We fully agree with the remarks made as to the use of morphine rather
than pethidine in patients with renal colic. During our investigations
primary pethidine was used in our institution and excursions about the use
of morphine were limited by the format of our publication. Therefore this
eletter is an extremely welcome contribution.
We write in response to the paper by Cross et al. on the use of NIV.[1] We are encouraged to see research into such an important and under
investigated area of emergency medicine.
We do however have concerns regarding the study design, in particular
the criteria on which NIV was initiated. The benefits of NIV have mainly
been demonstrated in patients with a respiratory acidosis rather th...
We write in response to the paper by Cross et al. on the use of NIV.[1] We are encouraged to see research into such an important and under
investigated area of emergency medicine.
We do however have concerns regarding the study design, in particular
the criteria on which NIV was initiated. The benefits of NIV have mainly
been demonstrated in patients with a respiratory acidosis rather than
those with symptoms of respiratory distress and/or hypoxia alone as in
this trial. Current widely accepted guidelines from the British Thoracic
Society recommend initiation of NIV for a respiratory acidosis (pH
<_7.35.2 thus="thus" knowledge="knowledge" of="of" arterial="arterial" blood="blood" tensions="tensions" is="is" critical="critical" to="to" its="its" application.="application." we="we" would="would" challenge="challenge" the="the" usefulness="usefulness" authors="authors" definition="definition" acute="acute" respiratory="respiratory" failure="failure" without="without" gas="gas" analysis.="analysis." p="p"/> In addition, NIV was initiated prior to a trial of accepted medical
therapy for acute respiratory failure, such as nebulized or intravenous
bronchodilators or vasodilators. Patients with acute hypercapnic
respiratory failure often improve rapidly with this initial treatment and
thus will not go on to require NIV. Furthermore the omission of arterial
blood gas analysis, prior to the initiation of NIV means that it is
difficult to gain an objective assessment of response to treatment.
In conclusion, further trials using more objective methods of patient
assessment, are required to guide future management of acute respiratory
failure in the emergency department.
References
1. Cross A M, Cameron P, Kierce M, Ragg M, and Kelly A-M. Non-
invasive ventilation in acute respiratory failure: a randomised comparison
of continuous positive airways pressure ands bi-level positive airway
pressure. Emerg Med J 2003; 20:531–534.
2. British Thoracic Society Guidelines on the use of NIV. Thorax
2002; 57:192–211.
The issue of cardiac troponins is not an issue regarding the decision
of whether to give thrombolysis in cardiac arrest, neither is
echocardiography. Thrombolysis if to be given needs to be given early.
Whether you feel it will be beneficial when administered to cardiac
arrests depends on how you interpret the available evidence, which to be
honest is of limited methodology.
I agree with Dr Lockers concerns regarding the publication of BETS in
a peer reviewed journal. BETS are useful for introducing people to the
theory of literature searching, and appraisal of published evidence, ideal
skills for SPR's working towards their clinical topic review. However this
does not necessarily warrant their publication in a peer reviewed journal.
They occupy valuable space within a journal...
I agree with Dr Lockers concerns regarding the publication of BETS in
a peer reviewed journal. BETS are useful for introducing people to the
theory of literature searching, and appraisal of published evidence, ideal
skills for SPR's working towards their clinical topic review. However this
does not necessarily warrant their publication in a peer reviewed journal.
They occupy valuable space within a journal which is only published
bimonthly, which could instead be used by studies with more rigourous
methodology. If the EMJ is to become to be a leading worldwide journal in
the field of Emergency medicine, should it be including BETS within its
pages? I don't see the Lancet or the BMJ publishing 6-7 pages of medline
searches each edition.
Though Dr Hogg does explain that she has carried out a rigorous search,
and had this checked, this itself does deviate from the initial aims of
BETS as something a clinician could do in a short period of time.
With the advent of nearly universal internet use is the Best bets website
not the best place for them to reside?
