Brown et al's [1] study provoked lively debate amongst the staff at Ipswich Hospital.
I would like to pose two questions:
1) What was the interval between sting challenge and onset of
symptoms? Was this related to severity of reaction?
2) What were the details of ethical approval, and what was the consent process and documentation?
I wonder if such a study would receive ethical approval in the UK. Were any estimations of risk given to participants before their recruitment?
This study reinforces the need for early and aggressive treatment of
anaphylaxis with adrenaline and large-volume fluid resuscitation. For
this, the bravery of both investigators and participants is to be applauded.
Reference
1. S G A Brown, K E Blackman, V Stenlake, and R J Heddle
Insect sting anaphylaxis; prospective evaluation of treatment with intravenous adrenaline and volume resuscitation
Emerg Med J 2004; 21: 149-154.
I congratulate Dr Brown and his colleagues on conducting the first
prospective trial of a management protocol for anaphylaxis.[1]
Perhaps one
of the most telling results was that corticosteroids and antihistamines
were prescribed for only three of the 21 patients. In my experience,
corticosteroids and antihistamines are frequently overprescribed and
overemphasised for the management of allergic...
I congratulate Dr Brown and his colleagues on conducting the first
prospective trial of a management protocol for anaphylaxis.[1]
Perhaps one
of the most telling results was that corticosteroids and antihistamines
were prescribed for only three of the 21 patients. In my experience,
corticosteroids and antihistamines are frequently overprescribed and
overemphasised for the management of allergic reactions. It would be
useful to know the initial reaction severity in these three patients, and
the authors’ perception of the usefulness or otherwise of the prescribed
corticosteroid and antihistamine therapy.
Previous reports have found that corticosteroid agents are used or
recommended too frequently; sometimes as the sole therapeutic agent.[2]
There is, however, no evidence of a therapeutic benefit for
corticosteroids in anaphylactic shock.[3] Yet many emergency medicine
textbooks recommend corticosteroids for all cases of anaphylaxis. In
severe reactions, often associated with bronchospasm, resuscitation may be
protracted and corticosteroids could play a role, but expert opinion
suggests that they are not the drugs of first choice.[4]
I would be interested in the authors’ views on this subject, in
particular the rationale behind their treatment protocol.
References
1. Brown SG, Blackman KE, Stenlake V, Heddle RJ. Insect sting
anaphylaxis; prospective evaluation of treatment with intravenous
adrenaline and volume resuscitation. Emerg Med J 2004;21(2):149-54.
2. Gupta S, O'Donnell J, Kupa A, Heddle R, Skowronski G, Roberts-Thomson
P. Management of bee-sting anaphylaxis. Med J Aust 1988;149(11-12):602-4.
3. Fisher M. Anaphylaxis. Dis Mon 1987;33(8):433-79.
4. Fisher MM, Baldo BA. Acute anaphylactic reactions. Med J Aust
1988;149(1):34-8.
I read with great interest the cross-sectional study about the prevalence
of domestic violence conducted by Sethi et al.[1]
I experienced a moment
of deja vu having published a study with almost identical methods and
conclusions in the EMJ in 2003.[2] It is reassuring to see that they came
to similar conclusions in a different department! This perhaps shows the
problems of a long submissio...
I read with great interest the cross-sectional study about the prevalence
of domestic violence conducted by Sethi et al.[1]
I experienced a moment
of deja vu having published a study with almost identical methods and
conclusions in the EMJ in 2003.[2] It is reassuring to see that they came
to similar conclusions in a different department! This perhaps shows the
problems of a long submission to publication time. Nevertheless the
authors should be congratulated for reinforcing the message that domestic
violence is an important and common health problem that requires awareness
on the part of emergency physicians and nurses
References
1. Experience of domestic violence by women attending an inner city
accident and emergency department
D Sethi1, S Watts, A Zwi, J Watson and C McCarthy Emerg Med J 2004; 21:180
-184.
2. Incidence and prevalence of domestic violence in a UK emergency
department A Boyle and C Todd
J. Accid. Emerg. Med., Sep 2003; 20: 438 - 442.
We thank Allison Walker for her letter and helpful comments.[1] With
respect to mention of the fire service with this patient group; care was
taken to generically include all pre-hospital carers and there were two
representatives from the fire service present at the consensus meeting.
The fire services nationally are looking to use these guidelines as a
standard of care and interface with their ambulanc...
We thank Allison Walker for her letter and helpful comments.[1] With
respect to mention of the fire service with this patient group; care was
taken to generically include all pre-hospital carers and there were two
representatives from the fire service present at the consensus meeting.
