The collated experiences and lessons from recent Major Incidents experienced in the UK is now juxtaposed with the ‘new normal’ of the healthcare community and emergency services operating with the threat of COVID-19 and the associated considerations of PPE against Aerosol Generating Procedures.
Emergency service personnel and hospital clinicians will have trained with ‘universal precautions’ and risk-specific personal protective equipment for Health Emergency Preparation Exercises (HEPE) previously. COVID-19 has resulted in wide-spread adoption of single-use coveralls and respiratory protective equipment (facemask and powered hoods) beyond the specialist responders who would have normally exercised for major incidents whilst operating with these.
With a return to a new normality of service provision and emergency preparedness, the clinical and logistical challenges of operating in AGP PPE need to be factored into MI plans and future practical exercises across the emergency services and acute hospital care. These range from those issues at the operational level such as dynamic risk assessment, identification and communication between clinicians and commanders at scene, record keeping and identifying the need to use COVID PPE (or when no longer needed, keeping in mind its exertional toll) and don and doff areas with ancillary staff.
Tactical issues include conveyance platforms and options for patients from scenes to hospital – some of...
The collated experiences and lessons from recent Major Incidents experienced in the UK is now juxtaposed with the ‘new normal’ of the healthcare community and emergency services operating with the threat of COVID-19 and the associated considerations of PPE against Aerosol Generating Procedures.
Emergency service personnel and hospital clinicians will have trained with ‘universal precautions’ and risk-specific personal protective equipment for Health Emergency Preparation Exercises (HEPE) previously. COVID-19 has resulted in wide-spread adoption of single-use coveralls and respiratory protective equipment (facemask and powered hoods) beyond the specialist responders who would have normally exercised for major incidents whilst operating with these.
With a return to a new normality of service provision and emergency preparedness, the clinical and logistical challenges of operating in AGP PPE need to be factored into MI plans and future practical exercises across the emergency services and acute hospital care. These range from those issues at the operational level such as dynamic risk assessment, identification and communication between clinicians and commanders at scene, record keeping and identifying the need to use COVID PPE (or when no longer needed, keeping in mind its exertional toll) and don and doff areas with ancillary staff.
Tactical issues include conveyance platforms and options for patients from scenes to hospital – some of which may then need to be taken out of service for deep cleaning and Emergency Department reception with definitive care; particularly given that many hospitals are still reconfiguring services and pathways around ‘red’ and ‘green’ intensive care beds and theatres. This continues to evolve with the deployment of rapid and point-of-care tests to inform bed and theatre decisions
At the strategic level, all stakeholders involved in the response to Major Incidents now have business continuity experience in a post COVID-19 world. This now needs to inform the persisting need for regular HEPEs in preparation for major incidents, mass casualty and marauding terror attacks.
There is no question that SARS-CoV-2 has dramatically increased the utilization of telehealth services in the US and elsewhere. However, the claim that telehealth was not a significant factor pre-COVID is simply not true. Here is the quote from the article: "Prior to the severe acute respiratory syndrome coronavirus 2 or COVID-19 pandemic, telehealth generally had little overall engagement in the US healthcare system."
In 2009 during the H1N1 epidemic, Kaiser Permanente-Northern California's (KP-NCAL) appointment and advice call centers (AACC) scheduled 900,000 telehealth visits. In 2010 in my capacity as Clinical Director of the KP-NCAL Sacramento AACC I organized a regional program employing telehealth to address the after hours needs of adults. That program over the next 8 years averaged 50,000 encounters per year on nights and weekends and backed up an additional 200,000+ locally managed afterhours telehealth visits per year. 24% of the total encounters in KP-NCAL's Adult and Family Medicine departments by 3.8 million adults in 2017 were delivered through virtual telehealth. I would say these efforts definitely qualify as substantial "overall engagement".
The use of Angiotensin II for cardiogenic shock(1) might be counterproductive in patients who have cardiogenic shock attributable to Takotsubo cardiomyopathy(TTC) characterised by left ventricular outflow tract(LVOT) obstruction. The following are the reasons justifying non-use of that treatment modality:-
Angiotensin II induces catecholamine release(2), thereby potentially exacerbating the catecholamine surge which characterises TTC. This catecholamine surge is mimicked by exogenous administration of epinephrine, the latter well documented as a trigger for de novo TTC in 22 patients reviewed in the literature search by Madisa et al(2). In another literature review, dobutamine(also a catecholamine ) triggered the onset of TTC in 22 patients(3). A typical example of the latter was a 61 year old woman who developed chest pain at 70% of her age-predicted heart rate, when she was on a 40 mcg/min infusion of dobutamine. Her electrocardiogram(ECG) then showed inferolateral ST segment elevation. Transthoracic echocardiography showed severe akinesia of the apical, anteroseptal, and apicolateral segments at peak dobutamine infusion. Coronary angiography disclosed normal epicardial vasculature(5).