Placement of chest drains can be associated with serious
complications
such as penetration of intra-thoracic and upper abdominal organs. This
should be a less common occurrence nowadays as trochar use is no longer
advocated.[1]
Chest tube malposition post insertion is also common[2] as it
can be difficult to manoeuvre the drain with the standard equipment once
it is in the chest cavity. Usin...
Placement of chest drains can be associated with serious
complications
such as penetration of intra-thoracic and upper abdominal organs. This
should be a less common occurrence nowadays as trochar use is no longer
advocated.[1]
Chest tube malposition post insertion is also common[2] as it
can be difficult to manoeuvre the drain with the standard equipment once
it is in the chest cavity. Using standard technique Chan[3] found that
placement of emergent thoracostomy tubes in the emergency department
does not result in an increased complication rate as compared to
placement on an inpatient ward. The instrumentation advised per the BTS
guidelines for inserting chest drains is not particularly designed for the
task.
A recent paper published by Andrews [4] may add further to the
question posed in the BET. He has designed a forceps specifically for
chest
drain introduction and has shown that it rated easier to use than standard
forceps by both experienced and inexperienced users. This may partly be
due to the design of his ratchet mechanism allowing the user to take
advantage of better motor control when flexing/gripping.
Standard forceps require the user to extend fingers in order to
dissect
down through the muscle layers. Difficulties may arise with the standard
technique if the user withdraws the forceps and cannot subsequently find
the track made necessitating further dissection and discomfort for the
patient. With this new forceps the drain is placed in a conduit or
circular
channel created by vertical extensions on each arm of the forceps and also
a 3rd limb proximally.
If Seldinger offers no advantage over traditional methods as shown in
this
BET[5] then the new forceps described by Andrews deserves
closer inspection in relation to chest drain placement in emergency
departments.
References
1. Haggie, J.A., Management of pneumothorax. Chest drain trocar
unsafe and unnecessary. Bmj, 1993. 307(6901):443.
2. Baldt, M.M., et al. Complications after emergency tube
thoracostomy: assessment with CT. Radiology, 1995. 195(2):539-43.
3. Chan, L., et al. Complication rates of tube thoracostomy. Am J
Emerg Med, 1997. 15(4):368-70.
4. Andrews, E.,et al. A new specifically designed forceps for chest
drain insertion. Injury, 2003. 34(12):957-9.
5. Argall, J. and J. Desmond, Seldinger technique chest drains and
complication rate. Emerg Med J, 2003. 20(2):169-70.
Since airbags were installed initially as a safety feature in
automobiles in
the early 1970s there has been a significant drop in severity of injuries arising out of motor vehicle collisions. Injuries to the eye in particular
have reduced since the introduction of laminated glass. Modern airbags
however have significant potential to cause serious permanent damage...
Since airbags were installed initially as a safety feature in
automobiles in
the early 1970s there has been a significant drop in severity of injuries arising out of motor vehicle collisions. Injuries to the eye in particular
have reduced since the introduction of laminated glass. Modern airbags
however have significant potential to cause serious permanent damage
to the eye from a number of mechanisms
1. Force of deployment
2. Situation of bags in steering wheel module and front driver side airbags
3. Driver positioning very close to steering wheel
4. Sodium hydroxide production as a byproduct of sodium azide
detonation [1,2] which is contained within the deployment mechanism of
the airbag itself.
These can result in physical damage to the ocular structures such as
abrasions or serious chemical injury from the alkalis produced.[3] The
alkalis cause a liquefactive necrosis and can result in permanent
blindness. Antosia [4] concluded that most injuries related to airbag
deployment are minor and must be viewed in context. I feel however
that the consequences of an alkali injury are such that emergency
department personnel should be educated with respect to examining,
recognising and treating urgently any patient presenting with decreased
vision post airbag deployment as a consequence of motor vehicle
collisions. I strongly concur with Wrigley and Blakeley in recommending
a careful eye examination in such cases. Airbags do provide significant
protection to the occupants of vehicles [5] but as with any intervention
we perform in the medical arena they must at first principles do no harm
References
1. Swanson-Biearman B et al. Air bags: lifesaving with toxic
potential? Am J Emerg Med, 1993. 11(1): p. 38-9.
