Latest from EMJ

An 80-year-old man with acute onset of right upper limb weakness [IMAGES IN EMERGENCY MEDICINE]

Sat, 1 Jun 2013 00:00:00 +0000

An 80-year-old man with a history of hypertension was referred under the suspicion of stroke. He suffered from acute onset of right upper limb weakness 4 h before presenting to our emergency department. He did not have dysarthria, facial palsy or positive pronator sign. But decreased right radial pulse and cold upper limb with cyanosis were noted. Emergent CT angiography was performed and revealed isolated spontaneous right subclavian artery dissection (figure 1A), which extended to axillary artery with compression of true lumen by thrombosed false lumen (figure 1B). He then received heparinisation treatment and the weakness of his right upper limb gradually recovered. Isolated spontaneous subclavian artery dissection is extremely rare.1 The initial clinical presentation is often misdiagnosed as stroke. To check the pulse of the ...

Transfer of patients with ruptured abdominal aortic aneurysm from general hospitals to specialist vascular centres: results of a Delphi consensus study [ORIGINAL ARTICLE]

Sat, 1 Jun 2013 00:00:00 +0000

AimTo explore areas of consensus and disagreement concerning the interhospital transfer of patients with a clinical diagnosis of ruptured abdominal aortic aneurysm. MethodsA three-round Delphi questionnaire approach was used among vascular and endovascular surgery and emergency medicine specialists to explore patient characteristics and clinical management issues for emergency interhospital transfer. Analysis is based on 38 responses to rounds 2 and 3 (19 vascular surgeons, 6 interventional radiologists, 13 emergency care specialists) with agreement reported when 70% of respondents were in agreement. ResultsInitially there was agreement that transfer patients should be <85 years of age, either alert or with fluctuating consciousness, with moderate or minimal systemic disease, needing no/some help with daily living. Round 3 clarified that patients requiring inotropes and those institutionalised for mental infirmity should be transferred. Those with cardiac arrest in current episode should not be transferred. There was no agreement as to whether those institutionalised with physical infirmities, unconscious/intubated patients or those with severe systemic disease should be transferred. Speed was accepted as important, with agreement for specialty trainees to arrange transfer if consultants were not on site. Consultant-consultant discussion was recommended for patients with severe systemic disease. CT confirmation of diagnosis was considered unnecessary before transfer but ultrasound assessment was desirable, and transfers should not be delayed by waiting for specific tests. There was no agreement about blood tests and ECG before transfer or whether blood should accompany the patient being transferred. There was no agreement as to whether specific staff/facilities needed to be in place at the specialist hospital. A systolic blood pressure [≥]70 mm Hg was sufficient for transfer without the need for intravenous fluids unless deterioration occurred. ConclusionsThere is broad agreement about the type of patient who should be eligible for transfer but disagreements about patient management before and during transfer remain.

Cardiac arrest management in general practice in Ireland: a 5-year cross-sectional study [RESEARCH]

Tue, 14 May 2013 00:00:00 +0000

ObjectiveTo document the involvement of general practitioners (GPs) in cardiac arrests with resuscitation attempts (CARAs) and to describe the outcomes. DesignA 5-year prospective cross-sectional study of GPs in Ireland equipped with automated external defibrillators (AEDs) and immediate care training by the MERIT Project, with data collection every 3 months over the 5-year period. Practices reported CARAs by quarterly survey with an 89% mean response rate (81-97% for the period). SettingGeneral practices throughout Ireland. Participants495 GP participated: 168 (33.9%) urban, 163 (32.9%) rural and 164 (33.1%) mixed. InterventionsAll participating practices received a standard AED and basic life support kit. Training in immediate care was provided for at least one GP in the practice. Main outcome measuresIncidence of CARA in participating practices. Return of spontaneous circulation (ROSC) and discharge alive from hospital. Results36% of practices were involved in a CARA during the 5-year period and 13% were involved in more than one CARA. Of the 272 CARAs reported, ROSC occurred in 32% (87/272) and discharge from hospital in 18.7% (49/262). In 45% of cases, the first AED was brought by the GP and in 65%, the GP arrived before the ambulance service. More cases occurred in rural and mixed settings than urban ones, but the survival rates did not differ between areas. In 65% of cases, the GP was on duty at the time of the incident and 47% of cases occurred in the patient's home. ConclusionsThese outcomes are comparable with more highly structured components of the emergency response system and indicate that GPs have an important role to play in the care of patients in their own communities. GPs experience cardiac arrest cases during the course of their daily work and provide prompt care which results in successful outcomes in urban, mixed and rural settings.

Shorter time until return of spontaneous circulation is the only independent factor for a good neurological outcome in patients with postcardiac arrest syndrome [ORIGINAL ARTICLE]

Thu, 2 May 2013 00:00:00 +0000

ObjectiveFew studies have reported factors that result in a better neurological outcome in patients with postcardiac arrest syndrome (PCAS) following return of spontaneous circulation (ROSC). We investigated the factors affecting neurological outcome in terms of both prehospital care and treatments after arrival at hospital in patients with PCAS. MethodsThe study enrolled patients with cardiogenic cardiac arrest who were admitted to an intensive care unit after ROSC with PCAS. We investigated the association of the following factors with outcome: age, gender, witness to event present, bystander cardiopulmonary resuscitation (CPR) performed, ECG waveform at the scene, time interval from receipt of call to arrival of emergency personnel, time interval from receipt of call to arrival at hospital, prehospital defibrillation performed, special procedures performed by emergency medical technician, and time interval from receipt of call to ROSC, coronary angiography/percutaneous coronary intervention (PCI) and therapeutic hypothermia performed. ResultsThe study enrolled 227 patients with PCAS. Compared with the poor neurological outcome group, the good neurological outcome group had a statistically significant higher proportion of the following factors: younger age, male, witness present, bystander CPR performed, first ECG showed ventricular fibrillation/pulseless ventricular tachycardia, defibrillation performed during transportation, short time interval from receipt of call to ROSC, coronary angiography/PCI and therapeutic hypothermia performed. Of these factors, the only independent factor associated with good neurological outcome was the short time interval from receipt of the call to ROSC. ConclusionsIn the present study, shortening time interval from receipt of call to ROSC was the only important independent factor to achieve good neurological outcome in patients with PCAS.

The association of alcohol drinking pattern and self-inflicted intentional injury in Korea: a cross-sectional WHO collaborative emergency room study [RESEARCH]

Tue, 30 Apr 2013 00:00:00 +0000

ObjectivesSelf-inflicted intentional injuries are increasing at an alarming rate in the Republic of Korea, yet few reports describe their relationship with alcohol consumption. The aim of this study was to characterise the association of alcohol drinking patterns and self-inflicted intentional injury in Korean emergency departments (EDs) using WHO collaborative study protocol. DesignCross-sectional study. SettingData were collected from four general hospital EDs in four geographically diverse regions of Korea: Seoul, Suwon, Chuncheon and Gwangju. ParticipantsInformation was collected on 1989 patients aged 18 and above. A representative probability sample was drawn from patients admitted to each ED for the first time within 6 h of injury. Primary and secondary outcome measuresAlcohol-related non-fatal injuries. ResultsAmong 467 persons with alcohol-related injuries, 33 (7.1%), were self-inflicted intentional injuries and 137 (29.3%) were intentional injuries caused by someone else. The adjusted odds of self-inflicted intentional injury verses unintentional injury were calculated for heavy (OR 1.764; 95% CI 0.783 to 3.976), binge (OR 2.125; 95% CI 0.930 to 4.858) and moderate drinking (OR 3.039; 95% CI 1.129 to 8.178) after controlling for demographic variables. Similar odds were reported for pooled intentional injury data (self-inflicted and caused by someone else) and drinking patterns. ConclusionsThese data show a strong association between all patterns of acute alcohol consumption and self-inflicted intentional injury in the Republic of Korea.

