The flowchart to guide management in paracetamol
overdose, by Wallace, Dargan and Jones (EMJ Vol 19
No.3 p202) was presented at our weekly Journal Club
and generated some thoughts and observations.
Along the "Single" overdose pathway for "Low risk"
patients the guideline suggests that if the ingested
dose of "< 150mg paracetamol per kg or UNKNOWN"
the patient can be discharged. Presumab...
The flowchart to guide management in paracetamol
overdose, by Wallace, Dargan and Jones (EMJ Vol 19
No.3 p202) was presented at our weekly Journal Club
and generated some thoughts and observations.
Along the "Single" overdose pathway for "Low risk"
patients the guideline suggests that if the ingested
dose of "< 150mg paracetamol per kg or UNKNOWN"
the patient can be discharged. Presumably this is a
typographical error, as it would make greater sense for
the box immediately below to read ">= 150mg
paracetamol per kg or UNKNOWN" as this path leads
to treatments.
Along the "Staggered" overdose pathway one route, is
taken based on an ingested dose of "< 75mg
paracetamol per kg PER DAY" whereas the other 3
routes are taken based on simply a dose per kg. It is
impossible to know what the message is here.
We also wondered what advice NPIS offers when a
staggered overdose of ">= 75 mg paracetamol per kg or
unknown" has been taken by an "At risk" patient - other
than: take LFT’s, INR, creatinine and bicarbonate; start
NAC and recheck bloods at a specified interval if the
first set are abnormal. Surely that advice, whatever it
may be, could be incorporated into the flowchart.
Along the pathways for "Single" ingestions <= 8hrs we
found ourselves uncomfortable at the prospect of
leaving checks of LFT’s, INR*, creatinine and
bicarbonate until the end of the NAC course. Twenty
hours is a long time to wait to discover that NAC has
failed to prevent coagulopathy.
Along the 8-24 hour pathway the guideline suggests
commencing treatment with NAC; taking bloods for
paracetamol etc; plotting the paracetamol; then
checking the bloods again before starting treatment.
This seems convoluted and illogical:
Firstly, with regard to the testing for paracetamol , our
understanding from local laboratory services and
Toxbase is that paracetamol levels taken while on NAC
are unreliable (because of the direct effect of NAC on
the paracetamol assay). It would therefore seem more
sensible to ensure the first set of bloods are taken off
before commencing the NAC.
Also, in this part of the flowchart, the blood tests are
repeated back to back with no obvious justification.
Perhaps it is intended that these should be rechecked
after a certain period of treatment with NAC, but this is
not stated and might well lead to confusion for those
unused to managing paracetamol overdose and relying
on the flowchart.
Similarly, for "Late" presentation or "Staggered"
overdose patients on NAC but with abnormal blood
results it would be useful to have some advice as to
when to recheck bloods rather than simply being
directed to the National Poisons Information Service.
We feel that monitoring coagulopathy is appropriate
even if the patient is already on treatment with NAC
since ongoing deterioration may demand consideration
of patient transfer to another unit (e.g. liver transplant
unit) which may be distant from the initial treating
hospital.
Finally, considering coagulopathy further, *we would
question the use of INR as a measure of coagulopathy
in paracetamol overdose. Our understanding is that
this test is reserved for guiding Warfarin dosage and
that Prothrombin time itself is more appropriate.
Overall, we approve of the idea of the flowchart but feel
that with the weaknesses detailed above it is perhaps
not quite ready for use, particularly by clinicians
unfamiliar with this common clinical problem.
Yours faithfully
Mr. Andrew Rowlands (SpR in Accident & Emergency)
Dr. John Thompson (SHO in Accident & Emergency)
We would like to congratulate Nolan and Clancy on their editorial
addressing a controversial area.[1] We would like to comment on some of
their points and add a few thoughts of our own.
Notwithstanding our experience that there is rarely a significant
delay in attendance to the emergency department (ED) by
anaesthetists/intensivists, we agree that there is likely to be an
increase in emer...
