I read with great interest the article by Liddler et al on the
appropriate use and administration of antidotes for recreational drug
toxicity. I would however like to seek clarification from the authors for
their justification in the use of iv Metoprolol in scenario 4 ( 42 – Year
old man with ingestion of two lines of cocaine presenting with ischaemic
chest pain, ECG changes-ST depression and a BP of...
I read with great interest the article by Liddler et al on the
appropriate use and administration of antidotes for recreational drug
toxicity. I would however like to seek clarification from the authors for
their justification in the use of iv Metoprolol in scenario 4 ( 42 – Year
old man with ingestion of two lines of cocaine presenting with ischaemic
chest pain, ECG changes-ST depression and a BP of 175/95mm Hg). Use of
beta blockers in this situation is contraindicated, as stated in a recent
scientific statement from American Heart Association1. and a point that
the authors acknowledge in the discussion section of their article. Given
the current widespread recreational use of cocaine in the UK and that it
is reported that up to 40% of cocaine users who present to the ED report
chest pain, I would thank the authors for addressing this important
clinical management point.
References:
1. Management of Cocaine-Associated Chest Pain and Myocardial
Infarction: A Scientific Statement From the American Heart Association
Acute Cardiac Care Committee of the Council on Clinical Cardiology.
McCord J, Jneid H, Hollander JE, et al. Circulation. 2008;117:1897-1907
EDITOR, As an anaesthesiologist, I must respectfully disagree with
the conclusion reached by Cho et al. that “[t]he porcine model is a more
useful training tool than the manikin model for cricothyrotomy with PCK
[Portex cricothyrotomy kit] because of its reality and similarity to human
anatomy.”(1)
Animal models have been shown previously to produce poor
cricothyrotomy placement accuracy by students.(2) Manikin...
EDITOR, As an anaesthesiologist, I must respectfully disagree with
the conclusion reached by Cho et al. that “[t]he porcine model is a more
useful training tool than the manikin model for cricothyrotomy with PCK
[Portex cricothyrotomy kit] because of its reality and similarity to human
anatomy.”(1)
Animal models have been shown previously to produce poor
cricothyrotomy placement accuracy by students.(2) Manikin models have been
shown to reduce cricothyrotomy attempts and improve successful placement
rates. One study including manikin models demonstrated that, by the fifth
attempt, 96 percent of participants were able to successfully perform a
cricothyrotomy in 40 seconds or less.(3) Another study found the TraumaMan
simulator “superior” to using animals for surgical airway placement
instruction.(4)
However, one of the most important criteria in determining
cricothyrotomy competency is the assurance that a patient will survive
after the procedure — a critical factor that the authors cannot measure
with their static pig model. Appropriate training methods assess the
student’s ability to appropriately oxygenate and ventilate patients. One
study using a computerized Medical Education Technologies, Inc. (METI)
Human Patient Simulator for emergency hypoxaemia found that cricothyroid
cannulas were successfully placed 100 percent of the time, as confirmed by
capnography.(5)
1. Cho J, et al. Comparison of manikin versus porcine models in
cricothyrotomy procedure training. Emergency Medicine Journal 2008;25:732-
4.
2. McCarthy M, et al. Accuracy of cricothyroidotomy performed in canine
and human cadaver models during surgical skills training. Journal of the
American College of Surgeons 2002;195:627-9.
3. Wong D, et al. What is the minimum training required for successful
cricothyroidotomy?: A study in mannequins. Anesthesiology 2003;98: 349-53.
4. Block EF, et al. Use of a human patient simulator for the advanced
trauma life support course. The American Surgeon 2002;68:648-51.
5. Vadodaria BS, et al. Comparison of four different emergency airway
access equipment sets on a human patient simulator. Anaesthesia 2004;59:73
-9.
I read with interest the BET ‘Is nebulized salbutamol indicated in
bronchiolitis?
Perhaps this is the wrong question. As emergency physicians(EP)
perhaps the more pertinent question is 'Does salbutamol decrease need for
hospital admission?'
We have addressed this question in an RCT which compared adrenaline
to salbutamol.1 We found that salbutamol decreased the need for admission.
