We read with interest and some sympathy the recent case report by Walker et al of an apparent 'Lazarus' phenomenon in which spontaneous circulation unexpectedly returned after abandoning resuscitation of a patient believed to have taken an opiate overdose [1]. In common with inner-city Emergency Departments the world over, heroin overdoses make up a significant proportion of our workload. It is establis...
We read with interest and some sympathy the recent case report by Walker et al of an apparent 'Lazarus' phenomenon in which spontaneous circulation unexpectedly returned after abandoning resuscitation of a patient believed to have taken an opiate overdose [1]. In common with inner-city Emergency Departments the world over, heroin overdoses make up a significant proportion of our workload. It is established practice in this context, along with other therapeutic maneuvers, to begin naloxone therapy with a 2mg bolus, which is then repeated if necessary up to a total of 10mg or more if the diagnosis of opiate overdose is still being maintained. The upper dose is suggested by the British National Formulary [2]. This applies to respiratory and cardio-respiratory arrests - remembering that one of the four 'T's of reversible causes of cardiac arrest in the Universal Algorithm of the European Resuscitation Council is Toxic/therapeutic disturbances [3].
In the case reported by Walker et al we would like to highlight the following points:
1. The patient initially responded to a total of 1.2mg intramuscular naloxone given on scene by the Paramedics, improving from GCS 3/15 to being able to walk to the ambulance. Thus the diagnosis of opiate overdose was highly likely.
2. In transit he deteriorated and subsequently had a cardio-respiratory arrest. He was in asystole on arrival to hospital. During the next 25 minutes of resuscitation he received only a further 3.6mg total of naloxone intravenously. Since his rhythm had been asystole for more than 25 minutes the resuscitation was not unreasonably abandoned. However, a few minutes later he recovered a perfusing rhythm. He left the hospital 18 days later with a full neurological recovery.
3. We suggest that the patient should have received 10mg of naloxone, or more, during the resuscitation. The probable diagnosis was demonstrated by his initial response to the naloxone administered by the Paramedics. It is likely that he took a massive overdose of opiate as indexed by his severe cardiac depression. However, as a habitual user, it is also likely that he would quickly metabolise his overdose if he remained alive long enough. To the credit of the team involved, the CPR during his 25 minutes of hospital resuscitation must have been enough to perfuse his brain, hence eventual full neurological recovery, and his liver, hence opiate metabolism enough to regenerate a perfusing rhythm.
References
(1) Walker A, McClelland H, Brenchley J. The Lazarus phenomenon following recreational drug use. Emergency Medicine Journal 2001; 18: 74 - 75.
(2) British National Formulary. Number 40. September 2000. British Medical Association and the Royal Pharmaceutical Society of Great Britian.
(3) Advanced Life Support Working Group of the European Resuscitation Council. The 1998 European Resuscitation Council guidelines for adult advanced life support. BMJ 1998; 316: 1863-1869
In his article, Dr Foëx sketched the history of intraosseous drug and
fluid administration, citing Tocantins and co-workers as the pioneers of
this technique. In all fairness, however, it should be pointed out that
this method was indeed described, and used clinically, even earlier than
that. In fact, one of the pioneers in this field, Henry Turkel, traces the
experimental studies of the bone marrow...
In his article, Dr Foëx sketched the history of intraosseous drug and
fluid administration, citing Tocantins and co-workers as the pioneers of
this technique. In all fairness, however, it should be pointed out that
this method was indeed described, and used clinically, even earlier than
that. In fact, one of the pioneers in this field, Henry Turkel, traces the
experimental studies of the bone marrow for fluid infusion well back into
the 19th century.[1]
If an inventor can be identified for the use of the marrow for the
administration of drugs and fluids, it is probably Cecil Drinker of Johns
Hopkins University. As early as 1916, he demonstrated in the dog that the
tibial marrow could be perfused with Ringers' solution.[2] In 1922, he
published further studies, using also cats and rabbits.[3] Unfortunately,
Tocantins and co-workers in their articles make little or no mentioning of
these early findings.