We would like to congratulate Nolan and Clancy on their editorial
addressing a controversial area.[1] We would like to comment on some of
their points and add a few thoughts of our own.
Notwithstanding our experience that there is rarely a significant
delay in attendance to the emergency department (ED) by
anaesthetists/intensivists, we agree that there is likely to be an
increase in emergency physicians in the United Kingdom performing
endotracheal intubations using anaesthetic drugs. However, we believe that
the care of critically ill patients must become more “fluid”, meaning that
it should be performed by those competent to do so regardless of their
speciality. Whilst some emergency physicians will feel uncomfortable
managing difficult airways, attending trainee anaesthetists may conversely
be less experienced in airway management than the referring emergency
physician. A recent paper has suggested that there is no difference in
success of airway management or complications in trauma patients whether
management is led by emergency physicians or anaesthetists.[2] As alluded
to in the editorial, sick patients are more frequently seen earlier by
senior doctors in all fields of medicine, and rightly so. However, if the
experienced emergency physician gets into difficulty managing an airway,
he must have quick access to someone who can help him, whilst following
agreed difficult airway management strategies.
From our experience, we believe gaining the required skills would
normally require a placement of about a year. This should include
anaesthesia as well as intensive care medicine (ICM) – most first-year SHO
anaesthetic posts will now include a 3 months block of ICM. There is often
too much to take in from ICM alone to acquire the ability to intubate, but
there is a need to appreciate the difficulties of intubating and then
managing critically ill patients, especially the pharmacology and
physiology. Exposure to ICM also gives a better understanding of which
patients are likely to benefit from intensive care. In the paper referred
to earlier, the emergency department residents have a more structured
training and greater exposure to airway management in the emergency
department than their UK counterparts.[2]
The most difficult part to address is how to maintain these acquired
skills. Everyday clinical practice is unlikely to provide enough
intubation experience, especially in some smaller units. Whilst
intermittent secondments to anaesthesia are likely to be helpful,
allocating time will be a major challenge. Simulators have not yet been
validated as a training tool – intuitively, they seem likely to complement
other approaches.
Finally, the most important point to take away from the editorial in
considering these issues is who makes the decision to induce anaesthesia
and intubate. These decisions have an enormous impact on the patient
and their family, as well as having major resource implications. What
happens, for example, if a patient is intubated in the emergency
department by the attending emergency physician and then refers the case
to the intensivist who feels it is inappropriate to admit him/her to the
intensive care unit. The decision should be collaborative involving
senior doctors experienced in the care of the critically ill. The
management of these patients should be multidisciplinary both in decision
making and at the bedside. With changes in the structure of units both
physically and logistically (e.g. acute medical units, critical care
units), these changes to the development of these core competencies will
lead to improvement in interfacing between departments.
Dr Matthew Williams
Specialist Registrar in Anaesthesia
Miss Leilah Dare
Clinical Fellow in Emergency Medicine
Dr Malcolm Watters
Consultant in Anaesthesia & Intensive Care Medicine
References
(1) Nolan J, Clancy M. Airway management in the emergency department.
British Journal of Anaesthesia 2002;88:9-11.
(2) Omert L, Yeaney W, Mizikowski S, Protetch J. Role of the Emergency
Medicine Physician in airway management of the trauma patient. Trauma
2001;51:1065-8.
As an anaesthetist, I read with interest the article by Carley and
colleagues regarding the necessity of having a drill for failed intubation
in the Emergency Department. A drill is essential and should be actively
taught and practised.
The algorithm you have developed is very similar to those used in
anaesthetic practice, but I wish to highlight a few points. The use of the
gum-elastic bougie...
As an anaesthetist, I read with interest the article by Carley and
colleagues regarding the necessity of having a drill for failed intubation
in the Emergency Department. A drill is essential and should be actively
taught and practised.
