance) misuse had a psychiatric disorder or emotional difficulties associated with deliberate self-harm.
Our experience in emergency psychiatry on a Psychiatric Intensive Care Unit (PICU) also identifies very high rates of substance misuse, (90-100%) among a cross section of presenters. Cannabis, crack, cocaine and amphetamines are the main drugs used. Individual or combined use of these substances is associated with wide variations in clinical presentation. This may be further complicated by use of “legal” substances, e.g. alcohol and mood altering prescribed medication (opioid analgesics and steroids). The patterns, quantity and aftermath of substance use invariably influence clinical interventions such as the need for admission and duration of hospitalization.[2,3]
An awareness of the stage in the career of substance misuse e.g. intoxication, dependence or withdrawal can inform emergency and post-emergency management. In such situations multidisciplinary interventions with Crisis Intervention, Psychiatric Liaison, or Addictions services may prove invaluable. The “revolving door” patient with unresolved crises can significantly impact on sparse resources and is best identified for more detailed assessment and intervention.[2,3] Some of these individuals also experience severe personality difficulties that may be emotionally challenging to staff.
Awareness of the relationship between substance misuse and its clinical consequences has public health implications as secondary psychiatric sequelae such as organic brain injury, drug-induced psychosis, mood disorders or schizophrenia may ensue. Furthermore, serious assaults or injury may lead to the development of posttraumatic stress disorder.
Extrapolating the findings that large numbers of emergency admissions are related to substance misuse, the clinical risk and resource implications are vast with significantly increased morbidity and mortality. As substance misuse is often associated with criminal behaviour, social, psychiatric and medical consequences, emergency presentations offer critical opportunities for multiagency interventions.
1. Binks S, Hoskins R, Salmon D, Benger J. Prevalence and healthcare burden of illegal drug use among emergency department patients. Emergency Medicine Journal 2005;22:872-873.
2. Zahl DL, Hawton K. Repetition of deliberate self-harm and subsequent suicide risk: long-term follow up study of 11 583 patients. British Journal of Psychiatry 2004; 185:70-75.
3. Kalucy R, Thomas L, King D. Changing demand for mental health services in the emergency department of a public hospital. Australia and New Zealand Journal of Psychiatry 2005; 39:74-80.
Preventing inflight medical emergencies by utilising the internet
As commercial air travel is moving toward an internet driven consumer booking system opportunities exist to remind travellers who may require medications to bring them in their carry on luggage and not to pack them. The first opportunity to do this occurs in the booking process where a flash screen reminding potential travellers that they should carry their medication could be programmed. If airlines were sufficently worried about this they could also include a tick box on the booking screen asking individuals whether they require medication. This could then be printed on their eTicket to remind them to carry the medication. Finally at the ticketless check ins, which are becoming more common, the individual traveller could again be reminded to carry their medications and not to place them in the luggage when they log in. Not all emergencies can be prevented but at least an IT solution does exist to prevent those emergencies which arise as a result of missing medications.
Airlines are already directing resources towards providing emergency medical kits, AEDs, monitors etc.[2,3] Some have access to ground based medical consultations in flight. Prevention in the first instance through directed reminders could reduce the need for inflight diversions and ensure a safer environment for the increasing market of elderly travellers.
1. Horvath LL, Murray CK, DuPont HL. Travel health information at commercial travel websites. J Travel Med 2003;10(5):272-8.
2. Lyznicki JM, Williams MA, Deitchman SD, Howe JP, 3rd. Inflight medical emergencies. Aviat Space Environ Med 2000;71(8):832-8.
3. Rayman RB, Zanick D, Korsgard T. Resources for inflight medical care. Aviat Space Environ Med 2004;75(3):278-80.
Definition of Relative Analgesia
I could not resist replying, even though time has passed since publication, as I will be conducting continuing education based in part on the classic text, first in the reference list, "Langa's Relative Analgesia in Dental Practice."
In this text's preface, Langa makes the statement, "The term 'relative analgesia' was introduced by the author many years ago." This would seem to be a credible statement, given the length of time he had been teaching.
In Chapter 4, section subtitle "The Planes of Analgesia," Langa lists the four stages of anesthesia and has divided Stage 1 into three planes: the first two being degrees of Relative Analgesia, and the third being the plane of Total Analgesia. Langa provides clinical signs to determine which plane the patient is experiencing.
The reader is warned to avoid the third plane because of its proximity to Stage 2 of Anesthesia, the Excitement/Delerium Stage. Langa notes that attempts to maintain Total Analgesia often result in the patient drifting in-and-out of the Excitement stage, causing undesirable lapses in patient co-operation.
While individuals vary considerably in their response to varying concentrations of nitrous oxide, given the doses reported in the original article, it is likely that many, if not all, of the subjects were, in fact, quite beyond the stage of Relative Analgesia.
This is not to be critical of the practice described, as the safety of the technique was amply documented. Apparently it enabled needed treatment to proceed. It is furthermore likely the procedures performed did not require patient co-operation, and the patient was not expected to look forward to experiencing repeated sessions with nitrous oxide, administered in this manner.
In summary, using Langa's technique and definitions, the procedure used for the children was probably not equivalent to Relative Analgesia in its classical sense, as is administered in an outpatient dental setting by a trained operator. I believe it was within this context, however, that Langa was speaking, when he originally defined the term.
I do like the last two sentences of the author's reply and would like to use it verbatim with credit, in my continuing education presentation: "Nitrous oxide provides analgesia, anxiolysis, and mild amnesia obtained with maintenance of verbal contact and predominantly intact laryngeal reflexes. No other single agent does this."
Association does not prove causality
I would like to briefly comment on the article entitled "Prehospital endotracheal intubation in adult major trauma patients with head injury" by Ayan Sen and Raj Nichani. In this excellent review, the authors point out that there are no prospective trials that have investigated the prehospital use of endotracheal intubation in adults. I believe it should be stressed that it is very difficult to account for all confounders using a retrospective design. It is extremely likely that the "sicker" patients were the ones who were intubated in the prehospital setting and therefore had worse outcomes. Until a prospective study is performed, I believe it is quite dangerous to jump to the conclusion that this association proves causality.
Brian Doyle, MD
All for US and US for all
Atkinson et al. in their paper highlighted how catheterisation of central venous system for vascular access is an essential skill for emergency physicians. Clinician inexperience has been identified as being associated with a higher number of complications.
Mansfield did not find that ultrasound usage in his study group, patients requiring chemotherapy, was beneficial. Miller however showed that ultrasound usage resulted in a shorter time from skin puncture to blood flash, a significant reduction in the number of attempts required to secure access and reduction in time to line placement. All laudable goals in an emergency department environment where time is a precious commodity.
Miller achieved these results with a short intense 1 hour training session for both residents and faculty. As the number of such procedures performed by an individual emergency physician in the UK or Ireland are likely to be low skill maintenance has rightly been higlighted as being important. Atkinson suggests that teaching the technique to other staff may help in this regard.
Rosenberg identified that ‘video game aptitude appears to predict the level of laparoscopic skill in the novice surgeon’. Hand eye coordination or visual-spatial skills are also required for the technique of ultrasound guided vascular access. Could it be possible that there is some benefit to being a member of the ‘playstation generation’ with respect to development of visual-spatial skills compelementary to medical practice?
One other method of skill retention could be to utilise ultrasound for difficult peripheral access intermittently to maintain familiarity with kit, machine and the visual spatial skills required. Abboud suggests that the general application of ultrasound guidance for venous access in the ED has reached a critical mass and the recent focus on patient safety and clinical outcomes has lead to increased attention being given to use of ultrasound in the emergency department. Even at a cost of £15,000 per ED and the requirements for ongoing training and certification it would appear as if the time of ultrasound has come for the emergency physician
1. Atkinson P, Boyle A, Robinson S, Campbell-Hewson G. Should ultrasound guidance be used for central venous catheterisation in the emergency department? Emerg Med J 2005;22(3):158-64.
2. Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Engl J Med 1994;331(26): 1735-8.
3. Miller AH, Roth BA, Mills TJ, Woody JR, Longmoor CE, Foster B. Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department. Acad Emerg Med 2002;9(8):800-5.
4. Rosenberg BH, Landsittel D, Averch TD. Can video games be used to predict or improve laparoscopic skills? J Endourol 2005;19(3):372-6.
5. Abboud PA, Kendall JL. Ultrasound guidance for vascular access. Emerg Med Clin North Am 2004;22(3):749-73.
Best Bets. A call for scrutiny.
Best BETS are based on specific clinical scenarios and aim to provide a clinical bottom line which should indicate, in the light of the evidence, what the clinician would do if faced with the same scenario again. The article by Sen and Nechani (EMJ 2005;22:887-889) serves to remind us that unless Best BETS are rigorously conducted their conclusions may be inappropriate.
Sen and Nechani wonder if pre-hospital intubation was of benefit to the major trauma patient they describe. They conclude that pre-hospital intubation is associated with increased mortality and imply that this intervention should not be undertaken.
There are two main problems with this. Firstly, evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. Accumulating bad evidence does not make it good. Good evidence answers a highly specific question and the results are similarly specific to the circumstances. Sen and Nechani ask a poorly focused question and do not define the circumstances surrounding pre-hospital intubation in the studies they review – especially whether anaesthetic drugs were used. Even a cursory glance at these studies reveals major differences in quality, study design, patient populations, the experience and training of the operator, the use of anaesthetic drugs and the operational environment. The brief conclusion is therefore completely inappropriate.