This decrease was su...
I read with interest the BET ‘Is nebulized salbutamol indicated in
bronchiolitis?
Perhaps this is the wrong question. As emergency physicians(EP)
perhaps the more pertinent question is 'Does salbutamol decrease need for
hospital admission?'
We have addressed this question in an RCT which compared adrenaline
to salbutamol.1 We found that salbutamol decreased the need for admission.
This decrease was sustained at three days post emergency department
(ED)discharge. The effect was similar across all levels of disease
severity. (Prior to our study we had suspected that only in those with
moderate disease would likely see a benefit large enough to affect need
for admission). The results were unchanged regardless of sensitivity
analysis for age less than 12 months, RSV status or prior episodes.
So for EPs the answer is clear, initial ED treatment with salbutamol
results in more successful discharges than does adrenaline.
For inpatient services the question is murkier. Admitted infants are
a selected sicker group who presumably failed ED treatment. Once admitted,
there is a myriad of non-disease factors that influence time to discharge.
Researchers have attempted to address this by using scoring systems.
Few of the bronchiolitis scoring systems used have actually been
validated. Many scoring systems consider only respiratory status. This is
problematic because an 11 month old happy wheezer who is devouring
everything set in front of him can be assigned a ‘sicker’ score than a
tiring dehydrated 2 month old with less dramatic wheezing.
Finally, absence of evidence of an effect is not evidence of absence
of an effect. The numbers involved in the cited inpatient studies were
small. The four largest studies cited had between 89 and 128 patients, but
each divided their sample into four groups. The remaining studies cited
had between 21 and 83 patients. Consequently important, particularly
categorical, outcome differences could have been missed.
Since salbutamol clearly decreases admissions from the ED,and solid
evidence for inpatients seems lacking, it seems reasonable to at least
try it in the inpatient setting also.
1. Walsh P, Caldwell J, McQuillan KK, Friese S, Robbins D, Rothenberg
SJ. Comparison of nebulized epinephrine to albuterol in bronchiolitis.
Acad Emerg Med 2008; Apr;15(4):305-13.
I enjoyed reading the commentary on Good Clinical Practice and
welcome the efforts of the College of Emergency Medicine to make training
in this important area available to emergency physicians.
I think, however, it is important to recognise the imnportance of
other disciplines - nurses and paramedics being key examples- in emergency
care research, and perhaps to foster collaboration with relevant partner
Colleg...
I enjoyed reading the commentary on Good Clinical Practice and
welcome the efforts of the College of Emergency Medicine to make training
in this important area available to emergency physicians.
I think, however, it is important to recognise the imnportance of
other disciplines - nurses and paramedics being key examples- in emergency
care research, and perhaps to foster collaboration with relevant partner
Colleges, to increase access to GCP training, particularly as efforts
increase to recruit patients to clinical trials in the pre-hospital
setting.
We read with interest the study by Babl et al “limited analgesia
efficacy of nitrous oxide for painful procedures in children” published in
the EMJ November 2008 Vol 25 No 11.
Central to the protocol and management is the use of clinical
assessment to determine adequacy and depth of analgesia/ sedation. We
agree with this wholeheartedly and support this method as it emphasises
the importanc...
We read with interest the study by Babl et al “limited analgesia
efficacy of nitrous oxide for painful procedures in children” published in
the EMJ November 2008 Vol 25 No 11.
Central to the protocol and management is the use of clinical
assessment to determine adequacy and depth of analgesia/ sedation. We
agree with this wholeheartedly and support this method as it emphasises
the importance of conscious sedation as an adjunct to therapy, rather than
unconscious sedation to compensate for inadequate analgesia. However it
is worth recognising that the inspired concentration (in your study stated
as 50-70% N20) does not relate to effector site concentration (in this
case the central nervous system) unless a steady state has been achieved,
the period of equilibration being approximately ten minutes. Without a
closed breathing circuit being used there will inevitably be a significant
entrainment of air resulting in a further reduction in real versus
expected nitrous oxide concentration. This means that the nitrous oxide
concentration achieved in the children in your study will be significantly
lower than the settings on the machines would suggest and be unpredictably
variable.
