Having already recieved correspondence via the BestBETs website regarding
various writer's preferred method of tick removal it would seem that
applying an evidence base to the subject was not as laughable as our work
colleagues first thought.
With reference to the De Boer paper,[1] although the authors felt that
rotation was justified by their results, these figures can equally be
applied to...
Having already recieved correspondence via the BestBETs website regarding
various writer's preferred method of tick removal it would seem that
applying an evidence base to the subject was not as laughable as our work
colleagues first thought.
With reference to the De Boer paper,[1] although the authors felt that
rotation was justified by their results, these figures can equally be
applied to the conclusions we took from the work to answer the three part
question given. For example, in the removal of adult female ixodes ticks,
pulling removed an undamaged tick in 41 % whilst rotation achieved this in
0 %. De Boer's conclusions stem from the fact that in those cases where the
tick was damaged the percentage of the mouthparts still in situ was 70 %
for pulling and 20 % for rotation. The conclusion we took from this was
that pulling was more likely to successfully remove an intact tick, but
when it does fail it is to a greater extent than the almost guaranteed
failure of rotation.
Although De Boer et al felt that rotation uses less force than a
straight pull this was not based on any reproducible measurement and there
is no scientific basis to say that the force of a straight pull is more
likely to cause regurgitation than the torque of rotation.
Finally De Boer states "taking what we know into consideration it is
not easy to make a firm recommendation on the preferred method" before
recommmending rotation. However, taking both available papers into
consideration we felt that mechanical methods are certainly superior and
of these a slow straight appears to have the edge.
Reference
(1) De Boer R, van den Bogaard AE. Removal of attached nymphs and adults of Ixodes ricinus (Acari: Ixodidae). J Med Entomol 1993;30:748–52.
Dyson et al [1] use a pragmatic design to address an interesting
question, but I am concerned that the statistical analysis may be
inappropriate and could have led to erroneous conclusions being drawn. The
study is a cluster randomised controlled trial. Instead of randomising
individual House Officers (HOs), the authors have randomised groups of HOs
(those working at the same hospital). This is entirely...
Dyson et al [1] use a pragmatic design to address an interesting
question, but I am concerned that the statistical analysis may be
inappropriate and could have led to erroneous conclusions being drawn. The
study is a cluster randomised controlled trial. Instead of randomising
individual House Officers (HOs), the authors have randomised groups of HOs
(those working at the same hospital). This is entirely appropriate. As the
authors point out, randomising individual HOs would risk contamination
between the two study groups by HOs sharing aide memoires.
However, if groups, rather than individuals, are randomised then the
use of standard statistical techniques may be inappropriate. These
techniques assume that all observations (i.e. all individuals) are
independent of each other. Yet in a cluster trial this may not be true.
HOs at the same hospital are likely to share characteristics and learning
experiences, and thus be more similar to each other than HOs at different
hospitals. Assuming independence in these circumstances may lead to an
overestimate of statistical power of the study and an underestimate of the
P value.
For this reason, cluster trials should be published with an estimate
of the degree of clustering within groups (the intraclass correlation
coefficient) and the effect that this has upon statistical power (the
design effect). The potential effect of clustering should be considered in
the sample size calculation and analysis should take potential clustering
into account. The fewer groups randomised and the more individuals there
are per group, the greater the potential impact of any clustering. This
study involved randomising eight hospitals, with presumably 15-20 HOs per
hospital, so the potential effect of clustering should not be ignored.
Before we can accept the conclusions of this study we need some more
information. What was the intraclass correlation coefficient for these
data? How many HOs were included from each hospital? Was analysis
undertaken at group (hospital) or individual (HO) level? If an individual
level analysis was undertaken, was this adjusted for potential clustering?
Cluster trials are a valuable tool in emergency medicine research,
and this study is a good example, yet care needs to be taken in
statistical analysis and reporting. This issue has been addressed by the
NHS Health Technology Assessment Programme [2], the BMJ [3], and the
emergency medicine literature [4]. Guidelines have recently been published
for reporting cluster trials [5], we should ensure that articles in the
EMJ follow them.
