I found the term "Induction of Anaesthesia" somewhat uninspiring,
especially as it was the header of a national survey.
The term is outdated and was replaced some 10 years ago by "Rapid Sequence Intubation". "Intubation" and "Induction" of anaesthesia are not interchangeable terms. The latter stops at "Time zero*" the former only after mission is accomplished and the airway is secured. We intubate. RSI
= Rapid S...
I found the term "Induction of Anaesthesia" somewhat uninspiring,
especially as it was the header of a national survey.
The term is outdated and was replaced some 10 years ago by "Rapid Sequence Intubation". "Intubation" and "Induction" of anaesthesia are not interchangeable terms. The latter stops at "Time zero*" the former only after mission is accomplished and the airway is secured. We intubate. RSI
= Rapid Sequence Intubation.
I welcome the opportunity to read this article and thank the authors
for their work which adds considerably to the literature on the topic of
Procedural Sedation and Analgesia (PSA) in Emergency Departments (EDs).
My own experience is similar, and I concluded some time ago that
complications, or situations where complications are more likely to occur,
can be minimised by a system of training, education, and by ch...
I welcome the opportunity to read this article and thank the authors
for their work which adds considerably to the literature on the topic of
Procedural Sedation and Analgesia (PSA) in Emergency Departments (EDs).
My own experience is similar, and I concluded some time ago that
complications, or situations where complications are more likely to occur,
can be minimised by a system of training, education, and by changing
department processes. Change included inserting multiple barriers
preventing situations where the "Swiss Cheese Effect" occurs (1.) These
barriers comprise steps where x cannot occur without y rather than a
guideline or protocol which staff may easily bypass by choice.
We now have a situation where the Anaesthetic and Sedative drugs are
locked and governed as Controlled Drugs (need to get keys from Shift
Leader nurse, check drugs etc.), the patient must be formally admitted to
ED - this involves approval from the duty ED Consultant, and the Shift co-
ordinator (senior Nurse). Certain documents must be completed including a
detailed Anaesthetic pre-assessment (this prompts consideration of medical
history, airway anatomy, age, fasting status, etc.) Equipment checks must
occur, the patient located in a Resus Bay. The nurses now have an embedded
culture of completing these documents PRIOR to getting any drugs out of
the cupboard. Fostering a department culture of questioning actions by all
staff where potential harm is occurring contributes to the Safety
atmosphere. Referring deviations from the process to the duty ED
consultant is encouraged.
The single biggest (and most popular) step is the introduction of a
Sedation Document pack including a Team-Time-Out checklist (see attached.)
This demands a process of reflection, double checking, and sign-off prior
to starting the Sedation.
However, I still struggle to see how I can prevent the index case
prompting this revision: a surgeon removing a syringe of Propofol from the
theatre Anaesthetic Room, walking into ED, and behind the curtain giving
the lot IV, incising an abscess, then leaving without informing
anyone...luckily an alert nurse went to see what he had done, rescued the
apnoeic hypotensive victim, and no harm occurred.
1. Human Error: Models and Managment. Reason J. BMJ 2000; 320:768-70
The National Audit Office (1) has evaluated delays when requesting Computed Tomography (CT) scans for patients with head injury and reveals that nationally, a quarter of patients may wait for more than two hours. This work also found, that in London alone the average delay in transfer from local hospital to specialist unit is typically six hours.
In the West Midlands Workforce Deanery, a survey of senior (ST4 and above) Emergency...
The National Audit Office (1) has evaluated delays when requesting Computed Tomography (CT) scans for patients with head injury and reveals that nationally, a quarter of patients may wait for more than two hours. This work also found, that in London alone the average delay in transfer from local hospital to specialist unit is typically six hours.
In the West Midlands Workforce Deanery, a survey of senior (ST4 and above) Emergency Medicine trainees was carried out to discover their experiences of requesting imaging in head injury. A good response rate (87% of 46 trainees) was achieved, with representation from all sixteen training sites in the region. Some 28% of trainees do not have 24/7 access to a CT scan, performed and reported, within an hour. With the imminent arrival of regional Trauma Networks the demand for rapid access to CT will increase in both large Major Trauma Centres and smaller Trauma Units alike. The survey makes it clear that not all EDs are able to access timely diagnostic imaging for their patients.