The eye response test alone is sufficient to predict stroke outcome--reintroduction of Japan Coma Scale: a cohort study [RESEARCH]

Mon, 29 Apr 2013 00:00:00 +0000

ObjectivesPrompt assessment of consciousness levels is vitally important during the emergency care of stroke patients. The Japan Coma Scale (JCS) is a one-axis coma scale published in 1974 with outstanding simplicity. The hypothesis is that JCS is sufficient to predict stroke outcome. The aim of the study was to verify the predictability of JCS, which should help JCS attain international recognition. DesignA cohort study. SettingA prefectural stroke registry. ParticipantsWe analysed 13 788 stroke patients identified from January 1999 to December 2009 inclusive in the entire Kyoto prefecture and registered in the Kyoto Stroke Registry (KSR). Main outcome measuresWe investigated the relationship between consciousness levels, based on JCS at stroke onset and activities of daily living (ADL) at 30 days or deaths within 30 days in a large population-based stroke registry. We calculated Spearman's coefficient for the correlation between JCS and the ADL scale, generated estimated survival curves by the Kaplan-Meier method and finally compared HRs for death within 30 days after onset, comparing patients with different conscious levels based on JCS. ResultsA total of 13 406 (97.2%) patients were graded based on JCS. JCS correlated to the ADL scale with Spearman's correlation coefficient of 0.61. HRs for death within 30 days were 1 (reference) (95% CIs), 5.55 (4.19 to 7.37), 9.54 (7.16 to 12.71) and 35.21 (26.10 to 44.83) in those scored as JCS0, JCS1, JCS2 and JCS3, respectively. ConclusionsUsing a single test of eye response, JCS has outstanding merits as a coma scale, that is, simplicity and applicability. The present study adds predictability for early outcome in stroke patients. JCS is valuable, especially in an emergency setting, when a prompt assessment of consciousness levels is needed.

Portrait of rural emergency departments in Quebec and utilisation of the Quebec Emergency Department Management Guide: a study protocol [PROTOCOL]

Mon, 29 Apr 2013 00:00:00 +0000

IntroductionEmergency departments are important safety nets for people who live in rural areas. Moreover, a serious problem in access to healthcare services has emerged in these regions. The challenges of providing access to quality rural emergency care include recruitment and retention issues, lack of advanced imagery technology, lack of specialist support and the heavy reliance on ambulance transport over great distances. The Quebec Ministry of Health and Social Services published a new version of the Emergency Department Management Guide, a document designed to improve the emergency department management and to humanise emergency department care and services. In particular, the Guide recommends solutions to problems that plague rural emergency departments. Unfortunately, no studies have evaluated the implementation of the proposed recommendations. Methods and analysisTo develop a comprehensive portrait of all rural emergency departments in Quebec, data will be gathered from databases at the Quebec Ministry of Health and Social Services, the Quebec Trauma Registry and from emergency departments and ambulance services managers. Statistics Canada data will be used to describe populations and rural regions. To evaluate the use of the 2006 Emergency Department Management Guide and the implementation of its various recommendations, an online survey and a phone interview will be administered to emergency department managers. Two online surveys will evaluate quality of work life among physicians and nurses working at rural emergency departments. Quality-of-care indicators will be collected from databases and patient medical files. Data will be analysed using statistical (descriptive and inferential) procedures. Ethics and disseminationThis protocol has been approved by the CSSS Alphonse-Desjardins research ethics committee (Project MP-HDL-1213-011). The results will be published in peer-reviewed scientific journals and presented at one or more scientific conferences.

Evaluation of the DAVROS (Development And Validation of Risk-adjusted Outcomes for Systems of emergency care) risk-adjustment model as a quality indicator for healthcare [ORIGINAL ARTICLE]

Fri, 19 Apr 2013 00:00:00 +0000

Background and objectiveRisk-adjusted mortality rates can be used as a quality indicator if it is assumed that the discrepancy between predicted and actual mortality can be attributed to the quality of healthcare (ie, the model has attributional validity). The Development And Validation of Risk-adjusted Outcomes for Systems of emergency care (DAVROS) model predicts 7-day mortality in emergency medical admissions. We aimed to test this assumption by evaluating the attributional validity of the DAVROS risk-adjustment model. MethodsWe selected cases that had the greatest discrepancy between observed mortality and predicted probability of mortality from seven hospitals involved in validation of the DAVROS risk-adjustment model. Reviewers at each hospital assessed hospital records to determine whether the discrepancy between predicted and actual mortality could be explained by the healthcare provided. ResultsWe received 232/280 (83%) completed review forms relating to 179 unexpected deaths and 53 unexpected survivors. The healthcare system was judged to have potentially contributed to 10/179 (8%) of the unexpected deaths and 26/53 (49%) of the unexpected survivors. Failure of the model to appropriately predict risk was judged to be responsible for 135/179 (75%) of the unexpected deaths and 2/53 (4%) of the unexpected survivors. Some 10/53 (19%) of the unexpected survivors died within a few months of the 7-day period of model prediction. ConclusionsWe found little evidence that deaths occurring in patients with a low predicted mortality from risk-adjustment could be attributed to the quality of healthcare provided.

Which extended paramedic skills are making an impact in emergency care and can be related to the UK paramedic system? A systematic review of the literature [REVIEW]

Wed, 10 Apr 2013 00:00:00 +0000

BackgroundIncreasing demand on the UK emergency services is creating interest in reviewing the structure and content of ambulance services. Only 10% of emergency calls have been seen to be life-threatening and, thus, paramedics, as many patients' first contact with the health service, have the potential to use their skills to reduce the demand on Emergency Departments. This systematic literature review aimed to identify evidence of paramedics trained with extra skills and the impact of this on patient care and interrelating services such as General Practices or Emergency Departments. MethodsInternational literature from Medline, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL), ProQuest, Scopus and grey literature from 1990 were included. Articles about any prehospital emergency care provider trained with extra skill(s) beyond their baseline competencies and evaluated in practice were included. Specific procedures for certain conditions and the extensively evaluated UK Emergency Care Practitioner role were excluded. Results8724 articles were identified, of which 19 met the inclusion criteria. 14 articles considered paramedic patient assessment and management skills, two articles considered paramedic safeguarding skills, two health education and learning sharing and one health information. There is valuable evidence for paramedic assessing and managing patients autonomously to reduce Emergency Department conveyance which is acceptable to patients and carers. Evidence for other paramedic skills is less robust, reflecting a difficulty with rigorous research in prehospital emergency care. ConclusionsThis review identifies many viable extra skills for paramedics but the evidence is not strong enough to guide policy. The findings should be used to guide future research, particularly into paramedic care for elderly people.