The fire services nationally are looking to use these guidelines as a
standard of care and interface with their ambulance service colleagues.
Whilst we acknowledge the importance of ABCs and these are included
early in our 9-point list. The vast majority of patients do not have life
threatening injuries and it was felt that for simplicity’s sake stop the
burning process, cool and dress (first aid) would do the "most for the
most" and it is these simple things which need most attention in our
experience of receiving these patients in hospital. In practise, some of
the nine point check list are done concurrently just as with the primary
survey in the ATLS mantra.
Burns patients will often not accept face dressings in the acute
stage of
their injury and clearly clingfilm is not appropriate. Waterjel products
are
ideal for dressing this area in the short term.
Serial halving for burns assessment is a new concept in the burns
literature and at the time this article was submitted, the serial halving
technique was also being circulated. We are glad that helpful comments
are being forwarded about the first edition of the burns consensus
document and hope that future editions can include them, without
losing sight that the guidelines should be simple and applicable to all
pre-hospital carers.
References
(1) Walker A. Consensus on the prehospital approach to burns patient management [electronic response to Allison and Porter; Consensus on the prehospital approach to burns patient management] emermed.com 2004http://emj.bmjjournals.com/cgi/eletters/21/1/112#191
Whilst I share Terry Brown's concern that some trainee physicians may
not receive adequate exposure to acutely ill adults, the role of the acute
general physician can not therefore be said to be in demise. The recent
emergence of acute medicine as a subspecialty in its own right, and the
recognition of this by the Royal Colleges of Physicians, has paralleled a
large expansion in the number of acute physi...
Whilst I share Terry Brown's concern that some trainee physicians may
not receive adequate exposure to acutely ill adults, the role of the acute
general physician can not therefore be said to be in demise. The recent
emergence of acute medicine as a subspecialty in its own right, and the
recognition of this by the Royal Colleges of Physicians, has paralleled a
large expansion in the number of acute physician posts being advertised
throughout the country. Trainees who are interested in acute general
medicine should be applying for training schemes in this subspecialty -
the number of NTNs is currently limited but undoubtedly will increase over
the next few years. SpRs seeking posts in emergency medicine would be
wrong to perceive that there is no specific training programme in acute
general medicine.
There is no intrinsic reason why emergency physicians should not
'take on responsibility for the first 24 hours of care of all patients
presenting to the department', and I would welcome emergency physicians to
share in the running of medical assessment units alongside the acute
physicians, but then who is going to run the Emergency Departments? The
way forward, I am sure, lies in ever closer collaboration and integration
between Emergency Medicine and Acute Medicine departments, whilst
recognising the complementary skills and training of each discipline.
It would be interesting to know if the airway obstruction occured
during the transfer of the patient from the A&E bed/trolley onto the
operating table, and whether the patient was maintained in an upright
sitting posture
Most texts deeling with the management of acute upper airway problems such
as this recommend that the patient is not moved from the A&E
resuscitation room. Awake nasal fib...
It would be interesting to know if the airway obstruction occured
during the transfer of the patient from the A&E bed/trolley onto the
operating table, and whether the patient was maintained in an upright
sitting posture
Most texts deeling with the management of acute upper airway problems such
as this recommend that the patient is not moved from the A&E
resuscitation room. Awake nasal fibreoptic intubation should be attempted
by an experienced anaesthetist, with an experienced ENT surgeon standing
by ready to perform a tracheostomy (or at least a cricothyroidotomy).