2. White, J.E., et al. Ocular alkali burn associated with automobile
air-
bag activation. Cmaj, 1995. 153(7): p. 933-4.
3. Nordt, S.P., et al. Burns from automobile airbags. J Emerg Med,
2003. 25(2): p. 201-2.
4. Antosia, R.E., R.A. Partridge, and A.S. Virk, Air bag safety. Ann
Emerg Med, 1995. 25(6): p. 794-8.
5. Murphy, R.X.J., et al. The influence of airbag and restraining
devices on the patterns of facial trauma in motor vehicle collisions.
Plast
Reconstr Surg, 2000. 105(2): p. 516-20.
We read with interest the artlcle by Heath et al. in the Emergency
Medicine Journal, looking at nurse initiated thrombolysis in the accident
and emergency department.[1]
Speed of thrombolysis (and hence the "door
to needle" time) is well recognised as being important in reducing
myocardial damage and decreasing mortality in acute myocardial infarction.
In fact, "pain to needle" time is ev...
We read with interest the artlcle by Heath et al. in the Emergency
Medicine Journal, looking at nurse initiated thrombolysis in the accident
and emergency department.[1]
Speed of thrombolysis (and hence the "door
to needle" time) is well recognised as being important in reducing
myocardial damage and decreasing mortality in acute myocardial infarction.
In fact, "pain to needle" time is even more important with respect to
thrombolysis therapy, and a meta-analysis published in JAMA concluded that
prehospital thrombolysis for acute myocardial infarction significantly
decreased the time to thrombolysis and all-cause hospital mortality.[2]
We therefore suggest that it would be more beneficial to aim resources at
prehospital thrombolysis, rather than increasing the number of hospital
staff with the ability to thrombolise.[3,4]
We also wonder whether the authors have considered the fact that
reduction in time to thrombolysis in their study may have been due to the
time of day at which the acute chest pain nurse specialists were employed.
We note that they only were available for 62.5 hours per week, although
the actual shift times are not noted in the article. In the assumption
that these times were mainly during "office hours", some of the delay
during the out of hours fast track system may have been due to a general
lack of medical, nursing, portering staff or other facilities at these
times. Finally, such a new system would presumably have been well
publicised in relevant hospital departments, and improvements might be
explained by a Hawthorne-type effect.
References
(1) Heath et al. Nurse initiated thrombolysis in the accident and
emergency department: safe, accurate and faster than fast track. Emerg Med
J 2003; 20:418-420.
(2) Morrison et al. Mortality and prehospital thrombolysis for acute
myocardial infarction- A meta-analysis. JAMA 2000; 283:2686-2692.
(3) Pedley et al. Prospective observational cohort study of time saved by
prehospital thrombolysis for ST elevation myocardial infarction delivered
by paramedics. BMJ 2003; 327:22-26.
(4) Keeling et al. Safety and feasibility of prehospital thrombolysis
carried out by paramedics. BMJ 2003; 327:27-28
In my opinion, it is much more important in the decision to discharge
a patient. It is relatively rare that I have not made a decision to admit
a patient within the first 30 seconds of presentation of an asthma attack-
the respiratory rate, the use of accessory muscles and the overall
behaviour of the patient is much more important than a number on the peak
flow meter.
I find it much more worrying that t...
In my opinion, it is much more important in the decision to discharge
a patient. It is relatively rare that I have not made a decision to admit
a patient within the first 30 seconds of presentation of an asthma attack-
the respiratory rate, the use of accessory muscles and the overall
behaviour of the patient is much more important than a number on the peak
flow meter.
I find it much more worrying that the percentage of patients being
discharged from hospital seem to have a significantly less frequently
recorded vital statistics that the ones being admitted. Personally I work
on the basis that I keep looking for a reason to worry until all options
are satisfied. As I said above, usually I made a decision to admit before
a peak flow measurement is necessary. However, if I think the patient is
going to be discharged then I want to be absolutely certain that all the
investigations are done.
