Brown et al's [1] study provoked lively debate amongst the staff at Ipswich Hospital.
I would like to pose two questions:
1) What was the interval between sting challenge and onset of
symptoms? Was this related to severity of reaction?
2) What were the details of ethical approval, and what was the consent process and documentation?
I wonder if such a study would receive ethical approval in the UK. Were any estimations of risk given to participants before their recruitment?
This study reinforces the need for early and aggressive treatment of
anaphylaxis with adrenaline and large-volume fluid resuscitation. For
this, the bravery of both investigators and participants is to be applauded.
Reference
1. S G A Brown, K E Blackman, V Stenlake, and R J Heddle
Insect sting anaphylaxis; prospective evaluation of treatment with intravenous adrenaline and volume resuscitation
Emerg Med J 2004; 21: 149-154.
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.
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 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.
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.
We do not want to detract from the overall value of the recent article by Wardrope and MacKenzie,[1] but we feel it important to point out our concerns over the proposed assessment of cognitive function.
Cognitive impairment due to dementia and delirium is common in emergency situations but formal assessment of cognitive function is rare. This could explain why at least 67% of older people wi...
We do not want to detract from the overall value of the recent article by Wardrope and MacKenzie,[1] but we feel it important to point out our concerns over the proposed assessment of cognitive function.
Cognitive impairment due to dementia and delirium is common in emergency situations but formal assessment of cognitive function is rare. This could explain why at least 67% of older people with delirium do not have their delirium detected by A&E staff, leading to poor outcomes.[2] Routine use of even basic screening instruments such as the AMTS [3] would help detection, but such routine use is rare.
We agree that it is useful to be able to compare the AMTS in an acute event with previously measured values, but for this comparison to be valid it is crucial that the same questions are used. It is therefore unfortunate that the version of the AMTS presented differs from the original one, and that the quoted cut-off score is incorrect.[3] It has previously been demonstrated that doctors are inconsistent when trying to assess cognition using the AMTS4, and we believe that use of the correct questions and scoring in Table 1 will help matters.
Table 1
Please follow scoring instructions.
A correct answer scores 1 mark. No half-marks are given. A score of 6 or below is abnormal
Question
Assessment
Rating
1 How old are
you?
Score for exact age
only
2 What is your
date of birth?
Only date and month
needed
3 What is the
year now?
Score for exact year
only
4 What is the
time of day?
Score if within 1hr
of correct time
5 Where are we?
What is this building?
Score for exact
place name e.g. “hospital” insufficient
Now ask subject to
remember an address: 42, West Street
6 Who is the
current monarch?
Score only current
monarch
7 What was the
date of the 1st World War?
Score for year
of start or finish
8 Can you count
down backwards from 20 to 1?
Score if no mistakes
or any mistakes corrected spontaneously
9 Can you tell me
what those 2 people do for a living?
Score if
recognises role of 2 people correctly e.g. Dr, nurse
10 Can you
remember the address I gave you?
Score for exact
recall only
TOTAL
/10
References
1. Wardrope J,.Mackenzie R. The system of assessment and care of the primary survey positive patient. Emergency Medicine Journal 2004;21:216-25.
2. Sanders AB. Missed delirium in older emergency department patients: a quality-of-care problem. Ann.Emerg.Med. 2002;39:338-41.
3. Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1972;1:233-8.
4. Holmes J,.Gilbody S. Differences in use of abbreviated mental test score by geriatricians and psychiatrists. BMJ 1996;313:465.
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)
Dr Fatovich asks about initial reaction severity in three participants
who were prescribed steroids and antihistamines for large local reactions
or persistent urticaria.[1]
Two initially had severe (hypotensive) reactions
whereas the other had no systemic reaction. Although frequently used, it
is difficult to determine the benefit of steroids and antihistamines to
manage large local reactions an...
Dr Fatovich asks about initial reaction severity in three participants
who were prescribed steroids and antihistamines for large local reactions
or persistent urticaria.[1]
Two initially had severe (hypotensive) reactions
whereas the other had no systemic reaction. Although frequently used, it
is difficult to determine the benefit of steroids and antihistamines to
manage large local reactions and allergic urticaria. One of us has
recently outlined why these agents are probably of little use in severe
allergic reactions.[2] We agree that they are over-emphasised in many
texts despite the absence of convincing evidence for therapeutic efficacy.