Secondly, good doctors use individual clinical expertise together with the best available evidence: neither alone is enough. Sen and Nechani question whether pre-hospital emergency anaesthesia is indicated in their patient. Such a question suggests that they do not appreciate the reality of pre-hospital critical care practice. The decision to anaesthetise and intubate an unconscious trauma patient is not controversial. The controversy relates to whether this critical care intervention can be undertaken competently and safely. Are they really suggesting that their potentially combative and physiologically compromised patient should preferentially undergo bag-valve-mask ventilation with an unsecured airway for a prolonged period (often greater than half an hour) with no reliable measure of end tidal CO2? Would this be acceptable in the hospital critical care environment?
The EMJ has a responsibility to ensure that Best BETS are properly conducted and reviewed. This is not the first time that clinical bottom lines with major implications have been questionable – perhaps it is time to review the process again?
1. Mackway-Jones, K. Towards evidence based emergency medicine: Best BETs from the Manchester Royal Infirmary. EMJ 2005;22:887.
2. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ 1996;312:71-72.
3. Mackenzie R, Lockey DJ. Pre-Hospital Emergency Anaesthesia. J R Army Med Corps 2004;150:59-71.
Treatment of acute paronychia
I am writing to express concern about the often nihilistic conclusions of many of the Best Evidence Reports appearing in the Journal. A case in point is the recent report on acute paronychia.
Acute bacterial paronychia is a painful condition which can progress to osteomyelitis. It's treatment, and indeed that of most bacterial abscesses, is drainage. This provides immediate relief of pain, prevents further complications, and avoids the unnecessary use of antibiotics. Given that these effects are obvious, and given the increasing problems with antibiotic resistance, it is wrong to conclude, as the authors have done, that acute paronychia may as well be treated with antibiotics as by drainage.
1. Shaw J, Body R. Incision and drainage preferable to oral antibiotics in acute paronychial nail infection? Emerg Med J 2005; 22: 813-814.
Flailing around over a definition!
With reference to Gundoz et al. and their article on CPAP vs. IPPV in the management of flail chest injuries I would just like to clarify a few points.
Firstly in their definition of what actually constitutes a flail chest, the presence of five or more rib fractures in a row was part of the inclusion criteria. There is no doubt that five consecutive rib fractures most definitely points to a severe thoracic injury, but strictly speaking, does it actually constitute a flail segment? I would like the author to clarify how many in the study actually had flail segments and what their outcome was.
The second query I have regards the use of ICU mortality as a primary end point. Surely length of hospital stay would be a much more useful marker in terms of knowing how well the subjects faired long term?
Overall, I found the article extremely useful and it certainly has generated debate in the ICU I work in about how best to manage these injuries.
Dr Aidan Cullen
C-reactive protein: a valuable acute investigation. A case of pneumococcal meningitis presenting as
I agree with the points made by Dr Hughes in the approach to the battery of tests that are often made in the undifferentiated patient. Too often a false positive test result occurs which means we have two choices to carry out another battery of tests which may produce further equivocal results or ignore the result. If the patient then later presents with a serious condition we will then be critiscised by various clinicians in possesion of the retrospectoscope.
I also recommend wiewers to watch the series of House, an example of how to really manage undifferentiated presentations. Hugh Laurie manages to start at least 2 life threatening treatments on every patient before coming up with the one unifying diagnois. His best effort would have been the lady who developed African sleeping sickness following a sexual relationship with someone who carried the disease years earlier. I am humble to his diagnostic skills.
Paronychia and advanced manicure.
When treating paronychia there is rarely any need for incision or aspiration. The infection usually enter via small lesions in the lateral nail fold. It can be drained in the same way. First the finger tip is soaked for approximatelky 10 minutes in saline. Then, under local anaestheic if necessary, the cuticle is pushed back along the lateral and proximal area of the nail. This opens up the potential space through which the pus drains.
Since learning this technique 10 years ago I have never had to use any sharp instruments on a paronychia.
This technique has the advantage over incision and drainage in that it does not leave the patient with a new iatrogenic wound to heal.
Simple technique for paronychia management: aspiration by wide bore needle
Having read the article by Jonathan Shaw, we would like to share a simple technique that we have using for managing acute paronychia with success, which may be equally beneficial to anyone dealing with this condition. Rather than using a scalpel, we have preferred using a wide bore needle (gauge 18 or 20) for aspirating pus, if it has pointed. This technique has also been favored by our patients over the conventional incision and drainage.
Antibiotics and topical applications usually suffice if the pus has not pointed. However once the pus is pointing, it requires a ‘release’. This can easily be provided by simple aspiration with a syringe capped with a wide bore needle (under asepsis), either with or without local anaesthetic support. For the grown ups and adults, spray of ethyl chloride is quite useful and suitable for this purpose. For children who are by and large apprehensive, premedication with a tranquillizer followed by ethyl chloride spray in the usual fashion, does the trick as the procedure is very short indeed. Needle tip is carefully passed until the skin punctures and pus is aspirated out. If patient was already on antibiotics, the same or another one is followed for next few days, whereas for the fresh cases a loading dose of antibiotic is prescribed and followed for just two to three days.
This technique allays the apprehension to a great extent as also the after pain, and also cuts down the cost of management. It is a simpler procedure for the management of acute paronychia and does not require any expertise or training.
1. Shaw J. Incision and drainage preferable to oral antibiotics in acute paronychial nail infection? Emergency Medicine Journal 2005; 22: 813 -814.
Author's reply re: Cranial computed tomography in trauma: the accuracy of interpretation by staff in
We thank Dr Hynes and colleagues for their interest in our Paper (Emerg Med J 2005;22:538-540). To have selected participants would indeed have introduced a bias. The five permanent members of staff who read the images constituted the only five permanent members of staff at that time, and between them saw all out of hours CT head scans done from A&E for trauma.
We agree that only persons deemed competent should interpret images and that historically in the case of computed tomography (CT) this has been done by radiologists. Our paper seeks to show that in many ways cranial CT is no different from other radiographic images. We would point out that many other images are interpreted by on call clinicians in the acute situation and reported later by radiologists. Many of these are more difficult to interpret, we would cite the chest radiograph as an example.
In our study the images were read by a stable group of experienced medical staff. We would suggest that this may be no worse than rotating trainees in radiology or neurosurgery who are viewing these images in the acute situation on a regular basis, particularly as these staff have undergone varying amounts of training in the interpretation of cranial CT images.
We accept that our study represents a small sample. We would welcome confirmation from larger studies. The case set in our paper is now over two years old, and in the intervening period audit has shown that no cases of “structural intracranial damage” has been missed by our emergency department (ED) staff. Rapid access to cranial CT in trauma is essential and with proper training and audit we believe ED staff can safely provide initial interpretation.
Unexplained variation in European ambulance services
Fairhurst highlights the variation in prehospital provision in Europe. In 2001, a study was undertaken of the 21 countries of the European Economic Area (only one failed to respond) which confirmed this. Ambulance services were being run by a wide variety of organisations including national ambulance services (n=4), local ambulance services (n=5), the Red Cross (n=1), the fire service or emergency care centres (n=5), a doctor or hospital (n=2) and in two of the countries, it varied in different parts of the country. Five used Criteria Based Dispatch and four Advanced Medical Priority Dispatch System. In 79% of countries, prioritisation determined speed of response and in 79% it determined level of response. The training of dispatchers was highly variable, ranging from no formal training in one country to more than two years in six countries and the range of professionals that could be dispatched also varied considerably. The European ‘112’ access number was available in 80% of countries but 11 different numbers existed. The number of emergency calls had a massive variation from 1,200 to 17,500 calls per 100,000 population per year.
This study preceded the expansion of the European community and so wider variation may now exist.
Such variation in provision may relate to healthcare systems but studying such variation may provide useful lessons for all countries.
1. Cooke MW, Bridge P, Wilson S. Variation in emergency ambulance dispatch in Western Europe. The Scandinavian Journal of Trauma and Emergency Medicine 2001; 9(2): 57-66.
Comparison between nurses and SHOs is misleading
Ezra et al.’s paper comparing Emergency Nurse Practioners (ENP) and Senior House Officers (SHO) ophthalmic examination and diagnosis demonstrates that experienced nurses given specific training can assess ophthalmic injuries. To those who work with ENPs this should come as no surprise. However the comparison with junior medical staff could lead to erroneous conclusions being drawn.
It is not clear at what point in the SHOs six month job this study was conducted, nor for how long the ENPs had been conducting these examinations. As a marked ‘learning curve’ is seen in most skills it would be unusual for this not to be the case for ophthalmic examination. There is also no indication as to how many cases were discussed with senior medical staff prior to referral. This may bias the accuracy of provisional diagnosis.
Case mix is described as equivalent between the groups and yet no data is provided to support this statement. If, for instance, SHOs saw a greater proportion of out of hours cases then bias may be introduced by increased proportion of those under the influence of alcohol and other drugs.
Comparison of visual acuity accuracy shows a much wider spread of results in the SHO group. A&E SHOs are a more heterogeneous group in terms of background and training than ENPs, and the few clear outliers could be enough to produce a statistically significant difference.
Beggs’s letter draws attention to the failure to control for differences in training and his experience of limited ophthalmological training is common to most UK medical schools. Very little of this training covers eye injuries and common emergency presentations.
As an evaluation of ENP activity in terms of outcomes it is a small if valuable study. However a lack of presented data and methodological flaws make the comparison between SHOs and ENPs unreliable.