Intravenous nicardipine and labetalol use in hypertensive patients with signs or symptoms suggestive of end-organ damage in the emergency department: a subgroup analysis of the CLUE trial [RESEARCH]

Tue, 26 Mar 2013 00:00:00 +0000

ObjectiveTo compare the efficacy of Food and Drug Administration recommended dosing of nicardipine versus labetalol for the management of hypertensive patients with signs and/or symptoms (S/S) suggestive of end-organ damage (EOD). DesignSecondary analysis of the multicentre prospective, randomised CLUE trial. Setting13 academic emergency departments in the USA. ParticipantsEligible patients had two systolic blood pressure (SBP) measures [≥]180 mm Hg at least 10 min apart, no contraindications to nicardipine or labetalol and predefined S/S suggestive of EOD on arrival. InterventionsMedications were administered by continuous infusion (nicardipine) or repeat intravenous bolus (labetalol) for a study period of 30 min or until a specified target SBP {+/-}20 mm Hg was achieved. Primary outcome measurePercentage of participants achieving a predefined target SBP range (TR) defined as an SBP within {+/-}20 mm Hg as established by the treating physician. ResultsOf the 141 eligible patients, 49.6% received nicardipine, 51.7% were women and 81.6% were black. Mean age was 52.2{+/-}13.9 years. Median initial SBP did not differ in the nicardipine (210.5 (IQR 197-226) mm Hg) and labetalol (210 (200-226) mm Hg) groups (p=0.862). Nicardipine patients were more likely to have a history of diabetes (41.4% vs 25.7%, p=0.05) but there were no other historical, demographic or laboratory differences between groups. Within 30 min, nicardipine patients more often reached the target SBP range than those receiving labetalol (91.4% vs 76.1%, difference=15.3% (95% CI 3.5% to 27.3%); p=0.01). On multivariable modelling with adjustment for gender and clinical site, nicardipine patients were more likely to be in TR by 30 min than patients receiving labetalol (OR 3.65, 95% CI 1.31 to 10.18, C statistic=0.72). ConclusionsIn the setting of hypertension with suspected EOD, patients treated with nicardipine are more likely to reach prespecified SBP targets within 30 min than patients receiving labetalol. Clinical Trial RegistrationNCT00765648, clinicaltrials.gov

Study protocol for a randomised controlled trial comparing the efficiency of two provider-endorsed manual paediatric fluid resuscitation techniques [PROTOCOL]

Thu, 21 Mar 2013 00:00:00 +0000

IntroductionPaediatric shock is a life-threatening condition with many possible causes and a global impact. Current resuscitation guidelines require rapid fluid administration as a cornerstone of paediatric shock management. However, little evidence is available to inform clinicians how to most effectively perform rapid fluid administration where this is clinically required, resulting in suboptimal knowledge translation of current resuscitation guidelines into clinical practice. ObjectivesThis study aims to determine which of the two commonly used techniques for paediatric fluid resuscitation (disconnect-reconnect technique and push-pull technique) yields a higher fluid administration rate in a simulated clinical scenario. Secondary objectives include determination of catheter dislodgement rates, subjective and objective measures of provider fatiguability and descriptive information regarding any technical issues encountered with performance of each method under the study. Methods and analysisThis study will utilise a randomised crossover trial design. Participants will include consenting healthcare providers from McMaster Children's Hospital. Each participant will administer 900 ml (60 ml/kg) of normal saline to a simulated 15 kg infant as quickly as possible on two separate occasions using the manual fluid administration techniques under the study. The primary outcome, rate of fluid administration, will be evaluated using a paired two-tailed Student t test. Ethics and disseminationThis protocol has been approved by the Hamilton Health Sciences Research Ethics Board. ResultsThese will be published in a peer-reviewed scientific journal and presented at one or more scientific conferences. Protocol RegistrationProtocol Registered on ClinicalTrials.gov NCT01774214

Streptococcal pharyngitis in children: a meta-analysis of clinical decision rules and their clinical variables [RESEARCH]

Sat, 9 Mar 2013 00:00:00 +0000

ObjectiveTo identify the best clinical decision rules (CDRs) for diagnosing group A streptococcal (GAS) pharyngitis in children. A combination of symptoms could help clinicians exclude GAS infection in children with pharyngitis. DesignSystematic review and meta-analysis of original articles involving CDRs in children. The Pubmed, OVID, Institute for Scientific and Technical Information and Cochrane databases from 1975 to 2010 were screened for articles that derived or validated a CDR on a paediatric population: 171 references were identified. SettingAny reference including primary care for children with pharyngitis. Data extractionThe methodological quality of the articles selected was analysed according to published quality standards. A meta-analysis was performed to assess the statistical performance of the CDRs and their variables for the diagnosis of GAS pharyngitis. Primary outcome measureThe main criterion was a false-negative rate in the whole population not any worse than that of a rapid diagnostic test strategy for all patients (high sensitivity and low negative likelihood ratio). Results4 derived and 12 validated CDRs for this diagnosis in children. These articles involved 10 523 children (mean age, 7 years; mean prevalence of GAS pharyngitis, 34%). No single variable was sufficient for diagnosis. Among the CDRs, that of Joachim et al had a negative likelihood ratio of 0.3 (95% CI 0.2 to 0.5), resulting in a post-test probability of 13%, which leads to 3.6% false-negative rate among low-risk patients and 10.8% overall, equivalent to rapid diagnostic tests in some studies. ConclusionsThe rule of Joachim et al could be useful for clinicians who do not use rapid diagnostic tests and should allow avoiding antibiotic treatment for the 35% of children identified by the rule as not having GAS pharyngitis. Owing to its poor specificity, such CDR should be used to focus rapid diagnostic tests to children with high risk of GAS pharyngitis to reduce the antibiotic consumption.

Cognitive ability and educational level in relation to concussion: a population study of young men [RESEARCH]

Sat, 9 Mar 2013 00:00:00 +0000

ObjectivesTo investigate the association of concussion with cognitive ability (CA) and educational level (EL). DesignEpidemiological--cross-linkage of national computer registers. SettingDenmark. Participants130 420 young men appearing before the Danish draft board during the period 2006-2010. Primary and secondary outcome measuresCA test scores, EL and occurrence of concussion during the period 2004-2009, treated either in an A&E unit or upon admission to a hospital ward. ResultsThe 3067 men who had suffered a concussion had lower CAs (mean=96.5, SD=15, 95% CI 95.0 to 97.0) than the total cohort and they were lower for 1452 who were admitted to a hospital ward (mean CA=95.8, SD=15, 95% CI 95.1 to 96.6) than for 1615 who were treated only at an A&E unit (mean CA=97.1, SD=15, 95% CI 96.3 to 98.0). Multiple logistic regressions revealed that the effects for EL were stronger than those for CA. Among 127 353 men not sustaining a concussion, 48% attended a gymnasium' (sixth-form college), among men treated for a concussion at an A&E unit, this falls to 36% and among men hospitalised for a concussion to 30%. Transfer to a gymnasium, if it happens, almost invariably does so before the 18th birthday. Among 701 men suffering a concussion and admitted to a hospital department after this date, only 26% (n=182) were previously transferred to a gymnasium. Among the 804 men treated at an A&E unit after their 18th birthday, 33% (n=265) had done so. These two percentages are significantly below the corresponding non-concussed population (48%). ConclusionsTaken together, the results suggest that lower CA and, in particular, lower EL are risk factors for sustaining a concussion, the risk increasing with the severity of the injury.