The algorithm you have developed is very similar to those used in
anaesthetic practice, but I wish to highlight a few points. The use of the
gum-elastic bougie should feature earlier in the algorithm. There are
groups that use it routinely for all intubations.[1,2] The gum-elastic
bougie is a great asset and is often underrated as a piece of equipment by
non-anaesthetists. Its routine use may decrease the frequency that the
failed intubation drill is required. It is usual that the first
laryngoscopic view is the best view so it is sensible to optimise the
chance of success at this stage.
My second point involves your suggested use of the laryngeal mask
airway (LMA). It has been shown to be a reasonable aid to airway
management for non-anaesthetists or those inexperienced in its use in
resuscitation. With appropriate education, its application is considered
relatively easy to learn. It is a less invasive, simpler and considering
the rarity of cricothyroidotomies, should routinely be used in the
algorithm before proceeding to the cricothyroidotomy. The LMA has been
shown to be a suitable choice for temporary airway control when intubation
fails.[3]
The ProSeal, a new laryngeal airway device may have a place in the
Emergency Department. It has a port to allow easy passage of an orogastric
tube. It has been compared with the LMA in anaesthetised, non-paralyzed
patients. The ProSeal is more difficult to insert but forms a better seal
and does aid the prompt passage of an orogastric tube.[4,5] It may
provide a temporary airway that allows the redirection of regurgitated
fluid away from the respiratory tract.[6,7] The possibility of
regurgitation cannot be excluded fully and thus the ProSeal cannot replace
an endotracheal tube.
Finally, the BURP technique or optimal external laryngeal
manipulation has been shown to be the most effective with pressure applied
to the low thyroid cartilage.[8] It must not be confused with cricoid
pressure.
It is essential to have a failed intubation drill in any location
that tracheal intubation is being undertaken. More importantly, it is
necessary to teach methods to optimise intubating conditions, including
patient positioning, having appropriate personnel present, being
proficient in the use of equipment and having all necessary equipment
checked and available.
References
(1) London Helicopter Emergency Medical Service Standard Operating
Procedures: Rapid sequence induction.
(2) Careflight Prehospital Trauma Course.
(3) Martin SE, Ochsner MG, Jarman RH, Agudelo WE, Davis FE. Use of the
laryngeal mask airway in air transport when intubation fails. J Trauma
1999;47:352-7.
(4) Brimacombe J, Keller C, Fullekrug B, Argo F, Rosenblatt W, Dierdorf
SE, Garcia de Lucas E, Capdevilla X, Brimacombe N. A multicentre study
comparing the ProSeal and Classic laryngeal mask airway in anesthetized,
nonparalyzed patients. Anesthesiol 2002;96: 289-95.
(5) Cook TM, Nolan JP, Verghese C, Strube PJ, Lees M, Millar JM,
Baskett PJF. Randomized crossover comparison of the ProSeal with the
classic laryngeal mask airway in unparalysed anaesthetized patients. BJA
2002;88:527-33.
(6) Keller C, Brimacombe J, Kleinsasser A, Loeckinger A. Does the
ProSeal laryngeal mask airway prevent aspiration of regurgitated fluid? Anesth Analg 2000;91:1017-20.
(7) Brimacombe J, Keller C. Airway protection with the Proseal
laryngeal mask airway. Anaesth Intensive Care 2001;29:288-91.
(8) Benumof JL, Cooper SD. Quantitative improvement in laryngoscopic
view by optimal external laryngeal manipulation. J Clin Anesth 1996;8:136-40.
The Emergency Department management of minor head injury in children
is an area of intense debate. It is encouraging that the BET (Best
Evidence Topic) on indications for Computerised Tomography (HCT) in minor
head injury in children published in November’s issue has stimulated
further discussion.
In his letter of criticism, Dr McCann expresses concern over the
omission of a review article on...
