This paper shows a good outcome of undiagnosed cervical spine trauma
when the intubation was performed by a senior practioner, in an ED of a
UK.
In USA, for example, paramedics perform access to airway in the local
of an accident, and they are members of the Fire Department of some city.
In Sao Paulo, the largest city of Brazil, with 10 million habitants,
this type of rescue is performed also by the Fire Departmet: there are
various Rescue Units without doctors. But here we have a difference: the
Fire Department is a department of the Military Police, and the soldier
that made the initial approach to one trauma patient in the
stree,generally aren’t whit a doctor with them. The system is generally
good: the time from one initial phone to dispatch an unit (the order to
send a car with or without a doctor is take from a senior MD) is about
seven minutes, even in a chaotic traffic: there are also motorcycles and
helychopters.But the FD soldiers of these unit only have a three months
“fellowship” in the biggest ER of the city, at the Hospital of the
University of Sao Paulo, and have the “practice” training in artificial
patients. In some cases they have to perform an intubation in the street,
these men with only the high school, a short stage and the real life.
The curious thing is that in a high number of cases attended by this
team in more than ten years, there aren’t notices of spinal lesions
worsened by them.
What can we conclude about these? They fix a collar in the patient,
put the victim in a rigid wood and there are not reports of worsened
lesions. In the beginning of this system, we doctors don’t agree with this
procedure, but the practice show the opposite. The training of soldiers by
good doctors can we assume that intubation in critical patients, like the
trauma ones, could be taken more seriously than when this type of training
is given to a medical student who does not to intube in his/her
professional life. Can these be correct?
I read with great interest the article by MC Howes. It concerns me
that much current practice in Emergency Medicine in the UK is still
dictated by those outside the speciality, who have little or no idea of
the needs of our patients, or the settings in which we work.
I was not surprised to read that, while ketamine sedation has been
accepted both in the US and Australia as a part of modern eme...
I read with great interest the article by MC Howes. It concerns me
that much current practice in Emergency Medicine in the UK is still
dictated by those outside the speciality, who have little or no idea of
the needs of our patients, or the settings in which we work.
I was not surprised to read that, while ketamine sedation has been
accepted both in the US and Australia as a part of modern emergency
medicine practice, the UK still cautions that use of general anaesthetic
(presumably including ketamine) should only be practiced by those trained
in paediatric or neonatal anaesthesia.
In our own (third world) department, ketamine is often used to sedate
children who need to undergo short, painful operations, including
manipulation of fractures and some suturing and incision and drainage
procedures.
We have a well written protocol (developed by my predecessor) which
has stood the test of time (it has been in force for the past 4 years with
no serious complications to date).
The key to safe and effective sedation hinges on the following:
careful selection of patients (including premorbid history, airway
assessment and fasting history); properly trained staff (for each
procedure, ther must be at least one person responsible for the airway who
can manage an emergent airway problem - this is NOT necessarily a
paediatric anaesthetist) and careful selection of drugs (we use ketamine
for all our younger children, with the addition of a small dose of
midazolam and atropine). Finally, the patient MUST be monitored carefully
until awake. In our department, pulse oximetry is mandatory, but the
importance of clinical observation is stressed to all staff.
I feel that it is more than time for practitioners in the UK to grasp
the nettle and produce their own guidelines regarding sedation in their
departments. This does not have to be 'sanctioned' by the Royal College of
Anaesthetists, though their input would be welcome. The important thing
for us to remember is that once we set ourselves certain standards, it is
our duty to live up to these, and in the case of untoward incidents, we
must be willing to accept responsibility. In the field of sedation in the
Emergency setting, the only professionals capable of creating meaningful
guidelines are Emergency Physicians.
Woollard and his colleagues' study on nalbuphine identifies the gap
that can exist between research and clinical practice. I resent the claims
in this paper that nalbuphine somehow is an effective analgesic.
