We note the experience of Dr Hayhurst and colleagues in the use of
echo in life support (ELS) with interest.[1] Our own anecdotal experience
agrees that focused ELS scans can be performed within the 10 second pause
in CPR for a pulse check, and provide additional diagnostic information
that can guide further resuscitative measures.
Moreover we have found that it is usually practical to extend the ELS
protocol to...
We note the experience of Dr Hayhurst and colleagues in the use of
echo in life support (ELS) with interest.[1] Our own anecdotal experience
agrees that focused ELS scans can be performed within the 10 second pause
in CPR for a pulse check, and provide additional diagnostic information
that can guide further resuscitative measures.
Moreover we have found that it is usually practical to extend the ELS
protocol to include assessment for pneumothorax, performed while CPR is
ongoing. Using a linear or phased array probe the anterior chest wall on
each side can be accessed around the person performing chest compressions.
Visual 2D (B-mode) appreciation of lung sliding, comets tails plus or
minus a lung point can quickly be appreciated. This can be supplemented
with an M-mode scan, if suspicious, in the next 10 second pulse check as
the use of this modality with on-going chest compression is virtually
impossible. [2] While this technique will not distinguish tension from
simple pneumothorax, in the context of cardiac arrest it seems reasonable
to perform chest decompression on the basis of this evidence.
This approach permits a method of looking for another remediable
cause of cardiac arrest, namely tension pneumothorax; alongside
consideration of hypovolaemia, cardiac tamponade, and massive PE by ELS.
The use of focused ultrasound in cardiac arrest provides a powerful method
of identifying reversible causes while resuscitation continues.
References
1. Hayhurst C, Lebus C, Atkinson PR, et al. An evaluation of echo in
life support (ELS): is it feasible? What does it add? Emerg. Med. J.
2011;28:119-121 doi:10.1136/emj.2009.084202 [Published Online First: 4
October 2010]
I recently came across your paper as I was in need of a power
calculation for diagnostic studies and have found your work to be very
helpful. I noted, however, a minor but important error in Table 6, that
outlines how to calculate sensitivity and specificity. The formula for
sensitivity is incorrectly stated as the true positives divided by true
positives plus false positives. Thi...
I recently came across your paper as I was in need of a power
calculation for diagnostic studies and have found your work to be very
helpful. I noted, however, a minor but important error in Table 6, that
outlines how to calculate sensitivity and specificity. The formula for
sensitivity is incorrectly stated as the true positives divided by true
positives plus false positives. This would provide a calculation for
positive predictive value. Instead, sensitivity is calculated as true
positives divided by true positives plus false negatives (1). I'm sure
this was just a minor typo, but I wanted to bring it to your attention.
Respectfully yours,
John Fralick, MSc
Resident Research Training Coordinator & Research Associate
Department of Family Medicine
University of Calgary, Calgary, Alberta, Canada
Source:
1) Oleckno, William A. Essential Epidemiology - Principles and
Applications. Long Grove: Waveland Press Inc, 2002. Print.
I found this article which showed suboptimal use of chaperones in
emergency departments to be of great interest. In my clinical work in
primary care in the UK, I often struggle with providing a chaperone for
intimate examinations. The two main issues I have are who we should bring
in, and what should they see.
Firstly I feel that the person brought in should be someone who is
allowed to examine patients themsel...
I found this article which showed suboptimal use of chaperones in
emergency departments to be of great interest. In my clinical work in
primary care in the UK, I often struggle with providing a chaperone for
intimate examinations. The two main issues I have are who we should bring
in, and what should they see.
Firstly I feel that the person brought in should be someone who is
allowed to examine patients themselves. The presence of a nurse would be
much better than that of a receptionist. I am not sure it is acceptable to
the patient or the non-clinical member of staff for someone non-clinical
to observe the patient in a state of undress. However in most practices
nurses are very busy-they are not waiting around to be called upon to
chaperone when necessary. They have their own patient lists, as do we. The
delay involved waiting for a nurse to become available impacts
significantly on the patients waiting for both nurse and doctor.
Secondly what should the chaperone see? The idea, as I understand it,
is that their presence protects the patient from a doctor doing something
inappropriate to the patient, but also as a protection for the doctor in
case the patient alleges that the doctor did something wrong. This
necessitates that they witness the examination explicitly--it is not
enough then for them to be in the same room behind a curtain.