The Emergency Department management of minor head injury in children
is an area of intense debate. It is encouraging that the BET (Best
Evidence Topic) on indications for Computerised Tomography (HCT) in minor
head injury in children published in November’s issue has stimulated
further discussion.
In his letter of criticism, Dr McCann expresses concern over the
omission of a review article on the management of apparent minor head
injury in children less than two years old.
BET methodology requires ‘highest level evidence’ to be used in the
data analysis. Because prospective studies are available that at least in
part cover the topic, the use of lower-level evidence is unjustified.
Literature was therefore excluded based on two criteria, either it was
not prospective or not considered relevant to the topic. Review articles
that contain retrospective studies are also not used.
The paper by Schutzman et al. contains three of the five studies
included in the BET and includes one study not shown in the BET (felt to
poorly address the clinical scenario). The inclusion of multiple
retrospective studies in their paper meant it could not be included in the
BET.
The studies examined in the BET show clearly that intracranial injury
(ICI) as shown by HCT occurs in up to 16% of asymptomatic children who
have apparently received trivial head trauma. One in six children in this
category have neurosurgical intervention. According to the risk
stratification shown in McCanns letter none of these children would be put
forward for HCT.
Dr McCann incorrectly believes the BET recommends all children with
scalp haematoma have HCT. The paper specifies this to be the case only
for infants.
Lastly, the point that McCann makes about vomiting, (as well as
seizure and loss of consciousness) as a poor predictor of ICI is also
shown in another BET 4.
References
(1) Munro A, Maconochie I. Indication for head CT in children with
mild head injury. Best BET EMJ 2001;18(6): 469-70.
(2) Schutzman SA, Barnes P. et al. Evaluation and management of
children younger than two years old with apparently minor head trauma:
proposed guidelines. Pediatrics 2001;107(5): 983-93.
The Best Evidence Topic published in November 2001 on absence of
skull fracture failing to predict intra-cranial injury (ICI) as determined
by head CT (HCT)[1] has provoked criticism on the methods used to find a
clinical bottom line.
Dr Geggie states that he produced a BET on the topic that appears not
to contradict the findings of the published result, but that there is
perhaps an unaccept...
The Best Evidence Topic published in November 2001 on absence of
skull fracture failing to predict intra-cranial injury (ICI) as determined
by head CT (HCT)[1] has provoked criticism on the methods used to find a
clinical bottom line.
Dr Geggie states that he produced a BET on the topic that appears not
to contradict the findings of the published result, but that there is
perhaps an unacceptable variance in the method used.
He finds the inclusion of two of the papers used in the BET to be
questionable.
Indeed, as Geggie states, the paper by Wang et al.[2] does not use skull plain
radiography. Head CT was used to determine the presence or otherwise of
skull abnormality. Accordingly, it was felt that analysis of the
relationship between skull and intra-cranial injuries is strengthened by
the use of gold standard imaging.
The addition of the paper by Dietrich et al.[3] was also criticised due
to small numbers and indirectly drawn inferences. 233 children with
‘mild’ head injury and a GCS of 15 formed a significant group in this
paper, and although as a sub-group the relationship between skull
fracture and ICI was not stated, the overall predictive value of skull
fracture to ICI was shown to be poor. It was felt that the importance of
lack of clinical predictors of ICI shown by this group was the main reason
for inclusion.
Geggie correctly states that Teasdales[4] paper was not used in the
analysis and that it was prospective. This paper could well have been
included in the overall BET and appears in the related BET by the same
authors in the same publication looking at clinical indicators for Head CT
scanning in the setting of mild paediatric head injury.
While I agree that analysis of retrospective papers on this subject
would have done little to change the clinical bottom line there is a clear
methodology available to ensure the highest level of evidence is used to
draw any firm conclusion in evidence based practice.
This is shown on the web site at: http://www.bestbets.org/background/bestcats.html
is prescriptive and
requires the use papers of the highest quality methodology. Thus little
variance between BETs based around the same clinical scenario should
occur.