Kastner and Tagg have produced a useful guideline for the emergency
management of renal colic.[1] I would disagree however with their
recommendation that Pethidine 50 to 100mg should be administered if pain
is not relieved by combinations of NSAID and co-codamol or Tramadol. There
is no evidence that Pethidine has any specific advantages over other
opioids and the belief that it provides better analgesi...
Kastner and Tagg have produced a useful guideline for the emergency
management of renal colic.[1] I would disagree however with their
recommendation that Pethidine 50 to 100mg should be administered if pain
is not relieved by combinations of NSAID and co-codamol or Tramadol. There
is no evidence that Pethidine has any specific advantages over other
opioids and the belief that it provides better analgesia for colicky pain
than other opioids has not been substantiated.[2] It does however have a
toxic metabolite, norpethidine, which accumulates with multiple dosing and
in renal impairment.[3] In addition, at least one clinical trial has
shown no significant difference between morphine and pethidine in renal
colic managed in the Emergency Department.[4] Thus, in the absence of any
specific advantage of pethidine, there seems little justification for
including it in the guideline. My personal view is that if an opioid is
required, morphine or diamorphine should be used.[5]
References
1. Kastner C, Tagg A. Improving the effectiveness of the emergency
management of renal colic in a district general hospital: a completed
audit cycle. Emerg Med J 2003; 20: 449-450
2. McQuay H, Moore A, Justins D. Treating acute pain in hospital. BMJ
1997;314:1531-5
4. O'Connor A, Schug SA, Cardwell HA. Comparison of the efficacy and
safety of morphine and pethidine as analgesia for suspected renal colic in
the emergency setting. J Accid Emerg Med 2000; 17: 261-264
5. Mackenzie R. Analgesia and sedation. J R Army Med Corps 2000; 146:
117-127.
I thank Dr Rosival for his interest in the article about DKA and for
his recent letter which mirrors a previous one.[1] This reply largely
covers the same ground as the reply to that earlier letter.[2]
Although the most recent American Diabetic Association guidance does
state that prognosis in DKA is worse in patients with coma [3] this is not
equivalent to the assertion that only comatose patie...
I thank Dr Rosival for his interest in the article about DKA and for
his recent letter which mirrors a previous one.[1] This reply largely
covers the same ground as the reply to that earlier letter.[2]
Although the most recent American Diabetic Association guidance does
state that prognosis in DKA is worse in patients with coma [3] this is not
equivalent to the assertion that only comatose patients will die. Fatal
dysrhythmias can occur in DKA because of hyper- or hypokalaemia and will
not necessarily be preceded by coma.
Coma may reflect cerebral oedema rather than (or as well as)
acidosis. Since this has such a high case fatality rate, the prognosis in
comatose patients will be worse than non-comatose patients. Retrospective
work [4] has demonstrated an association between cerebral oedema and low
partial pressure of CO2 and with high urea (but not with low pH). The
same work also demonstrated a four fold increased risk of cerebral oedema
in patients treated with bicarbonate.
With regard to the interpretation of studies, if Rosival believes
that raising a low pH is the mechanism by which bicarbonate exerts benefit
attention needs to be drawn to the following:
In Lutterman’s (retrospective) study there was no significant (or
clinically important) difference in the rise in pH in the first 2 hours
between the two groups nor in the time for pH to reach 7.30.
In Lever’s (retrospective) study the mean change in pH was not
significantly different between the two groups nor was the mean time to
complete consciousness.
The answer to the question posed in the third paragraph is that even
without sodium bicarbonate the low blood pH will rise provided fluid and
insulin are given.
Perhaps the best way of resolving this controversy is to conduct an
RCT in patients with severe acidosis (not just those with coma - which is
not equivalent to a GCS of 3-4 as Rosival previously wrote[1]), though if
evidence of an association between bicarbonate use and cerebral oedema
continues to grow the point at which this is no longer ethical may be
reached.