I feel that the current concepts regarding chaperone use need to be
revised. Perhaps clearer guidance should be developed that is more
practical for everyday clinical practice, both in primary and secondary
care.
I presume that Dr Fairhurst is referring to a substance used
ubiquitously in the Antipodes and more commonly spelled 'methoxyflurANE'.
It is estimated that over three million doses have been used over the
last 25 years in Australia (Jacobs, 2010). It is used by state ambulance
services in the pre-hospital environment in most states of Australia, by
the Australian Defence Forces, within emergency de...
I presume that Dr Fairhurst is referring to a substance used
ubiquitously in the Antipodes and more commonly spelled 'methoxyflurANE'.
It is estimated that over three million doses have been used over the
last 25 years in Australia (Jacobs, 2010). It is used by state ambulance
services in the pre-hospital environment in most states of Australia, by
the Australian Defence Forces, within emergency departments, on adults and
children, by St John's Ambulance and by the Surf Life Saving Association.
In May of 2010, it was added to the Pharmaceutical Benefits Scheme in
Australia, to be included in the GP 'Doctor's Bag List' (NPS, 2010).
Methoxyflurane did not have its license renewed in Europe and the USA
(it was not withdrawn) because of justifiable concerns regarding
nephropathy in anaesthetic doses. These are several orders of magnitude
different to those currently used for analgesic purposes in Australia.
Methoxyflurane is not an alternative to opiate analgesia, rather an
efficient and safe bridging agent that can be used prior to administration
of more definitive agents. It is therefore more akin to Entonox than
intranasal opiates, albeit more portable and easier to administer in
austere environments.
There are a number of situations where methoxyflurane is ideal. It
does not require IV access, which can be limited in patients with
trypanophobia, difficult vascular access, or those being treated by
providers not qualified to administer parenteral agents. It has been shown
to be of great utility in the past in dressing changes, particularly those
associated with burns. It could be an ideal agent in the mass casualty
incident scenario. It has a small volume, is significantly more portable
than Entonox, is neither flammable nor explosive, can be self-
administered, and can last up to an hour. It has been proposed by as a
suitable agent for the battlefield (McClellan, 2007).
As Dr Fairhurst indicates, it is almost inevitable that a "clinical
trial" in the UK will be required to reiterate what is already known in
Australia; that there is an abundance of experience that already exists to
suggest that methoxyflurane can be used, and is used, as an effective and
safe analgesic in the acute care environment.
References
Jacobs I. Health effects of patients given methoxyflurane in the pre-
hospital setting: A data linkage study. The Open Emergency Medicine
Journal 2010 (3) 7-13
NPS. Methoxyflurane (Penthrox) for analgesia (doctor's bag listing)
Available at
http://www.nps.org.au/health_professionals/publications/nps_radar/2010/may_2010/methoxyflurane?SQ_BACKEND_PAGE=main&backend_section=am&am_section=edit_asset&assetid=86209&asset_ei_screen=contents&sq_link_path=,0,165622,93,526,164474,148952,170094,170085&sq_asset_path=1,43,72,360,686,25055,86207,86208#fnote12,
Accessed June 6th, 2010.
McLennan JV. Is methoxyflurane a suitable battlefield analgesic? J R
Army Med Corps. 2007 Jun;153(2):111-3.
We read with interest the recent article of Grosomanidis et al.1, who
compared applicability and efficacy of the tracheal intubation using an
intubating laryngeal mask airway (ILMA) or an Airtraq? laryngoscope
(Airtraq) in four non-conventional positions in a manikin study. Their
findings that success rates of tracheal intubation using both techniques
in an acceptable time period (up to 120 s) are up to 100% appear very...
We read with interest the recent article of Grosomanidis et al.1, who
compared applicability and efficacy of the tracheal intubation using an
intubating laryngeal mask airway (ILMA) or an Airtraq? laryngoscope
(Airtraq) in four non-conventional positions in a manikin study. Their
findings that success rates of tracheal intubation using both techniques
in an acceptable time period (up to 120 s) are up to 100% appear very
encouraging, but there are some aspects of this study that require
discussion.