References
(1) Dyson E, Voisey S, Hughes S, Higgins B, McQuillan PJ. Educational
psychology in medical learning: a randomised controlled trial of two aide
memoires for the recall of causes of electromechanical dissociation. Emerg
Med J 2004;21:457-460.
(2) Ukoumunne et al. Methods for evaluating area-wide and organisation-
based interventions in health and health care: a systematic review. Health
Technology Assessment 1999;3(5).
(3) Campbell M, Grimshaw J. Cluster randomised trials: time for
improvement. BMJ 1998;317:1171-2.
(4) Wears RL. Statistical methods for analyzing cluster and cluster-
randomized data. Academic Emergency Medicine 2002;9:330-341.
(5) Campbell MK, Elbourne DR, Altman DG, for the CONSORT Group. CONSORT
statement: extension to cluster randomised trials. BMJ 2004;328:702-8.
I would like to thank Dr Shyr-Chyr Chen (1) for his warning about
Bonferroni adjustments in multi comparisons about the article by Chen et
al. (2). But to accentuate the some disadvantages of Bonferroni adjustment
is required for the readers to interpret the results of the study better.
We use the alpha level (0,05) to accept or refuse the null hypotesis.
When more than 2 independent...
I would like to thank Dr Shyr-Chyr Chen (1) for his warning about
Bonferroni adjustments in multi comparisons about the article by Chen et
al. (2). But to accentuate the some disadvantages of Bonferroni adjustment
is required for the readers to interpret the results of the study better.
We use the alpha level (0,05) to accept or refuse the null hypotesis.
When more than 2 independent tests are performed, the chance of at least
one test being significant is no longer 0,05. Because of this, many author
suggest performing Bonferroni adjustment by alpha/n (n is the number of
comparisons). But Bonferroni adjustment may create more problems than it
solves. Bonferroni method adjusts the alpha value according to the
foresight that all null hypotheses are true simultaneously. But after
then, we can not assess the each variable in its own right. Another
disadvantage of Bonferroni adjustment is to increase the possibility of
making type II error (to accept the null hypothesis when it is wrong
actually). This may cause an interpretation of assuming an effective
procedure not to be better than placebo.
Bonferroni adjustment should be applied when we are interested in the
universal hypothesis. If we are interested in a specific hypothesis,
Bonferroni adjustment has restricted application. In multi group
comparisons, to define why and what tests were carried out and which level
of significance was preferred should enable the reader to commend
conclusions of the study more properly (3).
References
1. Shyr-Chyr Chen, Zui-Shen Yen, Shey-Ying Chen, et al. Bonferroni
correction for multiple comparisons.2004 Nov 2.
2. Chen TA, Lai KH, Chang HT. Impact of a severe acute respiratory
syndrome outbreak in the emergency department: an experience in Taiwan.
Emerg Med J 2004;21:660ÝV662.
3. Perneger TV. What is wrong with Bonferroni adjustments. BMJ
1998;16:1236-1238
I read with interest the last article about paediatric sedation.[1] I
feel that some of the evidence about adverse events is put forward in a
slightly misleading way. Dr Doyle states that "...at least 52 deaths and 27
episodes of serious morbidity including six episodes of permanent
neurological damage and 15 prolonged hospitalisations attributed to
sedation. The causes of these events were mainly d...
I read with interest the last article about paediatric sedation.[1] I
feel that some of the evidence about adverse events is put forward in a
slightly misleading way. Dr Doyle states that "...at least 52 deaths and 27
episodes of serious morbidity including six episodes of permanent
neurological damage and 15 prolonged hospitalisations attributed to
sedation. The causes of these events were mainly drug overdose, inadequate
monitoring, inadequate training of the personnel involved, or premature
discharge."[2] This statement is placed in the middle of a paragraph about
sedation events occurring in emergency departments and might be taken to
imply that these events occurred in emergency departments. This series
about adverse sedation events was drawn from a wide variety of
specialities. Indeed, 29 of the deaths occurred in dental practice and 11
in radiology. There were no deaths or permanent neurological injuries
resulting from children sedated in emergency medicine and only 4 cases
resulting in prolonged hospitalisation in this series. One would hope that
the ability of emergency physicians to manage complications of sedation
would exceed that of community dentists. It is easy to imagine how adverse
events can occur in the dark, isolated corners of the radiology
department.
