It would be interesting to know if the airway obstruction occured
during the transfer of the patient from the A&E bed/trolley onto the
operating table, and whether the patient was maintained in an upright
sitting posture
Most texts deeling with the management of acute upper airway problems such
as this recommend that the patient is not moved from the A&E
resuscitation room. Awake nasal fib...
It would be interesting to know if the airway obstruction occured
during the transfer of the patient from the A&E bed/trolley onto the
operating table, and whether the patient was maintained in an upright
sitting posture
Most texts deeling with the management of acute upper airway problems such
as this recommend that the patient is not moved from the A&E
resuscitation room. Awake nasal fibreoptic intubation should be attempted
by an experienced anaesthetist, with an experienced ENT surgeon standing
by ready to perform a tracheostomy (or at least a cricothyroidotomy).
Authors had focused on the modus operandi rather than the features that would help to identify the nature of bioterrorism. Current
understanding is that infections like anthrax, botuilism, plague, small
pox, tularaemia and viral haemorrhagic fever are most likely to be
implicated in bioterrorism. Important aspects of these conditions are
summarized below-
Authors had focused on the modus operandi rather than the features that would help to identify the nature of bioterrorism. Current
understanding is that infections like anthrax, botuilism, plague, small
pox, tularaemia and viral haemorrhagic fever are most likely to be
implicated in bioterrorism. Important aspects of these conditions are
summarized below-
[A] Anthrax, caused by Bacillus anthracis, is susceptible to
penicillin, doxycycline, and fluoroquinolone. There is no need to immunize
or treat contacts.;
[B] Botulism can give rise to muscle-paralysis and
caused by Clostridium botulinum. Symptoms of food borne botulism begin
most commonly between 12 and 36 hours. Anti-botulinum antitoxin is
effective in reducing the severity of symptoms if administered early in
the course of the disease. Most patients eventually recover after weeks to
months of supportive care;
[C] Yersinia pestis is responsible for causing
plague. Pneumonic plague is one of several forms of plague. With pneumonic
plague, the features of fever, shortness of breath, chest pain and cough
can progress for 2 to 4 days. Streptomycin, gentamicin, the tetracycline,
and chloramphenicol are all effective and should be given within 24 hours
of the first symptom. Antibiotic treatment for 7 days will protect direct
and close contacts. Wearing a close-fitting surgical mask also protects
against infection;
[D] Smallpox is a serious, contagious, and sometimes
fatal infectious disease. The last naturally occurring case in the world
was in Somalia in 1977. The only treatment is prevention with vaccine;
[E] Features of tularemia, caused by Francisella tularensis, include muscle
and joint pain, progressive weakness, and those of pneumonia. Symptoms
usually appear 3 to 5 days following exposure. Tularemia is not known to
be spread from person to person, so there is no need for quarantine. Post
exposure prophylaxis with antibiotics is essential. A vaccine for
tularemia is under review; [F] Viral hemorrhagic fevers are usually mild,
although sometimes they can be severe and life-threatening. Treatment is
essentially supportive.
National Center for Infectious Diseases (NCID) is a central
organization that is equipped to deal with matters arising out of
bioterrorism in America. It has been urged that formation of a similar
central European organization would be helpful. European Centre for
Infectious Diseases (ECID), although sound like an European counterpart of
NCID, is an undertaking supported by a group of scientists and health
professionals, and not an official project of any national institution. It
is a matter that has to be taken up seriously by the politicians and
decision-makers.
I read with interest the case report by Urwin et al. but wonder if
there is another explanation for the patients’ deterioration, other than
the administration of oxygen by the ambulance crew. The case presented
involved a 64 year-old woman with undiagnosed chronic obstructive
pulmonary disease. She was referred by her GP with a four-day history of
increased shortness of breath. On arrival of...
I read with interest the case report by Urwin et al. but wonder if
there is another explanation for the patients’ deterioration, other than
the administration of oxygen by the ambulance crew. The case presented
involved a 64 year-old woman with undiagnosed chronic obstructive
pulmonary disease. She was referred by her GP with a four-day history of
increased shortness of breath. On arrival of the ambulance crew her GCS
was already 5 (E3,V1,M1) and her respiratory rate was 36. As this state of
affairs is not sustainable for four days it is reasonable to assume this
lady is undergoing acute decompensation of her ventilatory failure. Her
tachypnoea, attempting to increase her physiologically useful minute
volume, will ultimately result in respiratory fatigue and a reduced
respiratory rate. This will further exacerbate the carbon dioxide
retention and degree of coma, culminating in respiratory arrest over a
very short period of time. To blame her continuing deterioration to a GCS
of 3 and a respiratory rate of 4 on the 18 minutes of oxygen during
transit is to ignore the underlying pathophysiological process that would
culminate in this clinical picture anyway. It could as easily be argued
that it was only the administration of the oxygen in transit that kept her
alive until she could be intubated.