In 1934, Arnold Josefson, Professor of Medicine at Sabbatsberg
Hospital, Stockholm, presented a series of more than 50 intraossal
injections for the treatment of pernicious anemia.[4]
During the Second World War, the intraosseous method appears to have
been in quite widespread use by the U.S. Armed Forces.[5] It then
disappeared from the adult scene, only to reappear during the 1990's, when
more practical needles and devices became available (e.g. the Cook Sur-
Fast needle, the Wais-Med Bone Injection Gun [B.I.G.], and the Pyng
F.A.S.T. 1).
Eskil Dalenius MD DEAA RSwAFMC
References
(1) Turkel H. Transfusion by way of the bone marrow. Int Med Dig
1956;68:117-121.
(2) Drinker CK, Drinker KR. A method for maintaining an artificial
circulation through the tibia of the dog, with a demonstration of the
vasomotor control of the marrow vessels. Amer J Physiol 1916;40:514-521.
(3) Drinker C, Drinker KR, Lund CC. The circulation in the mammalian
bone marrow. Amer J Physiol 1922;62:1-92.
(4) Josefson A. A new method of treatment - Intraossal injections. Acta
Med Scand 1934;81:550-564.
(5) Turkel H. Emergency infusion through the bone. Milit Med
1984;149:349-350.
Whilst we broadly agree with the authors use of nitrous oxide as an
adjunct analgesic in emergency medicine,[1] we feel that there are better
alternatives to nitrous oxide in some cases. For example, we would suggest
the use of intravenous opioids and anti-emetics in myocardial and acute
sickle cell pain, non-steroidals in renal colic, and triptans in migraine.
Whilst we broadly agree with the authors use of nitrous oxide as an
adjunct analgesic in emergency medicine,[1] we feel that there are better
alternatives to nitrous oxide in some cases. For example, we would suggest
the use of intravenous opioids and anti-emetics in myocardial and acute
sickle cell pain, non-steroidals in renal colic, and triptans in migraine.
Secondly, in the United Kingdom we are fortunate to have premixed
cylinders of 50:50 oxygen: nitrous oxide (ENTONOX ® produced by BOC).
However, there is potential for confusion if anaesthetic machines are used
to obtain a 50:50 oxygen and nitrous oxide mixture when working overseas.
This is because of the differences in the colour codes of medical gas
cylinders. A number of countries use a gas cylinder code that differs from
the international code. In the United States of America the colour code is
almost identical to the international code- a notable exception being a
green cylinder for oxygen rather than white.[2]
References
(1) O’Sullivan I, Benger J. Nitrous oxide in emergency medicine. Emerg Med
J 2003;20:214-217.
(2) Dorsch J, Dorsch S. Understanding anaesthesia equipment, 4th edition.
Baltimore: Williams & Wilkins, 1999:13.
I read with interest the case reports on massive intrathoracic
haemorrhage after aspiration for spontaneous pneumothorax.
It has always
been my understanding that the reason for continuing to use the second
intercostal space, mid-clavicular line (2ICS MCL) approach for these
patients is more to do with convenience and ease of approach than for any
scientific reason. Aspirating 2 litres may take c...
I read with interest the case reports on massive intrathoracic
haemorrhage after aspiration for spontaneous pneumothorax.
It has always
been my understanding that the reason for continuing to use the second
intercostal space, mid-clavicular line (2ICS MCL) approach for these
patients is more to do with convenience and ease of approach than for any
scientific reason. Aspirating 2 litres may take considerable time, and
using the 2ICS MCL it is generally easy to find the intercostal space and
the patient can be in pretty much any position that is comfortable for
them and convenient for the 'aspirator'. I would contrast this to the 5th
intercostal space anterior axillary line approach, when it can be more
difficult to identify the space and awkward for both patient and doctor to
keep the arm in a convenient position. I tried this approach for a while
and have to admit to going back to the 2ICS MCL approach which I find much
easier.
Whilst tempting to blame the anatomy and dangerous 'big vessels' on each
of the cases presented, in none of them was a source of bleeding
identified. It is therefore not possible to conclude, as the authors
appear to, that similar complications would not occur if a different
approach occurred.