The safety of paediatric sedation is vexed and difficult question and it
is important that the evidence, such as it is, is appraised correctly.
References
(1) Doyle E. Emergency analgesia in the paediatric population. Part
IV Paediatric sedation in the accident and emergency department: pros and
cons. Emer Med J 2002;19:284-287.
(2) Cote CJ, Notterman DA, Karl HW, Weinberg JA, McCloskey C.
Adverse sedation events in Pediatrics: A Critical Incident Analysis of
Contributing Factors. Pediatrics 2000; 105(4):805-814.
Aruni Sen’s evident distaste for nalbuphine seems to have
precipitated a somewhat hasty and inaccurate reading of our paper [1].
Firstly, we did not claim that nalbuphine is an effective analgesic.
We did, however, offer empirical evidence that it is effective for many
patients –just under half of those treated had a pain score of three or
less (‘mild’ pain) on arrival at hospital. Less tha...
Aruni Sen’s evident distaste for nalbuphine seems to have
precipitated a somewhat hasty and inaccurate reading of our paper [1].
Firstly, we did not claim that nalbuphine is an effective analgesic.
We did, however, offer empirical evidence that it is effective for many
patients –just under half of those treated had a pain score of three or
less (‘mild’ pain) on arrival at hospital. Less than 15% were reported as
receiving further analgesia within 30 minutes of admission to A&E. I
would challenge the view that a reduction of three to four points on the
numerical rating scale is ‘hardly worth talking about from the patient’s
perspective’. By definition, this is a reduction in the degree of pain
that the patient can perceive, and represents at worst a change from
‘severe’ to ‘moderate’ pain and at best a reduction from ‘severe’ or
‘moderate’ pain to ‘mild’ pain [2].
Aruni Sen implies that nausea is a routine consequence of nalbuphine
administration. Our research found this occurred in less than 21% of
patients.
The incidence of antagonism to morphine identified by A&E doctors
during our study was very low. Of 176 patients recruited, we had complete
data from receiving hospitals for 110, from which there were four cases of
claimed antagonism (3.6%, 95% CI 1 to 9%). Of these four patients, the
recorded dose of diamorphine administered in the A&E department was
5mg in two cases and 7.5mg in a third. The fourth patient received 30 mg:
this was the only reported incidence of administration of a higher than
usual dose of analgesia. We did not report the dose of analgesic required
for all patients in hospital as several different drugs were used in
various A&E departments, making comparison difficult.
‘Drowsiness’ was a patient reported side-effect, not a description of
observations made by paramedics. Clearly, patients were reporting a
subjective sensation whilst paramedics objectively documented the best
score obtained for each facet of the GCS.
We decided not to test a 30mg initial dose of nalbuphine during the
study as this is outside of the licensed dose range for all sources of
pain other than myocardial infarction.
This research was not conducted to champion nalbuphine. Rather, it
sought to determine which of two nalbuphine dosing regimens in use at that
time was the most effective, as when this study was conducted it was the
only intravenous analgesic that paramedics could legally administer. Since
the administration of morphine by paramedics became legal, its
introduction into UK ambulance services has been slow. Until this has been
completed, we hope our research will encourage the use of the most
effective dosing regimen for nalbuphine to enhance patient comfort.
References
(1) Woollard M, Whitfield R, Smith K, Jones T, Thomas G, Thomas G,
Hinton C. Less IS less: a randomised controlled trial comparing cautious
and rapid nalbuphine dosing regimens. Emerg Med J, 2004;21(3):362-364.
(2) Bondestam E, Hovgren K, Gaston JF, et al. Pain assessment by
patients and nurses in the early phase of acute myocardial infarction. J
Adv Nurs, 1987;12(6):677-82.
