Bernard A Foëx

Emergency treatment of anaphylactic reactions—Guidelines for healthcare providers

*The UK incidence of anaphylactic reactions is increasing. *Patients who have an anaphylactic reaction have life-threatening airway and, or breathing and, or circulation problems usually associated with skin or mucosal changes. *Patients having an anaphylactic reaction should be treated using the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. *Anaphylactic reactions are not easy to study with randomised controlled trials. There are, however, systematic reviews of the available evidence and a wealth of clinical experience to help formulate guidelines. *The exact treatment will depend on the patients location, the equipment and drugs available, and the skills of those treating the anaphylactic reaction. *Early treatment with intramuscular adrenaline is the treatment of choice for patients having an anaphylactic reaction. *Despite previous guidelines, there is still confusion about the indications, dose and route of adrenaline. *Intravenous adrenaline must only be used in certain specialist settings and only by those skilled and experienced in its use. *All those who are suspected of having had an anaphylactic reaction should be referred to a specialist in allergy. *Individuals who are at high risk of an anaphylactic reaction should carry an adrenaline auto-injector and receive training and support in its use. *There is a need for further research about the diagnosis, treatment and prevention of anaphylactic reactions.

Magnetic resonance imaging or bone scintigraphy in the diagnosis of plain x ray occult scaphoid fractures

A short cut review was carried out to establish whether magnetic resonance scanning or bone scintigraphy is better at identifying scaphoid fractures not apparent on plain x rays. Altogether 11 papers were found using the reported search, of which four presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

Self-poisoning suicide deaths in England: could improved medical management contribute to suicide prevention?

BACKGROUND Suicide by self-poisoning is a major cause of death worldwide. Few studies have investigated the medical management of fatal self-poisoning. AIM To describe the characteristics and management of a national sample of individuals who died by intentional self-poisoning in hospital and assess the quality of care that they received. DESIGN National population-based descriptive study and confidential inquiry. METHODS Adults (aged ≥ 16 years) who had died by self-poisoning in English hospitals in 2005 and received a coroners verdict of suicide or undetermined death at inquest were included. Socio-demographic and clinical data were collected through detailed questionnaires sent to clinicians at the treating hospitals. A panel of three expert assessors rated each case with respect to quality of care and likely contribution to the fatal outcome. RESULTS We obtained information on 121 cases (response rate for questionnaires 77%). Expert assessors rated 41/104 cases [39% (95% CI 30-49%)] as having received inadequate care; in the majority (38/41-93%) of these, this poor care was felt to have potentially contributed to the patients death. The most common reason for a rating of inadequate care was poor airway management (recorded in over half of inadequate care cases). In three cases, the receipt of inadequate care was associated with the presence of some form of advance directive. CONCLUSION In as many as 39% of in-hospital self-poisoning fatalities, the care received may be in some way sub-optimal. The challenge for clinical services is to ensure that optimal management strategies are implemented in practice.

Discovery of the intraosseous route for fluid administration.

One of the many problems in the resuscitation of the shocked patient is how to gain access to the circulation to provide fluids or drugs. Since the 1830s fluids have been administered intravenously. Intravenous access is not always possible in the very shocked patient. An alternative, used in the first world war, was the rectal route. This has rarely been used on a large scale since. Just before the outbreak of the second world war a chance discovery resulted in the development of intraosseous infusions of fluid and drugs. From its discovery it was used in adults and children. For many years it seemed to be ignored in adult resuscitation, but there are now signs of renewed interest in the technique. This brief review traces the discovery of the intraosseous route to put the current developments into a historical context.

Advance directives and suicidal behaviour

How do you manage a patient who has self harmed but states she doesn’t want life saving treatment? Anthony David and colleagues draw on the case of Kerrie Wooltorton to discuss the difficulties, and in an accompanying article Navneet Kapur and colleagues consider the validity of advance directives

Corticosteroids in the management of near-drowning

Report by Bernard A Foex, Specialist Registrar Checked by Russell Boyd, Consultant (Adelaide, Australia) A 15 year old boy was playing in the local canal. He jumped off a small bridge and got his foot caught in an old shopping trolley on the bottom. He was pulled out but he was unconscious and apnoeic. He was given BLS by the paramedics so that when he arrived in accident and emergency he was conscious, tachypnoeic, and centrally cyanosed. He …

Optimising well-being: is it the pain or the hurt that matters?

In recent years there has been a commendable focus on patient-centred medicine, with increasing attention being paid to the timely assessment and management of acute pain. 78% of patients who attend the emergency department report pain, the severity of which is often used to determine clinical priority at triage. Clinical guidelines are increasingly including the timely provision of appropriate analgesia as a clinical standard. Pain scoring has been widely adopted, causing pain to be considered as the ‘fifth vital sign’ by some. Interestingly, there remains little evidence to support the benefit of this approach for patients. The aim of this review is to explore some of the assumptions that made in defining and addressing ‘pain’, and to explore whether it is truly ‘nociception’ or ‘suffering’ that ought to be addressed. Through two thought experiments, it is demonstrated that the current approach to pain relies heavily on addressing ‘nociception’ but does little to address the ‘suffering’ that is undoubtedly they key determinant of well-being in patients. It is demonstrated that the current naturalistic approach risks neglecting many ‘non-nociceptive’ sources of suffering, including physical (eg, nausea, vertigo, dyspnoea, pruritus) and mental (anxiety, depression, fear, anger) symptoms. In the humane quest to relieve suffering, there is a clear need to examine current practice. Indeed, the philosophical enquiry presented even questions whether our culture risks overemphasising the importance of pharmacological analgesia and calls for emergency physicians to take a more holistic approach to meeting patient needs.

Scorpion envenomation: does administration of antivenom alter outcome?

A short cut review was carried out to establish the clinical utility of antivenom in scorpion poisoning. Using the reported search, 69 papers were found, of which four presented the best evidence to answer the clinical question. The author, date, and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

Meta-analysis of controlled studies on immunotherapy in severe scorpion envenomation: a commentary

The WHO has recently described the management of potentially rabid mammal bites and envenomings by snakes or scorpions as ‘a global public health emergency’ (http://www.who.int/bloodproducts/animal_sera/Rabies.pdf). However, as far as Western medicine is concerned, scorpion envenomation may be considered as an orphan disease. An orphan disease, as defined by MedicineNet, is ‘A disease which has not been “adopted” by the pharmaceutical industry because it provides little financial incentive for the private sector to make and market new medications to treat or prevent it.’ An orphan disease may be: 1. A rare disease. According to US criteria, an orphan disease is one that affects fewer than 200 000 people. (There are more than 5000 such rare disorders.) 2. A common disease that has been ignored because it is far more prevalent in developing countries than in the developed world (http://www.medicinenet.com). The WHO report states, ‘Early administration of antivenom is highly effective, together with intensive care support in severe cases…rapid distribution of scorpion venom toxins…demands early treatment with antivenom and full cardio-respiratory support.’ The report goes on to discuss the fact that there is a massive shortfall in the production of antivenom compared with the potential need. The recent publication of two new studies …

Hyperbaric oxygen therapy in acute fracture management

A short cut review was carried out to establish whether hyperbaric oxygen therapy (HBOT) is advantageous in fracture healing. A total of 26 citations were found of which one answered the three part question. The clinical bottom line is that there is insufficient evidence to support the use of hyperbaric oxygen therapy for fracture healing.