The authors state that current evidence supports the use of a
negative D-dimer to rule out a suspicion of pulmonary embolism (PE) in
pregnancy. They show in Table 2 5 relevant studies to support their
conclusion. However, the study of Damodaram was the only study that
included patients with a clinical suspicion of venous thromboembolism,
thus including pulmonary embolism. All other 4 studies included either
healthy preg...
The authors state that current evidence supports the use of a
negative D-dimer to rule out a suspicion of pulmonary embolism (PE) in
pregnancy. They show in Table 2 5 relevant studies to support their
conclusion. However, the study of Damodaram was the only study that
included patients with a clinical suspicion of venous thromboembolism,
thus including pulmonary embolism. All other 4 studies included either
healthy pregnant patients or patients with a clinical suspicion of deep
vein thrombosis (DVT). Evidence found in healthy patients cannot be
extrapolated to pregnant symptomatic patients. Performance of the D-dimer
test should be tested in pregnant patients with a clinical suspicion of PE
before any recommendation can be made. Since PE is still one of the
leading causes of maternal death, ruling out this diagnosis accurately is
imperative.
Furthermore, in non-pregnant patients, use of D-dimer test as a stand
-alone test is not supported. The authors state that the Wells score can
be a useful tool in calculating pretest probability, as its categories
remain relevant. However, this statement is not supported by evidence. The
title of this BET may be interpreted as if a D-dimer test can be used as a
stand-alone test. In non-pregnant patients with a high suspicion of PE
(Wells score >4 points), the presence of PE is found to be 10%, despite
a negative D-dimer (Wells, Thromb Haemost 2000). Therefore, the most
important conclusion should be that there's a lack of good-quality
evidence concerning the management of a clinical suspicion of PE in
pregnancy.
A number of comments have been made to me regarding this article
since it was published. I would like to take this opportunity to clarify
that the experiences described did not occur whilst working at North Tees
University Hospital. This is where I currently work as a higher trainee in
Emergency Medicine. I am keen that the contents of the correspondence
address do not overshadow the key message of the article.
A number of comments have been made to me regarding this article
since it was published. I would like to take this opportunity to clarify
that the experiences described did not occur whilst working at North Tees
University Hospital. This is where I currently work as a higher trainee in
Emergency Medicine. I am keen that the contents of the correspondence
address do not overshadow the key message of the article.
As highlighted by Chou et al[1] it is becoming more evident that
extracorporeal membrane oxygenation (ECMO) during cardiopulmonary
resuscitation (CPR) is feasible and compares well against conventional
CPR. As technologies such as ECMO[2] and echocardiography (Echo),[3]
previously limited to intensive care units and cardiology suites, become
increasingly available in the Emergency Department (ED), it is important
that w...
As highlighted by Chou et al[1] it is becoming more evident that
extracorporeal membrane oxygenation (ECMO) during cardiopulmonary
resuscitation (CPR) is feasible and compares well against conventional
CPR. As technologies such as ECMO[2] and echocardiography (Echo),[3]
previously limited to intensive care units and cardiology suites, become
increasingly available in the Emergency Department (ED), it is important
that we fully utilize the information and support they can provide to
carefully select cardiac arrest patients for advanced ED resuscitation.
The percentage of patients who leave hospital alive following CPR
varies from 0% to 20% and has not significantly improved in the last 30
years.[4] The recently published CHEER trial (mechanical CPR, Hypothermia,
ECMO and Early Reperfusion), a single center, prospective, observational
study from Australia, assessed the CHEER protocol, developed for selected
patients with refractory in-hospital and out-of-hospital cardiac
arrest.[5] The protocol involved mechanical CPR, induction of intra-arrest
therapeutic hypothermia, early commencement of veno-arterial ECMO, and
early coronary angiography for patients with suspected coronary artery
occlusion. ECMO was established in 24 (92%) of 26 eligible patients, with
a median time from collapse until initiation of ECMO of 56 min. Return of
spontaneous circulation was achieved in 25 (96%) patients. Survival to
hospital discharge with full neurological recovery occurred in 14/26 (54%)
patients. Another study from the United States recently reported similar
survival rates; 13 of 24 (54%) patients survived to hospital discharge
with an ECMO based CPR protocol. Seven of these patients were discharged
without any neurological deficit.[6] While these early results show
promise for this form of advanced ED resuscitation, caution is required
before rolling out this technology for all cardiac arrest patients.