We thank Kounis & Kounis for their interest in our article. Their
insights into the link between allergic mechanisms and coronary disease
are interesting. However, the level of evidence supporting their
extrapolations of this and other animal data to human anaphylaxis is
limited.
Different species exhibit different patterns of organ involvement
during anaphylaxis [1]. Animal data can only...
We thank Kounis & Kounis for their interest in our article. Their
insights into the link between allergic mechanisms and coronary disease
are interesting. However, the level of evidence supporting their
extrapolations of this and other animal data to human anaphylaxis is
limited.
Different species exhibit different patterns of organ involvement
during anaphylaxis [1]. Animal data can only be regarded as hypothesis
generating, and unfortunately human data is scarce. Studies of
artificially sensitised isolated animal cardiac tissue and small animals
have only a limited application to immediately life-threatening
multisystem allergic events in intact humans with naturally acquired IgE-
mediated allergy.
Although cardiac dysfunction during human anaphylaxis (including ECG
changes and global suppression of myocardial function) has been reported,
the significance of these above other well-recognised events, seen in the
majority of cases and all physiologically antagonised by adrenaline,
remains uncertain. An understanding of global issues –upper airway
compromise and bronchospasm causing hypoxaemia, distributive shock,
hypovolaemic shock, reduced coronary and cerebral perfusion, and reflex
mechanisms– are probably more important in terms of emergency management.
Thus, the keys to treating the vast majority of cases continue to be;
the supine position, adrenaline, oxygen, and fluid (volume) resuscitation.
In the context of human anaphylaxis, it is incorrect to state that
"today it is almost certain that cardiac damage is the primary event".
Kounis & Kounis back up this statement with a single piece of original
research, which looked at artificially sensitised guinea pigs [2].
As we point out in our paper, there are several mechanisms that may
explain our observations of a cardiac effect during severe human
anaphylaxis. These include direct mediator actions on the heart, supported
by our observation in one case of ECG changes in the absence of
hypotension. But, we also observed that diastolic hypotension was an early
feature in those experiencing hypotension (as illustrated by case 1),
indicating systemic vasodilation to be important. Neurocardiogenic reflex
responses to the resulting reduction in venous return may partially
explain the association between death and the upright position (which
exacerbates venous pooling) observed by Pumphrey [3]. Fisher has also
demonstrated the importance of massive fluid loss by extravasation that
occurs during anaphylaxis in humans [4].
Kounis & Kounis refer to two deaths following the administration
of adrenaline [5]. However, these deaths involved the administration of
massive intravenous boluses that can only be interpreted as major errors
in management. In our response to previous correspondence we have outlined
why the intravenous route (by infusion, not bolus administration) may be
the best option in experienced hands [6].
To quote Fisher, "In severe anaphylaxis adrenaline by any route is
better than none" [7]. How this is achieved depends on the level of
expertise at hand.
References
1. Kemp SF and Lockey RF. Anaphylaxis: a review of causes and
mechanisms." J Allergy Clin Immunol 2002; 110(3): 341-8.
2. Felix SB, Baumann G, Berdel WE. Systemic anaphylaxis-separation of
cardiac reactions from respiratory and peripheral events. Res Exp Med
1990; 190: 239-252.
4. Fisher MM. Clinical observations on the pathophysiology and
treatment of anaphylactic cardiovascular collapse. Anaesth Intensive Care
1986; 14(1): 17-21.
5. Pumphrey RSH. Lessons for management of anaphylaxis froma study of
fatal reactions. Clin Exp Allergy 200; 30: 1144-1150.
I agree with the comments by Dr Harden that assessment of cognitive
function is important in the acutely confused patient.
However maybe a slight modification is necessary. Knowledge of the
start of the first world war is also partly dependent on level of
education. As the war started 90 years ago, for the majority of our
patients this was a long time before they were born. Perhaps asking when...
I agree with the comments by Dr Harden that assessment of cognitive
function is important in the acutely confused patient.