Since 1996, I have been receiving patients in my hospital who have
been given nalbuphine pre hospital with very little benefit and lot of
problem. These patients get grossly inadequate anal...
Woollard and his colleagues' study on nalbuphine identifies the gap
that can exist between research and clinical practice. I resent the claims
in this paper that nalbuphine somehow is an effective analgesic.
Since 1996, I have been receiving patients in my hospital who have
been given nalbuphine pre hospital with very little benefit and lot of
problem. These patients get grossly inadequate analgesia, a fact admitted
in this study. Interestingly, the reduction in pain score is quoted, but
not the end pain score. A reduction from 9 to 6 may look impressive on
statistics, but is hardly worth talking about from the patients'
perspective. These patients get troublesome nausea. The worst is the
significantly high doses of morhine needed to overcome the antagonism,
which then keeps them longer in the department.Perhaps this aspect of
hospital data should have been included to illustrate the problem.
In the doses discussed, the drug is ineffective - both as an
analgesic and as a narcotic! Can patients be called drowsy, if their GCS
is unchanged? Is it worth championing an analgesic, if the patients
subsequently need double the predicted dose of morphine?
Lastly, if 30mg nalbuphine (currently permitted upper limit in north wales
paramedic protocol)fails to achieve good analgesia, what is research
proving by comparing 10mg x2 vs 5mg x 4?
Rather than pursue futile research question, is it not better to campaign
for change of practice to morphine, which is guaranteed to work?
Neil Morton's points are concise and thought provoking as always.[1] The withdrawal and ongoing reevaluation of the SIGN
guidelines on paediatric procedural sedation were rightly welcomed as a
chance to address issues which many emergency physicians felt had been
overlooked. Our colleagues from Australasia and the United States are
somewhat puzzled by our hesitation in adopting what is viewed by them a...
Neil Morton's points are concise and thought provoking as always.[1] The withdrawal and ongoing reevaluation of the SIGN
guidelines on paediatric procedural sedation were rightly welcomed as a
chance to address issues which many emergency physicians felt had been
overlooked. Our colleagues from Australasia and the United States are
somewhat puzzled by our hesitation in adopting what is viewed by them as a
valuable adjunct in the care of children undergoing painful procedures in
the emergency department.
Having witnessed many situations where there has been only a stark
choice between wrapping a child in a blanket to do "a quick couple of
sutures" or transferring the child for a general anaesthetic and overnight
stay in hospital I sincerely hoped there might in future be better ways of
doing things. While I wouldnt rush to start using ketamine on every unruly
child the increasing body of research on this (from the UK) does not
support the notion that this is a colossally dangerous technique.
The majority of emergency medicine specialist registrars are now
competent in rapid sequence intubation by the end of their training and
many have formal training in safe sedation (including standardised
simulator training. Procedural sedation in paediatric emergency medicine
is not practiced in any of the three children's hospitals in Scotland but
many paediatric emergency medicine trainees have learned these techniques
in Australasia.
The arguments put forward against the use of ketamine are sadly
familiar to those of us who practice rapid sequence intubation in A&E.
In the same way, skilled, responsible and properly trained emergency
physicians will simply start doing it and zealously auditing it's safety
until it is considered normal.
It is only a matter of time until Neil Morton's own hospital appoints
an emergency physician who has this training and it is introduced safely
and effectively. These clinicians are very far removed from the "cowboys"
we are constantly being characterised as.
Reference
1. N S Morton. Ketamine is not a safe, effective, and appropriate technique for emergency department paediatric procedural sedation. Emerg Med J 2004; 21: 272-273.
We do not want to detract from the overall value of the recent article by Wardrope and MacKenzie,[1] but we feel it important to point out our concerns over the proposed assessment of cognitive function.
Cognitive impairment due to dementia and delirium is common in emergency situations but formal assessment of cognitive function is rare. This could explain why at least 67% of older people wi...
