I wonder if we may make further comment in light of the
reply of Jones et al. to our initial concerns over
perceived weaknesses of their flowchart on the
management of paracetamol poisoning.
Our ongoing major concern is that, in their reply, Jones
et al. appear to be holding to the position that INR is the
best prognostic indicator in paracetamol poisoning.
Studying the r...
I wonder if we may make further comment in light of the
reply of Jones et al. to our initial concerns over
perceived weaknesses of their flowchart on the
management of paracetamol poisoning.
Our ongoing major concern is that, in their reply, Jones
et al. appear to be holding to the position that INR is the
best prognostic indicator in paracetamol poisoning.
Studying the reference they give to back this position [1]
one finds two clear statements: Firstly, that "The most
sensitive prognostic marker is prothrombin time"; and
secondly that "In (their) clinical experience, when PT
starts to improve full recovery follows". Where INR is
mentioned is when the article itself refers to another
article [2] which, on closer scrutiny, does not in fact
make any reference to INR but does include
prothrombin time amongst the data collected and
presented .
We should be most grateful for final confirmation as to
which marker to monitor because if the answer is
prothrombin time, as we suspect, then further important
amendments will need to be made to the flowchart and
it's legend before reprinting.
Finally, and with all due respect to Jones et al.. can we
say that rather than misreading the 8-24hr pathway, we
evidently did not interpret it in the way which was
intended. Perhaps this in itself is justification for
reviewing the flowchart.
References
[1] Dargan PI, Jones AL. Acetaminophen poisoning:
an update for the intensivist. Critical Care
2002;6:108-10.
[2] Gyamlani GG, Parikh CR: Acetaminophen toxicity:
suicidal vs accidental. Critical Care 2002;6:155-9.
I read the position statement about anaesthetic machines in the
accident and emergency resuscitation room by M J Clancy [1] with some
disappointment. A perfect opportunity for the FAEM and BAEM to dispose of
many ancient and probably only a few newer Anaesthetic Machines has been
missed.
This position statement does not contain anything that should not be
done anyway.
All modern Anaesthe...
I read the position statement about anaesthetic machines in the
accident and emergency resuscitation room by M J Clancy [1] with some
disappointment. A perfect opportunity for the FAEM and BAEM to dispose of
many ancient and probably only a few newer Anaesthetic Machines has been
missed.
This position statement does not contain anything that should not be
done anyway.
All modern Anaesthetic Machines have to be fitted with a hypoxic mixture
guard and it is not more then good sensible practice to check equipment
before use. The Medical devices Agency also states, that 'before a
medical device is issued to a patient or carer they should receive
training in how to use the device. This should be supported by written
guidance.' [2]
Anaesthetic machines are designed to deliver hypnotic volatiles and
some oxygen. As anaesthetics are no longer given in A&E, I can see no
need for complex machines, which need trained operators with a trained
assistant and regular maintenance. They are rarely used for their designed
purpose and their cost alone should make their presence in A&E
prohibitive.
Emergency patients need oxygen and air. This is easier, and more
efficiently supplied from a piped gas supply with disposable oxygen
delivery devices. They are comparably cheap and simple in design, reducing
the potential for mistakes and failures. It is relatively easy to instruct
all practitioners in A&E in their efficient and safe use. Some
dedication from the Anaesthetic and A&E Departments would be required
in the teaching and maintenance of these skills but a regular 'refresher
day' in theatre is easy to organise.
This is in my view the only way to prevent tragic accidents. When a
certain piece of equipment is available for anybodies use, somebody will
use it one day, in a stressful and complex situation, not adequately
trained and 'rusty' skills; may be again with tragic consequences for
everybody involved.
J. Kuehne
Specialist Registrar in Anaesthesia
St. George’s School of Anaesthesia
Tooting, London
References
(1) M J Clancy, Anaesthetic machines in the accident and emergency resuscitation room. Emerg Med J 2002; 19:194.