When LVOT obstruction occurs in TTC it can give rise to severe hypotension, exemplified by a 60 year old woman with a nadir systolic blood pressure(SBP) of 80 mm Hg in association with a gradient of 58 mm Hg across the LVOT. After landiolol( a beta blocker) inf...
The use of Angiotensin II for cardiogenic shock(1) might be counterproductive in patients who have cardiogenic shock attributable to Takotsubo cardiomyopathy(TTC) characterised by left ventricular outflow tract(LVOT) obstruction. The following are the reasons justifying non-use of that treatment modality:-
Angiotensin II induces catecholamine release(2), thereby potentially exacerbating the catecholamine surge which characterises TTC. This catecholamine surge is mimicked by exogenous administration of epinephrine, the latter well documented as a trigger for de novo TTC in 22 patients reviewed in the literature search by Madisa et al(2). In another literature review, dobutamine(also a catecholamine ) triggered the onset of TTC in 22 patients(3). A typical example of the latter was a 61 year old woman who developed chest pain at 70% of her age-predicted heart rate, when she was on a 40 mcg/min infusion of dobutamine. Her electrocardiogram(ECG) then showed inferolateral ST segment elevation. Transthoracic echocardiography showed severe akinesia of the apical, anteroseptal, and apicolateral segments at peak dobutamine infusion. Coronary angiography disclosed normal epicardial vasculature(5).
When LVOT obstruction occurs in TTC it can give rise to severe hypotension, exemplified by a 60 year old woman with a nadir systolic blood pressure(SBP) of 80 mm Hg in association with a gradient of 58 mm Hg across the LVOT. After landiolol( a beta blocker) infusion her SBP recoverd to 120 mm Hg, and her LVOT resolved(6). In another study propranolol infusion also generated an improvement in SBP and an amelioration of LVOT obstruction(7). Conversely, Ansarin et al showed that rates of in-hospital events and short- as well as long-term mortality were significantly higher in TTC patients receiving catecholamine support as compared to other study patients(8). In one other report a 78 year old hypotensive woman with TTC, ST segment elevation , SBP 68 mm Hg and intraventricular pressure gradient(IVPG) 104 mm Hg was initially treated with a dopamine(20 mcg/kg/min) infusion. When the clinicians began to suspect that her prolonged hypotension was contributing to her prolonged hypotension they gradually decreased the dose of dopamine. Immediately after cessation of dopamine her SBP increased to 96 mm Hg and the IVPG fell to 54 mm Hg . She was subsequently treated with carvedilol. Five days later the IVPG had completely resolved (9)
TTC-related LVOT obstruction is often characterised by the presence of a systolic murmur even in the presence of severe hypotension. Accordingly, when cardiogenic shock is accompanied by a systolic murmur in a patient with ST segment elevation the differential diagnosis should include TTC-related LVOT obstruction . In that context beta adrenergic blocked should be prioritised over the use of noradrenaline, dopamine, or, even, Angiotensin II
I have no funding and no conflict of interest
References
(1) Wallis M., Chow JH., Winters M., McCurdy MT
Angiotensin II for the emergency physician
Emerg J Med 2019;doi.10.1136/emermed-2019-209062 Epub ahead of print
(2)Dendorfer A., Thornagel A., Raasch W., Grisk O., Tempel K., Dominiak P
Angiotensin II induces catecholamine release by direct ganglionic excitation
Hypertension 2002;40:348-354
(3) Madias JE
Epinephrine administration and Takotsubo syndrome : Lessons from past experience
Int J Cardiol 2016;doi.org/10.1016/j.ijcard 2016.01.145
(4) Hajsadeghi S., Rahbar MH., Iranpour A., Salehi A., Asadi O., Jafarian SR et al
Dobutamine induced takotsubo cardiomyopathy: A systematic review of the literature and case report
Abatol J Cardiol 2018;19:412-421
(5) Margey R., Diamond P., MvCann H., Surgue D
Dobutamine stress echo-induced apical ballooning(Takotsubo) syndrome
Eur J Echocardiogr 2009;10:395-399
(6) Takada T., Jujo K., Ishida I., Hagiwara N
Recurrent takotsubo syndrome with worsening of left ventricular outflow obstruction during hemodialysis: case report
Eur Heart J Case Reports 2020;4:1-4
(7) Yoshioka T., Hashimoto A., Tschihashi K., Nagao K., Kyuma M., Ooiwa H et al
Clinical implications of midventricular apical ballooning(Takotsubo cardiomyopathy)
Am Heart J 20018;155:526.e1-525.e7
(8) Ansari U., El-Battrawy I., Fastner C., Behnes M., Sattler K., Huseynov A et al
Clinical outcomes associated with catecholamine use in patients diagnosed with Takotsubo cardiomyopathy
BMC Cardiovascular Disorders doi.otg/10.1186/s12872-018-0784-6
(9)Abe Y., Tamura A., Kadora J
Prolonged cardiogenic shock caused by high-dose intravenous administration of dopamine in a patient with takotsubo cardiomyopathy
Int J Cardiol 2010;141:e1-e3
I enjoyed reading this article, however, the reference to a cytokine storm warrants clarification. An editorial in JAMA Internal Medicine doi:10.1001/jamainternmed.2020.3313 suggested little evidence for such a storm and this has been supported by more recent studies by Remy et al in JCI Insight (10.1172/jci.insight.140329) who demonstrated severe immunosuppression and Kox et al in JAMA (doi:10.1001/jama.2020.17052) who found multiple cytokines were reduced in severe COVID-19.