It is reassuring that Dr Geggie apparently has a similar clinical
bottom line despite evidently using a slightly different database.
References
(1) Munro A, Maconochie I. Does absence of skull fracture predict
absence of intra-cranial injury in children? Emerg Med J 2001;18:469-70.
(2) Wang MY, Griffith P et al. A prospective population-based study of
pediatric trauma patients with mild alterations in consciousness (Glasgow
coma scale score of 13014). Neurosurgery 2000;46:1093-9.
(3) Dietrich AM, Bowman MJ et al. Pediatric head injuries: can
clinical factors reliably predict an abnormality on computed tomography?
Ann Emerg Med 1993;22:1035-40.
(4) Teasdale GM, Murray G et al. Risks of acute traumatic intracranial
haematoma in children and adults: implications for managing head injuries.
BMJ 1990;300:363-7.
I would like to complement Wallace et al. for there production of a useful
and user friendly algorithm for the management of paracetamol poisoning.[1]
However, I would like to suggest that the addition of an acute psychiatric
evaluation in patients who present with intentional overdose would greatly
enhance the usefulness of the algorithm in the emergency department
environment. This evaluation sh...
I would like to complement Wallace et al. for there production of a useful
and user friendly algorithm for the management of paracetamol poisoning.[1]
However, I would like to suggest that the addition of an acute psychiatric
evaluation in patients who present with intentional overdose would greatly
enhance the usefulness of the algorithm in the emergency department
environment. This evaluation should be carried out either by the attending
emergency physician or a psychiatrist and will aid in planning patient
disposition from the emergency department. Such an evaluation should be
an essential part of management of all intentional acute poisoning.[2]
References
(1) CI Wallace, PI Dargan, AL Jones
Paracetamol overdose: an evidence based flowchart to guide management
Emerg Med J 2002; 19: 202-205.
(2) JM Bostwick, F Pochard, Robin M, et al. Treatment of Suicidal Patients N Engl J Med 1998;338:261-
262.
Dr Carley and colleagues have produced invaluable and highly
practical failed intubation guidelines for emergency physicians using RSI.
They highlight the emergency department cricothyrotomy rate in the United
States of 0.5-1.2%, and the lack of comparative United Kingdom rates,
which are thought to be lower.
As part of a prospective study of emergency airway management by
intensive care doctors...
Dr Carley and colleagues have produced invaluable and highly
practical failed intubation guidelines for emergency physicians using RSI.
They highlight the emergency department cricothyrotomy rate in the United
States of 0.5-1.2%, and the lack of comparative United Kingdom rates,
which are thought to be lower.
As part of a prospective study of emergency airway management by
intensive care doctors in a large UK district general hospital, we
examined 208 consecutive emergency rapid sequence intubations outside the
operating theatre, of which 76 were performed in the emergency department.
There were no cricothyrotomies, no failed intubations, and no deaths
during the procedure even though the intubating physicians were of varying
seniority, with career backgrounds in emergency medicine and general
medicine as well as anaesthesia. This suggests that, with proper training
and support, even junior doctors in A&E can undertake RSI with a low
risk of failure requiring an emergency surgical airway.
We agree that as long as such crucial training and senior support are
provided, UK emergency department patients will continue to experience
lower rates of cricothyrotomy and failed intubation than in the United
States. This will be necessary if RSI by non-anaesthetists is to become
widely accepted in the UK. The guidelines by Dr Carley et al are an
important contribution to this process.
Dr Cliff Reid
Registrar in Paediatric critical care
Childrens Hospital Westmead
New South Wales
Australia
Dr Louisa Chan
Registrar in emergency medicine
Gosford District Hospital
New South Wales
Australia
I look forward to taking a look at this book as I suspect it is much
needed! I would also agree that the ALS course is not tailored particularly
well to the pre-hospital environment.
The proposed "prehospital ALS" does already exist, however, in the form of
the Pre Hospital Emergency Care course run by the faculty of pre-hospital
care of the RCS Edinburgh (check...
