844 e-Letters

  • methodological variables involved in the measurement of blood pressure

    The conclusion that there is an association between systolic blood pressure and in-hospital mortality requires further qualification in view of the multiciplicity of variables which impact on the measurement of blood pressure in the older patient first evaluated in the emergency department. Firstly, blood pressure measurement in the Post-SPRINT era specifies that the blood pressure should be measured after 5 minutes rest in a quiet room, and that 3 readings should be taken at 1-minute intervals(1). Is that feasible at A & E?. Secondly, "It is axiomatic that ...measurement should be recorded in both arms.....the higher of the two readings should be used for diagnosis and management...."(2). Is that feasible at A & E?. Finally, allowance should be made for seasonal differences in blood pressure, given the fact that many hypertensive patients have higher blood pressure levels in winter than in summer(3). Those who "buck" this trend experience worse cardiovascular outcomes than those who conform to this trend(3).
    (1) Myers MG., Cloutier L., Gelfer M., Padwai RS., Kaczorowski J
    Blood pressure measurement in the Post-SPRINT Era
    Hypertension doi.org/10.1161/HYPERTANSIONAHA.116.07598
    (2)Giles TD., Egan P
    Inter-arm differences in blood pressure may have serious research and clinical implications
    The Journal of Clinical Hypertension 2012;14:491-492
    (2) Giles TD., Egan P
    Inter-arm dif...

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  • The “Do’s and Don’ts” of active compression decompression CPR with an accelerometer feedback device

    We read with interest the recent article by Setala et al, where active compression decompression cardiopulmonary resuscitation (ACD-CPR) was compared with manual CPR. 1 In this study, to ensure continuous high-quality resuscitation, an audiovisual feedback defibrillator (Zoll X Series, Real CPR Help, ZOLL Medical Corporation, USA) was used. This is a key element for cardiac arrest studies. It is known that quality of CPR is an important modifier in cardiac arrest studies. 2 High-quality CPR is necessary to be able to compare and generalize the results. There is, however, a major methodologic flaw in the Setala et al study. None of the accelerometers used in feedback defibrillator are adapted to analyze ACD-CPR. The issue arises from the fact that the accelerometers are designed to measure only one distance from the chest resting point at the end of the passive decompression to the compression maximum depth. In the Setala et al study, there was no difference in distance between groups 76 (SD 1.3) mm versus 71 (SD1.0) mm. However, in ACD CPR, you need active compression (5 cm) combined with active decompression (3 cm or 15kg of pulling). Given the reported data, there are two distinct possibilities. The first is that Setala et al were able to perform active decompression (rising the chest higher than the chest resting point) but that their compressions were not adequately deep enough. As a result, ETCO2 would be lower compared to CPR with high-quality compression. The second...

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  • Ill Advised Use of Tampons for Gunshot Wounds

    We applaud the authors for their effort to educate the bystander and even medical professionals with a means to provide care for the injured in terrorist attacks. While the majority of the information provided is based in historical evidence, in today’s era of superior wound packing materials the use of tampons for gunshot wounds (GSWs) is an inferior and dangerous suggestion.

    Tampons have been around for many thousands of years for vaginal bleeding, but nothing has been documented for their use in GSWs.[1] Stories of tampon use have been around since the Vietnam era. There have even been anecdotes posted on Snopes.com from the war in Iraq.[2] The story is full of unsubstantiated information, yet it is a common reference for many.

    One can find in the fringe of the Internet, other claims of tampon effectiveness. Bioprepper claims tampons are “designed to be ultra-absorbent” and “can be used to plug a bullet hole until…accounts of this use date back to World War I.”[3] They go on to say, “Many items in modern society were first developed as a facet of military research – tampons being a prime example.” This is absolutely false. Not only that the article itself never demonstrates a tampon being used to stop life threatening hemorrhage – rather it illustrates a plethora of Boy Scout novelties of the tampon.

    Elsewhere, there are anecdotes of tampons being used during World War I and II, but nothing specifically written from the era. Still, there is no def...

