I agree with the conclusion that Lorazepam might be more effcient as first-line therapy for status epilepticus (SE) than diazepam but the case is not proven. The study by Leppik et al compares a commonly used strategy for the swift termination of SE. The study by Treiman et al. sets out to investigate a number of treatments but I am not aware of any European neurologist using
phenytoin i.v. or phenobarbitone i.v...
I agree with the conclusion that Lorazepam might be more effcient as first-line therapy for status epilepticus (SE) than diazepam but the case is not proven. The study by Leppik et al compares a commonly used strategy for the swift termination of SE. The study by Treiman et al. sets out to investigate a number of treatments but I am not aware of any European neurologist using
phenytoin i.v. or phenobarbitone i.v. as first line treatment. Have the authors found evidence of the efficacy of benzodiazapines such as clonazepam or midazolam compared to diazepam or lorazepam?
I read with interest the article by Drs Boyd and Martin (Emerg Med J
2001; 18:212-213). This article needs to be read by all doctors working
in hospitals of developing countries. ESR as a single test is advised in
many conditions and the importance attached to it is well known. In
emergency as well as outpatient practice, the test is ordered very
often.
I read with interest the article by Drs Boyd and Martin (Emerg Med J
2001; 18:212-213). This article needs to be read by all doctors working
in hospitals of developing countries. ESR as a single test is advised in
many conditions and the importance attached to it is well known. In
emergency as well as outpatient practice, the test is ordered very
often.
Another point of concern is the strictness of the fasting condition
of the patient. Laboratory personnel as well as the clinicians insist that
the test should be carried out only in fasting condition. And in many
instances, the sample of blood is not tested or the patients is sent back,
if he/she has taken food.
So, to evaluate the difference in the test results of ESR in fasting
and post-prandial conditions, we conducted a small study. Blood was
collected from 50 patients (a) in a fasting state and (b) one hour after
of breakfast. ESR was estimated in these paired samples. The paired-t-
test did not reveal any difference between the two states.
Hence, according to these results, ESR estimation in fasting state is not mandatory.
With best regards
Sincerely
Dr Saroj K Mishra
Senior Deputy Director
Ispat General Hospital
F-139, Sector-19
Rourkela 769 005
Orissa, INDIA
Tele 091- 661- 640504
I would like to comment on the excellent article on use
of abdominal ultrasonography in paediatric trauma. Much
as I concur with the authors on the use of routine
sonography and computed tomography,in the third world
where I practise, clinical decisions have to be made in a different way - do we operate on this child or not? Hence, the greater reliance on clinical signs and 24hr expectant
observation - wi...
I would like to comment on the excellent article on use
of abdominal ultrasonography in paediatric trauma. Much
as I concur with the authors on the use of routine
sonography and computed tomography,in the third world
where I practise, clinical decisions have to be made in a different way - do we operate on this child or not? Hence, the greater reliance on clinical signs and 24hr expectant
observation - with the patient starved and prepared for
theatre. This has lessened the use of sonography,and
if we can't definitely rule out intra abdominal haemorrhage
we sadly have no choice but to perform "exploratory
laparatomy"
I read with interest Smart et al's letter [1] regarding the
assessment of paediatric cervical spine injuries.
It would certainly appear that many children in their cohort were Xrayed unnecessarily according to current guidelines. However, I would hope
that the practice in their institution has changed dramatically in the 6
years since the group attended.
I read with interest Smart et al's letter [1] regarding the
assessment of paediatric cervical spine injuries.
It would certainly appear that many children in their cohort were Xrayed unnecessarily according to current guidelines. However, I would hope
that the practice in their institution has changed dramatically in the 6
years since the group attended.
Current guidelines on selction of patients for imaging are based
primarily on adults. In the NEXUS group, only 30 children had a cervical
spine injury,[2] and in the Canadian c-spine group, there were no
children at all.[3] Extrapolating these results to children who may be
distressed or uncooperative should be performed with caution. The low
prevalence of cervicla spine injuries in children makes guidelines
difficult to create. In an 11 year analysis of the Trauma Audit Network
Database, only 239 children (out of 19,538 with major trauma) were
identified as having a cervical spine fracture and 21 with SCIWORA
(personal data, as yet unpublished).
