We are grateful to Lloyd et al.[1] and Rowlands et al.[2] for correctly
pointing out the typographical errors in our flowchart. These were
production errors, and did not reflect the original version supplied to
the journal. Patients who present after a paracetamol overdose with an
unknown quantity of paracetamol should definitely be treated as though
they may have taken a potentiall...
We are grateful to Lloyd et al.[1] and Rowlands et al.[2] for correctly
pointing out the typographical errors in our flowchart. These were
production errors, and did not reflect the original version supplied to
the journal. Patients who present after a paracetamol overdose with an
unknown quantity of paracetamol should definitely be treated as though
they may have taken a potentially hepatotoxic dose. Similarly, along the
staggered overdose pathway, all doses should be described on a dose/kg/day
and not a dose/kg basis. These errors are of sufficient importance that we
have asked the editor to reprint the flowchart with these corrected.
Rowlands et al.[2] ask for more detail on the management of at risk
patients who present with a staggered overdose of >= 75mg/kg/day or
unknown. The management of these patients is controversial and, we feel,
needs to be discussed on an individual case basis once the result of
baseline blood tests are available.
Patients who are treated with N-acetylcysteine within 8 hours of a
single paracetamol ingestion have a less than 1% risk of developing
hepatotoxicity [3] and for this reason do not require liver function
tests, INR, creatinine to be checked until after the course of N-acetylcysteine has been completed.
Rowlands et al[2] have misread the 8-24 hour pathway, the second box
refers to checking the blood results rather than taking a second blood
test.
We agree with Rowlands that there is minor interference by N-
acetylcysteine with certain paracetamol assays and doctors should check
with their local laboratory which assay is used in their hospital.
However, it is paramount that N-acetylcysteine is started as soon as
possible in late presenting patients as delayed treatment will result in
decreased efficacy. [3]
Late presenting patients and those with staggered overdose who have
abnormal blood tests carry a high mortality and management is complex and
ever changing.[4] Thus, it is critical both in terms of decisions on
management and criteria for transfer to liver units that discussion takes
place with a clinical toxicologist at a poisons centre.
INR is the best prognostic indicator in paracetamol poisoning.[4]
We agree with O’Connor et al.[5] that all patients who present after
paracetamol overdose require psychiatric evaluation and this is our every
day practice.
References
(1) Lloyd G, O'Sullivan I. Re: Psychiatric evaluation in acute poisoning [electronic response to Wallace et al. Paracetamol overdose: an evidence based flowchart to guide management. emjonline.com http://emj.bmjjournals.com/cgi/eletters/19/3/202#66
(2) Rowlands AB, Thomson J. Weaknesses in the flowchart in acute poisoning [electronic response to Wallace et al. Paracetamol overdose: an evidence based flowchart to guide management. emjonline.com http://emj.bmjjournals.com/cgi/eletters/19/3/202#65
(3) Prescott LF, Illingworth RN, Critchley JA et al. Intravenous N-
acetylcysteine: the treatment of choice for paracetamol poisoning. BMJ
1979;2:1097-100.
(4) Dargan PI, Jones AL. Acetaminophen poisoning: an update for the
intensivist. Critical Care 2002;6:108-10.
(5) O'Connor AE, Lockney AL. Psychiatric evaluation in acute poisoning [electronic response to Wallace et al. Paracetamol overdose: an evidence based flowchart to guide management. emjonline.com
http://emj.bmjjournals.com/cgi/eletters/19/3/202#58
In the paper of SGA Brown [1] adrenaline was
administered to 19 patients of 21, 3 of which in stage II and 5 in stage I
of Muller's grading of systemic allergic reactions, we think that
adrenaline administrationat at this stage is excessive and potentially
hazardous in respect to signs and symptoms, although the patients were
continuously monitored. We think adrenaline administration should be
avoided o...
In the paper of SGA Brown [1] adrenaline was
administered to 19 patients of 21, 3 of which in stage II and 5 in stage I
of Muller's grading of systemic allergic reactions, we think that
adrenaline administrationat at this stage is excessive and potentially
hazardous in respect to signs and symptoms, although the patients were
continuously monitored. We think adrenaline administration should be
avoided or carefully tritated especially in older and cardiopatic
patients in stage I and II of Muller's classification; and reserved only
for severe cases of anaphylactic reactions presenting with stridor,
wheezing, respiratory distress and clinical signs of shock.[2]
Besides,
discharge home after a symptom free interval of only two hours is probably
not safe, both for the risk of biphasic anaphylactic reaction (3) and
possibility of late side effects due to adrenaline intravenous
administration, especially in cardiopatic patiens. Moreover one of the
indications for starting the protocol was also , as stated at point 6,
only the request of a trial partecipant. We think this is not a reliable
way for assessing the clinical status of a patient on the base of which to
decide administration of adrenaline. Besides could be more useful and
safe to know data about hypoxia and acidosis trough haematic serial
samples, rather than performing spirometry.