I have followed with interest Major's (2) work using Transorbital Ultrasound to measure the Optic Nerve Sheath Diameter and evaluate raised intracranial pressure (ICP). Currently there is insufficient evidence to support such a use of ultrasound in the non-traumatic setting but it has potential as a triage tool, to rule in raised intracranial pressure in the context of head injury. A bedside test performed on arrival in a rural Trauma Unit could obviate unnecessary delay in obtaining CT and secondary transfer to a Major Trauma Centre.
1 Major Trauma Care in England, National Audit Office 2010, London
2 Major R., Girling S., Boyle A. Emerg Med J (2010). Doi;10.1136/emj.2009.087353
The authors of the recent study looking at the addition of a GP
within an Emergency Department are to be congratulated for their research
into a difficult area [1]. I would have to challenge the authors
conclusions that the addition of another body i.e. a GP would have only a
limited effect on patient process time compared to usual care. From the
staffing figures provided they are increasing clinician numbers from 3 to...
The authors of the recent study looking at the addition of a GP
within an Emergency Department are to be congratulated for their research
into a difficult area [1]. I would have to challenge the authors
conclusions that the addition of another body i.e. a GP would have only a
limited effect on patient process time compared to usual care. From the
staffing figures provided they are increasing clinician numbers from 3 to
4 which is a significant 33% increase, more if they had a GP registrar as
well. In addition they are creating a seperate "fast track scheme" that
has previously demonstrated significant benefits in reducing waiting times
[2]. Secondly the cost effectiveness of general practitioners will vary
dependant on the cost of employing the GP's and their prodcutivity. The
scheme I was involved with the cost of the GP's for covering weekday
shifts in the ED worked out at around 90 pounds/hour. This is more than
the cost of a Specialist in Emergency Medicine who is able to see a wider
range of conditions presenting to the ED. I am not against closer
integration of Emergency care as a wider range of skills offered will mean
it is more likely a patient will be treated by a clinician best trained to
treat them, rather than the situation of discrete urgent care providers
that currently compete in some areas and also allow patients to shop
around different providers only increasing the utilisation of scarce
healthcare resources. However it must be realised that not every situation
is the same and some solutions though may improve patient care may not
necessarily reduce costs.
1. Judith E Bosmans, A Joan Boeke, Marguerite E van Randwijck-Jacobze
et al. Addition of a general practitioner to the accident and emergency
department: a cost-effective innovation in emergency care.Emerg. Med. J.
2011 0:emj.2010.101949v1-emj.2010.101949
2. M Cooke, S Wilson, and S Pearson. The effect of a separate stream
for minor injuries on accident and emergency department waiting times.
Emerg Med J. 2002 January; 19(1): 28-30.
Conflict of Interest:
I have previously been involved with a scheme to integrate GP's within a UK Emergency Department
Dr Roland and Prof Coats raise some interesting reservations
regarding the adoption of hospital-wide track and trigger systems (TTS),
but I must take issue with some of their pessimism.
They argue that the application of TTSs in the ED will be limited by
the difference between the inpatient derivation sets of the TTS and the ED
population. I am not convinced that our patient populations are so
dif...
Dr Roland and Prof Coats raise some interesting reservations
regarding the adoption of hospital-wide track and trigger systems (TTS),
but I must take issue with some of their pessimism.
They argue that the application of TTSs in the ED will be limited by
the difference between the inpatient derivation sets of the TTS and the ED
population. I am not convinced that our patient populations are so
different; 60% of Prytherch's 35,000 patients were admitted via the
Emergency Department(1). As emergency physicians we accept the prognostic
value of physiological derangement in trauma (the Manchester triage sort
includes respiratory rate, systolic blood pressure and GCS(2)), and
although our patients may be relatively untreated compared with
inpatients, it is not unreasonable to suppose that abnormal physiology is
abnormal physiology whatever the context. This is currently under
investigation in an unselected patient set
(www.shef.ac.uk/scharr/sections/hsr/emergency/davros.html).
