I have used the pneumonic F.O.C.A.L when discussing the treatment of
septic patients with foundation doctors.
F- Fluids, (Give and measure).
O- Give Oxygen (If not contraindicated)
C- Culture
A- Antibiotics
L- Lactate
It's similar to 'MONA' used to remember ACS treatment. Junior doctors
and nurses have found this a useful aid memoir when treating septic
patients, I have also used it in a teaching proj...
I have used the pneumonic F.O.C.A.L when discussing the treatment of
septic patients with foundation doctors.
F- Fluids, (Give and measure).
O- Give Oxygen (If not contraindicated)
C- Culture
A- Antibiotics
L- Lactate
It's similar to 'MONA' used to remember ACS treatment. Junior doctors
and nurses have found this a useful aid memoir when treating septic
patients, I have also used it in a teaching project to promote both SSC
and Sepsis Six.
A commentary is, by its nature just that but I feel compelled to
rebut some of the conjecture and lack of evidence apparent in Alan
Leaman's recent piece 'an alternative way ahead'. [1]
We are aware as the author suggests that we are all struggling 'a little'
to achieve the four hour standard even at it's 95% threshold; and much
publicity has centred upon this in the general media of late. Reasons for
this are multi-fac...
A commentary is, by its nature just that but I feel compelled to
rebut some of the conjecture and lack of evidence apparent in Alan
Leaman's recent piece 'an alternative way ahead'. [1]
We are aware as the author suggests that we are all struggling 'a little'
to achieve the four hour standard even at it's 95% threshold; and much
publicity has centred upon this in the general media of late. Reasons for
this are multi-faceted and not quite as simplistic as other clinicians not
pulling their weight as Mr Leaman appears to suggest. Given the nature of
events surrounding catastrophic failings at an adjacent Trust to Mr
Leaman's one would have expected a perhaps more constructive response to
the findings of the investigative team within the department at Telford.
In short there are several major failings in the commentary; the fact that
the investigating team did not contain an emergency physician (or nurse
actually) may actually be advantageous - the role of the impartial and
unembroiled observer is well documented in enhancing objectivity in
circumstances such as these. It is also suggested that the problems the
department encounters began in 2004 when GP's ceased provision of out
hours care. Whilst I would agree that this exacerbated matters is it
really the case that we did not have patients lying around in the ED for
prolonged periods of time prior to this? Whilst citing no sources for the
data it is also identified that significantly less emergencies are seen by
GP's and admitted directly to a ward rather than passing through an ED
assessment prior to admission. The proposed solution for this is for
specialty teams to see patients who present (at night time in particular),
based on their presenting complaint without (it would appear) any form of
ED assessment. Thus we have the potential scenario of the patient
presenting with epigastric pain that having been seen by a general surgeon
turns out to have lower lobe pneumonia or a myocardial infarct. Conversely
the patient presenting with retrosternal chest pain being seen by a
medical team who discover little more insidious than a history of hiatus
hernia.
The notion that the minor injury workload is 'undervalued' because it may
be managed by Nurse Practitioners or GP's really says more about the
perception of the nurse and GP than any undervaluing of the workload: as
though some sort of second rate service is being offered to these
patients. Nurse Practitioners have been a part of the ED workforce in the
UK for 25 years now - many will have much experience which should be
considered part of the resource that enables junior medical staff to learn
about the management of minor trauma. They do not take this opportunity
for learning away - they enhance it.
The author knows of no paper comparing the treatment of minor injuries by
a nurse practitioner compared with a trained emergency physician. He does
however 'suggest' (despite this lack of evidence) that EM physicians will
essentially see and manage these patients more safely and effectively than
an NP. Can I please point out some potential items of interest to the
author:
* It is increasingly the case that NP's (and practitioners from other
backgrounds such as physiotherapy and pre-hospital care) manage the care
of any group of patients that attend the ED - this would not be the case
had they not been considered initially effective in managing the minor
trauma caseload
* I would highlight an article in this months edition of 'Emergency Nurse'
where it has been found that non-medical practitioners make more
appropriate referrals, document more complete and legible prescriptions,
improved clinical safety and effectiveness and manage the care of up to
53% of the total ED workload. [2] Links to other resources are also
available within this work enabling the comparison of the medical and non-
medical practitioner role
It is difficult and provokes certain anxieties and insecurities when our
practice is called into question or scrutinised in any manner. However
with limited resources and increasing demand the way ahead should be
collaborative rather than adversarial in nature. The fact that all
disciplines working within ED have much to learn from each other should be
seen as an opportunity to make this way ahead well signposted and
reasonably well lit rather than a dark and dimly lit fork in the road
References
1 Leaman, AM. (2013) An alternative way ahead. Emerg Med J 30, 6, 433
-434
2 Swann G., Chessum P, Fisher J. et al (2013) An autonomous role in
emergency departments. Emergency Nurse, 21, 3, 12-15
We read with interest the study by Cassidy et al. [1] addressing the
therapy for alcohol withdrawal syndrome; a very important and common
problem in the emercency department. The authors raised the question which
drug scheme for benzodiazepines (fixed-dose versus symptom-triggered)
regimen is superior. Although benzodiazepine treatment is recommended,
there are no data about respiratory depression in patients with alcohol...