1. D G Ezra, F Mellington, H Cugnoni, and M Westcott Reliability of ophthalmic accident and emergency referrals: a new role for the emergency nurse practitioner? Emerg Med J 2005; 22: 696-699
2. Beggs A Roles for Emergency Nurse Practitioners. Emerg Med J e- letter emj.bmjjournals.com/cgi/eletters accessed 21/10/05
ENP-exclusive eye emergencies?
The study by Ezra et al. found that Emergency Nurse Practitioners, presumably with several years’ experience and with specific training for several sessions in an ophthalmology clinic, were more accurate at ophthalmic assessment than SHOs, presumably with a few months’ experience and specific training in one short seminar. Comparison data for middle grades and consultants was not included. Nor was reference made to the length of time and cost-effectiveness of assessments. They concluded that ENPs could well see “all” eye emergencies.
There are some important caveats. Firstly, they have conducted a “strawman” comparison. SHOs are trainees, and should not be considered the main service providers in an Emergency Department. In the 1980s when SHOs made up the vast majority of clinical decision makers, it might have been appropriate to use them as a comparison. However, as medical service provision is increasingly at middle grade and consultant level, it is anachronistic to compare ENPs with SHOs.
Secondly, as trainees, SHOs are supposed to be supervised so that they learn and improve. If “all” eye emergencies were seen by ENPs and never by SHOs, then the next generation of specialists will have no experience of eye emergencies. Service provision will remain at the level of a better than average SHO. For a health service committed to excellence and specialist-delivered care, this would appear to be counter-productive.
It is vital that ENPs continue to develop their scope of practice, but this must not be at the expense of SHO training. SHOs, supervised by senior staff, must continue to be involved in the management of a full case-mix of all types of Emergency Department presentations. Instead of categorising certain conditions as “ENP only” there should be trans- disciplinary training and clinical supervision of both ENPs and SHOs by more experienced practitioners.
NICE head injury guidelines – the need for further studies before we judge them
There have been a series of articles recently published regarding the impact of NICE head injury guidelines and the rising cost implications.[1,2,3] One gets the impression that all NICE guidelines have done so far in the UK is to increase the number of CT scans but with no comment whether it has added positively to the high quality of service we intend to provide to head injury patients.
The studies published so far have extrapolated the guidelines onto patient data and produced figures for the extra number of patients that would have been scanned if the NICE guidelines were rigidly followed and stressed the importance of clinical judgement.[1,2,3] However we do not know for certain that the ones that were discharged out of these patients, who should theoretically have had a scan but did not, have any cerebral trauma because they were not followed up. Clinical judgements may vary a lot depending on the experience of the evaluating physician. In such circumstances who should make these decisions not to scan when they would have warranted one as per the NICE guidelines? Surely with these guidelines available to the general public and rising patient awareness, one would find it increasingly difficult in a court of law to defend such a decision if something actually went wrong.
The NICE guidelines intend to use CT as a screening test instead of skull x-rays and as with all screening tests it would be acceptable to have high sensitivities with a compromised specificity. Current literature does not give an idea of these figures in relation to the NICE guidelines and there have been no reports on the efficacy of the NICE guidelines as such. We know for sure that CT scan is a reliable and safe way of triaging head injury patients and the NICE guidelines have just reiterated this fact.
While I entirely agree that there is no substitute to an experienced clinician’s judgement in the actual management of head injuries I am not convinced we are right in criticizing these guidelines on the basis of the studies currently available.
1.Macgregor DM, McKie L. CT or not CT--that is the question. Whether 'tis better to evaluate clinically and x ray than to undertake a CT head scan! Emerg Med J. 2005 ;22:541-3.
2.Shravat BP, Hynes KA. The impact of NICE guidelines for the management of head injury on the workload of the radiology department. Emerg Med J. 2004 ;21:521-2.
3.Boyle A, Santarius L, Maimaris C. Evaluation of the impact of the Canadian CT head rule on British practice. Emerg Med J. 2004;21:426-8.
4.af Geijerstam JL, Britton M. Mild head injury: reliability of early computed tomographic findings in triage for admission. Emerg Med J. 2005;22:103-7.
Initial interpretation of head injury CT scans by A&E staff – the way forward?
Mucci et al. in their study have re-explored a possibility of scan interpretation by A&E staff, that is worth following up given the rising number of CT scans done for head injuries. The overall agreement and false negative rates demonstrated by the authors would be generally acceptable especially in the light of the fact that nothing that required a transfer to a neurosurgical unit was missed.
This system would work perfectly well if ‘permanent’ A&E staff were physically present in the department at all times to interpret such scans when they are done. However this is not always the case and if staff has to be called in for these purposes one would rather have a radiologist interpreting the scans rather than A&E staff primarily because the quality of neurosurgical response to emergencies depends on the reliability and completeness of the information received from referral hospitals. The present study was retrospective; I suspect a prospective study of a similar nature where the primary decision is taken by the A&E clinician out of hours and the scans later reviewed by a radiologist, would increase the false positives, decrease false negatives and increase both hospital admission rates and the amount of neurosurgical referrals, because A&E staff will be under pressure to be safe in their decision, which is not the case in a retrospective study where patients have been dealt with already. Also the aspect studied here is only trauma and the authors have rightly commented that skills in diagnosing medical conditions which might warrant a scan out of hours need further evaluation before this system can be implemented.
Teleradiology links to a neurosurgical centre is perhaps the best option, but these need to be rather robust and functional at all times to be effective. It results in more work for the neurosurgeons on duty, but unnecessary transfers can be avoided a better quality service can be provided for the whole area. Emergency image transfer system through a mobile telephone might be consideration for the future. What is more cost effective is something that needs some deliberation. I have no doubt that the authors idea is an excellent one and might be the way forward provided all A&E staff medical staff are properly trained.
1. Mucci B, Brett C, Huntley LS, Greene MK. Cranial computed tomography in trauma: the accuracy of interpretation by staff in the emergency department. Emerg Med J 2005;22:538-540.
2. Servadei F, Antonelli V, Mastrilli A, Cultrera F et al. Integration of image transmission into a protocol for head injury management: a preliminary report. Br J Neurosurg 2002 ;16:36-42.
3. Yamada M, Watarai H, Andou T, Sakai N. Emergency image transfer system through a mobile telephone in Japan: technical note. Neurosurgery 2003;52:986-8.
Response to Mucci's study of "ED staff’s interpretation of cranial CTs in trauma"
We read with interest Mucci’s study of the accuracy of interpretation by ED staff of cranial CTs in trauma. It is a topical subject that needs exploring, but we have questions with their design.
Firstly, their study was underpowered with only 100 scans examined. The quoted sensitivity of 86.6% has too low a 95% confidence interval (83.4% to 89.9%) to propose trusting the reliability of their ED staff interpretation of the CT scans. If these figures were translated into one scan been examined by one only reader, (which is more comparable to real-life practice) the corrected 95% CI would be 68.7%-94%. Is an error rate of more than 15% really acceptable?
We are concerned that multiple readers interpreted the same cases. They allude to Robinson’s findings about inter-observer variation, but they only studied the variability between radiologists interpreting plain radiographs. Can Robinson’s findings be extrapolated to inter-observer variation of ED staff interpreting CTs?
We are intrigued at the high proportion of ‘abnormal’ scans. Does the fact that skull radiographs are routinely done at their hospital suggest that only more injured patients are scanned, increasing the chance of having serious pathology, hence easier to identify on CT? If they scanned more patients would increasingly subtle abnormalities have been harder to detect?
Finally, we chuckled at the lack of conflicting interests. Would it be churlish to suggest radiologists would welcome any study that would reduce their out of hours workload?
Overall, we welcome Mucci’s paper, but suggest that they have placed too much significance on an underpowered study with considerable inter-observer variability. Further, larger studies are required (and are being performed) to answer this question more thoroughly.
1. Mucci B, Brett C, Huntley LS, Greene MK. Cranial computed tomography in trauma: the accuracy of interpretation by staff in the emergency department. Emerg Med J 2005;22(8):538-40.
2. Robinson PJ, Wilson D, Coral A, Murphy A, Verow P. Variation between experienced observers in the interpretation of accident and emergency radiographs. Br J Radiol 1999;72(856):323-30.
Andrew Hugman, Emergency Medicine SpR
Adrian Boyle, Emergency Medicine Consultant
Hills Road, Cambridge, CB2 2QQ, UK
Author's Reply: Emerging role comparisons
As the lead author of this paper I was glad to read the letters of Mason and Bilby who clearly add to the debate of how we should evaluated new and emerging roles.
To clarify our approach it must be understood that we were collecting data for this study in 2002, examining the role of four of the first ECPs in the country. We were asking the question 'if you change individuals roles (through training and the system of call out) what difference does it make to their practice'?
We took a multi-methods approach in that we used interpretist approaches (interviews and relective diaries)and a positivist stance in our comparison of ECP and paramedic roles. This was intended as a comparsion, the paramedics were not intend as a 'control' in any way.
We chose to compare roles, as at the time (2002) the 'crew room chat' was all about this new role with some holding the view that ECPs do little more than a good paramedic. In addition, as we mention in the discussion section of this paper, we may also have found that there was no difference, for example, in conveyance rates (paramedics v ECPs) which would have raised questions about the investment in the role.
The scene (2005) has now changed and ECPs do appear to be developing distinct and unique roles, so a comparsion with paramedics would indeed now be less relevant. In fact, in some current work we are now focussing on ECPs role in inter-professional collaboration, which in our provisional findings appear to be diverse, with many potential benefits for the patient.