References
1.SGA Brown, KE Blackman, V Stenlake, and R J Heddlel.: Insect sting
anaphylaxis; prospective evaluation of treatment with intravenous
adrenaline and volume resuscitation. Emerg Med J 2004; 21: 149-154.
2. Montanaro A, Bardana EJ Jr.: The mechanism, causes and the treatment of
anaphylaxis. J Invest Clin Immunol 2002;2:2-11.
3. Brazil E, MacNamara AF.: “Not so immediate” hypersensitivity- the
danger of biphasic anaphylactic reactions. J Accid Emerg Med 1998; 15: 252
-3.
Gori L, Cinotti S, Pappagallo S.
Department emergency medicine, Az USL 11 Empoli, ITALY
S. Giuseppe Hospital Viale Boccaccio 3 – 50053 Empoli, ITALY
tel: +39- 0571-702365 e-mail:s.cinotti@usl11.toscana.it
I was concerned that the above best evidence topic report suggestss
that it is safe to discharge opiod overdose patients one hour after
naloxone administration.[1] The topic report fails to mention whether this
applies to intravenous or intramuscular naloxone administartion (there is
oftwen confusion in emergency departments as to the best route) and the
authors admit that the evidence is poor....
I was concerned that the above best evidence topic report suggestss
that it is safe to discharge opiod overdose patients one hour after
naloxone administration.[1] The topic report fails to mention whether this
applies to intravenous or intramuscular naloxone administartion (there is
oftwen confusion in emergency departments as to the best route) and the
authors admit that the evidence is poor.
A few years ago I was involved in a case where a patient had taken an
opiod overdose and was treated successfully with 400mcg naloxone
intavenously. The patient subsequently tried to abscond and eventually
agreed to stay for an hour only despite us repeatedly urging the patient
to be admitted for longer; he then recieved 400mcg of naloxone
intramuscularly as staff were concerned that he might abscond prematurely.
The patient was discharged an hour and a half later with no symptoms, and
was known to be alive 6 hours later. He was found dead the next day and an
inquest found that the patient had 'fatal' plasma levels of opioid, and no
evidence to support a further overdose following discharge.
Given that the patient had repeatedly refused to stay longer and that
the department in question had no relevant guidelines, the staff involved
were exonerated.
The majority of patients with 30 minutes of chest pain 'could be
safely discharged within 1 hour', but a small number will then go on to
develop a potentially fatal arrythmia with serious consequences for the
patient and staff involved, and so we keep all these patients in. The
recommendation that it is safe to discharge opiod overdose patients after
1 hour if they have no symptoms is dangerous as the example above shows-
please keep these patients in for longer!
Francis Andrews
Reference
(1) Clarke S, Dargan P. Discharge of patients who have taken an overdose of opioids. Emerg Med J 2002;19:250-1.
This paper shows a good outcome of undiagnosed cervical spine trauma
when the intubation was performed by a senior practioner, in an ED of a
UK.
In USA, for example, paramedics perform access to airway in the local
of an accident, and they are members of the Fire Department of some city.
In Sao Paulo, the largest city of Brazil, with 10 million habitants,
this type of rescue is performed also by the Fire Departmet: there are
various Rescue Units without doctors. But here we have a difference: the
Fire Department is a department of the Military Police, and the soldier
that made the initial approach to one trauma patient in the
stree,generally aren’t whit a doctor with them. The system is generally
good: the time from one initial phone to dispatch an unit (the order to
send a car with or without a doctor is take from a senior MD) is about
seven minutes, even in a chaotic traffic: there are also motorcycles and
helychopters.But the FD soldiers of these unit only have a three months
“fellowship” in the biggest ER of the city, at the Hospital of the
University of Sao Paulo, and have the “practice” training in artificial
patients. In some cases they have to perform an intubation in the street,
these men with only the high school, a short stage and the real life.
The curious thing is that in a high number of cases attended by this
team in more than ten years, there aren’t notices of spinal lesions
worsened by them.