However maybe a slight modification is necessary. Knowledge of the
start of the first world war is also partly dependent on level of
education. As the war started 90 years ago, for the majority of our
patients this was a long time before they were born. Perhaps asking when
was the last time we won the World Cup, or some other significant event
would be an acceptable replacement. Judging by the way we played in Euro
2004, it could be a long time before we win anything of significance again
and perhaps this modification would require replacing too.
Black, Ward and Lockley are absolutely correct in stating that: ‘The
decision to use a helicopter is not straightforward, and a number of
important geographical, physiological, and pathological factors need to
be considered.(1)’ In mountain rescue (MR) these factors combine to give
a very challenging environment where the outcome of the casualty,
safety of the aircrew and the mountain rescuers have to...
Black, Ward and Lockley are absolutely correct in stating that: ‘The
decision to use a helicopter is not straightforward, and a number of
important geographical, physiological, and pathological factors need to
be considered.(1)’ In mountain rescue (MR) these factors combine to give
a very challenging environment where the outcome of the casualty,
safety of the aircrew and the mountain rescuers have to well thought-
out. There is no doubt that helicopters have an essential role in MR as
demonstrated regularly by RAF, Navy and Coastguard helicopters.
Casualties with time-critical injuries can be transported to definitive
(hospital) care in minutes rather than the hours it can take by the
traditional carry-off and ground ambulance (GA) route. However the
expansion of Air Ambulance services has given rise to some concern
within MR though their introduction heralds a new and hopefully
improved service to all that enjoy wild and remote places.
Helicopters operating in an Emergency Medical System (HEMS) have two
times the accident rate and 3.5 times the fatality rates of helicopters
operating in other capacities. The risk factors have been documented
and include night flying and poor weather.(2) From the MR perspective,
this is reflected in the death of rescuers. The International Commission
for Alpine Rescue (IKAR) has an incomplete data-set that shows an
alarming 29% of rescuers dying in helicopter accidents (n = 130); while
21% die in avalanches, 13% in falls, and 11% by drowning. The UK has the
lowest percentage of rescuer’s death from helicopter accidents - 1 of the
5 total deaths. IKAR has also published a paper on the medical
considerations in the use of helicopters.(3)
Critical incidents have been identified in the past and continue.
Many
have a common and recurring theme. From the medical perspective
these are an incomplete assessment and protection of the casualty
(recently focusing on spinal care) and an understanding of the medical
resources and equipment available from MR. From the operational
perspective many more serious critical incidents have occurred from
poor communication and planning of the helicopter role and, recently,
the duplicity of helicopter response.
In response to these concerns, the Lake District Search and Mountain
Rescue Association (LDSAMRA) has agreed a protocol with the Great
North Air Ambulance that places the Mountain Rescue Team Leader in a
central position in control of the incident. The Team Leader is best
placed to make operational decisions because he/she is likely to have an
intimate knowledge of the incident location (critical for assessing
landing
possibilities), weather conditions (including cloud cover), and other
resources in the area whether it be a mountain rescue vehicle or
personnel including Doctors. Such factors cannot be adequately
considered remotely, and Team Leaders have many years of experience
in making these assessments.
References
1) Black JJM, Ward ME, Lockey DJ. Appropriate use of helicopters to
transport trauma patients from incident scene to hospital in the Unitied
Kingdom: an algorithm. Emerg Med J 2004;21:355-361
3) Tomazin I. Kovacs T. International Commission for Mountain
Emergency Medicine. Medical considerations in the use of helicopters in
mountain rescue. [Review] [25 refs] High Altitude Medicine & Biology,
2003. 4(4):479-83
May I thank Ayan Sen and Raj Nichani for their recent “Best Bet” on
prehospital intubation in head injury. It was a pity however, that they
neglected to look deeper into the reasons why their conclusion, at least
at this point in time, was that there is insufficient evidence to support
its use. The very topic of prehospital rapid sequence induction (RSI), was
the subject of a panel discussion and p...