A timely and interesting read if for no other reason colleagues and I were discussing / bemoaning recurrent abdominal pain presentations only last week. Many of the features that act as obstacles were well recognised and omnipresent.
The solutions are an excellent mixture of skills and I can see much utility, I can also foresee the care pathways being highly personalised in our healthcare institutions (Daniels et al allude to this by describing one the ED consultants with an interest in HIU) and once that person moves job the pathway crumbles.
To an extent excluding medical emergency (the 1st E in ERROR) does require medicalisation whether it be vitals being taken or the initial bloods including lactate. I can see the purpose and benefit of not repeating unnecessary blood tests and I suspect not doing tests will be a feat more easily achieved with seniority, There is benefit in letting HIUs be seen exclusively by such.
I was surprised that Daniels and the other authors claim that "pain is not a central consideration in RCEM guidelines...". The college guidelines page (https://www.rcem.ac.uk/RCEM/Quality_Policy/Clinical_Standards_Guidance/R...) lists at east 3 where pain is most certainly the central consideration, or was this in relation to abdominal pain only?
A timely and interesting read if for no other reason colleagues and I were discussing / bemoaning recurrent abdominal pain presentations only last week. Many of the features that act as obstacles were well recognised and omnipresent.
The solutions are an excellent mixture of skills and I can see much utility, I can also foresee the care pathways being highly personalised in our healthcare institutions (Daniels et al allude to this by describing one the ED consultants with an interest in HIU) and once that person moves job the pathway crumbles.
To an extent excluding medical emergency (the 1st E in ERROR) does require medicalisation whether it be vitals being taken or the initial bloods including lactate. I can see the purpose and benefit of not repeating unnecessary blood tests and I suspect not doing tests will be a feat more easily achieved with seniority, There is benefit in letting HIUs be seen exclusively by such.
I was surprised that Daniels and the other authors claim that "pain is not a central consideration in RCEM guidelines...". The college guidelines page (https://www.rcem.ac.uk/RCEM/Quality_Policy/Clinical_Standards_Guidance/R...) lists at east 3 where pain is most certainly the central consideration, or was this in relation to abdominal pain only?
Overall good article. Timely and worthwhile for us all working in EDs.
We read with great interest the EMJ article by Bahreini and colleagues (published August 2020).1 The authors aimed to compare the relative efficacy and side effect profiles of sodium thiopental–fentanyl (TF) and ketamine–propofol (KP) when used for procedural sedation of 96 adult patients prior to undergoing a painful procedure in the emergency department setting. This randomised double-blind clinical trial quantitatively compared recovery time and both patient and provider satisfaction between the two treatment groups. Additionally, the study aimed to assess the prevalence of adverse effects occurring during recovery and patient recall of the procedure. The authors concluded that there was a statistically significant improvement in both patient and provider satisfaction and degree of procedure recall when using KP compared to TF. However, there was no statistically significant difference in recovery time or adverse effects between the treatment groups.
The authors discussed that the study was not adequately powered to assess the side effect profiles. However, using a systematic review of the effects of KP and propofol, it is possible to make comparisons with the current study regarding the KP side effect profile.2 In all cases, the occurrence of adverse events was greater in those studies included in the systemic review. For example, the POKER study reported that 14% of patients sedated with KP required an airway intervention 3 compared to only...
We read with great interest the EMJ article by Bahreini and colleagues (published August 2020).1 The authors aimed to compare the relative efficacy and side effect profiles of sodium thiopental–fentanyl (TF) and ketamine–propofol (KP) when used for procedural sedation of 96 adult patients prior to undergoing a painful procedure in the emergency department setting. This randomised double-blind clinical trial quantitatively compared recovery time and both patient and provider satisfaction between the two treatment groups. Additionally, the study aimed to assess the prevalence of adverse effects occurring during recovery and patient recall of the procedure. The authors concluded that there was a statistically significant improvement in both patient and provider satisfaction and degree of procedure recall when using KP compared to TF. However, there was no statistically significant difference in recovery time or adverse effects between the treatment groups.
