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190 EDITORIALS

Toxicology early to tell whether it has had any clini- 12 ...... cally significant impact yet. A number Emerg Med J: first published as 10.1136/emj.19.3.190 on 1 May 2002. Downloaded from of other measures have been considered to reduce overdoses. How- Advances, challenges, and ever, few of these are practical and some, such as the addition of have controversies in potential safety issues, which make them unsuitable.13 Prevention of para- A L Jones, P I Dargan cetamol poisoning is a significant issue, ...... but it is not, however, likely to be some- thing that individual accident and emer- The treatment of self poisoned in the emergency gency departments are going to be able department to have a significant impact on. Optimising early care of poisoned atients presenting with self - infarction, arrhythmias, and myocardial patients ing constitute a significant and dysfunction.8 It is important that cocaine The mainstay of gut decontamination in increasing workload in emergency use is considered in all patients, espe- P poisoning is the administration of acti- departments and rates in the cially young adults, presenting with vated charcoal within one hour of inges- UK (up to 347 per 100 000 per year) are acute coronary syndromes because this tion of a .14 However, recent studies among the highest in Europe.12 The will change the management strategy. have shown that as few as 15% of severity of poisoning has decreased over First line treatment for cocaine related patients are seen in hospital in the first the past decade with the introduction of myocardial ischaemia/infarction in- hour after self poisoning, and further safer drugs such as serotonin reuptake cludes benzodiazepines and nitrates to- delays can occur during triage, waiting to inhibitors over tricyclic antidepressants, gether with and oxygen; β block- see a doctor, and because of transport but there are still more than 2000 deaths ers are contraindicated and thrombolysis 15 16 3 delays in more remote, rural areas. It per year in the UK from self poisoning. should not be used routinely because the is important that those who have in- mechanism is coronary artery vaso- CHALLENGES IN CLINICAL spasm rather than thrombosis.58Alcohol gested a potentially serious overdose and remains the most widely used “drug of have presented within the one hour Recognition of severe poisoning misuse” throughout Europe and the interval are rapidly identified and “fast Fewer than 1% of people who present impact of a blood ethanol concentration tracked” for activated charcoal . with self poisoning develop severe clini- of greater than 0.50 g/l on road accidents Prehospital administration of charcoal cal effects.4 One of the main challenges is shown by Fabbri et al.9 by ambulance staff would allow earlier in managing poisoned patients is to administration and may be one aspect of identify this group as early as possible so Worldwide: issue of chemical the future of the treatment of poisoned that appropriate supportive, and if nec- preparedness patients, though the potential risk of essary, specific management steps can be The events of 11 September in the USA inducing and aspiration must http://emj.bmj.com/ instituted to prevent serious complica- have alerted us to be more prepared for be evaluated first. tions. Equally importantly, the vast ma- the unthinkable, including preparing for jority of patients (particularly children) receiving victims exposed to biological or To do simple things well. For require only supportive care and do not nerve warfare agents.10 Sarin exposure of example, weighing patients need to be exposed to unnecessary the public in a subway happened in The weight of patients is important in procedures. Meticulous supportive care peacetime in Tokyo.11 Lessons learned clinical toxicology because the toxic dose is the most important aspect of the man- from that tragedy included the need to of many compounds is expressed in 5 have adequate decontamination facilities agement of seriously poisoned patients. mg/kg body weight and the dose of some on September 25, 2021 by guest. Protected copyright. As a general rule complete elimination of available, to avoid contamination of medi- drugs used to treat poisoned patients a drug takes five half lives and seriously cal or nursing staff, and to have optimum (for example, N-) is weight poisoned patients, who are often fit procedures for admission and appropriate dependent. However, patients are often young adults, need to be kept alive to antidotal therapy for such patients.10 11 not weighed and doctors and nurses fre- allow elimination of the drug. If organ Further information is available from quently estimate the weight of patients; failure ensues, extracorporeal removal of the UK Public Health Laboratory Service these estimates of bodyweight are often may become necessary. web site (http://www.phls.org.uk/facts/ inaccurate.17 A simple set of weighing deliberate_releases.htm) and US Centers scales should be standard equipment in Drugs of misuse for Disease Control and Prevention all clinical areas treating poisoned pa- Presentation to hospital with clinical website (http://www.bt.cdc.gov/Agent/ tients and all patients presenting after effects from an ever growing number AgentlistChem.asp). taking an overdose should have a formal drugs of misuse is becoming more body weight measurement as a standard common, particularly in inner city Prevention of paracetamol 16 part of their management. All patients areas. In addition to newer drugs such poisoning given based on bodyweight as GHB (gammahydroxybutyrate) com- Paracetamol is the commonest drug should also be formally weighed. binations of drugs are often taken, for taken in overdose in the UK, accounting example, Sextasy (Ecstasy and Viagra).6 for 50% of all self poisoning episodes and This issue of EMJ contains a reminder of 100–200 deaths per year.13In September the potential for methaemoglobinaemia 1998 legislation was introduced in the RECENT ADVANCES IN CLINICAL from nitrite containing drugs of misuse UK limiting pack sizes available for sale TOXICOLOGY such as “poppers”.7 Cocaine use is in an attempt to decrease the number There have been a number of specific increasing as the price of cocaine has and severity of paracetamol overdoses. A advances in the understanding of the fallen in several inner city areas. Cocaine number of studies have attempted to mechanisms of poisoning and manage- misuse can result in cardiovascular com- assess the impact of this legislation with ment of patients with poisoning over the plications such as myocardial ischaemia/ conflicting findings and it is probably too past five years.