We read with interest the study by Cassidy et al. [1] addressing the
therapy for alcohol withdrawal syndrome; a very important and common
problem in the emercency department. The authors raised the question which
drug scheme for benzodiazepines (fixed-dose versus symptom-triggered)
regimen is superior. Although benzodiazepine treatment is recommended,
there are no data about respiratory depression in patients with alcohol
withdrawal symptoms [2]. To address this question, we conducted an
observational pilot study with fourteen subjects to evaluate the number
and magnitude of oxygen desaturations during benzodiazepine treatment.
According to the standard protocol in our clinic, the patients were
treated with a fixed-dose regimen: 2 mg oral lorazepam every 6 hours for
the first 24 hours. Lorazepam was then tapered by 2 mg every 24 hours. In
Addition to the routinely performed punctual measurements by the nursing
staff, every patient was monitored overnight with a continuous pulse
oximetry. The oxygen desaturation index (ODI) was defined as the number of
episodes per hour of sleep with a reduction in oxygen saturation of ?4%
from baseline and a duration ?10 s [3]. In analogy to the definition of
obstructive sleep apnea syndrome, we defined ?5 desaturations per hour as
relevant. Surprisingly, our results showed relevant desaturations
documented by continuous pulse oximetry monitoring in seven of the
fourteen patients (Figure 1).
To date there is no consensus on use of specific substance, dose or
treatment regimen. Accordingly, treatment protocols for alcohol withdrawal
management differ widely. In our institution, fixed-schedule regimen of
lorazepam is a longstanding and well-accepted protocol. Considering the
frequent oxygen desaturations, most probably due to apnea, our case-series
points to a relevant risk associated with this protocol. A symptom-
triggered approach may not only be feasible and reduce the length of stay
in comparison with a fixed dose regimen, it might also reduce dangerous
side effects as shown above.
References
1. Cassidy, E.M., et al., Symptom-triggered benzodiazepine therapy
for alcohol withdrawal syndrome in the emergency department: a comparison
with the standard fixed dose benzodiazepine regimen. Emergency Medicine
Journal, 2012. 29(10): p. 802-804.
2. Amato, L., et al. Benzodiazepines for alcohol withdrawal. Cochrane
Database of Systematic Reviews. DOI: 10.1002/14651858.CD005063.pub3.
3. Sleep-related breathing disorders in adults: recommendations for
syndrome definition and measurement techniques in clinical research. The
Report of an American Academy of Sleep Medicine Task Force. Sleep, 1999.
22(5): p. 667-89.
Use of cardiac troponins in combination with ECG findings is well
regarded as a standard way of diagnosing Acute Coronary Syndromes (ACS).
As this study illustrates the inclusion of risk stratification scoring
systems may also assist EM physicians in determining whether a short stay
clinical decision unit or full cardiology assessment via an acute medical
unit is required. However, whilst we as EM clinicians are focused...
Use of cardiac troponins in combination with ECG findings is well
regarded as a standard way of diagnosing Acute Coronary Syndromes (ACS).
As this study illustrates the inclusion of risk stratification scoring
systems may also assist EM physicians in determining whether a short stay
clinical decision unit or full cardiology assessment via an acute medical
unit is required. However, whilst we as EM clinicians are focused on
answering the question "has this patient had an ACS?", our patients'
question is often "Is it my heart?"
Whilst the outcome measures in this study, and those the TIMI score was
developed & validated on, of death, CPR & myocardial infarction
are clearly clinically important there are other questions in patients
presenting with chest pain we need to consider. In particular, has
coronary artery disease (CAD) been excluded?