First, this study showed significantly different intubation times with
ILMA and Airtraq in the Lat and Fac positions. However, comparing the
Airtraq intubation time with the ILMA intubation time is not an entirely
appropriate comparison, because the ILMA intubation time includes the
times needed for insertion of ILMA, confirmation of ventilation through
ILMA, blind advancement of the endotracheal tube (ETT) through ILMA and
finally confirmation of ventilation through the ETT. Actually, the
ventilatory capacity of ILMA is arguably equally important to its
effectiveness as an intubation conduit during airway resuscitation.2
Moreover, final goal of airway management in the prehospital emergency
setting is maintenance of oxygenation, rather than performing tracheal
intubation. The patients with difficult airways can desaturate during
laryngoscopy and intubation, but the ILMA is an effective ventilatory
device with a high success rates.3 If tracheal intubation is not
successful, the presence of an effective airway can evidently be
lifesaving.
Second, the study was performed using manikins. However, clinical
applicability and efficacy of the results from a manikin study are highly
dependent on the overall realism of the simulated setting. One can argue
that tracheal intubation is not reliably simulated by manikins due to the
use of rigid plastic, lack of collapsible soft tissues, and the fact that
many manikins have anatomically incorrect epiglottic and laryngeal
structures.4 Also, anatomic structures of the manikin's airway does not
accurately reflect changes of the human airway associated with different
positions. Indeed, evaluation of the intubation techniques in patients
with difficult airways or in non-conventional positions indeed is an
almost impossible undertaking. However, the manikin study should have
included the most common causes for difficult airway management in the
prehospital sitting. Other than the non-conventional positions, in an
actual prehospital emergency situation, tracheal intubation is often
performed in patients with limited head and neck movement or/and limited
mouth opening, even in presence of blood, vomit, sputum, debris or
excessive saliva in the oropharynx.5 In addition, in this study, the
manikin was also placed on a table with a suitable height for intubation
procedure, rather than on the ground. Thus, the overall level that this
study simulated real clinical practice was uncertain.
Recently, a
prospective, randomized control trial6 demonstrated that when the Airtraq
was used as first-line device for prehospital tracheal intubation (n=106),
success rate was only 47%. Also, reasons for failed Airtraq intubation
were related to the fiberoptic characteristic of this device (i.e.,
impaired sight due to blood and vomitus, n=11) or to assumed handling
problems (i.e., cuff damage, tube misplacement, or inappropriate
visualization of the glottis, n=24). For this reason, Trimmel et al.6
recommend that for the operators without significant clinical experience,
the Airtraq should not be used as a primary airway device in the
prehospital setting. Even experienced airway providers should be aware
that predominant manikin training does not qualify for successful Airtraq
use in emergency situations. We agree with their view that further
clinical studies are necessary in order to validate these preliminary data
in manikins.
Third, an important issue not discussed by the authors is the challenge of
obtaining proficiency while at the same time controlling cost. The
manufacturer recommends two to four uses before use in a patient with a
difficult intubation. As in all techniques for intubation, there is a
learning curve. Each Airtraq costs approximately $80 and cannot be reused.
This may pose a large expense to train an entire department.6 In addition,
Maharaj et al.7 observed a substantial decline in both direct laryngoscopy
and Airtraq skills over time and emphasized the need for continued
reinforcement of these complex skills. If at least 50 Airtraq intubations
in patients per year are considered as the minimum number needed to
achieve and maintain skills, implementation of this device becomes
expensive. In contrast, maintaining airway management skills with the ILMA
is associated less costs because it can be reused.
Four, other than same success rates of tracheal intubation (100%) with
both techniques, and a longer intubation time with ILMA than with Airtraq
in the Lat position, other results obtained in the four positions were
really better with ILMA than with Airtraq. Based on the results of this
study, we believe it would be more appropriate to conclude that both ILMA
and Airtraq can be used for securing airways when direct laryngoscopy is
impossible due to the patient's position in a prehospital sitting.
