eLetters

36 e-Letters

published between 2017 and 2020

  • Peripheral nerve stimulation use in the Emergency Department

    We would like to comment of the use of waveform capnography (WC) as an adjunct to help determine adequate paralysis during rapid sequence induction (RSI). The article used recognition of apnoea by loss of WC as an early indicator of muscle paralysis and evidence was presented that this method improved first pass success rates and reduced time to intubation for RSI in an emergency setting.

    Although apnoea can be a useful indicator for the presence of paralysis we would suggest that use of a peripheral nerve stimulator is a more accurate tool for determining when muscle relaxants have produced an adequate effect. The use of this simple and relatively inexpensive machine is standard practice for anaesthetists in determining the level of paralysis. It is also viewed as a standard for provision of anaesthesia outside of the operating theatre environment (Association of Anaesthetists of Great Britain and Ireland: Recommendations for standards of monitoring during anaesthesia and recovery, 2015, Page 8). We suggest from clinical experience that apnoea alone does not always reflect adequate muscle relaxation to allow for optimal intubating conditions. Reactive vocal cords may be present despite apparent correct dosing and timing of muscle relaxants. In addition, apnoea and loss of WC could possibly be a reflection of respiratory depression due to administration of the anaesthetic induction agent, opiods or a deteriorating clinical condition.

    We recognise that some Em...

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  • Climate change and the humanitarian response

    Sir,
    You articulate and document the catalogue of evidence supporting the health impacts of climate change admirably in your editorial ‘Peering through the hourglass’ (Lemery, 2017), but the Emergency Medicine world is not as disconnected as you make out. The Red Cross Movement, known traditionally for its humanitarian action, has long had expert emergency medicine at the heart of its work on preparedness for crisis, including natural disasters such as those precipitated by climate change.
    Our international First Aid and Resuscitation Guidelines (IFRC, 2016) are based soundly on science and support the interventions of lay responders and medical professionals across the globe. Our Global First Aid app is now used in 90 countries, bespoke to each one through careful translation and cultural relevance. The British Red Cross, American Red Cross and others have developed their own additional apps, specific to the disasters that might occur, such as flooding, hurricanes and tornadoes. These, too, are rooted in clinical science and educational methodology supporting the public to learn, be prepared and be resilient.
    Beyond technology, our thousands of staff and volunteers across the world work closely with local authorities in their planning for natural disasters, ensuring systems are in place to cope with the practical realities, as well as the humanitarian care needed for those affected. This work inevitably draws attention to the humanitarian crises that...

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  • Response to: Validity of the Manchester Triage System in patients with sepsis presenting at the ED

    Dear Sirs,

    I congratulate the authors on their research. It is important to highlight that the Manchester triage system does incorporate shock or low blood pressure into its flow charts. It is described in the general discriminator text and flow chart. Any patients who are shocked should be triaged into priority one, if following the rules of MTS.

    Therefore in this study all 9 of the 26 patients with a blood pressure of less than 90 mmHg should have been triaged into priority one, according to the rules of MTS. If these patients had been triaged in this way, the results of your study could be significantly affected.

    We look forward to seeing further research from your selves in this area

    Kind Regards

    Laura

  • No good evidence that Trendelenburg is better to cardiovert SVT

    Dear Sir,

    We read with interest the recent Best Evidence Topic (BET) report by L Varley and L Howard, ‘Trendelenburg position helps to cardiovert patients in SVT back to sinus rhythm.’[1] We are grateful that this BET highlighted the substantial benefit of using a postural modification to the Valsalva manoeuvre for re-entrant SVT[2]. However, whist we agree with the ‘Clinical Bottom Line’, we feel the title of this BET was misleading and does not reflect current evidence.

    ‘Trendelenburg position’ is typically used to describe a supine patient with the bed tilted head down below the level of the pelvis.[3] Although this position was associated with a higher rate of cardioversion in a small, uncontrolled before and after study[4], no physiological benefits of this position have been demonstrated[5] and it was not used in the REVERT trial, the largest RCT of VM modification to date.

    For clarification, in our study the Valsalva strain was conducted in the semi-sitting position with movement to the supine position with leg elevation, immediately at the end of the strain. There are plausible physiological reasons why this specific sequence of postural changes and timing of strain may improve Valsalva effectiveness as described in our paper. Although it is possible that Trendelenburg positioning after straining might further improve cardioversion rates, this has not been tested to date.

    Yours sincerely

    On behalf of the REVERT study Team

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  • Climate change and the humanitarian response

    Sir,
    You articulate and document the catalogue of evidence supporting the health impacts of climate change admirably in your editorial ‘Peering through the hourglass’ (Lemery, 2017), but the Emergency Medicine world is not as disconnected as you make out. The Red Cross Movement, known traditionally for its humanitarian action, has long had expert emergency medicine at the heart of its work on preparedness for crisis, including natural disasters such as those precipitated by climate change.
    Our international First Aid and Resuscitation Guidelines (IFRC, 2016) are based soundly on science and support the interventions of lay responders and medical professionals across the globe. Our Global First Aid app is now used in 90 countries, bespoke to each one through careful translation and cultural relevance. The British Red Cross, American Red Cross and others have developed their own additional apps, specific to the disasters that might occur, such as flooding, hurricanes and tornadoes. These, too, are rooted in clinical science and educational methodology supporting the public to learn, be prepared and be resilient.
    Beyond technology, our thousands of staff and volunteers across the world work closely with local authorities in their planning for natural disasters, ensuring systems are in place to cope with the practical realities, as well as the humanitarian care needed for those affected. This work inevitably draws attention to the humanitarian crises that...

    Show More
  • Request for information
    Jim Wardrope

    It would be useful to know the Total number of traumatic cardiac arrests treated by the system during these three years. Hard to draw conclusions on effectiveness without this figure. Also note different results in the paper Chiang W-C et all on the next page of the journal. (Emerg Med J 2017; 34: 39-45).

    Conflict of Interest:

    None declared

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