Authors had focused on the modus operandi rather than the features that would help to identify the nature of bioterrorism. Current
understanding is that infections like anthrax, botuilism, plague, small
pox, tularaemia and viral haemorrhagic fever are most likely to be
implicated in bioterrorism. Important aspects of these conditions are
summarized below-
Authors had focused on the modus operandi rather than the features that would help to identify the nature of bioterrorism. Current
understanding is that infections like anthrax, botuilism, plague, small
pox, tularaemia and viral haemorrhagic fever are most likely to be
implicated in bioterrorism. Important aspects of these conditions are
summarized below-
[A] Anthrax, caused by Bacillus anthracis, is susceptible to
penicillin, doxycycline, and fluoroquinolone. There is no need to immunize
or treat contacts.;
[B] Botulism can give rise to muscle-paralysis and
caused by Clostridium botulinum. Symptoms of food borne botulism begin
most commonly between 12 and 36 hours. Anti-botulinum antitoxin is
effective in reducing the severity of symptoms if administered early in
the course of the disease. Most patients eventually recover after weeks to
months of supportive care;
[C] Yersinia pestis is responsible for causing
plague. Pneumonic plague is one of several forms of plague. With pneumonic
plague, the features of fever, shortness of breath, chest pain and cough
can progress for 2 to 4 days. Streptomycin, gentamicin, the tetracycline,
and chloramphenicol are all effective and should be given within 24 hours
of the first symptom. Antibiotic treatment for 7 days will protect direct
and close contacts. Wearing a close-fitting surgical mask also protects
against infection;
[D] Smallpox is a serious, contagious, and sometimes
fatal infectious disease. The last naturally occurring case in the world
was in Somalia in 1977. The only treatment is prevention with vaccine;
[E] Features of tularemia, caused by Francisella tularensis, include muscle
and joint pain, progressive weakness, and those of pneumonia. Symptoms
usually appear 3 to 5 days following exposure. Tularemia is not known to
be spread from person to person, so there is no need for quarantine. Post
exposure prophylaxis with antibiotics is essential. A vaccine for
tularemia is under review; [F] Viral hemorrhagic fevers are usually mild,
although sometimes they can be severe and life-threatening. Treatment is
essentially supportive.
National Center for Infectious Diseases (NCID) is a central
organization that is equipped to deal with matters arising out of
bioterrorism in America. It has been urged that formation of a similar
central European organization would be helpful. European Centre for
Infectious Diseases (ECID), although sound like an European counterpart of
NCID, is an undertaking supported by a group of scientists and health
professionals, and not an official project of any national institution. It
is a matter that has to be taken up seriously by the politicians and
decision-makers.
I read with interest the case report by Urwin et al. but wonder if
there is another explanation for the patients’ deterioration, other than
the administration of oxygen by the ambulance crew. The case presented
involved a 64 year-old woman with undiagnosed chronic obstructive
pulmonary disease. She was referred by her GP with a four-day history of
increased shortness of breath. On arrival of...
I read with interest the case report by Urwin et al. but wonder if
there is another explanation for the patients’ deterioration, other than
the administration of oxygen by the ambulance crew. The case presented
involved a 64 year-old woman with undiagnosed chronic obstructive
pulmonary disease. She was referred by her GP with a four-day history of
increased shortness of breath. On arrival of the ambulance crew her GCS
was already 5 (E3,V1,M1) and her respiratory rate was 36. As this state of
affairs is not sustainable for four days it is reasonable to assume this
lady is undergoing acute decompensation of her ventilatory failure. Her
tachypnoea, attempting to increase her physiologically useful minute
volume, will ultimately result in respiratory fatigue and a reduced
respiratory rate. This will further exacerbate the carbon dioxide
retention and degree of coma, culminating in respiratory arrest over a
very short period of time. To blame her continuing deterioration to a GCS
of 3 and a respiratory rate of 4 on the 18 minutes of oxygen during
transit is to ignore the underlying pathophysiological process that would
culminate in this clinical picture anyway. It could as easily be argued
that it was only the administration of the oxygen in transit that kept her
alive until she could be intubated.
I am concerned that this case report may encourage inappropriate
oxygen restriction in some patients with severe acute ventilatory failure
in the emergency setting. When practicing emergency medicine, with its’
intrinsic constraints of time and available information a consistent
approach is important. While a few patients may indeed be harmed by
supplemental oxygen, many more will be helped. To that end the current
joint royal colleges ambulance liaison committee guidelines
(http://nww.warwickuniversity.nhs.uk/2002_Guidelines__v2.2.pdf) state,
“All medical emergencies should receive supplemental oxygen at a high flow
rate”.
I note with interest Graham's review of suggested desirable levels of
anaesthetic and critical care experience for emergency medicine trainees
and consultants. I entirely agree that RSI and endotracheal intubation
are the gold standard for airway management in any seriously unwell
patient, and as such, it is entirely appropriate and to be expected that
emergency physicians are able to provide this. Ho...
I note with interest Graham's review of suggested desirable levels of
anaesthetic and critical care experience for emergency medicine trainees
and consultants. I entirely agree that RSI and endotracheal intubation
are the gold standard for airway management in any seriously unwell
patient, and as such, it is entirely appropriate and to be expected that
emergency physicians are able to provide this. However, it is becoming
less possible, rather than more, to achieve this competence as a trainee
with the demise of the stand-alone anaesthetic SHO post. Anaesthetists
are understandably unwilling to offer rotation posts to non-anaesthetists,
and there are far too few emergency medicine rotations which include
enough anaesthetics or critical care. Without the opportunity to
undertake stand-alone post in anaesthetics and critical care I fail to see
how my colleagues or myself can achieve this undoubtably worthwhile goal.