(2) Equipped to Care: the safe use of medical devices in the 21st Century, MDA 01/10/2001.
If you are interested in the causes of violence and hostile
behaviour, and want insight then please take the time to read: www.abusedbythesystem.org.uk
for debate.
While the paracetamol overdose flowchart proposed by Wallace et al.
[1] puts forward a generally helpful approach to this common problem, I
would like to raise two points which could be of concern.
First, the authors do not recommend measurement of paracetamol levels
after a staggered overdose. Since a staggered overdose relies entirely on
the patient's history, a blood paracetamol level...
While the paracetamol overdose flowchart proposed by Wallace et al.
[1] puts forward a generally helpful approach to this common problem, I
would like to raise two points which could be of concern.
First, the authors do not recommend measurement of paracetamol levels
after a staggered overdose. Since a staggered overdose relies entirely on
the patient's history, a blood paracetamol level will at least help to
confirm the most recent ingestion and guide treatment.
Secondly, there is no mention of mental state assessment or
psychiatric liaison before discharging the patient. If junior doctors are
to use the flowchart as their guide for management, a reminder of the
inportance of mental state evaluation and,in particular,risk of further
suicide attempts is vital.
Michelle Jacobs
Reference
(1) Wallace CI,Dargan PI,Jones AL. Paracetamol overdose:an
evidence based flowchart to guide management. Emerg Med J2002;19:202-5.
We are grateful to Lloyd et al.[1] and Rowlands et al.[2] for correctly
pointing out the typographical errors in our flowchart. These were
production errors, and did not reflect the original version supplied to
the journal. Patients who present after a paracetamol overdose with an
unknown quantity of paracetamol should definitely be treated as though
they may have taken a potentiall...
We are grateful to Lloyd et al.[1] and Rowlands et al.[2] for correctly
pointing out the typographical errors in our flowchart. These were
production errors, and did not reflect the original version supplied to
the journal. Patients who present after a paracetamol overdose with an
unknown quantity of paracetamol should definitely be treated as though
they may have taken a potentially hepatotoxic dose. Similarly, along the
staggered overdose pathway, all doses should be described on a dose/kg/day
and not a dose/kg basis. These errors are of sufficient importance that we
have asked the editor to reprint the flowchart with these corrected.
Rowlands et al.[2] ask for more detail on the management of at risk
patients who present with a staggered overdose of >= 75mg/kg/day or
unknown. The management of these patients is controversial and, we feel,
needs to be discussed on an individual case basis once the result of
baseline blood tests are available.
Patients who are treated with N-acetylcysteine within 8 hours of a
single paracetamol ingestion have a less than 1% risk of developing
hepatotoxicity [3] and for this reason do not require liver function
tests, INR, creatinine to be checked until after the course of N-acetylcysteine has been completed.
Rowlands et al[2] have misread the 8-24 hour pathway, the second box
refers to checking the blood results rather than taking a second blood
test.
We agree with Rowlands that there is minor interference by N-
acetylcysteine with certain paracetamol assays and doctors should check
with their local laboratory which assay is used in their hospital.
However, it is paramount that N-acetylcysteine is started as soon as
possible in late presenting patients as delayed treatment will result in
decreased efficacy. [3]
Late presenting patients and those with staggered overdose who have
abnormal blood tests carry a high mortality and management is complex and
ever changing.[4] Thus, it is critical both in terms of decisions on
management and criteria for transfer to liver units that discussion takes
place with a clinical toxicologist at a poisons centre.
INR is the best prognostic indicator in paracetamol poisoning.[4]
We agree with O’Connor et al.[5] that all patients who present after
paracetamol overdose require psychiatric evaluation and this is our every
day practice.