I am concerned that the authors feel that a single lateral projection
should be adequate. The evidence for omitting the PEG view is based on
small case series [4] or questionnaires,[5] and certainly the odointoid
synchondrosis should be ossified by the age of 7.
Imaging of the paediatric cervical spine remains a difficult problem.
As the authors confirm, there is no substitute for adequate clinical
assessment, but where this is not possible, every effort should be made to
rule out a potentially devastating injury.
References
(1) Smart PJE, Hardy PJ, Buckley DMG, Somers JM, Broderick NJ,
Halliday KE, Williams L. Cervical spine injuries to children under 11:
should we use radiography more selectively in their initial assessment?
Emerg Med J 2003;20:225-227.
(2) Viccellio P, Simon H, Pressman BD, Shah MN, Mower WR, Hoffman JR.
A prospective multicenter study of cervical spine injury in children.
Pediatrics 2001;108:e20.
(3) Stiell IG, Wells GA, Vandemheem KL, Clement CM, Lesiuk H, De Maio
VJ, Laupacis A, Schull M, McKnight RD, Verbeek R, Brison R, Cass D, Dreyer
J, Eisenhauer MA, Greenberg GH, MacPhail I, Morrison L, Reardin M,
Worthington J. The Canadian C-Spine Rule for Radiography in Alert and
Stable Trauma Patients. JAMA 2001;286:1841-1848.
(4) Buhs C, Cullen M, Klein M, Farmer D. The pediatric trauma c-spine:
is the 'odointoid' view necessary? J Pediatr Surg 2000;35:994-997.
(5) Swischuk LE, John SD, Hendrick EP. Is the open-mouth odointoid
view necessary in children under 5 years? Pediatr Radiol 2000;30:186-189.
Management of non-serious 999 calls by nurse-led telephone triage and advice or referral: building on initial research
The Editors’ response to Dale et al.’s paper [1] rightly highlights the need for further research to
evaluate the safety, appropriateness and effectiveness of the management
of some non-serious 999 calls with telephone advice only.
Management of non-serious 999 calls by nurse-led telephone triage and advice or referral: building on initial research
The Editors’ response to Dale et al.’s paper [1] rightly highlights the need for further research to
evaluate the safety, appropriateness and effectiveness of the management
of some non-serious 999 calls with telephone advice only.
At the time of the ‘Telephone Advice study’ that was undertaken in
London and the West Midlands Ambulance Services, NHS Direct did not exist
and the Reforming Emergency Care agenda was in its infancy. Developments
since then have only served to reinforce the importance and relevance of
this initial work, as well as providing a further context and opportunity
to take this research forward. Most recently, the Department of Health has
in “Developing NHS Direct” [2] clearly set out a target for the management of
some low priority 999 calls by NHS Direct.
We have now secured funding to carry out a collaborative project
between the Universities of Sheffield and Swansea and in three ambulance
and corresponding NHS Direct Sites (Wales, Manchester and Thames Valley)
to evaluate the management of non-serious 999 calls with either self care
or referral to alternative healthcare following nurse-led telephone
triage. This two-year study is being funded by the Department of Health
Service Delivery and Organisation (SDO) Research Programme starting in
April 2003.
The study is being undertaken in three phases:
1. Identification of appropriate ambulance service dispatch codes for
transfer to NHS Direct for further triage 2. A randomised controlled trial of passing calls within the designated
codes to NHS Direct nurses for further triage and subsequent self-care
advice or referral to alternative care agencies 3. Full testing of capacity, resource and operational consequences for the
ambulance service and NHS Direct of implementing the new service
Outcomes to be measured include:
processes of care
how many calls are passed back to the 999 service following assessment
by NHS Direct?
