The two cases of penetration of the skull by falling onto electrical
plugs could have easily been prevented with a design which caused the
prongs to be in a horizontal rather than verticle position when placed on
a flat surface. A rounded or roof-shaped backing, instead of the usual
flat backing, would do the trick nicely, forcing the prongs to a 45-90
degree angle not likely to cause any damage to fa...
The two cases of penetration of the skull by falling onto electrical
plugs could have easily been prevented with a design which caused the
prongs to be in a horizontal rather than verticle position when placed on
a flat surface. A rounded or roof-shaped backing, instead of the usual
flat backing, would do the trick nicely, forcing the prongs to a 45-90
degree angle not likely to cause any damage to falling objects such as
baby's head.
Although I do not have any experience of the industrial rope access
industry I do have considerable personal experience of rock climbing,
general mountaineering and ski mountaineering and a long term interest in
mountain medicine over the last 35 years, so it was with interest that I
read the paper by Lee and Porter (1) in the EMJ. They suggest that they
have never seen a case of suspension trauma...
Although I do not have any experience of the industrial rope access
industry I do have considerable personal experience of rock climbing,
general mountaineering and ski mountaineering and a long term interest in
mountain medicine over the last 35 years, so it was with interest that I
read the paper by Lee and Porter (1) in the EMJ. They suggest that they
have never seen a case of suspension trauma or heard of one by personal
communication. In their conclusions they postulate that this may be a
hypothetical risk.
I suspect that this postulation is totally correct when applied to
climbers in the UK using modern harness and rope systems. In the UK it
would be very rare for an unconscious climber to hang in a situation where
they could not be lowered. At a recent (28th April 2007) mountain rescue
conference held at Ambleside in the UK Dr Xanvier Ledoux (France ICAR)
presented a paper on this subject and was able to quote probable cases in
industrial access workers, cavers and canyoners but no confirmed cases in
mountaineers. Research was limited to harnesses that had not been designed
for climbing. Nobody in the audience could quote specific cases since 1970
in climbers in the UK.
Lee and Porter quote results Patsheider’s 1972 study of
mountaineering deaths between 1957 and 1968 (2) and it is interesting to
note that this coincides with the development of modern harness design by
the UK climber Don Whillans for the 1970 Annapurna South Face Expedition.
Initially climbers attached themselves to the rope by a direct tie to the
waist, they then used multiple hemp waist loops which evolved into waist
belts in the late 1960s. The Moac/Irvine and Troll chest harnesses also
appeared on the market in the late 60s but the Whillans harness was such a
revolution that it went into commercial production by Troll soon after the
Annapurna expedition and all modern harnesses have evolved from it.
These modern combination, waist, hip and thigh harnesses ensure that
any unconscious climber falling free of the rock will hang almost
horizontally. The exact angle will depend on the attachment point and
whether or not a ruscac is being carried. In addition developments in
methods of tying onto the rope for glacier travel ensure that the level of
the anchor point can be varied for loads carried, terrain and position on
the rope. The only time a modern climber is likely to hang in the vertical
position is if they fall into a narrowing crevasse and get stuck at the
constriction. In these circumstances hypothermia is likely to complicate
any identification of possible Suspension Syndrome.
Yours sincerely,
Dr David Hillebrandt
Hon Medical Advisor to the British Mountaineering Council,
Vice President of the UIAA Medical committee
References:
1. Lee C, Porter KM. Suspension Trauma, Review. EMJ Vol 24, No 4
April 2007.
2.Patsheilder H. Pathologico-anatomical examination results in cases of
death caused by hanging on the rope. Papers of the Second International
Conference of Mountain Rescue Doctors. Austria 1972.
Lomas and Dunning have shown that serum S-100B concentration,
measured at initial assessement, relates to outcome after head injury. The
potential role of a blood test for head injury severity must be evaluated
against what can be inferred from clinical parameters that we already
record routinely.
In one of the studies the authors reviewed, of 148 patients in three
UK Emergency departments[1],...
Lomas and Dunning have shown that serum S-100B concentration,
measured at initial assessement, relates to outcome after head injury. The
potential role of a blood test for head injury severity must be evaluated
against what can be inferred from clinical parameters that we already
record routinely.
In one of the studies the authors reviewed, of 148 patients in three
UK Emergency departments[1], S-100B was the only independent predictor of
one month Glasgow Outcome Score, compared with clinical indices of
severity such as conscious level, post traumatic amnesia and head injury
symptoms.