Cranial computed tomography in trauma: The accuracy of interpretation by staff in the emergency dept
We read with interest the article Emerg Med J 2005;22:538-540 by Mucci, Brett, Huntley and Greene. In the methods section it mentions that the CT scans were reviewed retrospectively by five permanent members of the emergency department medical staff. We would be interested to know how these 5 members were chosen. Were there only five members of permanent medical staff in the acute Trust or were there other Consultants Associate Specialists or Staff Grades and why they were excluded from the study. Was it done randomly or was there a method. We suggest that the validity of the conclusion may be biased because individuals with greater knowledge than average might be more enthusiastic to participate in this study. We suggest that to demonstrate any validity all emergency department permanent medical staff in North Cumbria Acute Hospitals NHS Trust should have participated and preferably some other Trust also. We suggest that this study only demonstrates that five selected members of permanent medical staff in West Cumberland Hospital Emergency Department can safely interpret CT scans of the head in trauma patients.
In these days of heightened medico-legal awareness it is not just necessary to be able to do something, one has also to have been trained and updated and to prove one can read CT scans which has been the domain of the Consultant Radiologist. We suspect any mistake could prove very costly and the safe interpretation of a hundred images done in a study would not be considered adequate evidence of the knowledge to read CT scans.
Kilian Hynes MRCP FFAEM
Consultant in Accident & Emergency Medicine
Barnet Hospital, Barnet & Chase Farm Hospitals Trust
Barnet, EN5 3DJ,
Brijendra Shravat FRCSEd FFAEM
Lead Clinician and Consultant in Accident & Emergency Medicine
Barnet Hospital, Barnet & Chase Farm Hospitals Trust
Barnet, EN5 3DJ
Turan Huseyin FRCS FFAEM
Consultant in Accident & Emergency Medicine
Barnet Hospital, Barnet & Chase Farm Hospitals Trust
Barnet, EN5 3DJ
Transporting amputated digits for replantation
The article “Preoperative management of the amputated limb” presents a concise protocol for the management of the amputated limb.1 However the authors are concerned mainly with major limb amputations, such as the forearm or arm. Amputations of the digits are more common in clinical practice. Unfortunately, it is not uncommon for amputated parts to arrive in a microsurgical unit in an unsalvageable condition because of direct contact with ice and water.
The authors make the point that direct contact of the amputated part with ice may result in tissue damage akin to frost bite and suggest wrapping the limb in moist gauze before placing it in a chest containing crushed ice and water. We do not believe that this protocol emphasizes the importance of completely insulating the amputated part by placing it first in a plastic bag or container.2,3 Whilst the protocol described may be adequate for large amputated parts, for amputated digits we suggest a simple method using supplies readily available in all Accident and Emergency Departments.
The amputated part is wrapped in damp clean gauze and placed in a clean plastic bag (such as that used for transporting blood specimen tubes). This bag is then placed in a second plastic bag that contains crushed ice and water. This prevents not only tissue damage from direct contact with ice but also maceration from direct contact with water.
Mr Kamal El-Ali and Mr Christopher Dunkin
Department of Burns and Reconstructive Plastic Surgery Northern General Hospital, Sheffield S5 7AU
1. Preoperative management of the amputated limb M S Lloyd, T C Teo, M A Pickford, P M Arnstien Emerg.med.j. 2005;22:478-480
2. Lipton MA. Care of traumatically amputated digits. Letter. N Eng J Med. 1979 Sep 6;301(10):556.
3. Michalko KB, Bentz ML. Digital replantation in children. Crit Care Med. 2002 Nov;30(11 Suppl):S444-7
This article highlights the difficulties encountered in screening for possible CO exposure. Venous blood has been shown in several studies to be as 'accurate' as arterial for assessing COHb levels, but even this can be difficult, especailly in large groups of children.
There is a breath meter available (Bedfont Instruments 01634 375614) which gives a digital display of equivalent COHb levels after a single breath. It is used in a similar way to a 'breathalyser'. it is simple to use and calibrate, and easily accurate enough to screen out those who do not need more invasive investigation. It is also worth mentioning that COHb levels can be a very poor indicator of both degree of exposure, and likely outcome.
Alcohol and violence, time for a statement?
Goodacre's letter clearly describes the likely problems that are going to result from the changes in licensing legislation. Most emergency physicians are convinced of the dangers of passive drinking, even if our politicians are not. We need to make sure that we are collecting the simple and easily obtainable data about assaults that has been piloted in Cardiff. This data should be shared with the local Crime and Disorder Reduction Partnership.
While many organisations and professional bodies have expressed their concerns about these changes, our specialty has been remarkably quiet.[1,2] Should our association publish a position statement? After all, we will be bearing the brunt of this change. The focus of statements from healthcare has been on the medical and psychiatric aspects of increased drinking. It is surely right that we draw attention to the likely increased rate of injuries due to alcohol.
1. Royal College of Physicians http://www.rcplondon.ac.uk/pubs/wp_actnhsai_summary.htm
2. Her majesty's council of circuit judges http://news.bbc.co.uk/1/hi/uk/4134772.stm
Simpler thrombolysis decisions in patients with LBBB
I read the article by Reuben and Mann “simplifying thrombolysis decisions in patients with left bundle branch block” with considerable interest. This is a useful way of presenting the Sgarbossa criteria, which have high specificity for acute myocardial infarction (AMI). Unfortunately, however, these criteria are far too insensitive to exclude MI, being present in only 20% of patients with left bundle branch block (LBBB) and confirmed AMI.[2,3] It is therefore important that less experienced practitioners do not conclude that thrombolysis should be withheld if these ECG features are absent.
In fact, the simplest thrombolysis decision is that all patients with a history strongly suggestive of AMI and LBBB should receive thrombolysis, unless significant contraindications exist. Even the well-rehearsed medical myths relating to the age of the LBBB are of minimal relevance, as described in an elegant editorial referenced by the authors. Patients with left bundle branch block have the most to gain from thrombolysis, but are still failing to receive this highly effective therapy in too many cases.
In summary, therefore, where Sgarbossa criteria are seen on the ECG AMI is highly likely. However even in the absence of these features patients with a convincing history of AMI and LBBB should still receive thrombolysis, unless there are compelling reasons against.
1. Reuben AD, Mann CJ. Simplifying thrombolysis decisions in patients with left bundle branch block. Emerg Med J 2005;22:617-20.
2. Kontos MC, McQueen RH, Jesse RL, et al. Can myocardial infarction be rapidly identified in emergency department patients who have left bundle branch block? Ann Emerg Med 2001;37:431-8.
3. Li SF, Walden PL, Marcilla O, et al. Electrocardiographic diagnosis of myocardial infarction in patients with left bundle branch block. Ann Emerg Med 2000;36:561-5.
4. Gallagher EJ. Which patients with suspected myocardial ischemia and left bundle branch block should receive thrombolytic agents? Ann Emerg Med 2001;37:439-44.
5. Newby KH, Pisano E, Krikoff MW, et al. Incidence and clinical relevance of the occurrence of bundle-branch block in patients treated with thrombolytic therapy. Circulation 1999;94:2424-8.
We note with interest the comments on our report made by David Wood and colleagues at the Guy’s Poisons Unit. Our response to these is as follows.
The evidence for our conclusion is obtained from the literature on troponins as well as the two case reports by Mullins and ourselves. As troponin testing is relatively new and colchicine overdose a rare event it will take many years to build up more evidence on the predictive value of troponin testing in this setting.
Troponin is the marker of choice for cardiac injury and the enzymes creatine kinase and aspartate transaminase are non-specific for cardiac injury and less sensitive for detecting minor damage. Myocardial injury by anti-cancer drugs may be monitored using troponins.
In our case report there were no clinical features of cardiovascular involvement during the first two days after overdose and hence the impending myocardial collapse was not suspected.
We agree that rising troponin concentrations are not specific for colchicine induced damage and may be due to myocardial ischaemia from any cause including myocardial under perfusion.
A review of troponin elevation in critically ill patients concludes that even minor elevations are specific for myocardial injury but not for myocardial infarction. In another review, cardiac troponin I is regarded as a specific biomarker able to detect non-ischaemic cardiac damage in different clinical settings. Serial measurements of troponins are used in cardiology to predict outcome, a strategy we have illustrated is relevant in colchicine overdose and possibly other poisonings where cardiac toxicity is an issue.
We believe that our case report supports the conclusion reached by Mullins that early troponin testing in colchicine poisoning may be useful in alerting the clinician to impending cardiovascular collapse.
1. Malasky BR, Alpert JS. Diagnosis of myocardial injury by biochemical markers: problems and promises. Cardiol Rev. 2002 Sep-Oct;10(5):306-17. Review.
2. Sparano JA, Brown DL, Wolff AC. Predicting cancer therapy-induced cardiotoxicity: the role of troponins and other markers. Drug Saf.2002;25(5):301-11. Review.
3. Gunnewiek JM, Van der Hoeven JG. Cardiac Troponin elevations among critically ill patients. (Review) Curr Opin Crit Care. 2004, 342-6
4. Ni CY Cardiac Troponin I: a biomarker for detection and risk stratification of minor myocardiac damage. (Review) Clin Lab. 2001, 47, 483-92
5. Del Carlo CH, Pereira-Barretto AC, Cassaro- Strunz C, Latorre Mdo R, Ramires JA. Serial measure of cardiac troponin T levels for predication of clinical events in decompensated heart failure. J Card Fail. 2004 Feb;10(1):43-8.