The 2010 NICE guideline on chest pain commences with exclusion of ACS via
clinical history & investigations, it continues by giving an
alternative population based risk stratification to determine risk of CAD
- this then guides further investigations. In our own retrospective study
of 220 "low risk ACS" CDU patients, as determined by TIMI 0 or 1 we
compared the TIMI score with the NICE risk stratification against the
final diagnosis of CAD, determined by CT coronary angiogram or invasive
angiogram as >50% stenosis. 5.6% of those with a TIMI score 0 had an
eventual diagnosis of CAD, this increased to 17.6% when TIMI was 1.
1.4% of those with a NICE risk of 0-10% had an eventual diagnosis of CAD,
with 6.2% of the 11-29% group being diagnosed with CAD. Whilst TIMI was
developed & validated on those already known to have CAD, the NICE
risk stratification was developed for an unselected patient group with
chest pain.
Once we have excluded ACS in patients presenting with chest pain, we must
be clear that we have not excluded CAD and consider the design of primary
& secondary care systems to facilitate further investigation of those
who still need the question answering; "Is it my heart?".
We recently read Rice and Zhu's [1] widely circulated article on risk
of fatal injury and driver obesity. Presently, there is no consensus on
the relationship between obesity and motor vehicle-related injuries and
fatalities [2, 3, 4]. Indeed, some researchers have argued that obesity is
a protective factor in motor vehicle-related injuries and fatalities [2,
3, 4]. The focus of Rice and Zhu study [1], therefore, was to de...
We recently read Rice and Zhu's [1] widely circulated article on risk
of fatal injury and driver obesity. Presently, there is no consensus on
the relationship between obesity and motor vehicle-related injuries and
fatalities [2, 3, 4]. Indeed, some researchers have argued that obesity is
a protective factor in motor vehicle-related injuries and fatalities [2,
3, 4]. The focus of Rice and Zhu study [1], therefore, was to determine if
obesity is a determinant of fatality among individuals involved in motor
vehicle crashes. Accordingly, Rice and Zhu [1] article attempted to fill
the gap in the literature in this important area.
Although the study authors have highlighted that there is a few
studies have looked at how obesity affects non-fatal and fatal injuries
among vehicle occupants and this statement is not true. In fact, there is
a systematic review published in this area by our research group [5]. In
our systematic review we found that obesity was associated with higher
fatality risk (Odds Ratio (OR) 1.89, 95% confidence interval (CI): 1.51-
2.37, P=0.0001; pooled estimate from 6 studies)[5].
Our main recommendations stem from this review were to develop
interventions that address the incompatibility of standard vehicle safety
design systems with obese physiques, and develop safety measures that
could minimize the impact of a crash on an obese person [5]. We believe
that automotive industry should move toward smart restraint systems which
are calibrated for the weight and height of the particular occupant. This
idea should be seriously pursued as discomfort is shown as one of the
disincentives of restraint use in many countries [5].
In our systematic review we strongly proposed that future studies
should be more rigorous and control for confounding factors such as
obesity-related co-morbidities [5]. Unfortunately, Rice and Zhu [1] study
failed to control these important confounders in their study.
REFERENCE:
(1). Rice TM, Zhu M. Driver obesity and the risk of fatal injury
during traffic collisions. Emerg Med J. 2013 Jan 25. [Epub ahead of print]
(2). Zhu S, Kim JE, Ma X, Shih A, Laud PW, Pintar F, Shen W,
Heymsfield SB, Allison DB. BMI and risk of serious upper body injury
following motor vehicle crashes: concordance of real-world and computer-
simulated observations. PLoS Med. 2010; 30;7(3):e1000250. doi:
10.1371/journal.pmed.1000250.
(3). Ryb GE, Dischinger PC. Injury severity and outcome of overweight
and obese patients after vehicular trauma: a crash injury research and
engineering network (CIREN) study. J Trauma. 2008;64(2):406-11. doi:
10.1097/TA.0b013e31802beff9.
(4). Mock CN, Grossman DC, Kaufman RP, Mack CD, Rivara FP. The
relationship between body weight and risk of death and serious injury in
motor vehicle crashes. Accid Anal Prev. 2002;34(2):221-8.
(5). Desapriya E, Giulia S, Subzwari S, Peiris DC, Turcotte K, Pike
I, Sasges D, Hewapathirane DS. Does Obesity Increase the Risk of Injury or
Mortality in Motor Vehicle Crashes? A Systematic Review and Meta-Analysis.
