We congratulate Wallace et al on producing a useful paracetemol
overdose flowchart. It does appear to have a typographical error. Unknown
quantaties of ingested paracetemol should be boxed with > not <150
mg paracetemol. If the pdf file could be amended we will gladly update our
on-line departmental handbook. The point regarding psychiatric assessment
has already been made.
We do not want to detract from the overall value of the recent article by Wardrope and MacKenzie,[1] but we feel it important to point out our concerns over the proposed assessment of cognitive function.
Cognitive impairment due to dementia and delirium is common in emergency situations but formal assessment of cognitive function is rare. This could explain why at least 67% of older people wi...
We do not want to detract from the overall value of the recent article by Wardrope and MacKenzie,[1] but we feel it important to point out our concerns over the proposed assessment of cognitive function.
Cognitive impairment due to dementia and delirium is common in emergency situations but formal assessment of cognitive function is rare. This could explain why at least 67% of older people with delirium do not have their delirium detected by A&E staff, leading to poor outcomes.[2] Routine use of even basic screening instruments such as the AMTS [3] would help detection, but such routine use is rare.
We agree that it is useful to be able to compare the AMTS in an acute event with previously measured values, but for this comparison to be valid it is crucial that the same questions are used. It is therefore unfortunate that the version of the AMTS presented differs from the original one, and that the quoted cut-off score is incorrect.[3] It has previously been demonstrated that doctors are inconsistent when trying to assess cognition using the AMTS4, and we believe that use of the correct questions and scoring in Table 1 will help matters.
Table 1
Please follow scoring instructions.
A correct answer scores 1 mark. No half-marks are given. A score of 6 or below is abnormal
Question
Assessment
Rating
1 How old are
you?
Score for exact age
only
2 What is your
date of birth?
Only date and month
needed
3 What is the
year now?
Score for exact year
only
4 What is the
time of day?
Score if within 1hr
of correct time
5 Where are we?
What is this building?
Score for exact
place name e.g. “hospital” insufficient
Now ask subject to
remember an address: 42, West Street
6 Who is the
current monarch?
Score only current
monarch
7 What was the
date of the 1st World War?
Score for year
of start or finish
8 Can you count
down backwards from 20 to 1?
Score if no mistakes
or any mistakes corrected spontaneously
9 Can you tell me
what those 2 people do for a living?
Score if
recognises role of 2 people correctly e.g. Dr, nurse
10 Can you
remember the address I gave you?
Score for exact
recall only
TOTAL
/10
References
1. Wardrope J,.Mackenzie R. The system of assessment and care of the primary survey positive patient. Emergency Medicine Journal 2004;21:216-25.
2. Sanders AB. Missed delirium in older emergency department patients: a quality-of-care problem. Ann.Emerg.Med. 2002;39:338-41.
3. Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1972;1:233-8.
4. Holmes J,.Gilbody S. Differences in use of abbreviated mental test score by geriatricians and psychiatrists. BMJ 1996;313:465.
The flowchart to guide management in paracetamol
overdose, by Wallace, Dargan and Jones (EMJ Vol 19
No.3 p202) was presented at our weekly Journal Club
and generated some thoughts and observations.
Along the "Single" overdose pathway for "Low risk"
patients the guideline suggests that if the ingested
dose of "< 150mg paracetamol per kg or UNKNOWN"
the patient can be discharged. Presumab...
The flowchart to guide management in paracetamol
overdose, by Wallace, Dargan and Jones (EMJ Vol 19
No.3 p202) was presented at our weekly Journal Club
and generated some thoughts and observations.
Along the "Single" overdose pathway for "Low risk"
patients the guideline suggests that if the ingested
dose of "< 150mg paracetamol per kg or UNKNOWN"
the patient can be discharged. Presumably this is a
typographical error, as it would make greater sense for
the box immediately below to read ">= 150mg
paracetamol per kg or UNKNOWN" as this path leads
to treatments.
Along the "Staggered" overdose pathway one route, is
taken based on an ingested dose of "< 75mg
paracetamol per kg PER DAY" whereas the other 3
routes are taken based on simply a dose per kg. It is
impossible to know what the message is here.
We also wondered what advice NPIS offers when a
staggered overdose of ">= 75 mg paracetamol per kg or
unknown" has been taken by an "At risk" patient - other
than: take LFT’s, INR, creatinine and bicarbonate; start
NAC and recheck bloods at a specified interval if the
first set are abnormal. Surely that advice, whatever it
may be, could be incorporated into the flowchart.
Along the pathways for "Single" ingestions <= 8hrs we
found ourselves uncomfortable at the prospect of
leaving checks of LFT’s, INR*, creatinine and
bicarbonate until the end of the NAC course. Twenty
hours is a long time to wait to discover that NAC has
failed to prevent coagulopathy.