We do not want to detract from the overall value of the recent article by Wardrope and MacKenzie,[1] but we feel it important to point out our concerns over the proposed assessment of cognitive function.
Cognitive impairment due to dementia and delirium is common in emergency situations but formal assessment of cognitive function is rare. This could explain why at least 67% of older people with delirium do not have their delirium detected by A&E staff, leading to poor outcomes.[2] Routine use of even basic screening instruments such as the AMTS [3] would help detection, but such routine use is rare.
We agree that it is useful to be able to compare the AMTS in an acute event with previously measured values, but for this comparison to be valid it is crucial that the same questions are used. It is therefore unfortunate that the version of the AMTS presented differs from the original one, and that the quoted cut-off score is incorrect.[3] It has previously been demonstrated that doctors are inconsistent when trying to assess cognition using the AMTS4, and we believe that use of the correct questions and scoring in Table 1 will help matters.
Table 1
Please follow scoring instructions.
A correct answer scores 1 mark. No half-marks are given. A score of 6 or below is abnormal
Question
Assessment
Rating
1 How old are
you?
Score for exact age
only
2 What is your
date of birth?
Only date and month
needed
3 What is the
year now?
Score for exact year
only
4 What is the
time of day?
Score if within 1hr
of correct time
5 Where are we?
What is this building?
Score for exact
place name e.g. “hospital” insufficient
Now ask subject to
remember an address: 42, West Street
6 Who is the
current monarch?
Score only current
monarch
7 What was the
date of the 1st World War?
Score for year
of start or finish
8 Can you count
down backwards from 20 to 1?
Score if no mistakes
or any mistakes corrected spontaneously
9 Can you tell me
what those 2 people do for a living?
Score if
recognises role of 2 people correctly e.g. Dr, nurse
10 Can you
remember the address I gave you?
Score for exact
recall only
TOTAL
/10
References
1. Wardrope J,.Mackenzie R. The system of assessment and care of the primary survey positive patient. Emergency Medicine Journal 2004;21:216-25.
2. Sanders AB. Missed delirium in older emergency department patients: a quality-of-care problem. Ann.Emerg.Med. 2002;39:338-41.
3. Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1972;1:233-8.
4. Holmes J,.Gilbody S. Differences in use of abbreviated mental test score by geriatricians and psychiatrists. BMJ 1996;313:465.
Dr Fatovich asks about initial reaction severity in three participants
who were prescribed steroids and antihistamines for large local reactions
or persistent urticaria.[1]
Two initially had severe (hypotensive) reactions
whereas the other had no systemic reaction. Although frequently used, it
is difficult to determine the benefit of steroids and antihistamines to
manage large local reactions an...
Dr Fatovich asks about initial reaction severity in three participants
who were prescribed steroids and antihistamines for large local reactions
or persistent urticaria.[1]
Two initially had severe (hypotensive) reactions
whereas the other had no systemic reaction. Although frequently used, it
is difficult to determine the benefit of steroids and antihistamines to
manage large local reactions and allergic urticaria. One of us has
recently outlined why these agents are probably of little use in severe
allergic reactions.[2] We agree that they are over-emphasised in many
texts despite the absence of convincing evidence for therapeutic efficacy.
Our decision to give adrenaline by intravenous infusion was based on
an ethical requirement to provide optimal resuscitation. This approach
prevented both the inadequate response to treatment that might result from
delayed absorption after IM administration, and the adverse reactions seen
with IV boluses.
Heywood’s first question[3] is better answered by another (larger) sting
challenge study that found a clear inverse relationship between the
challenge-to-reaction interval and subsequent reaction severity.[4] We
found no such relationship, but because of our small sample size this
analysis was underpowered. Practically such knowledge is of limited use,
as demonstrated by case 3 where symptoms did not occur until 20 minutes
after the sting, compared to the overall median of 8 minutes.
Our consent process and ethical considerations, reviewed by two
respected university hospital ethics committees, have already been
outlined both in the EMJ and Lancet.[5] In accordance with good ethical
practice the risks of participation (including the small risk of death)
were clearly outlined both verbally and in writing.
