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A valuable lesson is reiterated
Nick W Emms
Further to the case report presented by Carter and Wilby (Emerg Med J 2000 17:387) where a valuable lesson is demonstrated regarding overlooking lisfranc fractures in the presence of polytrauma, we would like to add to this a patient we encountered in order to emphasize the point.
A 27-year-old male was admitted following a road traffic accident where the patient riding a motorcycle collided with a car...
A 27-year-old male was admitted following a road traffic accident where the patient riding a motorcycle collided with a car at high speed. His obvious injury was a fractured right femur, which was grossly angulated at the level of the midshaft. He also had a cold cyanotic forefoot on the same side with an absent Dorsalis Pedis pulse on doppler examination. Femoral artery damage was suspected and an angiogram was therefore performed which demonstrated a normal vascular tree.
Radiographs of the foot, which was relatively painless, demonstrated a lisfranc fracture, which was openly reduced and internally fixed following intra-medullary nailing of the femur. During open reduction the vascularity of the foot which was now swollen and tense rapidly improved. We believe this represented a compartment syndrome in the foot secondary to the lisfranc fracture.
To reinforce the original point made by Carter and Wilby, this lisfranc fracture could have been overlooked whilst attention was being paid to the more painful injury, in this case the fractured femur and concerns regarding femoral artery damage. We would therefore like to reiterate that in a case of major trauma foot injuries might be overlooked unless a detailed secondary survey is performed to exclude them.
Re: Use 10mg of naloxone before abandoning resuscitation of cardio-respiratory arrest caused by opia
Alison Walker
While it is reasonable to use large doses of Naloxone as described in the BNF (the maximum dose recommended is 10mg), the National poisons information service recommend that dose is titrated to response. Naloxone however, has also been attributed to improving GCS in gamma-hydroxybutyrate and alcohol overdoses.
Large doses of opiate antagonists may be used in simple opiate overdose, however it was not cle...
Large doses of opiate antagonists may be used in simple opiate overdose, however it was not clear in this case that the cause of cardiac arrest was opiate induced. The patient had a primary asystolic arrest in the ambulance without a preceding respiratory arrest, which would be unusual for a massive opiate overdose. Also it is unlikely that a large enough quantity of opiate to cause a cardiac arrest would be metabolised by the liver to a degree sufficient to restore spontaneous cardiac output within 25 minutes. We feel that the clinical progress and outcome for this patient may not have been significantly influenced by larger doses of Naloxone. Dr Alison Walker
Use 10mg of naloxone before abandoning resuscitation of cardio-respiratory arrest caused by opiate
We read with interest and some sympathy the recent case report by Walker et al of an apparent 'Lazarus' phenomenon in which spontaneous circulation unexpectedly returned after abandoning resuscitation of a patient believed to have taken an opiate overdose [1]. In common with inner-city Emergency Departments the world over, heroin overdoses make up a significant proportion of our workload. It is establis...
We read with interest and some sympathy the recent case report by Walker et al of an apparent 'Lazarus' phenomenon in which spontaneous circulation unexpectedly returned after abandoning resuscitation of a patient believed to have taken an opiate overdose [1]. In common with inner-city Emergency Departments the world over, heroin overdoses make up a significant proportion of our workload. It is established practice in this context, along with other therapeutic maneuvers, to begin naloxone therapy with a 2mg bolus, which is then repeated if necessary up to a total of 10mg or more if the diagnosis of opiate overdose is still being maintained. The upper dose is suggested by the British National Formulary [2]. This applies to respiratory and cardio-respiratory arrests - remembering that one of the four 'T's of reversible causes of cardiac arrest in the Universal Algorithm of the European Resuscitation Council is Toxic/therapeutic disturbances [3].
In the case reported by Walker et al we would like to highlight the following points:
1. The patient initially responded to a total of 1.2mg intramuscular naloxone given on scene by the Paramedics, improving from GCS 3/15 to being able to walk to the ambulance. Thus the diagnosis of opiate overdose was highly likely.