In our experience using a closed mask system (such as a T – piece or
close fitting demand mask) and end tidal gas monitoring provides a breath
by breath analysis of end tidal nitrous oxide and oxygen concentration.
These are analogous to arterial blood levels and thus reflect much more
closely the effector site concentration.
As a second point we note that all 8 patients who received codeine
(which has a sedative effect) within two hours of sedation were not
excluded from the study, although it was stated in the protocol that those
given sedatives would be excluded.
We agree with your findings that nitrous oxide is a useful adjunct in
conscious sedation in painful procedures in children. We suggest this
could be made more effective and predictable delivering nitrous oxide
within an anaesthetic closed circuit in the Emergency department using end
tidal gas monitoring.
Licence for PublicationThe Corresponding Author has the right to
grant on behalf of all authors and does grant on behalf of all authors, an
exclusive licence (or non exclusive for government employees) on a
worldwide basis to the BMJ Publishing Group Ltd to permit this article (if
accepted) to be published in EMJ and any other BMJPGL products and
sublicences such use and exploit all subsidiary rights, as set out in our
licence (http://emj.bmjjournals.com/misc/ifora/licenceform.dtl). Competing
Interest: None declared.
Several models had been suggested for ultrasonographic training for
intervention {1,2}.
The main criteria of the models should be more or less simulate the
human body organs, cost no much and easily prepared, {3}.
For three years of trying in this field in my radiology laboratory
the potatoes models were on the top of all ,{4}.
After boiling of the potatoes the trainer can do any model you
imagine.
For example
== For venous access models, a tunnel can be created in it and filled
with ultrasonographic gel
This tunnel can be created at different distance from the surface of
the potato
And the degree of difficulty can be changed by selecting the shape of the
potato. the distance of the tunnel, the diameter of the tunnel and the
direction of the substance in the tunnel . The longitudinal scan appear
like a vessel and the transverse scan will appear like a cyst.
==For an abscess or collection models a different size of cavities
can be done inside potatoes and filled with gel or jelly.
== For simulation of liver bilary radicals recent boiled potatoes
show a central network of branching tunnels of small calibers that
resemble bilary radicals.
The old boiled potatoes this water in is tunnels is replaced by air that
looks like the pneumonia in consolidated lung or pneumobilia in liver
organ .
An embedded nerve under water will be used for nerve injection simulation.
==A tunnel filled with air is used to simulate a pathway to an
underlying target covered by dense echogenic tissue.
==A blood filled cavity in well boiled potato model will simulate a
recent hematoma in brain or any suggested organ.
== Small tongue depressors penetrate the entire thickness of potatoes and
a cavity created under them filled with air will simulate a lung model.
When the cavity filed with water it will simulate a pleural effusion
model.
……………A thick layer of cooked potatoes overlie a cup of water with
heavy small balls on its floor will be used as a pleardo table and when
the needle is pushed by ultrasound giddiness to attack the balls then you
start the game of potatoes sonopleardo
[1]C Brown, B McNicholl, and R Wright
Ultrasound simulator for venous access
Emerg Med J 2008; 25: 122
[2]Arne Rose
Ultrasound venous access simulation - the Italian Job
http://emj.bmj.com/cgi/eletters/25/2/122#5810, 31 Jan 2008
[3]=Chris M Turner
Cost per use of USS
http://emj.bmj.com/cgi/eletters/22/8/608-b#1875, 9 Jan 2007
[4]Mahamoud M Gabal
Critical cases direct our needs and skills
http://emj.bmj.com/cgi/eletters/22/8/608-b#1830, 8 Dec 2006
PLEASE NOTE THIS IS A RESUBMISSION FOR PRINTING PURPOSES WITH THE
NECESSARY PERMISSIONS AS REQUESTED EMERMED/2008/069971 - Notify Author Re:
Deficiencies
We read with interest this article by Shavit et al comparing the
Alder Hey Triage Pain Score with a subjective scoring tool. The finding of
a discrepancy in scoring between the tools, with the AHTPS scoring lower,
is entirely consistent with the similar finding...