It is also likely that CT is a relatively insensitive tool for
predicting high risk patient for neuropsychological sequelae, if the rates
of scan abnormality (around 6%) and disablility (around 18%) are compared.
(The relationship between CT findings and neuropsychological outcome has
yet to be reported in a large cohort of mild head injury patients.)
It may be necessary, therefore, for biomarkers to be included in
large scale studies of head injury outcome prediction if a useful
decision tool is to be derived.
References
(1)Townend WJ, Guy MJ, Pani MA. et al. Head injury outcome prediction
in the emergency department: a role for protein S-100B? Journal of
Neurology, Neurosurgery & Psychiatry 2002;73:542–6.
(2)Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM.
Indications for computed tomography in patients with minor head injury.
N Engl J Med. 2000 Jul 13;343(2):100-5.
(3)van der Naalt J, van Zomeren AH, Sluiter WJ, Minderhoud JM. One
year outcome in mild to moderate head injury: the predictive value of
acute injury characteristics related to complaints and return to work.J
Neurol Neurosurg Psychiatry. 1999 Feb;66(2):207-13.
The authors consider that screening all deliberate overdose patients
for an antidote requiring paracetamol overdose (ARPO) is justified. They
cite the large study sample size (20,000) required to define the risk of
concealed ARPO in a conscious co-operative patient, and estimate that this
may be as low as 1/50
However, in this study and the six cited references it occurred in
0/946 (upper 95 %...
The authors consider that screening all deliberate overdose patients
for an antidote requiring paracetamol overdose (ARPO) is justified. They
cite the large study sample size (20,000) required to define the risk of
concealed ARPO in a conscious co-operative patient, and estimate that this
may be as low as 1/50
However, in this study and the six cited references it occurred in
0/946 (upper 95 % C.I. 0.37 % or 1/270).
Unless concealed overdoses are more likely to require treatment than
announced overdoses, ARPO would be expected in less than 1/25*1/16 = 0.6 %,
95 % CI 0.25-1.05 %. (proportion of ARPO in ingestion history positive
patients, multiplied by the risk of detectable levels in patients denying
ingestion).
Their quoted sample size is correct for their methodology and a false
-negative history (FN) rate of <_0.1 _="_" ignoring="ignoring" the="the" typographical="typographical" error.="error." but="but" having="having" established="established" incidence="incidence" of="of" overdose="overdose" and="and" proportion="proportion" ingestion="ingestion" positive="positive" histories="histories" all="all" that="that" is="is" needed="needed" active="active" surveillance="surveillance" concealed="concealed" antidote="antidote" requiring="requiring" paracetamol="paracetamol" overdoses.="overdoses." this="this" method="method" could="could" quantify="quantify" very="very" rare="rare" event="event" at="at" a="a" reasonable="reasonable" cost.="cost." p="p"/> The probable low benefit from screening all overdoses does not
justify a change in practice for those departments that already test
selectively. Patients who conceal paracetamol overdose may be less likely
to present and less likely to comply with treatment. In the meantime when
doctors are risk averse and wish to minimise inconvenience to patients and
"left department" rates, early qualitative near patient testing offers
this, at a modest increase in cost.
In the elegant paper of Brown et al [1] concerning insect sting
anaphylaxis and its treatment, two patients developed electrocardiographic
changes suggesting acute inferior myocardial ischaemia with normal
troponin and cardiac enzymes. These cases are characteristic examples of
type II variant of Kounis syndrome [2].
Kounis syndrome [3][4][5] is the concurrence of allergic or
hypersensitivit...
In the elegant paper of Brown et al [1] concerning insect sting
anaphylaxis and its treatment, two patients developed electrocardiographic
changes suggesting acute inferior myocardial ischaemia with normal
troponin and cardiac enzymes. These cases are characteristic examples of
type II variant of Kounis syndrome [2].
Kounis syndrome [3][4][5] is the concurrence of allergic or
hypersensitivity reactions with acute coronary syndromes. Kounis syndrome
is caused by conditions such as angioedema, bronchial asthma, exercise-
induced anaphylaxis, food allergy, idiopathic anaphylaxis, serum sickness,
urticaria, and mastocytosis; drugs such as antibiotics, antineoplastics,
contrast media, corticosteroids, intravenous anaesthetics, nonsteroidal
antiinflammatory drugs, skin disinfectants,thrombolytics and others;
certain environmental exposures, poisons, and venoms. This occurs via
inflammatory mediators such as histamine, tryptase, chymase, and
arachidonic acid products such as thromboxane and leucotrienes. These mediators
are released from mast cells during an allergic insult. However, these mediators
have been found in blood or urine of patients suffering from acute coronary
episodes of non allergic aetiology [3].
