While it is reasonable to use large doses of Naloxone as described in the BNF (the maximum dose recommended is 10mg), the National poisons information service recommend that dose is titrated to response. Naloxone however, has also been attributed to improving GCS in gamma-hydroxybutyrate and alcohol overdoses.
Large doses of opiate antagonists may be used in simple opiate overdose, however it was not cle...
While it is reasonable to use large doses of Naloxone as described in the BNF (the maximum dose recommended is 10mg), the National poisons information service recommend that dose is titrated to response. Naloxone however, has also been attributed to improving GCS in gamma-hydroxybutyrate and alcohol overdoses.
Large doses of opiate antagonists may be used in simple opiate overdose, however it was not clear in this case that the cause of cardiac arrest was opiate induced. The patient had a primary asystolic arrest in the ambulance without a preceding respiratory arrest, which would be unusual for a massive opiate overdose. Also it is unlikely that a large enough quantity of opiate to cause a cardiac arrest would be metabolised by the liver to a degree sufficient to restore spontaneous cardiac output within 25 minutes. We feel that the clinical progress and outcome for this patient may not have been significantly influenced by larger doses of Naloxone.
Dr Alison Walker
McPherson et al’s article [1] generates some interesting questions
concerning disproportionately high levels of psychological distress
amongst Emergency Department (ED) Senior House Officers (SHOs). The
combination of shiftwork, a challenging working environment, broad case
mix, and newly acquired decision latitude may explain the findings.
We did have some reservations about the article...
McPherson et al’s article [1] generates some interesting questions
concerning disproportionately high levels of psychological distress
amongst Emergency Department (ED) Senior House Officers (SHOs). The
combination of shiftwork, a challenging working environment, broad case
mix, and newly acquired decision latitude may explain the findings.
We did have some reservations about the article. We are unfamiliar
with the General Health Questionnaire (GHQ) and brief COPE questionnaire.
A more detailed description and explanation of terms would have been
valuable. We felt that SHOs on nights (if not those on holiday) should
have been included to reduce sample bias. Confining the study to units
based in DGHs raises questions regarding generalisation. It would have
been interesting to know the degree of shop-floor senior cover in the
units studied, and to examine whether this influenced distress levels.
How can we apply this useful work to our own practice? If we
acknowledge the core finding, and accept that there is a problem amongst
our junior colleagues, we then need to ask whether intervention is
required. SHOs are required to have regular contact with a consultant
supervisor, but there is potential tension between the roles of
supervision, and support. Formal mentoring schemes offer an alternative,
but their value in the ED has been questioned.[2] It may be that the best
way to support SHOs is to be aware of their potential vulnerability to
psychological distress, and to encourage a team-based and pastoral
atmosphere within our departments. This will allow individuals recognising
a need for support to seek it out from for themselves, from people who
they feel are appropriate for the problem in hand. This is the approach we
have, in the past, taken within our own unit. However, as a response to
this article we will incorporate a session on stress management into our
SHO teaching, perhaps in conjunction with administration of the GHQ and
brief COPE …. once we find out more about them.
References
(1) Mcpherson S, Hale R, Richardson P, Obholzer A. Stress and coping in
accident and emergency senior house officers. Emerg Med J 2003;20: 230-231.
(2) Mentoring senior house officers. Is there a role for middle grade
doctors? Okereke CD, Naim M. Emerg Med J 2001; 18:259-262
Further to the case report presented by Carter and Wilby (Emerg Med J 2000 17:387) where a valuable lesson is demonstrated regarding overlooking lisfranc fractures in the presence of polytrauma, we would like to add to this a patient we encountered in order to emphasize the point.
A 27-year-old male was admitted following a road traffic accident where the patient riding a motorcycle collided with a car...
Further to the case report presented by Carter and Wilby (Emerg Med J 2000 17:387) where a valuable lesson is demonstrated regarding overlooking lisfranc fractures in the presence of polytrauma, we would like to add to this a patient we encountered in order to emphasize the point.
A 27-year-old male was admitted following a road traffic accident where the patient riding a motorcycle collided with a car at high speed. His obvious injury was a fractured right femur, which was grossly angulated at the level of the midshaft. He also had a cold cyanotic forefoot on the same side with an absent Dorsalis Pedis pulse on doppler examination. Femoral artery damage was suspected and an angiogram was therefore performed which demonstrated a normal vascular tree.
