856 e-Letters

  • No good evidence that Trendelenburg is better to cardiovert SVT

    Dear Sir,

    We read with interest the recent Best Evidence Topic (BET) report by L Varley and L Howard, ‘Trendelenburg position helps to cardiovert patients in SVT back to sinus rhythm.’[1] We are grateful that this BET highlighted the substantial benefit of using a postural modification to the Valsalva manoeuvre for re-entrant SVT[2]. However, whist we agree with the ‘Clinical Bottom Line’, we feel the title of this BET was misleading and does not reflect current evidence.

    ‘Trendelenburg position’ is typically used to describe a supine patient with the bed tilted head down below the level of the pelvis.[3] Although this position was associated with a higher rate of cardioversion in a small, uncontrolled before and after study[4], no physiological benefits of this position have been demonstrated[5] and it was not used in the REVERT trial, the largest RCT of VM modification to date.

    For clarification, in our study the Valsalva strain was conducted in the semi-sitting position with movement to the supine position with leg elevation, immediately at the end of the strain. There are plausible physiological reasons why this specific sequence of postural changes and timing of strain may improve Valsalva effectiveness as described in our paper. Although it is possible that Trendelenburg positioning after straining might further improve cardioversion rates, this has not been tested to date.

    Yours sincerely

    On behalf of the REVERT study Team

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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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  • Request for information
    Jim Wardrope

    It would be useful to know the Total number of traumatic cardiac arrests treated by the system during these three years. Hard to draw conclusions on effectiveness without this figure. Also note different results in the paper Chiang W-C et all on the next page of the journal. (Emerg Med J 2017; 34: 39-45).

    Conflict of Interest:

    None declared

  • high fentanyl doses - is this an error?
    Gael J Smits

    Dear authors,

    In your intersting RCT of propofol versus midazolam sedation, you describe giving a fentanyl dose of 3mcg/kg, in conjunction with a titrated dose of propofol or midazolam.

    This appears a pretty large dose, compared to the procedural sedation literature, where the usual dose is 1 mcg/kg (min-max 0.5-2.0).[1-2]

    From previous research with propofol and midazolam in the Emergency Depa...

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  • A timely health warning.
    Anisa J N Jafar

    We thank the authors Challen and Roland for their review (1) which highlights a very important issue faced daily in our Emergency Departments.

    The use of, and more importantly, reliance on the Early Warning Score (EWS) carries risk as up to 1:3 patients admitted to ICU from ED will not score highly on the EWS (2). Clinician opinion may prove a superior assessment tool; this is not adequately explored. Experien...

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  • The Golden Rule
    Thomas Benzoni

    Dr. Basu et al. make an interesting observation: if you kick the dog, eventually he will bite the mailman. How is it we think we can treat the workers without compassion or empathy while expecting them to treat the patients with these same virtues, ones we don't practice?

    This article and an ever-expanding body of literature make it clear: we must treat our staff in the same way we expect them to treat patients....

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  • The Critical Role of Medical Scribe Training
    Nicholas Rich

    Walker et al. report the first economic analysis of the cost of training medical scribes (1). The concept of the medical scribe has been around for at least 4 decades (2), but with the recent advent of the electronic medical record (EMR), especially in the US, there has been a rapid increase in the use of scribes, particularly in emergency departments (3). The ongoing exponential growth in the use of scribes has been re...

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  • Accurate diagnostic strategies for PE
    Philip D Kaye

    The reported algorithm for diagnosis and exclusion of PE using Wells score < 2 plus negative d-dimer to indicate the patient does not require further imaging is a validated pathway. However, d-dimer specificity is low resulting in large numbers of patients who are low-risk for PE still requiring CTPA or a ventilation-perfusion scan. The aim of recent diagnostic studies, including this study reported by Theunissen JMG e...

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  • Response to Obstacle Course runs: Review of Qcquired injries and illnessas at a series of Canadian events (RACE)
    Marna Greenberg

    As authors of a previous report about serious injuries that occurred during an extreme sports obstacle course in the U.S. (1), we read with interest the article by Alana Hawley, etal describing injury and illness outcomes in a series of Canadian obstacle course events. (2) In this Canadian study a small percentage of participants presented to onsite medial services; the majority of complaints were minor and musculoskele...

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  • In response to the e-letter "An interesting study of the wrong cohort"
    Carl Marincowitz

    Many thanks for your interest in our study.

    We agree that as a retrospective study that compares head injured patients presenting within and after 24 hours of injury that have undergone CT imaging our study does have limitations. However, there are currently few data to guide clinicians in this area. We found only 2 other retrospective cohort studies and an abstract that assessed such patients in a recently pu...

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