To understand the ethical justification for this trial it must be
appreciated that:
1) Patients may die if they erroneously believe treatment to be
effective.[6] Thus, it is unethical to conduct a poorly designed trial.
2) Efficacy can only be proven if a control group demonstrates that
severe reactions can be precipitated by the challenge procedure. The
alternative –waiting for an accidental sting away from medical care– is
not ethical.
3) Large studies have demonstrated the safety of sting challenge
using strict exclusion criteria,[4,7] even if adrenaline is withheld
during hypotensive reactions.[8] We gave adrenaline immediately when
objective features of respiratory or cardiovascular compromise were
identified. This approach is consistent with published consensus
indications for the use of adrenaline.[9,10]
4) The small short-term risk from the trial needs to be balanced
against the far greater reduction in long-term risk from providing an
effective immunotherapy.
5) There can be little doubt as to the informed nature of the consent
process if it is remembered that participants had previously experienced
reactions in the field, away from emergency medical care.
We hope that ethics committees in the UK would not deny people the
opportunity to participate in the rigorous assessment of a treatment that
could provide them with dramatic quality of life benefits, [11] as well as
protection from potentially lethal reactions in the setting of a community
where one in every eight people receives an accidental sting every year.[12]
There can be little doubt as to the commitment and altruism of trial
participants, many of whom considered this to be important research that
would benefit others. However, implications that the trial was ill
considered, reckless, or unethical do not stand up to careful scrutiny.
References
1. Fatovich DM. Limited use of corticosteroids for insect sting anaphylaxis [electronic response to Brown et al. Insect sting anaphylaxis; prospective evaluation of treatment with intravenous adrenaline and volume resuscitation] emjonline.com 2004http://emj.bmjjournals.com/cgi/eletters/21/2/149#230
2. Brown SGA. Parallel infusion of hydrocortisone with/without
chlorpheniramine bolus injection to prevent acute adverse reactions to
antivenom for snakebites. Med J Aust 2004;180(8):428-9.
3. Heywood M. Questions raised by this study [electronic response to Brown et al. Insect sting anaphylaxis; prospective evaluation of treatment with intravenous adrenaline and volume resuscitation] emjonline.com 2004http://emj.bmjjournals.com/cgi/eletters/21/2/149#238
4. van der Linden PW, Hack CE, Struyvenberg A, van der Zwan JK.
Insect-sting challenge in 324 subjects with a previous anaphylactic
reaction: current criteria for insect-venom hypersensitivity do not
predict the occurrence and the severity of anaphylaxis. J Allergy Clin
Immunol 1994;94(2 Pt 1):151-9.
5. Brown SGA, Wiese MD, Blackman KE, Heddle RJ. Ant venom
immunotherapy: a double-blind, placebo-controlled, crossover trial. Lancet
2003;361(9362):1001-6.
6. Brown SGA, Wu QX, Kelsall GR, Heddle RJ, Baldo BA. Fatal
anaphylaxis following jack jumper ant sting in southern Tasmania. Med J
Aust 2001;175(11-12):644-7.
7. Blaauw PJ, Smithuis OL, Elbers AR. The value of an in-hospital
insect sting challenge as a criterion for application or omission of venom
immunotherapy. J Allergy Clin Immunol 1996;98(1):39-47.
8. van der Linden PW, Hack CE, Poortman J, Vivie-Kipp YC,
Struyvenberg A, van der Zwan JK. Insect-sting challenge in 138 patients:
relation between clinical severity of anaphylaxis and mast cell
activation. J Allergy Clin Immunol 1992;90(1):110-8.
9. Emergency medical treatment of anaphylactic reactions. Project
Team of The Resuscitation Council (UK). Resuscitation 1999;41(2):93-9.
10. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Part 8: advanced challenges in resuscitation: section
3: special challenges in ECC. Anaphylaxis. The American Heart Association
in collaboration with the International Liaison Committee on
Resuscitation. Circulation 2000;102(8 Suppl):I241-3.
11. Oude Elberink JN, De Monchy JG, Van Der Heide S, Guyatt GH, Dubois
AE. Venom immunotherapy improves health-related quality of life in
patients allergic to yellow jacket venom. J Allergy Clin Immunol
2002;110(1):174-82.
12. Brown SGA, Franks RW, Baldo BA, Heddle RJ. Prevalence, severity,
and natural history of jack jumper ant venom allergy in Tasmania. J
Allergy Clin Immunol 2003;111(1):187-92.
Leah et al’s interesting paper describes a 10.5-minute time saving
based on preparation of thrombolytic therapy for acute myocardial
infarction (AMI). They go on to demonstrate an improvement in performance
against the door to needle standard.[1]
While no cost – benefit examination is made, the authors make
reference to Boersma’s work to illustrate the benefits of early
thrombolysis.[2...
Leah et al’s interesting paper describes a 10.5-minute time saving
based on preparation of thrombolytic therapy for acute myocardial
infarction (AMI). They go on to demonstrate an improvement in performance
against the door to needle standard.[1]
While no cost – benefit examination is made, the authors make
reference to Boersma’s work to illustrate the benefits of early
thrombolysis.[2] Perhaps more useful is work by Morrison et al which
presents a linear model suggesting a mortality benefit of 2 lives per 100
patients treated per hour of earlier thrombolysis delivery.[3] Using this
model the authors would need to treat 300 patients to save a life.
Studies have shown pre-hospital thrombolysis to be feasible, safe and
effective. Impressive call-to-needle time savings of 240 minutes were
demonstrated by the GREAT study based in rural North East Scotland.[4]
Similarly benefits in the urban environment have been described.[5]
Our point is simply that if we are to invest in expensive bolus
thrombolytics, we should perhaps also develop systems to allow their
administration in the pre-hospital setting.
References
(1) V Leah, C Clark, K Doyle, and T J Coats. Does a single bolus
thrombolytic reduce door to needle time in a district general hospital?
Emerg Med J 2004 21: 162-164.
(2) Boersma E, Maas ACP, Deckers JW, Simoons ML. Early thrombolytic
treatment in acute myocardial infarction: reappraisal of the golden hour.
Lancet 1996; 348: 771-75.
(3) Morrison LJ, Verbeek PR, McDonald AC, Sawadsky BV, Cook DJ.
Mortality and prehospital thrombolysis for acute myocardial infarction. A
meta-analysis. JAMA 2000; 283: 2686-92.2.
(4) GREAT Group. Feasibility, safety and efficacy of domiciliary
thrombolysis by General Practitioners: Grampian region Anistriplase trial:
BMJ 1992; 305: 548 – 553.
(5) J R Benger. The case for urban prehospital thrombolysis. Emerg.
Med. J., Sep 2002; 19: 441 - 443.
I agree with Karthikeyan et al.[1] regarding simple and safe evacuation
of pretibial haematomas using a Yankauer sucker as a means to evacuate a
haematoma and thereby reducing skin loss. However, the procedure described
needs to be carried out under aseptic conditions which was not emphasized
with care to avoid damage to underlying structures and to prevent further
haematoma formation.
I agree with Karthikeyan et al.[1] regarding simple and safe evacuation
of pretibial haematomas using a Yankauer sucker as a means to evacuate a
haematoma and thereby reducing skin loss. However, the procedure described
needs to be carried out under aseptic conditions which was not emphasized
with care to avoid damage to underlying structures and to prevent further
haematoma formation.
Patients on Warfarin are particularly at risk of
bleeding with minor surgical procedures and could bleed uncontrollably
necessitating good surgical exposure to find the bleeding point which is
inappropriate to carry out in the Accident and Emergency department or on
the ward.