Can our health care systems afford the increased requirement of
intensive care bed-hours that such a policy would lead to? Can we select
which patients are most likely to benefit from ED-ECMO?
A meta-analysis of predictors of survival from out-of-hospital
cardiac arrest in 2010 found that survival to hospital discharge was more
likely among those witnessed by a bystander or emergency medical services
(EMS), those who received bystander CPR, were found in a shockable rhythm
(VF/VT), or achieved return of spontaneous circulation (ROSC).[4] A
further meta-analysis in 2012 looked at the of detection of cardiac
activity on echo to predict survival during cardiac arrest. Pooled data
showed that as a predictor of ROSC during cardiac arrest, echo had a
pooled sensitivity of 91.6%, and specificity was 80.0%;[7] promising, but
not independently predictive of survival.
Protocols including ED-ECMO are feasible and may be associated with a
relatively high survival rate. The introduction of such protocols to
emergency medicine should be encouraged, but must involve careful patient
selection, optimizing survival benefit. This may involve bedside echo in
the ED, as well as other demographic and clinically derived predictors of
survival.
1. Chou T.-H. An observational study of extracorporeal CPR for in-
hospital cardiac arrest secondary to myocardial infarction. Emerg Med J
2014;31: 441-7.
2. Shinar Z, Bellezzo J, Paradis N, et al. Emergency department
initiation of cardiopulmonary bypass: a case report and review of the
literature. J Emerg Med. 2012;43(1):83-6.
3. Hayhurst C, Lebus C, Atkinson PR, et al. An evaluation of echo in
life support (ELS): is it feasible? What does it add? Emerg Med J. 2011
Feb;28(2):119-21.
4. Stub D, Bernard S, Pellegrino V, et al. Refractory cardiac arrest
treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the
CHEER trial). Resuscitation 2014. DOI:
http://dx.doi.org/10.1016/j.resuscitation.2014.09.010.
5. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival
from out-of-hospital cardiac arrest: a systematic review and meta-
analysis. ?Circ Cardiovasc Qual Outcomes 2010;3:63-81.
6. Peigh G, Pitcher H, Cavarocchi N, Hirose H. Saving Life And Brain
With Extracorporeal Cardiopulmonary Resuscitation (E-Cpr) Chest.
2014;146(4_MeetingAbstracts):722A. doi:10.1378/chest.1990723.
7. Blyth L, Atkinson P, Gadd K, Lang E. Bedside Focused
Echocardiography as Predictor of Survival in Cardiac Arrest Patients: A
Systematic Review. Acad Emerg Med 2012;19: 1119-1126.
Kaye and Govier's case series of propofol sedation for DC cardioversion 1 provides a useful contribution to the relatively evidence-light area of Emergency Department (ED) sedation. I would, however, urge caution in their conclusion that propofol is a "safe" drug for the uses they describe.
Safety is obviously relative but, in the grand scheme of things, their series of 111 patients is small. The statistical "...
Kaye and Govier's case series of propofol sedation for DC cardioversion 1 provides a useful contribution to the relatively evidence-light area of Emergency Department (ED) sedation. I would, however, urge caution in their conclusion that propofol is a "safe" drug for the uses they describe.
Safety is obviously relative but, in the grand scheme of things, their series of 111 patients is small. The statistical "rule of three"2 suggests that, in a series with a zero incidence of a particular complication, the upper limit of the 95% confidence interval for the rate of that complication is approximately equal to one in n/3. Therefore, in the population they sampled, the rate of sentinel complications could as high as 1:37.
Although their paper adds useful further evidence of the utility of propofol for ED sedation, I would venture that few clinicians would consider a potential rate of CPR or death of 2.7% indicative of a "safe" sedation technique. Larger studies are needed, although I would agree wholeheartedly with their assertion that midazolam is far from the gold standard drug for these patients.