The authors discussed that the study was not adequately powered to assess the side effect profiles. However, using a systematic review of the effects of KP and propofol, it is possible to make comparisons with the current study regarding the KP side effect profile.2 In all cases, the occurrence of adverse events was greater in those studies included in the systemic review. For example, the POKER study reported that 14% of patients sedated with KP required an airway intervention 3 compared to only 8.5% in the current study. As expected, the disparity is even greater for infrequent adverse events. For example, the current study showed the rates of apnoeic and hypotensive episodes were 2.02% and 0% respectively, while the POKER study identified rates of 4% and 1%, respectively. This suggests that the side effect profile may be an underestimation for both treatment arms. It is important to note that there are slight variations in the initial dosing across these studies, which makes direct comparisons difficult. This is further complicated by the fact that additional doses were given to ‘maintain adequate sedation’ and that different sedation scales were used to achieve this. Regardless, further data collection is required to be able to draw conclusions on the secondary outcome of this study. This is particularly important since there is little differentiation between the efficacy of KP and TF, therefore a favourable side effect profile would indicate the preferable treatment option.
Additionally, research which is properly powered for adverse events is salient when discussing the side effect profile for TF, as sodium thiopental is known to cause serious cardiac dysfunction including arrhythmias and myocardial depression.4 However, the authors mention that the concerning respiratory complications of TF can be ‘overcome by careful titration’ and continued monitoring. Therefore, it is also important to discuss that there may be some disparity between the rate of adverse effects observed during a study versus that of regular clinical practice where time pressures and limited resources may apply. To account for this and reach a more practical representation, it may be beneficial to use a retroactive study to assess the presence of adverse events given the use of TF or KP sedation.
References
1. Bahreini M, Talebi Garekani M, Sotoodehnia M, Rasooli F. Comparison of the Efficacy of Ketamine-propofol versus Sodium Thiopental-Fentanyl in Sedation: A Randomised Clinical Trial [published online ahead of print, 2020 Aug 28]. Emerg Med J. 2020;emermed-2020-209542. doi:10.1136/emermed-2020-209542
2. Ghojazadeh M, Sanaie S, Paknezhad SP, Faghih SS, Soleimanpour H. Using Ketamine and Propofol for Procedural Sedation of Adults in the Emergency Department: A Systematic Review and Meta-Analysis. Adv Pharm Bull. 2019;9(1):5-11. doi:10.15171/apb.2019.002
3. Ferguson I, Bell A, Treston G, New L, Ding M, Holdgate A. Propofol or Ketofol for Procedural Sedation and Analgesia in Emergency Medicine-The POKER Study: A Randomized Double-Blind Clinical Trial. Ann Emerg Med. 2016;68(5):574-582.e1. doi:10.1016/j.annemergmed.2016.05.024
4. Uchida K, Shimizu H, Nagafuchi H, Yamamoto A, Ono S. Severe cardiac dysfunction induced by thiopental sodium. Pediatr Int. 2019;61(12):1270-1272. doi:10.1111/ped.14031
What this proposed reset does not describe is a reorganisation of 'at the door' triage based on the type of presentation.
The need for effective patient throughput (patient flow); the major problem in contemporary A&E (at least pre Covid19) has not been addressed.
.
I propose triaging 'at the door' carried out by nurse practitioners (assisted by paramedic crews bringing patients in) and admin staff to access medical information rapidly (for example via the Great North Care Record). These insights were gained from camp Bastion in Afghanistan.
There should be 4 key portals and pathways thereafter.
a) The seriously ill (Major Trauma, Sepsis, Stroke, Cardiac Infarcts, Acute Abdomens etc.)
b) Cases of frailty (mainly elderly people, including delirium / dementia, minor trauma)
c) mental Health presentations (of all ages, including learning disability)
d) overspill from General Practice
These pathways would be staffed by specialist nurse practitioners, pharmacists and speciality doctors, working on prearranged algorithms with electronic prescribing and discharge / handover templates (ideally in a SBAR format) to assist patient flow. cross referral (called scaffolding in mental health) should be possible on occasion. Overall, a duty matron should keep overall control of activity through an electronic dashboard. Paramedic / ambulance crews should have access to this matron remotely to make crucial d...
What this proposed reset does not describe is a reorganisation of 'at the door' triage based on the type of presentation.
The need for effective patient throughput (patient flow); the major problem in contemporary A&E (at least pre Covid19) has not been addressed.
.
I propose triaging 'at the door' carried out by nurse practitioners (assisted by paramedic crews bringing patients in) and admin staff to access medical information rapidly (for example via the Great North Care Record). These insights were gained from camp Bastion in Afghanistan.
There should be 4 key portals and pathways thereafter.
a) The seriously ill (Major Trauma, Sepsis, Stroke, Cardiac Infarcts, Acute Abdomens etc.)
b) Cases of frailty (mainly elderly people, including delirium / dementia, minor trauma)
c) mental Health presentations (of all ages, including learning disability)
d) overspill from General Practice
These pathways would be staffed by specialist nurse practitioners, pharmacists and speciality doctors, working on prearranged algorithms with electronic prescribing and discharge / handover templates (ideally in a SBAR format) to assist patient flow. cross referral (called scaffolding in mental health) should be possible on occasion. Overall, a duty matron should keep overall control of activity through an electronic dashboard. Paramedic / ambulance crews should have access to this matron remotely to make crucial decisions on decisions to pick up patients from homes or to leave them to be attended by 'hospital at home' services (including mental health crisis / street triage).