What time delays do patients experience
clinical safety
patient satisfaction
resource usage
operational impact – improvement in 999 response times for life-
threatening calls, decrease in inappropriate ambulance admissions to
A&E, and staffing requirements for NHS Direct
Providing appropriate care for 999 callers is a key aspect of the
Reforming Emergency Care programme. Telephone triage, advice or referral
provided by NHS Direct seems to offer a sensible and efficient
alternative, but will depend on the triage systems being compatible and
capacity being available. As the EMJ Editors point out, identifying non-
serious 999 calls at the point of the call being made is not simple, and
not all non-serious calls are suitable for telephone advice. Older people
who fall, for instance, may not need an immediate, ‘lights and sirens’
response – but telephone advice will not help them off the floor either.
Only robust, well-designed research can answer the questions that surround
the tempting alternative of NHS Direct management of some 999 calls. We
hope that this study will provide these answers and look forward to
sharing our results at the end of the research.
Helen Snooks Janette Turner Malcolm Woollard
on behalf of the project team.
References
(1) J Dale, J Higgins, S Williams, T Foster, H Snooks, R Crouch, C Hartley-Sharpe, E Glucksman, R Hooper, S George. Computer assisted
assessment and advice for “non-serious” 999 ambulance service callers: the
potential impact on ambulance despatch. Emerg Med J 2003; 20:178-183.
(2) Department of Health. Developing NHS Direct: A strategy document for
the next three years. London: Department of Health, April 2003.
King and Reid [1] highlight a number of standards relating to child
protection procedures within emergency departments. In January 2003, Lord
Laming published his report of the Victoria Climbie Inquiry which contains
further recommendations regarding healthcare arrangements for children and
procedures for investigation of possible deliberate harm. Those relevant
to emergency department practice mainly conc...
King and Reid [1] highlight a number of standards relating to child
protection procedures within emergency departments. In January 2003, Lord
Laming published his report of the Victoria Climbie Inquiry which contains
further recommendations regarding healthcare arrangements for children and
procedures for investigation of possible deliberate harm. Those relevant
to emergency department practice mainly concern administrative standards,
such as recording the name of the "primary carer" for each child attending
the department and obtaining information on previous attendances at other
hospitals when concerns about deliberate harm have been raised. The
recommendations have various suggested timescales for implementation
ranging from 3 months to 2 years from the publication date and we would
urge all those involved with child protection to read the report summary
(available at http://www.victoria-climbie-inquiry.org.uk/index.htm) and check
that their practice complies with the recommendations.
Reference
(1) W King and C Reid. National audit of emergency department child
protection procedures. Emerg Med J 2003;20: 222-224.
While it is reasonable to use large doses of Naloxone as described in the BNF (the maximum dose recommended is 10mg), the National poisons information service recommend that dose is titrated to response. Naloxone however, has also been attributed to improving GCS in gamma-hydroxybutyrate and alcohol overdoses.
Large doses of opiate antagonists may be used in simple opiate overdose, however it was not cle...
While it is reasonable to use large doses of Naloxone as described in the BNF (the maximum dose recommended is 10mg), the National poisons information service recommend that dose is titrated to response. Naloxone however, has also been attributed to improving GCS in gamma-hydroxybutyrate and alcohol overdoses.
Large doses of opiate antagonists may be used in simple opiate overdose, however it was not clear in this case that the cause of cardiac arrest was opiate induced. The patient had a primary asystolic arrest in the ambulance without a preceding respiratory arrest, which would be unusual for a massive opiate overdose. Also it is unlikely that a large enough quantity of opiate to cause a cardiac arrest would be metabolised by the liver to a degree sufficient to restore spontaneous cardiac output within 25 minutes. We feel that the clinical progress and outcome for this patient may not have been significantly influenced by larger doses of Naloxone.
Dr Alison Walker
McPherson et al’s article [1] generates some interesting questions
concerning disproportionately high levels of psychological distress
amongst Emergency Department (ED) Senior House Officers (SHOs). The
combination of shiftwork, a challenging working environment, broad case
mix, and newly acquired decision latitude may explain the findings.
We did have some reservations about the article...
McPherson et al’s article [1] generates some interesting questions
concerning disproportionately high levels of psychological distress
amongst Emergency Department (ED) Senior House Officers (SHOs). The
combination of shiftwork, a challenging working environment, broad case
mix, and newly acquired decision latitude may explain the findings.