References
(1) Lloyd G, O'Sullivan I. Re: Psychiatric evaluation in acute poisoning [electronic response to Wallace et al. Paracetamol overdose: an evidence based flowchart to guide management. emjonline.com http://emj.bmjjournals.com/cgi/eletters/19/3/202#66
(2) Rowlands AB, Thomson J. Weaknesses in the flowchart in acute poisoning [electronic response to Wallace et al. Paracetamol overdose: an evidence based flowchart to guide management. emjonline.com http://emj.bmjjournals.com/cgi/eletters/19/3/202#65
(3) Prescott LF, Illingworth RN, Critchley JA et al. Intravenous N-
acetylcysteine: the treatment of choice for paracetamol poisoning. BMJ
1979;2:1097-100.
(4) Dargan PI, Jones AL. Acetaminophen poisoning: an update for the
intensivist. Critical Care 2002;6:108-10.
(5) O'Connor AE, Lockney AL. Psychiatric evaluation in acute poisoning [electronic response to Wallace et al. Paracetamol overdose: an evidence based flowchart to guide management. emjonline.com
http://emj.bmjjournals.com/cgi/eletters/19/3/202#58
We were interested to read the review of airway management in the
emergency department by Clancy and Nolan.[1] Immediate airway care is in the
corner stone of patient management - its importance is exemplified by
the 'A' of the ABC mantra. We do not wish to go over the issues already
raised but to introduce another aspect to the discussion.
We are members of a local pre-hospital care group. Our...
We were interested to read the review of airway management in the
emergency department by Clancy and Nolan.[1] Immediate airway care is in the
corner stone of patient management - its importance is exemplified by
the 'A' of the ABC mantra. We do not wish to go over the issues already
raised but to introduce another aspect to the discussion.
We are members of a local pre-hospital care group. Our 'day jobs' are
various and therefore the level of anaesthetic experience varies between
us. The discussion over how we should manage the pre-hospital airway wanes
and waxes but is never resolved. There are many advantages of definitive
pre-hospital airway care, ensuring the delivery of high concentrations
of oxygen to the lungs, protecting the airway against contamination,
lowering intracranial pressure when practiced correctly, to mention a few.
The main disadvantages include lack of practical experience and the
potential adverse pharmacological effects of anaesthetic drugs. Currently,
advanced airway care is one skill that pre-hospital doctors can offer over
paramedics who remain constrained by protocol to intubate only comatose or
dead patients.
We would like to see the education of advanced airway care extended
to include pre-hospital carers. Courses similar to the three day National
Emergency Airway Management course could offer excellent coverage of core
techniques and the use of a few key drugs. Failed intubation protocols
would ensure that no patient would be left anaesthetised without an
adequate airway.
Intubating patients can be daunting, especially when away from
controlled environment of the hospital and when unassisted. Should
endotracheal intubation fail there are alternatives including the
laryngeal mask and new intubating laryngeal mask airways, the combitube
and so on.
We also recommend the maintenance an anaesthetic logbook as evidence
of training and experience. Data on equipment, drugs, techniques, problems
encountered and their corrective measures should be compiled. This should
provide proof of knowledge, experience and skill for the non-anaesthetist.
Most BASICS (British Association for Immediate Care) members are GPs.
Anaesthetists form a minority. In pre-hospital care successful advanced
airway management cannot just be the remit of anaesthetists. Education
followed by relevant experience and revalidation must be the way forward.
K Roberts
SHO Surgical Rotation Birmingham Heartlands and Solihull
NHS Trust
N Sherwood
Consultant Anaesthetist City Hospital NHS Trust Birmingham
A Bleetman
Consultant in Emergency Medicine
Birmingham Heartlands and
Solihull NHS Trust
Reference
(1) Clancy M, Nolan J. Airway management in the emergency department. Emerg Med J 2002;19:2-3.
I was concerned that the above best evidence topic report suggestss
that it is safe to discharge opiod overdose patients one hour after
naloxone administration.[1] The topic report fails to mention whether this
applies to intravenous or intramuscular naloxone administartion (there is
oftwen confusion in emergency departments as to the best route) and the
authors admit that the evidence is poor....
