3deec5229d973831ac
2
Delayed lethal arrhythmia after an electrical injury Bailey et al are to be co ngratul at e d on condu cting a pros pecti ve study of elect rical injury. 1 The ‘‘abnormal’’ ECGs were mos tly non-specific abnormalities, and only occurred in 11% those who were deemed to have a risk factor. As a result, I searched the literature for cases of delaye d lethal arrhyth mias. Bailey reported on a 16-year-old subject with a past history of palpitations who was assessed for painful burns on both hands after a 750 V DC shock. 2 She was found dead 10 h later. No mentio n of an ECG was made. The coroner concluded that she had died from arrhythmia not necessaril y direct ly relate d to the electric shock. The pat ients report ed by Jensen to have delaye d danger ous ventr icula r arrhy thmi as al so had de laye d pr es enta ti on s (up to 2 months) and had initial ECG abnormalities. 3 The other patient, a 43-y ear-o ld electr ician , was exposed to a 3000 V DC electrical injury. Twelv e hours later while playi ng football, he collapsed and was resuscitated from ventricu- lar fibri llatio n. Unfo rtunat ely, there was no intervening ECG. Sharma et al describe the case of a 24-year- old man who ha d an ECG 45 mi n af te r con tac tin g a 220–240 V alt ernati ng cur rent switch. 4 Thi s showed low vol tage and a fir st degree atrioventricular (AV) block (PR interval of 0.3 s). After 2 h, he developed a Mobitz type I Wenkebach AV block. The next day, he had complete AV block. Six hours later, he devel- oped ventricular fibrillation and needed defi- brillation. He was observed for 6 more weeks without problems. 4 So when assessing patients after an electric shock, these reports confirm that one can be conf ident that if the patien t is asymp tomatic and has a normal ECG, cardiac monitoring is not requir ed. 5 This is re ass uring for both patien ts and staff. Delaye d lethal arrhyt hmia must be exceptionally rare. Daniel M Fatovi ch Department of Emergency Medicine, Royal Perth Hospital, Perth, Australia Correspondence to: Dr Daniel Fatovich; [email protected] Competing interests: None declared. References 1 Bailey B, Gaudreault P, Thivierge RL. Cardiac monitoring of high-risk patients after an electrical injury: a prospective multicentre study. Emerg Med J 2007;24:348–52. 2 Bailey B, Forget S, Gaudreault P. Prevalence of potential risk factors in victims of electrocution. Forensic Sci Int 2001; 123:58–62. 3 Jensen PJ, Thomsen PE, Bagger JP, et al. Electrical injury causing ventricular arrhythmias. Br Heart J 1987;57 :279–83. 4 Sharma BC, Patial RK, Pal LS, et al. Electrocardiographic manifestations following household electric current injury. J Assoc Physicians India 1990; 38:938–9. 5 Fish RM. Electric injury, part III: cardiac monitoring indications, the pregnant patient, and lightning. J Emerg Med 2000; 18:181–7. Skin turgor: author’s response I was deli ghted to read the cr it ique of the recent Best Evidence Topic (BET) summar y on the reliability of skin turgor as a method for assessing dehydration in children, 1 and would like to accept your invitation to respond. My con tri but ion, as thi rd aut hor for thi s paper, was to check and update the search strategy and to review the final manuscript. Wh il e I am sorr y that th e BET di d n ot pro vide Dr Smi th wit h the inf ormati on he desired regardin g the diagn ostic accuracy of skin turgor in assessi ng dehydrati on in chil- dren, I fear that he may perhaps be looking in the wrong pla ce for this answe r. Just as we would not criticise a paper published within the Emergency Casebook for not being a randomised cont rolled trial, it is perhaps wrong to criticise a BET for not being a thorough systematic review of the assessment of dehydration in children. BETs were designed to ‘‘bring the evidence one step closer to the bedside, by pro viding answers to ver y spe cif ic cli nic al pro ble ms, usin g the bes t available evi dence’ ’ (ht tp: // www.bestbets.org/ho me/betsintro.html). The BET in ques tio n asked a ver y spe cif ic thr ee part question regarding the interobserver relia- bility of skin turgor, as designed by Drs Fayomi and Maconc hi e. If skin turgor cannot be reliably measured by emergency physicians, it is perhaps of dubious value as a diagnostic test. Th e s ea rc h st rate gy w as al so pe rh aps unf air ly cri tic ise d. All of the pap ers cit ed by Dr Smi th wer e ide ntifie d usi ng the rep orted search . None of these papers assessed inter- obser ver reli abil it y and theref ore di d not answer the three part question that had been posed. All of these papers were also included in the systematic review that we cited. 