Along the 8-24 hour pathway the guideline suggests
commencing treatment with NAC; taking bloods for
paracetamol etc; plotting the paracetamol; then
checking the bloods again before starting treatment.
This seems convoluted and illogical:
Firstly, with regard to the testing for paracetamol , our
understanding from local laboratory services and
Toxbase is that paracetamol levels taken while on NAC
are unreliable (because of the direct effect of NAC on
the paracetamol assay). It would therefore seem more
sensible to ensure the first set of bloods are taken off
before commencing the NAC.
Also, in this part of the flowchart, the blood tests are
repeated back to back with no obvious justification.
Perhaps it is intended that these should be rechecked
after a certain period of treatment with NAC, but this is
not stated and might well lead to confusion for those
unused to managing paracetamol overdose and relying
on the flowchart.
Similarly, for "Late" presentation or "Staggered"
overdose patients on NAC but with abnormal blood
results it would be useful to have some advice as to
when to recheck bloods rather than simply being
directed to the National Poisons Information Service.
We feel that monitoring coagulopathy is appropriate
even if the patient is already on treatment with NAC
since ongoing deterioration may demand consideration
of patient transfer to another unit (e.g. liver transplant
unit) which may be distant from the initial treating
hospital.
Finally, considering coagulopathy further, *we would
question the use of INR as a measure of coagulopathy
in paracetamol overdose. Our understanding is that
this test is reserved for guiding Warfarin dosage and
that Prothrombin time itself is more appropriate.
Overall, we approve of the idea of the flowchart but feel
that with the weaknesses detailed above it is perhaps
not quite ready for use, particularly by clinicians
unfamiliar with this common clinical problem.
Yours faithfully
Mr. Andrew Rowlands (SpR in Accident & Emergency)
Dr. John Thompson (SHO in Accident & Emergency)
Dr Fatovich asks about initial reaction severity in three participants
who were prescribed steroids and antihistamines for large local reactions
or persistent urticaria.[1]
Two initially had severe (hypotensive) reactions
whereas the other had no systemic reaction. Although frequently used, it
is difficult to determine the benefit of steroids and antihistamines to
manage large local reactions an...
Dr Fatovich asks about initial reaction severity in three participants
who were prescribed steroids and antihistamines for large local reactions
or persistent urticaria.[1]
Two initially had severe (hypotensive) reactions
whereas the other had no systemic reaction. Although frequently used, it
is difficult to determine the benefit of steroids and antihistamines to
manage large local reactions and allergic urticaria. One of us has
recently outlined why these agents are probably of little use in severe
allergic reactions.[2] We agree that they are over-emphasised in many
texts despite the absence of convincing evidence for therapeutic efficacy.
Our decision to give adrenaline by intravenous infusion was based on
an ethical requirement to provide optimal resuscitation. This approach
prevented both the inadequate response to treatment that might result from
delayed absorption after IM administration, and the adverse reactions seen
with IV boluses.
Heywood’s first question[3] is better answered by another (larger) sting
challenge study that found a clear inverse relationship between the
challenge-to-reaction interval and subsequent reaction severity.[4] We
found no such relationship, but because of our small sample size this
analysis was underpowered. Practically such knowledge is of limited use,
as demonstrated by case 3 where symptoms did not occur until 20 minutes
after the sting, compared to the overall median of 8 minutes.
Our consent process and ethical considerations, reviewed by two
respected university hospital ethics committees, have already been
outlined both in the EMJ and Lancet.[5] In accordance with good ethical
practice the risks of participation (including the small risk of death)
were clearly outlined both verbally and in writing.
To understand the ethical justification for this trial it must be
appreciated that:
1) Patients may die if they erroneously believe treatment to be
effective.[6] Thus, it is unethical to conduct a poorly designed trial.
2) Efficacy can only be proven if a control group demonstrates that
severe reactions can be precipitated by the challenge procedure. The
alternative –waiting for an accidental sting away from medical care– is
not ethical.
3) Large studies have demonstrated the safety of sting challenge
using strict exclusion criteria,[4,7] even if adrenaline is withheld
during hypotensive reactions.[8] We gave adrenaline immediately when
objective features of respiratory or cardiovascular compromise were
identified. This approach is consistent with published consensus
indications for the use of adrenaline.[9,10]
4) The small short-term risk from the trial needs to be balanced
against the far greater reduction in long-term risk from providing an
effective immunotherapy.
5) There can be little doubt as to the informed nature of the consent
process if it is remembered that participants had previously experienced
reactions in the field, away from emergency medical care.