Our decision to give adrenaline by intravenous infusion was based on
an ethical requirement to provide optimal resuscitation. This approach
prevented both the inadequate response to treatment that might result from
delayed absorption after IM administration, and the adverse reactions seen
with IV boluses.
Heywood’s first question[3] is better answered by another (larger) sting
challenge study that found a clear inverse relationship between the
challenge-to-reaction interval and subsequent reaction severity.[4] We
found no such relationship, but because of our small sample size this
analysis was underpowered. Practically such knowledge is of limited use,
as demonstrated by case 3 where symptoms did not occur until 20 minutes
after the sting, compared to the overall median of 8 minutes.
Our consent process and ethical considerations, reviewed by two
respected university hospital ethics committees, have already been
outlined both in the EMJ and Lancet.[5] In accordance with good ethical
practice the risks of participation (including the small risk of death)
were clearly outlined both verbally and in writing.
To understand the ethical justification for this trial it must be
appreciated that:
1) Patients may die if they erroneously believe treatment to be
effective.[6] Thus, it is unethical to conduct a poorly designed trial.
2) Efficacy can only be proven if a control group demonstrates that
severe reactions can be precipitated by the challenge procedure. The
alternative –waiting for an accidental sting away from medical care– is
not ethical.
3) Large studies have demonstrated the safety of sting challenge
using strict exclusion criteria,[4,7] even if adrenaline is withheld
during hypotensive reactions.[8] We gave adrenaline immediately when
objective features of respiratory or cardiovascular compromise were
identified. This approach is consistent with published consensus
indications for the use of adrenaline.[9,10]
4) The small short-term risk from the trial needs to be balanced
against the far greater reduction in long-term risk from providing an
effective immunotherapy.
5) There can be little doubt as to the informed nature of the consent
process if it is remembered that participants had previously experienced
reactions in the field, away from emergency medical care.
We hope that ethics committees in the UK would not deny people the
opportunity to participate in the rigorous assessment of a treatment that
could provide them with dramatic quality of life benefits, [11] as well as
protection from potentially lethal reactions in the setting of a community
where one in every eight people receives an accidental sting every year.[12]
There can be little doubt as to the commitment and altruism of trial
participants, many of whom considered this to be important research that
would benefit others. However, implications that the trial was ill
considered, reckless, or unethical do not stand up to careful scrutiny.
References
1. Fatovich DM. Limited use of corticosteroids for insect sting anaphylaxis [electronic response to Brown et al. Insect sting anaphylaxis; prospective evaluation of treatment with intravenous adrenaline and volume resuscitation] emjonline.com 2004http://emj.bmjjournals.com/cgi/eletters/21/2/149#230
2. Brown SGA. Parallel infusion of hydrocortisone with/without
chlorpheniramine bolus injection to prevent acute adverse reactions to
antivenom for snakebites. Med J Aust 2004;180(8):428-9.
3. Heywood M. Questions raised by this study [electronic response to Brown et al. Insect sting anaphylaxis; prospective evaluation of treatment with intravenous adrenaline and volume resuscitation] emjonline.com 2004http://emj.bmjjournals.com/cgi/eletters/21/2/149#238
4. van der Linden PW, Hack CE, Struyvenberg A, van der Zwan JK.
Insect-sting challenge in 324 subjects with a previous anaphylactic
reaction: current criteria for insect-venom hypersensitivity do not
predict the occurrence and the severity of anaphylaxis. J Allergy Clin
Immunol 1994;94(2 Pt 1):151-9.
5. Brown SGA, Wiese MD, Blackman KE, Heddle RJ. Ant venom
immunotherapy: a double-blind, placebo-controlled, crossover trial. Lancet
2003;361(9362):1001-6.
6. Brown SGA, Wu QX, Kelsall GR, Heddle RJ, Baldo BA. Fatal
anaphylaxis following jack jumper ant sting in southern Tasmania. Med J
Aust 2001;175(11-12):644-7.
7. Blaauw PJ, Smithuis OL, Elbers AR. The value of an in-hospital
insect sting challenge as a criterion for application or omission of venom
immunotherapy. J Allergy Clin Immunol 1996;98(1):39-47.