2 It may be of further int erest to Dr Smi th that, for the detect ion of 5% dehyd ratio n, abnor mal skin turgor carried a pooled sensitivity of 58% (95% con fidence int erval (CI) 40% to 75%) and specificity of 76% (95% CI 59% to 93%) in this well designed systematic review, although the BET in quest ion di d not seek to report on diagnostic accuracy. Finally, Dr Smith states that the usefulness of BETs has been debated and urges caution in the interpretation of their conclusions. While it is true that caution should be exercised in the interpretation of all medical literature, I should like to pass comment for the reader who will infer from this a criticism of BETs as a concept. Where else within the emergency medicine literature can one easily access an up-to-date concise summary of the best available evidence for topics ranging from the use of Buscopan in oesop hageal food impac tion to the sensit ivity of a nor mal chest x ray for exclud ing aortic dis sec tion; fro m the use of oxy gen in acu te myoc ardial infarctio n to the progn ostic effect of clopidogrel in head injury? Truly, BETs have revolu tio nis ed our app roach to emer gency me di ci ne bo th wi thin this co untr y and (increasingly) internationally, as demonstrated by recent publ ic ations from the USA and Australia. Much of th e be auty of BETs is in th e ir simplicity. Let us not overcomplicate the issue. Richard Body Accident and Emergency Department, Manchester Royal Infirmary, Manchester, UK Correspondence to: Dr Richard Body; [email protected] Competing interests: None declared. References 1 Fayomi O, Maconchie I, Body R. Is skin turgor reliable as a means of assessing hydration status in children? Emerg Med J 2007; 24:124. 2 Steiner MJ, DeWalt DA, Byerle y JS. The rationa l clinical examination: is this child dehydrated? JAMA 2004;291:2746–54. PostScript .................................................................................................. LETTERS CORRECTION doi: 10.1136/emj.200 7.049478co rr1 Redmon d AD. Debrie fing. Emerg Med J 2007; 24:605. The journal apologises for an error that has occurred within the last sentence of this letter. The letter should read as follows. In the article by Doy et al 1 reference is made to ‘‘criti cal incid ent stress debri efing ’’. It was suggested there was some disagreement as to its effec tiven ess, but never theles s the artic le appeared to be recommending its use. I would, however, refer readers to the National Institute for Health and Clini cal Excellenc e guideli nes on post-traumat ic st ress di sorder (www. nice. org. uk). These guideli nes state that for individuals who have experienced a traumatic event, the systematic provision to that indivi- dual alone of brief, single session interventions (often referred to as debriefing) which focus on the traumatic incident should not (their bold typ e) be routine practi ce whe n del iverin g services. Emerg Med J 2007;24:743 743 www.emjonline. com
-
Upload
wisnu-yudho-h -
Category
Documents
-
view
214 -
download
0
Transcript of 3deec5229d973831ac
8/12/2019 3deec5229d973831ac
http://slidepdf.com/reader/full/3deec5229d973831ac 1/1
Delayed lethal arrhythmia after anelectrical injury Bailey et al are to be congratulated onconducting a prospective study of electricalinjury.1 The ‘‘abnormal’’ ECGs were mostlynon-specific abnormalities, and only occurredin 11% those who were deemed to have a riskfactor. As a result, I searched the literature forcases of delayed lethal arrhythmias.
Bailey reported on a 16-year-old subject witha past history of palpitations who was assessedfor painful burns on both hands after a 750 VDC shock.2 She was found dead 10 h later. Nomention of an ECG was made. The coronerconcluded that she had died from arrhythmianot necessarily directly related to the electricshock.
The patients reported by Jensen to have
delayed dangerous ventricular arrhythmiasalso had delayed presentations (up to2 months) and had initial ECG abnormalities.3
The other patient, a 43-year-old electrician, was exposed to a 3000 V DC electrical injury.Twelve hours later while playing football, hecollapsed and was resuscitated from ventricu-lar fibrillation. Unfortunately, there was nointervening ECG.
Sharma et al describe the case of a 24-year-old man who had an ECG 45 min aftercontacting a 220–240 V alternating currentswitch.4 This showed low voltage and a firstdegree atrioventricular (AV) block (PR intervalof 0.3 s). After 2 h, he developed a Mobitz typeI Wenkebach AV block. The next day, he had
complete AV block. Six hours later, he devel-oped ventricular fibrillation and needed defi-brillation. He was observed for 6 more weeks without problems.4
So when assessing patients after an electricshock, these reports confirm that one can beconfident that if the patient is asymptomaticand has a normal ECG, cardiac monitoring isnot required.5 This is reassuring for bothpatients and staff. Delayed lethal arrhythmiamust be exceptionally rare.
Daniel M FatovichDepartment of Emergency Medicine, Royal Perth
Hospital, Perth, Australia
Correspondence to: Dr Daniel Fatovich;
[email protected] interests: None declared.