2. In transit he deteriorated and subsequently had a cardio-respiratory arrest. He was in asystole on arrival to hospital. During the next 25 minutes of resuscitation he received only a further 3.6mg total of naloxone intravenously. Since his rhythm had been asystole for more than 25 minutes the resuscitation was not unreasonably abandoned. However, a few minutes later he recovered a perfusing rhythm. He left the hospital 18 days later with a full neurological recovery.
3. We suggest that the patient should have received 10mg of naloxone, or more, during the resuscitation. The probable diagnosis was demonstrated by his initial response to the naloxone administered by the Paramedics. It is likely that he took a massive overdose of opiate as indexed by his severe cardiac depression. However, as a habitual user, it is also likely that he would quickly metabolise his overdose if he remained alive long enough. To the credit of the team involved, the CPR during his 25 minutes of hospital resuscitation must have been enough to perfuse his brain, hence eventual full neurological recovery, and his liver, hence opiate metabolism enough to regenerate a perfusing rhythm.
(1) Walker A, McClelland H, Brenchley J. The Lazarus phenomenon following recreational drug use. Emergency Medicine Journal 2001; 18: 74 - 75.
(2) British National Formulary. Number 40. September 2000. British Medical Association and the Royal Pharmaceutical Society of Great Britian.
(3) Advanced Life Support Working Group of the European Resuscitation Council. The 1998 European Resuscitation Council guidelines for adult advanced life support. BMJ 1998; 316: 1863-1869
Is fasting necessary for ESR estimation ?
Saroj K Mishra
I read with interest the article by Drs Boyd and Martin (Emerg Med J 2001; 18:212-213). This article needs to be read by all doctors working in hospitals of developing countries. ESR as a single test is advised in many conditions and the importance attached to it is well known. In emergency as well as outpatient practice, the test is ordered very often.
Another point of concern is the strictness...
Another point of concern is the strictness of the fasting condition of the patient. Laboratory personnel as well as the clinicians insist that the test should be carried out only in fasting condition. And in many instances, the sample of blood is not tested or the patients is sent back, if he/she has taken food.
So, to evaluate the difference in the test results of ESR in fasting and post-prandial conditions, we conducted a small study. Blood was collected from 50 patients (a) in a fasting state and (b) one hour after of breakfast. ESR was estimated in these paired samples. The paired-t- test did not reveal any difference between the two states. Hence, according to these results, ESR estimation in fasting state is not mandatory.
Dr Saroj K Mishra
Senior Deputy Director
Ispat General Hospital
F-139, Sector-19
Rourkela 769 005
Orissa, INDIA
Tele 091- 661- 640504
Management article
Some responses to the in tray problems at St Judes
(1) Dear Chief Executive,
Thank you for welcoming me to the trust. I look forward to working with you in solving the many problems challenging the Emergency Dept (a term I refer to as Casualty). I'd be grateful if your PA can arrange our meeting urgently. I'd like to know from you where the ED and its service fit in with the strategic direction of the Tr...
Thank you for welcoming me to the trust. I look forward to working with you in solving the many problems challenging the Emergency Dept (a term I refer to as Casualty). I'd be grateful if your PA can arrange our meeting urgently. I'd like to know from you where the ED and its service fit in with the strategic direction of the Trust and what resources you will be providing me with.
These matters were only discussed loosely at my interview.
(2) Dear Mrs Penny,
I will look into this sad and tragic event as soon as possible. As you may know I am newly appointed and am just finding my feet. In the meantime I will write to the family and apologise for the events surrounding the death. In due course I will be happy to meet them.
(3) Dear Personnel,
Before I complete this job description can you please forward me a copy of the St Judes template for such posts. It is wise to have a consistent approach to such things.