Although Subbe's paper comparing the predictive value of TTSs with
Manchester triage is often quoted, Subbe et al were unfortunate in that
their unselected ED patient cohort included no patients requiring critical
care, an unfortunate circumstance which limits the interpretation of the
value of TTSs in ED patients. Their set of patients with delayed
admission to critical care, however, did include 7 of 50 patients whose
poorlier state was preferentially identified by MEWS (in addition to the
28 identified by Manchester triage), precisely the patient group under
discussion.(3) Subbe himself has made the argument for an NHS-wide
standardised Early Warning Score.(4)
Roland and Coats argue that TTSs proposed for use in the ED must be
validated in the ED; I strongly agree. A number of attempts have been
made to do this; variations on a score of acute physiological derangement
have achieved AUROCs of between 0.72 and 0.77 in predicting mortality in a
variety of ED patient sets.(5-8) I accept that the varying prevalence of
serious acute disease in different parts of the NHS will have an impact on
the positive predictive value of any TTS. However, this in itself is not
a reason not to use a TTS, simply to tailor the local response
appropriately.
Yours sincerely
Kirsty Challen
1. Prytherch DR, Smith GB, Schmidt PE, Featherstone PI. ViEWS--
Towards a national early warning score for detecting adult inpatient
deterioration. Resuscitation. 2010;81:932-7.
3. Subbe C, Slater A, Menon D, Gemmell L. Validation of physiological
scoring systems in the accident and emergency department. Emergency
Medicine Journal. 2006;23:841-5.
4. Subbe CP. Better ViEWS ahead? It is high time to improve patient safety
by standardizing Early Warning Scores. Resuscitation. 2010;81:923-4.
5. Goodacre S, Turner J, Nicholl J. Prediction of mortality among
emergency medical admissions. Emergency Medicine Journal. 2006;23:372-5.
6. Olsson T, Terent A, Lind L. Rapid Emergency Medicine score: a new
prognostic tool for in-hospital mortality in nonsurgical emergency
department patients. Journal of Internal Medicine. 2004;255:579-87.
7. Man SY, Chan KM, Wong FY, Wong KY, Yim CL, Mak PS, et al. Evaluation of
the performance of a modified Acute Physiology and Chronic Health
Evaluation (APACHE II) scoring system for critically ill patients in
emergency departments in Hong Kong. Resuscitation. 2007;74:259-65.
8. Cattermole GN, Mak SP, Liow CE, Ho MF, Hung KYG, Keung KM, et al.
Derivation of a prognostic score for identifying critically ill patients
in an emergency department resuscitation room. Resuscitation. 2009;80:1000
-5.
We read, with interest, the article by Benger and Hopkins,[1]
published March 2011 describing the results of their national census of
rapid sequence induction anaesthesia in UK emergency departments.
The authors report an overall rate of RSI by unsupervised trainees as
45%, increasing to 71% out of hours. However, their conclusion that 57% of
RSIs are carried out by senior anaesthetic traine...
We read, with interest, the article by Benger and Hopkins,[1]
published March 2011 describing the results of their national census of
rapid sequence induction anaesthesia in UK emergency departments.
The authors report an overall rate of RSI by unsupervised trainees as
45%, increasing to 71% out of hours. However, their conclusion that 57% of
RSIs are carried out by senior anaesthetic trainees may undermine the
relevance of this finding. The current curriculum for training in
anaesthesia,[2] requires, as a core clinical skill, that to progress to
higher training, a trainee must "Be able to manage acute, life-threatening
airway problems safely and effectively with distant supervision."
Therefore, an ST5 trainee or above would not be expected to be supervised
in emergency airway management, unless they requested senior help
following assessment of the case in question.
Using the authors figures (1 in 800 ED RSI's, 60,000 attendances a
year, 20% EM physician RSI rate), an average department will perform 15
emergency physician RSI's each year, a number which would make the
maintenance of safe airway skills difficult. This is especially true as
the authors highlight the higher rate of difficult and failed intubation
in non-operating theatre environments. The same point regarding ED RSI
skill retention is also relevant for anaesthetists, given that, by the
authors' numbers, there will be around 60 ED RSI's performed by all
anaesthetic trainees or consultants in a DGH.