I look forward to taking a look at this book as I suspect it is much
needed! I would also agree that the ALS course is not tailored particularly
well to the pre-hospital environment.
The proposed "prehospital ALS" does already exist, however, in the form of
the Pre Hospital Emergency Care course run by the faculty of pre-hospital
care of the RCS Edinburgh (check http://www.basics.org.uk for more information).
It's a little expensive but I've had good feedback from those (mostly
A&E middle-grades and immediate care GPs) who've done it.
In "best BETs" of november 2001, regarding indications for head CT in
children with mild head injury [1], Dr Munro makes no mention of the
labours of Schutzman et al who sought to address this issue in the younger
than 2 years age group. An expert panel drew evidence from 404 articles in
total and presented their findings as "guidelines for the evaluation and
management of children less than 2 with appa...
In "best BETs" of november 2001, regarding indications for head CT in
children with mild head injury [1], Dr Munro makes no mention of the
labours of Schutzman et al who sought to address this issue in the younger
than 2 years age group. An expert panel drew evidence from 404 articles in
total and presented their findings as "guidelines for the evaluation and
management of children less than 2 with apparently minor head trauma" in
the may 2001 edition of Pediatrics [2]. Of 5 key questions the panel
sought to address, the first was: "what are the indications for CT?"
Using the evidence the expert panel derived high, intermediate and
low risk groups for intracranial injury (ICI). Those at high risk are
deemed to require CT.
High risk features include:
1)deressed mental status (difficulty rousing / not maintaining an
awake state)
2)focal neurology
3)signs of depressed or basal skull fracture
4)acute skull fracture by examination or xray
5)irritability, and
6)bulging fontanelle.
The BET recommends that all children with a scalp haematoma should
have a CT. However frontal haematomas have been shown to have a low risk
for complications [3]. The presence of temperoparietal or large boggy
haematomas puts the chid in Schultzmans intermediate risk group of
observation for 6 hours or CT.
Interestingly, the guidelines also point out that seizure, vomiting
or loss of consciousness are not independent predictors for ICI.
References
(1) Munro A, Maconchie I. Indications for head ct in children with
mild head injury. BET:EMJ 2001;18(6):469-470.
(2) Schutzman S et al. Evaluation and management of children younger
than 2 years old with apparently minor head trauma: proposed guidelines.
Pediatrics 2001;107(5):983-993.
(3) Greenes D et al. Clinical significance of scalp abnormalities in
asymptomatic head injured infants. Ped Emerg Care 2001;17:88-92
The authors have done well to show that allocating staff resources to
a Fast Track stream can shorten waiting times without adversely affecting
higher-acuity care. However, the duration of the study may have been too
short to detect a secondary effect of worsening workload in the medium and
long term.
Emergency Departments (EDs) provide a highly attractive option for patients
in the community:...
The authors have done well to show that allocating staff resources to
a Fast Track stream can shorten waiting times without adversely affecting
higher-acuity care. However, the duration of the study may have been too
short to detect a secondary effect of worsening workload in the medium and
long term.
Emergency Departments (EDs) provide a highly attractive option for patients
in the community: 24-hour, 7-day availability of a facility staffed by
specialised nurses and (sometimes) doctors, with "one-stop" access to the
hospital's extensive diagnostic and treatment services. The queue in the
waiting room is one of the few major disincentives for all unwell patients
to attend EDs as a first option.
If the service improves significantly for patients with minor
injuries, this will become known in the community and may encourage more
patients to present to the ED.
Our ED (in a metropolitan general hospital in New Zealand) employed
an extra doctor to run a Fast Track service on weekends, to help manage
long waiting times for lower acuity patients. This was initially very
successful and especially popular with the beleagured ED nurses. However,
after several months the waiting times had returned to their baseline and
more patients with less-serious complaints seemed to be attending our
service.
