PostScript
`
`A laryngeal mask airway may certainly
`have a role as a backup device, but is not
`always easy to insert, particularly in the mul-
`tiply
`injured patient
`requiring
`cervical
`stabilisation.2 Comparative studies are re-
`quired to determine the best approach to a
`failed prehospital intubation.
`C Kelly (Mackay), T Coats
`Helicopter Emergency Medical Service, Royal
`London Hospital, Whitechapel, London, UK;
`cathy.kelly@luht.scot.nhs.uk
`
`References
`1 Cook TM. A new practical classification of
`laryngeal view. Anaesthesia 2000;55:274–9.
`2 Gabbot DA, Sasada MP. Laryngeal mask
`airway insertion using cricoid pressure and
`manual in line neck stabilisation. Anaesthesia
`1995;50:674–6.
`
`Intranasal naloxone for life
`threatening opioid toxicity
`Heroin overdose is a major cause of death in
`Western countries. Many lives are saved by the
`administration of naloxone by emergency
`department and ambulance staff. In Aus-
`tralia, there have recently been calls by drug
`and alcohol dependence agencies and coro-
`ners for the extension of this treatment to
`other emergency service and community
`workers.
`Parenteral
`administration
`of
`naloxone however has some problems. It
`entails administration by way of an injection,
`mandating training of personnel and secure
`storage of equipment. There is also risk of
`transmission of blood-borne diseases such as
`hepatitis C to the treating person by way of
`needlestick injuries.
`Currently available pharmacology data sug-
`gest that naloxone has high bioavailability
`through the nasal mucosa, with onset of
`action and plasma bioavailability curves that
`are very similar to the intravenous route.1
`Work in the field of drug addiction has shown
`that intranasal naloxone is effective in detec-
`tion of opioid dependence 2 and is as effective
`as parenteral naloxone for the reversal of
`opioid effects.3 To date, the intranasal admin-
`istration of naloxone for the emergency treat-
`ment of opioid overdose has not been reported
`in the literature.
`Six cases of isolated acute heroin overdose
`were treated with intranasal naloxone,
`in
`addition to ventilatory support, in the Depart-
`ment of Emergency Medicine of Western
`Hospital, Melbourne, Australia. All patients
`had return of adequate spontaneous respira-
`tion within two minutes, with a median of 50
`seconds (table 1). Doses used ranged from 0.8
`to 2 mg and were at the treating doctor’s dis-
`cretion.
`If intranasal administration of naloxone
`could be shown in larger series to be effective
`and practical, there is the potential to extend
`
`Table 1
`
`Patient
`
`Dose IN
`naloxone
`
`Time to
`spontaneous
`respiration
`
`1
`2
`3
`4
`5
`6
`
`0.8 mg
`1.6 mg
`1.6 mg
`2 mg
`1.6 mg
`0.8 mg
`
`40 seconds
`2 minutes
`30 seconds
`1 minute
`90 seconds
`30 seconds
`
`this treatment to a wide variety of community
`workers without the risk of needlestick injury
`and with minimal training. This may well
`translate into an increase in lives saved.
`A prospective clinical trial comparing the
`effectiveness and safety of the intranasal
`route for administration of naloxone to the
`intramuscular route in the prehospital setting
`is planned to begin in December 2001.
`
`A-M Kelly
`Joseph Epstein Centre for Emergency Medicine
`Research and Department of Emergency Medicine,
`Western Hospital, Australia and The University of
`Melbourne, Australia
`
`Z Koutsogiannis
`Joseph Epstein Centre for Emergency Medicine
`Research and Department of Emergency Medicine,
`Western Hospital, Australia
`
`Correspondence to: Professor A-M Kelly, Joseph
`Epstein Centre for Emergency Medicine Research,
`Western Hospital, Private Bag, Footscray 3011,
`Australia; Anne-Maree.Kelly@wh.org.au
`
`References
`1 Hussain AA, Kimura R, Huang CH. Nasal
`absorption of naloxone and buprenorphine in
`rats. IntJPharmacol 1984;21:233.
`2 Loimer N, Hofmann P, Chaudhry HR. Nasal
`administration of naloxone for detection of
`opiate dependence. JPsychiatrRes
`1992;26:39–43.
`3 Loimer N, Hofmann P, Chaudhry HR. Nasal
`administration of naloxone is as effective as
`the intravenous route in opiate addicts. IntJ
`Addict 1994;29:819–27.
`
`Anti-D immunoprophylaxis
`within the accident and
`emergency department
`The debate on anti-D prophylaxis rages on.