References
1 Bailey B, Gaudreault P, Thivierge RL. Cardiacmonitoring of high-risk patients after an electricalinjury: a prospective multicentre study. Emerg Med J 2007;24:348–52.
2 Bailey B, Forget S, Gaudreault P. Prevalence of potential risk factors in victims of electrocution.Forensic Sci Int 2001;123:58–62.
3 Jensen PJ, Thomsen PE, Bagger JP, et al. Electricalinjury causing ventricular arrhythmias. Br Heart J 1987;57 :279–83.
4 Sharma BC, Patial RK, Pal LS, et al.Electrocardiographic manifestations followinghousehold electric current injury. J Assoc PhysiciansIndia 1990;38:938–9.
5 Fish RM. Electric injury, part III: cardiac monitoringindications, the pregnant patient, and lightning.
J Emerg Med 2000;18:181–7.
Skin turgor: author’s responseI was delighted to read the critique of therecent Best Evidence Topic (BET) summary onthe reliability of skin turgor as a method forassessing dehydration in children,1 and wouldlike to accept your invitation to respond. Mycontribution, as third author for this paper, was to check and update the search strategyand to review the final manuscript.
While I am sorry that the BET did notprovide Dr Smith with the information hedesired regarding the diagnostic accuracy of skin turgor in assessing dehydration in chil-dren, I fear that he may perhaps be looking inthe wrong place for this answer. Just as we would not criticise a paper published withinthe Emergency Casebook for not being arandomised controlled trial, it is perhaps wrong to criticise a BET for not being athorough systematic review of the assessmentof dehydration in children.
BETs were designed to ‘‘bring the evidenceone step closer to the bedside, by providinganswers to very specific clinical problems,using the best available evidence’’ (http://
www.bestbets.org/home/betsintro.html). TheBET in question asked a very specific threepart question regarding the interobserver relia-bility of skin turgor, as designed by Drs Fayomiand Maconchie. If skin turgor cannot bereliably measured by emergency physicians, itis perhaps of dubious value as a diagnostic test.
The search strategy was also perhapsunfairly criticised. All of the papers cited byDr Smith were identified using the reportedsearch. None of these papers assessed inter-observer reliability and therefore did notanswer the three part question that had beenposed. All of these papers were also included inthe systematic review that we cited.2 It may beof further interest to Dr Smith that, for thedetection of 5% dehydration, abnormal skin
turgor carried a pooled sensitivity of 58% (95%confidence interval (CI) 40% to 75%) andspecificity of 76% (95% CI 59% to 93%) in this well designed systematic review, although theBET in question did not seek to report ondiagnostic accuracy.
Finally, Dr Smith states that the usefulnessof BETs has been debated and urges caution inthe interpretation of their conclusions. While itis true that caution should be exercised in the
interpretation of all medical literature, I shouldlike to pass comment for the reader who willinfer from this a criticism of BETs as a concept.
Where else within the emergency medicineliterature can one easily access an up-to-dateconcise summary of the best available evidence
for topics ranging from the use of Buscopan inoesophageal food impaction to the sensitivityof a normal chest x ray for excluding aorticdissection; from the use of oxygen in acutemyocardial infarction to the prognostic effectof clopidogrel in head injury? Truly, BETs haverevolutionised our approach to emergencymedicine both within this country and(increasingly) internationally, as demonstratedby recent publications from the USA and Australia.
Much of the beauty of BETs is in theirsimplicity. Let us not overcomplicate the issue.
Richard Body Accident and Emergency Department, Manchester
Royal Infirmary, Manchester, UK
Correspondence to: Dr Richard Body;[email protected]
Competing interests: None declared.
References
1 Fayomi O, Maconchie I, Body R. Is skin turgor reliable as a means of assessing hydration status inchildren? Emerg Med J 2007;24:124.
2 Steiner MJ, DeWalt DA, Byerley JS. The rationalclinical examination: is this child dehydrated?
JAMA 2004;291:2746–54.
PostScript . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
LETTERS
CORRECT ION
doi: 10.1136/emj.2007.049478corr1
Redmond AD. Debriefing. Emerg Med J 2007;24:605.
The journal apologises for an error that hasoccurred within the last sentence of this letter.The letter should read as follows.
In the article by Doy et al1 reference is madeto ‘‘critical incident stress debriefing’’. It wassuggested there was some disagreement as toits effectiveness, but nevertheless the articleappeared to be recommending its use. I would,however, refer readers to the National Institute
for Health and Clinical Excellence guidelineson post-traumatic stress disorder (www.nice.org.uk). These guidelines state that forindividuals who have experienced a traumaticevent, the systematic provision to that indivi-dual alone of brief, single session interventions(often referred to as debriefing) which focus onthe traumatic incident should not (their boldtype) be routine practice when deliveringservices.
Emerg Med J 2007;24:743 743
www.emjonline.com