We therefore certainly agree with the issues raised by the authors
pertaining to airway skill training and skill retention for the emergency
physician. We also agree with the recent NAP4 audit project
recommendations,[3] that ED airway management should be carried out by the
"right person", whether they be from an ED or anaesthetic background.
References
1. Benger J, Hopkinson S. Rapid sequence induction of anaesthesia in
UK emergency departments: a national census. Emerg Med J.
2011;28(3):217-20.
2. The Royal College of Anaesthetists. CCT in anaesthetics, Annex C.
Edition 2, 2010;c-42
3. Benger J. Airway management in the emergency department and
remote hospital locations. In: Cook T, Woodall N, Frerk C eds. NAP4 Major
complications of airway management in the United Kingdom: Report and
findings. London: Royal College of Anaesthetists, March 2011:143-54.
The commentary on early warning scores in the ED presents an
interesting viewpoint on their use. NCEPOD, NICE and CEMACH all recommend
the use of track and trigger systems in acute hospital settings, a
Department of Health review found that most NHS trusts were using
aggregate weighting systems such as Modified Early Warning Scores (MEWS)
(1). MEWS have been validated in the medical and surgical ward s...
The commentary on early warning scores in the ED presents an
interesting viewpoint on their use. NCEPOD, NICE and CEMACH all recommend
the use of track and trigger systems in acute hospital settings, a
Department of Health review found that most NHS trusts were using
aggregate weighting systems such as Modified Early Warning Scores (MEWS)
(1). MEWS have been validated in the medical and surgical ward settings
with paediatric and obstetric specific scores also validated in their own
specialist settings (2). These scoring systems are well recognised and
utilised by these specialities and provide a common ground for
communication of physiological abnormality.
As noted there have been few studies based within the ED to validate
the use of these scoring systems in this setting. Since the systematic
review by Gao et al, 11 further studies with the ED setting and 3 within
the pre-hospital setting have been published. These studies have shown
significant increases in the odds ratios for mortality and need for higher
dependency care as MEWS increases; with most studies identifying MEWS
>/= 4 as the optimum cut off. Area under the receiver operator curves
range between 0.72 - 0.96 for MEWS in the ED population, demonstrating
acceptable to excellent predictive ability (3, 4).
The validation in the ED study by Subbe et al failed to demonstrate
significant benefit overall in using MEWS in addition to the Manchester
Triage Scale(MTS)(5). However, in the group of ED patients who were not
initially recognised as needing a higher level care and subsequently were
transferred from the ward to ITU, using MEWS would have detected an
additional 7/49 above MTS. The numbers in this study requiring higher
level care were low but this indicates a potential significant benefit
above previous standard triage practice alone.
Whilst a universal EWS system cannot cover our entire patient
population and does not replace clinical judgement, it does provide a
framework for recognition of physiological abnormality and the
communication of this to other specialities. Predictive value can be
increased by excluding use in those known to have critical conditions
regardless of physiology e.g. Acute MI's, Head injury. In the busy ED,
MEWS can be utilised to direct senior review towards those needing early
decision making on need for higher dependency care, directed treatment and
resuscitation.
Dr S. Dorrian
SpR Emergency Medicine
Birmingham Heartlands Hospital
1. Department of Health and NHS Modernisation Agency (2003) The
National Outreach Report. Department of Health, London
2. Subbe CP, Kruger M, Rutherford P, Gemmel L, Validation of a
modified Early Warning Score in Medical admissions QJM 2001; 94:521 - 526
3. Lam TS et al Validation of a Modified Early Warning Score (MEWS)
in emergency department observation ward patients Hong Kong Journal of
Emergency Medicine 2006; 60(6): 547 - 553
4. Vorwerk et al Prediction of mortality in adult emergency
department patients with sepsis Emergency Medicine Journal 2009; 26: 254 -
258
5. Subbe et al Validation of physiological scoring systems in the
accident and emergency department Emergency Medicine Journal 2006; 23:841
- 845
By a preliminary prospective, multicentre, observational study, Cavus
et al.1 concluded that the C-MAC videolaryngoscope was suitable for
prehospital emergency intubations with complicated airway conditions.