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Improved understanding of depressants, in whom additional CNS THE FUTURE: DEVELOPMENT OF mechanisms in poisoning, for depression would be difficult to manage. AN EVIDENCE BASE FOR THE Emerg Med J: first published as 10.1136/emj.19.3.190 on 1 May 2002. Downloaded from example, late paracetamol MANAGEMENT OF POISONED Novel treatment methods, for poisoning PATIENTS example, Haemofiltration, Molecular The mechanism of in early para- Guidelines for the management of poi- cetamol poisoning is well established and Adsorbent Recycling System (MARS) Extracorporeal drug removal techniques soned patients should be evidence N-acetylcysteine (NAC) protects against based.26 However, the level of evidence in 18 such as haemoperfusion and haemodi- in these patients. Until toxicology is often poor and based on recently, comparatively little was known alysis are indicated in a minority of 23 case reports/series or observational stud- about the mechanisms of toxicity in late severe cases of poisoning. However, each technique has problems such as ies that have been performed on highly (more than 15 selected patients and so are subject to hours after ingestion). Recent studies limited availability, poor tolerance in haemodynamically compromised pa- significant bias. There has been little have shown that factors such as produc- tients, and poor removal of protein hypothesis testing research performed in tion of cytokines and chemokines, nu- bound drugs.23 toxicology. Many management strategies clear transcription factors, free radicals, Haemofiltration is available in most have been developed as an extrapolation and caspases are involved in hepatotoxic- intensive care units and is better toler- from the pharmacological effects of ity in late paracetamol poisoning.18 NAC ated in hypotensive patients but there drugs or from animal data or generalisa- is less effective in late paracetamol are limited data on the use of haemofil- tions from drugs within the same class, poisoning,18 and knowledge of the tration in poisoned patients. Recent, in which is far from satisfactory. mechanisms of injury, at the haemo- vitro studies have shown significant There are a number of questions that dynamic and subcellular level, is impor- removal of salicylate by haemofiltration24 need to be answered, including whether tant in the development of new treat- but further work is required before it can various gut decontamination methods ments for paracetamol overdose, be recommended in the management of have an impact on the outcome of particularly for patients who present late. poisoned patients patients with severe poisoning. In addi- However, until these new treatments are MARS is an extracorporeal device that tion, there are a number of specific issues available NAC remains the treatment of combines conventional haemodialysis to be addressed such as the indications choice in patients presenting with late with a secondary system containing an for hyperbaric oxygen in carbon monox- paracetamol poisoning.18 albumin impregnated dialysis membrane ide poisoning, the optimum regimen and New , for example, (with an albumin containing dialysate) mechanism of action of sodium bicarbo- 4-methylpyrazole in ethylene glycol in addition to anion-exchange and char- nate in tricyclic antidepressant poison- coal columns.25 It has been used in the ing, management of late paracetamol and poisoning 25 Ethylene glycol and methanol are me- management of acute and poisoning, and length of treatment with tabolised to toxic metabolites by because it is able to remove protein deferoxamine in to name dehydrogenase and significant clinical bound substances could theoretically be but a few. effects including metabolic , CNS used in the management of severe Clinicians in centres need to depression, and acute renal failure can poisoning with highly protein bound work with those working in emergency occur in overdose. The mainstay of man- drugs such as salicylates in the future, medicine to develop modern, evidence