PLEASE NOTE THIS IS A RESUBMISSION FOR PRINTING PURPOSES WITH THE
NECESSARY PERMISSIONS AS REQUESTED EMERMED/2008/069971 - Notify Author Re:
Deficiencies
We read with interest this article by Shavit et al comparing the
Alder Hey Triage Pain Score with a subjective scoring tool. The finding of
a discrepancy in scoring between the tools, with the AHTPS scoring lower,
is entirely consistent with the similar finding we reported in our paper
(archdischild.2004;89;625-630). The conclusion drawn by the authors that
this indicates that observational scoring should not be recommended is not
justified. The findings may reflect the fact that the observational tool
is not fully refined and the weighting for the different elements needs
further research and development.
In the Shavit study pain scores were lower at triage assessment than
in the waiting room. It was suggested that the reason for this was that
Triage was a more reassuring environment. The inference made from this is
that pain scoring is significantly influenced by anxiety. However, while
this is likely, a subjective tool would be more affected by anxiety than
an observational tool (AHTPS) and indeed the difference between the scores
in the different settings reflected this.
In order to eliminate as much of the anxiety element as possible
subjective tools were initially developed in the situation of recurrent or
procedural pain on the basis that there is an opportunity to explain the
scoring tool prior to the painful event. This is not the case with
children presenting at the ED with acute pain, which is why we do not
think this type of scoring is appropriate for the ED setting where
children in pain cannot be expected to consider and accurately interpret a
new task. In addition there are some children who deny pain on subjective
tools because of fear. This is why we still maintain that subjective
scoring is inappropriate for A&E Triage.
We also believe that it is possible that our tool underestimates pain and
that it requires further research and refinement especially to re examine
the parameters of the tool and their relative values to see how it can be
improved. This area should be further explored before such methods are
rejected. The need for a valid pain scoring tool is to indicate the
appropriate level of analgesia to be prescribed.
We acknowledge that the area of pain assessment is very complex and are
committed to providing the best pain management to all children and would
welcome interest, from others, in work to further refine the AHTPS.
"The Corresponding Author has the right to grant on behalf of all
authors and
does grant on behalf of all authors, an exclusive licence (or non
exclusive
for government employees) on a worldwide basis to the BMJ Publishing
Group Ltd
and its Licensees to permit this article (if accepted) to be published
in EMJ
editions and any other BMJPGL products to exploit all subsidiary rights,
as
set out in our licence(http://emj.bmjjournals.com/ifora/licence.dtl)."
Competing Interest
Please list Competing Interests if they exist, if not please include the
following statement; Competing Interest: None to declare.
We read with interest the study by Babl et al “limited analgesia
efficacy of nitrous oxide for painful procedures in children” published in
the EMJ November 2008 Vol 25 No 11.
Central to the protocol and management is the use of clinical
assessment to determine adequacy and depth of analgesia/ sedation. We
agree with this wholeheartedly and support this method as it emphasises
the importance...
We read with interest the study by Babl et al “limited analgesia
efficacy of nitrous oxide for painful procedures in children” published in
the EMJ November 2008 Vol 25 No 11.
Central to the protocol and management is the use of clinical
assessment to determine adequacy and depth of analgesia/ sedation. We
agree with this wholeheartedly and support this method as it emphasises
the importance of conscious sedation as an adjunct to therapy, rather than
unconscious sedation to compensate for inadequate analgesia. However it
is worth recognising that the inspired concentration (in your study stated
as 50-70% N20) does not relate to effector site concentration (in this
case the central nervous system) unless a steady state has been achieved,
the period of equilibration being approximately ten minutes. Without a
closed breathing circuit being used there will inevitably be a significant
entrainment of air resulting in a further reduction in real versus
expected nitrous oxide concentration. This means that the nitrous oxide
concentration achieved in the children in your study will be significantly
lower than the settings on the machines would suggest and be unpredictably
variable.
In our experience using a closed mask system (such as a T – piece or
close fitting demand mask) and end tidal gas monitoring provides a breath
by breath analysis of end tidal nitrous oxide and oxygen concentration.