Furthermore, it should be borne in mind that the procudure advocated by
the authors may just be a "holding" procedure prior to surgery and that if
the skin is so traumatised than the only solution is excision of the
damaged skin and skin grafting. This can be carried out under local or
regional anaesthesia in a surgically unfit patient.
For this reason assessment of the skin viability is of crucial importance
and using a 21 gauge needle to prick the damaged skin should yield bright
red blood suggesting good inflow and outflow. However, if the needle prick
yields dark blood or no blood this suggests impaired venous drainage or no
blood supply to the skin.[2] In this situation the skin is deemed non-
viable and needs excision with the possible need of skin grafting.
References
1. G S Karthikeyan, S Vadodaria, and P R W Stanley. Simple and safe treatment of pretibial haematoma in elderly patients. Emerg Med J 2004; 21: 69-70
De Souza B. A., Ghattaura A., Nduka C.,Moir G., Carver N. &
Shibu M. Major degloving injuries in multi-trauma patients - a management
protocol. (Presentation British Trauma Society Meeting - Sep 2003).
There are two points we would like to raise in the management of the
case described. We feel they are important "lessons learned" and have not
been given emphasis by the authors.
1. The patient’s symptoms were recorded in detail (noisy, gurgling
breathing with drooling of saliva; dyspnoea; dysphagia; trismus; bilateral
submandibular tense swellings; elevated, immobile tongue; tachycardia;...
There are two points we would like to raise in the management of the
case described. We feel they are important "lessons learned" and have not
been given emphasis by the authors.
1. The patient’s symptoms were recorded in detail (noisy, gurgling
breathing with drooling of saliva; dyspnoea; dysphagia; trismus; bilateral
submandibular tense swellings; elevated, immobile tongue; tachycardia;
tachypnoea; saturation of 95% on air rising to 99% on 15L/min oxygen and
pyrexia of 39.2c) however the patient was deemed stable and transferred to
theatre.
In retrospect, the patient’s airway was not stable as he soon
developed complete obstruction. Perhaps an important lesson learned,
specifically in the context of Ludwig’s Angina, is that these symptoms and
signs should be interpreted as advanced airway embarrassment and a secure
airway should be achieved immediately prior to ANY other management,
including transfer. In our experience of Ludwig’s Angina, the airway can
deteriorate very quickly. Indeed, in extreme cases, even simple
oropharyngeal examination can tip the balance towards airway loss.
2. The patient suffered a respiratory arrest and a tracheostomy was
performed. Again in retrospect, should a cricothyroidotomy have been
attempted? The authors do not mention this treatment option. Many
surgical texts, including the ATLS manual, recommend this as the surgical
airway of choice in the emergency situation.
In summary, Ludwig’s Angina is a life threatening condition which
should be treated with the utmost respect. This case acts as a useful
reminder of the importance of the establishment of an early secure airway.
Reference
1. Advanced Trauma Life Support Student Manual, 6th Edition. American College of Surgeons.
Sethi et al.[1] state that a lack of data on the prevalence of
domestic violence is particularly true of A&E departments and that
only two studies of prevalence were identified in the past ten years.
In 1995 we published a combined prospective and retrospective study [2] of violence against women presenting to Glasgow Royal Infirmary over a
six month period. The prevalence was 0.75%....
Sethi et al.[1] state that a lack of data on the prevalence of
domestic violence is particularly true of A&E departments and that
only two studies of prevalence were identified in the past ten years.
In 1995 we published a combined prospective and retrospective study [2] of violence against women presenting to Glasgow Royal Infirmary over a
six month period. The prevalence was 0.75%. 55% of victims and 61% of
assailants had consumed alcohol and 43% of women in the prospective group
had been assaulted previously. Advice and follow up were offered to those
identified in the prospective part of the study but the response to this
was very poor. Support and follow up were accepted in only two cases.