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  • Response to: Hospital readmissions among mechanically ventilated in the ED: Is it feasibly a preventative strategy?

    Dr. Purro,

    First off, thank you for taking the time to read and respond to our article.  We are in agreement that invasive mechanical ventilation and hospital readmissions are important as they pertain to both patient-centered outcomes and resource utilization. 

    We also agree with your statement that Emergency Department (ED) length of stay is comparatively short when compared to the time spent in the hospital. However, in time-critical conditions such as sepsis, trauma, acute ischemic stroke, and myocardial infarction, this time period is highly influential on long-term patient outcomes. Regarding the management of mechanical ventilation, our group has previously demonstrated that the initial management of ventilator settings in the ED influences outcome (i.e. ventilator-associated lung injury and exposure to hyperoxia are also time-sensitive) (1-3). As it was previously unknown if hospital readmissions are influenced by initial ED management, and readmission is a patient-centered reflection of morbidity, we felt this topic merited further evaluation.

    We agree that the relationship between chronic illness and clinically significant outcomes is important (i.e. length of stay, duration of mechanical ventilation, etc.). Unfortunately, we felt that this data and subsequent analysis was beyond the scope of our paper.  Our aim was simply to evaluate whether or not processes of care in the ED influenced the rate of hospital readmissions in patients requir...

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  • Hospital readmissions among mechanically ventilated in ED. Is it feasibly a preventative strategy?

    Dear Editor,

    It is widely recognised that the management of patients with acute respiratory failure in the Emergency Department (ED) is a pivotal point that may influence outcomes at later stages in patient care pathways. In particular, the decision to submit patients to invasive mechanical ventilation (IMV) and the mode of ventilator settings utilised are of relevance in determining patient outcomes. It is also acknowledged that early hospital readmission following an episode of acute critical illness is a major problem not only for patients’ quality of life but also healthcare systems in general. Thus we read with great interest the recent retrospective study by Page DB et al., in which the authors investigated the relationship between ED pathways of care and the risk factors for unplanned 30-day readmissions. We applaud the authors on their efforts, however we also feel that there are several confounding issues that warrant further discussion.

    Firstly, the length of the time for which patients were treated and mechanically ventilated in the ED was relatively short - at 5 hours and 30 mins - compared the total length of stay (LOS) in hospital. We feel that this short period is unlikely to have contributed any meaningful effect on overall patient outcomes. Moreover, it would have been of great interest to discuss any changes in ventilator parameters between ED and ICU, and if the initial choice of ventilator settings could have influenced patient outcomes, i...

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  • Reply to Zhou and Wu

    We would like to thank Zhou and Wu for their thoughtful comments on our paper.

    The discrepancy in Table 1 between the first and second to last row is due to an error. The first row should note ‘Admitted to ICU (n=53)’.

    The NEWS, SIRS, and qSOFA scores were directly recorded in the patient electronic medical record (EMR), and our initial step was to extract these scores from the EMR. When these values were missing, the individual components of the scores were extracted from paper records, and the scores calculated. The high number of missing values of the qSOFA were due to the fact that it was not routinely recorded until part way through the study period. The fact that 6% of subjects still had missing values after manual chart review resulted from one or more of the components of any of the three scores not being recorded (or the record being missing) when the patient initially presented to the emergency department (ED).

    Regarding the time window, the qSOFA, NEWS, and SIRS scores used in our analysis were all based on their initial values when the patient was assessed, which would typically be within minutes of ED arrival. This therefore reflects the values upon which clinicians initially treating the patients would base their decisions.

    The high proportion of patients who died that were not admitted to ICU reflects the fact that many patients with advanced age and co-morbidities ultimately die from infection, which at some stage may meet sepsis...