Evaluation of clinically significant adverse events in patients discharged from a tertiary-care emergency department in Taiwan [ORIGINAL ARTICLE]

Fri, 1 Mar 2013 00:00:00 +0000

ObjectiveTo investigate the reasons for the occurrence of clinically significant adverse events (CSAEs) in emergency department-discharged patients through emergency physicians' (EPs) subjective reasoning and senior EPs' objective evaluation. DesignThis was a combined prospective follow-up and retrospective review of cases of consecutive adult non-traumatic patients who presented to a tertiary-care emergency department in Taiwan between 1 September 2005 and 31 July 2006. Data were extracted from on-duty EPs' subjective reasoning for discharging patients with CSAEs (study group) and without CSAEs (control group)' and objective evaluation of CSAEs by senior EPs, using clinical evidences such as recording history, physical examinations, laboratory/radiological examinations and observation of inadequacies in the basic management process (such as recording history, physical examinations, laboratory/radiological examinations and observation) as the guide'. Subjective reasons for discharging patients' improvement of symptoms, and the certainty of safety of the discharge were compared in the two groups using {chi}2 statistics or t test. ResultsOf the 20 512 discharged cases, there were 1370 return visits (6.7%, 95% CI 6.3% to 7%) and 165 CSAEs due to physicians' factors (0.82%, 95% CI 0.75% to 0.95%). In comparisons between the study group and the control group, only some components of discharge reasoning showed a significant difference (p<0.001). Inadequacies in the basic management process were the main cause of CSAEs (164/165). ConclusionThe authors recommended that EP follow-up of the basic management processes (including history record, physical examination, laboratory and radiological examinations, clinical symptoms/signs and treatment) using clinical evidence as a guideline should be made mandatory.

Mortality and morbidity after high-dose methylprednisolone treatment in patients with acute cervical spinal cord injury: a propensity-matched analysis using a nationwide administrative database [ORIGINAL ARTICLE]

Thu, 28 Feb 2013 00:00:00 +0000

ObjectiveTo examine the magnitude of the adverse impact of high-dose methylprednisolone treatment in patients with acute cervical spinal cord injury (SCI). MethodsWe examined the abstracted data from the Japanese Diagnosis Procedure Combination database, and included patients with ICD-10 code S141 who were admitted on an emergency basis between 1 July and 31 December in 2007-2009. The investigation evaluated the patients' sex, age, comorbidities, Japan Coma Scale, hospital volume and the amount of methylprednisolone administered. One-to-one propensity-score matching between high-dose methylprednisolone group (>5000 mg) and control group was performed to compare the rates of in-hospital death and major complications (sepsis; pneumonia; urinary tract infection; gastrointestinal ulcer/bleeding; and pulmonary embolism). ResultsWe identified 3508 cervical SCI patients (2652 men and 856 women; mean age, 60.8{+/-}18.7 years) including 824 (23.5%) patients who received high-dose methylprednisolone. A propensity-matched analysis with 824 pairs of patients showed a significant increase in the occurrence of gastrointestinal ulcer/bleeding (68/812 vs 31/812; p<0.001) in the high-dose methylprednisolone group. Overall, the high-dose methylprednisolone group demonstrated a significantly higher risk of complications (144/812 vs 96/812;OR, 1.66; 95% CI 1.23 to 2.24; p=0.001) than the control group. There was no significant difference in in-hospital mortality between the high-dose methylprednisolone group and the control group (p=0.884). ConclusionsPatients receiving high-dose methylprednisolone had a significantly increased risk of major complications, in particular, gastrointestinal ulcer/bleeding. However, high-dose methylprednisolone treatment was not associated with any increase in mortality.

The incidence of rugby-related catastrophic injuries (including cardiac events) in South Africa from 2008 to 2011: a cohort study [RESEARCH]

Tue, 26 Feb 2013 00:00:00 +0000

ObjectivesTo establish an accurate and comprehensive injury incidence registry of all rugby union-related catastrophic events in South Africa between 2008 and 2011. An additional aim was to investigate correlates associated with these injuries. DesignProspective. SettingThe South African amateur and professional rugby-playing population. ParticipantsAn estimated 529 483 Junior and 121 663 Senior rugby union ( rugby') players (population at risk). Outcome measuresAnnual average incidences of rugby-related catastrophic injuries by type (cardiac events, traumatic brain and acute spinal cord injuries (ASCIs)) and outcome (full recoveries--fatalities). Playing level (junior and senior levels), position and event (phase of play) were also assessed. ResultsThe average annual incidence of ASCIs and Traumatic Brain Injuries combined was 2.00 per 100 000 players (95% CI 0.91 to 3.08) from 2008 to 2011. The incidence of ASCIs with permanent outcomes was significantly higher at the Senior level (4.52 per 100 000 players, 95% CI 0.74 to 8.30) than the Junior level (0.24 per 100 000 players, 95% CI 0 to 0.65) during this period. The hooker position was associated with 46% (n=12 of 26) of all permanent ASCI outcomes, the majority of which (83%) occurred during the scrum phase of play. ConclusionsThe incidence of rugby-related catastrophic injuries in South Africa between 2008 and 2011 is comparable to that of other countries and to most other collision sports. The higher incidence rate of permanent ASCIs at the Senior level could be related to the different law variations or characteristics (eg, less regular training) compared with the Junior level. The hooker and scrum were associated with high proportions of permanent ASCIs. The BokSmart injury prevention programme should focus efforts on these areas (Senior level, hooker and scrum) and use this study as a reference point for the evaluation of the effectiveness of the programme.

The acute management of haemorrhage, surgery and overdose in patients receiving dabigatran [REVIEW]

Fri, 22 Feb 2013 00:00:00 +0000

Dabigatran is an oral direct thrombin inhibitor (DTI) licensed for stroke prevention in atrial fibrillation and likely to be soon approved in Europe for treatment of venous thrombosis. Predictable pharmacokinetics and a reduced risk of intracranial haemorrhage do not negate the potential risk of haemorrhage. Unlike warfarin, there is no reversal agent and measurement of the anticoagulant effect is not routine'. The prothrombin time/international normalised ratio response to dabigatran is inconsistent and should not be measured when assessing a patient who is bleeding or needs emergency surgery. The activated partial thromboplastin time (APTT) provides a qualitative measurement of the anticoagulant effect of dabigatran. Knowledge of the time of last dose is important for interpretation of the APTT. Commercially available DTI assays provide a quantitative measurement of active dabigatran concentration in the plasma. If a patient receiving dabigatran presents with bleeding: omit/delay next dose of dabigatran; measure APTT and thrombin time (consider DTI assay if available); administer activated charcoal, with sorbitol, if within 2 h of dabigatran ingestion; give tranexamic acid (1 g intravenously if significant bleeding); maintain renal perfusion and urine output to aid dabigatran excretion. Dabigatran exhibits low protein binding and may be removed by dialysis. Supportive care should form the mainstay of treatment. If bleeding is life/limb threatening, consider an additional haemostatic agent. There is currently no evidence to support the choice of one haemostatic agent (FEIBA, recombinant factor VIIa, prothrombin complex concentrates) over another. Choice will depend on access to and experience with available haemostatic agent(s).