We hope that ethics committees in the UK would not deny people the
opportunity to participate in the rigorous assessment of a treatment that
could provide them with dramatic quality of life benefits, [11] as well as
protection from potentially lethal reactions in the setting of a community
where one in every eight people receives an accidental sting every year.[12]
There can be little doubt as to the commitment and altruism of trial
participants, many of whom considered this to be important research that
would benefit others. However, implications that the trial was ill
considered, reckless, or unethical do not stand up to careful scrutiny.
References
1. Fatovich DM. Limited use of corticosteroids for insect sting anaphylaxis [electronic response to Brown et al. Insect sting anaphylaxis; prospective evaluation of treatment with intravenous adrenaline and volume resuscitation] emjonline.com 2004http://emj.bmjjournals.com/cgi/eletters/21/2/149#230
2. Brown SGA. Parallel infusion of hydrocortisone with/without
chlorpheniramine bolus injection to prevent acute adverse reactions to
antivenom for snakebites. Med J Aust 2004;180(8):428-9.
3. Heywood M. Questions raised by this study [electronic response to Brown et al. Insect sting anaphylaxis; prospective evaluation of treatment with intravenous adrenaline and volume resuscitation] emjonline.com 2004http://emj.bmjjournals.com/cgi/eletters/21/2/149#238
4. van der Linden PW, Hack CE, Struyvenberg A, van der Zwan JK.
Insect-sting challenge in 324 subjects with a previous anaphylactic
reaction: current criteria for insect-venom hypersensitivity do not
predict the occurrence and the severity of anaphylaxis. J Allergy Clin
Immunol 1994;94(2 Pt 1):151-9.
5. Brown SGA, Wiese MD, Blackman KE, Heddle RJ. Ant venom
immunotherapy: a double-blind, placebo-controlled, crossover trial. Lancet
2003;361(9362):1001-6.
6. Brown SGA, Wu QX, Kelsall GR, Heddle RJ, Baldo BA. Fatal
anaphylaxis following jack jumper ant sting in southern Tasmania. Med J
Aust 2001;175(11-12):644-7.
7. Blaauw PJ, Smithuis OL, Elbers AR. The value of an in-hospital
insect sting challenge as a criterion for application or omission of venom
immunotherapy. J Allergy Clin Immunol 1996;98(1):39-47.
8. van der Linden PW, Hack CE, Poortman J, Vivie-Kipp YC,
Struyvenberg A, van der Zwan JK. Insect-sting challenge in 138 patients:
relation between clinical severity of anaphylaxis and mast cell
activation. J Allergy Clin Immunol 1992;90(1):110-8.
9. Emergency medical treatment of anaphylactic reactions. Project
Team of The Resuscitation Council (UK). Resuscitation 1999;41(2):93-9.
10. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Part 8: advanced challenges in resuscitation: section
3: special challenges in ECC. Anaphylaxis. The American Heart Association
in collaboration with the International Liaison Committee on
Resuscitation. Circulation 2000;102(8 Suppl):I241-3.
11. Oude Elberink JN, De Monchy JG, Van Der Heide S, Guyatt GH, Dubois
AE. Venom immunotherapy improves health-related quality of life in
patients allergic to yellow jacket venom. J Allergy Clin Immunol
2002;110(1):174-82.
12. Brown SGA, Franks RW, Baldo BA, Heddle RJ. Prevalence, severity,
and natural history of jack jumper ant venom allergy in Tasmania. J
Allergy Clin Immunol 2003;111(1):187-92.
We read with interest the article by Weinberg[1] which
revealed a lack of awareness amongst A&E staff of the risks of rhesus
sensitisation as a consequence of threatened miscarriage. Similar findings
were reported in previous studies on anti-D use in A&E.[2] This problem
also exists in cases of maternal trauma in early pregnancy.
We conducted a telephone survey of A&E Senior House O...
We read with interest the article by Weinberg[1] which
revealed a lack of awareness amongst A&E staff of the risks of rhesus
sensitisation as a consequence of threatened miscarriage. Similar findings
were reported in previous studies on anti-D use in A&E.[2] This problem
also exists in cases of maternal trauma in early pregnancy.
We conducted a telephone survey of A&E Senior House Officers (SHOs) in the North-West region.
A clinical scenario was given of a patient of 18 weeks gestation with
closed abdominal trauma due to domestic violence. SHOs were asked
regarding their management of this case. Sixty-two responses were
obtained. The possibility of rhesus alloimmunisation was identified by 19(
31 %) doctors. Three of these 19 would request a Kleihauer test while the
remainder would check maternal rhesus status. If rhesus negative, 9 would
give anti-D in the A+E department. The other 9 SHOs would refer the
patient to the obstetricians on call for further evaluation. Our survey
then prompted the remaining 44 doctors with regard to rhesus
incompatibility by bringing to attention previously documented rhesus
negativity in the patient’s casenotes. Equiped with this knowledge, only 8
doctors would then give anti-D immunoglobulin in A&E, while 11 would refer
the patient for this purpose. Even then, the need for anti-D was still
unrecognised by 25/44(57 %) SHOs.
