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.
Lowering of blood pressure is a reflex phenomenon after GTN
ingestion.GTN is a nitric oxide donor The response is due to increase in
cGMP level. The metabolic consequence of this bio activation depends on
the chemical structure. This is a systemic arterial response, with some
effect on the platelet aggregation but no expression of the adhesion
molecule. The other hypothesis is that it activates ATP...
Lowering of blood pressure is a reflex phenomenon after GTN
ingestion.GTN is a nitric oxide donor The response is due to increase in
cGMP level. The metabolic consequence of this bio activation depends on
the chemical structure. This is a systemic arterial response, with some
effect on the platelet aggregation but no expression of the adhesion
molecule. The other hypothesis is that it activates ATP sensitive K+
channel. Low blood pressure is due to decrease venous return .In case of
coronary circulation it targets large vessel and prevents coronary steal.
The presence or absence of level of GTN in blood after sublingual
administration is via a large volume of distribution and rapid rate of
total body clearance which depends not only on liver, but also other
organs for elimination.Bezold Zarisch reflex states that cardio-pulmonary
and carotid –aortic reflex in an intact vagii serves as a defence
mechanism .In this circumstances of hypotension and bradycardia needs
restore of blood volume deficit and venous return. This choice could be
atropine, ephedrine.
I was heartened by the courageous but constructive critique of the
ATLS Course by Driscoll and Wardrope [1]. It promises an end to my lonely
position as ATLS-Skeptic, which began in 1999 when I suggested that, while
ATLS was “the greatest reformation in trauma care” in the late twentieth
century [2], it was “an American solution in a British context” (your readers
may have noticed the subsequent regre...
I was heartened by the courageous but constructive critique of the
ATLS Course by Driscoll and Wardrope [1]. It promises an end to my lonely
position as ATLS-Skeptic, which began in 1999 when I suggested that, while
ATLS was “the greatest reformation in trauma care” in the late twentieth
century [2], it was “an American solution in a British context” (your readers
may have noticed the subsequent regrettable trend in which car occupants
who are one minute squabbling vigorously about responsibility for a
collision are, the next, abruptly strait-jacketed in yellow plastic). I
fretted that the Course was based on a dubious notion that trauma is a
“surgical” disease, that it had become The New Dogma, and was suspiciously
clubby (“I’m an ATLS Instructor and you’re not”). But my real concerns
were that:
(1) the ATLS Course represents a major drain on scarce human
and educational resources (how many days do consultants in emergency
medicine spend away from their departments on these courses?; how much is
the NHS spending on the course fees?);
(2) ATLS only addresses the initial
part of trauma care and is not a panacea (injury prevention and
rehabilitation are at least as important);
(3) while evidence-based
medicine is something to which we all now aspire, the massive changes in
the ATLS Manual since its inception is a worrying illustration of the
dearth of serious science underpinning what ATLS promotes.
I share
Driscoll and Wardrope’s disappointment at the continuing exclusion of
emergency physicians from the development of ATLS. But happily, five years
after I quit the NHS, the Royal College of Surgeons in Ireland has
addressed my concerns with a set of Clinical Guidelines [3] that I believe
recognizes the realities of trauma care in these islands.
May I invite
your readers to peruse a document [3] which is by no means perfect but which
reflects their daily experience, along with that of their anaesthetic,
surgical and other colleagues? The sheer number of consultants and
trainees in emergency medicine who contributed to this important document
may reassure those of your readers who feel a little excluded, by the ATLS
“elite”, that their contribution to trauma care is in fact incalculable. I
hope it may also offer some encouragement to those who believe that there
are other options in trauma care on this side of the Atlantic, and that
Emergency Medicine will show the way.
Yours etc.
Chris Luke,
Department of Emergency Medicine,
Cork University Hospital, Ireland.
lukec@shb.ie
References
(1) Driscoll P, Wardrope J. ATLS: past, present, and future. Emerg Med
J 2005;22:2-3
(2) Luke L C. ATLS: has the end become the means? CPD Anaesthesia
1999;1(2):94-96
(3) Clinical Guidelines Committee, Royal College of Surgeons in
Ireland. Initial Management of the Severely Injured Patient. Dublin,
November 2003.
www.rcsi.ie/postgraduate_surgery/surgical_guidelines_protocols/Initial_Mgt._of_the_Severely_Injured_patient/index.asp?