May I thank Ayan Sen and Raj Nichani for their recent “Best Bet” on
prehospital intubation in head injury. It was a pity however, that they
neglected to look deeper into the reasons why their conclusion, at least
at this point in time, was that there is insufficient evidence to support
its use. The very topic of prehospital rapid sequence induction (RSI), was
the subject of a panel discussion and presentation at the National
Association of Emergency Medical Service Physicians annual meeting in
Arizona in 2004. They, fortunately, delved deeper into the issues
surrounding RSI in head injured patients. One of the most important
findings from this discussion was that most of the ambulance services
involved in studies surrounding RSI / sedation assisted intubation, did so
without the benefit of End-Tidal Carbon Dioxide (ETCo2) or even oxygen
saturation monitoring. This, coupled with the widespread use of
hyperventilation and inadequate preoxygenation went some way to explain
the adverse findings found.
In one of the largest studies, the San Diego
Paramedic RSI study, when one ambulance service introduced the use of
ETCo2 monitoring, further analysis found hyperventilation (<30mmhg)
occurred in 79% and severe hyperventilation (<25mmhg) occurred in 59%
of intubated patients. Post introduction of ETCo2 monitoring, the
incidence of inadvertent hyperventilation was significantly reduced. The
only RSI subgroup without increased mortality were in those patients who
underwent paramedic RSI but were then transported by air medical crews who
had substantial experience using ETCo2 to guide ventilation.
The San Diego trial uncovered many adverse findings, but in a positive
light, many important lessons were learned.
First, advanced monitoring including pulse oximetry and ETCo2 should be
mandatory when performing ETI with or without RSI.
Second, adequate preoxygenation prior to RSI and close oxygen saturation
monitoring during laryngoscopy should be routine.
Third, hyperventilation should be avoided.
In stark contrast to the San Diego study, the Whatcom Medic One program in
Washington has experienced none of the desaturation/bradycardia issues and
has an intubation success rate of 96.6%. All failed intubations were
successfully managed. This successful RSI program is as a result of
rigorous training, clinical governance, medical oversight, continuous
quality assurance and of course the investment in adequate monitoring
including ETCo2.
The most startling contrast between the USA and the UK, is that only
physicians here undertake RSI. The monitoring described above is now
mandatory in the emergency department (ED) and the anaesthetic room after
a position statement by both the Royal College of Anaesthetists and our
own faculty. In my scheme (Hampshire) and many others, we fully extend
this to the prehospital theatre. In conclusion, if we are to accept that
RSI in traumatic brain injury is a valid and meaningful intervention in
the ED, then would it not follow that this is also true prehospital?
Dr Rob Dawes BM MFAEM DipIMC RCSed REMT-P
References
1. Ayan Sen and Raj Nichani: Prehospital endotracheal intubation in
adult major trauma patients with head injury Emerg Med J 2005; 22.
2. Wang HE et al. Prehospital Rapid Sequence Intubation – What does the evidence show?: Proceedings from the 2004 national association of EMS
physicians annual meeting: Prehospital Emergency Care Volume 8 No 4.
3. Position Statement 1: Confirmation of endotracheal tube placement
with end tidal CO2 detection: March 2001 Emerg Med J 2001; 18:329.
Reid and colleagues have produced an interesting observational study
on rapid sequence intubation (RSI) [1].
The authors comment on the lack of data on complications of RSI in
the UK hospital setting. In 2003, we published complication data from a
multi-centre prospective observational study of 735 patients undergoing
RSI in seven Scottish urban emergency departments (ED) [2].
Reid and colleagues have produced an interesting observational study
on rapid sequence intubation (RSI) [1].
The authors comment on the lack of data on complications of RSI in
the UK hospital setting. In 2003, we published complication data from a
multi-centre prospective observational study of 735 patients undergoing
RSI in seven Scottish urban emergency departments (ED) [2].
The authors further comment that the underlying patient diagnosis may
influence intubating conditions and subsequent complications. Significant
complications may also result from operator inexperience together with
limited understanding of the pharmacology of induction and other drugs
administered during RSI. Propofol was the induction agent used in almost
50% of patients in Reid’s paper. In our study thiopentone and etomidate
were the most frequently used induction agents (44% and 33% respectively).