These are analogous to arterial blood levels and thus reflect much more
closely the effector site concentration.
As a second point we note that all 8 patients who received codeine
(which has a sedative effect) within two hours of sedation were not
excluded from the study, although it was stated in the protocol that those
given sedatives would be excluded.
We agree with your findings that nitrous oxide is a useful adjunct in
conscious sedation in painful procedures in children. We suggest this
could be made more effective and predictable delivering nitrous oxide
within an anaesthetic closed circuit in the Emergency department using end
tidal gas monitoring.
We read with interest the study by Egdell et al (1).
In a busy Paediatric Emergency Department, there is a need for a tool
to help determine those children who are critically ill or deteriorating
and need intervention to prevent morbidity and mortality.
Recent NICE guidance on the initial assessment and management of
feverish illness in children under 5 years suggests the use of a traffic
light system...
We read with interest the study by Egdell et al (1).
In a busy Paediatric Emergency Department, there is a need for a tool
to help determine those children who are critically ill or deteriorating
and need intervention to prevent morbidity and mortality.
Recent NICE guidance on the initial assessment and management of
feverish illness in children under 5 years suggests the use of a traffic
light system to grade risk of serious illness (2). It is an example of the
use of visual systems to stratify patients according to risk. It is hoped
that such prompts will alert professionals earlier to potential serious
illness and therefore patients are more likely to receive appropriate,
timely investigation and management.
In our department, a modified Brighton Paediatric Early Warning Score
(PEWS) system is used (3). A key difference between the PEWS and the
Paediatric Advanced Warning Score (PAWS) systems is that PAWS includes a
score for oxygen saturations and work of breathing. However, we note that
although there is room for documentation of the inspired oxygen
concentration, having an oxygen requirement is not weighted in the PAWS
score. Therefore a patient with a saturation of greater or equal to 93% in
air or oxygen would be given a score of zero. We wonder whether this would
miss identifying those children maintaining normal saturations in high
amounts of inspired oxygen.
One criterion for admission to high dependency care specified in the
NHS Scotland audit is an oxygen requirement of more than 40% or 2
litres/min (4). We expect that including a score for oxygen requirement in
a warning score system may further increase the likelihood of identifying
children presenting to the Emergency Department that require high
dependency or intensive care admission. We therefore recommend the authors
consider including oxygen requirement in future prospective validation
studies of PAWS.
References
1. P Egdell, L Finlay, and D K Pedley. The PAWS score: validation of
an early warning scoring system for the initial assessment of children in
the emergency department. Emergency Medicine Joural 2008; 25: 745-749
2. Feverish illness in children. Assessment and initial management in
children younger than 5 years. NICE clinical guideline 47. May 2007
www.nice.org.uk
3. Monaghan P.Detecting and managing deterioration in children.
Pediatric Nursing 2005;17;32-35
4. High dependency audit of children and young people in Scotland.
NHS Scotland. July 2006
http://www.nsd.scot.nhs.uk/services/hdc/criterianew.pdf
We read with interest the recent article by Babl et al but feel the
paper, its provocative title and accompanying editorial comment could be
misleading and potentially damaging to the use of this useful agent.
In our experience, ‘intra procedural’ pain scoring by the patient
during adequately administered 70% nitrous would in most cases be
impossible. Indeed...
We read with interest the recent article by Babl et al but feel the
paper, its provocative title and accompanying editorial comment could be
misleading and potentially damaging to the use of this useful agent.
In our experience, ‘intra procedural’ pain scoring by the patient
during adequately administered 70% nitrous would in most cases be
impossible. Indeed the study design suggests that these pain scores were
in fact taken ‘immediately after’ completion of the procedure. As the
analgesic effects of nitrous oxide rapidly reverse at the end of
administration, there seems a risk that the authors were measuring the
after effects of a painful procedure and the ongoing pain of the
condition, without effective analgesia.
Given that a quarter of these procedures were for fractures severe
enough to require manipulation, that nearly 90% of patients had no other
adjuvant analgesia and those who had received parenteral opiates were
excluded (although this was not defined as a priori), it was not
surprising pain scores remained high. As the authors point out, we know
that ‘N2O is highly affective when accompanied by additional analgesic
interventions for fracture reduction’ and so we would also question the
ethics of not providing this standard of care.