I would also be interested to know what technique was used for aspiration
- with modern purpose designed seldinger technique kits (or just an old
fashioned single lumen cvp line kit) the needle used to punture the chest
wall is of a relatively small calibre. It would be a rare occurence to
cause a massive haemothorax even when deliberately puncturing subclavian
vessels for central venous access, so it does seem incredibly unlucky to
have 3 cases in such a short period of time.
Reference
(1) R Rawlins, KM Brown, CS Carr, CR Cameron. Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emerg Med J 2003;20:383-384.
The use of dipsticks in A&E has been looked at extensively. The
underlying problem is the lack of a "gold standard" in that microscopy is
not a 100% reliable and apparent positive cultures on MSUs can be due to
contamination whilst getting an MSU.
Using Strip Testing we were able to demonstrate a predictive value
for a negative result of 96.4%, but we were using 4 parameters
(blood,protein,...
The use of dipsticks in A&E has been looked at extensively. The
underlying problem is the lack of a "gold standard" in that microscopy is
not a 100% reliable and apparent positive cultures on MSUs can be due to
contamination whilst getting an MSU.
Using Strip Testing we were able to demonstrate a predictive value
for a negative result of 96.4%, but we were using 4 parameters
(blood,protein,leucocytes and nitrites)not just 2 as highlighted in the
BET. These strips were visually read, so it is highly likely that the use
of photometers to read the strip would improve on this value.
We concluded that by excluding these specimens there would be a reduction in 37% of MSUs requested.[1]
Some screening test is needed.
Reference
(1) McGlone R, Lambert M, Clancy M, Hawkey PM. Use of Ames SG10 Urine Dipstick for diagnosis of abdominal pain in the
accident and emergency department. Archives of Emergency Med1990;7(1):42-7.
The paper by Harvey and colleagues is a slightly overdramatic. In
their audit they found that PEFR was not regularly recorded in the notes.
However this does not mean that the assessment of patients is unsafe.
Asthma severity as they point out is based on a number of physiological
and clinical parameters. PEFR is used as a measure of severity but it has
a severe limitations as it requires a good techniqu...
The paper by Harvey and colleagues is a slightly overdramatic. In
their audit they found that PEFR was not regularly recorded in the notes.
However this does not mean that the assessment of patients is unsafe.
Asthma severity as they point out is based on a number of physiological
and clinical parameters. PEFR is used as a measure of severity but it has
a severe limitations as it requires a good technique to produce a reliable
result, which may be difficult especially for young children. It is
probably less useful as single readings than a regular readings
documenting an individuals deterioration in performance. It is reassuring
to see that other more reliable measured parameter were usually measured
i.e. pulse and respiratory rate, and oxygen saturation.
Personally I feel that my clinical decision making is often unnaffected by
an absence of a PEFR. If I have a child charging around the room,
asymptomatic, normal pulse and respiratory rate I am unlikely to keep them
in. If however they are too breathless to play and have an elevated
respiratory rate I would treat and if not improve refer.
Dr. Leung's first comment relates to our method of calculating the proportions of child attenders in each deprivation category. The numerator we use to calculate each proportion is based on the number of first-time attenders, while the denominator represents the total population in each category. Dr. Leung argues that the proportion of children who were 'at risk' of being first attenders will be lower in the de...
Dr. Leung's first comment relates to our method of calculating the proportions of child attenders in each deprivation category. The numerator we use to calculate each proportion is based on the number of first-time attenders, while the denominator represents the total population in each category. Dr. Leung argues that the proportion of children who were 'at risk' of being first attenders will be lower in the deprivation categories with higher attendance rates (since they would be more likely to be previous attenders).
While acknowledging this, we would argue that the conclusion we draw - i.e. that attendance rates are higher for patients in the more deprived categories - is nonetheless fully supported by the data. Our reasoning is as follows. Let us accept that the population numbers on which our proportions were calculated overstate the 'true' populations (since not all children in each population are potential first-time attenders, due to some having presented previously at the A&E facility involved). From this, it follows that the proportions of first-time attenders given by us understate the 'true' proportions (since the numerators remain fixed, while the denominators reduce by an unknown amount). Now, if we accept that children in the more deprived groups are less likely to be first-time attenders, then it follows that any disparity between the proportions we give and the 'true' proportions will be greater in the more deprived categories (with their unknown, but presumed higher, rates of previous attendance) than in the less deprived categories (where previous attendance is less likely). In other words, the true proportions of first-time attenders in the less deprived groups will be higher than our estimates, but the true proportions of such attenders in the more deprived categories will, relatively speaking, be higher still. Thus, the proportions we present can reasonably be regarded as conservative estimates, and we argue that our basic conclusion - higher attendance rates in more deprived groups - remains fully tenable.