Although they may have provided valuable information, several aspects of
their study should be clarified and discussed.
First, in results, the authors stated that it was possible to obtain a
view of the glotti...
By a preliminary prospective, multicentre, observational study, Cavus
et al.1 concluded that the C-MAC videolaryngoscope was suitable for
prehospital emergency intubations with complicated airway conditions.
Although they may have provided valuable information, several aspects of
their study should be clarified and discussed.
First, in results, the authors stated that it was possible to obtain a
view of the glottis and to intubate all patients with the C-MAC (100%). In
fact, five of 80 patients have a Cormack-Lehane class 3 or 4 laryngeal
view without glottis, which is generally regarded as a difficult
laryngoscopy.2 The authors did not comment the detailed reasons of these
inadequate laryngeal views. Also, it was not clear how tracheal intubation
was completed in these patients with a difficult laryngoscopy.
Second, all patients were successfully intubated, but 17 of 80 patients
(21%) required two or more attempts to complete tracheal intubation. Also,
maximum time to successful intubation was 300 s. The authors did not
specify the causes of multiple intubation attempts and long intubation
time in these patients. We speculate that these issues may be contributed
to difficulty delivering the tracheal tube through the glottis under the
videolaryngoscopic view because of no use of a stylet. A Macintosh
laryngoscope blade design of the C-MAC can indeed reduce stylet use
compared with the angulated videolaryngoscopes, but use of a stylet may be
valuable in controlling the direction of passage of an EET under indirect
view of steering videolaryngoscopes. By providing increased rigidity and
malleability, it allows more accuracy to guide the tracheal tube into the
glottis under the videolaryngoscopic view.3 In this study from prehospital
emergent environment, 6 of 80 patients (7.5%) could not be intubated with
the videolaryngoscopic view of the C-MAC because of difficulty to advance
the tracheal tube through the glottis. In a study from controlled
operating room environment, a stylet must to be used for successful
intubation in 7% of the anesthetized patients when tracheal intubation is
performed with the V-MAC, older model of the C-MAC.4 In contrast, in the
operating room, when a styletted tracheal tube is used for tracheal
intubation with the C-MAC in 17 patients with easy and difficult airways,
all cases are intubated successfully on the first attempt either under
direct vision or using the video view.5 Other than success rate of
tracheal intubation, the intubation time is actually also an important
parameter to evaluate performance of airway management device in
prehospital sitting, because any prolongation of intubation time could
increase a risk of hypoxia or aspiration, especially in critically ill,
trauma, or already hypoxic or aspirating patients.6 Thus, it may be
unacceptable in certain critical situations if the advantage of no stylet
use is achieved at the expense of multiple attempts and a considerably
longer time required for tracheal intubation. We recommend that when
emergent intubation is performed with the C-MAC in prehospital sitting, a
styletted tracheal tube be best used, especially when difficulty to
delivery tracheal tube into the glottis occurs.
Third, the authors seem to overemphasize the problems by use of a stylet
under the videolaryngoscopic view. Although videolaryngoscopes has been
practiced for more than ten years, there have been very few reported
complications and most of complications are of a minor nature. Besides
use of a stylet, other possible reasons for the airway injuries are use of
too large blades, or unnecessary force during insertion of the tracheal
tube.7 Furthermore, it is generally believed that traumatic airway
complications can be avoided by correct intubation procedures. For
example, tracheal tube is inserted under direct observation, until it
reaches the uvula and then the operator's attention is directed to the
monitor.
Fourth, in this study, 28% of patients presented with challenging
intubation conditions such as limited mouth opening or maxillofacial
trauma, and 31% had a Mallampati grade 3 or 4. They may indeed make airway
management complex, but do not necessarily result in difficult tracheal
intubation. Actually, difficult tracheal intubation are often contributed
to multiple causes, such as reduced head and neck mobility, limited mouth
opening, reduced mandibular space, obesity and poor dentition.2 The design
of the C-MAC blade has the unique advantage that it provides both direct
and indirect glottic views, but the sharp angle of the angulated
videolaryngoscopes may be advantageous in patients with anatomic
variations, such as anterior larynx, micrognathia, neck immobility, or
sublingual tonsillar hypertrophy, etc.7,8
Moreover, a clinical study from
the emergency department showed that, of the 158 patients with good
laryngeal view on direct laryngoscopy of the C-MAC, video laryngoscopy
worsened the laryngeal view in 4 cases (3%).9 Thus, further clinical
studies are necessary to evaluate the role of C-MAC in securing an airway
for patients with difficult tracheal intubation in the prehospital
setting.