However, ILMA may be more effective and safer device because of less
numbers of attempts for successful intubation, low risk of airway injury,
and less difficulty of intubation procedure. In an unanticipated difficult
airway management algorithm in the prehospital emergency setting, the ILMA
has been recommended as a rescue airway device after failed intubation
with direct laryngoscopy.8
Fifth, when an ILMA is used as a rescue airway device in the prehospital
setting, we recommend to use the ILMA CTrach? with the integrated
fibreoptic channels and a detachable liquid crystal display viewer, rather
than the ILMA Fastrach?. The clinical trial has demonstrated that compared
with the ILMA Fastrach?, the ILMA CTrach? can enable a higher first-
attempt success rate of tracheal intubation because of its ability to view
the glottis, optimize placement of device and observe the process of
tracheal intubation through the devices.9 Also, data from the clinical
study of Nickel et al3 suggest that the ILMA CTrach? is a suitable device
for emergency airway management in the prehospital setting as it provides
ventilation and facilitates intubation with a very high success rate.
References
1. Grosomanidis V, Amaniti E, Pourzitaki C, et al. Comparison between
intubation through ILMA and Airtraq, in different non-conventional patient
positions: a manikin study. Emerg Med J 2011 doi:10.1136/emj.2010.100933.
2. Goldman A, Rosenblatt W. The LMA CTrach? in Airway Resuscitation: Six
case reports. Anaesthesia 2006; 61:975-7.
3. Nickel EA, Timmermann A, Roessler M, et al. Out-of-hospital airway
management with the LMA CTrach--a prospective evaluation. Resuscitation
2008; 79:212-8.
4. Rai MR, Popat MT. Evaluation of airway equipment: man or manikin?
Anaesthesia 2011; 66: 1-3.
5. Helm M, Hossfeld B, Sch?fer S, et al. Factors influencing emergency
intubation in the pre-hospital setting-a multicentre study in the German
Helicopter Emergency Medical Service. Br J Anaesth 2006; 96: 67-71.
6. Trimmel H, Kreutziger J, Fertsak G, et al. Use of the Airtraq
laryngoscope for emergency intubation in the prehospital setting: A
randomized control trial. Crit Care Med 2011?39: In press. DOI:
10.1097/CCM.0b013e318206b69b.
7. Maharaj CH, Costello J, Higgins BD, et al. Retention of tracheal
intubation skills by novice personnel: A comparison of the Airtraq and
Macintosh laryngoscopes. Anaesthesia 2007; 62:272-278.
8. Combes X, Jabre P, Margenet A, et al. Unanticipated difficult airway
management in the prehospital emergency setting: prospective validation of
an algorithm. Anesthesiology 2011; 114:105-10.
9. Liu EH, Goy RW, Lim Y, et al. Success of tracheal intubation with
intubating laryngeal mask airways: A randomized trial of the LMA Fastrach
and LMA CTrach. Anesthesiology 2008; 108:621-6.
With great interest we read the report by Parsons et al. regarding
the effects of the weather on trauma unit admissions.[1] We would like to
bring to the authors attention our study, in which we studied the same
effects in an area in the Netherlands geographically and metereologically
similar to the United Kingdom over a total period of 36 years, including
over 350,000 patients.[2] Although the authors of the present stu...
With great interest we read the report by Parsons et al. regarding
the effects of the weather on trauma unit admissions.[1] We would like to
bring to the authors attention our study, in which we studied the same
effects in an area in the Netherlands geographically and metereologically
similar to the United Kingdom over a total period of 36 years, including
over 350,000 patients.[2] Although the authors of the present study looked
at a particular subset of ED admissions with relatively severe injury
while we included all trauma patients, overall their findings were very
similar to ours. However on one point they failed to see a pattern that is
most likely present in their data, because they assumed a linear model for
all weather variables. In our study we used a general model which allows
for non-linear relationships explaining the patterns present in the data.
Our results show that a linear model provides a reasonable estimation for
all variables, except for (maximum) temperature. The graph plotting the
trauma incidence against the maximum temperature shows a V-shape with the
lowest trauma incidence at approximately 5 degrees Celcius. Both below and
above that temperature there is a sharp increase in trauma incidence and
in fact, this was the strongest effect observed in our study. We would
like to suggest the authors of the present study to look at their data to
see if a similar pattern exists, explaining both the rise in adult trauma
patients with falling minimum temperatures found by the authors, as well
as the increase in patients with higher maximum temperatures reported
elsewhere in the literature and also observed in the current study.