We are aware of information about 'distance decay effect' of patients living far from from NHS facilities using them less. While it is true that many British cities have disadvantaged city centres near to Accident and Emergency Departments with local populations using them heavily, this is not the case in Lothian. In Edinburgh our disadvantaged areas are typically peripheral housing estates and in fact the RHSC is located in a relatively affluent part of the city and at a distance from disadvantaged areas.
We apologise for our omission not citing the source of the populations used. These were the 1996 mid year estimates of the General Registrar's Office (Scotland).
Dr T F Beattie
Accident and Emergency Care
Dr D R Gorman
Public Health Medicine
Mr J Walker
Community Health Sciences
Reference
(1) Beattie TF, Gorman DR, Walker JJ. The association between deprivation levels, attendance rate and triage category of children attending a children's accident and emergency department. Emerg Med J 2001;18:110-111.
I read with interest the report of Rawlins and colleagues,[1] which gave
account of 3 cases in which life threatening haemorrhage was associated
with anterior needle aspiration of pneumothorax.
The authors commented
that data on complications of needle aspiration in spontaneous
pneumothorax were limited. They cited one study on traumatic pneumothorax
in which needle aspiration was associated with...
I read with interest the report of Rawlins and colleagues,[1] which gave
account of 3 cases in which life threatening haemorrhage was associated
with anterior needle aspiration of pneumothorax.
The authors commented
that data on complications of needle aspiration in spontaneous
pneumothorax were limited. They cited one study on traumatic pneumothorax
in which needle aspiration was associated with a low complication rate.
There are at least 6 more studies in the literature that report low
complication rate with simple aspiration using the anterior approach
(second intercostal space, mid-clavicular line).[2-7] Haemorrhage was
reportedly very rare.
In the authors' institution, 3 cases with haemorrhage occurred over a
6 month period. I would be interested to know the number of cases over the
same period in which simple aspiration was successful, and uncomplicated.
References
(1) Rawlins R, Brown KM, Carr CS, Cameron CR. Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emerg Med J 2003;20:383-384.
(2) Noppen M, Alexander P, Driesen P, et al. Manual aspiration versus
chest tube drainage in first episodes of primary spontaneous pneumothorax.
A multicenter, prospective, randomised pilot study. Am J Respir Crit Care
Med 2002;165:1240-1244
(3) Harvey J, Prescott RJ. Simple aspiration versus intercostal tube
drainage for spontaneous pneumothorax in patients with healthy lungs. BMJ 1994;309:1338-9
(4) Soulsby T. British Thoracic Society guidelines for the management of
spontaneous pneumothorax: do we comply with them and do they work? J Accid
Emerg Med 1998;15(5):317-21
(5) Ng AW, Chan KW and Lee SK. Simple aspiration of pneumothorax. Singapore
Med J 1994;35(1):50-2
(6) Markos J, Mc Conigle P, Phillips MJ. Pneumothorax: treatment by small-
lumen catheter aspiration. Aust N Z J Med 1990;20:775-781
(7) Hayes JA, Burdon JGW. The management of spontaneous pneumothorax by
simple aspiration. Aust Fam Physician 1988; 17:458-462.
Dr Riordam's study on promptness of antibiotic treatment for
meningococcal disease revealed that "door to needle" time to
administration of appropriate antibiotic for children decreased clearly
from before to after a teaching intervention was given to nurses and
doctors.[1] That this decrease occurred only for the children who had
typical rash on arrival is not a surprise, given that the interventi...
Dr Riordam's study on promptness of antibiotic treatment for
meningococcal disease revealed that "door to needle" time to
administration of appropriate antibiotic for children decreased clearly
from before to after a teaching intervention was given to nurses and
doctors.[1] That this decrease occurred only for the children who had
typical rash on arrival is not a surprise, given that the intervention was
a lecture that focused on recognition of the rash. But could the
intervention be different from that? Petechial rash is the sign that,
although not pathognomonic, is highly suggestive of meningococcal disease.