I was concerned that the above best evidence topic report suggestss
that it is safe to discharge opiod overdose patients one hour after
naloxone administration.[1] The topic report fails to mention whether this
applies to intravenous or intramuscular naloxone administartion (there is
oftwen confusion in emergency departments as to the best route) and the
authors admit that the evidence is poor.
A few years ago I was involved in a case where a patient had taken an
opiod overdose and was treated successfully with 400mcg naloxone
intavenously. The patient subsequently tried to abscond and eventually
agreed to stay for an hour only despite us repeatedly urging the patient
to be admitted for longer; he then recieved 400mcg of naloxone
intramuscularly as staff were concerned that he might abscond prematurely.
The patient was discharged an hour and a half later with no symptoms, and
was known to be alive 6 hours later. He was found dead the next day and an
inquest found that the patient had 'fatal' plasma levels of opioid, and no
evidence to support a further overdose following discharge.
Given that the patient had repeatedly refused to stay longer and that
the department in question had no relevant guidelines, the staff involved
were exonerated.
The majority of patients with 30 minutes of chest pain 'could be
safely discharged within 1 hour', but a small number will then go on to
develop a potentially fatal arrythmia with serious consequences for the
patient and staff involved, and so we keep all these patients in. The
recommendation that it is safe to discharge opiod overdose patients after
1 hour if they have no symptoms is dangerous as the example above shows-
please keep these patients in for longer!
Francis Andrews
Reference
(1) Clarke S, Dargan P. Discharge of patients who have taken an overdose of opioids. Emerg Med J 2002;19:250-1.
Good article but for wrinkly, rheumy old gits like me I cannot read
the [I'm sure ] excellent flowchart.
The main thrust of an article is to
have it read. Do you supply free magnifiers for the 'aged ' ?!! this also
goes for the splendid algorithm om page 207 on salycilates.
We read with interest the article by Weinberg[1] which
revealed a lack of awareness amongst A&E staff of the risks of rhesus
sensitisation as a consequence of threatened miscarriage. Similar findings
were reported in previous studies on anti-D use in A&E.[2] This problem
also exists in cases of maternal trauma in early pregnancy.
We conducted a telephone survey of A&E Senior House O...
We read with interest the article by Weinberg[1] which
revealed a lack of awareness amongst A&E staff of the risks of rhesus
sensitisation as a consequence of threatened miscarriage. Similar findings
were reported in previous studies on anti-D use in A&E.[2] This problem
also exists in cases of maternal trauma in early pregnancy.
We conducted a telephone survey of A&E Senior House Officers (SHOs) in the North-West region.
A clinical scenario was given of a patient of 18 weeks gestation with
closed abdominal trauma due to domestic violence. SHOs were asked
regarding their management of this case. Sixty-two responses were
obtained. The possibility of rhesus alloimmunisation was identified by 19(
31 %) doctors. Three of these 19 would request a Kleihauer test while the
remainder would check maternal rhesus status. If rhesus negative, 9 would
give anti-D in the A+E department. The other 9 SHOs would refer the
patient to the obstetricians on call for further evaluation. Our survey
then prompted the remaining 44 doctors with regard to rhesus
incompatibility by bringing to attention previously documented rhesus
negativity in the patient’s casenotes. Equiped with this knowledge, only 8
doctors would then give anti-D immunoglobulin in A&E, while 11 would refer
the patient for this purpose. Even then, the need for anti-D was still
unrecognised by 25/44(57 %) SHOs.
Our study is in agreement with the author’s findings that guidelines
for rhesus prophylaxis are not being followed. In the revised guidelines,
unlike threatened abortion at less than 12 weeks gestation, closed
abdominal injury is recognised as a sensitising event.[3] Without
continuing educational initiatives aimed at A+E doctors, these guidelines
will continue to be ignored.