The conclusion of the accompanying editorial (page 709) that
emergency physicians will need to ‘look to other agents for painful
procedures’ is misleading. 70% nitrous is a useful agent for painful
procedures, but does not treat pain before of after its use. ED sedation
is a complex, challenging area of emergency medicine and maintaining a
range of techniques, including high concentration nitrous oxide and
balanced effective analgesia, is vital to safe and effective procedural
sedation.
Dear Sir,
I read with great interest the article by Liddler et al on the appropriate use and administration of antidotes for recreational drug toxicity. I would however like to seek clarification from the authors for their justification in the use of iv Metoprolol in scenario 4 ( 42 – Year old man with ingestion of two lines of cocaine presenting with ischaemic chest pain, ECG changes-ST depression and a BP of...
EDITOR, As an anaesthesiologist, I must respectfully disagree with the conclusion reached by Cho et al. that “[t]he porcine model is a more useful training tool than the manikin model for cricothyrotomy with PCK [Portex cricothyrotomy kit] because of its reality and similarity to human anatomy.”(1)
Animal models have been shown previously to produce poor cricothyrotomy placement accuracy by students.(2) Manikin...
I read with interest the BET ‘Is nebulized salbutamol indicated in bronchiolitis?
Perhaps this is the wrong question. As emergency physicians(EP) perhaps the more pertinent question is 'Does salbutamol decrease need for hospital admission?'
We have addressed this question in an RCT which compared adrenaline to salbutamol.1 We found that salbutamol decreased the need for admission. This decrease was su...
I enjoyed reading the commentary on Good Clinical Practice and welcome the efforts of the College of Emergency Medicine to make training in this important area available to emergency physicians.
I think, however, it is important to recognise the imnportance of other disciplines - nurses and paramedics being key examples- in emergency care research, and perhaps to foster collaboration with relevant partner Colleg...
Dear Sir,
We read with interest the study by Babl et al “limited analgesia efficacy of nitrous oxide for painful procedures in children” published in the EMJ November 2008 Vol 25 No 11.
Central to the protocol and management is the use of clinical assessment to determine adequacy and depth of analgesia/ sedation. We agree with this wholeheartedly and support this method as it emphasises the importanc...
Dear Editor
Several models had been suggested for ultrasonographic training for intervention {1,2}.
The main criteria of the models should be more or less simulate the human body organs, cost no much and easily prepared, {3}.
For three years of trying in this field in my radiology laboratory the potatoes models were on the top of all ,{4}.
After boiling of the potatoes the trai...
PLEASE NOTE THIS IS A RESUBMISSION FOR PRINTING PURPOSES WITH THE NECESSARY PERMISSIONS AS REQUESTED EMERMED/2008/069971 - Notify Author Re: Deficiencies
We read with interest this article by Shavit et al comparing the Alder Hey Triage Pain Score with a subjective scoring tool. The finding of a discrepancy in scoring between the tools, with the AHTPS scoring lower, is entirely consistent with the similar finding...
Dear Sir,
We read with interest the study by Babl et al “limited analgesia efficacy of nitrous oxide for painful procedures in children” published in the EMJ November 2008 Vol 25 No 11.
Central to the protocol and management is the use of clinical assessment to determine adequacy and depth of analgesia/ sedation. We agree with this wholeheartedly and support this method as it emphasises the importance...
We read with interest the study by Egdell et al (1).
In a busy Paediatric Emergency Department, there is a need for a tool to help determine those children who are critically ill or deteriorating and need intervention to prevent morbidity and mortality.
Recent NICE guidance on the initial assessment and management of feverish illness in children under 5 years suggests the use of a traffic light system...
Dear Sir
RE: The Efficacy of N2O
We read with interest the recent article by Babl et al but feel the paper, its provocative title and accompanying editorial comment could be misleading and potentially damaging to the use of this useful agent.
In our experience, ‘intra procedural’ pain scoring by the patient during adequately administered 70% nitrous would in most cases be impossible. Indeed...
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