I read with interest the letter publication by Knowles on routine use
of thrombolysis during all non-traumatic cardiac arrests, whether caused
by pulmonary embolism
( PE ) or by myocardial infarction (MI).[1] His comment was based in
relation to a case report by MacCarthy P et al (Emerg Med J 2002; 19: 178
-79.)
BTS guidelines mention performing urgent echocardiography for massive
PE with...
I read with interest the letter publication by Knowles on routine use
of thrombolysis during all non-traumatic cardiac arrests, whether caused
by pulmonary embolism
( PE ) or by myocardial infarction (MI).[1] His comment was based in
relation to a case report by MacCarthy P et al (Emerg Med J 2002; 19: 178
-79.)
BTS guidelines mention performing urgent echocardiography for massive
PE with collapse or hypotension. Right ventricular dysfunction on
echocardiography has been reliably established as a predictor of increased
likelihood of death from PE.
Recent research interest, however, has been hovering around measuring
cardiac troponin (cTnT) in acute PE to assist risk stratification.[2] PE
patients with elevated cTnT levels should undergo echocardiography to
detect right ventricular dysfunction. This may portend a lethal
combination in the presence of an elevated cTnT level. These patients
could then be assessed to determine whether thrombolysis or embolectomy is
a clically appropriate strategy.
Several issues would need to be resolved before such policy is
implemented. Firstly, like in acute coronary syndrome optimal role and
timing of measurement of troponin level in patients with PE need to be
determined. Secondly, it is not known yet, whether elevated cTnt level is
actually prognostically more important than right ventricular dysfunction
on echocardiogram or not. Thirdly, whether the biomarkers such as brain
natriuretic peptides will become more useful, equivalent or complementary
to cTnT level in acute PE or not.[3]
Thrombolysis has its own hazards and therefore can not routinely be
recommended in a ‘cardiac arrest’ scenario.
References
(1) Knowles P. Transthoracic echocardiography during cardiac arrest
due to massive pulmonary embolism. Emerg Med J 2003; 20: 395.
(2) Goldhaber SZ. Cardiac biomarkers in pulmonary embolism. Chest 2003;
123: 1782-84.
(3) Kucher N, Printzen G, Doernhoefer T, et al. Low pro-brain natriuretic
peptide levels predict benign clinical outcome in acute pulmonary
embolism. Circulation 2003; 107: 1576-78.
There has been considerable discussion recently about the best name
for the specialty currently called Accident and Emergency Medicine. Could
I suggest the specialty be renamed "Emergency and Trauma Care"? If this
name were adopted, both the name and the abbreviation would reflect the
nature of work undertaken by the specialty.
Richard Hardern
JohnRyan
29 April, 2016
Dear Editor
It seems that the authors of this paper were surprised to find such an elevated phenytoin
level. A few questions sprung to mind:
1) Did they repeat the level ?
2) Are they sure this level was before the phosphenytoin was commenced?
3) Was the patient symptomatic of phenytoin toxicity prior to being found seizing? One would have suspected ataxia and nystagmus e...
It seems that the authors of this paper were surprised to find such an elevated phenytoin
level. A few questions sprung to mind:
1) Did they repeat the level ?
2) Are they sure this level was before the phosphenytoin was commenced?
3) Was the patient symptomatic of phenytoin toxicity prior to being found seizing? One would have suspected ataxia and nystagmus etc.
4) Do they explain the high levels as an intentional overdose, in which case did
he have mental health evalutaion when he woke up and were enquiries made about the possibility of deliberate self harm?
5) Did he have cardiovascular/ecg manifestations of phenytoin toxicity ?
The explanation you give for his seizures is phenytoin toxicity?
The evidence for this, based on just one level seemed to me a little too thin.
In my opinion, it is much more important in the decision to discharge
a patient. It is relatively rare that I have not made a decision to admit
a patient within the first 30 seconds of presentation of an asthma attack-
the respiratory rate, the use of accessory muscles and the overall
behaviour of the patient is much more important than a number on the peak
flow meter.
I find it much more worrying that t...
In my opinion, it is much more important in the decision to discharge
a patient. It is relatively rare that I have not made a decision to admit
a patient within the first 30 seconds of presentation of an asthma attack-
the respiratory rate, the use of accessory muscles and the overall
behaviour of the patient is much more important than a number on the peak
flow meter.