REFERENCES 1. Kaye P, Govier M. Procedural sedation with propofol for emergency DC cardioversion. Emerg. Med. J. 2014 31:904-908; doi:10.1136/emermed-2013-202742 2. Hanley JA, Lippman-Hand A. If nothing goes wrong, is everything alright?. JAMA 1983; 249 (13): 1743-5. doi:10.1001/jama.1983.03330370053031
I agree with the authors that using the guidelines may not avoid
subdiaphragmatic viceral injuries. First, many underlying diseases could
alter the thorax shape and the diaphragm position. Second, in patients
using positive mechanical ventilation support, many different ventilatory
strategies, such as lung recruitment strategy, can alter the diaphragm
level.
Moreover, among some special groups of patients, such as patie...
I agree with the authors that using the guidelines may not avoid
subdiaphragmatic viceral injuries. First, many underlying diseases could
alter the thorax shape and the diaphragm position. Second, in patients
using positive mechanical ventilation support, many different ventilatory
strategies, such as lung recruitment strategy, can alter the diaphragm
level.
Moreover, among some special groups of patients, such as patients with
severe chest wall burn injury, the surface markers are not easily
identified.
Therefore, I use thoracic ultrasound before placing a chest tube, even
without a chest x ray film. Common diseases requiring a chest drainage,
including pneumothorax, hemothorax, empyema, and massive pleural effusion,
can be diagnosed by thoracic ultrasound. A quick look via thoracic
ultrasound can also prevent medical error, including placing a drain in
the wrong side or even in a different patient.
I was interested to read the paper by Castle & Naguran describing
use of the intubating laryngeal mask airway (iLMA) in an entrapped patient
[1]. The authors might be interested to know that I have also used the
iLMA in the treatment of trapped trauma patients [2][3], and their case
bears striking similarities to the ones that I encountered. Their report
provides further evidence of the efficacy of the iLMA in trapped...
I was interested to read the paper by Castle & Naguran describing
use of the intubating laryngeal mask airway (iLMA) in an entrapped patient
[1]. The authors might be interested to know that I have also used the
iLMA in the treatment of trapped trauma patients [2][3], and their case
bears striking similarities to the ones that I encountered. Their report
provides further evidence of the efficacy of the iLMA in trapped trauma
situations, both as a primary airway rescue device and as a bridge to
tracheal intubation. Their report was encouraging, but I felt that there
were a number of important questions left unanswered, and I would like to
draw attention to these and offer some observations of my own.
The first important issue concerns the use of drugs. The authors
failed to say if an anaesthetic or sedative agent was used to assist with
insertion of the iLMA, and whether or not a neuro-muscular blocking agent
(NMBA) was used to facilitate intubation via the device. In my own small
case series involving five hypoxaemic trapped trauma patients, four of the
patients who went on to survive to discharge from hospital required the
administration of a dose of midazolam to facilitate insertion of the iLMA,
and the single patient who accepted the iLMA without the need for
medication was the only non-survivor. Although it has been shown that
there is no statistical difference in the success rates for intubation via
the iLMA between chemically paralysed and non-paralysed patients [4], the
incidence of reflex coughing is likely to be higher in non-paralysed
individuals, and the possible implications of coughing in the presence of
brain injury and raised intracranial pressure clearly need to be borne in
mind. Consequently, I would be interested to know if any drugs were used.
Secondly, although the SpO2 and EtCO2 readings suggested that there
was a significant improvement in the casualty's condition after insertion
of the device, we were not told if the patient went on to survive to
discharge from hospital - an important test of the efficacy and safety of
any prehospital intervention.
Finally, the authors omitted to mention the size and type of ET tube
that they used, and it would be interesting to know if the iLMA's
dedicated atraumatic wire-reinforced tube was employed, or simply a
standard ETT rotated through 180-degrees, as some authors have recommended
[5].