I suspect that in a substantial proportion of those children who had no
rash on arrival the diagnosis was actually investigated or made only when
the typical rash appeared.
Notwithstanding the decrease in door to needle time, it is
disappointing to learn from Riordam's study that the case-fatality ratio
of cases diagnosed after the intervention was actually higher than before
(11.9%, 95% confidence interval [CI] 4.5% to 26.4%, vs 6.1%, 95% CI 1.1%
to 21.6%), with a risk ratio of 1.96 (95% CI 0.41 to 9.49). Because the
numbers were small one cannot rule out the role of chance to explain this
finding, but one can also speculate that the decrease in door to needle
time was not the major determinant in terms of risk of death from
meningococcal disease. It is well possible that early recognition of
petechiae by parents or caregivers and their understanding that this
finding requires prompt intervention by a doctor would have a higher
impact on mortality from meningococcal disease. "First manifestation to
first examination" time could therefore be a better indicator of
prognosis. If this is so, focus on teaching interventions should be
shifted from physicians and nurses to parents and caregivers.
Reference
1. Riordam FAI. Improving promptness of antibiotic treatment in
meningococcal disease. Emerg Med J 2001;18:162-163.
We read the article by Brookes et al. with great interest. [1] The work was well
conducted and the authors should be appreciated for the study. The need
for continuous, non-invasive and reliable respiratory rate monitoring has
long been recognised. The continuous respiratory monitoring of the
spontaneously as well as compromised breathing patients in the emergency
and inpatient hospital practi...
We read the article by Brookes et al. with great interest. [1] The work was well
conducted and the authors should be appreciated for the study. The need
for continuous, non-invasive and reliable respiratory rate monitoring has
long been recognised. The continuous respiratory monitoring of the
spontaneously as well as compromised breathing patients in the emergency
and inpatient hospital practice would be considerably improved with
regular use of such monitors.
There are few points in the published article, which need further
elaboration. It is commented in the discussion about this study as a pilot
study, validating the PEP as an accurate measure of the respiratory rate.1
There are several studies published prior to the current one on PEP and
related respiratory monitors in order to develop a non-invasive
respiratory monitoring device.[2-8]
It can be argued that the sample size of 12 volunteers is enough to
validate such study and to conclude regarding the correlation and the
agreement among different techniques of respiratory rate monitoring.
Furthermore, capnography, although a gold standard respiratory rate
monitoring device is mainly used in intubated patients. In the current
study, the PEP monitor was primarily compared against capnography. The two
systems can not be compared to prove one better as there are remarkable
differences in their applicability and clinical usage.
It is well described in the literature that routine recording of the
respiratory rate is inconsistent and inaccurate.[9] In such event, a world
wide need in the medical profession to have a safe, non-invasive and cheap
method for respiratory rate measurement can be well appreciated and PEP
monitor can be a milestone in the coming future. Not only in compromised
patients who present to emergency departments, but PEP monitor can also be
used in the wards and recovery rooms as to detect the alteration in
physiology at an early stage. Further large multi-specialty clinical
trials are required to establish a standard for the measurement of the
respiratory rate in both awake and sedated patients as well as acutely and
chronically compromised patients of varying age.
References
(1) Brookes CN, Whittaker JD, Moulton C, Dodds D. The PEP respiratory
monitor: a validation study. Emerg Med J 2003;20(4):326-8.
(2) Rapoport I, Cousin AJ. A pilot clinical PEP monitor. IEEE Trans
Biomed Eng 1979;26(6):345-9.
(3) Folke M, Granstedt F, Hok B, Scheer H. Comparative provocation
test of respiratory
monitoring methods. J Clin Monit Comput 2002; 17(2):97-103.
(4) Doyle DJ, Volgyesi GA Design and evaluation of a new respiratory
monitor. Anaesthesia 1990;45(6):492-3.
(5) Kulkarni V, Cyna A, Hutchison JM, Tunstall ME, Mallard JR. AURA: a
new respiratory monitor. Biomed Sci Instrum 1990; 26:111-20.