Asia Pac J Public Health. 2011 Dec 20. [Epub ahead of print]
We note the concerns of Arkell et al [1] about the National Poisons
Information Service's TOXBASE guidance for management of paracetamol
poisoning. However, the NPIS must provide advice that is consistent with
recent guidance from the Commission on Human Medicines (CHM) [2] and the
new marketing authorisation (licence) for acetylcysteine, especially as
the CHM guidance was endorsed by the UK's Chief Medical Officers. The...
We note the concerns of Arkell et al [1] about the National Poisons
Information Service's TOXBASE guidance for management of paracetamol
poisoning. However, the NPIS must provide advice that is consistent with
recent guidance from the Commission on Human Medicines (CHM) [2] and the
new marketing authorisation (licence) for acetylcysteine, especially as
the CHM guidance was endorsed by the UK's Chief Medical Officers. The NPIS
has therefore revised TOXBASE following this guidance and after extensive
discussion with the MHRA to seek clarity on certain issues.
We applaud the aims of this new guidance to simplify the management
of acute overdose and reduce the risk of untreated patients developing
life-threatening hepatotoxicity. We also acknowledge, however, that more
patients will require hospital admission and acetylcysteine therapy with a
consequent increase in adverse reactions, especially as these are more
common in those with lower plasma paracetamol concentrations [3]. The risk
benefit of this approach is currently unclear and its cost effectiveness
has not been assessed.
We are concerned that the new CHM guidance has introduced
considerable uncertainty and confusion about the appropriate management of
patients with chronic or staggered overdose. For example, CHM did not
define a staggered overdose in terms of the dose ingested. As a result
patients at minimal risk of toxicity may now be referred to hospital and
treated. Also, the CHM required that 'clinical judgment', rather than
assessment of any defined risk factors, should be used for those ingesting
paracetamol in the range 75-150 mg/kg/day, without defining precisely the
basis on which such a judgment should be made.
Concerning the patient of Arkell et al [1] paracetamol doses within
the licensed dose range of 4 g/day for adults are not regarded as
'overdoses'. Their 19-year-old horse rider would not therefore require
treatment with acetylcysteine.
Clinicians always have the opportunity to call the NPIS to discuss a
case with a consultant if they are uncertain as to the most appropriate
treatment. We welcome such enquiries and over 1500 cases of poisoning are
discussed with a consultant each year [4].
References
[1] Arkell PE, Power R, Harrison M. Toxbase madness! Emerg Med J
2013, Feb 14.
[2] Medicines and Healthcare products Regulatory Agency (MHRA).
Paracetamol overdose: simplification of the use of intravenous
acetylcysteine. MHRA website 2012 September 3 [cited 2013 Feb 25];
Available from: URL:
http://www.mhra.gov.uk/Safetyinformation/Safetywarningsalertsandrecalls/Safetywarningsandmessagesformedicines/CON178225
[3] Waring WS, Stephen AF, Robinson OD, Dow MA, Pettie JM. Lower
incidence of anaphylactoid reactions to N-acetylcysteine in patients with
high acetaminophen concentrations after overdose. Clin Toxicol 2008; 46:
496-500.
[4] National Poisons Information Service. National Poisons
Information Service - Annual Report 2011/2012. HPA website 2012. Available
from: URL: http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317136044886
We reported the predictive value of modified VitalPAC Early Warning
Score(ViEWS) with lactate level, which named ViEWS-L score[1]. However,
queries are raised about the ViEWS using in the present manuscript. First,
the weightings for the four SpO2 ranges. Second, the weightings for the
five temperature ranges. And third, ambiguities in the cut-off points
between the weighting bands for the respiratory rate values.
We che...
We reported the predictive value of modified VitalPAC Early Warning
Score(ViEWS) with lactate level, which named ViEWS-L score[1]. However,
queries are raised about the ViEWS using in the present manuscript. First,
the weightings for the four SpO2 ranges. Second, the weightings for the
five temperature ranges. And third, ambiguities in the cut-off points
between the weighting bands for the respiratory rate values.
We checked it again and found that we made fatal mistakes. As raised
queries, the ViEWS in the present manuscript was different with an
originally described ViEWS [2]. We offer apologies for these mistakes and
thanks for us to correct those. We performed re-analysis of our data using
the correct weightings for ViEWS. And we asked the editorial office to
republish this article according to re-analysis.
The coefficient of ViEWS was 0.166 (previously 0.169) and that of lactate
was 0.207 (previously 0.208). Calculation of the ViEWS-L was not changed
(ViEWS-L score = ViEWS +lactate (mmol/l)).