I am concerned that this case report may encourage inappropriate
oxygen restriction in some patients with severe acute ventilatory failure
in the emergency setting. When practicing emergency medicine, with its’
intrinsic constraints of time and available information a consistent
approach is important. While a few patients may indeed be harmed by
supplemental oxygen, many more will be helped. To that end the current
joint royal colleges ambulance liaison committee guidelines
(http://nww.warwickuniversity.nhs.uk/2002_Guidelines__v2.2.pdf) state,
“All medical emergencies should receive supplemental oxygen at a high flow
rate”.
I note with interest Graham's review of suggested desirable levels of
anaesthetic and critical care experience for emergency medicine trainees
and consultants. I entirely agree that RSI and endotracheal intubation
are the gold standard for airway management in any seriously unwell
patient, and as such, it is entirely appropriate and to be expected that
emergency physicians are able to provide this. Ho...
I note with interest Graham's review of suggested desirable levels of
anaesthetic and critical care experience for emergency medicine trainees
and consultants. I entirely agree that RSI and endotracheal intubation
are the gold standard for airway management in any seriously unwell
patient, and as such, it is entirely appropriate and to be expected that
emergency physicians are able to provide this. However, it is becoming
less possible, rather than more, to achieve this competence as a trainee
with the demise of the stand-alone anaesthetic SHO post. Anaesthetists
are understandably unwilling to offer rotation posts to non-anaesthetists,
and there are far too few emergency medicine rotations which include
enough anaesthetics or critical care. Without the opportunity to
undertake stand-alone post in anaesthetics and critical care I fail to see
how my colleagues or myself can achieve this undoubtably worthwhile goal.
Mr Graham has written an excellent article reviewing the latest
evidence on minimum competencies required to manage the emergency airway.
In current emergency medicine practice there are many hurdles to overcome
not just developing and maintaining skills. Most departments have not
enough experienced practioners to offer this service more than
sporadically. There are also other aspects other than...
Mr Graham has written an excellent article reviewing the latest
evidence on minimum competencies required to manage the emergency airway.
In current emergency medicine practice there are many hurdles to overcome
not just developing and maintaining skills. Most departments have not
enough experienced practioners to offer this service more than
sporadically. There are also other aspects other than the airway to look
at, for example management of injuries, FAST ultrasound scanning. We are
unlikely to be able to manage the airway and deal with everything else in
the resuscitation. Another significant problem is the lack of an
experienced airway assistant (ODP/ODA/anaesthetic nurse). It is considered
standard practice in the UK to undertake RSI only in the presence of an
assistant, if the anaesthetist is busy it is likely the ODP is too. I
think it is unrealistic to expect to train Emergency department nursing
staff to the same level, and in the heat of the moment are you going to
trust them to the same degree.
It is a skill I enjoy, but as the paper suggests we need to demonstrate
safe practice to protect ourselves when things will inevitably go wrong.
We fully agree with the remarks made as to the use of morphine rather
than pethidine in patients with renal colic. During our investigations
primary pethidine was used in our institution and excursions about the use
of morphine were limited by the format of our publication. Therefore this
eletter is an extremely welcome contribution.
We write in response to the paper by Cross et al. on the use of NIV.[1] We are encouraged to see research into such an important and under
investigated area of emergency medicine.
We do however have concerns regarding the study design, in particular
the criteria on which NIV was initiated. The benefits of NIV have mainly
been demonstrated in patients with a respiratory acidosis rather th...
We write in response to the paper by Cross et al. on the use of NIV.[1] We are encouraged to see research into such an important and under
investigated area of emergency medicine.