I agree with the authors that it is probably wise to leave the iLMA
in situ during transportation to hospital, even when tracheal intubation
via the iLMA has been undertaken in the prehospital phase, since
manipulation to remove the device from around the tracheal tube could
cause the tube to become accidentally dislodged. It should be noted,
however, that when the iLMA is left in situ after intubation, the
manufacturer recommends reducing the volume of air in the cuff of the iLMA
by 50%. This reduces pressure on the hypopharyngeal mucosa with the aim of
preventing possible ischaemic damage to tissues.
Castle & Naguran report that the first attempt to intubate via
the iLMA was unsuccessful, with resistance felt at the point where the ETT
should have entered the larynx, but that a second attempt at intubation
was successful after the iLMA was repositioned and forward traction
applied. Early studies suggested that a learning curve of approximately
twenty cases existed for proficiency in tracheal intubation via the iLMA
[6]. However, subsequent refinements to the recommended insertion
technique have managed to improve first-time intubation success rates
significantly [7].
The recommended technique for intubation via the iLMA is sometimes
called the 'Chandy' manoeuvre, named after the UK anaesthetist, Dr Chandy
Verghese. The first part of the Chandy manoeuvre involves grasping the
iLMA by its handle and moving it back-and-forth in the sagittal plane
while noting the rise-and-fall of the chest (tidal volume) together with
the resistance to manual ventilation. This optimises ventilation through
the device which occurs when the distal airway aperture in bowl of the
mask is directly opposite the laryngeal inlet. The second part of the
manoeuvre involves lifting the handle of the iLMA at 45% to the horizontal
plane of the patient's chest. This helps to align the angled ramp at the
distal end of the airway aperture with the longitudinal axis of the upper
trachea, so facilitating direct and unhindered passage of the tip of the
tube into the upper trachea. Use of the Chandy manoeuvre can be expected
to improve first-time intubation rates with the iLMA to levels approaching
100%.
Castle and Maguran's case report shows the potential value of the
iLMA as a device for rapid control of the airway in the prehospital
setting, particularly when there is restricted access to a trapped
casualty. They also show the value of the device as a bridge to blind
intubation of the trachea.
I believe that the iLMA is a much underrated and underused
supraglottic airway device which is particularly suitable in a trapped
trauma situation where there is limited access to the casualty. Its
benefits include:
1. Insertion and ventilation can be achieved easily by persons with
minimal training [8][9][10][11][12]
2. Functions as an initial rescue airway device in its own right
3. Laryngoscopy unnecessary
4. Neutral alignment of head & neck is a pre-requisite for
insertion, rendering manipulation of a potentially injured cervical spine
unnecessary
5. Insertion requires an interdental gap of only 20mm
6. Neuromuscular blockade not essential for insertion of the iLMA or
subsequent intubation via the device
7. Can be introduced blindly with one hand from any position
8. No need to insert a finger into patient's mouth
9. Rigid airway tube resists occlusion by biting
10. When the cuff is inflated, this provides protection of the airway
from bleeding arising above
11. Facilitates seamless progression to tracheal intubation
12. Permits ventilation between and even during intubation attempts
13. Available as a disposable single-use device.
With regard to the iLMA as a suitable rescue ventilation device for
prehospital trauma care, one is tempted to ask, 'What is there not to
like?'
[1] Castle N, Naguran S. Reflection: on the use of the ILMA in an
entrapped patient. Emerg Med J 2014; 31(12): 1014-1015
[2] Mason AM. Use of the intubating laryngeal mask airway in pre-
hospital care: a case report. Resuscitation 2001 Oct; 51(1): 91-5
[3] Mason AM. Prehospital use of the intubating laryngeal mask airway
in patients with severe polytrauma: a case series. Case Rep Med 2009;
2009:938531. doi: 10.1155/2009/938531. Available for free download at:
http://www.hindawi.com/journals/crim/2009/938531/
[4] Ambulkar R, Tan AYH, Chia NCH, Low TC. Comparison between use of
neuromuscular blocking
agent and placebo with the intubating laryngeal mask airway. Singapore Med
J. 2008; 49(6): 462-465
[5] Shah VR, Bhosale GP, Mehta T, Parikh GP. A comparison of
conventional endotracheal tube with silicone wire-reinforced tracheal tube
for intubation through intubating laryngeal mask airway. Saudi J Anaesth
2014; doi:10.4103/1658-354X.130702
[6] Baskett PJF, Parr MJA, Nolan JP, et al. The intubating laryngeal
mask. Results of a multicentre trial with experience of 500 cases.