I read with interest the article by K Mohanty et al. The authors correctly point out that, though not common, apparently minor injury can produce posterior dislocations of the hip. It has been shown that low energy injuries can lead to dislocations of the immature hip.1 In low energy injuries it is more of levering out the joint, rather than brute force dislocating the joint. Hence, the position of th...
I read with interest the article by K Mohanty et al. The authors correctly point out that, though not common, apparently minor injury can produce posterior dislocations of the hip. It has been shown that low energy injuries can lead to dislocations of the immature hip.1 In low energy injuries it is more of levering out the joint, rather than brute force dislocating the joint. Hence, the position of the limb and the direction of the force involved are more relevant. The article did not mention the exact mechanism of the injury, in terms of whether the injury occurred due to the tackle itself or due to an awkward fall and/or due to fall of other players onto an abnormally positioned hip. Another point to note is that casual game of rugby does not necessarily mean lesser degree of force. Since this article is about an unusual mechanism of injury, I feel that this should have been dealt with in more detail.
Mr Gunasekaran Kumar, F.R.C.S.
Reference
(1) Posterior dislocation of hip in adolescents attributable
to casual rugby. Emerg Med J 2000;17:429-431.
Whilst I very much enjoyed the article on whether to report gunshot
wounds to the police, I feel that an important aspect has been ommited.
Patients that present with gunshot wounds are clearly vulnerable to
further attack. This could potentially place both them, and those people
caring for them, in serious danger.
I remember hearing of a case in South Africa where a man with serious
gunshot wounds wa...
Whilst I very much enjoyed the article on whether to report gunshot
wounds to the police, I feel that an important aspect has been ommited.
Patients that present with gunshot wounds are clearly vulnerable to
further attack. This could potentially place both them, and those people
caring for them, in serious danger.
I remember hearing of a case in South Africa where a man with serious
gunshot wounds was being attended to by a paramedic at the side of a road.
A "passer-by" approached the paramedic and asked whether the man was going
to be ok. When the paramedic said "yes", the assailant pulled out a gun
and finished the patient off.
This has implications for all of us working with patients in this group.
As a nurse I would have (and have in the past), no hesitation in reporting
attacks such as these to the police. Indeed i would suggest that we have a
duty to do so.
To “shoot the messenger” is to reply to an argument by attacking the
person presenting the argument rather than the argument itself. It is a
time-honoured way of dealing with unpleasant messages. The underlying
sentiment is perhaps best expressed by Sophocles: “How dreadful knowledge
of the truth can be when there is no help in the truth” (1).
To “shoot the messenger” is to reply to an argument by attacking the
person presenting the argument rather than the argument itself. It is a
time-honoured way of dealing with unpleasant messages. The underlying
sentiment is perhaps best expressed by Sophocles: “How dreadful knowledge
of the truth can be when there is no help in the truth” (1).
Dr Mason suggests that the criticism of Sen and Nichani’s BET is
motivated by a dislike of the message itself rather than a deep and
genuine concern about the strength and reliability of the underpinning
evidence (2). As a co-author of the letter by French et al.(3), I would
like to emphasise that the criticism of the BET was, as is reflected in
the title, on methodological and clinical grounds. It was not a personal
reaction to the ‘distress generated by uncertainty and the realization of
the limits of our knowledge’ (4).
In promoting the ILMA as an alternative to tracheal intubation in the
pre-hospital setting, Dr Mason has, I fear, misunderstood the two main
criticisms of the BET. The first was that the ‘clinical bottom line’
(prehospital endotracheal intubation is associated with increased
mortality in patients with moderate to severe traumatic brain injury)
could not be reliably concluded from the literature reviewed in the BET.
It is, as Dr Mason acknowledges, “somewhat over-simplistic”. This seems a
perfectly fair and reasonable criticism to make of an article published in
a major emergency medicine journal.