but for now it remains a research tool in http://emj.bmj.com/ agement is inhibition of alcohol dehy- based practice that recognises the sensi- the few centres in which it is available. drogenase and thus reduction of toxic tivity of this group of patients and their 19 metabolite formation. Until recently Better training: greater availability special needs. Large, multicentre studies the only agent available was ethanol, but of information and courses across many hospitals in different re- treatment with ethanol causes CNS In the UK, several databases have been gions are needed to study outcomes and depression and hypoglycaemia and re- developed to meet the increasing needs treatment strategies and to collect data quires close laboratory monitoring of of doctors and nurses for easy access to to optimise the management of poisoned blood ethanol concentrations.19 A new patients. Let us hear from you and we information on poisoning. TOXBASE on September 25, 2021 by guest. Protected copyright. alcohol dehydrogenase inhibitor is now (http://www.spib.axl.co.uk/), a compu- can get started! available: 4-methylpyrazole (4-MP, fo- terised database run by the National Poi- Emerg Med J 2002;19:190–191 mepizole). 4-MP is well tolerated and sons Information Service, has been blood concentrations are not required to available over the internet to health pro- ...... monitor treatment; the main drawback fessionals in the UK since 1999, having Authors’ affiliations of 4-MP is its cost of £1000–£2000 per replaced the former Viewdata database A L Jones, P I Dargan, National Poisons treatment course. There have been three of the same name that was developed in Information Service, Guy’s and St Thomas’ NHS recently published multicentre prospec- the 1970s. ISABEL (http://www. Trust, Avonley Road, London, SE14 5ER, UK tive case series describing the successful isabel.org.uk/) is a new medical infor- Correspondence to: Dr A L Jones; use of 4-MP in adults with ethylene gly- mation system, also delivered via the [email protected] col and methanol poisoning.20–22 There internet, that provides support in diag- have been no trials comparing ethanol nosis and management of children and REFERENCES and 4-MP and until these data are avail- includes toxicology as one of its compo- 1 Townsend E, Hawton K, Harriss L, et al. able, ethanol is generally the of nents. As well as an aid to the manage- Substances used in deliberate self-poisoning choice in ethylene glycol and methanol ment of individual patients, both of 1985–1997: trends and associations with poisoning. However, there are certain these web sites can be used as an age, gender, repetition and suicide intent. Soc Psychiatr Epidemiol circumstances where we would advocate educational tool. 2001;36:228–34. the use of 4-MP.For example, in asymp- Poisoning is an important part of the 2 Michel K, Ballinari P, Bille-Brahe U, et al. tomatic patients (particularly children) workload in , gen- Methods used for parasuicide: results of the who present early after a witnessed large WHO/EURO multicentre study on eral medicine, and intensive care. NPIS parasuicide. Soc Psychiatry Psychiatr ingestion with biochemical evidence of centres offer a wide range of training Epidemiol 2000;35:156–63. poisoning (a raised osmolal gap, or if courses for doctors and nurses in all of 3 Hawton K, Townsend E, Deeks J, et al. Effects available a raised methanol/ethylene gly- these disciplines; details of these courses of legislation restricting pack sizes of paracetamol and salicylate on self- poisoning col concentration) and potentially in are available on TOXBASE (http:// in the UK: before and after study. BMJ patients who have coingested CNS www.spib.axl.co.uk/). 2001;322:1203–7.

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4 Litovitz TL, Klein-Schwartz W, White S, et al. 12 Dargan PI, Jones AL. The impact of 20 Brent J, McMartin K, Phillips S, et al.