Histamine exerts its action via H1-, H2-, and H3- histamine
receptors. H1-receptors mediate constriction of coronary smooth muscle and
initiate rhythmic phasic activity,H2-receptors mediate a minor degree of
relaxation, and H3-receptors inhibit endogenous norepinephrine release from
sympathetic nerves and accentuate the degree of shock observed during antigen
challenge since they block neural adrenergic stimulation [6]. Tryptase and chymase effectively activate the zymogen forms of
metalloproteinases such as interstitial collagenase,and stromelysin found
in atheromatous plaques and may play an important role in atheromatous plaque
erosion or rupture [7]. Chymase converts angiotensin I into
angiotensin II and angiotensin II receptors are found in the medial muscle
cells of human coronary arteries. Thus, angiotensin II generated by the
chymase released from mast cells could act synergetically with histamine
and could aggravate the local spasm of the infarcted coronary artery [8].
Today, it is almost certain that the majority of cases of unstable angina
and acute myocardial infarction are the result of combined coronary artery
spasm and atheromatous erosion or rupture followed by thrombus formation.
In contrary to what is generally believed, that anaphylactic cardiac
damage is due to peripheral vasodilatation and hypotension, today it is
almost certain that cardiac damage is the primary event during
anaphylaxis [9], followed by hypotension. Experimental studies have proven
that anaphylactic reactions can induce rapid decline in coronary blood
flow rates due to marked coronary vasoconstriction followed by clinical
events and electrocardiographic changes [10].
Adrelaline reverses the immediate symptoms of anaphylaxis by its
effects on á and â adrenoceptors and by counteracting the histamine
effects through the H3- receptors.It reverses perirheral vasodilatation,
reduces oedema, induces bronchodilatation, has positive inotropic and
chronotropic action on the myocardium and suppresses further mediator
release [11]. Although careful titrated intravenous adrenaline is an
effective strategy in treating anaphylaxis, its use is not without risk,
especially in patients with cardiovascular comorbidity. In a recent report [12]
two deaths occurred from myocardial infarction after adrenaline administration
for mild iatrogenic reactions. Recent experimental studies [13] have shown that when adrenaline is administered during maximum
anaphylactic shock and after the mediators have been released it may have
limited utility in the treatment of cardiovasculal collapse. Earlier
administration, before maximal hypotension occurs, adrenaline may produce
a more beneficial effect.
Therefore, intravenous adrenaline should be reserved for extreme
emergencies when there is doubt about the adequacy of the circulation [11].
References
(1) Brown SGA, Blackman KE, Stenlake V , et al. Insect sing
anaphylaxis; prospective evaluation of treatment with intravenous
adrenaline and volume resuscitation. Emerg Med J 2004; 21: 149-154.
(2) Nikolaidis LA, Kounis NG, Grandman AH. Allergic angina and allergic
myocardial infarction: A new twist on an old syndrome. Can J Cardiol 2002;
18: 508-511.
(3) Zavras GM, Papadaki PJ, Kokkinis CE, et al. Kounis syndrome secondary to
allergic reaction following shellfish ingestion. Int J Clin Pract 2003;
57: 622-624.
(4) Koutsojannis CM, Kounis NG. Lepirudin anaphylaxis and Kounis syndrome.
Circulation 2004; 109: e315.
(5) Koutsojannis CM, Mallioris CN, Kounis NG. Corticosteroids, Kounis
syndrome and the treatment of refractory vasospastic angina. Circulation J
2004: 68: 806-807.
(6) Chrusch C, Sharma S, Unruh H, et al. Histamine H3 receptor bockade
improves cardiac function in canine anaphylaxis. Am J Respir Care Med
1999; 160: 1142-1149.
(7) Johnson JC, Jackson CL, Angelini GD, et al.Activation of matrx-degrating
metalloproteinases by mast cell proteases in atherosclerotic plaques.
Arterioscler Thromb Vasc Biol 1998; 18: 1707-1715.
(8) Laine P, Kaartinen M, Penttila A, et al. Association between myocardial
infarction and mast cells in adventitia of the infart-related coronary
artery. Circulation 1999; 99: 361-369.