We agree that this problem requires better documentation by medical
staff who should specifically question women on this subject but remain
uncertain about the effectiveness of intervention offered within the
Accident & Emergency Department.
References
1. D Sethi, S Watts, A Zwi, J Watson, and C McCarthy
Experience of domestic violence by women attending an inner city accident
and emergency department
Emerg Med J 2004; 21: 180-184
2. RM Makower, AG Pennycook, R Crawford. Women attending an accident
and emergency department after assaults. Journal of Accident and Emergency
Medicine 1995; 12: 15-19
Dear Editor
This paper shows a good outcome of undiagnosed cervical spine trauma when the intubation was performed by a senior practioner, in an ED of a UK.
In USA, for example, paramedics perform access to airway in the local of an accident, and they are members of the Fire Department of some city.
In Sao Paulo, the largest city of Brazil, with 10 million habitants, this type of rescue is perfor...
Dear Editor
I read with great interest the article by MC Howes. It concerns me that much current practice in Emergency Medicine in the UK is still dictated by those outside the speciality, who have little or no idea of the needs of our patients, or the settings in which we work.
I was not surprised to read that, while ketamine sedation has been accepted both in the US and Australia as a part of modern eme...
Dear Editor
Woollard and his colleagues' study on nalbuphine identifies the gap that can exist between research and clinical practice. I resent the claims in this paper that nalbuphine somehow is an effective analgesic.
Since 1996, I have been receiving patients in my hospital who have been given nalbuphine pre hospital with very little benefit and lot of problem. These patients get grossly inadequate anal...
Dear Editor
Neil Morton's points are concise and thought provoking as always.[1] The withdrawal and ongoing reevaluation of the SIGN guidelines on paediatric procedural sedation were rightly welcomed as a chance to address issues which many emergency physicians felt had been overlooked. Our colleagues from Australasia and the United States are somewhat puzzled by our hesitation in adopting what is viewed by them a...
Dear Editor
We do not want to detract from the overall value of the recent article by Wardrope and MacKenzie,[1] but we feel it important to point out our concerns over the proposed assessment of cognitive function.
Cognitive impairment due to dementia and delirium is common in emergency situations but formal assessment of cognitive function is rare. This could explain why at least 67% of older people wi...
Dear Editor
Dr Fatovich asks about initial reaction severity in three participants who were prescribed steroids and antihistamines for large local reactions or persistent urticaria.[1]
Two initially had severe (hypotensive) reactions whereas the other had no systemic reaction. Although frequently used, it is difficult to determine the benefit of steroids and antihistamines to manage large local reactions an...
Dear Editor
Leah et al’s interesting paper describes a 10.5-minute time saving based on preparation of thrombolytic therapy for acute myocardial infarction (AMI). They go on to demonstrate an improvement in performance against the door to needle standard.[1]
While no cost – benefit examination is made, the authors make reference to Boersma’s work to illustrate the benefits of early thrombolysis.[2...
Dear Editor
I agree with Karthikeyan et al.[1] regarding simple and safe evacuation of pretibial haematomas using a Yankauer sucker as a means to evacuate a haematoma and thereby reducing skin loss. However, the procedure described needs to be carried out under aseptic conditions which was not emphasized with care to avoid damage to underlying structures and to prevent further haematoma formation.
...
Dear Editor
There are two points we would like to raise in the management of the case described. We feel they are important "lessons learned" and have not been given emphasis by the authors.
1. The patient’s symptoms were recorded in detail (noisy, gurgling breathing with drooling of saliva; dyspnoea; dysphagia; trismus; bilateral submandibular tense swellings; elevated, immobile tongue; tachycardia;...
Dear Editor
Sethi et al.[1] state that a lack of data on the prevalence of domestic violence is particularly true of A&E departments and that only two studies of prevalence were identified in the past ten years.
In 1995 we published a combined prospective and retrospective study [2] of violence against women presenting to Glasgow Royal Infirmary over a six month period. The prevalence was 0.75%....
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