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
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.
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%....
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...
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