I find it much more worrying that the percentage of patients being
discharged from hospital seem to have a significantly less frequently
recorded vital statistics that the ones being admitted. Personally I work
on the basis that I keep looking for a reason to worry until all options
are satisfied. As I said above, usually I made a decision to admit before
a peak flow measurement is necessary. However, if I think the patient is
going to be discharged then I want to be absolutely certain that all the
investigations are done.
I read with interest the article by Yuen et al[1]. Anterior shoulder
dislocation accounts for a significant proportion of joint injury in
emergency medicine and any technique that improves our care for these
patients is to be welcomed.
The authors state that the technique is easily learned by senior house
officers and this certainly is important. Often the patient is seen by a
junior doctor when se...
I read with interest the article by Yuen et al[1]. Anterior shoulder
dislocation accounts for a significant proportion of joint injury in
emergency medicine and any technique that improves our care for these
patients is to be welcomed.
The authors state that the technique is easily learned by senior house
officers and this certainly is important. Often the patient is seen by a
junior doctor when senior supervision may not be available so a safe, easy
technique is to be commended. We were concerned by the large numbers of
patients (57%) who required intravenous valium. We would advocate that
techniques that use no sedation or small amounts of NSAID or opiate are
safer for the senior house officer. Currently at Oxford we are using a
specially designed chair and back-rest to act as an external fulcrum in
the axilla. Gentle downward traction on the affected limb with external
rotation is then used to affect reduction. This is yielding an 85% success
rate without opiates or benzodiazepines[2]. Patient satisfaction is high
as their time in the department is minimised – typically less than 45
minutes from triage to discharge. The departments utilisation of staff is
improved since long term monitoring of the sedated patient is not needed.
No method offers 100% success and so operators need to be familiar with
alternatives.
Our second concern relates to biomechanics. The Spaso technique relies
primarily on traction and this is associated with inherent risks to soft
tissue structures. The literature is full of ‘easy techniques to reduce
anterior shoulder dislocation’[3]. We do not need yet another but should
consolidate our current practices to a safe approach to a common problem
in our Emergency Departments.
Yours sincerely
Kelvin Wright
SpR A&E
John Radcliffe Hospital
References
(1) Yuen MC, Yap PG, Chan YT et al. An easy method to reduce anterior
shoulder dislocation:the Spaso technique. Emerg. Med J 2001;18(5):370-372
(2) Wright KD, Hormbrey PJ. Anterior shoulder dislocation reduction: the
Oxford chair method. To be presented FAEM meeting London 2001
(3) Mattick A, Wyatt JP. From Hippocates to the Eskimo – a history of
techniques to reduce anterior shoulder dislocation. J R Coll Surg Edin
2000, 45:312-316
I read with interest the paper on repeated use of the emergency
department by some patients. Like the authors I carried out a qualitative
study looking at use of the emergency department, focusing however on the
use made by homeless families for minor illnesses within the UK. To
explore the reasons underlying the reason to attend, I interviewed 10
families living in temporary accommodation (mainly...
I read with interest the paper on repeated use of the emergency
department by some patients. Like the authors I carried out a qualitative
study looking at use of the emergency department, focusing however on the
use made by homeless families for minor illnesses within the UK. To
explore the reasons underlying the reason to attend, I interviewed 10
families living in temporary accommodation (mainly refugee families from
several countries).
While my findings were similar to this study, I found that
homelessness adds another dimension. Management of minor illness within
bed and breakfast accommodation appears to be beyond parents' percieved
locus of control; their anxiety is heightened and any sense of normality is
redefined. In addition primary socialisation to services within other
countries, poor security within temporary accommodation and social
isolation may contribute to the decision to attend the emergencey
department.
Homelessness places additional stress on young families and reduces their
ability to cope with minor illness, leading to the use of the emergency
department. It is important that greater recognition of these stress factors
(psychological, social and environmental) is made so that appropriate
services, be it in the emergencey department, or primary care can be
provided.
I thank Dr Rosival for his interest in the article about DKA and for
his recent letter which mirrors a previous one.[1] This reply largely
covers the same ground as the reply to that earlier letter.[2]
Although the most recent American Diabetic Association guidance does
state that prognosis in DKA is worse in patients with coma [3] this is not
equivalent to the assertion that only comatose patie...
I thank Dr Rosival for his interest in the article about DKA and for
his recent letter which mirrors a previous one.[1] This reply largely
covers the same ground as the reply to that earlier letter.[2]
Although the most recent American Diabetic Association guidance does
state that prognosis in DKA is worse in patients with coma [3] this is not
equivalent to the assertion that only comatose patients will die. Fatal
dysrhythmias can occur in DKA because of hyper- or hypokalaemia and will
not necessarily be preceded by coma.