Charles van Heyningen
Consultant Chemical Pathologist
Ian D. Watson
Consultant Clinical Scientist
Following human bites: Something more than antibiotics
Following human bites, the patient's history should include drug allergies, tetanus immunization status. HIV transmission has been noted only rarely after a human bite. Exposure to saliva alone is not considered a risk factor for HIV (or hepatitis) transmission. Transmission requires HIV- infected blood mixed in the saliva of the biter and a skin break on the victim. A 2005 Centers for Disease Control and Prevention recommendation states that post-exposure prophylaxis with a 28-day course of highly active antiretroviral therapy (HAART) should be used in such a situation.
Right upper lobe consolidation-a complication of uneventful endotracheal intubation
I was surprised to see the case report in the Sep EMJ of right upper lobe consolidation occurring after a general anaesthetic for an elective shoulder repair. My first thought was that it did not strike me as typical Emergency Medical Journal material, sounding more relevant to a journal such as Anaesthesia.
Having said that, as an anaesthetist I was interested to read the account, however, I feel that I should stick my neck out and suggest that perhaps the authors' conclusion may not be correct.
A CXR showing collapse would indeed suggest occlusion of the right upper lobe by the endotracheal tube. As stated, this may also occur with 'correct' positioning of the tube, when the upper lobe is arising from the trachea above the carina.
The chest x-ray in this case, however, showed consolidation, suggesting organisation/exudation. I would suggest that this is unlikely to occur during the time of the operation (whereas collapse clearly can occur rapidly). Given that most young fit ASA1 patients for elective limb procedures tend to get a rather cursory examination from most anaesthetists (usually limited to airway assessment), my suggestion is that the consolidation/pneumonia was actually present preoperatively.
Unless exerting himself, the patient may well have had no overt symptoms of consolidation of what appears to be the lower half of the right upper lobe. Following an hour or two of general anaesthesia he will inevitably have acquired dependent atelectasis of his lungs, as all patients do. This, along with increased atelectasis of the infected area, would have been sufficient for him to then show overt signs and symptoms in the recovery room.
Oxygen saturation in theatre may well be relatively normal with an FiO2 of 0.4 and 10ml/kg tidal volumes of positive pressure. During the wake up period prior to extubation, shallow spontaneous breaths under the influence of volatile anaesthesia and opioids may allow significant atelectasis to occur and hence reduced saturations following extubation.
As mentioned, if right mainstem intubation had occurred, both left lung and right upper lobe are very likely to show collapse on post-op CXR.
It is certainly worth reminding emergency department physicians who perform intubation infrequently that right mainstem intubation is a real possibility. It should be consciously avoided by observing tube length during insertion, bilateral auscultation and adequately securing the tube in position. Right main stem intubation must always be ruled out in the event of poor oxygenation.
In this case, however, I believe that right upper lobe consolidation did not actually occur as a complication of uneventful endotracheal intubation.
Roles for Emergency Nurse Practitioners
Emergency Nurse Practitioners are an invaluable part of any Emergency Department. However in the abstract in the EMJ, the study by Ezra et al. does not account for differences in the ophthalmological training between the ENP and SHO cohorts, giving a erroneous impression.
As the authors point out in their conclusions, there are marked differences between the training of these two groups. Ophthalmology training in UK medical schools is patchy at best, usually consisting of one or two week’s attachment.
Therefore the study cannot be used to justify the use of Emergency Nurse Practitioners instead of Senior House Officers until they are assessed after equal training.
Dear Editor Fleming et al. state in their article that this may be effective in detecting hypertension in the urban poor for whom the Emergency department is their sole source of freely avaliable healthcare. Is it then likely that these individuals are going to be effectively managed seeing as they seek Medical advice on such an adhock basis? Will they comply with their treatment and who is going to monitor it? Is it now the job of Emergency Physicians to take on another General practice role? Clearly this artcle is only relevant to a very specific population surrounding a big teaching hospital in an ethnically diverse metropolis and further studies will have to be done as to it's relevance for the population surrounding a DGH in rural Suffolk!
SOCRATES episode II
Thank you for your letter. I am delighted that there have been significant additions to the Cochrane Database of Systematic Reviews (CDSR) and indeed some alterations to the original reviews since the SOCRATES series was first accepted for publication. The SOCRATES series was aimed at highlighting the very useful resource that is available in the CDSR. As you are aware SOCRATES the series arose out of a study into the applicability of the information in the CDSR to Emergency Medicine. The fact that there have been changes to the CDSR and new additions since we performed the original study is hardly a surprise. As you will be aware there is often a significant delay between performing a study and the paper appearing in print particularly if the paper is the last in a large series.
We have already put together a new group of SOCRATES reviewers with the intention of producing SOCRATES Episode II and this will involve looking at the most recent additions to the CDSR. Thank you for your work with the Cochrane Library and for your suggestions.
Use of a template to improve the management of distal radial fractures
We congratulate Kotnis et al. on their clear and well-structured paper further substantiating safe guidelines for whether or not to reduce a displaced Colles fracture.
It is always in our patients’ best interests to have consistency of management with our orthopaedic friends, remembering the high turnover of junior staff in both our specialities.[2,3]
However, Professor Rolfe Birch (Consultant Orthopaedic Surgeon, RNOH Stanmore, who ran the AED at St Mary’s, Paddington, prior to my arrival 20.7.86) and I, devised and implemented this template in 1986, as the ‘Mary’s Ready Reckoner’, see Figure.
This is freely available - as a transparency - on request:
Accident and emergency
St Mary’s Hospital
1. Kotnis R, Waites MD, Fayomi O, Dega R. The use of a template to improve the management of distal radial fractures. EMJ 2005;22:544-547.
2. Touquet R, Fothergill J, Fertleman M, McCann P. Ten clinical governance safeguards for AEDs. Clinical Risk 1999;1:44-49.
3. Touquet R, Fothergill J, Henry JA, Harris NH. Accident and Emergency Medicine, In Clinical Negligence, Eds Powers MJ, Harris NH, 3rd edition, Butterworths 2000.
Figure: Mary’s Ready Reckoner
The need for up-to-date evidence summaries
As an author of several Cochrane reviews in the management of distal radial and proximal femoral fractures (two of which featured in SOCRATES 6), I am pleased to see this initiative. I have some concerns, however, that the sample of reviews is outdated (2000 & 2001) and also that several of the reviews featured have been superseded by versions presenting important new evidence and sometimes revised conclusions.
The most recent issue of the Cochrane Library (Issue 3, 2005) has 2435 reviews of which 79 were new to the issue. A further 54 reviews had been revised and updated to such an extent that people who read an earlier version should look at the new one. I thus suggest that emergency physicians would be better served by commentary highlighting reviews in the current or at least a much more up-to-date version of The Cochrane Library.
CRP is not a useful investigation
Huntley and Kelly neatly illustrate the prevailing approach to the use of investigations in clinical practice in their case report in the most recent edition of the EMJ. (C reactive protein a valuable acute investigation. A case of pneumococcal meningitis presenting as ankle pain).
They eschew reason in favour of randomness, and when an occasional result proves positive, congratulate themselves on their foresight.
Their patient had two X-rays of the ankle, in the absence of any physical signs: they were normal. This did not stop an attempt at aspiration. Other than the CRP, her blood tests were normal: repeating them did not help. The basis upon which a head CT was performed is not clear, as her relevant physical signs are clearly described as negative. Kernig’s sign does not accurately discriminate between patients with meningitis and those without.
The evidence for “precipitant sepsis” appears weak, as she became only moderately unwell, and that was shortly after the intravenous injection of penicillin. Consideration of a cause other than sepsis appears to have been neglected.
We must insist upon a reasoned approach to the use of investigations, remembering that:
- The primary purpose of investigations is to rule in or rule out a diagnosis suggested by the clinical findings.
- The secondary purpose of investigations is to assess disease severity, plan treatment and monitor the effects of such treatment once a diagnosis is made.
- This requires an estimation of the predictive of value of the test based on its sensitivity and specificity for the diagnosis being considered. One can then confirm or exclude a diagnosis with confidence and accuracy.
The authors of this case report may be fortunate in having picked up a most unusual presentation of what is assumed to be pneumococcal meningitis, but fail to mention the large number of patients who are disadvantaged by having inappropriate, wasteful and time consuming investigations, the results of which are commonly misinterpreted by the investigator. We should also remember that an unjustified investigation can be considered an assault upon the patient, and informed consent is not valid if the information is erroneous.
Please remember the old injunction that we should ‘first do no harm’, or at least watch Hugh Laurie in action on channel 5’s “House” – he appears to understand evidence-based medicine!
Dr Dyfrig Hughes
Consultant and Hon Senior Lecturer
1. Thomas, K E et al. Clin Infect Dis July 1, 2002;35:46-52. Accuracy of bedside examination for meningitis.
We welcome the recent comments from Dr Chiquito-Lopez but despite the difficulty in correctly diagnosing this condition we would re-iterate our belief that needle thoracocentesis is sometimes performed indiscriminately and its use should be limited – a view shared by other authors.[1-5] The decision relating to whether or not to immediately decompress a suspected tension pneumothorax depends on whether the patient is still compensating (more likely if spontaneously ventilating than if ventilated) and the only absolute indication is decompensation. We would stress that an awake, tachypnoeic, normotensive patient is still compensating. Box 7 of our review along with the sections on needle thoracocentesis and tube thoracostomy in the article main text and summary provide further discussion on this.