1. Modelling the effects of the weather on admissions to UK trauma
units: a cross-sectional study. Parsons N, Odumenya M, Edwards A, Lecky F,
Pattison G. Emerg Med J. 2010 Nov 22. [Epub ahead of print]
2. Relation of the weather and the lunar cycle with the incidence of
trauma in the Groningen region over a 36-year period. Stomp W, Fidler V,
ten Duis HJ, Nijsten MW. J Trauma. 2009 Nov;67(5):1103-8.
Treating hypoglycaemia in Acute care due to insulin and oral agents
create very different challenges.
Decrease in blood sugar due to oral agents may be due to skipped meals or
exercise. However concurrent illness (dehydration etc), new onset renal
dysfunction and drug interactions are major factors that cause oral agents
induced hypoglycaemia; such events prolong the half life of sulfonylureas....
Treating hypoglycaemia in Acute care due to insulin and oral agents
create very different challenges.
Decrease in blood sugar due to oral agents may be due to skipped meals or
exercise. However concurrent illness (dehydration etc), new onset renal
dysfunction and drug interactions are major factors that cause oral agents
induced hypoglycaemia; such events prolong the half life of sulfonylureas.
Common drug interactions (sulfa, ciprofloxacin), NSAID's, Coumadin
may impair oral agent metabolism and hypoglycaemia follows.
These hypoglycaemic patients require a long period of observation
(>24 hours) in Acute care units due to prolonged action of these agents
and search for the cause of hypoglycaemia is necessary and may require
significant change of medications before discharge.
Insulin related hypoglycaemia is relatively simple to treat; it is
often due to skipped meal/ snack/ exercises, treat with 50 cc of 50 %
Dextrose and food.
Patient may be discharged early (6 hours). Giving too much dextrose will
not cause increase in insulin release and cause paradoxical hypoglycaemia
(these patients do not have their own insulin to release).
Oral agents are not so easy to treat:
Sulfonylureas are a major problem, all these agents peak up to 8
hours and may last >24 hours and hypoglycaemia is seen many hours after
the dose. Glyburide is more long acting than Gliclazide and Glimeperide.
Sulfonylurea related hypoglycaemia is very different than the insulin
induced1.
A typical patient is an ill elderly patient from nursing home, too
much IV dextrose may be harmful as it promotes excess insulin release
(usually after 60-120 minutes due to presence of oral agents which
potentiate insulin release) and the blood sugar drops prompting further
treatment with more dextrose and the cycle continues. It might require ?
Normal Saline + 5% or 10% Dextrose as a slow infusion to stabilise the
glucose.
Blood sugar needs to be monitored every 2 hours and the literature
recommends observation for more than 24 hours and it is best to keep it in
between 5-7 mmol/l as higher levels would cause hyperinsulinemia1.
Use of glucagon is a potential problem for sulfonylurea2, 3 -
hypoglycaemia as it takes 20 minutes to work and the patients may develop
nausea and vomiting and be unable to eat.
Glucagon 1mg IM/ SC usually increases blood sugar by 3-12 mmol in
<60 minutes( IV dextrose is faster)2,3 and may not increase blood
sugar enough in malnourished people due to poor glycogen reserves in
liver.
Glucagon may increase the blood sugar too much prompting a reactive
hypoglycemia due to excessive insulin release. Glucagon paradoxically can
stimulate insulin release directly and may cause delayed drop in blood
glucose.
Octreotide may be considered as a relatively new option4, 5, 6
Octreotide inhibits release of Insulin, Glucagon and Growth Hormone.
If given SQ peaks around 30 minutes and has a half life of 1.5- 2 hours.
Uncommonly it has been used in non- overdose sulfonylurea related
hypoglycemia (used frequently in true OD of sulfonylureas6).
A single 75 mcg SC dose might be considered for a patient having
recurrent hypoglycemia after 50cc of D50 but the patients still needs to
stay for at least 24 hours.
First prospective placebo controlled study published in 20084
concluded that the addition of octreotide to standard therapy in
hypoglycemic patients receiving treatment with a sulfonylurea increased
serum glucose values for the first 8 hours after administration in
patients. Recurrent hypoglycemic episodes occurred less frequently in
patients who received Octreotide compared with those who received placebo.
Summary:
The major potential adverse effect of use of sulfonylurea agents is a
hyper-insulinaemic state that causes hypoglycemia. It may be observed
during chronic therapeutic dosing, even with very low doses of a
sulfonylurea, and especially in older patients.
