eLetters

820 e-Letters

  • Can observational pain scoring in elderly cognitively impaired reduce time to appropriate analgesia?

    Do the authors have data on the type of analgesia that was provided, that would enable a secondary analysis with the outcome of "time to APPROPRIATE analgesia"? Whilst there was no statistical difference on the time to first analgesia, it is possible that using an observational score will enable a clinician to provide more appropriate (stronger) analgesia to non-verbal elderly patients with long bone fractures, which would be a valuable intervention.

  • Peripheral nerve stimulation use in the Emergency Department

    We would like to comment of the use of waveform capnography (WC) as an adjunct to help determine adequate paralysis during rapid sequence induction (RSI). The article used recognition of apnoea by loss of WC as an early indicator of muscle paralysis and evidence was presented that this method improved first pass success rates and reduced time to intubation for RSI in an emergency setting.

    Although apnoea can be a useful indicator for the presence of paralysis we would suggest that use of a peripheral nerve stimulator is a more accurate tool for determining when muscle relaxants have produced an adequate effect. The use of this simple and relatively inexpensive machine is standard practice for anaesthetists in determining the level of paralysis. It is also viewed as a standard for provision of anaesthesia outside of the operating theatre environment (Association of Anaesthetists of Great Britain and Ireland: Recommendations for standards of monitoring during anaesthesia and recovery, 2015, Page 8). We suggest from clinical experience that apnoea alone does not always reflect adequate muscle relaxation to allow for optimal intubating conditions. Reactive vocal cords may be present despite apparent correct dosing and timing of muscle relaxants. In addition, apnoea and loss of WC could possibly be a reflection of respiratory depression due to administration of the anaesthetic induction agent, opiods or a deteriorating clinical condition.

    We recognise that some Em...

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  • Climate change and the humanitarian response

    Sir,
    You articulate and document the catalogue of evidence supporting the health impacts of climate change admirably in your editorial ‘Peering through the hourglass’ (Lemery, 2017), but the Emergency Medicine world is not as disconnected as you make out. The Red Cross Movement, known traditionally for its humanitarian action, has long had expert emergency medicine at the heart of its work on preparedness for crisis, including natural disasters such as those precipitated by climate change.
    Our international First Aid and Resuscitation Guidelines (IFRC, 2016) are based soundly on science and support the interventions of lay responders and medical professionals across the globe. Our Global First Aid app is now used in 90 countries, bespoke to each one through careful translation and cultural relevance. The British Red Cross, American Red Cross and others have developed their own additional apps, specific to the disasters that might occur, such as flooding, hurricanes and tornadoes. These, too, are rooted in clinical science and educational methodology supporting the public to learn, be prepared and be resilient.
    Beyond technology, our thousands of staff and volunteers across the world work closely with local authorities in their planning for natural disasters, ensuring systems are in place to cope with the practical realities, as well as the humanitarian care needed for those affected. This work inevitably draws attention to the humanitarian crises that...

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  • Response to: Validity of the Manchester Triage System in patients with sepsis presenting at the ED

    Dear Sirs,

    I congratulate the authors on their research. It is important to highlight that the Manchester triage system does incorporate shock or low blood pressure into its flow charts. It is described in the general discriminator text and flow chart. Any patients who are shocked should be triaged into priority one, if following the rules of MTS.

    Therefore in this study all 9 of the 26 patients with a blood pressure of less than 90 mmHg should have been triaged into priority one, according to the rules of MTS. If these patients had been triaged in this way, the results of your study could be significantly affected.

    We look forward to seeing further research from your selves in this area

    Kind Regards

    Laura

  • No good evidence that Trendelenburg is better to cardiovert SVT

    Dear Sir,

    We read with interest the recent Best Evidence Topic (BET) report by L Varley and L Howard, ‘Trendelenburg position helps to cardiovert patients in SVT back to sinus rhythm.’[1] We are grateful that this BET highlighted the substantial benefit of using a postural modification to the Valsalva manoeuvre for re-entrant SVT[2]. However, whist we agree with the ‘Clinical Bottom Line’, we feel the title of this BET was misleading and does not reflect current evidence.

    ‘Trendelenburg position’ is typically used to describe a supine patient with the bed tilted head down below the level of the pelvis.[3] Although this position was associated with a higher rate of cardioversion in a small, uncontrolled before and after study[4], no physiological benefits of this position have been demonstrated[5] and it was not used in the REVERT trial, the largest RCT of VM modification to date.

    For clarification, in our study the Valsalva strain was conducted in the semi-sitting position with movement to the supine position with leg elevation, immediately at the end of the strain. There are plausible physiological reasons why this specific sequence of postural changes and timing of strain may improve Valsalva effectiveness as described in our paper. Although it is possible that Trendelenburg positioning after straining might further improve cardioversion rates, this has not been tested to date.

    Yours sincerely

    On behalf of the REVERT study Team

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  • Climate change and the humanitarian response

    Sir,
    You articulate and document the catalogue of evidence supporting the health impacts of climate change admirably in your editorial ‘Peering through the hourglass’ (Lemery, 2017), but the Emergency Medicine world is not as disconnected as you make out. The Red Cross Movement, known traditionally for its humanitarian action, has long had expert emergency medicine at the heart of its work on preparedness for crisis, including natural disasters such as those precipitated by climate change.
    Our international First Aid and Resuscitation Guidelines (IFRC, 2016) are based soundly on science and support the interventions of lay responders and medical professionals across the globe. Our Global First Aid app is now used in 90 countries, bespoke to each one through careful translation and cultural relevance. The British Red Cross, American Red Cross and others have developed their own additional apps, specific to the disasters that might occur, such as flooding, hurricanes and tornadoes. These, too, are rooted in clinical science and educational methodology supporting the public to learn, be prepared and be resilient.
    Beyond technology, our thousands of staff and volunteers across the world work closely with local authorities in their planning for natural disasters, ensuring systems are in place to cope with the practical realities, as well as the humanitarian care needed for those affected. This work inevitably draws attention to the humanitarian crises that...

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  • Request for information
    Jim Wardrope

    It would be useful to know the Total number of traumatic cardiac arrests treated by the system during these three years. Hard to draw conclusions on effectiveness without this figure. Also note different results in the paper Chiang W-C et all on the next page of the journal. (Emerg Med J 2017; 34: 39-45).

    Conflict of Interest:

    None declared

  • high fentanyl doses - is this an error?
    Gael J Smits

    Dear authors,

    In your intersting RCT of propofol versus midazolam sedation, you describe giving a fentanyl dose of 3mcg/kg, in conjunction with a titrated dose of propofol or midazolam.

    This appears a pretty large dose, compared to the procedural sedation literature, where the usual dose is 1 mcg/kg (min-max 0.5-2.0).[1-2]

    From previous research with propofol and midazolam in the Emergency Depa...

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  • A timely health warning.
    Anisa J N Jafar

    We thank the authors Challen and Roland for their review (1) which highlights a very important issue faced daily in our Emergency Departments.

    The use of, and more importantly, reliance on the Early Warning Score (EWS) carries risk as up to 1:3 patients admitted to ICU from ED will not score highly on the EWS (2). Clinician opinion may prove a superior assessment tool; this is not adequately explored. Experien...

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  • The Golden Rule
    Thomas Benzoni

    Dr. Basu et al. make an interesting observation: if you kick the dog, eventually he will bite the mailman. How is it we think we can treat the workers without compassion or empathy while expecting them to treat the patients with these same virtues, ones we don't practice?

    This article and an ever-expanding body of literature make it clear: we must treat our staff in the same way we expect them to treat patients....

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