We are firm advocates of taking an immediate CXR in all spontaneously ventilating patients who may have a tension pneumothorax but who are compensating. We agree that the concept of "the chest radiograph that should never have been taken" has encouraged unnecessary blind treatment of patients who may still be compensating well and many of whom may not even have a pneumothorax.
A fuller review of the complications of tube thoracostomy was not possible given the constraints of the article. We therefore gave similar references to those cited by Dr Chiquito-Lopez as well as mentioning the important complications in the section on tube thoracostomy in the article along with box 10.
1. Trauma.org. Needle Decompression - discussion forum. http://www.trauma.org/archives/ncdeco.html 1997:(accessed apr 2004).
2. Trauma.org. Needle Thoracostomy - discussion forum. http://www.trauma.org/archives/needlethoracostomy.html 2003;8(2):(accessed apr 2004).
3. Cullinane DC, Morris JA, Jr., Bass JG, Rutherford EJ. Needle thoracostomy may not be indicated in the trauma patient. Injury 2001;32(10):749-52.
4. Etoch SW, Bar-Natan MF, Miller FB, et al. Tube thoracostomy. Factors related to complications. Arch Surg 1995;130:521–5, 525–6.
5. Bjerke H. Tension pneumothorax. Emedicine Specialities, 2002. (http://www.emedicine.com/med/topic2793.htm).
6. S Leigh-Smith, Harris T. Tension pneumothorax-time for a re-think? Emerg Med J 2005; 22 (1): 8-16.
Revision for flow chart - figure 3
I read this article by A Reuben and C Mann with interest and congratulate them on their approach and success with this work. They have succinctly clarified a decision tree which previously took some mental effort to navigate.
The heading for the third box in the middle of figure 3 should read ST depression > 1mm rather than as stated elevation.
While this undoubtedly represents a typing error and is clear both from Sgarbossas own criteria and from the rest of the article, I felt it worth highlighting in case readers considered the flow chart in isolation.
Screening for hypertension in the ED
I read with interest the paper by Fleming et al., concerning screening for hypertension in the Emergency Department. The significant Public Health issues and current emphasis on screening are well illustrated in this paper.
However, there is increasing debate concerning the appropriateness of routine enquiry, as debated in the commentary by Lee. If screening for a condition is warranted it should, at least approximately, fulfil the Wilson Criteria. The diagnosis of hypertension fails to meet these criteria in a number of important regards.
Firstly, the end point of screening is to establish the diagnosis in order that prevention of an adverse end point is achieved on a population basis. In this paper only 2.5% of patients’ General Practitioners were directly informed of the diagnosis, and there is no data on the clinical results for these patients. The screening has become an end (to achieve diagnosis) not a means.
Secondly systematic testing of a population for hypertension should be performed on a continuous and total basis, and this paper reveals that this is difficult to achieve.
Lastly, the case-finding needs to be economically balanced in relation to diagnosis and treatment and possible total health care expenditure, and this is not discussed.
While universal screening for hypertension in the Emergency department may not be appropriate for the reasons above, or desirable for reasons related to service configuration, targeted screening for an essentially asymptomatic disease will fail almost be definition. This is not to say, however, that opportunistic detection in the Emergency department is not appropriate.
Consultant in A&E
1. Fleming J, Meredith C, Henry J. Ddetection of hypertension in the emergency department. Emerg Med J 2005; 22: 636-9.
2. Lee J. Should emergency departemtns really be screening fro hypertension? Emerg Med J 2005; 22: 640.
3. Wilson JMG, Junger G. Principles and practice of screening for disease. Geneva: World Health Organisation, 1968. (Public health papers No 34).
Re: Paramedics and thrombolytic treatment
We would like to thank Professor Quinn for his letter supporting the conclusions of our paper and providing clarification of the referencing.
We are happy to provide the questionnaire to paramedics and “correct answers” for our paper. The evidence for the answers at the time was based on information on in-hospital thrombolysis and has now been surpassed by the ASA audit information with the lower risk of serious adverse incidents for pre-hospital thrombolysis (which should provide greater reassurance to paramedics undergoing thrombolysis training and education).
I have sent the questionnaire which includes the answers. The document is in the same format as that used to feedback to the WYMAS paramedics in the WYMAS "Insight" in house publication. The answers are highlighted with the relevant references included.
1. Paramedics and thrombolytic treatment. Tom Quinn. Emerg Med J, 2 Aug 2005. http://emj.bmjjournals.com/cgi/eletters/22/6/450#600
2. J Humphrey, A Walker, T B Hassan. What are the beliefs and attitudes of paramedics to pre- hospital thrombolysis? A questionnaire study. Emerg Med J 2005;22:450-451.
Neck pain and torticollis in adults - a cause for alarm
I read with interest the short report by Dr Natarajan.
We need to be aware of such sinister pathologies even when dealing with adult patients presenting with neck pain and deformity e.g. torticollis. Many a times, the x-ray picture is normal. It is the persistence and worsening of symptoms which prompts the clinician to investigate.
I was involved in the management of a middle age man who presented with persistent neck pain, torticollis and earache. He had to support his head with his hands to relieve the pain. Initial x-rays were normal and it was further investigations with CT and MRI that revealed an abscess involving C2 to C4 vertebrae. In retrospect the large soft tissue swelling seen on the initial x-rays was identified. The patient underwent debridement and stabilization and made full recovery.
Neck pain with torticollis of acute onset is always a condition which needs thorough investigation and management.
The case report  by Chen et al was very informative and explains how an unusual presentation of acute pancreatitis can be a challenge in a busy Emergency Department (ED).
Recently we came across an interesting case of a 59 year old, male patient with right sided flank pain and fever which very well fitted with a diagnosis of pyelonephritis. While assessing a patient with flank pain all possibilities should be considered which are relevant anatomically.
Our patient presented to the ED with right loin pain for 2 days associated with vomiting on and off. He described the pain as a dull ache and was also associated with sweating and shivering. Initial blood tests showed a raised white cell count 18.9 (Normal-3.8-11) and CRP >200 (Normal-0-10 mg/l). Urine dipstick was positive for nitrite and blood. With a tentative diagnosis of pyelonephritis patient was referred to the medical team, but the surgical team was also involved to rule out intraabdominal pathology
Serum amylase was 1808 (Normal-30-125), and a diagnosis of acute pancreatitis was made. Though an elevated amylase in acute setting does not have a diagnostic implication, subsequent ultrasound and CT of the abdomen showed gallstones with normal biliary tract and extensive inflammatory stranding around the entire pancreas with moderate peripancreatic free fluid. Patient was treated conservatively with a plan for a laparoscopic cholecystectomy.
Acute Pancreatitis was last of the possibilities in the initial evaluation, as he did not have any epigastric pain, back pain, history of alcohol consumption, jaundice or gallstones. He was a known diabetic started on insulin recently because of poor control of diabetes and hypertensive
This, we believe is quite an unusual presentation compared to the case report by J-H Chen et al. as patient with left flank pain can have a possibility of pancreatitis with involvement of tail of pancreas. Our patient had a totally obscure picture where the right flank was involved with urinalysis in favour of infection although blood and urine cultures did not show any growth. Both these cases emphasize the need to keep an open mind in an emergency setting, to astute clinicians examining patients with abdominal pain in grey areas such as flank, loin and groin. Also it would be interesting to know if the amylase levels in the reported patient were raised on subsequent blood tests.
1) J-H Chen et al, Emerg Med J 2005; 22:452-453
A.B. Reddy, Senior House Officer, General Surgery
C. Kaliaperumal, Senior House Officer, ED
Mr G. T. Manivannan, Consultant, ED. Wycombe General Hospital, High Wycombe.
Using up to date evidence
I agree with the sentiments of Dr Williamson treat the patients not the x-ray. Another important point is the method of analgesia. Intravenous regional anaesthesia is often a superior technique compared to the haematoma block for analgesia and will make the reduction easier. This could also have been done on the patients admitted from fracture clinic still avoiding the need for a general anaesthetic.
CRP in the Emergency Department
I read with interest the report of a case of pneumococcal meningitis presenting as ankle pain. Although it discussed the management of an interesting and highly unusual patient, I found it hard to follow the logic of the conclusion that "CRP is an important investigation for emergency departments".
As the authors state, C-reactive protein is an acute phase protein. Levels of CRP are elevated in the serum of patients with acute and chronic inflammatory, infective and neoplastic disorders. A recent systematic review by van der Meer et al. examined the evidence pertaining to the contribution of CRP in patients with lower respiratory tract infections (such as pneumococcus). They found that in 12 studies reviewed the relationship between an elevated CRP and a bacterial aetiology of the infection was poor: sensitivity ranged from 8-99% and specificity from 27 -95%. Other studies in which CRP has been used as a diagnostic tool for other conditions have echoed these findings.
An audit performed by myself in a large teaching hospital Emergency Department found that between 250 and 500 CRP studies were being requested per month. These were being requested indiscriminantly for the full spectrum of presenting conditions, from chest and abdominal pain to one patient that presented with a stab wound! Although individual tests were relatively cheap, because of the numbers being requested the total annual cost to the department was almost £13000. As a literature review at the time found no evidence to support the use of CRP in the ED, departmental policy was altered to prevent the requesting of CRP as routine.