Coma may reflect cerebral oedema rather than (or as well as)
acidosis. Since this has such a high case fatality rate, the prognosis in
comatose patients will be worse than non-comatose patients. Retrospective
work [4] has demonstrated an association between cerebral oedema and low
partial pressure of CO2 and with high urea (but not with low pH). The
same work also demonstrated a four fold increased risk of cerebral oedema
in patients treated with bicarbonate.
With regard to the interpretation of studies, if Rosival believes
that raising a low pH is the mechanism by which bicarbonate exerts benefit
attention needs to be drawn to the following:
In Lutterman’s (retrospective) study there was no significant (or
clinically important) difference in the rise in pH in the first 2 hours
between the two groups nor in the time for pH to reach 7.30.
In Lever’s (retrospective) study the mean change in pH was not
significantly different between the two groups nor was the mean time to
complete consciousness.
The answer to the question posed in the third paragraph is that even
without sodium bicarbonate the low blood pH will rise provided fluid and
insulin are given.
Perhaps the best way of resolving this controversy is to conduct an
RCT in patients with severe acidosis (not just those with coma - which is
not equivalent to a GCS of 3-4 as Rosival previously wrote[1]), though if
evidence of an association between bicarbonate use and cerebral oedema
continues to grow the point at which this is no longer ethical may be
reached.
References
1. Rosival V. Should sodium bicarbonate bicarbonate be administered
in diabetic ketoacidosis? Am J Respir Crit Care Med 2002;166:290.
2. Boord JB, Graber AL, Christman JW, Powers AC. Should sodium bicarbonate
bicarbonate be administered in diabetic ketoacidosis? Am J Respir Crit
Care Med 2002;166:290.
3. American Diabetes Association. Hyperglycaemic crises in diabetes.
Diabetes Care 2004;27(suppl 1):S94-102.
4. Glaser N, Barnett P, McCaslin I et al. Risk factors for cerebral edema
in children with diabetic ketoacidosis. NEJM 2001;344:264-269.
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.
The excellent editorial written by Carl Gwinnut raises
important issues regarding airway care of critically ill patients at the
interface between anaesthetics and emergency care medicine.[1] The
conclusion of the editorial suggested airway management in an emergency
department is dependant on the available personnel and resources present,
and that a co-ordinated approach is beneficial. As General Prac...
The excellent editorial written by Carl Gwinnut raises
important issues regarding airway care of critically ill patients at the
interface between anaesthetics and emergency care medicine.[1] The
conclusion of the editorial suggested airway management in an emergency
department is dependant on the available personnel and resources present,
and that a co-ordinated approach is beneficial. As General Practitioners
in rural Scotland, we feel that this is a constructive and positive
approach, which could be developed further in order to benefit
practitioners who cover isolated populations.
General Practitioners are mainly responsible for the running of
community hospitals in Scotland. Over the past ten years in rural Argyll,
there has been an increase in the frequency of multiple trauma dealt with
in the community hospitals. This precipitated a dialogue with the staff at
the teaching hospital to which these critically ill patients were
subsequently transferred. The result was that over the past four years
regular anaesthetic attachments have been secured for three of the doctors
from the practice. A co-ordinated programme has been introduced with the
help of consultant staff in Accident and Emergency and the department of
Anaesthetics. This is a rolling multi-faceted programme, which involves
theatre sessions where practical skills can be reinforced, coupled with
scenario-based learning, with critical care issues also explored.
There are obvious implications for our practice in taking on such a
role. We work to strict guidelines and are involved in ongoing audit of
our work. There are obvious and justifiable concerns regarding non-
anesthetists becoming involved in airway management.[2] We all agree that
specialist input for definitive airway management is the ideal.
Unfortunately, given our geographical location and that of other community
hospitals, this is not always possible. A retrieval service for critically
ill patients is still evolving, and we hope that some of these issues will
be overcome by a rapid response. Safe and responsible practice is
paramount. Regular training, audit, discussion of all cases and close
liaison with specialists is vital for airway management skills to be safe
and effective.