Anaesthesia 1998; 53(12): 1174-1179
[7] Ferson DZ, Rosenblatt WH, Johansen MJ, Osborn I, Ovassapian A.
Use of the intubating LMA-Fastrach in 254 patients with difficult-to-
manage airways. Anesthesiology 2001; 95(5): 1175-1181
[8] Levitan RM, Ochroch EA, Stuart S, Hollander JE. Use of the
intubating laryngeal mask airway by medical and nonmedical personnel. Am J
Emerg Med 2000; 18(1): 12-16
[9] Reeves MD, Skinner MW, Ginifer CJ. Evaluation of the intubating
laryngeal mask airway used by occasional intubators in simulated trauma.
Anaesth Intens Care 2004; 32(1): 73-76
[10] Menzies R, Manj H. The intubating laryngeal mask: is there a
role for paramedics. Emerg Med J 2007; 24(3): 198-199
[11] Timmermann A, Russo SG, Crozier TA, et al. Laryngoscopic versus
intubating LMA guided tracheal intubation by novice users - a manikin
study. Resuscitation 2007; 73(3): 412-416
[12] McCall MJ, Reeves M, Skinner M, Ginifer C, Myles P, Dalwood N.
Paramedic tracheal intubation using the intubating laryngeal mask airway.
Prehosp Emerg Care 2008; 12(1): 30-34.
Conflict of Interest:
AMM is a former adviser in prehospital care to both Intavent Direct and the Laryngeal Mask Company, former distributors of the iLMA. Opinions expressed are purely those of AMM who has no connection with the current distributor(s) and no financial interest in sales of the iLMA.
We read with interest the article by Rashid et al (1) documenting current UK practice with regards to hip fractures (HF) and regional analgesia (RA); only 44% of their respondents reported local use of RA for this indication. The two main reasons highlighted were lack of equipment availability and lack of staff training; they therefore suggest that an appropriate protocol, a "Hip Block Box", audit and staff training may i...
We read with interest the article by Rashid et al (1) documenting current UK practice with regards to hip fractures (HF) and regional analgesia (RA); only 44% of their respondents reported local use of RA for this indication. The two main reasons highlighted were lack of equipment availability and lack of staff training; they therefore suggest that an appropriate protocol, a "Hip Block Box", audit and staff training may improve RA utilisation. They also highlight the utility of the Fascia Iliaca Compartment Block (FICB) in an emergency department setting.
Our local guidance advises the use of the FICB in all patients with HF unless contraindicated. An audit of 100 consecutive hip fracture presentations in 2012 demonstrated disappointing performance with only 40% managed appropriately. Following a local survey of clinicians, the main reasons cited for limited utilisation of the FICB were:
1) Lack of familiarity with the technique
2) Lack of awareness of the protocol
3) Difficulty locating equipment
These findings mirror those of Rashid et al (1).
In order to address this we undertook an education programme with middle grade doctors in the department; they were then encouraged to disseminate their knowledge to the junior team. The survey identified that consultant awareness of, and familiarity with, the procedure was already adequate. A simplified dosing regime was developed in consultation with the anaesthetic team; this facilitated the introduction of a simplified protocol. We also introduced "Block Boxes" to relevant clinical areas containing all the equipment necessary to perform the block.
The audit cycle was completed approximately a year later and demonstrated appropriate management in 76% of patients. This represents an absolute improvement of 36% and a relative improvement of 90%.
Our local findings demonstrate the efficacy of simple changes in generating significant improvements in the management of this cohort of patients. The changes implemented mirror those advocated by Rashid et al and we lend our support both to their utility and to the ease with which they can be introduced.
References
1. Rashid A, Beswick E, Galitzine S, Fitton L. Regional analgesia in the emergency department for hip fractures: survey of current UK practice and its impact on services in a teaching hospital. Emerg Med J 2014;31(11):909-13; doi:10.1136/emermed-2013-202794
Skrobo and Kelleher rightly stress the importance of accurate, rapid
weight estimation in children when the situation precludes actual
measurement of their weight.[1] They also rightly emphasise the need for
estimation tools to be validated locally.
