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 p...
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
References
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.
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[1]. Acute paronychia is one
of the most common infections of the hand. Far from being a simple
digital abscess, acute paronychia represents a dynamic...
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[1]. 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[2].
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.
References
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.
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...
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.
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.
We note with interest findings by Binks et al.[1] 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 mi...
We note with interest findings by Binks et al.[1] 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.[3]
References
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.
As commercial air travel is moving toward an internet driven consumer
booking system[1] 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 ai...
As commercial air travel is moving toward an internet driven consumer
booking system[1] 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.
References
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.
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...
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."
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 accou...
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
Emergency Physician
Seattle, Washington
Atkinson et al.[1] 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.[2]
Mansfield did not find that ultrasound usage in his study group,
patients
requiring chemotherapy, was beneficial. Miller[3] howev...
Atkinson et al.[1] 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.[2]
Mansfield did not find that ultrasound usage in his study group,
patients
requiring chemotherapy, was beneficial. Miller[3] 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[4] 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[5] 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
References
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 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.[1] 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.
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.[1] 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.[2]
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.[2] 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.[3] 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?
References
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.
Dear Editors,
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 p...
Dear Editor,
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[1]. Acute paronychia is one of the most common infections of the hand. Far from being a simple digital abscess, acute paronychia represents a dynamic...
Dear Editor,
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...
Dear Editor,
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.
With regards.
Dear Editor,
We note with interest findings by Binks et al.[1] 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 mi...
Dear Editor,
As commercial air travel is moving toward an internet driven consumer booking system[1] 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 ai...
Dear Editor,
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...
Dear Editor,
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 accou...
Dear Editor,
Atkinson et al.[1] 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.[2]
Mansfield did not find that ultrasound usage in his study group, patients requiring chemotherapy, was beneficial. Miller[3] howev...
Dear Editors,
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.[1] 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 wond...
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