I read with interest the recent article by Carley et al., “Evidence-based medicine and COVID-19: what to believe and when to change”1. The authors pay homage to the challenges of keeping pace with a pandemic growing at unprecedented speeds, forcing the hand of clinicians to make therapeutic decisions on the basis of weak, often unvalidated evidence. They also note the influence of political opinion, referencing Donald Trump’s infamous declaration on the efficacy of hydroxychloroquine as a treatment for COVID-192. In their concluding statements, the authors eloquently present the need to follow science rather than emotions or politics.
Having worked in a large critical care unit over the pandemic, I question how easy this is in practice. Clinicians, nurses and Allied Health Professionals do not exist in a vacuum, but rather their opinions and knowledge are inevitably shaped by social and cultural rhetoric. I use the example of Personal Protective Equipment (PPE), an acronym once reserved to select professions yet now colloquially used by the lay person. Information regarding the appropriate PPE to be worn was disseminated in multiple formats, from news broadcasts to social media platforms such as Twitter. As knowledge developed about how the SARS-COV-2 virus was transmitted, recommendations on PPE changed accordingly. As of July 23rd, it was recommended that double gloving was not necessary3, and in fact increased the risk of transmitting e-coli...
I read with interest the recent article by Carley et al., “Evidence-based medicine and COVID-19: what to believe and when to change”1. The authors pay homage to the challenges of keeping pace with a pandemic growing at unprecedented speeds, forcing the hand of clinicians to make therapeutic decisions on the basis of weak, often unvalidated evidence. They also note the influence of political opinion, referencing Donald Trump’s infamous declaration on the efficacy of hydroxychloroquine as a treatment for COVID-192. In their concluding statements, the authors eloquently present the need to follow science rather than emotions or politics.
Having worked in a large critical care unit over the pandemic, I question how easy this is in practice. Clinicians, nurses and Allied Health Professionals do not exist in a vacuum, but rather their opinions and knowledge are inevitably shaped by social and cultural rhetoric. I use the example of Personal Protective Equipment (PPE), an acronym once reserved to select professions yet now colloquially used by the lay person. Information regarding the appropriate PPE to be worn was disseminated in multiple formats, from news broadcasts to social media platforms such as Twitter. As knowledge developed about how the SARS-COV-2 virus was transmitted, recommendations on PPE changed accordingly. As of July 23rd, it was recommended that double gloving was not necessary3, and in fact increased the risk of transmitting e-coli infection. Clinical staff reacted to the change with a mixture of concern and mistrust, referencing the ever-changing advice from government sources and the differences in practices across trusts.
This pandemic has led to an unprecedented change to the dissemination of scientific information. In usual times, it is expected that evidence-based medicine (EBM) forms the pillar from which clinical practice is developed. The channels in which this information is delivered are well-established and validated through peer-review, as the authors note. The vast public interest and vested political interest in the outcomes and development of the pandemic has led to more scientific information being shared on public platforms.
With this in mind, I propose to the authors an addition to their fourth solution: “design studies for deployment in future pandemics and place them in a ‘hibernated state’ such that the future research infrastructure is in place prior to requirement”1. I suggest the implementation of internal trust structures for the dissemination of up-to-date EBM and resulting changes to clinical practices and policies. This may be in the format of daily or weekly briefings, perhaps through trust intranet services or via a specified research guardian dedicated to the communication of EBM to staff.
The authors have proposed detailed suggestions as to how EBM should be upheld during the COVID-19, and future, pandemics. I caution the need to maintain and uphold channels for communicating such evidence, particularly when social media, news outlets and politicians proliferate information at a speed greater than traditional avenues for the dissemination of research.
References
1. Carley S, Horner D, Body R, et al Evidence-based medicine and COVID-19: what to believe and when to change. Emergency Medicine Journal Published Online First: 10 July 2020. doi: 10.1136/emermed-2020-210098
2. Rome BN, Avorn J. Drug evaluation during the Covid-19 pandemic. N Engl J Med 2020;382:2282 doi:10.1056/NEJMp2009457 pmid:http://www.ncbi.nlm.nih.gov/pubmed/32289216
3. COVID-19 personal protective equipment (PPE) [Internet]. GOV.UK. 2020 [cited 6 August 2020]. Available from: https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infec...
This article draws its evidence from two citations, one by Madsen et al., and the other from a systematic review, which has been mis-cited as a duplicate of the Madsen reference. The correct citation to the systematic review is not Madsen et al., but Tarnutzer et al., PubMed ID 28356464 (Tarnutzer AA, Lee SH, Robinson KA, Wang Z, Edlow JA, Newman-Toker DE. ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis. Neurology. 2017;88(15):1468-1477. doi:10.1212/WNL.0000000000003814.).