The CORKSCREW study convincingly demonstrates that the mean bias of
weight estimates using the Luscombe formula (3xage+7) is much smaller than
that...
Skrobo and Kelleher rightly stress the importance of accurate, rapid
weight estimation in children when the situation precludes actual
measurement of their weight.[1] They also rightly emphasise the need for
estimation tools to be validated locally.
The CORKSCREW study convincingly demonstrates that the mean bias of
weight estimates using the Luscombe formula (3xage+7) is much smaller than
that for the old APLS formula (2xage+8). Interestingly, this was true for
1-5 year olds too, which suggests that it might be better to use the
Luscombe formula in all children, rather than just in 6-12 year olds as
recommended in the latest APLS manual.
However, the authors have not provided any results for the precision
of these methods, although they suggest that estimates should be within
15% of actual weight. The ISO standard for accuracy of measurement methods
defines both trueness and precision.[2] Trueness is the closeness of
agreement between the arithmetic mean of a large number of test results
and the true or accepted reference value. This is what the CORKSCREW study
has presented. Precision refers to the closeness of agreement between test
results. It is quite easy for a method to have very good trueness (for
example, using the median weight for a given age, as found on standard age
-weight curves), but have such an imprecision that it is clinically
useless. One commonly used method to describe trueness and precision is
described by Bland Altman.[3] The bias reflects trueness, and the limits
of agreement (LOA) reflect precision. For a given weight estimate, LOA
indicate the range of actual weights within which 95% of subjects will
fall.
Of the published methods of paediatric weight estimation, age-based
methods have the worst precision, deteriorating with increasing age.[4] We
would be particularly wary of using age-based weight estimation in
teenagers, as the range of weights for a given age is far too broad to
allow meaningful estimates in individuals. In comparison, the Broselow
tape is a very precise method in children, but not useful in over 10s.[5]
Newer methods of estimation based on mid-arm circumference (MAC) appear to
be at least as precise as the Broselow tape in older children and
adolescents.[6,7]
Of course, tape-based methods require the presence of the child, and
age-based methods might still have a role to play during preparation for a
child's arrival in the resuscitation room. A MAC tape could be readily
available pre-hospital as well as in the emergency department, and useful
when the condition of the patient precludes objective measurement of their
weight.
Sincerely,
Giles N Cattermole
Colin A Graham
Timothy H Rainer
References:
[1] Skrobo D, Kelleher G. CORKSCREW 2013 CORK study of children's
realistic estimation of weight. Emerg Med J 2015;32:32-5
[2] ISO 5725-1:1994. https://www.iso.org/obp/ui/#iso:std:iso:5725:-1:ed-
1:v1:en
[3] Bland JM, Altman DG. Statistical methods for assessing agreement
between two methods of clinical measurement. Lancet. 1986 Feb
8;1(8476):307-10.
[4] Cattermole GN, Leung MPY, So HK, Mak PSK, Graham CA, Rainer TH. Age-
based formulae to estimate children's weight in the emergency department.
Emerg Med J 2011;28:390-6.
[5] Cattermole GN, Leung PYM,Graham CA, Rainer TH. Too tall for the tape:
the weight of schoolchildren who do not fit the Broselow tape. Emerg Med J
2014;31:541-544.
[6] Cattermole GN, Leung PYM, Mak PSK, Graham CA, Rainer TH. Mid-arm
circumference can be used to estimate children's weights. Resuscitation
2010;81:1105-10.
[7] Abdel-Rahman SM, Ridge AL. An improved pediatric weight estimation
strategy. Open Med Devices J 2012;4:87-97.
An alternative to the use of a bite guard in conjunction with the LMA
would be to employ the intubating laryngeal mask airway (iLMA), since the
single-use version of the iLMA has a rigid plastic airway tube which
resists occlusion by biting, as does the silicone-coated stainless steel
tube with the reusable version. Additional benefits would be that the iLMA
can facilitate seamless progression to blind tracheal intubation...