(6) Hok B, Wiklund L, Henneberg S A new respiratory rate monitor:
development and initial clinical experience. Int J Clin Monit Comput 1993;10(2):101-7.
(7) Arnson LA, Rau JL Jr, Dixon RJ. Evaluation of two electronic
respiratory rate monitoring systems. Respir Care 1981;26(3):221-7.
(8) Dodds D, Purdy J, Moulton C. The PEP transducer: a new way of
measuring respiratory rate in the non-intubated patient. J Accid Emerg
Med 1999;16(1):26-8.
(9) Kory RC. Routine measurement of the respiratory rate: an expensive
tribute to tradition. JAMA 1957;165:448–50.
We read with interest and some sympathy the recent case report by Walker et al of an apparent 'Lazarus' phenomenon in which spontaneous circulation unexpectedly returned after abandoning resuscitation of a patient believed to have taken an opiate overdose [1]. In common with inner-city Emergency Departments the world over, heroin overdoses make up a significant proportion of our workload. It is establis...
Dear Editor,
In his article, Dr Foëx sketched the history of intraosseous drug and fluid administration, citing Tocantins and co-workers as the pioneers of this technique. In all fairness, however, it should be pointed out that this method was indeed described, and used clinically, even earlier than that. In fact, one of the pioneers in this field, Henry Turkel, traces the experimental studies of the bone marrow...
Dear Editor
Whilst we broadly agree with the authors use of nitrous oxide as an adjunct analgesic in emergency medicine,[1] we feel that there are better alternatives to nitrous oxide in some cases. For example, we would suggest the use of intravenous opioids and anti-emetics in myocardial and acute sickle cell pain, non-steroidals in renal colic, and triptans in migraine.
Secondly, in the United Kingdom we...
Dear Edito
I read with interest the case reports on massive intrathoracic haemorrhage after aspiration for spontaneous pneumothorax.
It has always been my understanding that the reason for continuing to use the second intercostal space, mid-clavicular line (2ICS MCL) approach for these patients is more to do with convenience and ease of approach than for any scientific reason. Aspirating 2 litres may take c...
Dear Editor
The use of dipsticks in A&E has been looked at extensively. The underlying problem is the lack of a "gold standard" in that microscopy is not a 100% reliable and apparent positive cultures on MSUs can be due to contamination whilst getting an MSU.
Using Strip Testing we were able to demonstrate a predictive value for a negative result of 96.4%, but we were using 4 parameters (blood,protein,...
Dear Editor
The paper by Harvey and colleagues is a slightly overdramatic. In their audit they found that PEFR was not regularly recorded in the notes. However this does not mean that the assessment of patients is unsafe. Asthma severity as they point out is based on a number of physiological and clinical parameters. PEFR is used as a measure of severity but it has a severe limitations as it requires a good techniqu...
Dr. Leung's first comment relates to our method of calculating the proportions of child attenders in each deprivation category. The numerator we use to calculate each proportion is based on the number of first-time attenders, while the denominator represents the total population in each category. Dr. Leung argues that the proportion of children who were 'at risk' of being first attenders will be lower in the de...
Dear EDitor
I read with interest the report of Rawlins and colleagues,[1] which gave account of 3 cases in which life threatening haemorrhage was associated with anterior needle aspiration of pneumothorax.
The authors commented that data on complications of needle aspiration in spontaneous pneumothorax were limited. They cited one study on traumatic pneumothorax in which needle aspiration was associated with...
Dear Editor,
Dr Riordam's study on promptness of antibiotic treatment for meningococcal disease revealed that "door to needle" time to administration of appropriate antibiotic for children decreased clearly from before to after a teaching intervention was given to nurses and doctors.[1] That this decrease occurred only for the children who had typical rash on arrival is not a surprise, given that the interventi...
Dear Editor
We read the article by Brookes et al. with great interest. [1] The work was well conducted and the authors should be appreciated for the study. The need for continuous, non-invasive and reliable respiratory rate monitoring has long been recognised. The continuous respiratory monitoring of the spontaneously as well as compromised breathing patients in the emergency and inpatient hospital practi...
Pages