References
1. Rosival V. Should sodium bicarbonate bicarbonate be administered
in diabetic ketoacidosis? Am J Respir Crit Care Med 2002;166:290.
2. Boord JB, Graber AL, Christman JW, Powers AC. Should sodium bicarbonate
bicarbonate be administered in diabetic ketoacidosis? Am J Respir Crit
Care Med 2002;166:290.
3. American Diabetes Association. Hyperglycaemic crises in diabetes.
Diabetes Care 2004;27(suppl 1):S94-102.
4. Glaser N, Barnett P, McCaslin I et al. Risk factors for cerebral edema
in children with diabetic ketoacidosis. NEJM 2001;344:264-269.
Dear Editor
We fully agree with the remarks made as to the use of morphine rather than pethidine in patients with renal colic. During our investigations primary pethidine was used in our institution and excursions about the use of morphine were limited by the format of our publication. Therefore this eletter is an extremely welcome contribution.
Thank you very much.
Dear Editor
We write in response to the paper by Cross et al. on the use of NIV.[1] We are encouraged to see research into such an important and under investigated area of emergency medicine.
We do however have concerns regarding the study design, in particular the criteria on which NIV was initiated. The benefits of NIV have mainly been demonstrated in patients with a respiratory acidosis rather th...
Dear Editor
The issue of cardiac troponins is not an issue regarding the decision of whether to give thrombolysis in cardiac arrest, neither is echocardiography. Thrombolysis if to be given needs to be given early. Whether you feel it will be beneficial when administered to cardiac arrests depends on how you interpret the available evidence, which to be honest is of limited methodology.
Dear Editor
I agree with Dr Lockers concerns regarding the publication of BETS in a peer reviewed journal. BETS are useful for introducing people to the theory of literature searching, and appraisal of published evidence, ideal skills for SPR's working towards their clinical topic review. However this does not necessarily warrant their publication in a peer reviewed journal. They occupy valuable space within a journal...
Dear Editor
Placement of chest drains can be associated with serious complications such as penetration of intra-thoracic and upper abdominal organs. This should be a less common occurrence nowadays as trochar use is no longer advocated.[1]
Chest tube malposition post insertion is also common[2] as it can be difficult to manoeuvre the drain with the standard equipment once it is in the chest cavity. Usin...
Dear Editor
Air Bags-Primum non nocere
Since airbags were installed initially as a safety feature in automobiles in the early 1970s there has been a significant drop in severity of injuries arising out of motor vehicle collisions. Injuries to the eye in particular have reduced since the introduction of laminated glass. Modern airbags however have significant potential to cause serious permanent damage...
Dear Editor
We read with interest the artlcle by Heath et al. in the Emergency Medicine Journal, looking at nurse initiated thrombolysis in the accident and emergency department.[1]
Speed of thrombolysis (and hence the "door to needle" time) is well recognised as being important in reducing myocardial damage and decreasing mortality in acute myocardial infarction. In fact, "pain to needle" time is ev...
Dear Editor
In my opinion, it is much more important in the decision to discharge a patient. It is relatively rare that I have not made a decision to admit a patient within the first 30 seconds of presentation of an asthma attack- the respiratory rate, the use of accessory muscles and the overall behaviour of the patient is much more important than a number on the peak flow meter. I find it much more worrying that t...
Dear Editor
Kastner and Tagg have produced a useful guideline for the emergency management of renal colic.[1] I would disagree however with their recommendation that Pethidine 50 to 100mg should be administered if pain is not relieved by combinations of NSAID and co-codamol or Tramadol. There is no evidence that Pethidine has any specific advantages over other opioids and the belief that it provides better analgesi...
Dear Editor
I thank Dr Rosival for his interest in the article about DKA and for his recent letter which mirrors a previous one.[1] This reply largely covers the same ground as the reply to that earlier letter.[2]
Although the most recent American Diabetic Association guidance does state that prognosis in DKA is worse in patients with coma [3] this is not equivalent to the assertion that only comatose patie...
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