In our opinion, propofol should be used with caution during RSI as the
pharmacokinetic profile of propofol is not suitable for this role and it
has an unacceptably high incidence of hypotension associated with
induction [3][4][5].
Reid also notes that intubation in the ED was associated with a lower
immediate complication rate and postulated that this was due to the
‘relative cardiovascular stability and normal respiratory function of ED
patients’. This contrasts markedly with our data where 29.5% of patients
underwent RSI for hypoventilation and 8.1% for ‘shock’.
In our study patients intubated by emergency physicians were more likely
to be physiologically compromised (prior to RSI) than those intubated by
anaesthetists. This may in part reflect the lower numbers in Reid’s single
centre study (208 patients) compared to our larger multi-centre study with
735 adult RSIs.
We agree that there is evidence that RSI can be safely performed by
emergency physicians [6][7][8]. However, further analysis of data from the
single largest contributor to our study (the Royal Infirmary of Edinburgh,
n=441) showed that there was an increased RSI complication rate for
emergency physicians compared to anaesthetists in that centre and this led
to the development of a joint RSI protocol.
This protocol ensures that, wherever possible, a senior anaesthetist
or intensive care specialist is present when the emergency physician
performs the RSI. This collaborative approach has improved communication
and collaboration and reduced the complication rate in the group intubated
by emergency physicians [9]. We have also developed an RSI assistant
training programme and continue to prospectively audit every intubation
attempt in the ED, as part of ongoing quality of care monitoring.
We agree wholeheartedly with Reid that continuing cooperation and
collaboration with our anaesthetic colleagues is vital and that continuous
audit and quality assurance are mandatory.
A J Oglesby, Consultant in Accident & Emergency Medicine, Royal
Infirmary of Edinburgh,
Old Dalkeith Road, Edinburgh, EH16 4SU, Scotland, UK
M J D Dunn, Specialist Registrar in Accident & Emergency
Medicine, Royal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh, EH16
4SU, Scotland, UK
A J Gray, Consultant in Accident & Emergency Medicine, Royal
Infirmary of Edinburgh,
Old Dalkeith Road, Edinburgh, EH16 4SU, Scotland, UK
D Beard, Director, Scottish Trauma Audit Group, Royal Infirmary of
Edinburgh, Old Dalkeith Road, Edinburgh, EH16 4SU, Scotland, UK
D W McKeown, Consultant in Anaesthesia & Intensive Care Medicine,
Royal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh, EH16 4SU,
Scotland, UK
C A Graham, Associate Professor, Accident and Emergency Academic
Unit, Chinese University of Hong Kong, Trauma and Emergency Centre, Prince
of Wales Hospital, Shatin NT, Hong Kong
Correspondence to: Dr A J Oglesby, A&E Department, Royal
Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh, EH16 4SU or email:
angela.oglesby@luht.scot.nhs.uk
Competing interests: None declared
References
(1) Reid C, Chan L, Tweeddale M. The who, where, and what of rapid
sequence intubation: prospective observational study of emergency RSI
outside the operating theatre.
Emerg Med J 2004;21:296-301
(2) Graham CA, Beard D, Oglesby AJ, et al. Rapid sequence intubation
in Scottish urban emergency departments. Emerg Med J 2003;20:3-5
(3) Harsten A, Gillberg L. Intubating conditions provided by
propofol and alfentanil, acceptable but not ideal. Acta Anaesth Scand
1997;41:985-987
(4) Kazama T, Ikeda K, Morita K et al. Propofol concentration
required for endotracheal intubation with a laryngoscope or fiberscope and
its interaction with fentanyl. Anesth Analg 1998;86:872-879
(5) Skinner HJ, Biswas A, Mahajan RP. Evaluation of intubating
conditions with rocuronium and either propofol or etomidate for rapid
sequence induction. Anaesthesia 1998;53:702-710
(6) Walls RM, Vissers RJ, Sagarin MJ, et al. Emergency Department
intubations – final report of the National Emergency Airway Registry Pilot
Project. J Accid Emerg Med 1998;15:392 [Abstract]
(7) Sackle JC, Laurin EG, Rantapaa AA, Panacek EA. Airway management
in the emergency department: a one year study of 610 tracheal intubations.