The second was that the BETS process seems to ignore a key principle
of evidence based practice: the combination of the best available evidence
with clinical experience. Those of us with extensive pre-hospital
experience do not question the clinical need for pre-hospital emergency
anaesthesia, intubation, ventilation and retrieval to the most appropriate
hospital for selected patients. We question how we might target this
intervention more appropriately, how we might train paramedic
practitioners to undertake it and how we might properly and thoroughly
evaluate its safety and effectiveness compared to alternatives. The
example given by French et al. was intended to highlight, to use Dr
Mason’s words, another of the “ongoing absurdities in emergency medicine”
– the historical acceptance of a standard of critical care in the pre-
hospital phase which would be completely unacceptable in any hospital
setting.
Neither the BET or the letter by French et al. concerned the role of
the ILMA (or any other supraglottic airway device) or the role of
professional paramedics in provision of pre-hospital critical care. The
subject under discussion was the BET. Dr Mason's comments therefore seem a
little unfair. Even if we can be accused of shooting the messenger, then
two wrongs certainly don’t make a right. As a messenger who has been shot
many times, I would ask Dr Mason to holster his gun, critically appraise
the BET in question and re-read the correspondence related to it.
Roderick Mackenzie
PhD MRCP FFAEM
Clinical Fellow
Conflict of interest
Dr Mason and I have previously drawn pistols at dawn regarding the
use of the ILMA in pre-hospital care (5,6).
References
1. Lloyd-Jones H (ed.) Sophocles. Ajax. Electra. Oedipus Tyrannus,
Harvard University Press 1994.
2. Mason AM. Please don't shoot the messengers! EMJ Electronic
Letter, 16 January 2006.
3. French J, Steel A, Clements R, et al., Best Bets. A call for
scrutiny. EMJ Electronic Letter, 13 December 2005.
4. Choi PTL, Jadad AR. Systematic reviews in anesthesia: should we
embrace them or shoot the messenger? Canadian Journal of Anesthesia
2000;47:486-493.
5. Mason AM, Use of the intubating laryngeal mask airway in pre-
hospital care: a case report. Resuscitation, 2001;51:91-5.
6. Mackenzie R, The ILMA in pre-hospital care. Resuscitation,
2002;53:227.
The authors describe a case of fatal paracetamol overdose (4 hour
paracetamol concentration 534 mg/L) despite initiation of N-acetylcysteine
within 8 hours of ingestion.
Although the cause of death was ascribed to paracetamol, several
aspects of this case are not typical of paracetamol toxicity:
1) The early development of neurological symptoms (agitation, confusion
and falling conscious l...
The authors describe a case of fatal paracetamol overdose (4 hour
paracetamol concentration 534 mg/L) despite initiation of N-acetylcysteine
within 8 hours of ingestion.
Although the cause of death was ascribed to paracetamol, several
aspects of this case are not typical of paracetamol toxicity:
1) The early development of neurological symptoms (agitation, confusion
and falling conscious level) is very unusual.
2) The elevations in ALT and INR were moderate and do not suggest severe
paracetamol-induced hepatotoxicity, which is characterised by markedly
elevated ALT (usually in excess of 1000). Post-mortem examination
revealed a normal looking liver. Even though histology was not performed,
the liver would be expected to look macroscopically abnormal if massive
hepatic necrosis had occurred.
3) The development of vasodilatory shock and acute respiratory distress
syndrome in the absence of acute liver failure suggest sepsis (possibly
from aspiration) or toxins other than paracetamol.
Many of the features of this case (e.g renal failure, shock, ARDS)
can be explained by severe salicylate toxicity. The authors mention that
the salicylate concentrations were not significantly raised but the timing
of the samples is not clear.
The authors suggest that N-acetylcysteine should be started earlier
in patients with a raised lactate. Studies of patients admitted to a
tertiary-care intensive care unit with paracetamol-induced acute liver
failure have shown a raised lactate to be a poor predictor of outcome in
addition to the established King’s College criteria.1,2 This cannot be
extrapolated to patients presenting early following paracetamol overdose
and without evidence of hepatotoxicity.
This case demonstrates that the initiation of N-acetylcysteine within
8 hours is indeed effective in preventing serious hepatotoxicity, as
demonstrated by Prescott et al3 and backed by clinical experience.