What can we conclude about these? They fix a collar in the patient,
put the victim in a rigid wood and there are not reports of worsened
lesions. In the beginning of this system, we doctors don’t agree with this
procedure, but the practice show the opposite. The training of soldiers by
good doctors can we assume that intubation in critical patients, like the
trauma ones, could be taken more seriously than when this type of training
is given to a medical student who does not to intube in his/her
professional life. Can these be correct?
We were interested to read the review of airway management in the
emergency department by Clancy and Nolan.[1] Immediate airway care is in the
corner stone of patient management - its importance is exemplified by
the 'A' of the ABC mantra. We do not wish to go over the issues already
raised but to introduce another aspect to the discussion.
We are members of a local pre-hospital care group. Our...
We were interested to read the review of airway management in the
emergency department by Clancy and Nolan.[1] Immediate airway care is in the
corner stone of patient management - its importance is exemplified by
the 'A' of the ABC mantra. We do not wish to go over the issues already
raised but to introduce another aspect to the discussion.
We are members of a local pre-hospital care group. Our 'day jobs' are
various and therefore the level of anaesthetic experience varies between
us. The discussion over how we should manage the pre-hospital airway wanes
and waxes but is never resolved. There are many advantages of definitive
pre-hospital airway care, ensuring the delivery of high concentrations
of oxygen to the lungs, protecting the airway against contamination,
lowering intracranial pressure when practiced correctly, to mention a few.
The main disadvantages include lack of practical experience and the
potential adverse pharmacological effects of anaesthetic drugs. Currently,
advanced airway care is one skill that pre-hospital doctors can offer over
paramedics who remain constrained by protocol to intubate only comatose or
dead patients.
We would like to see the education of advanced airway care extended
to include pre-hospital carers. Courses similar to the three day National
Emergency Airway Management course could offer excellent coverage of core
techniques and the use of a few key drugs. Failed intubation protocols
would ensure that no patient would be left anaesthetised without an
adequate airway.
Intubating patients can be daunting, especially when away from
controlled environment of the hospital and when unassisted. Should
endotracheal intubation fail there are alternatives including the
laryngeal mask and new intubating laryngeal mask airways, the combitube
and so on.
We also recommend the maintenance an anaesthetic logbook as evidence
of training and experience. Data on equipment, drugs, techniques, problems
encountered and their corrective measures should be compiled. This should
provide proof of knowledge, experience and skill for the non-anaesthetist.
Most BASICS (British Association for Immediate Care) members are GPs.
Anaesthetists form a minority. In pre-hospital care successful advanced
airway management cannot just be the remit of anaesthetists. Education
followed by relevant experience and revalidation must be the way forward.
K Roberts
SHO Surgical Rotation Birmingham Heartlands and Solihull
NHS Trust
N Sherwood
Consultant Anaesthetist City Hospital NHS Trust Birmingham
A Bleetman
Consultant in Emergency Medicine
Birmingham Heartlands and
Solihull NHS Trust
Reference
(1) Clancy M, Nolan J. Airway management in the emergency department. Emerg Med J 2002;19:2-3.
If you are interested in the causes of violence and hostile
behaviour, and want insight then please take the time to read: www.abusedbythesystem.org.uk
for debate.
While the paracetamol overdose flowchart proposed by Wallace et al.
[1] puts forward a generally helpful approach to this common problem, I
would like to raise two points which could be of concern.
First, the authors do not recommend measurement of paracetamol levels
after a staggered overdose. Since a staggered overdose relies entirely on
the patient's history, a blood paracetamol level...
While the paracetamol overdose flowchart proposed by Wallace et al.
[1] puts forward a generally helpful approach to this common problem, I
would like to raise two points which could be of concern.
First, the authors do not recommend measurement of paracetamol levels
after a staggered overdose. Since a staggered overdose relies entirely on
the patient's history, a blood paracetamol level will at least help to
confirm the most recent ingestion and guide treatment.
Secondly, there is no mention of mental state assessment or
psychiatric liaison before discharging the patient. If junior doctors are
to use the flowchart as their guide for management, a reminder of the
inportance of mental state evaluation and,in particular,risk of further
suicide attempts is vital.
Michelle Jacobs
Reference
(1) Wallace CI,Dargan PI,Jones AL. Paracetamol overdose:an
evidence based flowchart to guide management. Emerg Med J2002;19:202-5.