2000 Annual report of the American paracetamol pack-size legislation on for the treatment of ethylene Emerg Med J: first published as 10.1136/emj.19.3.190 on 1 May 2002. Downloaded from Association of Poison Control Centers Toxic paracetamol poisoning. J Evidence Based glycol poisoning. N Engl J Med Exposure Surveillance System. Am J Emerg Healthcare 2001;5:117–18. 1999;340:832–8. Med 2001;19:337–95. 13 Norman E, Dhairiwan R, Dargan PI, et al. 21 Borron SW, Megarbane B, Baud FJ. 5 Jones AL, Dargan PI. Churchill’s pocketbook Paracetamol poisoning: can it be prevented? Fomepizole in the treatment of uncomplicated Proc R Coll Edinb 2001;31:62–5. of toxicology. Edinburgh: Churchill ethylene glycol poisoning. Lancet 14 American Academy of Clinical Toxicology & Livingstone, Harcourt, 2001. 1999;354:831. 6 Jones AL, Volans G. Recent advances: European Association of Poisons Control Centres and Clinical Toxicologists. Position 22 Brent J, McMartin K, Phillips S, et al. management of self-poisoning. BMJ Fomepizole for the treatment of methanol 1999;319:1414–17. statement: Single-dose activated charcoal. J 35 poisoning. N Engl J Med 2001;344:424–9. 7 Modaria B, Kapadia YK, Kerins M, et al. Toxicol Clin Toxicol 1997; :721–41. 15 Thakore S, Murphy N. The potential role of 23 Pond S. Extracorporeal techniques in the : a treatment for severe prehospital administration of activated treatment of poisoned patients. Med J Aust methaemoglobinaemia secondary to misuse of charcoal. Emerg Med J 2002;19:63–5. 1991;154:617–22. amyl nitrate. Emerg Med J 2002;19:271–2. 16 Karim A, Ivatts S, Dargan PI, et al. How Dargan PI 8 Lange RA, Hillis LD. Medical progress: 24 , Jones AL, Salimi Gilani P, et al. feasible is it to conform to the European Hemofiltration–a potential new treatment for cardiovascular complications of cocaine use. guidelines on the administration of activated NEJM 2001;345:351–8. . J Toxicol Clin Toxicol charcoal within one hour of overdose? Emerg 2001;39:483. 9 Fabbri A, Marchesini G, Morselli-Labate AM, Med J 2001;18:390–2. 25 Strange J, Mitzner SR, Risler T, et al. et al. Positive blood alcohol concentration and 17 Dargan PI, Shin GY, Jones AL. How well do Molecular Adsorbent Recycling System road accidents. A prospective study in an doctors and nurses estimate the weight of Italian . Emerg Med J patients? J Toxicol Clin Toxicol (MARS): clinical results of a new 2002;19:210–14. 2001;39:567–8. membrane-based blood purification system for 10 Flanagan RJ, Jones AL. Antidotes. London: 18 Jones AL. Recent advances in the bioartificial liver support. Artif Organs Taylor-Francis, 2001. management of late paracetamol poisoning. 1999;23:319–30. 11 Okumura T, Suzuki K, Fukuda A, et al.The Emergency Medicine (Australia) 26 Wallace CI, Dargan PI, Jones AL. Tokyo subway Sarin attack disaster 2000;12:14–21. Paracetamol overdose: an evidence based management. Part 2; Hospital report. Acad 19 Brent J. Current management of ethylene flowchart to guide management. Emerg Med J Emerg Med 1998;6:618–24. glycol poisoning. Drugs 2001;61:979–88. 2002;19:202–5.

Toxicology CLINICAL ISSUES IN ...... PARACETAMOL POISONING Paracetamol is still the commonest sub- stance taken in overdose in Britain, and Troublesome toxins in many places paracetamol ingestion forms 50% of all poisoning cases seen.2 A Parfitt, J A Henry Despite a clear exposition on manage- ment in the British National Formulary ...... and the availability of guidelines and The treatment of patients with acute poisoning admitted to the posters from the British Association for Accident and Emergency Medicine, pa- emergency department is discussed racetamol remains the commonest cause