(9) Felix SB, Baumann G, Berdel WE. Systemic anaphylaxis-separation of
cardiac reactions from respiratory and peripheral events. Res Exp Med
1990; 190: 239-252.
(10) Levi R. Cardiac anaphylaxis: models, mediators, mechanisms, and
clinical considerations. In: Maronne G, Lichtenstein LM, Condorelli M,
Fauci AS (Eds) Human inflammatory disease, vol1: Clinical immunology.
Decker, Toronto, pp 93-105.
(11) Johnston SL, Unsworth J, Gompels MM. Adrenaline given outside the
context of life threatening allergic reactions. BMJ 2003; 326: 589-590.
(12) Pumphrey RSH. Lessons for management of anaphylaxis froma study of
fatal reactions. Clin Exp Allergy 200; 30: 1144-1150.
(13) Bautista E, Simons FE, Simons KJ, et al. Epinephrine fails to hasten hemodynamic recovery in fully developed canine anaphylactic shock. Int
Arch Allergy Immunol 2002; 128: 151-164.
The quoted aim of best evidence topic reviews (BETs) is to produce a
clinical bottom line which indicates, in the light of the evidence found,
what the reporting clinician would do if faced with the same scenario
again[1]. Such an objective is only achieved if the recommendation of the
BET accurately reflects the results of the evidence review. May and
Kumar[2] conclude that “cyclizine should be avoid...
The quoted aim of best evidence topic reviews (BETs) is to produce a
clinical bottom line which indicates, in the light of the evidence found,
what the reporting clinician would do if faced with the same scenario
again[1]. Such an objective is only achieved if the recommendation of the
BET accurately reflects the results of the evidence review. May and
Kumar[2] conclude that “cyclizine should be avoided in patients with acute
coronary events”, although we note with interest and concern that this
conclusion differs from the on-line version on the BEST Bets website,
which is that “There appears to be no firm evidence that cyclizine
increases morbidity and mortality in patients with myocardial ischaemia”.
We have further concerns about the conclusion in the paper edition of
the journal. The paper reviews a single 16 year old study, which looked
at a small number of patients suffering from heart failure. To their
credit May and Kumar observe that it was a small study in a very specific
group of patients. Unfortunately the published clinical bottom line
appears to draw conclusions that are not limited to treatment of patients
suffering from heart failure.
The study by Tan, Bryant and Murray[3], which was reviewed, contained
measurement data when cyclizine was given 30 minutes before diamorphine.
While cyclizine significantly increased heart rate, right atrial,
pulmonary arterial, pulmonary artery wedge and systemic arterial
pressures, the subsequent diamorphine tended to change those variables
toward the basal values, although right atrial and pulmonary arterial
pressures remained significantly above basal values. Tan et al quoted
work that concluded that cyclizine may be useful if avoidance or prompt
reversal of the hypotensive effect of opiate is required[4],which
potential benefit does not appear to have been considered by May and
Kumar.
It is also relevant to observe that no data is given for simultaneous
administration of cyclizine with opiate, for cyclizine administered after
the opiate and the study excluded use of any other drugs.. Since
cyclizine may be administered simultaneously with, or shortly after the
opiate in the clinical situation, considerable caution is required if the
conclusions of this study are to be translated into advice about clinical
care.
The clinical bottom line has the disadvantage of being a negative
recommendation, which begs the question "if not cyclizine what should I
use?" The authors have noted that the effects of other antiemetics have
not been studied, and do not therefore exclude the possibility that other
anti-emetics may have more frequent or more severe adverse effects than
cyclizine. We repeated their search strategy but replacing the cyclizine
search with metoclopramide or stemetil/prochlorperazine, revealing no
studies of the effects of these two commonly used drugs. A Cochrane study
is being undertaken to review other anti-emetics[5], and recommendations
regarding use of cyclizine or other anti-emetics in acute coronary events
must surely await a broader review of this type.
In summary, the clinical bottom line propounded by May and Kumar does
not accurately reflect the findings of the single study review; we would
suggest that it would have been more appropriate to conclude that "There
is the possibility of adverse homodynamic effects of cyclizine in patients
with heart failure, and of beneficial effects in patients with opiate
induced hypotension; the effects of other known anti-emetics are unknown."
References
1. Carley SD ed Towards evidence based emergency medicine: best
BETs from Manchester Royal Infirmary Emerg Med J 2006; 61-66.