Fu Shan Xue, Xu Liao, Yu-Jing Yuan, Qiang Wang, Jian-Hua Liu
Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, People's
Republic of China.
Correspondence to Fu Shan Xue, Department of Anesthesiology, Plastic
Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union
Medical College, 33 Ba-Da-Chu Road, Shi-Jing-Shan District, Beijing
100144,China. Email: fruitxue@yahoo.com.cn
References
1. Cavus E, Callies A, Doerges V, et al. The C-MAC videolaryngoscope for
prehospital emergency intubation: a prospective, multicentre,
observational study. Emerg Med J 2011; 28:In Press.
doi:10.1136/emj.2010.098707
2. Caplan RA, Benumof JL, Berry FA, et al. Practice guidelines for
management of the difficult airway: an updated report by the American
Society of Anesthesiologists Task Force on Management of the Difficult
Airway. Anesthesiology 2003; 98: 1269-77.
3. Cooper RM, Pacey JA, Bishop MJ, et al. Early clinical experience with a
new videolaryngoscope (GlideScope?) in 728 patients. Can J Anesth 2005;
52: 191-8.
4. van Zundert A, Maassen R, Lee R, et al. A Macintosh laryngoscope blade
for videolaryngoscopy reduces stylet use in patients with normal airways.
Anesth Analg 2009; 109:825-31.
5. Aziz M, Brambrink A. The Storz C-MAC video laryngoscope: description of
a new device, case report, and brief case series. J Clin Anesth 2011;
23:149-52.
6. Maruyama K, Tsukamoto S, Ohno S, et al. Effect of cardiopulmonary
resuscitation on intubation using a Macintosh laryngoscope, the AirWay
Scope, and the gum elastic bougie: a manikin study. Resuscitation 2010;
81:1014-1018.
7. Niforopoulou P, Pantazopoulos I, Demestiha T, et al. Video-
laryngoscopes in the adult airway management: a topical review of the
literature. Acta Anaesthesiol Scand 2010; 54:1050-61.
8. Maassen R, Lee R, Hermans B, et al. A comparison of three
videolaryngoscopes: the Macintosh laryngoscope blade reduces, but does not
replace, routine stylet use for intubation in morbidly obese patients.
Anesth Analg 2009; 109:1560-5.
9. Brown CA 3rd, Bair AE, Pallin DJ, et al. Improved glottic exposure with
the video Macintosh laryngoscope in adult emergency department tracheal
intubations. Ann Emerg Med 2010; 56:83-8.
Affiliations: 1. Service Médical d'Urgence de la Brigade des Sapeurs Pompiers de Paris - France
2. Pôle Anesthesie - Réanimation - SAMU - Urgences Centre Hospitalo-Universitaire de Brest - France
3. Inserm U1018, Centre for research in Epidemiology and Population Health, Epidemiology of occupational and social determinants of health, Villejuif, France
4. Université de Versailles St-Quentin AP-HP, Poincaré...
Affiliations: 1. Service Médical d'Urgence de la Brigade des Sapeurs Pompiers de Paris - France
2. Pôle Anesthesie - Réanimation - SAMU - Urgences Centre Hospitalo-Universitaire de Brest - France
3. Inserm U1018, Centre for research in Epidemiology and Population Health, Epidemiology of occupational and social determinants of health, Villejuif, France
4. Université de Versailles St-Quentin AP-HP, Poincaré University Hospital, Occupational health department/ EMS92 (SAMU92) , Garches, France
We read with interest the article written by Craig and al. (Emerg Med
J, March 1, 2011) and we would like to make several remarks about it.
