856 e-Letters

  • Vitamin C may shorten ICU stay

    The paper by Sheikh and Horner [1] does not properly describe the context for vitamin C.

    Fourteen trials have investigated the effect of vitamin C against post-operative AF (POAF), and significant heterogeneity has appeared between studies carried out in the USA and outside of the USA [2]. In 9 non-US studies vitamin C decreased the incidence of POAF on average by 46% (P<0.00001), but no benefit was seen in 5 US studies.

    In 5 non-US studies, intravenous vitamin C shortened the duration of hospital stay on average by 16% and by 1.47 days (P<0.00001). In 7 non-US studies, oral and intravenous vitamin C shortened the duration of ICU stay on average by 7% (P=0.002)[2]. Thus, there is strong evidence from randomized trials indicating that vitamin C may influence the duration of hospital stay and ICU stay in some contexts. It is not reasonable to restrict to mortality as the only outcome of interest [1], when considering potential effects of vitamin C on ICU patients.

    Sheikh and Horner do not mention that sometimes vitamin C levels are very low in hospital patients. For example, in one study 18 patients with clinical symptoms of scurvy were identified out of 145 consecutive patients [3]. Scurvy has been reported also in modern ICUs [4].

    In their clinical scenario, Sheikh and Horner described a patient with pneumonia, but ignored the association between vitamin C and pneumonia. Vitamin C deficiency increases the risk of pneumonia, and pneumonia d...

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  • A brief history of the specialty of emergency medicine

    Dear Dr Beecham

    Thank you for your detailed response to my recent article outlining the history of the specialty of Emergency Medicine. You are, of course, absolutely right that the Royal Charter was granted at the time of the formation of the College in 2008 and I should have written that in 2015 the Queen granted the College its Royal title. Thank you for pointing out this error.

    With best wishes


  • Reply to: Diphenhydramine should be co-administered with intravenous prochlorperazine to prevent akathisia

    Dear Editor,
    We thank Drs. Vinson et al. for their thoughtful comments as well as their important research that was the basis for our systematic review.1 While we proposed that difference in administration time was one possible explanation for the heterogeneity that we identified, Dr. Vinson’s proposal that the between-drug differences could also explain the heterogeneity is just as plausible. Although we did not include the two trials investigating different administration times of prochlorperazine since we limited our inclusion criteria to trials that used diphenhydramine prophylaxis, we do acknowledge the importance that infusion time of prochlorperazine does not affect the incidence of akathisia given the current evidence.2 3 We completely concur with Dr. Vinson’s conclusion that the differences between prochlorperazine and metoclopramide deserve to be further explored in a randomized trial, but until then, his suggestions of how to proceed appear consistent with our study’s findings.

    1. D'Souza RS, Mercogliano C, Ojukwu E, et al. Effects of prophylactic anticholinergic medications to decrease extrapyramidal side effects in patients taking acute antiemetic drugs: a systematic review and meta-analysis. Emerg Med J 2018.
    2. Collins RW, Jones JB, Walthall JD, et al. Intravenous administration of prochlorperazine by 15-minute infusion versus 2-minute bolus does not affect the incidence of akathisia: a prospective, randomized, contro...

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  • Diphenhydramine should be co-administered with intravenous prochlorperazine to prevent akathisia

    Dear Editor,

    We commend Dr D’Souza et al for their systematic review of the effects of prophylactic diphenhydramine in the reduction of akathisia induced by intravenous dopamine D2 antagonist antiemetics.1 Akathisia is a dysphoric feeling of restlessness that ranges from mild to severe, the more severe expressions of which can be quite distressing to patients.2 Attention to its prevention is welcome. We took particular interest in the systematic review because we led three of the four studies included in the meta-analysis.2-4

    The authors conclude that adjunct diphenhydramine reduces akathisia when dopamine D2 antagonist antiemetics are administered over 2 minutes, but diphenhydramine fails to augment the reduction in akathisia achieved by simply slowing the antiemetic infusion to 15 minutes. They report moderately high heterogeneity among the four included studies (I2 =43%).5 This reveals an inconsistency in results between studies that precludes a one-size-fits-all recommendation on the use of prophylactic diphenhydramine. Such an elevated I2 requires explanation. The authors attribute this heterogeneity to rates of infusion and determine that a 15-minute infusion is less likely to cause akathisia.

    But another explanation for the heterogeneity is at hand that the authors did not explore: prochlorperazine and metoclopramide behave differently when it comes to akathisia preventio...

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  • Abnormal stress response from mTBI often sometimes leads to headaches

    Post traumatic headaches are seriously debilitating. They are often a late symptom in the recovery from brain injury. They tend to be more frequent in female patients with post-concussion syndrome and may be associated with prior migraines. A headache log may help identify environmental underpinnings and shape the treatment plan. I am using a biofeedback protocol here in the Boston area to help down-train the sympathetic-parasympathetic mismatch that is common in TBI. The protocol involves paced breathing and has a growing body of literature in support of treating poor regulation in the autonomic nervous system. Stress of all kinds correlates highly with post-concussion syndrome often prolonging recovery. The protocol I use tends to reduce the impact of the physiological reactivity seen in many TBI and mTBI cases who are still recovering. Sleep hygiene may be a further underlying source of post-concussion syndrome and the heads associated with concussion. I have a few posts on this topic: www.concussionassessment.wordpress.com

  • A right royal title

    The article is incorrect when it states that "... in 2015, the Queen granted the college its royal charter. True independence had at last been gained ..." A glance at the footer of any printed communication sent on the college's official notepaper will reveal that the College of Emergency Medicine (as it was then named) was, in fact, incorporated by royal charter in 2008. The Privy Council granted the college its royal seal on 29 February that year, giving the college its autonomous legal identity. It had previously separated from its six parent colleges in 2006, by means of the Faculty of Accident and Emergency Medicine reconstituting itself as a limited company under the new name.

    The title "Royal" is a separate matter; it is not conferred by the Privy Council, and does not necessarily imply that the organisation holds a Royal Charter. It is instead a mark of favour, granted with the permission of the monarch but in practice conferred on the advice of the Ministry of Justice and, latterly, the Royal Names Team at the Cabinet Office. The process is somewhat opaque, and the CEM (as it then was) had begun seeking the royal appellation as early as 2009. Other newer medical colleges in the UK have experienced similar lag periods between their promotion to full college status and the conferral of the royal title.

    It is worth noting that royal patronage is yet another concept; the Princess Royal has served as the college's patron sinc...

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  • Can observational pain scoring in elderly cognitively impaired reduce time to appropriate analgesia?

    Do the authors have data on the type of analgesia that was provided, that would enable a secondary analysis with the outcome of "time to APPROPRIATE analgesia"? Whilst there was no statistical difference on the time to first analgesia, it is possible that using an observational score will enable a clinician to provide more appropriate (stronger) analgesia to non-verbal elderly patients with long bone fractures, which would be a valuable intervention.

  • 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

    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