Ann Emerg Med 1998;31:325-332
(8) Tayal VS, Riggs RW, Marx JA, at al. Rapid sequence intubation at
an emergency medicine registry: success rate and adverse events during a
two year period. Acad Emerg Med 1999;6(1):31-7
(9) Oglesby AJ, Dunn MJG, Beard D, McKeown DW, Robertson CE. Rapid
Sequence Intubation: Collaboration between Emergency Medicine and
Anaesthesia. Emerg Med J 2004; 21(2):e4 [Abstract]
Dear Editor
Having already recieved correspondence via the BestBETs website regarding various writer's preferred method of tick removal it would seem that applying an evidence base to the subject was not as laughable as our work colleagues first thought.
With reference to the De Boer paper,[1] although the authors felt that rotation was justified by their results, these figures can equally be applied to...
Dear Editor
Dyson et al [1] use a pragmatic design to address an interesting question, but I am concerned that the statistical analysis may be inappropriate and could have led to erroneous conclusions being drawn. The study is a cluster randomised controlled trial. Instead of randomising individual House Officers (HOs), the authors have randomised groups of HOs (those working at the same hospital). This is entirely...
Dear Editor
I would like to thank Dr Shyr-Chyr Chen (1) for his warning about Bonferroni adjustments in multi comparisons about the article by Chen et al. (2). But to accentuate the some disadvantages of Bonferroni adjustment is required for the readers to interpret the results of the study better.
We use the alpha level (0,05) to accept or refuse the null hypotesis. When more than 2 independent...
Dear Editor
I read with interest the last article about paediatric sedation.[1] I feel that some of the evidence about adverse events is put forward in a slightly misleading way. Dr Doyle states that "...at least 52 deaths and 27 episodes of serious morbidity including six episodes of permanent neurological damage and 15 prolonged hospitalisations attributed to sedation. The causes of these events were mainly d...
Dear Editor
Aruni Sen’s evident distaste for nalbuphine seems to have precipitated a somewhat hasty and inaccurate reading of our paper [1].
Firstly, we did not claim that nalbuphine is an effective analgesic. We did, however, offer empirical evidence that it is effective for many patients –just under half of those treated had a pain score of three or less (‘mild’ pain) on arrival at hospital. Less tha...
Dear Editor
We thank Kounis & Kounis for their interest in our article. Their insights into the link between allergic mechanisms and coronary disease are interesting. However, the level of evidence supporting their extrapolations of this and other animal data to human anaphylaxis is limited.
Different species exhibit different patterns of organ involvement during anaphylaxis [1]. Animal data can only...
Dear Editor
I agree with the comments by Dr Harden that assessment of cognitive function is important in the acutely confused patient.
However maybe a slight modification is necessary. Knowledge of the start of the first world war is also partly dependent on level of education. As the war started 90 years ago, for the majority of our patients this was a long time before they were born. Perhaps asking when...
Dear Editor
Black, Ward and Lockley are absolutely correct in stating that: ‘The decision to use a helicopter is not straightforward, and a number of important geographical, physiological, and pathological factors need to be considered.(1)’ In mountain rescue (MR) these factors combine to give a very challenging environment where the outcome of the casualty, safety of the aircrew and the mountain rescuers have to...
Dear Editors,
May I thank Ayan Sen and Raj Nichani for their recent “Best Bet” on prehospital intubation in head injury. It was a pity however, that they neglected to look deeper into the reasons why their conclusion, at least at this point in time, was that there is insufficient evidence to support its use. The very topic of prehospital rapid sequence induction (RSI), was the subject of a panel discussion and p...
Dear Editor
Reid and colleagues have produced an interesting observational study on rapid sequence intubation (RSI) [1].
The authors comment on the lack of data on complications of RSI in the UK hospital setting. In 2003, we published complication data from a multi-centre prospective observational study of 735 patients undergoing RSI in seven Scottish urban emergency departments (ED) [2].
The...
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