References
(1) Weinberg L. Use of anti-D immunoglobulin in the treatment of
threatened miscarriage in the accident and emergency department. Emerg Med J 2001;18:444-7.
(2) Huggon AM, Watson DP. Use of anti-D in an accident and emergency
department. Arch Emerg Med 1993;10:306-9.
(3) Joint Working Group of the British Blood Transfusion Society and
the Royal College of Obstetricians and Gynaecologists. Recommendations for
the use of anti-D immunoglobulin for Rh prophylaxis. Tranfus Med 1999;9:93-7.
We congratulate Wallace et al on producing a useful paracetemol
overdose flowchart. It does appear to have a typographical error. Unknown
quantaties of ingested paracetemol should be boxed with > not <150
mg paracetemol. If the pdf file could be amended we will gladly update our
on-line departmental handbook. The point regarding psychiatric assessment
has already been made.
Dear Editors,
I wonder if we may make further comment in light of the reply of Jones et al. to our initial concerns over perceived weaknesses of their flowchart on the management of paracetamol poisoning.
Our ongoing major concern is that, in their reply, Jones et al. appear to be holding to the position that INR is the best prognostic indicator in paracetamol poisoning. Studying the r...
Dear Editor
I read the position statement about anaesthetic machines in the accident and emergency resuscitation room by M J Clancy [1] with some disappointment. A perfect opportunity for the FAEM and BAEM to dispose of many ancient and probably only a few newer Anaesthetic Machines has been missed.
This position statement does not contain anything that should not be done anyway. All modern Anaesthe...
If you are interested in the causes of violence and hostile behaviour, and want insight then please take the time to read:
www.abusedbythesystem.org.uk
for debate.
Thank you.
Dear Editor
While the paracetamol overdose flowchart proposed by Wallace et al. [1] puts forward a generally helpful approach to this common problem, I would like to raise two points which could be of concern.
First, the authors do not recommend measurement of paracetamol levels after a staggered overdose. Since a staggered overdose relies entirely on the patient's history, a blood paracetamol level...
Dear Editors
We are grateful to Lloyd et al.[1] and Rowlands et al.[2] for correctly pointing out the typographical errors in our flowchart. These were production errors, and did not reflect the original version supplied to the journal. Patients who present after a paracetamol overdose with an unknown quantity of paracetamol should definitely be treated as though they may have taken a potentiall...
Dear Editor
We were interested to read the review of airway management in the emergency department by Clancy and Nolan.[1] Immediate airway care is in the corner stone of patient management - its importance is exemplified by the 'A' of the ABC mantra. We do not wish to go over the issues already raised but to introduce another aspect to the discussion.
We are members of a local pre-hospital care group. Our...
Dear Editor
I was concerned that the above best evidence topic report suggestss that it is safe to discharge opiod overdose patients one hour after naloxone administration.[1] The topic report fails to mention whether this applies to intravenous or intramuscular naloxone administartion (there is oftwen confusion in emergency departments as to the best route) and the authors admit that the evidence is poor....
Dear Editor
Good article but for wrinkly, rheumy old gits like me I cannot read the [I'm sure ] excellent flowchart. The main thrust of an article is to have it read. Do you supply free magnifiers for the 'aged ' ?!! this also goes for the splendid algorithm om page 207 on salycilates.
Dear Editor
We read with interest the article by Weinberg[1] which revealed a lack of awareness amongst A&E staff of the risks of rhesus sensitisation as a consequence of threatened miscarriage. Similar findings were reported in previous studies on anti-D use in A&E.[2] This problem also exists in cases of maternal trauma in early pregnancy.
We conducted a telephone survey of A&E Senior House O...
Dear Editor
We congratulate Wallace et al on producing a useful paracetemol overdose flowchart. It does appear to have a typographical error. Unknown quantaties of ingested paracetemol should be boxed with > not <150 mg paracetemol. If the pdf file could be amended we will gladly update our on-line departmental handbook. The point regarding psychiatric assessment has already been made.
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