We have read with great interest the article by Vihonen et al, ‘Glucose as an additional parameter to National Early Warning Score in prehospital setting enhances identification of patients at risk of death: an observational cohort study’, recently published in your journal.(1)
Traditionally, the scores published to assess the risk of mortality in patients attended in a prehospital setting, the predictive value of which had been questioned until recent studies, did not include the quantification of glycemia among the parameters analysed in the initial assessment of the patient.(2-4)
Overlooking its systematic determination in the initial care of any critically ill patient represents an easily avoidable risk, due to its accessibility and to the ease in interpreting results in any setting. This shortcoming is especially relevant in the initial care of patients with acute poisoning, due to the limitations of the anamnesis and the need to establish a rapid and reliable differential diagnosis in patients with often complex and plural clinical symptoms.(5,6) In this regard, the prognostic value of glycemia as a biomarker in some acute, highly lethal levels of poisoning must also be taken into account.(7,8)
In Catalonia, two studies undertaken by the Prehospital Medical Emergency Service in recent years have shown that only 30.1% of those poisoned by caustic products or 15.2% of the 1,930 people poisoned by carbon monoxide or smoke released f...
We have read with great interest the article by Vihonen et al, ‘Glucose as an additional parameter to National Early Warning Score in prehospital setting enhances identification of patients at risk of death: an observational cohort study’, recently published in your journal.(1)
Traditionally, the scores published to assess the risk of mortality in patients attended in a prehospital setting, the predictive value of which had been questioned until recent studies, did not include the quantification of glycemia among the parameters analysed in the initial assessment of the patient.(2-4)
Overlooking its systematic determination in the initial care of any critically ill patient represents an easily avoidable risk, due to its accessibility and to the ease in interpreting results in any setting. This shortcoming is especially relevant in the initial care of patients with acute poisoning, due to the limitations of the anamnesis and the need to establish a rapid and reliable differential diagnosis in patients with often complex and plural clinical symptoms.(5,6) In this regard, the prognostic value of glycemia as a biomarker in some acute, highly lethal levels of poisoning must also be taken into account.(7,8)
In Catalonia, two studies undertaken by the Prehospital Medical Emergency Service in recent years have shown that only 30.1% of those poisoned by caustic products or 15.2% of the 1,930 people poisoned by carbon monoxide or smoke released from fire, had their glycemia levels determined in a prehospital setting, an issue which we consider can really be improved. For all these reasons, we have recently proposed that the determination of glycemia in poisoned patients should be routine, being included in the panel of indicators of healthcare quality of these patients(9), which reinforces the conclusion of Vihonen et al.
References
1. Vihonen H, Lääperi M, Kuisma M, Pirneskoski J, Nurmi J. Glucose as an additional parameter to National Early Warning Score in prehospital setting enhances identification of patients at risk of death: an observational cohort study. Emerg Med J. 2020; 37:286-92.
2. Kievlan DR, Martin-Gill C, Kahn JM, Callaway CW, Yealy DM, Angus DC, et al. External validation of a prehospital risk score for critical illness. Crit Care. 2016; 20:255-61.
3. Lane DJ, Wunsch H, Saskin R, et al. Assessing Severity of Illness in Patients Transported to Hospital by Paramedics: External Validation of 3 Prognostic Scores. Prehosp Emerg Care. 2020; 24:273‐81.
4. Patel R, Nugawela MD, Edwards HB, Richards A, Le Roux H, Pullyblank A, et al. Can early warning scores identify deteriorating patients in pre-hospital settings? A systematic review. Resuscitation. 2018; 132:101-11.
5. Amrein K, Kachel N, Fries H, Hovorka R, Pieber TR, Plank J, et al. Glucose control in intensive care: usability, efficacy and safety of SpaceGlucose Control in two medical European intensive care units. BMC Endocr Disord. 2014; 14: 62.
6. Erickson TB, Thompson TM, Lu JL. The approach to the patient with an unknown overdose. Emerg Med Clin N Am. 2007; 25: 249-81.
7. Moon JM, Chun BJ, Cho YS. Hyperglycemia at presentation is associated with in hospital mortality in non-diabetic patient with organophosphate poisoning. Clin Toxicol. 2016; 54:252‐8.
8. Sharma A, Balasubramanian P, Gill KD, Bhalla A. Prognostic Significance of Blood Glucose Levels and Alterations Among Patients with Aluminium Phosphide Poisoning. Sultan Qaboos Univ Med J. 2018; 18: e299‐e303.
9. Ferrés-Padró V, Amigó-Tadín M, Puiguriguer-Ferrando J, Nogué-Xarau S. Proposal for a new quality indicator for care of patients with acute poisoning. JHQR. 2020. (In press) JHQR-D-19-00203R1.
Dear Editor,
The collated experiences and lessons from recent Major Incidents experienced in the UK is now juxtaposed with the ‘new normal’ of the healthcare community and emergency services operating with the threat of COVID-19 and the associated considerations of PPE against Aerosol Generating Procedures.