Neil Morton's points are concise and thought provoking as always.[1] The withdrawal and ongoing reevaluation of the SIGN
guidelines on paediatric procedural sedation were rightly welcomed as a
chance to address issues which many emergency physicians felt had been
overlooked. Our colleagues from Australasia and the United States are
somewhat puzzled by our hesitation in adopting what is viewed by them a...
Neil Morton's points are concise and thought provoking as always.[1] The withdrawal and ongoing reevaluation of the SIGN
guidelines on paediatric procedural sedation were rightly welcomed as a
chance to address issues which many emergency physicians felt had been
overlooked. Our colleagues from Australasia and the United States are
somewhat puzzled by our hesitation in adopting what is viewed by them as a
valuable adjunct in the care of children undergoing painful procedures in
the emergency department.
Having witnessed many situations where there has been only a stark
choice between wrapping a child in a blanket to do "a quick couple of
sutures" or transferring the child for a general anaesthetic and overnight
stay in hospital I sincerely hoped there might in future be better ways of
doing things. While I wouldnt rush to start using ketamine on every unruly
child the increasing body of research on this (from the UK) does not
support the notion that this is a colossally dangerous technique.
The majority of emergency medicine specialist registrars are now
competent in rapid sequence intubation by the end of their training and
many have formal training in safe sedation (including standardised
simulator training. Procedural sedation in paediatric emergency medicine
is not practiced in any of the three children's hospitals in Scotland but
many paediatric emergency medicine trainees have learned these techniques
in Australasia.
The arguments put forward against the use of ketamine are sadly
familiar to those of us who practice rapid sequence intubation in A&E.
In the same way, skilled, responsible and properly trained emergency
physicians will simply start doing it and zealously auditing it's safety
until it is considered normal.
It is only a matter of time until Neil Morton's own hospital appoints
an emergency physician who has this training and it is introduced safely
and effectively. These clinicians are very far removed from the "cowboys"
we are constantly being characterised as.
Reference
1. N S Morton. Ketamine is not a safe, effective, and appropriate technique for emergency department paediatric procedural sedation. Emerg Med J 2004; 21: 272-273.
I wonder if we may make further comment in light of the
reply of Jones et al. to our initial concerns over
perceived weaknesses of their flowchart on the
management of paracetamol poisoning.
Our ongoing major concern is that, in their reply, Jones
et al. appear to be holding to the position that INR is the
best prognostic indicator in paracetamol poisoning.
Studying the r...
I wonder if we may make further comment in light of the
reply of Jones et al. to our initial concerns over
perceived weaknesses of their flowchart on the
management of paracetamol poisoning.
Our ongoing major concern is that, in their reply, Jones
et al. appear to be holding to the position that INR is the
best prognostic indicator in paracetamol poisoning.
Studying the reference they give to back this position [1]
one finds two clear statements: Firstly, that "The most
sensitive prognostic marker is prothrombin time"; and
secondly that "In (their) clinical experience, when PT
starts to improve full recovery follows". Where INR is
mentioned is when the article itself refers to another
article [2] which, on closer scrutiny, does not in fact
make any reference to INR but does include
prothrombin time amongst the data collected and
presented .
We should be most grateful for final confirmation as to
which marker to monitor because if the answer is
prothrombin time, as we suspect, then further important
amendments will need to be made to the flowchart and
it's legend before reprinting.
Finally, and with all due respect to Jones et al.. can we
say that rather than misreading the 8-24hr pathway, we
evidently did not interpret it in the way which was
intended. Perhaps this in itself is justification for
reviewing the flowchart.
References
[1] Dargan PI, Jones AL. Acetaminophen poisoning:
an update for the intensivist. Critical Care
2002;6:108-10.
[2] Gyamlani GG, Parikh CR: Acetaminophen toxicity:
suicidal vs accidental. Critical Care 2002;6:155-9.
I read with great interest the article by MC Howes. It concerns me
that much current practice in Emergency Medicine in the UK is still
dictated by those outside the speciality, who have little or no idea of
the needs of our patients, or the settings in which we work.
I was not surprised to read that, while ketamine sedation has been
accepted both in the US and Australia as a part of modern eme...
I read with great interest the article by MC Howes. It concerns me
that much current practice in Emergency Medicine in the UK is still
dictated by those outside the speciality, who have little or no idea of
the needs of our patients, or the settings in which we work.
I was not surprised to read that, while ketamine sedation has been
accepted both in the US and Australia as a part of modern emergency
medicine practice, the UK still cautions that use of general anaesthetic
(presumably including ketamine) should only be practiced by those trained
in paediatric or neonatal anaesthesia.