2. May G, Kumar R Use of intravenous cyclizine in cardiac chest pain Emerg
Med J 2006; 61-62.
3. Tan LB, Bryant S, Murray RG detrimental Haemodynamic effects of
cyclizine in heart failure Lancet 1988; 1: 560-1.
4. Christie G, Gershon S, Gray R, Shaw FH, McCance I, Bruce DW Treatment
of certain effects of morphine Br Med J 1968; I: 675-678.
5. Smith E, Wasiak J, Boyle M. Prophylactic antiemetic therapy in the
emergency and ambulance setting for preventing opioid induced nausea and
vomiting. (Protocol) The Cochrane Database of Systematic Reviews 2004,
Issue 3.
We read the article by Mattick et al. [1,2] on the use of tissue
adhesives in the management of paediatric lacerations. The authors touched
upon the hazards of the glue getting into the eye. We recently came across
a 6 years old patient whose eyelids were glued together. She had sustained
a forehead laceration just above the eyebrow after a fall and presented to
the local casualty unit. After initial...
We read the article by Mattick et al. [1,2] on the use of tissue
adhesives in the management of paediatric lacerations. The authors touched
upon the hazards of the glue getting into the eye. We recently came across
a 6 years old patient whose eyelids were glued together. She had sustained
a forehead laceration just above the eyebrow after a fall and presented to
the local casualty unit. After initial assessment, tissue glue
(LiquibandTM) was applied to the laceration. The glue was applied in a
sitting position with the eye unprotected. During application the glue
accidentally went into the left eye and caused complete lid closure. The
patient was referred to us and the lashes were cut and lids separated. No
ocular complication was noticed apart from minimal glue on the
conjunctival surface that was removed with a thorough saline irrigation.
This case highlights the importance of protecting the eye with a guage
before glue application for facial lacerations. In addition, we would like
to recommend that all the facial laceration be glued with the child lying
flat on a bed. Interestingly, the product information sheet of the glue
makes no mention of eye protection prior to its application for facial
laceration.
References
(1) Mattick A. Use of tissue adhesives in the management of paediatric
lacerations. Emerg Med J 2002;19:382-385.
(2) Mattick A, Clegg G, Beattie T et al. A randomised controlled trial
comparing a tissue adhesive (2-octylcyanoacrylate) with adhesive tissue
strips (steristrips) for paediatric laceration repair. Emerg Med J 2002;
19:405-407.
In clinical practice most of us at some point have come across
patients who are Jehovah’s Witness. According to their religious way of
life they cannot take any form blood or blood related products, which
includes immunoglobulin, but in the event of traumatic wound what are our
options if patient also has hypersensitivity to tetanus toxoid?
I was referred from casualty a right-handed male pat...
In clinical practice most of us at some point have come across
patients who are Jehovah’s Witness. According to their religious way of
life they cannot take any form blood or blood related products, which
includes immunoglobulin, but in the event of traumatic wound what are our
options if patient also has hypersensitivity to tetanus toxoid?
I was referred from casualty a right-handed male patient aged 57,who
had injured his left index finger while making a wooden toy using a router
(circular saw). He sustained an irregular wound involving the radial side
of his middle and distal phalanx down to bone with significant soft tissue
injury. Finger appeared viable.
He mentioned he was a Jehovah’s witness, and a devout follower, but
that didn't worry me, as he was in no danger of haemorrhaging. What got me
concerned was the fact that he gave a history of severe allergic reaction
to tetanus toxoid, which was last administered to him before 30 years. I
proceeded to examine the wound under a ring block, washed it with plenty
of normal saline, applied a sterile dressing and started him on IV
antibiotics
Now I was faced with a dilemma, this gentleman was in need of tetanus
cover, the only other available choice was to give this patient tetanus
immunoglobulin, but this was unacceptable to the patient due to his
religious way of life. The question for which I did not have answer for
was, do the tetanus boosters/diftavax, which are in use today; are the
constituents similar to the ones used 30 years before, would they cause a
similar reaction?
The recommendation by Consultant Microbiologist was very helpful.