of enquiries to the United Kingdom http://emj.bmj.com/ National Poisons Information Service in expert opinion in Europe and the USA cute poisoning now accounts for both adults and children.11 12 It is impor- about 3%–5% of emergency de- considers activated charcoal the pre- tant to be aware that the great majority partment attendances in most ferred treatment for most poisons within of overdose cases will be asymptomatic A 23 countries with developed medical one hour of ingestion. Karim et al have when seen, so that every requires 12 services. Each patient presents a chal- recently drawn attention in this journal a plasma paracetamol level at least four lenge to the skills of the doctor, who has to time constraints in the administration hours after ingestion in order to decide to deal not only with the toxic effects of of charcoal, while Wolseley et al in the on the need for treatment. on September 25, 2021 by guest. Protected copyright. the poison but also with the mental state USA have noted that patients brought to What are the main things that the of the patient, anxious parents, friends hospital by ambulance are given charcoal “doctor at the door” needs to know about or relatives. Because of this, many earlier after arrival.56 The other treat- paracetamol? Firstly, that we have highly doctors find the poisoned patient more ment deserving consideration in special effective antidotes, provided they are difficult to deal with than a “straightfor- given within about 10 hours of ingestion. circumstances is whole bowel lavage, ward” medical or surgical case. Here we Secondly,the decision to treat is based on which uses a large amount of isotonic consider a few current topics in poison- a nomogram involving time since inges- ing. fluid (as in bowel preparation for radio- tion of a single overdose and the plasma logical procedures) to empty the gut by paracetamol level. Thirdly, that it is safer “flushing out” the intestinal contents. to give the antidotes than not to give GASTROINTESTINAL This technique is of special use for them unless one can be completely sure DECONTAMINATION sustained release preparations (such as of the history, the timing of ingestion Some junior doctors still think that a lithium, theophylline, and propranolol), and the blood level—if there are con- decision not to empty the stomach might heavy compounds, iron, and illicit founding issues, such as a staggered to an appearance in the coroner’s drug packets in body packers.7–10 The overdose or an unreliable history, the court. However, there is no evidence that technique is less disturbing to the patient must be treated. And fourthly, reducing absorption of ingested toxins patient than might be imagined and fla- one has to determine whether the shortens the duration of admission to patient falls into a “high risk” category, 3 voured formulations exist for children. hospital or saves life. - so that the patient must be treated at uanha, although an effective emetic, This brief look at methods of intestinal lower blood paracetamol levels as the does not effectively empty the stomach decontamination will hopefully encour- current guidelines indicate. Knowledge and should not be used. age hospital doctors to revise their of these simple facts alone should enable also has drawbacks and may force knowledge concerning the appropriate the great majority of cases to be treated poisons through the pylorus into the methods for use in their own effectively without the need for further proximal small intestine.4 Consensus of environment.23 advice.

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CARBON MONOXIDE sodium thiosulphate is slower acting but 5 Karim A, Ivatts S, Dargan P, et al. How

Carbon monoxide is still the commonest harmless. There is now a further anti- feasible is it to conform to the European Emerg Med J: first published as 10.1136/emj.19.3.190 on 1 May 2002. Downloaded from 15 16 guidelines on administration of activated cause of poisoning deaths in the United dote, . This drug charcoal within one hour of an overdose? Kingdom. In the emergency department, should be more widely used because it Emerg Med J 2001;18:390–2. may be especially useful in patients with 6 Wolseley BA, McKinney PE. Does acute and subacute exposure are impor- transportation by ambulance decrease time to tant presentations to recognise and treat. smoke inhalation, as it is not toxic and gastrointestinal decontamination after Many departments in the UK wisely can be given outside the hospital. overdose? Ann Emerg Med teach on the common and non-specific 2000;35:579–84. 7 American Academy of Clinical Toxicology symptoms that result from poisoning at CONCLUSION and European Association of Poison Control the start of the winter months. Treat- The scene changes from time to time. We Centres and Clinical Toxicologists. Position ment is controversial. Publication of the statement: single dose activated charcoal. Clin have tried to point out a few of the Toxicol 1997;35:721–41. first double blind trial of hyperbaric oxy- developments in poisoning where 8 American Academy of Clinical Toxicology gen in carbon monoxide poisoning in the changes are taking place. Hippocrates is and European Association of Poison Control Australian Journal of Medicine has cast reputed to have said “Primum non Centres and Clinical Toxicologists. Position statement: whole bowel irrigation. Clin Toxicol doubt on the usefulness of hyperbaric nocere” (first of all do not cause harm). 1997;35:753–62. therapy,13 14 but a further study as yet Many dramatic interventions are avail- 9 Caruana DS, Weinbach B, Goerg D, et al. only published in abstract form is likely able, but the risk-benefit balance has to Cocaine packet ingestion: diagnosis, management and natural history. Ann Intern to show that it is effective (LK Weaver, et be borne in mind so that the patient Med 1984;100:73–4. al, UHMS Annual Scientific Meeting recovers as a result of good medicine. 10 Tenenbein M. Whole bowel irrigation as a Session Texas, 2001). Many recommend gastrointestinal decontamination procedure Emerg Med J 2002;19:192–193 after acute poisoning. hyperbaric oxygen in those who have lost 1988;3:77–84. consciousness, those with a blood car- ...... 11 BMA/RPSGB. British National Formulary. No boxyhaemoglobin over 20% on arrival, 42. London: British Medical Association/ Authors’ affiliations Royal Pharmaceutical Society of Great Britain, the pregnant patient and those with A Parfitt, J A Henry, Academic Department of 2001. neurological or electrocardiographic Accident and Emergency Medicine, Imperial 12 Bialas MC, Evans RJ, Hutchins AD, et al The changes. Hyperbaric centres are available College School of Medicine, St Mary’s Hospital, impact of nationally distributed guidelines on London W2 1NY, UK the management of paracetamol poisoning in for expert consultation and generally accident and emergency departments. J Accid rely on the clinical picture to reach a Correspondence to: Professor J A Henry; Emerg Med 1998:15:13–17. decision regarding treatment. [email protected] 13 Scheinkestel CD,BaileyM,MylesPS,et al. Hyperbaric or normobaric oxygen for acute carbon monoxide poisoning a randomised REFERENCES controlled trial. Med J Aust 1999;170:203– Although rare, acute 1 Greaves I, Goodacre S, Grout P. 10. requires immediate action. Many pa- Management of in A and E 14 Weaver LK. Hyperbaric oxygen in carbon departments in the United Kingdom. J Accid monoxide poisoning. BMJ 1999;319:1083– tients suffering from smoke inhalation Emerg Med 1996;13:43–8. 4. or burns may also have cyanide toxicity, 2 Jones AI, Volans G. Management of self 15 Houeto P, Hoffman JR, Baud FJ, et al. and may present with a metabolic acido- poisoning. BMJ 1999;319:1414–17. Relation of blood cyanide to plasma 3 Henry JA, Hoffman JR. Continuing cyanocobalamin concentration after a fixed sis not responding to oxygen administra- controversy in gut decontamination. Lancet dose of hydroxocobalamin in cyanide tion. Different antidotes are used in 1998;352:420–1. poisoning. Lancet 1995;346:605–8. http://emj.bmj.com/ different countries, cobalt edetate (UK) 4 Saetta JP, March S, Gaunt ME, et al. Gastric 16 Beasley DM, Glass WI. Cyanide poisoning: emptying procedures in the self poisoned pathophysiology and treatment and (USA) are the com- patient: are we forcing gastric content beyond recommendations. Occup Med monest, each with its drawbacks, while the pylorus? J R Soc Med 1991;84:274–6. 1998;48:427–31. on September 25, 2021 by guest. Protected copyright.