It may also result from accidental or intentional poisoning in both
diabetic and non diabetic patients. The traditional approach to
sulfonylurea's-induced hypoglycemia includes administration of glucose,
and glucagon or diazoxide in those who remain hypoglycemic despite
repeated or continuous glucose supplementation.
However, these antidotal approaches are associated with several
shortcomings, including further exacerbation of insulin release by glucose
and glucagon, leading only to a temporary beneficial effect and later
relapse into hypoglycemia, as well as the adverse effects of both glucagon
and diazoxide.
Octreotide inhibits the secretion of several neuropeptides, including
insulin, and has successfully been used to control life-threatening
hypoglycemia caused by insulinoma, sulfonylurea overdose or persistent
hyperinsulinaemic hypoglycemia of infancy
References:
1. Herbel G, Boyle PJ. Hypoglycemia:Pathophysiology and
treatment.Endocrinol Metab Clin North Am. 2000 Dec; 29(4): 725-43
2. Vukmir RB, Paris PM, Yealy DM. Glucagon: prehospital therapy for
hypoglycemia. Ann Emerg Med. 1991 Apr; 20(4): 375-9
3. Yale J. Hypoglycemia.Canadian journal of diabetes 2008; 32 (
supplement) S62-S64
4. Fasano CJ, O'Malley G, Dominici P, Aguilera E, Latta DR.
Comparison of octreotide and standard therapy versus standard therapy
alone for the treatment of sulfonylurea-induced hypoglycemia. Ann Emerg
Med. 2008 Apr; 51(4):400-6. Epub 2007 Aug 30
5. McLaughlin SA, Crandall CS, McKinney PE.Octreotide: an antidote
for sulfonylurea-induced hypoglycemia. Ann Emerg Med. 2000 Aug;36(2):133-8
6. Carr R, Zed PJ. Octreotide for sulfonylurea-induced hypoglycemia
following overdose. Ann Pharmacother. 2002 Nov;36 (11): 1727-32
The question you ask is akin to asking whether drugs can cure a
headache. You cannot lump all probiotics together. Probiotics are defined
as "live microorganisms that when administered in adequate amounts confer
a health benefit on the host"(WHO 2001). Not all micro-organisms will
confer a health benefit and the actions of potential probiotics are strain
specific. Therefore, your question should be 'Which, if any, probiot...
The question you ask is akin to asking whether drugs can cure a
headache. You cannot lump all probiotics together. Probiotics are defined
as "live microorganisms that when administered in adequate amounts confer
a health benefit on the host"(WHO 2001). Not all micro-organisms will
confer a health benefit and the actions of potential probiotics are strain
specific. Therefore, your question should be 'Which, if any, probiotics,
reduce the incidence of antibiotic associated diarrhoea in adults?' Your
bottom line would be that Lactobacillus rhamnosus GG, Saccharomyces
boulardii and the mixture containing L. casei DN114001 reduce the
incidence of antibiotic associated diarrhoea in adults.
Milligan, et al. (1) provides valuable insight into the varied management of massive haemorrhage post trauma. However, the conclusions that emergency physicians lacked core knowledge and were unaware of how to prevent and treat early coagulopathy appear unfounded. It would be more prudent to conclude that a paucity of high level of evidence guiding trauma resuscitation was responsible for this varied practice.
Milligan, et al. (1) provides valuable insight into the varied management of massive haemorrhage post trauma. However, the conclusions that emergency physicians lacked core knowledge and were unaware of how to prevent and treat early coagulopathy appear unfounded. It would be more prudent to conclude that a paucity of high level of evidence guiding trauma resuscitation was responsible for this varied practice.
The definition of massive transfusion has little clinical significance during trauma resuscitation and even so, remains debated with an acute definition likely to be more effective than the traditional definition. (2) Massive blood transfusion during trauma resuscitation is rarely based on a target haemoglobin and current experience with thromboelastography suggests that platelet function rather than absolute platelet counts should direct platelet transfusion. The ideal ratio of packed red blood cells to fresh frozen plasma similarly has been gleaned from retrospective associations only, confounded by multiple biases. Recent randomised controlled trials have failed to show any outcome benefit from the stated indication for recombinant factor VIIa.