8. van der Linden PW, Hack CE, Poortman J, Vivie-Kipp YC,
Struyvenberg A, van der Zwan JK. Insect-sting challenge in 138 patients:
relation between clinical severity of anaphylaxis and mast cell
activation. J Allergy Clin Immunol 1992;90(1):110-8.
9. Emergency medical treatment of anaphylactic reactions. Project
Team of The Resuscitation Council (UK). Resuscitation 1999;41(2):93-9.
10. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Part 8: advanced challenges in resuscitation: section
3: special challenges in ECC. Anaphylaxis. The American Heart Association
in collaboration with the International Liaison Committee on
Resuscitation. Circulation 2000;102(8 Suppl):I241-3.
11. Oude Elberink JN, De Monchy JG, Van Der Heide S, Guyatt GH, Dubois
AE. Venom immunotherapy improves health-related quality of life in
patients allergic to yellow jacket venom. J Allergy Clin Immunol
2002;110(1):174-82.
12. Brown SGA, Franks RW, Baldo BA, Heddle RJ. Prevalence, severity,
and natural history of jack jumper ant venom allergy in Tasmania. J
Allergy Clin Immunol 2003;111(1):187-92.
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.
Woollard and his colleagues' study on nalbuphine identifies the gap
that can exist between research and clinical practice. I resent the claims
in this paper that nalbuphine somehow is an effective analgesic.
Since 1996, I have been receiving patients in my hospital who have
been given nalbuphine pre hospital with very little benefit and lot of
problem. These patients get grossly inadequate anal...
Woollard and his colleagues' study on nalbuphine identifies the gap
that can exist between research and clinical practice. I resent the claims
in this paper that nalbuphine somehow is an effective analgesic.
Since 1996, I have been receiving patients in my hospital who have
been given nalbuphine pre hospital with very little benefit and lot of
problem. These patients get grossly inadequate analgesia, a fact admitted
in this study. Interestingly, the reduction in pain score is quoted, but
not the end pain score. A reduction from 9 to 6 may look impressive on
statistics, but is hardly worth talking about from the patients'
perspective. These patients get troublesome nausea. The worst is the
significantly high doses of morhine needed to overcome the antagonism,
which then keeps them longer in the department.Perhaps this aspect of
hospital data should have been included to illustrate the problem.
In the doses discussed, the drug is ineffective - both as an
analgesic and as a narcotic! Can patients be called drowsy, if their GCS
is unchanged? Is it worth championing an analgesic, if the patients
subsequently need double the predicted dose of morphine?
Lastly, if 30mg nalbuphine (currently permitted upper limit in north wales
paramedic protocol)fails to achieve good analgesia, what is research
proving by comparing 10mg x2 vs 5mg x 4?
Rather than pursue futile research question, is it not better to campaign
for change of practice to morphine, which is guaranteed to work?
Dear Editor
Brown et al's [1] study provoked lively debate amongst the staff at Ipswich Hospital.
I would like to pose two questions:
1) What was the interval between sting challenge and onset of symptoms? Was this related to severity of reaction?
2) What were the details of ethical approval, and what was the consent process and documentation?
I wonder if such a stu...
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
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 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
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 Editor
We do not want to detract from the overall value of the recent article by Wardrope and MacKenzie,[1] but we feel it important to point out our concerns over the proposed assessment of cognitive function.
Cognitive impairment due to dementia and delirium is common in emergency situations but formal assessment of cognitive function is rare. This could explain why at least 67% of older people wi...
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
Dr Fatovich asks about initial reaction severity in three participants who were prescribed steroids and antihistamines for large local reactions or persistent urticaria.[1]
Two initially had severe (hypotensive) reactions whereas the other had no systemic reaction. Although frequently used, it is difficult to determine the benefit of steroids and antihistamines to manage large local reactions an...
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
Woollard and his colleagues' study on nalbuphine identifies the gap that can exist between research and clinical practice. I resent the claims in this paper that nalbuphine somehow is an effective analgesic.
Since 1996, I have been receiving patients in my hospital who have been given nalbuphine pre hospital with very little benefit and lot of problem. These patients get grossly inadequate anal...
Pages