(4) Xray requests I would ask to see the notes of some of the cases - the 1st to 8th, and 9th cases. I would add to my action list to review the xray report system - not a priority.
(5) The SpR letter.
I would file for now and wait for the outcome of my meeting with the CEO and further chats with regional colleagues - middle priority.
(6) The computer - I would ask my business manager to sort it out as a top priority.
I hope these are interesting,
Macduff Ogwido
I would like to comment on the excellent article on use of abdominal ultrasonography in paediatric trauma. Much as I concur with the authors on the use of routine sonography and computed tomography,in the third world where I practise, clinical decisions have to be made in a different way - do we operate on this child or not? Hence, the greater reliance on clinical signs and 24hr expectant observation - wi...
I would like to comment on the excellent article on use of abdominal ultrasonography in paediatric trauma. Much as I concur with the authors on the use of routine sonography and computed tomography,in the third world where I practise, clinical decisions have to be made in a different way - do we operate on this child or not? Hence, the greater reliance on clinical signs and 24hr expectant observation - with the patient starved and prepared for theatre. This has lessened the use of sonography,and if we can't definitely rule out intra abdominal haemorrhage we sadly have no choice but to perform "exploratory laparatomy"
Dr. Ogwido M
It was an accident - is it an Emergency?
Patrick K Plunkett
I think readers will be interested in the fact that the Medical Council (Ireland) recently approved a petition from the practitioners to change the name of the specialty from Accident & Emergency Medicine to Emergency Medicine, in line with international practice.
All the consultants in the specialty in this country are FFAEM.
You might wish to know that there were misgivings from t...
You might wish to know that there were misgivings from the higher echelons in the ranks of RCPI, but the RCSI backed our wishes.
For once, it would appear we have led the way, rather than following the UK, which is the norm!!
Methodological problems in the study on deprivation and attendance at an A&E department
Wai-Ching Leung
Beattie et al found a trend towards increased attendance for the more deprived categories of children attending a children's accident and emergency department. However, there are weaknesses in their study methodology.
First, in calculating the proportion of population in each deprivation category, they included only true "first attenders" in the numerator but all children in the appropriate dep...
First, in calculating the proportion of population in each deprivation category, they included only true "first attenders" in the numerator but all children in the appropriate deprivation categories in the denominator. The proportion of children who were "at risk" of being first attenders would be lower in deprivation categories with higher attendance rates, since they were more likely to be previous attenders. Hence, the denominators used by the authors were overestimated to a larger extent for deprivation categories with higher attendance rates. This mismatch between numerator and denominator makes it impossible to interpret the proportions. Second, the home-to-hospital distance may act as a confounding variable - patients would have been more likely to use other services (e.g. GPs) for minor illness if the accident and emergency department were far away. Therefore, the results might be entirely explained if the hospital was closer to the more deprived communities. Third, the authors did not state the source of their data for the population of children in different deprivation categories served by the RHSCE. Using the 1991 census data would have been inappropriate as the relevant data for children under 13 would have changed considerably by 1996.
Treatment of status epilepticus
Dirk Ulbricht
I agree with the conclusion that Lorazepam might be more effcient as first-line therapy for status epilepticus (SE) than diazepam but the case is not proven. The study by Leppik et al compares a commonly used strategy for the swift termination of SE. The study by Treiman et al. sets out to investigate a number of treatments but I am not aware of any European neurologist using phenytoin i.v. or phenobarbitone i.v...
I agree with the conclusion that Lorazepam might be more effcient as first-line therapy for status epilepticus (SE) than diazepam but the case is not proven. The study by Leppik et al compares a commonly used strategy for the swift termination of SE. The study by Treiman et al. sets out to investigate a number of treatments but I am not aware of any European neurologist using phenytoin i.v. or phenobarbitone i.v. as first line treatment. Have the authors found evidence of the efficacy of benzodiazapines such as clonazepam or midazolam compared to diazepam or lorazepam?