They were, to give the tetanus toxoid and closely observe patients
clinical condition, (as the newer tetanus toxoids are quite different from
what where used 30 years ago), wash the wound thoroughly, and also add
metronidazole to cover for clostridium tetani. Armed with more information
I approached the patient again, I discussed with the patient at length,
the options available and the advice given by the consultant
microbiologist. In the end patient decided not to have the tetanus toxoid
as he did not want to risk a reaction, and also not to have tetanus
immunoglobulin, in view of his religious beliefs. I started him on IV
antibiotics (metronidazole and penicillins), made the necessary
documentation. The following day patients had a wound debridement. He was
discharged on oral antibiotics 2 days later. Review showed, his wound
healed well, he regained good functional recovery, although he was left
with sensory deficit on the radial side of the finger.
Literature search led me to find various facts about Jehovah’s
Witness and also about blood and blood fractions. Jehovah's Witnesses
prohibit blood transfusions because they view them as a form of consuming
blood, which they say is prohibited in the Bible. It also led me to find
that there are relaxations to this belief, especially involving minor
blood fractions (immunoglobulin, albumin) and it’s a matter of
individual’s conscience.
We work in the NHS, every 6 months we have new doctors inducted in to
the system a lot of us from other countries. As a part of our induction,
Pathology Department does give us guidance regarding blood transfusions;
there always is a mention of Jehovah's Witnesses during the process. But,
I feel there is a need for more attention and education especially with
regard to minor blood fractions, and tetanus cover .This was the problem
and also a good learning experience, I have to say there is a need for
more light to be shed on this subject.
References
(1) J R Army Med Corps. 2002 Jun; 148(2): 148-50.Tetanus immunisation in
hypersensitive individuals.Williams AN, Kabuubi JB, Owen JP, Wells J.
(2) Eur J Pediatr. 1999 May; 158(5): 434. Anaphylaxis following
diphtheria-tetanus-pertussis vaccination--a reminder. Turktas I, Ergenekon
E.
(4) Watch Tower Bible and Tract Society of Pennsylvania. Reasoning From
the Scriptures: 1989. Brooklyn, NY: Watch Tower Bible and Tract Society of
Pennsylvania; 1989:73.
Details contained in a recent paper by Kane and colleagues [1] contained non-clinical information that allowed rapid and easy
identification of the patient concerned. This was compounded by inclusion
of a figure that had been widely reported in the national press at the
time of the accident.
The maintenance of patient confidentiality is a prerequisite in the
publication of case reports. I would...
Details contained in a recent paper by Kane and colleagues [1] contained non-clinical information that allowed rapid and easy
identification of the patient concerned. This was compounded by inclusion
of a figure that had been widely reported in the national press at the
time of the accident.
The maintenance of patient confidentiality is a prerequisite in the
publication of case reports. I would encourage the editors to reject such
articles in future.
Reference
(1) Kane TPC, Nuttall MC, Bowyer RC, Patel V. Failure of detection of
pneumothorax on initial chest radiograph. Emerg Med J 2001;19:468-469.
Sen and Nichani[1] should be congratulated for drawing our attention
to one of the ongoing absurdities in emergency medicine; namely, that UK
paramedics are provided with tracheal tubes, but are not given the drugs
or monitoring equipment which enable their safe and effective use in
salvageable trauma patients. The ability to intubate a trauma patient
without the benefit of drugs is known to be an e...
Sen and Nichani[1] should be congratulated for drawing our attention
to one of the ongoing absurdities in emergency medicine; namely, that UK
paramedics are provided with tracheal tubes, but are not given the drugs
or monitoring equipment which enable their safe and effective use in
salvageable trauma patients. The ability to intubate a trauma patient
without the benefit of drugs is known to be an extremely grave sign[2],
yet we don’t seem to be able to pluck up courage either to withdraw them
from use, or to offer a viable alternative. Part of the problem comes
from within the Ambulance Service itself, with many paramedics regarding
the tracheal tube as the touchstone of their status.
The authors certainly don’t deserve to have their conclusions
rubbished. Steel et al.[3] challenge them by asking if a potentially
combative and physiologically compromised patient should preferentially
undergo bag-valve-mask ventilation (BVMV) with an unsecured airway for a
prolonged period, as if there were only two solutions to this problem;
full-blown rapid-sequence intubation (RSI) or BVMV in the unsedated
patient. Clearly, there is a third way that they omitted to mention, and
that is the use of a supraglottic device in conjunction with appropriate
sedation. They themselves had the opportunity to put forward evidence to
convince us of the potential value and safety of endotracheal intubation
in the hands of paramedics with or without drugs, but simply chose to take
pot-shots at the messengers instead. Sen and Nichani’s bottom line may
have been somewhat over-simplistic, but it has to be met with good
evidence for the efficacy and safety of tracheal intubation in prehospital
care before it can simply be dismissed.