Radiographs of the foot, which was relatively painless, demonstrated a lisfranc fracture, which was openly reduced and internally fixed following intra-medullary nailing of the femur. During open reduction the vascularity of the foot which was now swollen and tense rapidly improved. We believe this represented a compartment syndrome in the foot secondary to the lisfranc fracture.
To reinforce the original point made by Carter and Wilby, this lisfranc fracture could have been overlooked whilst attention was being paid to the more painful injury, in this case the fractured femur and concerns regarding femoral artery damage. We would therefore like to reiterate that in a case of major trauma foot injuries might be overlooked unless a detailed secondary survey is performed to exclude them.
Regarding the article by O’Cathain et al. [1] it was interesting to note the conflicting statements made towards the end of the paper.
The systems of NHS Direct
were identified as having poor sensitivity and specificity when dealing
with the studied calls, yet at the end the paper it states that the types
of low priority calls referred need refinement due to at least one-fifth
may be pass...
Regarding the article by O’Cathain et al. [1] it was interesting to note the conflicting statements made towards the end of the paper.
The systems of NHS Direct
were identified as having poor sensitivity and specificity when dealing
with the studied calls, yet at the end the paper it states that the types
of low priority calls referred need refinement due to at least one-fifth
may be passed back to the ambulance service. My interpretation the
findings are that calls are referred back to the ambulance
service as not being suitable for telephone advice and/or treatment but as
the sensitivity and specificity are so low, surely it is the NHSD systems
that need investigating and refining!!
Also the paper makes no reference to the type of priority dispatch in
use to identify the original calls. Criteria Based Dispatch is a semi-
structured system with call-takers having the opportunity to be flexible
in the triage of the patient ( and has been shown to be potentially risky)
and AMPDS is a structured, rigid process where compliance to the system
impacts the accuracy of detection. Without an explanation of which of
these systems was in use and, if AMPDS, the compliance - the use of calls
"triaged by priority dispatch as low priority" is meaningless because is
it the system being measured or is the call-taker?
Reference
(1) A O’Cathain, E Webber, J Nicholl, J Munro, and E Knowles. NHS Direct: consistency of triage outcomes.
Emerg Med J 2003; 20:289-292.
We read with interest and some sympathy the recent case report by Walker et al of an apparent 'Lazarus' phenomenon in which spontaneous circulation unexpectedly returned after abandoning resuscitation of a patient believed to have taken an opiate overdose [1]. In common with inner-city Emergency Departments the world over, heroin overdoses make up a significant proportion of our workload. It is establis...
We read with interest and some sympathy the recent case report by Walker et al of an apparent 'Lazarus' phenomenon in which spontaneous circulation unexpectedly returned after abandoning resuscitation of a patient believed to have taken an opiate overdose [1]. In common with inner-city Emergency Departments the world over, heroin overdoses make up a significant proportion of our workload. It is established practice in this context, along with other therapeutic maneuvers, to begin naloxone therapy with a 2mg bolus, which is then repeated if necessary up to a total of 10mg or more if the diagnosis of opiate overdose is still being maintained. The upper dose is suggested by the British National Formulary [2]. This applies to respiratory and cardio-respiratory arrests - remembering that one of the four 'T's of reversible causes of cardiac arrest in the Universal Algorithm of the European Resuscitation Council is Toxic/therapeutic disturbances [3].
In the case reported by Walker et al we would like to highlight the following points:
1. The patient initially responded to a total of 1.2mg intramuscular naloxone given on scene by the Paramedics, improving from GCS 3/15 to being able to walk to the ambulance. Thus the diagnosis of opiate overdose was highly likely.
2. In transit he deteriorated and subsequently had a cardio-respiratory arrest. He was in asystole on arrival to hospital. During the next 25 minutes of resuscitation he received only a further 3.6mg total of naloxone intravenously. Since his rhythm had been asystole for more than 25 minutes the resuscitation was not unreasonably abandoned. However, a few minutes later he recovered a perfusing rhythm. He left the hospital 18 days later with a full neurological recovery.