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  • The relationship between qSOFA score and NEWS score

    The relationship between qSOFA score and NEWS score

    We read with interest the paper by Goulden R and colleagues 1 who compare the efficacy of qSOFA, SIRS and NEWS score in predicting the inhospital mortality of septic patients. Though the research seems to be scientific, we still have some concerns to put forward.
    To begin with, there are some minor errs existed in Table 1 of the commented paper 1, as indicated in the first row of Table 1, the total number who was admitted to the intensive care unit (ICU) was 52, however, the second row from the bottom of Table 1 indicates 53 persons had ICU admission, so, how to explain this discordance?
    Additionally, according to the data provided by Goulden R et al, the study initially included 1942 patients, nevertheless, to our surprise, 1117 (58%) of them had missing values of qSOFA score, far more than the number of 103 (5%) and 335 (17%) who had missing SIRS scores and missing NEWS scores respectively. There were still 6% missing values in the final analysis of 1818 patients, though most of missing values were supplemented by manual review of paper charts, thus, we are afraid that the major missing values were from qSOFA score, which will result in underestimated sensitivity of qSOFA in predicting the inhospital mortality. As we all know, the qSOFA score contains 3 elements 2 - respiratory rate, mental status, and systolic blood pressure, while NEWS score incorporates 7 elements - respiratory rate, mental stat...

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  • Triage in a developing country

    Dear Sirs
    We read with interest your article entitled ‘Inter-rater and intrarater reliability of the South African Triage Scale in low-resource settings of Haiti and Afghanistan (1).’
    We undertook a study in one of our Accident and Emergency departments which utilised a modified version of the Canadian Triage Acuity Scale (2). Our country is Trinidad and Tobago, in the same geographical region as Haiti. Trinidad, although not classified as a low to middle income country is a developing country. The health expenditure as a percentage of the gross domestic product is 6%.
    We appreciated your article and the findings on reliability among nurses about the South African Triage Scale for use in a low to middle income country.
    The Accident and Emergency department we studied provides care and treatment to patients with a wide variety of illnesses ranging from motor vehicle accidents and gunshot wounds to presentations such as back pain. Briefly, our study found that those in the immediate category were seen almost immediately. Those in other categories needed to wait and some waited more than 4 hours for a bed once a decision to admit was made. We cited staffing and systematic issues as possible reasons for the delays seen. Our study suffered from not documenting presenting symptoms and signs in order to validate the assigned triage category. The South African Triage Scale is perhaps more realistic in a developing country setting with the green category se...

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  • Vitamin C may shorten ICU stay

    The paper by Sheikh and Horner [1] does not properly describe the context for vitamin C.

    Fourteen trials have investigated the effect of vitamin C against post-operative AF (POAF), and significant heterogeneity has appeared between studies carried out in the USA and outside of the USA [2]. In 9 non-US studies vitamin C decreased the incidence of POAF on average by 46% (P<0.00001), but no benefit was seen in 5 US studies.

    In 5 non-US studies, intravenous vitamin C shortened the duration of hospital stay on average by 16% and by 1.47 days (P<0.00001). In 7 non-US studies, oral and intravenous vitamin C shortened the duration of ICU stay on average by 7% (P=0.002)[2]. Thus, there is strong evidence from randomized trials indicating that vitamin C may influence the duration of hospital stay and ICU stay in some contexts. It is not reasonable to restrict to mortality as the only outcome of interest [1], when considering potential effects of vitamin C on ICU patients.

    Sheikh and Horner do not mention that sometimes vitamin C levels are very low in hospital patients. For example, in one study 18 patients with clinical symptoms of scurvy were identified out of 145 consecutive patients [3]. Scurvy has been reported also in modern ICUs [4].

    In their clinical scenario, Sheikh and Horner described a patient with pneumonia, but ignored the association between vitamin C and pneumonia. Vitamin C deficiency increases the risk of pneumonia, and pneumonia d...

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  • A brief history of the specialty of emergency medicine

    Dear Dr Beecham

    Thank you for your detailed response to my recent article outlining the history of the specialty of Emergency Medicine. You are, of course, absolutely right that the Royal Charter was granted at the time of the formation of the College in 2008 and I should have written that in 2015 the Queen granted the College its Royal title. Thank you for pointing out this error.

    With best wishes