Attempts to develop massive transfusion protocols supported by inadequate evidence have previously resulted in marked variability in practice.(3) A massively haemorrhaging trauma patient presents a challenging scenario to most emergency physicians and in the face of poor level of evidence to guide practice, it is not surprising that most use clinical gestalt (referred by the authors as "guess"). Rather than criticising the knowledge of emergency physicians or imposing non-evidence based "protocols", research efforts should be directed at multicentre, outcome focused randomised controlled trials comparing different but valid strategies in managing massive haemorrhage. Only then can we embark on developing effective massive transfusion guidelines.
References
1. Milligan C, Higginson I, Smith JE. Emergency department staff knowledge of massive transfusion for trauma: the need for an evidence based protocol. Emerg Med J. 2010 (In Press). doi:10.1136/emj.2009.088138.
2. Mitra B, Cameron PA, Gruen R, et al. The definition of massive transfusion in trauma: a critical variable in examining evidence for resuscitation. Eur J Emerg Med. 2010 (In Press). doi: 10.1097/MEJ.0b013e328342310e
3. Schuster KM, Davis KA, Lui FY, et al. The status of massive transfusion protocols in United States trauma centers: massive transfusion or massive confusion? Transfusion 2010; 50(7): 1545-1551.
We note the experience of Dr Hayhurst and colleagues in the use of echo in life support (ELS) with interest.[1] Our own anecdotal experience agrees that focused ELS scans can be performed within the 10 second pause in CPR for a pulse check, and provide additional diagnostic information that can guide further resuscitative measures.
Moreover we have found that it is usually practical to extend the ELS protocol to...
Dear Dr. Jones and colleagues,
I recently came across your paper as I was in need of a power calculation for diagnostic studies and have found your work to be very helpful. I noted, however, a minor but important error in Table 6, that outlines how to calculate sensitivity and specificity. The formula for sensitivity is incorrectly stated as the true positives divided by true positives plus false positives. Thi...
I found this article which showed suboptimal use of chaperones in emergency departments to be of great interest. In my clinical work in primary care in the UK, I often struggle with providing a chaperone for intimate examinations. The two main issues I have are who we should bring in, and what should they see.
Firstly I feel that the person brought in should be someone who is allowed to examine patients themsel...
Sir-
I presume that Dr Fairhurst is referring to a substance used ubiquitously in the Antipodes and more commonly spelled 'methoxyflurANE'.
It is estimated that over three million doses have been used over the last 25 years in Australia (Jacobs, 2010). It is used by state ambulance services in the pre-hospital environment in most states of Australia, by the Australian Defence Forces, within emergency de...
We read with interest the recent article of Grosomanidis et al.1, who compared applicability and efficacy of the tracheal intubation using an intubating laryngeal mask airway (ILMA) or an Airtraq? laryngoscope (Airtraq) in four non-conventional positions in a manikin study. Their findings that success rates of tracheal intubation using both techniques in an acceptable time period (up to 120 s) are up to 100% appear very...
With great interest we read the report by Parsons et al. regarding the effects of the weather on trauma unit admissions.[1] We would like to bring to the authors attention our study, in which we studied the same effects in an area in the Netherlands geographically and metereologically similar to the United Kingdom over a total period of 36 years, including over 350,000 patients.[2] Although the authors of the present stu...
Acute Care issues:
Treating hypoglycaemia in Acute care due to insulin and oral agents create very different challenges. Decrease in blood sugar due to oral agents may be due to skipped meals or exercise. However concurrent illness (dehydration etc), new onset renal dysfunction and drug interactions are major factors that cause oral agents induced hypoglycaemia; such events prolong the half life of sulfonylureas....
The question you ask is akin to asking whether drugs can cure a headache. You cannot lump all probiotics together. Probiotics are defined as "live microorganisms that when administered in adequate amounts confer a health benefit on the host"(WHO 2001). Not all micro-organisms will confer a health benefit and the actions of potential probiotics are strain specific. Therefore, your question should be 'Which, if any, probiot...
Milligan, et al. (1) provides valuable insight into the varied management of massive haemorrhage post trauma. However, the conclusions that emergency physicians lacked core knowledge and were unaware of how to prevent and treat early coagulopathy appear unfounded. It would be more prudent to conclude that a paucity of high level of evidence guiding trauma resuscitation was responsible for this varied practice.
The defin...
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