We do however have concerns regarding the study design, in particular
the criteria on which NIV was initiated. The benefits of NIV have mainly
been demonstrated in patients with a respiratory acidosis rather than
those with symptoms of respiratory distress and/or hypoxia alone as in
this trial. Current widely accepted guidelines from the British Thoracic
Society recommend initiation of NIV for a respiratory acidosis (pH
<_7.35.2 thus="thus" knowledge="knowledge" of="of" arterial="arterial" blood="blood" tensions="tensions" is="is" critical="critical" to="to" its="its" application.="application." we="we" would="would" challenge="challenge" the="the" usefulness="usefulness" authors="authors" definition="definition" acute="acute" respiratory="respiratory" failure="failure" without="without" gas="gas" analysis.="analysis." p="p"/> In addition, NIV was initiated prior to a trial of accepted medical
therapy for acute respiratory failure, such as nebulized or intravenous
bronchodilators or vasodilators. Patients with acute hypercapnic
respiratory failure often improve rapidly with this initial treatment and
thus will not go on to require NIV. Furthermore the omission of arterial
blood gas analysis, prior to the initiation of NIV means that it is
difficult to gain an objective assessment of response to treatment.
In conclusion, further trials using more objective methods of patient
assessment, are required to guide future management of acute respiratory
failure in the emergency department.
References
1. Cross A M, Cameron P, Kierce M, Ragg M, and Kelly A-M. Non-
invasive ventilation in acute respiratory failure: a randomised comparison
of continuous positive airways pressure ands bi-level positive airway
pressure. Emerg Med J 2003; 20:531–534.
2. British Thoracic Society Guidelines on the use of NIV. Thorax
2002; 57:192–211.
The issue of cardiac troponins is not an issue regarding the decision
of whether to give thrombolysis in cardiac arrest, neither is
echocardiography. Thrombolysis if to be given needs to be given early.
Whether you feel it will be beneficial when administered to cardiac
arrests depends on how you interpret the available evidence, which to be
honest is of limited methodology.
I agree with Dr Lockers concerns regarding the publication of BETS in
a peer reviewed journal. BETS are useful for introducing people to the
theory of literature searching, and appraisal of published evidence, ideal
skills for SPR's working towards their clinical topic review. However this
does not necessarily warrant their publication in a peer reviewed journal.
They occupy valuable space within a journal...
I agree with Dr Lockers concerns regarding the publication of BETS in
a peer reviewed journal. BETS are useful for introducing people to the
theory of literature searching, and appraisal of published evidence, ideal
skills for SPR's working towards their clinical topic review. However this
does not necessarily warrant their publication in a peer reviewed journal.
They occupy valuable space within a journal which is only published
bimonthly, which could instead be used by studies with more rigourous
methodology. If the EMJ is to become to be a leading worldwide journal in
the field of Emergency medicine, should it be including BETS within its
pages? I don't see the Lancet or the BMJ publishing 6-7 pages of medline
searches each edition.
Though Dr Hogg does explain that she has carried out a rigorous search,
and had this checked, this itself does deviate from the initial aims of
BETS as something a clinician could do in a short period of time.
With the advent of nearly universal internet use is the Best bets website
not the best place for them to reside?
Placement of chest drains can be associated with serious
complications
such as penetration of intra-thoracic and upper abdominal organs. This
should be a less common occurrence nowadays as trochar use is no longer
advocated.[1]
Chest tube malposition post insertion is also common[2] as it
can be difficult to manoeuvre the drain with the standard equipment once
it is in the chest cavity. Usin...
Placement of chest drains can be associated with serious
complications
such as penetration of intra-thoracic and upper abdominal organs. This
should be a less common occurrence nowadays as trochar use is no longer
advocated.[1]
Chest tube malposition post insertion is also common[2] as it
can be difficult to manoeuvre the drain with the standard equipment once
it is in the chest cavity. Using standard technique Chan[3] found that
placement of emergent thoracostomy tubes in the emergency department
does not result in an increased complication rate as compared to
placement on an inpatient ward. The instrumentation advised per the BTS
guidelines for inserting chest drains is not particularly designed for the
task.
A recent paper published by Andrews [4] may add further to the
question posed in the BET. He has designed a forceps specifically for
chest
drain introduction and has shown that it rated easier to use than standard
forceps by both experienced and inexperienced users. This may partly be
due to the design of his ratchet mechanism allowing the user to take
advantage of better motor control when flexing/gripping.