PAin SoluTions In the Emergency Setting (PASTIES); a protocol for two open-label randomised trials of patient-controlled analgesia (PCA) versus routine care in the emergency department [PROTOCOL]

Thu, 14 Feb 2013 00:00:00 +0000

IntroductionPain is the commonest reason that patients present to an emergency department (ED), but it is often not treated effectively. Patient controlled analgesia (PCA) is used in other hospital settings but there is little evidence to support its use in emergency patients. We describe two randomised trials aiming to compare PCA to nurse titrated analgesia (routine care) in adult patients who present to the ED requiring intravenous opioid analgesia for the treatment of moderate to severe pain and are subsequently admitted to hospital. Methods and analysisTwo prospective multi-centre open-label randomised trials of PCA versus routine care in emergency department patients who require intravenous opioid analgesia followed by admission to hospital; one trial involving patients with traumatic musculoskeletal injuries and the second involving patients with non-traumatic abdominal pain. In each trial, 200 participants will be randomised to receive either routine care or PCA, and followed for the first 12 h of their hospital stay. The primary outcome measure is hourly pain score recorded by the participant using a visual analogue scale (VAS) over the 12 h study period, with the primary statistical analyses based on the area under the curve of these pain scores. Secondary outcomes include total opioid use, side effects, time spent asleep, patient satisfaction, length of hospital stay and incremental cost effectiveness ratio. Ethics and disseminationThe study is approved by the South Central--Southampton A Research Ethics Committee (REC reference 11/SC/0151). Data collection will be completed by August 2013, with statistical analyses starting after all final data queries are resolved. Dissemination plans include presentations at local, national and international scientific meetings held by relevant Colleges and societies. Publications should be ready for submission during 2014. A lay summary of the results will be available to study participants on request, and disseminated via a publically accessible website. Registration detailsThe study is registered with the European Clinical Trials Database (EudraCT Number: 2011-000194-31) and is on the ISCRTN register (ISRCTN25343280).

Randomised comparison of the effectiveness of the laryngeal mask airway supreme, i-gel and current practice in the initial airway management of prehospital cardiac arrest (REVIVE-Airways): a feasibility study research protocol [PROTOCOL]

Wed, 13 Feb 2013 00:00:00 +0000

IntroductionEffective cardiopulmonary resuscitation with appropriate airway management improves outcomes following out-of-hospital cardiac arrest (OHCA). Historically, tracheal intubation has been accepted as the optimal form of OHCA airway management in the UK. The Joint Royal Colleges Ambulance Liaison Committee recently concluded that newer supraglottic airway devices (SADs) are safe and effective devices for hospital procedures and that their use in OHCA should be investigated. This study will address an identified gap in current knowledge by assessing whether it is feasible to use a cluster randomised design to compare SADs with current practice, and also to each other, during OHCA. Methods and analysisThe primary objective of this study is to assess the feasibility of a cluster randomised trial to compare the ventilation success of two newer SADs: the i-gel and the laryngeal mask airway supreme to usual practice during the initial airway management of OHCA. The secondary objectives are to collect data on ventilation success, further airway interventions required, loss of a previously established airway during transport, airway management on arrival at hospital (or termination of the resuscitation attempt), initial resuscitation success, survival to intensive care admission, survival to hospital discharge and patient outcome at 3 months. Ambulance paramedics will be randomly allocated to one of the three methods of airway management. Adults in medical OHCA attended by a trial paramedic will be eligible for the study. Ethics and disseminationApproval for the study has been obtained from a National Health Service Research Ethics Committee with authority to review proposals for trials of a medical device in incapacitated adults. The results will be made publicly available on an open access website, and we will publish the findings in appropriate journals and present them at national and international conferences relevant to the subject field. Trial registrationISRCTN: 18528625.

Decreased length of stay after addition of healthcare provider in emergency department triage: a comparison between computer-simulated and real-world interventions [ORIGINAL ARTICLES]

Fri, 1 Feb 2013 00:00:00 +0000

Objective(1) To determine the effects of adding a provider in triage on average length of stay (LOS) and proportion of patients with >6 h LOS. (2) To assess the accuracy of computer simulation in predicting the magnitude of such effects on these metrics. MethodsA group-level quasi-experimental trial comparing the St. Louis Veterans Affairs Medical Center emergency department (1) before intervention, (2) after institution of provider in triage, and discrete event simulation (DES) models of similar (3) before' and (4) after' conditions. The outcome measures were daily mean LOS and percentage of patients with LOS >6 h. ResultsThe DES-modelled intervention predicted a decrease in the %6-hour LOS from 19.0% to 13.1%, and a drop in the daily mean LOS from 249 to 200 min (p<0.0001). Following (actual) intervention, the number of patients with LOS >6 h decreased from 19.9% to 14.3% (p<0.0001), with the daily mean LOS decreasing from 247 to 210 min (p<0.0001). ConclusionPhysician and mid-level provider coverage at triage significantly reduced emergency department LOS in this setting. DES accurately predicted the magnitude of this effect. These results suggest further work in the generalisability of triage providers and in the utility of DES for predicting quantitative effects of process changes.

A woman with sudden-onset facial oedema [IMAGES IN EMERGENCY MEDICINE]

Wed, 30 Jan 2013 00:00:00 +0000

An 84-year-old woman presented with acute facial oedema that developed suddenly 2 h prior to the visit. She had no particular medical history, no episode of neck injury, nor was she on any anticoagulant or antiplatelet agent. CT showed a pharyngeal mass (figure 1), which was confirmed as a retropharyngeal haematoma with a nasopharyngeal fiberscope (figure 2). A clinical diagnosis of spontaneous retropharyngeal haematoma was established. Retropharyngeal haematoma is a rare but potentially life-threatening condition; it can progress rapidly, causing airway obstruction once it starts to grow.1 It has been reported to develop in patients who have suffered blunt head or neck trauma or who are on anticoagulants or antiplatelet agents, and spontaneous cases are rare. Airway management is cruci ...

Development of a predictive model to identify inpatients at risk of re-admission within 30 days of discharge (PARR-30) [RESEARCH]

Wed, 30 Jan 2013 00:00:00 +0000

ObjectivesTo develop an algorithm for identifying inpatients at high risk of re-admission to a National Health Service (NHS) hospital in England within 30 days of discharge using information that can either be obtained from hospital information systems or from the patient and their notes. DesignMultivariate statistical analysis of routinely collected hospital episode statistics (HES) data using logistic regression to build the predictive model. The model's performance was calculated using bootstrapping. SettingHES data covering all NHS hospital admissions in England. ParticipantsThe NHS patients were admitted to hospital between April 2008 and March 2009 (10% sample of all admissions, n=576 868). Main outcome measuresArea under the receiver operating characteristic curve for the algorithm, together with its positive predictive value and sensitivity for a range of risk score thresholds. ResultsThe algorithm produces a risk score' ranging (0-1) for each admitted patient, and the percentage of patients with a re-admission within 30 days and the mean re-admission costs of all patients are provided for 20 risk bands. At a risk score threshold of 0.5, the positive predictive value (ie, percentage of inpatients identified as high risk who were subsequently re-admitted within 30 days) was 59.2% (95% CI 58.0% to 60.5%); representing 5.4% (95% CI 5.2% to 5.6%) of all inpatients who would be re-admitted within 30 days (sensitivity). The area under the receiver operating characteristic curve was 0.70 (95% CI 0.69 to 0.70). ConclusionsWe have developed a method of identifying inpatients at high risk of unplanned re-admission to NHS hospitals within 30 days of discharge. Though the models had a low sensitivity, we show how to identify subgroups of patients that contain a high proportion of patients who will be re-admitted within 30 days. Additional work is necessary to validate the model in practice.