Emergency service personnel and hospital clinicians will have trained with ‘universal precautions’ and risk-specific personal protective equipment for Health Emergency Preparation Exercises (HEPE) previously. COVID-19 has resulted in wide-spread adoption of single-use coveralls and respiratory protective equipment (facemask and powered hoods) beyond the specialist responders who would have normally exercised for major incidents whilst operating with these.
With a return to a new normality of service provision and emergency preparedness, the clinical and logistical challenges of operating in AGP PPE need to be factored into MI plans and future practical exercises across the emergency services and acute hospital care. These range from those issues at the operational level such as dynamic risk assessment, identification and communication between clinicians and commanders at scene, record keeping and identifying the need to use COVID PPE (or when no longer needed, keeping in mind its exertional toll) and don and doff areas with ancillary staff.
Tactical issues include conveyance platforms and options for patients from scenes to hospital – some of...
Show MoreThere is no question that SARS-CoV-2 has dramatically increased the utilization of telehealth services in the US and elsewhere. However, the claim that telehealth was not a significant factor pre-COVID is simply not true. Here is the quote from the article: "Prior to the severe acute respiratory syndrome coronavirus 2 or COVID-19 pandemic, telehealth generally had little overall engagement in the US healthcare system."
In 2009 during the H1N1 epidemic, Kaiser Permanente-Northern California's (KP-NCAL) appointment and advice call centers (AACC) scheduled 900,000 telehealth visits. In 2010 in my capacity as Clinical Director of the KP-NCAL Sacramento AACC I organized a regional program employing telehealth to address the after hours needs of adults. That program over the next 8 years averaged 50,000 encounters per year on nights and weekends and backed up an additional 200,000+ locally managed afterhours telehealth visits per year. 24% of the total encounters in KP-NCAL's Adult and Family Medicine departments by 3.8 million adults in 2017 were delivered through virtual telehealth. I would say these efforts definitely qualify as substantial "overall engagement".
The use of Angiotensin II for cardiogenic shock(1) might be counterproductive in patients who have cardiogenic shock attributable to Takotsubo cardiomyopathy(TTC) characterised by left ventricular outflow tract(LVOT) obstruction. The following are the reasons justifying non-use of that treatment modality:-
Show MoreAngiotensin II induces catecholamine release(2), thereby potentially exacerbating the catecholamine surge which characterises TTC. This catecholamine surge is mimicked by exogenous administration of epinephrine, the latter well documented as a trigger for de novo TTC in 22 patients reviewed in the literature search by Madisa et al(2). In another literature review, dobutamine(also a catecholamine ) triggered the onset of TTC in 22 patients(3). A typical example of the latter was a 61 year old woman who developed chest pain at 70% of her age-predicted heart rate, when she was on a 40 mcg/min infusion of dobutamine. Her electrocardiogram(ECG) then showed inferolateral ST segment elevation. Transthoracic echocardiography showed severe akinesia of the apical, anteroseptal, and apicolateral segments at peak dobutamine infusion. Coronary angiography disclosed normal epicardial vasculature(5).
When LVOT obstruction occurs in TTC it can give rise to severe hypotension, exemplified by a 60 year old woman with a nadir systolic blood pressure(SBP) of 80 mm Hg in association with a gradient of 58 mm Hg across the LVOT. After landiolol( a beta blocker) inf...
I enjoyed reading this article, however, the reference to a cytokine storm warrants clarification. An editorial in JAMA Internal Medicine doi:10.1001/jamainternmed.2020.3313 suggested little evidence for such a storm and this has been supported by more recent studies by Remy et al in JCI Insight (10.1172/jci.insight.140329) who demonstrated severe immunosuppression and Kox et al in JAMA (doi:10.1001/jama.2020.17052) who found multiple cytokines were reduced in severe COVID-19.
A timely and interesting read if for no other reason colleagues and I were discussing / bemoaning recurrent abdominal pain presentations only last week. Many of the features that act as obstacles were well recognised and omnipresent.
The solutions are an excellent mixture of skills and I can see much utility, I can also foresee the care pathways being highly personalised in our healthcare institutions (Daniels et al allude to this by describing one the ED consultants with an interest in HIU) and once that person moves job the pathway crumbles.
To an extent excluding medical emergency (the 1st E in ERROR) does require medicalisation whether it be vitals being taken or the initial bloods including lactate. I can see the purpose and benefit of not repeating unnecessary blood tests and I suspect not doing tests will be a feat more easily achieved with seniority, There is benefit in letting HIUs be seen exclusively by such.
I was surprised that Daniels and the other authors claim that "pain is not a central consideration in RCEM guidelines...". The college guidelines page (https://www.rcem.ac.uk/RCEM/Quality_Policy/Clinical_Standards_Guidance/R...) lists at east 3 where pain is most certainly the central consideration, or was this in relation to abdominal pain only?
Overall...