Mr Graham has written an excellent article reviewing the latest
evidence on minimum competencies required to manage the emergency airway.
In current emergency medicine practice there are many hurdles to overcome
not just developing and maintaining skills. Most departments have not
enough experienced practioners to offer this service more than
sporadically. There are also other aspects other than...
Mr Graham has written an excellent article reviewing the latest
evidence on minimum competencies required to manage the emergency airway.
In current emergency medicine practice there are many hurdles to overcome
not just developing and maintaining skills. Most departments have not
enough experienced practioners to offer this service more than
sporadically. There are also other aspects other than the airway to look
at, for example management of injuries, FAST ultrasound scanning. We are
unlikely to be able to manage the airway and deal with everything else in
the resuscitation. Another significant problem is the lack of an
experienced airway assistant (ODP/ODA/anaesthetic nurse). It is considered
standard practice in the UK to undertake RSI only in the presence of an
assistant, if the anaesthetist is busy it is likely the ODP is too. I
think it is unrealistic to expect to train Emergency department nursing
staff to the same level, and in the heat of the moment are you going to
trust them to the same degree.
It is a skill I enjoy, but as the paper suggests we need to demonstrate
safe practice to protect ourselves when things will inevitably go wrong.
Dear Editor
Brown et al's [1] study provoked lively debate amongst the staff at Ipswich Hospital.
I would like to pose two questions:
1) What was the interval between sting challenge and onset of symptoms? Was this related to severity of reaction?
2) What were the details of ethical approval, and what was the consent process and documentation?
I wonder if such a stu...
Dear Editor
I congratulate Dr Brown and his colleagues on conducting the first prospective trial of a management protocol for anaphylaxis.[1]
Perhaps one of the most telling results was that corticosteroids and antihistamines were prescribed for only three of the 21 patients. In my experience, corticosteroids and antihistamines are frequently overprescribed and overemphasised for the management of allergic...
Dear Editor
I read with great interest the cross-sectional study about the prevalence of domestic violence conducted by Sethi et al.[1]
I experienced a moment of deja vu having published a study with almost identical methods and conclusions in the EMJ in 2003.[2] It is reassuring to see that they came to similar conclusions in a different department! This perhaps shows the problems of a long submissio...
Dear Editor
We thank Allison Walker for her letter and helpful comments.[1] With respect to mention of the fire service with this patient group; care was taken to generically include all pre-hospital carers and there were two representatives from the fire service present at the consensus meeting. The fire services nationally are looking to use these guidelines as a standard of care and interface with their ambulanc...
Dear Editor
Whilst I share Terry Brown's concern that some trainee physicians may not receive adequate exposure to acutely ill adults, the role of the acute general physician can not therefore be said to be in demise. The recent emergence of acute medicine as a subspecialty in its own right, and the recognition of this by the Royal Colleges of Physicians, has paralleled a large expansion in the number of acute physi...
Dear Editor
It would be interesting to know if the airway obstruction occured during the transfer of the patient from the A&E bed/trolley onto the operating table, and whether the patient was maintained in an upright sitting posture
Most texts deeling with the management of acute upper airway problems such as this recommend that the patient is not moved from the A&E resuscitation room. Awake nasal fib...
Dear Editor
Authors had focused on the modus operandi rather than the features that would help to identify the nature of bioterrorism. Current understanding is that infections like anthrax, botuilism, plague, small pox, tularaemia and viral haemorrhagic fever are most likely to be implicated in bioterrorism. Important aspects of these conditions are summarized below-
[A] Anthrax, caused by Bacillus ant...
Dear Editor
I read with interest the case report by Urwin et al. but wonder if there is another explanation for the patients’ deterioration, other than the administration of oxygen by the ambulance crew. The case presented involved a 64 year-old woman with undiagnosed chronic obstructive pulmonary disease. She was referred by her GP with a four-day history of increased shortness of breath. On arrival of...
Dear Editor
I note with interest Graham's review of suggested desirable levels of anaesthetic and critical care experience for emergency medicine trainees and consultants. I entirely agree that RSI and endotracheal intubation are the gold standard for airway management in any seriously unwell patient, and as such, it is entirely appropriate and to be expected that emergency physicians are able to provide this. Ho...
Dear Editor
Mr Graham has written an excellent article reviewing the latest evidence on minimum competencies required to manage the emergency airway.
In current emergency medicine practice there are many hurdles to overcome not just developing and maintaining skills. Most departments have not enough experienced practioners to offer this service more than sporadically. There are also other aspects other than...
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