Emergency department visits for fall-related fractures among older adults in the USA: a retrospective cross-sectional analysis of the National Electronic Injury Surveillance System All Injury Program, 2001-2008 [RESEARCH]

Thu, 24 Jan 2013 00:00:00 +0000

ObjectivesTo describe the demographic characteristics and incidence of unintentional fall-related fractures among older adults treated in the US hospital emergency departments (EDs). DesignRetrospective observational study. SettingsHospitals' ED participants in the National Electronic Injury Surveillance System All Injury Program (NEISS-AIP). ParticipantsThe NEISS-AIP was used to generate national estimates of hospital ED visits for unintentional fall-related fracture among adults aged 65 years or older between 2001 and 2008. Census population estimates were used as the denominator to calculate age-specific and age-adjusted fracture rates per 100 000 persons. Main outcome measuresFall-related fracture rates and ED disposition. ResultsOn the basis of 70 199 cases, an estimated 4.05 million older adults were treated in US hospital EDs for fall-related fracture during the 8-year period. Two-thirds of the injuries occurred at home and 69.5% (95% CI 59.7% to 77.8%) of the affected individuals were white. Fall-related fracture rates increased gradually with age and were on average twofold higher among women. Of those hospitalised, women and fractures of the lower trunk represented 75.2% and 65.1% of the admissions, respectively. The estimated number of fall-related fractures treated in EDs increased from 574 500 in 2001 to 714 800 in 2008, a 24.4% increase. By gender, a non-significant upward trend in age-adjusted fall-related fracture rates was predominantly seen among men at an annual rate of 1.9% (95% CI -0.1% to 4.0%), whereas fracture rates among women remained stable at 0.9% (95% CI -0.7% to 2.5%) per year. ConclusionsThe oldest old, women and lower trunk fractures account for the majority of fall-related fractures among persons aged 65 years or older treated in US hospital EDs. Increasing ED visits and hospitalisations for fall-related fracture among older adults deserve further research.

Water is a safe and effective alternative to sterile normal saline for wound irrigation prior to suturing: a prospective, double-blind, randomised, controlled clinical trial [EMERGENCY MEDICINE]

Wed, 16 Jan 2013 00:00:00 +0000

ObjectiveTo determine if there is a significant difference in the infection rates of wounds irrigated with sterile normal saline (SS) versus tap water (TW), before primary wound closure. DesignSingle centre, prospective, randomised, double-blind controlled trial. Wound irrigation solution type was computer randomised and allocation was done on a sequential basis. SettingStanford University Medical Center Department of Emergency Medicine. ParticipantsPatients older than 1 year of age, who presented to the emergency department with a soft tissue laceration requiring repair, were entered into the study under informed consent. Exclusion criteria included any underlying immunocompromising illness, current use of antibiotics, puncture or bite wounds, underlying tendon or bone involvement, or wounds more than 9 h old. InterventionsNon-caregivers used a computer generated randomisation code to prepare irrigation basins prior to treatment. Patients had their wounds irrigated either with TW or SS prior to closure, controlling for the volume and irrigation method used. The patient, the treating physician and the physician checking the wound for infection were all blind regarding solution type. Structured follow-up was completed at 48 h and 30 days to determine the presence of infection. Main outcome measuresThe primary outcome measured was the difference in wound infection rates between the two randomised groups. ResultsDuring the 18-month study period, 663 consecutive patients were enrolled. After enrolment, 32 patients were later excluded; 29 patients because they were concurrently on antibiotics; two patients secondary to steroid use and one because of tendon involvement. Of the 631 remaining patients, 318 were randomised into the TW group and 313 into the SS group. Six patients were lost to follow-up (5 SS, 1 TW). A total of 625 patients were included in the statistical analysis. There were no differences in the demographic and clinical characteristics of the two groups. There were 20 infections 6.4% (95% CI 9.1% to 3.7%) in the SS group compared with 11 infections 3.5% (95% CI 5.5% to 1.5%) in the TW group, a difference of 2.9% (95% CI -0.4% to 5.7%). ConclusionsThere is no difference in the infection rate of wounds irrigated with either TW or SS solution, with a clinical trend towards fewer wound infections in the TW group, making it a safe and cost-effective alternative to SS for wound irrigation.

A randomised trial comparing the cost effectiveness of different emergency department healthcare professionals in soft tissue injury management [RESEARCH]

Thu, 3 Jan 2013 00:00:00 +0000

ObjectivesTo evaluate the cost effectiveness of soft tissue injury management by emergency nurse practitioners (ENPs) and extended scope physiotherapists (ESPs) compared with the routine care provided by doctors in an emergency department (ED). DesignRandomised, pragmatic trial of equivalence. SettingA single ED in England. Participants372 patients were randomised, 126 to the ESP group, 123 to the ENP group and 123 to the doctor group. Participants were adults (16 years and older) presenting to the ED with a peripheral soft tissue injury eligible for management by any of the three professional groups. InterventionsPatients were randomised to treatment by an ESP, ENP or routine care provided by doctors (of all grades). Main outcome measuresEconomic cost-minimisation evaluation from a funder perspective of the National Health Service, England incorporating analysis of the direct, indirect and tangible costs of care in primary and secondary settings. ResultsFrom a funder perspective in primary and secondary care, ESPs and ENPs are at best equivalent and could not cost less than routine care. Uncertainty in cost arises from ESPs and ENPs incurring greater indirect costs, such as those associated with follow-up appointments and subsequent primary care visits. Comparison from a funder perspective in secondary care, that is, considering those costs incurred in secondary care alone, demonstrates that ENPs are equivalent in cost to routine care, while ESPs are either equivalent or possibly cheaper than routine care. ConclusionsThese results question the notion that training the healthcare workforce to undertake extensions of their role is generally cost effective. While the randomised trial indicated that the three professional groups have equivalent clinical outcomes, this economic analysis suggests that substitution of routine care with a predominantly ESP or ENP workforce could prove more expensive. Further research is required to understand the underlying reasons for this. The trial has been registered with ISRCTN-ISRCTN 70891354.

The impact of the 2011 Great East Japan Earthquake on hospitalisation for respiratory disease in a rapidly aging society: a retrospective descriptive and cross-sectional study at the disaster base hospital in Ishinomaki [RESEARCH]

Thu, 3 Jan 2013 00:00:00 +0000

ObjectiveTo investigate the impact in an aging society of the 2011 Great East Japan earthquake on hospitalisation for respiratory disease at the disaster base hospital. DesignDescriptive and cross-sectional study. SettingEmergency care in Japanese Red Cross Ishinomaki Hospital, a regional disaster base hospital in Miyagi, Japan. Participants322 emergency patients who were hospitalised for respiratory disease from 11 March to 9 May 2011, and 99 and 105 emergency patients who were hospitalised in the corresponding periods in 2009 and 2010, respectively. Main outcome measuresDescription and comparison of patient characteristics and disease distribution in terms of age, time after the disaster and activities of daily living (ADL). Results1769 patients were admitted to our hospital during the study period (compared to 850 in 2009 and 1030 in 2010), among whom 322 were hospitalised for respiratory disease (compared to 99 in 2009 and 105 in 2010). Pneumonia (n=190, 59.0%) was the most frequent cause of admission for pulmonary disease, followed by acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) (n=53, 16.5%), asthma attacks (n=27, 8.4%) and progression of lung cancer (n=22, 6.8%). Compared with the corresponding periods in 2009 and 2010, the increase in the absolute numbers of admissions was highest for pneumonia, followed by AE-COPD and asthma attacks. At hospitalisation, 195 patients were dependent' and 54 patients were partially dependent'. Respiratory admissions accompanied by deterioration of ADL after the disaster were more frequent in elderly and female patients. ConclusionsAfter the Great East Japan Earthquake, admissions for pneumonia and exacerbation of chronic respiratory disease in the elderly increased at the disaster base hospital.