We did have some reservations about the article. We are unfamiliar
with the General Health Questionnaire (GHQ) and brief COPE questionnaire.
A more detailed description and explanation of terms would have been
valuable. We felt that SHOs on nights (if not those on holiday) should
have been included to reduce sample bias. Confining the study to units
based in DGHs raises questions regarding generalisation. It would have
been interesting to know the degree of shop-floor senior cover in the
units studied, and to examine whether this influenced distress levels.
How can we apply this useful work to our own practice? If we
acknowledge the core finding, and accept that there is a problem amongst
our junior colleagues, we then need to ask whether intervention is
required. SHOs are required to have regular contact with a consultant
supervisor, but there is potential tension between the roles of
supervision, and support. Formal mentoring schemes offer an alternative,
but their value in the ED has been questioned.[2] It may be that the best
way to support SHOs is to be aware of their potential vulnerability to
psychological distress, and to encourage a team-based and pastoral
atmosphere within our departments. This will allow individuals recognising
a need for support to seek it out from for themselves, from people who
they feel are appropriate for the problem in hand. This is the approach we
have, in the past, taken within our own unit. However, as a response to
this article we will incorporate a session on stress management into our
SHO teaching, perhaps in conjunction with administration of the GHQ and
brief COPE …. once we find out more about them.
References
(1) Mcpherson S, Hale R, Richardson P, Obholzer A. Stress and coping in
accident and emergency senior house officers. Emerg Med J 2003;20: 230-231.
(2) Mentoring senior house officers. Is there a role for middle grade
doctors? Okereke CD, Naim M. Emerg Med J 2001; 18:259-262
Further to the case report presented by Carter and Wilby (Emerg Med J 2000 17:387) where a valuable lesson is demonstrated regarding overlooking lisfranc fractures in the presence of polytrauma, we would like to add to this a patient we encountered in order to emphasize the point.
A 27-year-old male was admitted following a road traffic accident where the patient riding a motorcycle collided with a car...
Further to the case report presented by Carter and Wilby (Emerg Med J 2000 17:387) where a valuable lesson is demonstrated regarding overlooking lisfranc fractures in the presence of polytrauma, we would like to add to this a patient we encountered in order to emphasize the point.
A 27-year-old male was admitted following a road traffic accident where the patient riding a motorcycle collided with a car at high speed. His obvious injury was a fractured right femur, which was grossly angulated at the level of the midshaft. He also had a cold cyanotic forefoot on the same side with an absent Dorsalis Pedis pulse on doppler examination. Femoral artery damage was suspected and an angiogram was therefore performed which demonstrated a normal vascular tree.
Radiographs of the foot, which was relatively painless, demonstrated a lisfranc fracture, which was openly reduced and internally fixed following intra-medullary nailing of the femur. During open reduction the vascularity of the foot which was now swollen and tense rapidly improved. We believe this represented a compartment syndrome in the foot secondary to the lisfranc fracture.
To reinforce the original point made by Carter and Wilby, this lisfranc fracture could have been overlooked whilst attention was being paid to the more painful injury, in this case the fractured femur and concerns regarding femoral artery damage. We would therefore like to reiterate that in a case of major trauma foot injuries might be overlooked unless a detailed secondary survey is performed to exclude them.
Regarding the article by O’Cathain et al. [1] it was interesting to note the conflicting statements made towards the end of the paper.
The systems of NHS Direct
were identified as having poor sensitivity and specificity when dealing
with the studied calls, yet at the end the paper it states that the types
of low priority calls referred need refinement due to at least one-fifth
may be pass...
Regarding the article by O’Cathain et al. [1] it was interesting to note the conflicting statements made towards the end of the paper.
The systems of NHS Direct
were identified as having poor sensitivity and specificity when dealing
with the studied calls, yet at the end the paper it states that the types
of low priority calls referred need refinement due to at least one-fifth
may be passed back to the ambulance service. My interpretation the
findings are that calls are referred back to the ambulance
service as not being suitable for telephone advice and/or treatment but as
the sensitivity and specificity are so low, surely it is the NHSD systems
that need investigating and refining!!