And the ViEWS-L score showed better predictive value to the ViEWS for
hospital mortality (AUC for ViEWS-L: 0.802 (0.729-0.874) vs AUC for VIEWS:
0.744 (0.663-0.825)). Other results are shown in figure.
Again, we offer apologies for our mistakes.
1. Jo S, Lee JB, Jin YH et al. Modified early warning score with
rapid lactate level in critically ill medical patients: the ViEWS-L score.
Emerg Med J 2013;30:123-9
2. Prytherch DR, Smith GB, Schmidt PE, et al. ViEWS - towards a
national early warning score for detecting adult inpatient deterioration.
Resuscitation 2010;81:932-7.
I sincerely enjoyed reading the study by Mache et al. as it provides
an insight into the daily division of duties in a German emergency unit. I
fully agree that further, larger studies are required to create a more
accurate data pool that represents the entire industry but it is a start
and could be utilized as a guideline for further research.
One point I would like to raise however, in the conclusion of the article
it s...
I sincerely enjoyed reading the study by Mache et al. as it provides
an insight into the daily division of duties in a German emergency unit. I
fully agree that further, larger studies are required to create a more
accurate data pool that represents the entire industry but it is a start
and could be utilized as a guideline for further research.
One point I would like to raise however, in the conclusion of the article
it says "this study is the first of its kind to examine the working
activities of junior doctors in cardiology departments", I think this was
meant to say emergency care units.
We read with great interest the article by A. Ross Naylor et al ; the
face arm speech test: does it encourage rapid recognition of important
stroke warning symptoms? This study helps in generating awareness of the
early stroke symptoms in the population. Similar studies were done in the
past like Cincinnati prehospital stroke scale (CPSS) which had a positive
predictive value between 72%-85%.1 Los Angeles Prehospital stro...
We read with great interest the article by A. Ross Naylor et al ; the
face arm speech test: does it encourage rapid recognition of important
stroke warning symptoms? This study helps in generating awareness of the
early stroke symptoms in the population. Similar studies were done in the
past like Cincinnati prehospital stroke scale (CPSS) which had a positive
predictive value between 72%-85%.1 Los Angeles Prehospital stroke screen
and ABCD2 score are other studies with a good positive predictive
values.2,3
Despite these milestone studies and various awareness programs conducted
we are miles away in getting the desired results. Since the Food and Drug
association has approved the thrombolytic therapy for acute ischemic
stroke only less than 5% have received this therapy. This was mainly
because of the unawareness of early stroke symptoms in majority of the
patients which landed them out of the therapeutic window period of three
hours.4
An early non contrast CT scan of the head, to rule out haemorrhage along
with a normal blood sugar is required to start thrombolytic therapy. In up
to 35%-53% patients of acute stroke of less than 3hours duration subtle CT
findings like hyper dense MCA, obscuration of lenticular nucleus and loss
of grey white interface can be observed. However these findings are not
mandatory to start thrombolytic therapy.5,6
Population awareness programs regarding identification of early symptoms
of stroke, effective ambulance services, smooth transition, coordination
between emergency physician, neurologist and neuroradiologist is
indispensible for early treatment to reduce mortality, morbidity and
disability.
References
1. Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. "Cincinnati
Prehospital Stroke Scale: reproducibility and validity." Ann Emerg Med
1999 Apr;33(4):373-8
2. Prospective validation of the Los Angeles prehospital stroke
screen (LAPSS)." Stroke 2000 Jan; Kidwell CS, Starkman S, Eckstein M,
Weems K, Saver JL. "Identifying stroke in the field. 31(1):71-6.
3. Johnston SC, Rothwell PM, Huynh-Huynh MN, Giles MF, Elkins JS, Sidney
S, "Validation and refinement of scores to predict very early stroke risk
after transient ischemic attack," Lancet. 2007; 369:283-292.
4. O'Connor RE, McGraw P, Edelsohn L. Thrombolytic therapy for acute
ischemic stroke: why the majority of patients remain ineligible for
treatment. Ann Emerg Med. 1999;33:9 -11.
5. Keith W. Muir et al. imaging of acute stroke. Lancet Neurology.
2006; 5:755-766.
6. Gyanendra Kumar et al. Penumbra, the bas of neuroimaging in acute
stroke treatment: current evidence. Journal of Neurological Sciences.
2010; 288:13-24.
We read the article by kyuseok Kim et al and found it interesting.