Is secondary preventive care improving? Observational study of 10-year trends in emergency admissions for conditions amenable to ambulatory care [RESEARCH]

Wed, 2 Jan 2013 00:00:00 +0000

ObjectiveTo identify trends in emergency admissions for patients with clinical conditions classed as ambulatory care sensitive' (ACS) and assess if reductions might be due to improvements in preventive care. DesignObservational study of routinely collected hospital admission data from March 2001 to April 2011. Admission rates were calculated at the population level using national population estimates for area of residence. ParticipantsAll emergency admissions to National Health Service (NHS) hospitals in England from April 2001 to March 2011 for people residents in England. Main outcome measuresAge-standardised emergency admissions rates for each of 27 specific ACS conditions (ICD-10 codes recorded as primary or secondary diagnoses). ResultsBetween April 2001 and March 2011 the number of admissions for ACS conditions increased by 40%. When ACS conditions were defined solely on primary diagnosis, the increase was less at 35% and similar to the increase in emergency admissions for non-ACS conditions. Age-standardised rates of emergency admission for ACS conditions had increased by 25%, and there were notable variations by age group and by individual condition. Overall, the greatest increases were for urinary tract infection, pyelonephritis, pneumonia, gastroenteritis and chronic obstructive pulmonary disease. There were significant reductions in emergency admission rates for angina, perforated ulcers and pelvic inflammatory diseases but the scale of these successes was relatively small. ConclusionsIncreases in rates of emergency admissions suggest that efforts to improve the preventive management of certain clinical conditions have failed to reduce the demand for emergency care. Tackling the demand for hospital care needs more radical approaches than those adopted hitherto if reductions in emergency admission rates for ACS conditions overall are to be seen as a positive outcome of for NHS.

Screening for carbon monoxide exposure in selected patient groups attending rural and urban emergency departments in England: a prospective observational study [RESEARCH]

Thu, 13 Dec 2012 00:00:00 +0000

ObjectivesCarbon monoxide (CO) exposure does not produce a classical toxidrome and so it is thought that it may easily be missed, allowing patients to continue to be exposed to CO. The aim of this study was to determine the proportion of raised carboxyhaemoglobin (COHb) levels in a targeted population of patients presenting to four emergency departments (EDs) in England. DesignA prospective observational study undertaken over a 9-month period. SettingFour EDs; one in a rural/suburban area and three serving urban populations. Participants1758 patients presenting to the EDs with chest pain, exacerbation of chronic obstructive pulmonary disease (COPD), non-traumatic headache, seizures or flu-like symptoms. Main outcomeMeasures COHb levels measured using a pulse CO-oximeter or venous sample. Patients with COHb levels [≥]2.5% (non-smokers) or [≥]5% (smokers) completed a questionnaire assessing potential sources. Patients were defined to be positive for CO exposure if they had a positive COHb and either an identified source or no other reason for their raised level. ResultsProportion of positive patients was: overall--4.3%; COPD--7.5%; headache--6.3%; flu-like--4.3%; chest pain--3.3%; seizures--2.1%. A variety of gas and solid (predominantly charcoal) fossil fuel sources were identified. ConclusionsThis study showed that 4.3% of patients presenting to EDs with non-specific symptoms had unexpectedly raised COHb levels 1.4% of patients had a source of CO identified. Study limitations included non-consecutive recruitment, delays in COHb measurements and a lack of ambient CO measurements, which precludes precise determination of incidence. However, this study should alert clinicians to consider CO exposure in patients presenting with non-specific symptoms, in particular headache and exacerbation of COPD, and if necessary refer patients for suitable public-health follow-up, even in the presence of low COHb readings. Further research should include standardised scene assessments.

Comparison of emergency hospital admissions for drug poisoning and major diseases: a retrospective observational study using a nationwide administrative discharge database [RESEARCH]

Wed, 5 Dec 2012 00:00:00 +0000

ObjectiveTo compare the clinical and procedural characteristics of emergency hospital admissions for drug poisoning and major diseases. DesignRetrospective observational study. SettingDischarged patients from 855 acute care hospitals from 1 July to 31 December in 2008 in Japan. ResultsThere were a total of 1 157 893 emergency hospital admissions. Among the top 100 causes, drug poisoning was ranked higher in terms of the percentage of patients using ambulance services (74.1%; second) and tertiary emergency medical services (37.8%; first). Despite higher utilisation of emergency care resources, drug poisoning ranked lower in terms of the median length of stay (2 days; 100th), percentage of requirement for surgical procedures (1.7%; 91st) and inhospital mortality ratio (0.3%; 74th). ConclusionsDrug poisoning is unique among the top 100 causes of emergency admissions. Our findings suggest that drug poisoning imposes a greater burden on emergency care resources but has a less severe clinical course than other causes of admissions. Future research should focus on strategies to reduce the burden of drug poisoning on emergency medical systems.

Does prior coronary artery bypass surgery alter the gender gap in patients presenting with acute coronary syndrome? A 20-year retrospective cohort study [RESEARCH]

Wed, 28 Nov 2012 00:00:00 +0000

ObjectivesPrevious studies demonstrated women presenting with acute coronary syndrome (ACS) have poor outcomes when compared with men the gender gap phenomenon'. The impact of prior coronary artery bypass graft (CABG) on women presenting with ACS is unknown. We hypothesised that the gender gap is altered in ACS patients with prior CABG. The aim of this study was to evaluate patients presenting with ACS according to their gender and history of prior CABG. DesignRetrospective, observational (cohort) study. SettingData were collected from hospital-based registry of patients hospitalised with ACS in Doha, Qatar, from 1991 through 2010. The data were analysed according to their gender and history of prior CABG. ParticipantsA total of 16 750 consecutive patients with ACS were studied. In total, 693 (4.3%) patients had prior CABG; among them 125 (18%) patients were women. Primary and secondary outcome measuresComparisons of clinical characteristics, inhospital treatment, and outcomes, including inhospital mortality and stroke were made. ResultsWomen with or without prior CABG were older, less likely to be smokers, but more likely to have diabetes mellitus (DM), hypertension and renal impairment than men (p=0.001). Women were less likely to receive reperfusion and early invasive therapies. When compared with men, women without prior CABG carried higher inhospital mortality (11% vs 4.9%; p=0.001) and stroke rates (0.9% vs 0.3%; p=0.001). Female gender was independent predictor of poor outcome. Among prior CABG patients, despite the fact that women had worse baseline characteristics and were less likely to receive evidence-based therapy, there were no significant differences in mortality or stroke rates between the two groups. ConclusionsConsistent with the world literature, women presenting with ACS and without prior CABG had higher death rates compared with men. Patients with prior CABG had comparable death rates regardless of the gender status.