Our study is in agreement with the author’s findings that guidelines
for rhesus prophylaxis are not being followed. In the revised guidelines,
unlike threatened abortion at less than 12 weeks gestation, closed
abdominal injury is recognised as a sensitising event.[3] Without
continuing educational initiatives aimed at A+E doctors, these guidelines
will continue to be ignored.
References
(1) Weinberg L. Use of anti-D immunoglobulin in the treatment of
threatened miscarriage in the accident and emergency department. Emerg Med J 2001;18:444-7.
(2) Huggon AM, Watson DP. Use of anti-D in an accident and emergency
department. Arch Emerg Med 1993;10:306-9.
(3) Joint Working Group of the British Blood Transfusion Society and
the Royal College of Obstetricians and Gynaecologists. Recommendations for
the use of anti-D immunoglobulin for Rh prophylaxis. Tranfus Med 1999;9:93-7.
Woollard and his colleagues' study on nalbuphine identifies the gap
that can exist between research and clinical practice. I resent the claims
in this paper that nalbuphine somehow is an effective analgesic.
Since 1996, I have been receiving patients in my hospital who have
been given nalbuphine pre hospital with very little benefit and lot of
problem. These patients get grossly inadequate anal...
Woollard and his colleagues' study on nalbuphine identifies the gap
that can exist between research and clinical practice. I resent the claims
in this paper that nalbuphine somehow is an effective analgesic.
Since 1996, I have been receiving patients in my hospital who have
been given nalbuphine pre hospital with very little benefit and lot of
problem. These patients get grossly inadequate analgesia, a fact admitted
in this study. Interestingly, the reduction in pain score is quoted, but
not the end pain score. A reduction from 9 to 6 may look impressive on
statistics, but is hardly worth talking about from the patients'
perspective. These patients get troublesome nausea. The worst is the
significantly high doses of morhine needed to overcome the antagonism,
which then keeps them longer in the department.Perhaps this aspect of
hospital data should have been included to illustrate the problem.
In the doses discussed, the drug is ineffective - both as an
analgesic and as a narcotic! Can patients be called drowsy, if their GCS
is unchanged? Is it worth championing an analgesic, if the patients
subsequently need double the predicted dose of morphine?
Lastly, if 30mg nalbuphine (currently permitted upper limit in north wales
paramedic protocol)fails to achieve good analgesia, what is research
proving by comparing 10mg x2 vs 5mg x 4?
Rather than pursue futile research question, is it not better to campaign
for change of practice to morphine, which is guaranteed to work?
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?
Dear Editor
We congratulate Wallace et al on producing a useful paracetemol overdose flowchart. It does appear to have a typographical error. Unknown quantaties of ingested paracetemol should be boxed with > not <150 mg paracetemol. If the pdf file could be amended we will gladly update our on-line departmental handbook. The point regarding psychiatric assessment has already been made.
Dear Editor
We do not want to detract from the overall value of the recent article by Wardrope and MacKenzie,[1] but we feel it important to point out our concerns over the proposed assessment of cognitive function.
Cognitive impairment due to dementia and delirium is common in emergency situations but formal assessment of cognitive function is rare. This could explain why at least 67% of older people wi...
Dear Sir,
The flowchart to guide management in paracetamol overdose, by Wallace, Dargan and Jones (EMJ Vol 19 No.3 p202) was presented at our weekly Journal Club and generated some thoughts and observations.
Along the "Single" overdose pathway for "Low risk" patients the guideline suggests that if the ingested dose of "< 150mg paracetamol per kg or UNKNOWN" the patient can be discharged. Presumab...
Dear Editor
Dr Fatovich asks about initial reaction severity in three participants who were prescribed steroids and antihistamines for large local reactions or persistent urticaria.[1]
Two initially had severe (hypotensive) reactions whereas the other had no systemic reaction. Although frequently used, it is difficult to determine the benefit of steroids and antihistamines to manage large local reactions an...
Dear Editor
We read with interest the article by Weinberg[1] which revealed a lack of awareness amongst A&E staff of the risks of rhesus sensitisation as a consequence of threatened miscarriage. Similar findings were reported in previous studies on anti-D use in A&E.[2] This problem also exists in cases of maternal trauma in early pregnancy.
We conducted a telephone survey of A&E Senior House O...
Dear Editor
Woollard and his colleagues' study on nalbuphine identifies the gap that can exist between research and clinical practice. I resent the claims in this paper that nalbuphine somehow is an effective analgesic.
Since 1996, I have been receiving patients in my hospital who have been given nalbuphine pre hospital with very little benefit and lot of problem. These patients get grossly inadequate anal...
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...
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