Since the changes made by American Heart Association (AHA) in 2010 in
Basic Life Support we always wondered that what should be the upper limit
of chest compression. Though European Resuscitation council (ERC) has
recommended chest compression rate to be kept between 100-120/min. Now we
have an answer from this study that it should be kept between 100-12...
We read the article by kyuseok Kim et al and found it interesting.
Since the changes made by American Heart Association (AHA) in 2010 in
Basic Life Support we always wondered that what should be the upper limit
of chest compression. Though European Resuscitation council (ERC) has
recommended chest compression rate to be kept between 100-120/min. Now we
have an answer from this study that it should be kept between 100-120/min
as rate more than this would compromise complete chest recoil. Incomplete
chest recoil will affect the cardiac preload and output. It will also
decrease passive air inhalation during cardio pulmonary resuscitation. As
this study was done on manikin, a larger trial on human being in the
future may resolve the issue.
I have used the pneumonic F.O.C.A.L when discussing the treatment of septic patients with foundation doctors.
F- Fluids, (Give and measure). O- Give Oxygen (If not contraindicated) C- Culture A- Antibiotics L- Lactate
It's similar to 'MONA' used to remember ACS treatment. Junior doctors and nurses have found this a useful aid memoir when treating septic patients, I have also used it in a teaching proj...
A commentary is, by its nature just that but I feel compelled to rebut some of the conjecture and lack of evidence apparent in Alan Leaman's recent piece 'an alternative way ahead'. [1] We are aware as the author suggests that we are all struggling 'a little' to achieve the four hour standard even at it's 95% threshold; and much publicity has centred upon this in the general media of late. Reasons for this are multi-fac...
We read with interest the study by Cassidy et al. [1] addressing the therapy for alcohol withdrawal syndrome; a very important and common problem in the emercency department. The authors raised the question which drug scheme for benzodiazepines (fixed-dose versus symptom-triggered) regimen is superior. Although benzodiazepine treatment is recommended, there are no data about respiratory depression in patients with alcohol...
Use of cardiac troponins in combination with ECG findings is well regarded as a standard way of diagnosing Acute Coronary Syndromes (ACS). As this study illustrates the inclusion of risk stratification scoring systems may also assist EM physicians in determining whether a short stay clinical decision unit or full cardiology assessment via an acute medical unit is required. However, whilst we as EM clinicians are focused...
We recently read Rice and Zhu's [1] widely circulated article on risk of fatal injury and driver obesity. Presently, there is no consensus on the relationship between obesity and motor vehicle-related injuries and fatalities [2, 3, 4]. Indeed, some researchers have argued that obesity is a protective factor in motor vehicle-related injuries and fatalities [2, 3, 4]. The focus of Rice and Zhu study [1], therefore, was to de...
We note the concerns of Arkell et al [1] about the National Poisons Information Service's TOXBASE guidance for management of paracetamol poisoning. However, the NPIS must provide advice that is consistent with recent guidance from the Commission on Human Medicines (CHM) [2] and the new marketing authorisation (licence) for acetylcysteine, especially as the CHM guidance was endorsed by the UK's Chief Medical Officers. The...
We reported the predictive value of modified VitalPAC Early Warning Score(ViEWS) with lactate level, which named ViEWS-L score[1]. However, queries are raised about the ViEWS using in the present manuscript. First, the weightings for the four SpO2 ranges. Second, the weightings for the five temperature ranges. And third, ambiguities in the cut-off points between the weighting bands for the respiratory rate values. We che...
I sincerely enjoyed reading the study by Mache et al. as it provides an insight into the daily division of duties in a German emergency unit. I fully agree that further, larger studies are required to create a more accurate data pool that represents the entire industry but it is a start and could be utilized as a guideline for further research. One point I would like to raise however, in the conclusion of the article it s...
We read with great interest the article by A. Ross Naylor et al ; the face arm speech test: does it encourage rapid recognition of important stroke warning symptoms? This study helps in generating awareness of the early stroke symptoms in the population. Similar studies were done in the past like Cincinnati prehospital stroke scale (CPSS) which had a positive predictive value between 72%-85%.1 Los Angeles Prehospital stro...
We read the article by kyuseok Kim et al and found it interesting. Since the changes made by American Heart Association (AHA) in 2010 in Basic Life Support we always wondered that what should be the upper limit of chest compression. Though European Resuscitation council (ERC) has recommended chest compression rate to be kept between 100-120/min. Now we have an answer from this study that it should be kept between 100-12...
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