In our own (third world) department, ketamine is often used to sedate
children who need to undergo short, painful operations, including
manipulation of fractures and some suturing and incision and drainage
procedures.
We have a well written protocol (developed by my predecessor) which
has stood the test of time (it has been in force for the past 4 years with
no serious complications to date).
The key to safe and effective sedation hinges on the following:
careful selection of patients (including premorbid history, airway
assessment and fasting history); properly trained staff (for each
procedure, ther must be at least one person responsible for the airway who
can manage an emergent airway problem - this is NOT necessarily a
paediatric anaesthetist) and careful selection of drugs (we use ketamine
for all our younger children, with the addition of a small dose of
midazolam and atropine). Finally, the patient MUST be monitored carefully
until awake. In our department, pulse oximetry is mandatory, but the
importance of clinical observation is stressed to all staff.
I feel that it is more than time for practitioners in the UK to grasp
the nettle and produce their own guidelines regarding sedation in their
departments. This does not have to be 'sanctioned' by the Royal College of
Anaesthetists, though their input would be welcome. The important thing
for us to remember is that once we set ourselves certain standards, it is
our duty to live up to these, and in the case of untoward incidents, we
must be willing to accept responsibility. In the field of sedation in the
Emergency setting, the only professionals capable of creating meaningful
guidelines are Emergency Physicians.
Dear Editors
We are grateful to Lloyd et al.[1] and Rowlands et al.[2] for correctly pointing out the typographical errors in our flowchart. These were production errors, and did not reflect the original version supplied to the journal. Patients who present after a paracetamol overdose with an unknown quantity of paracetamol should definitely be treated as though they may have taken a potentiall...
Dear Editor
In the paper of SGA Brown [1] adrenaline was administered to 19 patients of 21, 3 of which in stage II and 5 in stage I of Muller's grading of systemic allergic reactions, we think that adrenaline administrationat at this stage is excessive and potentially hazardous in respect to signs and symptoms, although the patients were continuously monitored. We think adrenaline administration should be avoided o...
Dear Editor
I was concerned that the above best evidence topic report suggestss that it is safe to discharge opiod overdose patients one hour after naloxone administration.[1] The topic report fails to mention whether this applies to intravenous or intramuscular naloxone administartion (there is oftwen confusion in emergency departments as to the best route) and the authors admit that the evidence is poor....
Dear Editor
This paper shows a good outcome of undiagnosed cervical spine trauma when the intubation was performed by a senior practioner, in an ED of a UK.
In USA, for example, paramedics perform access to airway in the local of an accident, and they are members of the Fire Department of some city.
In Sao Paulo, the largest city of Brazil, with 10 million habitants, this type of rescue is perfor...
Dear Editor
We were interested to read the review of airway management in the emergency department by Clancy and Nolan.[1] Immediate airway care is in the corner stone of patient management - its importance is exemplified by the 'A' of the ABC mantra. We do not wish to go over the issues already raised but to introduce another aspect to the discussion.
We are members of a local pre-hospital care group. Our...
If you are interested in the causes of violence and hostile behaviour, and want insight then please take the time to read:
www.abusedbythesystem.org.uk
for debate.
Thank you.
Dear Editor
While the paracetamol overdose flowchart proposed by Wallace et al. [1] puts forward a generally helpful approach to this common problem, I would like to raise two points which could be of concern.
First, the authors do not recommend measurement of paracetamol levels after a staggered overdose. Since a staggered overdose relies entirely on the patient's history, a blood paracetamol level...
Dear Editor
Neil Morton's points are concise and thought provoking as always.[1] The withdrawal and ongoing reevaluation of the SIGN guidelines on paediatric procedural sedation were rightly welcomed as a chance to address issues which many emergency physicians felt had been overlooked. Our colleagues from Australasia and the United States are somewhat puzzled by our hesitation in adopting what is viewed by them a...
Dear Editors,
I wonder if we may make further comment in light of the reply of Jones et al. to our initial concerns over perceived weaknesses of their flowchart on the management of paracetamol poisoning.
Our ongoing major concern is that, in their reply, Jones et al. appear to be holding to the position that INR is the best prognostic indicator in paracetamol poisoning. Studying the r...
Dear Editor
I read with great interest the article by MC Howes. It concerns me that much current practice in Emergency Medicine in the UK is still dictated by those outside the speciality, who have little or no idea of the needs of our patients, or the settings in which we work.
I was not surprised to read that, while ketamine sedation has been accepted both in the US and Australia as a part of modern eme...
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