I suspect even the most skilled of Emergency Physicians may have found the diagnosis of pneumococcal meningitis based on a presentation of ankle pain difficult, with or without a CRP result. As CRP lacks the diagnostic specificity to be of help in the initial assessment of the patient, I feel that it is misleading to advocate its widespread use based on this case alone.
1. Huntley JS, Kelly MB C-reactive protein: a valuable acute investigation. A case of pneumococcal meningitis presenting as ankle pain Emerg Med J 2005;22:602-603
2.van der Meer V, Neven AK et al Diagnostic value of C reactive protein in infections of the lower respiratory tract: a systematic review BMJ 2005;331:26-9
Serial Troponin-I measurements are unlikely to be useful in acute colchicine toxicity
van Heyningen and Watson reported a case of acute colchicine poisoning, associated with significant cardiovascular compromise, with elevated troponin-I concentrations, resulting in death. Elevation of cardiac troponin concentrations in acute colchicine toxicity has been previously reported. The authors concluded that in future cases serial 12 hourly troponin measurements should be undertaken in acute colchicine toxicity to predict cardiovascular collapse; however they do not provide evidence for this conclusion.
The basis for the author’s assumption for serial measurement of troponin-I concentrations in acute colchicine poisoning, is that troponin concentrations rose in line with clinical deterioration of their patient. However they report in Table 1 that creatinine kinase and aspartate transaminase, alternative markers of myocardial injury, were also elevated in line with the patients deterioration. In addition to elevation of other biochemical markers of myocardial injury, there is clear history of clinical deterioration and impending myocardial collapse
It seems unclear why the authors have focused on serial troponin-I measurements rather than other biochemical or clinical indicators of cardiovascular collapse. Elevated troponin concentrations not only reflect myocardial ischaemia in the context of underlying coronary artery disease. The finding of raised troponin-I concentrations is not unique to colchicine poisoning and may be found in any patient subjected a severe systemic insult secondary to poisoning, trauma, sepsis, or any other condition causing poor myocardial perfusion. In acute colchicine poisoning hypovolaemia, hypotension and poor myocardial perfusion can result from colchicine-induced nausea, vomiting, diarrhoea and cardiac arrhythmias. Elevation of troponin concentrations probably reflects these clinical features rather than direct colchicine toxicity itself.
Raised troponin-I concentrations may indicate a "sick heart" following overdose of colchicine, however this is neither unique in terms of severe poisoning, or likely to be clinically helpful in guiding provision of the meticulous supportive care indicated for these patients.
1.van Heyningen C, Watson ID. Troponin for prediction of cardiovascular collapse in acute colchicine overdose. Emerg Med J. 2005 Aug; 22(8): 599-600
2.Mullins ME, Robertson DG, Norton RL. Troponin I as a marker of cardiac toxicity in acute colchicine overdose. Am J Emerg Med. 2000 Oct; 18(6): 743-4
3.Jeremias A, Gibson CM. Narrative review: alternative causes for elevated cardiac troponin levels when acute coronary syndromes are excluded. Ann Intern Med. 2005 May 3; 142(9): 786-91
David M Wood
Specialist Registrar in Clinical Toxicology
Shaun L Greene
Associate Specialist in Clinical Toxicology
Paul I Dargan
Consultant Clinical Toxicologist
Alison L Jones
Director and Clinical Toxicologist
Guy’s Poisons Unit
Guy’s and St Thomas’ Hospital NHS Foundation Trust
Paramedics and thrombolytic treatment
I enjoyed reading the paper by Humphrey et al. exploring paramedics' perceptions of their emerging role in providing early thrombolytic treatment in acute myocardial infarction.
There are some areas requiring clarification however. The NHS Plan did not precede publication of the coronary heart disease National Service Framework (NSF), as stated (the NSF was published in March 2000, the NHS Plan the following July). The consideration of pre-hospital thrombolysis where call-to-hospital arrival time delays exceed 30 minutes was taken from the European Society of Cardiology and European Resuscitation Council guidelines  published some years before either the NSF or NHS Plan, and informed both policies. The 'golden hour' referred to in Humphrey et al.’s paper  is in fact a 60 minute call-to-needle time NSF (and European ) standard whereas the true 'golden hour' is measured from the onset of symptoms rather than the time of call for help. Clearly the aim is to start treatment at the earliest safe opportunity.
The authors set out in their table the 'correct' answer to the questions put to paramedics in the questionnaire, but readers are not given the opportunity to see for themselves the evidence on which these 'correct' answers were based, nor was the questionnaire provided for comment or critical appraisal by readers. The availability of both supporting documents on the EMJ website would have added to the value of what is an important and informative paper, the central conclusions of which - that paramedics should be more engaged in the development of new policies and service improvements - are entirely in concert with the views of this reader.
1. Humphrey J, Walker A, Hassan B What are the beliefs and attitudes of paramedics to prehospital thrombolysis? A questionnaire study. Emerg Med J 2005;22:450-451.
2.The pre-hospital management of acute heart attacks. Report of a Task Force of the European Society of Cardiology and the European Resuscitation Council. European Heart Journal 1998;1140-1164.
3. Boersma E, Maas ACP, Deckers JW, Simoons ML Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet 1996;348: 771-775.
It is unfortunate that while we are trying to raise our profile amongst our colleagues the journal continues to allow the use of the term 'casualty department' by our colleagues in other medical specialties!!!
Treating x-rays not patients
I was very disappointed to read R Kotnis et al.'s article on the manipulation of distal radial fractures. They have based their entire article on outdated evidence and opinion that these fractures all require manipulation (their references 4,7,8,10,11). They have ignored more recent, and frankly much better, evidence (their reference 9) that we should have much greater tolerance of displacement in these fractures, particularly in older patients.
They would have been much better employed researching the functional outcome of patients with these fractures rather than trying to treat their x-rays.
Tension pneumothorax - time for a re-think?
I have two comments to make to the interesting and stimulating article by S Leigh-Smith and T Harris on tension pneumothorax.
1. The number of needle thoracocentesis far exceeds the incidence of tension pneumothorax because it can be difficult to distinguish this condition from a large or even moderate size pneumothorax presenting with rapid respiratory or haemodynamic deterioration in patients with poor cardio-respiratory reserve. The concept of: "the chest radiograph that should never have been taken" may also play a role, as it encourages urgent decompression before the diagnosis is confirmed, even in patients that could have tolerated a short delay and benefited from the chest x-ray. However, this is not an easy decision to make and most would err on the side of caution.
2. Recognized complications associated with the procedure of tube thoracostomy were omitted. Tube blockages, kinks and inadequate positioning within the pleural cavity can cause tube malfunction, which is associated with incomplete evacuation of collections and poor lung re-expansion, variables that predispose to empyema, clotted haemothorax and lung entrapment.[2,3] Non therapeutic tube insertions , accidental removals of the tube and excessive pain during the procedure are also significant complications.
1. S Leigh-Smith, Harris T. Tension pneumothorax-time for a re-think? Emerg Med J 2005; 22 (1): 8-16.
2. Millikan JS, Moore EE, Steiner E, et al. Complications of tube thoracostomy in acute trauma. Am J Surg 1980; 140: 738-741.
3. Fallon WF. Post-traumatic empyema. J Am Coll Surg 1994; 179: 483- 491.
4. Schmidt U, Stalp M, Gerich T, et al. Chest tube decompression of Blunt chest injuries by Physicians in the Field: Effectiveness and Complications. J Trauma 1998: 44 (1): 98-101.
Re: incorrect table
We would like to thank our colleagues from St Vincent's Emergency Department. They are right about the error in table IV. At 20 minutes places of systolic and diastolic pressures were exchanged.
Thank you for your interest,
Dr. Zulfi Engindeniz
Treatment of epistaxis in the ED
I read with interest Leong et al.’s article on the management of epistaxis and I would like to add some tips that I would consider useful.
In the treatment of ‘active’ anterior epistaxis, merely spraying the anterior cavity with a combination vasoconstrictor and local anaesthetic is often not enough to stem the bleeding. Using cotton wool, one can form a wick of about five cms long, and, after soaking it in a solution of constrictor / anaesthetic, apply it with a Tilley’s forceps into the bleeding nasal cavity. Ask the patient to apply digital pressure to the nose for about ten minutes. The increased contact to the bleeding point in Little’s area is more likely to stem the bleeding, and can then be localized and cauterized.
The ‘scorched earth’ technique of cauterizing a general area in the hope of stopping the bleed is not to be entertained, as there is increased risk of septal cartilage necrosis. Using a torch and not a headlamp, and failure to use a nasal speculum contributes to the aforementioned. If a bleeding point cannot be identified, cautery should not be attempted. The origin of the bleed might be posterior.
It is advisable to discharge patients with anterior epistaxis (that have been successfully treated) with an ointment/cream. If your department does not have Naseptin, one can advise the patient to put Vaseline on a cotton bud, and gently roll it onto the affected area couple of times a day. This stops the scab from drying out, becoming itchy and then picked off prematurely, leading to rebleeding.
The digital pressure applied to the nose in figure 1(B) is better applied with the fingers in a flexed, fist-like position and the dorsal aspect of the middle phalanx of the index finger resting on the maxilla. The pinch action is then completed by applying the palmar aspect of the interphalangeal joint area of the thumb to the lower part of the nose on the other side.