3. We suggest that the patient should have received 10mg of naloxone, or more, during the resuscitation. The probable diagnosis was demonstrated by his initial response to the naloxone administered by the Paramedics. It is likely that he took a massive overdose of opiate as indexed by his severe cardiac depression. However, as a habitual user, it is also likely that he would quickly metabolise his overdose if he remained alive long enough. To the credit of the team involved, the CPR during his 25 minutes of hospital resuscitation must have been enough to perfuse his brain, hence eventual full neurological recovery, and his liver, hence opiate metabolism enough to regenerate a perfusing rhythm.
References
(1) Walker A, McClelland H, Brenchley J. The Lazarus phenomenon following recreational drug use. Emergency Medicine Journal 2001; 18: 74 - 75.
(2) British National Formulary. Number 40. September 2000. British Medical Association and the Royal Pharmaceutical Society of Great Britian.
(3) Advanced Life Support Working Group of the European Resuscitation Council. The 1998 European Resuscitation Council guidelines for adult advanced life support. BMJ 1998; 316: 1863-1869
In his article, Dr Foëx sketched the history of intraosseous drug and
fluid administration, citing Tocantins and co-workers as the pioneers of
this technique. In all fairness, however, it should be pointed out that
this method was indeed described, and used clinically, even earlier than
that. In fact, one of the pioneers in this field, Henry Turkel, traces the
experimental studies of the bone marrow...
In his article, Dr Foëx sketched the history of intraosseous drug and
fluid administration, citing Tocantins and co-workers as the pioneers of
this technique. In all fairness, however, it should be pointed out that
this method was indeed described, and used clinically, even earlier than
that. In fact, one of the pioneers in this field, Henry Turkel, traces the
experimental studies of the bone marrow for fluid infusion well back into
the 19th century.[1]
If an inventor can be identified for the use of the marrow for the
administration of drugs and fluids, it is probably Cecil Drinker of Johns
Hopkins University. As early as 1916, he demonstrated in the dog that the
tibial marrow could be perfused with Ringers' solution.[2] In 1922, he
published further studies, using also cats and rabbits.[3] Unfortunately,
Tocantins and co-workers in their articles make little or no mentioning of
these early findings.
In 1934, Arnold Josefson, Professor of Medicine at Sabbatsberg
Hospital, Stockholm, presented a series of more than 50 intraossal
injections for the treatment of pernicious anemia.[4]
During the Second World War, the intraosseous method appears to have
been in quite widespread use by the U.S. Armed Forces.[5] It then
disappeared from the adult scene, only to reappear during the 1990's, when
more practical needles and devices became available (e.g. the Cook Sur-
Fast needle, the Wais-Med Bone Injection Gun [B.I.G.], and the Pyng
F.A.S.T. 1).
Eskil Dalenius MD DEAA RSwAFMC
References
(1) Turkel H. Transfusion by way of the bone marrow. Int Med Dig
1956;68:117-121.
(2) Drinker CK, Drinker KR. A method for maintaining an artificial
circulation through the tibia of the dog, with a demonstration of the
vasomotor control of the marrow vessels. Amer J Physiol 1916;40:514-521.
(3) Drinker C, Drinker KR, Lund CC. The circulation in the mammalian
bone marrow. Amer J Physiol 1922;62:1-92.
(4) Josefson A. A new method of treatment - Intraossal injections. Acta
Med Scand 1934;81:550-564.
(5) Turkel H. Emergency infusion through the bone. Milit Med
1984;149:349-350.
Whilst we broadly agree with the authors use of nitrous oxide as an
adjunct analgesic in emergency medicine,[1] we feel that there are better
alternatives to nitrous oxide in some cases. For example, we would suggest
the use of intravenous opioids and anti-emetics in myocardial and acute
sickle cell pain, non-steroidals in renal colic, and triptans in migraine.
Whilst we broadly agree with the authors use of nitrous oxide as an
adjunct analgesic in emergency medicine,[1] we feel that there are better
alternatives to nitrous oxide in some cases. For example, we would suggest
the use of intravenous opioids and anti-emetics in myocardial and acute
sickle cell pain, non-steroidals in renal colic, and triptans in migraine.
Secondly, in the United Kingdom we are fortunate to have premixed
cylinders of 50:50 oxygen: nitrous oxide (ENTONOX ® produced by BOC).