Unfortunately, the patient died from other complications which may or may
not be due to paracetamol. There is no evidence that N-acetylcysteine is
effective in preventing complications such as acute renal failure and
earlier administration of N-acetylcysteine was not warranted in this case
despite the large amount ingested.
Current NPIS guidelines recommend awaiting the 4-hour paracetamol
concentration before initiating N-acetylcysteine in patients presenting
less than 4 hours after ingestion.4 We do not feel that these guidelines
need to be changed in the light of this report. The risk of adverse
reactions to N-acetylcysteine is higher in patients with low paracetamol
concentrations.5 Reported ingested amounts are often unreliable and many
patients not requiring antidotal therapy would suffer adverse reactions
unnecessarily if clinicians were to adopt the practice of starting N-
acetylcysteine before the 4-hour paracetamol concentration was known.
Yours sincerely,
Euan Sandilands, Specialist Registrar
HKR Thanacoody, Consultant Clinical Toxicologist
NPIS Edinburgh
References
1.Schmidt LE, Larsen FS. Prognostic implications of hyperlactatemia,
multiple organ failure, and systemic inflammatory response syndrome in
patients with acetaminophen-induced acute liver failure. Crit Care Med.
2006; 34(2):337-43
2.Bernal W, Donaldson N, Wyncoll D, Wendon J. Blood lactate as an
early predictor of outcome in paracetamol-induced acute liver failure: a
cohort study. Lancet. 2002 ;359(9306):558-63.
3 Prescott LF, Illingworth RN, Critchley JA, et al. Intravenous N-
acetylcysteine: the treatment of choice for paracetamol poisoning. BMJ
1979;2: 1097-100.
4. http://www.toxbase.org
5. Waring WS, Pettie JM, Dow MA, Bateman DN. Paracetamol appears to
protect from against N-acetylcysteine-induced anaphylactoid reactions.
Clin Toxicol 2006: 44:441-442.
Clenaghan et al [1] have demonstrated that Trendelenberg tilt
increases the diameter of the internal jugular vein (IJV) in healthy
volunteers. This confirms the results of previous studies.[2]
While the benefits of Trendelenburg tilt are well known, the negative
effects of other commonly performed manoeuvres are less well appreciated.
Gentle palpation of the carotid artery and neck extensio...
Clenaghan et al [1] have demonstrated that Trendelenberg tilt
increases the diameter of the internal jugular vein (IJV) in healthy
volunteers. This confirms the results of previous studies.[2]
While the benefits of Trendelenburg tilt are well known, the negative
effects of other commonly performed manoeuvres are less well appreciated.
Gentle palpation of the carotid artery and neck extension cause
significant decreases in IJV size.[2] Textbooks describe the IJV as lying
lateral to the carotid artery but ultrasound studies show that it overlies
the carotid artery to some degree in 54% of subjects. The degree of
overlap increases with head rotation [3], which may increase the risk of
carotid artery puncture, especially if the needle passes through the
posterior wall of the IJV.
Carotid artery palpation, neck extension and head rotation are often
used during IJV cannulation. These manoeuvres decrease the target size and
potentially increase the risk of failure or complications, and should be
avoided during IJV cannulation using a landmark technique.
References
1. Clenaghan S, McLaughlin RE, Martyn C et al. Relationship between
Trendelenberg tilt and internal jugular vein diameter. Emerg Med J
2005;22:867-8.
2. Armstrong PJ, Sutherland R, Scott DHT. The effect of position and
different manoeuvres on internal jugular vein diameter size. Acta
Anaesthesiol Scand 1994;38:229-31.
3. Sulek CA, Gravenstein N, Blackshear RH et al. Head rotation during
internal jugular vein cannulation and the risk of carotid artery puncture.
Anesth Analg 1996;82:125-8.
Clearly the ACE inhibitor in this case is significant in light of
this lady's acute (presumably mixed "pre-renal" and "renal") renal
failure. However, this was not due solely to one drug and I suspect that
her illness highlights a more significant problem i.e. that of the
widespread use of loop diuretics and the balance between fluid offload and
renal function. Although the precise nature of her vasc...