Show MoreDear Editor,
We read with great interest the EMJ article by Bahreini and colleagues (published August 2020).1 The authors aimed to compare the relative efficacy and side effect profiles of sodium thiopental–fentanyl (TF) and ketamine–propofol (KP) when used for procedural sedation of 96 adult patients prior to undergoing a painful procedure in the emergency department setting. This randomised double-blind clinical trial quantitatively compared recovery time and both patient and provider satisfaction between the two treatment groups. Additionally, the study aimed to assess the prevalence of adverse effects occurring during recovery and patient recall of the procedure. The authors concluded that there was a statistically significant improvement in both patient and provider satisfaction and degree of procedure recall when using KP compared to TF. However, there was no statistically significant difference in recovery time or adverse effects between the treatment groups.
The authors discussed that the study was not adequately powered to assess the side effect profiles. However, using a systematic review of the effects of KP and propofol, it is possible to make comparisons with the current study regarding the KP side effect profile.2 In all cases, the occurrence of adverse events was greater in those studies included in the systemic review. For example, the POKER study reported that 14% of patients sedated with KP required an airway intervention 3 compared to only...
Show MoreWhat this proposed reset does not describe is a reorganisation of 'at the door' triage based on the type of presentation.
The need for effective patient throughput (patient flow); the major problem in contemporary A&E (at least pre Covid19) has not been addressed.
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I propose triaging 'at the door' carried out by nurse practitioners (assisted by paramedic crews bringing patients in) and admin staff to access medical information rapidly (for example via the Great North Care Record). These insights were gained from camp Bastion in Afghanistan.
There should be 4 key portals and pathways thereafter.
a) The seriously ill (Major Trauma, Sepsis, Stroke, Cardiac Infarcts, Acute Abdomens etc.)
b) Cases of frailty (mainly elderly people, including delirium / dementia, minor trauma)
c) mental Health presentations (of all ages, including learning disability)
d) overspill from General Practice
These pathways would be staffed by specialist nurse practitioners, pharmacists and speciality doctors, working on prearranged algorithms with electronic prescribing and discharge / handover templates (ideally in a SBAR format) to assist patient flow. cross referral (called scaffolding in mental health) should be possible on occasion. Overall, a duty matron should keep overall control of activity through an electronic dashboard. Paramedic / ambulance crews should have access to this matron remotely to make crucial d...
Show MoreDear Editor,
I read with interest the recent article by Carley et al., “Evidence-based medicine and COVID-19: what to believe and when to change”1. The authors pay homage to the challenges of keeping pace with a pandemic growing at unprecedented speeds, forcing the hand of clinicians to make therapeutic decisions on the basis of weak, often unvalidated evidence. They also note the influence of political opinion, referencing Donald Trump’s infamous declaration on the efficacy of hydroxychloroquine as a treatment for COVID-192. In their concluding statements, the authors eloquently present the need to follow science rather than emotions or politics.
Having worked in a large critical care unit over the pandemic, I question how easy this is in practice. Clinicians, nurses and Allied Health Professionals do not exist in a vacuum, but rather their opinions and knowledge are inevitably shaped by social and cultural rhetoric. I use the example of Personal Protective Equipment (PPE), an acronym once reserved to select professions yet now colloquially used by the lay person. Information regarding the appropriate PPE to be worn was disseminated in multiple formats, from news broadcasts to social media platforms such as Twitter. As knowledge developed about how the SARS-COV-2 virus was transmitted, recommendations on PPE changed accordingly. As of July 23rd, it was recommended that double gloving was not necessary3, and in fact increased the risk of transmitting e-coli...
Show MoreThis article draws its evidence from two citations, one by Madsen et al., and the other from a systematic review, which has been mis-cited as a duplicate of the Madsen reference. The correct citation to the systematic review is not Madsen et al., but Tarnutzer et al., PubMed ID 28356464 (Tarnutzer AA, Lee SH, Robinson KA, Wang Z, Edlow JA, Newman-Toker DE. ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis. Neurology. 2017;88(15):1468-1477. doi:10.1212/WNL.0000000000003814.).
Dear Editor,
We have read with great interest the article by Vihonen et al, ‘Glucose as an additional parameter to National Early Warning Score in prehospital setting enhances identification of patients at risk of death: an observational cohort study’, recently published in your journal.(1)
Show MoreTraditionally, the scores published to assess the risk of mortality in patients attended in a prehospital setting, the predictive value of which had been questioned until recent studies, did not include the quantification of glycemia among the parameters analysed in the initial assessment of the patient.(2-4)
Overlooking its systematic determination in the initial care of any critically ill patient represents an easily avoidable risk, due to its accessibility and to the ease in interpreting results in any setting. This shortcoming is especially relevant in the initial care of patients with acute poisoning, due to the limitations of the anamnesis and the need to establish a rapid and reliable differential diagnosis in patients with often complex and plural clinical symptoms.(5,6) In this regard, the prognostic value of glycemia as a biomarker in some acute, highly lethal levels of poisoning must also be taken into account.(7,8)
In Catalonia, two studies undertaken by the Prehospital Medical Emergency Service in recent years have shown that only 30.1% of those poisoned by caustic products or 15.2% of the 1,930 people poisoned by carbon monoxide or smoke released f...
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