Cooke et al mention that 5% of their attendances were suitable for
care by general practitioners (this is remarkably low; a typical estimate
for EDs would be closer to 50%) and they have "a system ... to refer such
patients to the out of hours centre": this strategy carries some risk and
is not practical for most EDs.
It is a paradox of open-ended urban ED care that the better our
service, the longer our queues may become. This point was made in the
study reported by Krakau I, Hassler E. "Provision for clinic patients in
the ED produces more nonemergency visits". Am J Emerg Med 1999; 17: 18-20.
In a metropolitan ED, the queues will always be with us.
Dear Sir,
The flowchart to guide management in paracetamol overdose, by Wallace, Dargan and Jones (EMJ Vol 19 No.3 p202) was presented at our weekly Journal Club and generated some thoughts and observations.
Along the "Single" overdose pathway for "Low risk" patients the guideline suggests that if the ingested dose of "< 150mg paracetamol per kg or UNKNOWN" the patient can be discharged. Presumab...
Dear Editor
We would like to congratulate Nolan and Clancy on their editorial addressing a controversial area.[1] We would like to comment on some of their points and add a few thoughts of our own.
Notwithstanding our experience that there is rarely a significant delay in attendance to the emergency department (ED) by anaesthetists/intensivists, we agree that there is likely to be an increase in emer...
Dear Editor
As an anaesthetist, I read with interest the article by Carley and colleagues regarding the necessity of having a drill for failed intubation in the Emergency Department. A drill is essential and should be actively taught and practised.
The algorithm you have developed is very similar to those used in anaesthetic practice, but I wish to highlight a few points. The use of the gum-elastic bougie...
Dear Editor
The Emergency Department management of minor head injury in children is an area of intense debate. It is encouraging that the BET (Best Evidence Topic) on indications for Computerised Tomography (HCT) in minor head injury in children published in November’s issue has stimulated further discussion.
In his letter of criticism, Dr McCann expresses concern over the omission of a review article on...
Dear Editor
The Best Evidence Topic published in November 2001 on absence of skull fracture failing to predict intra-cranial injury (ICI) as determined by head CT (HCT)[1] has provoked criticism on the methods used to find a clinical bottom line.
Dr Geggie states that he produced a BET on the topic that appears not to contradict the findings of the published result, but that there is perhaps an unaccept...
Dear Editor
I would like to complement Wallace et al. for there production of a useful and user friendly algorithm for the management of paracetamol poisoning.[1] However, I would like to suggest that the addition of an acute psychiatric evaluation in patients who present with intentional overdose would greatly enhance the usefulness of the algorithm in the emergency department environment. This evaluation sh...
Dear Editor
Dr Carley and colleagues have produced invaluable and highly practical failed intubation guidelines for emergency physicians using RSI. They highlight the emergency department cricothyrotomy rate in the United States of 0.5-1.2%, and the lack of comparative United Kingdom rates, which are thought to be lower.
As part of a prospective study of emergency airway management by intensive care doctors...
Dear Editor
I look forward to taking a look at this book as I suspect it is much needed! I would also agree that the ALS course is not tailored particularly well to the pre-hospital environment. The proposed "prehospital ALS" does already exist, however, in the form of the Pre Hospital Emergency Care course run by the faculty of pre-hospital care of the RCS Edinburgh (check...
Dear Editor
In "best BETs" of november 2001, regarding indications for head CT in children with mild head injury [1], Dr Munro makes no mention of the labours of Schutzman et al who sought to address this issue in the younger than 2 years age group. An expert panel drew evidence from 404 articles in total and presented their findings as "guidelines for the evaluation and management of children less than 2 with appa...
Dear Editor
The authors have done well to show that allocating staff resources to a Fast Track stream can shorten waiting times without adversely affecting higher-acuity care. However, the duration of the study may have been too short to detect a secondary effect of worsening workload in the medium and long term.
Emergency Departments (EDs) provide a highly attractive option for patients in the community:...
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