An alternative to the use of a bite guard in conjunction with the LMA
would be to employ the intubating laryngeal mask airway (iLMA), since the
single-use version of the iLMA has a rigid plastic airway tube which
resists occlusion by biting, as does the silicone-coated stainless steel
tube with the reusable version. Additional benefits would be that the iLMA
can facilitate seamless progression to blind tracheal intubation without
any interruption in oxygenation or ventilation, and the fact that there is
no separate bite guard to become dislodged and obstruct the patient's
airway.
Your article on ED patients' suffering came to me only this week
through Medscape.com. I would like to thank you for your analysis and for
bringing this topic to the surface.
I have been waiting thirty years for this concept to be treated in
the scientific literature. When I started practice in 1983 in a busy urban
academic Emergency Department in Baltimore, Maryland, and for the next
twenty-five years, THIS was...
Your article on ED patients' suffering came to me only this week
through Medscape.com. I would like to thank you for your analysis and for
bringing this topic to the surface.
I have been waiting thirty years for this concept to be treated in
the scientific literature. When I started practice in 1983 in a busy urban
academic Emergency Department in Baltimore, Maryland, and for the next
twenty-five years, THIS was the main driver of my practice style. It was
very rewarding and I am thrilled to see it championed so.
The authors state that current evidence supports the use of a negative D-dimer to rule out a suspicion of pulmonary embolism (PE) in pregnancy. They show in Table 2 5 relevant studies to support their conclusion. However, the study of Damodaram was the only study that included patients with a clinical suspicion of venous thromboembolism, thus including pulmonary embolism. All other 4 studies included either healthy preg...
A number of comments have been made to me regarding this article since it was published. I would like to take this opportunity to clarify that the experiences described did not occur whilst working at North Tees University Hospital. This is where I currently work as a higher trainee in Emergency Medicine. I am keen that the contents of the correspondence address do not overshadow the key message of the article.
C...
As highlighted by Chou et al[1] it is becoming more evident that extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (CPR) is feasible and compares well against conventional CPR. As technologies such as ECMO[2] and echocardiography (Echo),[3] previously limited to intensive care units and cardiology suites, become increasingly available in the Emergency Department (ED), it is important that w...
Safety is obviously relative but, in the grand scheme of things, their series of 111 patients is small. The statistical "...
I agree with the authors that using the guidelines may not avoid subdiaphragmatic viceral injuries. First, many underlying diseases could alter the thorax shape and the diaphragm position. Second, in patients using positive mechanical ventilation support, many different ventilatory strategies, such as lung recruitment strategy, can alter the diaphragm level. Moreover, among some special groups of patients, such as patie...
I was interested to read the paper by Castle & Naguran describing use of the intubating laryngeal mask airway (iLMA) in an entrapped patient [1]. The authors might be interested to know that I have also used the iLMA in the treatment of trapped trauma patients [2][3], and their case bears striking similarities to the ones that I encountered. Their report provides further evidence of the efficacy of the iLMA in trapped...
Editor,
Skrobo and Kelleher rightly stress the importance of accurate, rapid weight estimation in children when the situation precludes actual measurement of their weight.[1] They also rightly emphasise the need for estimation tools to be validated locally.
The CORKSCREW study convincingly demonstrates that the mean bias of weight estimates using the Luscombe formula (3xage+7) is much smaller than that...
An alternative to the use of a bite guard in conjunction with the LMA would be to employ the intubating laryngeal mask airway (iLMA), since the single-use version of the iLMA has a rigid plastic airway tube which resists occlusion by biting, as does the silicone-coated stainless steel tube with the reusable version. Additional benefits would be that the iLMA can facilitate seamless progression to blind tracheal intubation...
Your article on ED patients' suffering came to me only this week through Medscape.com. I would like to thank you for your analysis and for bringing this topic to the surface.
I have been waiting thirty years for this concept to be treated in the scientific literature. When I started practice in 1983 in a busy urban academic Emergency Department in Baltimore, Maryland, and for the next twenty-five years, THIS was...
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