However, there is potential for confusion if anaesthetic machines are used
to obtain a 50:50 oxygen and nitrous oxide mixture when working overseas.
This is because of the differences in the colour codes of medical gas
cylinders. A number of countries use a gas cylinder code that differs from
the international code. In the United States of America the colour code is
almost identical to the international code- a notable exception being a
green cylinder for oxygen rather than white.[2]
References
(1) O’Sullivan I, Benger J. Nitrous oxide in emergency medicine. Emerg Med
J 2003;20:214-217.
(2) Dorsch J, Dorsch S. Understanding anaesthesia equipment, 4th edition.
Baltimore: Williams & Wilkins, 1999:13.
I read with interest the case reports on massive intrathoracic
haemorrhage after aspiration for spontaneous pneumothorax.
It has always
been my understanding that the reason for continuing to use the second
intercostal space, mid-clavicular line (2ICS MCL) approach for these
patients is more to do with convenience and ease of approach than for any
scientific reason. Aspirating 2 litres may take c...
I read with interest the case reports on massive intrathoracic
haemorrhage after aspiration for spontaneous pneumothorax.
It has always
been my understanding that the reason for continuing to use the second
intercostal space, mid-clavicular line (2ICS MCL) approach for these
patients is more to do with convenience and ease of approach than for any
scientific reason. Aspirating 2 litres may take considerable time, and
using the 2ICS MCL it is generally easy to find the intercostal space and
the patient can be in pretty much any position that is comfortable for
them and convenient for the 'aspirator'. I would contrast this to the 5th
intercostal space anterior axillary line approach, when it can be more
difficult to identify the space and awkward for both patient and doctor to
keep the arm in a convenient position. I tried this approach for a while
and have to admit to going back to the 2ICS MCL approach which I find much
easier.
Whilst tempting to blame the anatomy and dangerous 'big vessels' on each
of the cases presented, in none of them was a source of bleeding
identified. It is therefore not possible to conclude, as the authors
appear to, that similar complications would not occur if a different
approach occurred.
I would also be interested to know what technique was used for aspiration
- with modern purpose designed seldinger technique kits (or just an old
fashioned single lumen cvp line kit) the needle used to punture the chest
wall is of a relatively small calibre. It would be a rare occurence to
cause a massive haemothorax even when deliberately puncturing subclavian
vessels for central venous access, so it does seem incredibly unlucky to
have 3 cases in such a short period of time.
Reference
(1) R Rawlins, KM Brown, CS Carr, CR Cameron. Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emerg Med J 2003;20:383-384.
The use of dipsticks in A&E has been looked at extensively. The
underlying problem is the lack of a "gold standard" in that microscopy is
not a 100% reliable and apparent positive cultures on MSUs can be due to
contamination whilst getting an MSU.
Using Strip Testing we were able to demonstrate a predictive value
for a negative result of 96.4%, but we were using 4 parameters
(blood,protein,...
The use of dipsticks in A&E has been looked at extensively. The
underlying problem is the lack of a "gold standard" in that microscopy is
not a 100% reliable and apparent positive cultures on MSUs can be due to
contamination whilst getting an MSU.
Using Strip Testing we were able to demonstrate a predictive value
for a negative result of 96.4%, but we were using 4 parameters
(blood,protein,leucocytes and nitrites)not just 2 as highlighted in the
BET. These strips were visually read, so it is highly likely that the use
of photometers to read the strip would improve on this value.
We concluded that by excluding these specimens there would be a reduction in 37% of MSUs requested.[1]
Some screening test is needed.
Reference
(1) McGlone R, Lambert M, Clancy M, Hawkey PM. Use of Ames SG10 Urine Dipstick for diagnosis of abdominal pain in the
accident and emergency department. Archives of Emergency Med1990;7(1):42-7.
The paper by Harvey and colleagues is a slightly overdramatic. In
their audit they found that PEFR was not regularly recorded in the notes.
However this does not mean that the assessment of patients is unsafe.
Asthma severity as they point out is based on a number of physiological
and clinical parameters. PEFR is used as a measure of severity but it has
a severe limitations as it requires a good techniqu...
The paper by Harvey and colleagues is a slightly overdramatic. In
their audit they found that PEFR was not regularly recorded in the notes.
