Casualty: the BBC series/Letters to the Editor 301 and the general practitioner (I'm sure that many is popular for many reasons. It is part soap J Accid Emerg Med: first published as 10.1136/emj.13.4.301-c on 1 July 1996. Downloaded from readers will believe this is the most important opera, part education, and it appeals to the message of all to portray). In each episode there public fascination with all things medical. It may actually be several messages, each targeting portrays life in an "average" A&E depart- a different type ofviewer. ment, warts and all. I have been fortunate to be involved with it and in Clive Mantle Conclusion (who plays the consultant Mike Barret) I The programme is not perfect as there are have found one of the few people I can beat limitations which define how it is made. It at golf. LETTERS TO THE EDITOR Fluid resuscitation in traumatic that directly compared ATLS with some 1 Greaves I, Goodacre S. Grout P. Management of drug overdose in accident and emergency haemorrhage other control. It is for this reason that I departments in the United Kingdom. J Accid suggested in the article, that components of EmergMed 1996;13:46-8. EDITOR,-The article "Fluid resuscitation in ATLS, for example the fluid resuscitation 2 Roy B, Crawford R. Pitfalls in diagnosis and traumatic haemorrhage" by R Cutress' con- regime, be individually taken and put to test. management of carbon monoxide poisoning. JAccid Emerg Med 1996;13:62-3. tains a significant error (or perhaps a mis- 3 Smith JS, Brandon S. Morbidity from acute print). The author states "...ATLS as a RAMSEY CUTRESS carbon monoxide poisoning at 3 year follow package has been shown to be more effective 1 Mill Close, Hemingford Grey, up. BMJ 1973;i:318-21. Cambnidgeshire 4 Tibbles PM, Perrotta PL. Treatment of carbon in prehospital treatment than Basic Life monoxide poisoning: a critical review of Support", citing references 22 and 23. 1 Ali J, Adam R, Butler AK, Chang H, Howard outcome studies comparing normo- M, Gonsalves D, et al. Trauma outcome human Neither of the articles referenced looked at improves following the Advanced Trauma baric oxygen with hyperbaric oxygen. Ann ATLS. They compared ALS (Advanced Life Life Support program in a developing Emerg Med 1994;24:269-76. Support) for ambulancemen (the equivalent country. J Trauma 1993;34:890-8. of extended training) to basic ambulance 2 Vestrup JA, Stormorken A, Wood V. Impact of Advanced Trauma Life Support training on training and found it produced better results. early trauma management. Am Jf Surg However, this conclusion must be regarded 1 988;155:704-7. with caution as the methodology in both studies was weak. The author states that "ATLS has been shown to make a substantial contribution to the management of trauma". As an ATLS Paracetamol overdose enthusiast I agree with the spirit of this state- ment. However, I am unaware of any trial of EDITOR,-The treatment of paracetamol Management poisoning overdose has been and remains a contentious showing that ATLS has a significant impact http://emj.bmj.com/ on morbidity or mortality. Perhaps it is not ED1ToR,-The recent paper from Greaves issue among both toxicologists and A&E necessary to prove that it does. But then, as et al' suggests the management of poisoning doctors. The opinions expressed in the recent the author has demonstrated, when you is likely to be variable and that the existing review of the management of drug overdoses examine the conventional wisdom, as he does literature is interpreted in different ways by in A&E departments in the United with intravenous fluid, the results can be different people. The staff in Glasgow Kingdom,' however, were misleading and surprising. deserve credit for diagnosing acute carbon failed to indicate the currently accepted monoxide poisoning and for the satisfactory guidelines for the management of acute para- BRIAN MCNICHOLL cetamol overdosage.2 In both scenario 1 and A&E Department, Royal Victonia Hospital outcome of the patients they report.2 Despite Grosvenor Road, Belfast the certainty with which they recommend 2 it was implied that gastric lavage was an on September 26, 2021 by guest. Protected copyright. hyperbaric oxygen (HBO) for acute carbon inappropriate measure, but from the history 1 Cutress R. Fluid resuscitation in traumatic monoxide poisoning, the data they cite are in both cases gastric lavage with charcoal was haemorrhage. J Accid Emerg Med 1995; the treatment of choice. I find the assertion 12:165. limited.3 Some clinicians hold a contrary view. Authors of a review of controlled trials regarding the patient in scenario 1 comparing normobaric and hyperbaric particularly alarming as the only early diag- concluded that further trials were nostic aid in cases of paracetamol overdose is oxygen the history taken from the patient. It should The author replies needed to establish the role of HBO.4 Until these have been carried out, the risks of be of little relevance how frequently the transferring critically ill patients must be patient attends or how many previous over- I would like to thank Brian McNicholl for doses the patient has taken; patients should pointing out an error in my article "Fluid balanced against possible benefits of HBO. Further studies are needed in other areas of be treated according to accepted guidelines resuscitation in traumatic haemorrhage". As until proof exists that the history is he correctly states the sentence should read poisoning but, to avoid unnecessary dupli- inaccurate. Gastric lavage is rapidly losing "There has been no evidence to date cation of previous work, systematic review of evidence is needed. A is favour in the treatment of paracetamol over- suggesting that prehospital administration of current group dose but gastric lavage alone has been shown intravenous fluids is of benefit to trauma currently trying to establish (with the support and Australasian to lower plasma paracetamol levels by up to patients (reference 21), although ALS of the UK Cochrane 39-3%3 and in combination with charcoal is (Advanced Life Support ) as a package has Centres) a Cochrane Collaborative Review on and envenomation. still regarded as the optimum treatment of been shown to be more effective in pre- Group poisoning paracetamol overdose within two hours of hospital treatment than Basic Life Support Anyone wishing to contribute to this can ingestion. (references 22, 23 )." contact the following: R D Hardem, Accident The effect of ATLS has been studied by and Emergency, St James's University Hospi- J WHI-IrAKER comparing patient outcome before and after tal, Beckett Street, Leeds LS9 7TF, United Accident and Emergency Department, the introduction ofATLS. In this way ATLS Kingdom, or Dr N Buckley, Discipline of Royal Preston Hospital, Preston has been shown to improve patient outcome.' Clinical Pharmacology, Mater Misercordiae 1 Greaves I, Goodacre S, Grout P. Management Such studies however, do not always show Hospital, Watarah, NSW 2298, Australia. of drug overdoses in accident and emergency significant improvement.2 I am sure that departmnents in the United Kingdom. J Accid RICHARD HARDERN EmergMed 1996;13:46-8. there would be inherent difficulties in the Accident and Emergency, 2 Management of acute paracetamol overdosage. design and methodology of an "ideal" trial St James's University Hospital, Leeds Guidelines from the Paracetamol Information.