Clearly the ACE inhibitor in this case is significant in light of
this lady's acute (presumably mixed "pre-renal" and "renal") renal
failure. However, this was not due solely to one drug and I suspect that
her illness highlights a more significant problem i.e. that of the
widespread use of loop diuretics and the balance between fluid offload and
renal function. Although the precise nature of her vasculopathy and rest
of her medical history is not given I would suggest that this is the least
appropriate of her medication - unless good evidence existed of poor LV
function etc. Her electrolytes three weeks prior were not normal and I
would have thought that diuretic therapy at that stage should have been
reviewed or her electrolytes repeated sooner. Diuretic induced renal
failure - or at least "renal impairment" - is much more frequent in acute
admissions than once per month. Furthermore, they are often prescribed to
patients who seem neither to have significant relevant symptomatology or
appropriate monitoring in place.
This is a very helpful review. The use of alternatives to sutures is
often seen as a second best. Children must be treated in the most
appropriate manner. Any slight imperfection may become a lifelong problem.
A useful addition would be a clarification of the selection criteria
for wounds in the study; were site, shape, depth, tension important
issues.
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...
Dear Editor,
Lowering of blood pressure is a reflex phenomenon after GTN ingestion.GTN is a nitric oxide donor The response is due to increase in cGMP level. The metabolic consequence of this bio activation depends on the chemical structure. This is a systemic arterial response, with some effect on the platelet aggregation but no expression of the adhesion molecule. The other hypothesis is that it activates ATP...
Dear Editor
I was heartened by the courageous but constructive critique of the ATLS Course by Driscoll and Wardrope [1]. It promises an end to my lonely position as ATLS-Skeptic, which began in 1999 when I suggested that, while ATLS was “the greatest reformation in trauma care” in the late twentieth century [2], it was “an American solution in a British context” (your readers may have noticed the subsequent regre...
Dear Editor
I read with interest the article by K Mohanty et al. The authors correctly point out that, though not common, apparently minor injury can produce posterior dislocations of the hip. It has been shown that low energy injuries can lead to dislocations of the immature hip.1 In low energy injuries it is more of levering out the joint, rather than brute force dislocating the joint. Hence, the position of th...
Dear Editor
Whilst I very much enjoyed the article on whether to report gunshot wounds to the police, I feel that an important aspect has been ommited. Patients that present with gunshot wounds are clearly vulnerable to further attack. This could potentially place both them, and those people caring for them, in serious danger. I remember hearing of a case in South Africa where a man with serious gunshot wounds wa...
Dear Editors,
To “shoot the messenger” is to reply to an argument by attacking the person presenting the argument rather than the argument itself. It is a time-honoured way of dealing with unpleasant messages. The underlying sentiment is perhaps best expressed by Sophocles: “How dreadful knowledge of the truth can be when there is no help in the truth” (1).
Dr Mason suggests that the criticism of Sen...
Dear Editor,
The authors describe a case of fatal paracetamol overdose (4 hour paracetamol concentration 534 mg/L) despite initiation of N-acetylcysteine within 8 hours of ingestion.
Although the cause of death was ascribed to paracetamol, several aspects of this case are not typical of paracetamol toxicity: 1) The early development of neurological symptoms (agitation, confusion and falling conscious l...
Dear Editor,
Clenaghan et al [1] have demonstrated that Trendelenberg tilt increases the diameter of the internal jugular vein (IJV) in healthy volunteers. This confirms the results of previous studies.[2]
While the benefits of Trendelenburg tilt are well known, the negative effects of other commonly performed manoeuvres are less well appreciated. Gentle palpation of the carotid artery and neck extensio...
Dear Editor,
Clearly the ACE inhibitor in this case is significant in light of this lady's acute (presumably mixed "pre-renal" and "renal") renal failure. However, this was not due solely to one drug and I suspect that her illness highlights a more significant problem i.e. that of the widespread use of loop diuretics and the balance between fluid offload and renal function. Although the precise nature of her vasc...
Dear Editor
This is a very helpful review. The use of alternatives to sutures is often seen as a second best. Children must be treated in the most appropriate manner. Any slight imperfection may become a lifelong problem.
A useful addition would be a clarification of the selection criteria for wounds in the study; were site, shape, depth, tension important issues.
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