Chris Downs
Mark Simpson
Adrian Ward
General Practitioners. Mid Argyll Hospital, Lochgilphead Argyll PA31 8LU
References (1) Gwinnut CL. The interface between anaesthesia and emergency
medicine. Emerg Med J 2001;18:325-329
(2) Nicol MF. You can't anaesthetize patients-you are not employed as an
anaethetist (letter). Emerg Med J 2001;18:414
This consensus paper on the burns patient management in prehospital
care1 is an important development in the standardised care of these
patients by providers of early emergency care. However, there appear to be
a few anomalies in the paper.
The authors fail to mention the role of the fire service in the early
management of these patients, although several services carry burns first
aid equipment and me...
This consensus paper on the burns patient management in prehospital
care1 is an important development in the standardised care of these
patients by providers of early emergency care. However, there appear to be
a few anomalies in the paper.
The authors fail to mention the role of the fire service in the early
management of these patients, although several services carry burns first
aid equipment and medical gases and have undergone first aid training,
sometimes in conjunction with their local ambulance service.
Standard first aid, emergency department and trauma training has
historically placed the “ABCs” after the SAFE approach and before
treatment of non-life threatening injuries. The consensus guidelines
appear to place this assessment after the treatment of the burn. Unless
there is ABC compromise directly from the burn this would seem
inappropriate.
Although Clingfilm dressings are generally appropriate, mention of the
management with significant facial burns with other dressings may have
been a useful addition.
Also many ED staff are unfamiliar with the use of serial halves to assess
burns and a reference for this would be helpful.
Overall this paper is a vital step in the integration of prehospital and
emergency care for patients with burns.
References
1. Allison K, Porter K. Consensus on the prehospital approach to burns
patient management. Emerg Med J 2004;21:112-14.
Dear Editor
I read with interest the letter publication by Knowles on routine use of thrombolysis during all non-traumatic cardiac arrests, whether caused by pulmonary embolism ( PE ) or by myocardial infarction (MI).[1] His comment was based in relation to a case report by MacCarthy P et al (Emerg Med J 2002; 19: 178 -79.)
BTS guidelines mention performing urgent echocardiography for massive PE with...
Dear Editor
There has been considerable discussion recently about the best name for the specialty currently called Accident and Emergency Medicine. Could I suggest the specialty be renamed "Emergency and Trauma Care"? If this name were adopted, both the name and the abbreviation would reflect the nature of work undertaken by the specialty.
Richard Hardern
Dear Editor
It seems that the authors of this paper were surprised to find such an elevated phenytoin level. A few questions sprung to mind:
1) Did they repeat the level ?
2) Are they sure this level was before the phosphenytoin was commenced?
3) Was the patient symptomatic of phenytoin toxicity prior to being found seizing? One would have suspected ataxia and nystagmus e...
Dear Editor
In my opinion, it is much more important in the decision to discharge a patient. It is relatively rare that I have not made a decision to admit a patient within the first 30 seconds of presentation of an asthma attack- the respiratory rate, the use of accessory muscles and the overall behaviour of the patient is much more important than a number on the peak flow meter. I find it much more worrying that t...
Dear Editor,
I read with interest the article by Yuen et al[1]. Anterior shoulder dislocation accounts for a significant proportion of joint injury in emergency medicine and any technique that improves our care for these patients is to be welcomed. The authors state that the technique is easily learned by senior house officers and this certainly is important. Often the patient is seen by a junior doctor when se...
Dear Editor
I read with interest the paper on repeated use of the emergency department by some patients. Like the authors I carried out a qualitative study looking at use of the emergency department, focusing however on the use made by homeless families for minor illnesses within the UK. To explore the reasons underlying the reason to attend, I interviewed 10 families living in temporary accommodation (mainly...
Dear Editor
I thank Dr Rosival for his interest in the article about DKA and for his recent letter which mirrors a previous one.[1] This reply largely covers the same ground as the reply to that earlier letter.[2]
Although the most recent American Diabetic Association guidance does state that prognosis in DKA is worse in patients with coma [3] this is not equivalent to the assertion that only comatose patie...
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...
Dear Editor
The excellent editorial written by Carl Gwinnut raises important issues regarding airway care of critically ill patients at the interface between anaesthetics and emergency care medicine.[1] The conclusion of the editorial suggested airway management in an emergency department is dependant on the available personnel and resources present, and that a co-ordinated approach is beneficial. As General Prac...
Dear Editor
This consensus paper on the burns patient management in prehospital care1 is an important development in the standardised care of these patients by providers of early emergency care. However, there appear to be a few anomalies in the paper. The authors fail to mention the role of the fire service in the early management of these patients, although several services carry burns first aid equipment and me...
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