Standard forceps require the user to extend fingers in order to
dissect
down through the muscle layers. Difficulties may arise with the standard
technique if the user withdraws the forceps and cannot subsequently find
the track made necessitating further dissection and discomfort for the
patient. With this new forceps the drain is placed in a conduit or
circular
channel created by vertical extensions on each arm of the forceps and also
a 3rd limb proximally.
If Seldinger offers no advantage over traditional methods as shown in
this
BET[5] then the new forceps described by Andrews deserves
closer inspection in relation to chest drain placement in emergency
departments.
References
1. Haggie, J.A., Management of pneumothorax. Chest drain trocar
unsafe and unnecessary. Bmj, 1993. 307(6901):443.
2. Baldt, M.M., et al. Complications after emergency tube
thoracostomy: assessment with CT. Radiology, 1995. 195(2):539-43.
3. Chan, L., et al. Complication rates of tube thoracostomy. Am J
Emerg Med, 1997. 15(4):368-70.
4. Andrews, E.,et al. A new specifically designed forceps for chest
drain insertion. Injury, 2003. 34(12):957-9.
5. Argall, J. and J. Desmond, Seldinger technique chest drains and
complication rate. Emerg Med J, 2003. 20(2):169-70.
Dear Editor
It would be interesting to know if the airway obstruction occured during the transfer of the patient from the A&E bed/trolley onto the operating table, and whether the patient was maintained in an upright sitting posture
Most texts deeling with the management of acute upper airway problems such as this recommend that the patient is not moved from the A&E resuscitation room. Awake nasal fib...
Dear Editor
Authors had focused on the modus operandi rather than the features that would help to identify the nature of bioterrorism. Current understanding is that infections like anthrax, botuilism, plague, small pox, tularaemia and viral haemorrhagic fever are most likely to be implicated in bioterrorism. Important aspects of these conditions are summarized below-
[A] Anthrax, caused by Bacillus ant...
Dear Editor
I read with interest the case report by Urwin et al. but wonder if there is another explanation for the patients’ deterioration, other than the administration of oxygen by the ambulance crew. The case presented involved a 64 year-old woman with undiagnosed chronic obstructive pulmonary disease. She was referred by her GP with a four-day history of increased shortness of breath. On arrival of...
Dear Editor
I note with interest Graham's review of suggested desirable levels of anaesthetic and critical care experience for emergency medicine trainees and consultants. I entirely agree that RSI and endotracheal intubation are the gold standard for airway management in any seriously unwell patient, and as such, it is entirely appropriate and to be expected that emergency physicians are able to provide this. Ho...
Dear Editor
Mr Graham has written an excellent article reviewing the latest evidence on minimum competencies required to manage the emergency airway.
In current emergency medicine practice there are many hurdles to overcome not just developing and maintaining skills. Most departments have not enough experienced practioners to offer this service more than sporadically. There are also other aspects other than...
Dear Editor
We fully agree with the remarks made as to the use of morphine rather than pethidine in patients with renal colic. During our investigations primary pethidine was used in our institution and excursions about the use of morphine were limited by the format of our publication. Therefore this eletter is an extremely welcome contribution.
Thank you very much.
Dear Editor
We write in response to the paper by Cross et al. on the use of NIV.[1] We are encouraged to see research into such an important and under investigated area of emergency medicine.
We do however have concerns regarding the study design, in particular the criteria on which NIV was initiated. The benefits of NIV have mainly been demonstrated in patients with a respiratory acidosis rather th...
Dear Editor
The issue of cardiac troponins is not an issue regarding the decision of whether to give thrombolysis in cardiac arrest, neither is echocardiography. Thrombolysis if to be given needs to be given early. Whether you feel it will be beneficial when administered to cardiac arrests depends on how you interpret the available evidence, which to be honest is of limited methodology.
Dear Editor
I agree with Dr Lockers concerns regarding the publication of BETS in a peer reviewed journal. BETS are useful for introducing people to the theory of literature searching, and appraisal of published evidence, ideal skills for SPR's working towards their clinical topic review. However this does not necessarily warrant their publication in a peer reviewed journal. They occupy valuable space within a journal...
Dear Editor
Placement of chest drains can be associated with serious complications such as penetration of intra-thoracic and upper abdominal organs. This should be a less common occurrence nowadays as trochar use is no longer advocated.[1]
Chest tube malposition post insertion is also common[2] as it can be difficult to manoeuvre the drain with the standard equipment once it is in the chest cavity. Usin...
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