The protocol chosen for the administration of morphine seems to us to be
too different from common practice. The morphine must be titled, thus
allowing a decrease in the frequency of its side effects. The authors
should have performed a randomized, double-blind protocol by integrating
the titration, which would have been more practical. On the other hand, it
is not clear that other non-medicinal analgesic treatments were taken into
account. Indeed, concerning patients already relieved by immobilization,
the administration of morphine can express itself more readily by its side
effects than by its analgesic action. Rescue analgesia was only
administered if the "patient's pain relief was judged to be inadequate". A
clearer redefinition of the term "inadequate" would be welcome given that
a third of the patients were concerned. It would also have been important
to determine the possible link between dissatisfaction and rescue
analgesia. In the beginning of the discussion, the authors emphasize the
similarity of the treatments, leading readers to believe that it was a
study about equivalence, whereas it was actually a study about
superiority.
Concerning the statistical analysis, the author did not take into account
repeated measures from the same individual. The sample size calculation,
as well as the statistical analysis, seems to be inappropriate to us. In
our extra-hospital activities, the objective is to reach a VAS < 40.
This level was not reached in this study. The conclusion is the
insufficient efficiency of both of the proposed protocols. The impact of
this article on actual practice thus seems to us to be limited, despite
the certain interest in the questions that are asked.
Absolutely Correct. You can not immobilize a spine to a flat surface.
Conflict of Interest:
None declared
I found the term "Induction of Anaesthesia" somewhat uninspiring, especially as it was the header of a national survey.
The term is outdated and was replaced some 10 years ago by "Rapid Sequence Intubation". "Intubation" and "Induction" of anaesthesia are not interchangeable terms. The latter stops at "Time zero*" the former only after mission is accomplished and the airway is secured. We intubate. RSI = Rapid S...
I welcome the opportunity to read this article and thank the authors for their work which adds considerably to the literature on the topic of Procedural Sedation and Analgesia (PSA) in Emergency Departments (EDs).
My own experience is similar, and I concluded some time ago that complications, or situations where complications are more likely to occur, can be minimised by a system of training, education, and by ch...
The authors of the recent study looking at the addition of a GP within an Emergency Department are to be congratulated for their research into a difficult area [1]. I would have to challenge the authors conclusions that the addition of another body i.e. a GP would have only a limited effect on patient process time compared to usual care. From the staffing figures provided they are increasing clinician numbers from 3 to...
Sir
Dr Roland and Prof Coats raise some interesting reservations regarding the adoption of hospital-wide track and trigger systems (TTS), but I must take issue with some of their pessimism.
They argue that the application of TTSs in the ED will be limited by the difference between the inpatient derivation sets of the TTS and the ED population. I am not convinced that our patient populations are so dif...
Dear Editor,
We read, with interest, the article by Benger and Hopkins,[1] published March 2011 describing the results of their national census of rapid sequence induction anaesthesia in UK emergency departments.
The authors report an overall rate of RSI by unsupervised trainees as 45%, increasing to 71% out of hours. However, their conclusion that 57% of RSIs are carried out by senior anaesthetic traine...
Dear Sir
The commentary on early warning scores in the ED presents an interesting viewpoint on their use. NCEPOD, NICE and CEMACH all recommend the use of track and trigger systems in acute hospital settings, a Department of Health review found that most NHS trusts were using aggregate weighting systems such as Modified Early Warning Scores (MEWS) (1). MEWS have been validated in the medical and surgical ward s...
By a preliminary prospective, multicentre, observational study, Cavus et al.1 concluded that the C-MAC videolaryngoscope was suitable for prehospital emergency intubations with complicated airway conditions. Although they may have provided valuable information, several aspects of their study should be clarified and discussed.
First, in results, the authors stated that it was possible to obtain a view of the glotti...
Affiliations:
1. Service Médical d'Urgence de la Brigade des Sapeurs Pompiers de Paris - France
2. Pôle Anesthesie - Réanimation - SAMU - Urgences Centre Hospitalo-Universitaire de Brest - France
3. Inserm U1018, Centre for research in Epidemiology and Population Health, Epidemiology of occupational and social determinants of health, Villejuif, France
4. Université de Versailles St-Quentin AP-HP, Poincaré...
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