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Research fully substitute for undertaking a course

...... of research under good supervision. It Emerg Med J: first published as 10.1136/emj.19.3.190 on 1 May 2002. Downloaded from does however provide guidance on how to go about emergency medicine re- Introduction to the research series search and discuss solutions to the com- mon difficulties encountered. A M T Good, P Driscoll We offer therefore a starting point. It is ...... hoped that in time this series will be supplemented with further well in- This short editorial introduces the series on research in formed articles. This then will add to the emergency medicine that starts in this issue pool of knowledge available to facilitate high quality emergency medicine re- search. To provide not only the maps and confidence to approach experienced t was Sir William Osler who said that Unfortunately for the majority of navigators but also a well founded visiting patients without having read those who undertake research in emer- enthusiasm for going to sea. Imedicine was like going to sea without gency medicine no such luxury is avail- maps. One might say this of research. able. They therefore often set off without Most doctors enter higher specialist proper preparation, the ability to deal training with only a rudimentary knowl- with difficulties that arise or even a clear edge of how to conduct a scientific study. destination. Some if not many give up ...... Those that decide to take up an academic disillusioned. Authors’ affiliations post will have a supervisor (or navigator) The objective of this series of 10 A M T Good, Royal Liverpool University to help them though planning their articles is to help disseminate the wis- Hospital, Prescot Street, Liverpool L7 8XP, UK P Driscoll, Hope Hospital, Salford, UK research and negotiating the difficulties dom that is often held in established that arise. research centres. Such a series cannot Correspondence to: Dr A M T Good

POSITION STATEMENT ...... Anaesthetic machines in the accident and emergency resuscitation room http://emj.bmj.com/

lease ensure that any anaesthetic machine used in the accident and emergency resuscitation room Pcomplies with safety notice MDA SN2001(15). Recommendations • All anaesthetic machines used in A&E must be equipped with a hypoxic mixture guard with an audi-

ble alarm to prevent the delivery of a gas mixture containing less than 20% oxygen to a patient. on September 25, 2021 by guest. Protected copyright. • No practitioner should use an anaesthetic machine unless they have been trained and are competent in its use. All anaesthetic machines must be checked regularly and before each use by an authorised person. M J Clancy on behalf of FAEM and BAEM

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