`Recently the subject was discussed in a green
`top guideline from the Royal College of
`Obstetricians and Gynaecologists.1 There are
`still approximately 50 deaths per annum
`attributable to rhesus isoimmunisation in the
`UK. In reviewing the reasons why these
`deaths still occur, the Consensus Conference
`on Anti D in 1997 admitted that the 1991
`Recommendations are not being adhered to
`by all units and that a substantial proportion
`of accident and emergency (A&E) depart-
`ments did not administer anti-D when appro-
`priate (Consensus Conference on Anti-D
`Prophylaxis, Edinburgh, UK 8–9 April, 1997).
`The conference discussed but did not
`conclude on the need for anti-D prophylaxis
`where threatened miscarriage and resolution
`occurs in the first trimester, or when sponta-
`neous miscarriage occurs at this time without
`instrumentation. The College guidelines go
`further in advocating non-use of anti-D when
`pregnancy bleeding occurs in the first trimes-
`ter with a viable fetus and supports the use of
`anti-D when “bleeding is heavy or repeated,
`when abdominal pain is present or when ges-
`tation approaches 12 weeks”.
`There is a need here for more precision.
`Many SHOs in A&E have limited gynaecologi-
`cal experience and under the new guidelines
`will be expected to determine which patients
`require anti-D.
`Furthermore, the present recommendation
`for non-use of anti D is based largely on two
`observational studies, (Grade C recommen-
`dation). In this era of evidence based medi-
`cine is this sufficient basis for a change in
`policy?
`In the past anti-D immunoprophylaxis was
`routinely given to all rhesus negative women
`
`375
`
`with early pregnancy bleeding. This has not
`been shown so far to be significantly associ-
`ated with adverse side effects and the cost
`implications are not prohibitive.
`Perhaps the way forward is shown in a
`more recent RCOG guideline, on the manage-
`ment of early pregnancy loss.2 The same
`dilemma is dealt with in a caveat “if there is
`clinical doubt then anti D should be given”.
`Until more conclusive information is to hand,
`rather than obfuscating the issue, a return to
`a policy of administering anti-D to all rhesus
`negative women with early pregnancy bleed-
`ing seems a more plausible option.
`M J Kavanagh, T Dada
`Accident and Emergency and Obstetrics and
`Gynaecology Departments, St James’s University
`Hospital, Beckett Street, Leeds LS 9 7TF, UK
`References
`1 Royal College of Obstetrics and
`Gynaecology Guidelines. Useofanti-D
`immunoglobulinforRhprophylaxis. 2000
`(www.rcog.uk/guidelines/antid.html)
`2 Royal College of Obstetrics and
`Gynaecology Guidelines. Managementof
`earlypregnancyloss. 2000
`(www.rcog.uk/guidelines25.html)
`
`Teaching and learning
`We read with interest the paper by Dr Lockey
`describing the different learning approaches
`that may be taken by students.1 We are aware
`that the field of educational psychology is
`woolly and littered with many definitions and
`it may be difficult to give a brief overview of
`learning approaches. The author has made a
`valid point in suggesting that as doctors we
`are expected to teach but are rarely trained in
`the teaching process. The author goes on to
`describe how there are essentially two learn-
`ing approaches adopted by students: “sur-
`face” and “deep”. We are then told how deep
`learning is superior to surface and that as
`educators we should attempt to promote deep
`learning.
`This is fine. However, Dr Lockey has made
`an important omission in his paper. The
`author has failed to describe a third and very
`important learning approach. That is the
`“strategic” approach as described by Miller
`and Partlett.2
`The strategic learner is a success driven
`person who approaches the learning process
`as a game where a high mark is the end point.
`These people will focus only on what they
`perceive to be relevant to exam success and
`disregard additional information. They may
`attempt exam prediction or even attempt to
`obtain inside information from authority fig-
`ures. This approach results in poor long term
`recall and patchy subject knowledge. Mc-
`Manus et al have shown that medical students
`with the most clinical experience do not
`perform best in final exams but deep and
`strategic approaches do correlate well will
`exam success.3 The worry here is that as
`medical students these people may flourish in
`exams but as clinicians lack the knowledge
`base or understanding to work safely or effec-
`tively.
`
`R McLaughlin
`Emergency Department, Royal Victoria Hospital,
`Grosvenor Road, Belfast BT12 6BA, UK
`R Bell
`Radiology Department, Royal Victoria Hospital
`References
`1 Lockey A. Teaching and learning. Emerg
`MedJ 2001;18:451–2.
`
`www.emjonline.com
`
`Opiant Exhibit 2013
`Nalox-1 Pharmaceuticals, LLC v. Opiant Pharmaceuticals, Inc.
`IPR2019-00690
`Page 1
`
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