1. S.C. Leong, R.J. Roe, A. Karkanevatos. No frills management of epistaxis. Emerg Med J 2005;22:470- 472.
The EFAST for post-traumatic pneumothoraces
We appreciate both the effort towards and the conclusions of the recent Best evidence topic report (BET) by Jaffer and McAuley that concluded that bedside clinician-performed ultrasound may detect post- traumatic pneumothoraces. We hope to take the opportunity to follow up on their comments. In terms of methodology, the CT radiologists were blinded to the results of the US. Most importantly, all US studies were performed as the first imaging study, prior to the availability of any other imaging information. It is a very minor point to note that the country of the study should be Canada. We completely concur that further studies regarding the integration of these techniques into the trauma resuscitation are warranted.
Great article but do all packed noses need admission?
I congratulate the authors on the excellent step by step guide to management of epistaxis. A useful guide for juniors to use.
From my experiences in my previous post in Perth, I would disagree that all patients who need packing have to be admitted. Patients who either ourselves or ENT had packed and had no further postnasal bleeding, and were deemed safe for discharge, were sent home to be reviewed for pack removal in 24 hours. If patients are given safe discharge instructions is there a reason to routinely admit this group?
Re: complications following attempted rapid sequence intubation
Dr. Hulme raises several important points. First, Rapid Sequence Intubation is not to be taken lightly even by experience physicians. It is fraught with danger that can be disastrous.
Second, I fully acknowledge that the second dose of succinylcholine should not have been given, but do not feel that this would have played out any differently. This patient had been loosing his airway even before attempted RSI, and would have required one form of definitive airway. As stated in the article, several attempts by the Attending Anesthesiologist at nasal intubation were also unsuccessful.
I also acknowledge that Malignant Hyperthermia should be considered in the differential diagnosis for massester spasm. However, as stated in the discussion, this patient had no other cardinal manifestations of MH. Unfortunately no biopsy was performed, so we will never know if he was susceptible or not.
Finally, discontinuing anesthesia is appropriate during elective procedures (as stated in the article), however this is not always prudent in emergent cases.
MAJ (Dr.) Steven Bauer
Targeting the Targets
In his recent letter to this journal, Dan Ellis writes regarding the growth of See and Treat "the public perception of see and treat will be that it is acceptable to come to the emergency department instead of going to your GP". He continues that we in emergency medicine "are trying to persuade the public that only emergencies should come to emergency departments".
Another key element is that the increase in primary care type attendances to Emergency Departments (ED) are subject to the 4-hour emergency care target.
We, along with most other EDs continue to see a steady rise in attendances. In the second quarter of this year (April-June 2005) our ED saw an increase of 8% compared to the same quarter in 2004. The increase in the number of patients with primary care problems is particularly apparent at the weekend. Procedures for the redirection of such patients to primary care are incomplete, so ED doctors and ENPs are having to assess these patients. These patients obviously fall within the 4-hour target and on occasions great pressure is exerted to distort clinical priorities in order to achieve the target.
How many other specialties are faced with targets that do not specify the patient group? At the very least, GPs and cancer specialists have an obligation to see only urgent requests for appointments in their respective prescribed time frames. Surely it would not be unreasonable to define what constitutes an "emergency" and then limit the 4 hour target for emergency care to that patient group. This would help relieve the mounting pressure on EDs and perhaps deflect some of the pressure to provide primary care services back to primary care service providers.
1. Ellis DY. "See and treat" is great - if you’re a general practitioner. Emerg Med J 2005; 22:234
Herpes Zoster in HIV infected: two first reports (old) of unusual complications
Having read the interesting, detailed and very well written case report by Goddard R , I was reminded of two very unusual manifestations of herpes zoster that had also led me to search for underlying HIV infection. In a patient with HIV infection, herpes zoster can manifest in dramatic manner, that maybe not that well known.[2,3] First is about a patient who had developed herpes zoster rash over T5-6 (RT), which was confirmed by serological tests and Tzank smear. HIV test was also found positive. While in hospital, three days after appearance of herpetic rash, the patient had complained of a vague chest discomfort with giddiness, when a muffled first heart sound along with bradycardiaand non- specific ST-T ECG changes were detected. His ESR, that was 02mm initially, was now detected at 85 mm. Simultaneously the cardiotropic enzymes were studied which also showed elevation and slow return to baseline along with the ESR, consonant with the recovery of this patient.
The next unusual manifestation seen with herpes zoster was that of dermatomal and disseminated rash, afflicting a HIV infected patient , whose HIV status once again came to light following his unusual presentation like in the earlier case above. Both these patients survived their presenting illnesses (despite my best efforts). They received an antibiotic cover for prevention of secondary infection, along with symptomatic therapy and multivitamins, and no cardiac drugs or antivirals were given. Facilities for determining CD4/CD8 counts were not available. They were kept under very close observation and bed rest, with measures ready to intervene if need be.
Dr. Rajesh Chauhan. MBBS, DFM, FCGP, ADHA, FISCD, FAIMS. Consultant, Family Medicine & Communicable Diseases.
Dr. Akhilesh Kumar Singh MBBS, MD.
Dr. Parul Kushwah MBBS, MISMCD.
1. Goddard R. The reawakening of a sleeping little giant. Emerg Med J 2005; 22: 384-86.
2. Myocarditis in Herpes Zoster. Chauhan R, Singh RP, Hooda AK et al. JAPI 1996; 44(6): 427-28. (PubMed; PMID: 9282569).
3. Dermatomal and disseminated Varicella Zoster lesions in a HIV infected individual. Chauhan R, Singh RP, Hooda AK, Vadhera V, Singh VP, Mabena DMS. MJAFI 1996; 52: 55-6 (IndMed) (http://medind.nic.in/cgi/siss.pl?plrd+MFN-017308).
Complications following attempted rapid sequence intubation
The case report by Bauer et al. highlights that problems occur following rapid sequence induction (RSI) and may lead to invasive procedures. These can cause harm to the patient.
There are other lessons to be learnt that the authors have not elaborated upon.
The presence of fasciculations and flaccid paralysis following the first dose of suxamethonium indicated the onset of the expected effect.
Despite masseter spasm, the patient could be easily ventilated with a bag and mask. Subsequent deterioration in oxygenation after some time resulted in a surgical airway.
A significant learning point omitted from the authors' summary was the administration to this patient of a second dose of suxamethonium in the presence of masseter spasm. This should not have occurred for two reasons.
1. Masseter spasm is an early sign of malignant hyperpyrexia (MH), which has a mortality rate even with dantrolene of around 5%. Suxamethonium is a significant precipitant in susceptible individuals.
2. Repeated doses of suxamethonium change the paralysing effect of the drug from one that wears off within 3-5 minutes ("Phase I block") to one resembling a non-depolarising neuromuscular block ("Phase II block") which lasts significantly longer. It has been long established that this type of block may begin at doses of 2mg/kg.
The appropriate action when unable to intubate, is to maintain oxygenation, call for experienced help and strongly consider terminating anaesthesia. In this case, the need for a surgical airway may well have been avoided.
Repeated doses of suxamethonium can disproportionately extend the duration of paralysis and may add to a developing, potentially fatal condition (MH) caused by the first dose.
The process of inducing anaesthesia and paralysis is not usually as difficult as dealing with the problems that may arise if things do not go smoothly. Practitioners should be aware of the adverse effects of drugs they are using and be able to instigate appropriate methods of dealing with problems before undertaking RSI.
1. Bauer SJ, Orio K, Adams BD. Succinylcholine induced masseter spasm during rapid sequence intubation may require a surgical airway: case report. Emerg Med J 2005; 22: 456-458
2. Lee C. Dose relationships of phase II, tachyphylaxis and train-of- four fade in suxamethonium-induced dual neuromuscular block in man. Br. J. Anaesth., Aug 1975; 47: 841 – 845.
3. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Henderson JJ, Popat MT, Latto IP, Pearce AC; Difficult Airway Society. Anaesthesia. 2004 Jul;59(7):675-94.
Focused emergency ultrasound
As a radiologist, I read with interest the recently published paper by R McLaughlin et al concerning emergency department ultrasound. At the time the article was written, there has been an absence of agreed UK accreditation guidelines. However, recently the Royal College of Radiologist has published ultrasound training recommendations for medical non radiologists. This included Focused Emergency Ultrasound (FEU). Recommendations of training included both theoretical (physics, techniques, anatomy and pathology in relation to ultrasound) as well as practical aspects, which lead to three levels of competency.
There are certainly benefits of FEU but it is important to be aware of the limitations. It is primarily used to answer specific questions. For example, to look for pericardial/pleural effusions, abdominal aortic aneurysms, abdominal free fluid and deep vein thromboses.
There is also the risk of misdiagnosis. Would the practitioner recognise other causes for abdominal pain when scanning for abdominal aortic aneurysm or other causes of leg swelling (for instance Baker’s cyst or a soft tissue sarcoma) when scanning for DVT?
Therefore, education by an experienced radiologist is essential. Training should be adequately funded so that this does not adversely affect the service provision to patients and the training of radiologists and sonographers. Finally, it is important to audit this type of service to ensure and maintain high clinical standards.
1. R McLaughlin, N Collum, S McGovern, C Martyn and J Bowra Emergency department ultrasound (EDU): clinical adjunct or plaything? Emerg Med J 2005; 22:333-335.
2. The Royal College of Radiologists. Ultrasound Training Recommendations for Medical and Surgical Specialties. Jan 2005 http://www.rcr.ac.uk/index.asp?PageID=310&PublicationID=209.
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Among patients with minor TBI (GCS 13-15) getting CT scans ≥ 24 hours after injury, what proportion have a traumatic finding?
0.5% - 43% response rate
3% - 41% response rate
10% - 16% response rate