However this does not mean that the assessment of patients is unsafe.
Asthma severity as they point out is based on a number of physiological
and clinical parameters. PEFR is used as a measure of severity but it has
a severe limitations as it requires a good technique to produce a reliable
result, which may be difficult especially for young children. It is
probably less useful as single readings than a regular readings
documenting an individuals deterioration in performance. It is reassuring
to see that other more reliable measured parameter were usually measured
i.e. pulse and respiratory rate, and oxygen saturation.
Personally I feel that my clinical decision making is often unnaffected by
an absence of a PEFR. If I have a child charging around the room,
asymptomatic, normal pulse and respiratory rate I am unlikely to keep them
in. If however they are too breathless to play and have an elevated
respiratory rate I would treat and if not improve refer.
While it is reasonable to use large doses of Naloxone as described in the BNF (the maximum dose recommended is 10mg), the National poisons information service recommend that dose is titrated to response. Naloxone however, has also been attributed to improving GCS in gamma-hydroxybutyrate and alcohol overdoses.
Large doses of opiate antagonists may be used in simple opiate overdose, however it was not cle...
Dear Editor
McPherson et al’s article [1] generates some interesting questions concerning disproportionately high levels of psychological distress amongst Emergency Department (ED) Senior House Officers (SHOs). The combination of shiftwork, a challenging working environment, broad case mix, and newly acquired decision latitude may explain the findings.
We did have some reservations about the article...
Further to the case report presented by Carter and Wilby (Emerg Med J 2000 17:387) where a valuable lesson is demonstrated regarding overlooking lisfranc fractures in the presence of polytrauma, we would like to add to this a patient we encountered in order to emphasize the point.
A 27-year-old male was admitted following a road traffic accident where the patient riding a motorcycle collided with a car...
Dear Editor
Regarding the article by O’Cathain et al. [1] it was interesting to note the conflicting statements made towards the end of the paper.
The systems of NHS Direct were identified as having poor sensitivity and specificity when dealing with the studied calls, yet at the end the paper it states that the types of low priority calls referred need refinement due to at least one-fifth may be pass...
We read with interest and some sympathy the recent case report by Walker et al of an apparent 'Lazarus' phenomenon in which spontaneous circulation unexpectedly returned after abandoning resuscitation of a patient believed to have taken an opiate overdose [1]. In common with inner-city Emergency Departments the world over, heroin overdoses make up a significant proportion of our workload. It is establis...
Dear Editor,
In his article, Dr Foëx sketched the history of intraosseous drug and fluid administration, citing Tocantins and co-workers as the pioneers of this technique. In all fairness, however, it should be pointed out that this method was indeed described, and used clinically, even earlier than that. In fact, one of the pioneers in this field, Henry Turkel, traces the experimental studies of the bone marrow...
Dear Editor
Whilst we broadly agree with the authors use of nitrous oxide as an adjunct analgesic in emergency medicine,[1] we feel that there are better alternatives to nitrous oxide in some cases. For example, we would suggest the use of intravenous opioids and anti-emetics in myocardial and acute sickle cell pain, non-steroidals in renal colic, and triptans in migraine.
Secondly, in the United Kingdom we...
Dear Edito
I read with interest the case reports on massive intrathoracic haemorrhage after aspiration for spontaneous pneumothorax.
It has always been my understanding that the reason for continuing to use the second intercostal space, mid-clavicular line (2ICS MCL) approach for these patients is more to do with convenience and ease of approach than for any scientific reason. Aspirating 2 litres may take c...
Dear Editor
The use of dipsticks in A&E has been looked at extensively. The underlying problem is the lack of a "gold standard" in that microscopy is not a 100% reliable and apparent positive cultures on MSUs can be due to contamination whilst getting an MSU.
Using Strip Testing we were able to demonstrate a predictive value for a negative result of 96.4%, but we were using 4 parameters (blood,protein,...
Dear Editor
The paper by Harvey and colleagues is a slightly overdramatic. In their audit they found that PEFR was not regularly recorded in the notes. However this does not mean that the assessment of patients is unsafe. Asthma severity as they point out is based on a number of physiological and clinical parameters. PEFR is used as a measure of severity but it has a severe limitations as it requires a good techniqu...
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