References
1. Sen A, Nichani R. Prehospital endotracheal intubation in adult major trauma patients with head injury Emerg Med J 2005; 22.
2. Lockey D, Davies G, Coats T. Survival of trauma patients who have
prehospital tracheal intubation without anaesthesia or muscle relaxants:
observational study. Brit Med J 2001;323:141.
3. French J, Steel A, Clements R, Lewis S, Wilson M, Teasdale B,
Mackenzie R, Black J. Best BETS. A call for scrutiny. EMJ Electronic
Letter, 13 December 2005.
CONFLICT OF INTEREST STATEMENT:
AMM is Adviser in Prehospital Care to Intavent Orthofix Ltd, distributor
of the LMA in the UK. This is an unsalaried position, but AMM has received
occasional payment from the company for advisory work in connection with
use of the LMA and iLMA in the prehospital environment.
Dear Editor
The two cases of penetration of the skull by falling onto electrical plugs could have easily been prevented with a design which caused the prongs to be in a horizontal rather than verticle position when placed on a flat surface. A rounded or roof-shaped backing, instead of the usual flat backing, would do the trick nicely, forcing the prongs to a 45-90 degree angle not likely to cause any damage to fa...
Dear Editor,
Although I do not have any experience of the industrial rope access industry I do have considerable personal experience of rock climbing, general mountaineering and ski mountaineering and a long term interest in mountain medicine over the last 35 years, so it was with interest that I read the paper by Lee and Porter (1) in the EMJ. They suggest that they have never seen a case of suspension trauma...
Dear Editor,
Lomas and Dunning have shown that serum S-100B concentration, measured at initial assessement, relates to outcome after head injury. The potential role of a blood test for head injury severity must be evaluated against what can be inferred from clinical parameters that we already record routinely.
In one of the studies the authors reviewed, of 148 patients in three UK Emergency departments[1],...
Dear Editor
The authors consider that screening all deliberate overdose patients for an antidote requiring paracetamol overdose (ARPO) is justified. They cite the large study sample size (20,000) required to define the risk of concealed ARPO in a conscious co-operative patient, and estimate that this may be as low as 1/50
However, in this study and the six cited references it occurred in 0/946 (upper 95 %...
Dear Editor
In the elegant paper of Brown et al [1] concerning insect sting anaphylaxis and its treatment, two patients developed electrocardiographic changes suggesting acute inferior myocardial ischaemia with normal troponin and cardiac enzymes. These cases are characteristic examples of type II variant of Kounis syndrome [2].
Kounis syndrome [3][4][5] is the concurrence of allergic or hypersensitivit...
Dear Editor,
The quoted aim of best evidence topic reviews (BETs) is to produce a clinical bottom line which indicates, in the light of the evidence found, what the reporting clinician would do if faced with the same scenario again[1]. Such an objective is only achieved if the recommendation of the BET accurately reflects the results of the evidence review. May and Kumar[2] conclude that “cyclizine should be avoid...
Dear Editor
We read the article by Mattick et al. [1,2] on the use of tissue adhesives in the management of paediatric lacerations. The authors touched upon the hazards of the glue getting into the eye. We recently came across a 6 years old patient whose eyelids were glued together. She had sustained a forehead laceration just above the eyebrow after a fall and presented to the local casualty unit. After initial...
Dear Editor
In clinical practice most of us at some point have come across patients who are Jehovah’s Witness. According to their religious way of life they cannot take any form blood or blood related products, which includes immunoglobulin, but in the event of traumatic wound what are our options if patient also has hypersensitivity to tetanus toxoid?
I was referred from casualty a right-handed male pat...
Dear Editor
Details contained in a recent paper by Kane and colleagues [1] contained non-clinical information that allowed rapid and easy identification of the patient concerned. This was compounded by inclusion of a figure that had been widely reported in the national press at the time of the accident.
The maintenance of patient confidentiality is a prerequisite in the publication of case reports. I would...
Dear Editors,
Sen and Nichani[1] should be congratulated for drawing our attention to one of the ongoing absurdities in emergency medicine; namely, that UK paramedics are provided with tracheal tubes, but are not given the drugs or monitoring equipment which enable their safe and effective use in salvageable trauma patients. The ability to intubate a trauma patient without the benefit of drugs is known to be an e...
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