Also the paper makes no reference to the type of priority dispatch in
use to identify the original calls. Criteria Based Dispatch is a semi-
structured system with call-takers having the opportunity to be flexible
in the triage of the patient ( and has been shown to be potentially risky)
and AMPDS is a structured, rigid process where compliance to the system
impacts the accuracy of detection. Without an explanation of which of
these systems was in use and, if AMPDS, the compliance - the use of calls
"triaged by priority dispatch as low priority" is meaningless because is
it the system being measured or is the call-taker?
Reference
(1) A O’Cathain, E Webber, J Nicholl, J Munro, and E Knowles. NHS Direct: consistency of triage outcomes.
Emerg Med J 2003; 20:289-292.
Editor,
I agree with the conclusion that Lorazepam might be more effcient as first-line therapy for status epilepticus (SE) than diazepam but the case is not proven. The study by Leppik et al compares a commonly used strategy for the swift termination of SE. The study by Treiman et al. sets out to investigate a number of treatments but I am not aware of any European neurologist using phenytoin i.v. or phenobarbitone i.v...
Dear Sir,
I read with interest the article by Drs Boyd and Martin (Emerg Med J 2001; 18:212-213). This article needs to be read by all doctors working in hospitals of developing countries. ESR as a single test is advised in many conditions and the importance attached to it is well known. In emergency as well as outpatient practice, the test is ordered very often.
Another point of concern is the strictness...
Dear Editor,
I would like to comment on the excellent article on use of abdominal ultrasonography in paediatric trauma. Much as I concur with the authors on the use of routine sonography and computed tomography,in the third world where I practise, clinical decisions have to be made in a different way - do we operate on this child or not? Hence, the greater reliance on clinical signs and 24hr expectant observation - wi...
Dear Editor
I read with interest Smart et al's letter [1] regarding the assessment of paediatric cervical spine injuries.
It would certainly appear that many children in their cohort were Xrayed unnecessarily according to current guidelines. However, I would hope that the practice in their institution has changed dramatically in the 6 years since the group attended.
Current guidelines on sel...
Dear Editor
Management of non-serious 999 calls by nurse-led telephone triage and advice or referral: building on initial research
The Editors’ response to Dale et al.’s paper [1] rightly highlights the need for further research to evaluate the safety, appropriateness and effectiveness of the management of some non-serious 999 calls with telephone advice only.
At the time of the ‘Telephone Ad...
Dear Editor
King and Reid [1] highlight a number of standards relating to child protection procedures within emergency departments. In January 2003, Lord Laming published his report of the Victoria Climbie Inquiry which contains further recommendations regarding healthcare arrangements for children and procedures for investigation of possible deliberate harm. Those relevant to emergency department practice mainly conc...
While it is reasonable to use large doses of Naloxone as described in the BNF (the maximum dose recommended is 10mg), the National poisons information service recommend that dose is titrated to response. Naloxone however, has also been attributed to improving GCS in gamma-hydroxybutyrate and alcohol overdoses.
Large doses of opiate antagonists may be used in simple opiate overdose, however it was not cle...
Dear Editor
McPherson et al’s article [1] generates some interesting questions concerning disproportionately high levels of psychological distress amongst Emergency Department (ED) Senior House Officers (SHOs). The combination of shiftwork, a challenging working environment, broad case mix, and newly acquired decision latitude may explain the findings.
We did have some reservations about the article...
Further to the case report presented by Carter and Wilby (Emerg Med J 2000 17:387) where a valuable lesson is demonstrated regarding overlooking lisfranc fractures in the presence of polytrauma, we would like to add to this a patient we encountered in order to emphasize the point.
A 27-year-old male was admitted following a road traffic accident where the patient riding a motorcycle collided with a car...
Dear Editor
Regarding the article by O’Cathain et al. [1] it was interesting to note the conflicting statements made towards the end of the paper.
The systems of NHS Direct were identified as having poor sensitivity and specificity when dealing with the studied calls, yet at the end the paper it states that the types of low priority calls referred need refinement due to at least one-fifth may be pass...
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