Risk factors for injury mortality in rural Tanzania: a secondary data analysis [RESEARCH]

Mon, 19 Nov 2012 00:00:00 +0000

BackgroundInjuries rank high among the leading causes of death and disability annually, injuring over 50 million and killing over 5 million people globally. Approximately 90% of these deaths occur in developing countries. ObjectivesTo estimate and identify the risk factors for injury mortality in the Rufiji Health and Demographic Surveillance System (RHDSS) in Tanzania. MethodsSecondary data from the RHDSS covering the period 2002 and 2007 was examined. Verbal autopsy data was used to determine the causes of death based on the 10th revision of the International Classification of Diseases (ICD-10). Trend and Poisson regression tests were used to investigate the associations between risk factors and injury mortality. ResultsThe overall crude injury death rate was 33.4/100 000 population. Injuries accounted for 4% of total deaths. Men were three times more likely to die from injuries compared with women (adjusted IRR (incidence risk ratios)=3.04, p=0.001, 95% CI (2.22 to 4.17)). The elderly (defined as 65+) were 2.8 times more likely to die from injuries compared with children under 15 years of age (adjusted IRR=2.83, p=0.048, 95% CI (1.01 to 7.93)). The highest frequency of deaths resulted from road traffic crashes. ConclusionsInjury is becoming an important cause of mortality in the Rufiji district. Injury mortality varied by age and gender in this area. Most injuries are preventable, policy makers need to institute measures to address the issue.

Childhood motocross truncal injuries: high-velocity, focal force to the chest and abdomen [RESEARCH]

Mon, 19 Nov 2012 00:00:00 +0000

ObjectivesTo review the need for operative intervention and critical care services for motocross truncal injuries in children. Design cohortRetrospective review of patients identified via the hospital trauma registry. SettingOur Level 1 Pediatric Trauma Center serves five motocross tracks. These patients require frequent medical care for injuries. ParticipantsAll patients [≤]17 years of age with truncal injuries sustained during motocross activities, between 2000 and 2011, were identified through the trauma registry. Primary and secondary outcome measuresOperative intervention, intensive care unit (ICU) admission, length of stay, morbidity and demographics were reviewed. ResultsMotocross injured 162 children. Thirty (18.5%) were thoracic or abdominal injuries. Operative intervention was required in eight (27%) patients. Mean injury severity score (ISS) was 11.8. ICU admission was required in 50% and average hospital length of stay was 4.1 days. The most common injuries include pulmonary contusion, pneumothorax, spleen and liver lacerations. 13% of subjects suffered truncal injury from motocross on more than one occasion. ConclusionsPaediatric motocross-related truncal injuries are significant. Surgical intervention is required in 27% of patients. The lower ISS incurred from motocross combined with high surgical and ICU admission rates suggests focal high-impact injuries to the chest and abdomen. Despite significant injury, 13% of motocross patients suffer recurrent injuries. Parents and children need injury prevention education.

Support and assessment for fall emergency referrals (SAFER 2) research protocol: cluster randomised trial of the clinical and cost effectiveness of new protocols for emergency ambulance paramedics to assess and refer to appropriate community-based care [PROTOCOL]

Mon, 12 Nov 2012 00:00:00 +0000

IntroductionEmergency calls to ambulance services are frequent for older people who have fallen, but ambulance crews often leave patients at the scene without ongoing care. Evidence shows that when left at home with no further support older people often experience subsequent falls which result in injury and emergency-department attendances. SAFER 2 is an evaluation of a new clinical protocol which allows paramedics to assess and refer older people who have fallen, and do not need hospital care, to community-based falls services. In this protocol paper, we report methods and progress during trial implementation. SAFER 2 is recruiting patients through three ambulance services. A successful trial will provide robust evidence about the value of this new model of care, and enable ambulance services to use resources efficiently. DesignPragmatic cluster randomised trial. Methods and analysisWe randomly allocated 25 participating ambulance stations (clusters) in three services to intervention or control group. Intervention paramedics received training and clinical protocols for assessing and referring older people who have fallen to community-based falls services when appropriate, while control paramedics deliver care as usual. Patients are eligible for the trial if they are aged 65 or over; resident in a participating falls service catchment area; and attended by a trial paramedic following an emergency call coded as a fall without priority symptoms. The principal outcome is the rate of further emergency contacts (or death), for any cause and for falls. Secondary outcomes include further falls, health-related quality of life, fear of falling', patient satisfaction reported by participants through postal questionnaires at 1 and 6 months, and quality and pathways of care at the index incident. We shall compare National Health Service (NHS) and patient/carer costs between intervention and control groups and estimate quality-adjusted life years (QALYs) gained from the intervention and thus incremental cost per QALY. We shall estimate wider system effects on key-performance indicators. We shall interview 60 intervention patients, and conduct focus groups with contributing NHS staff to explore their experiences of the assessment and referral service. We shall analyse quantitative trial data by treatment allocated'; and qualitative data using content analysis. Ethics and disseminationThe Research Ethics Committee for Wales gave ethical approval and each participating centre gave NHS Research and Development approval. We shall disseminate study findings through peer-reviewed publications and conference presentations. Trial Registration: ISRCTN 60481756

A randomised trial comparing the clinical effectiveness of different emergency department healthcare professionals in soft tissue injury management [RESEARCH]

Thu, 8 Nov 2012 00:00:00 +0000

ObjectivesTo evaluate the clinical effectiveness of soft tissue injury management by emergency nurse practitioners (ENPs) and extended scope physiotherapists (ESPs) compared to the routine care provided by doctors in a UK emergency department (ED). DesignRandomised, pragmatic trial of equivalence. SettingOne adult ED in England. Participants372 patients were randomised; 126 to the ESP group, 123 to the ENP group and 123 to the doctor group. Participants were adults (older than 16 years) presenting to the ED with a peripheral soft tissue injury eligible for management by any of the three professional groups. Patients were excluded if they had any of the following: injury greater than 72 hours old; systemic disease; dislocated joints; recent surgery; unable to give informed consent (eg, dementia), open wounds; major deformities; opiate analgesia required; concurrent chest/rib injury; neurovascular deficits and associated fracture. InterventionsPatients were randomised to treatment by ESPs, ENPs or routine care provided by doctors (of all grades). Main outcome measuresUpper-limb and lower-limb functional scores, quality of life, physical well-being, preference-based health measures and the number of days off work. ResultsThe clinical outcomes of soft tissue injury treated by ESPs and ENPs in the ED were equivalent to routine care provided by doctors. ConclusionsAs all groups were clinically equivalent it is other factors such as cost, workforce sustainability, service provision and skill mix that become important. This result validates the role of the ENP, which is becoming established as an integral part of minor injuries care, and demonstrates that the ESP should be considered as part of the clinical skill mix without detriment to outcomes. ISRCTN-ISRCTN trials register number70891354.

Weekend admissions as an independent predictor of mortality: an analysis of Scottish hospital admissions [RESEARCH]

Tue, 6 Nov 2012 00:00:00 +0000

ObjectivesWeekend admissions have been shown to be associated with an increased risk of mortality compared with weekday admissions for many diagnoses. We analysed emergency department admissions within the Scottish National Health Service to investigate whether mortality is increased in case of weekend emergency department admissions. DesignA cohort study. SettingScotland National Health Service (NHS) emergency departments. Participants5 271 327 emergency department admissions between 1999 and 2009. We included all patients admitted via emergency departments recorded in the Scottish Morbidity Records (SMR01) in NHS, Scotland for whom complete demographic data were available. Primary outcome measuresDeath as recorded by the General Register Office (GRO). ResultsThere was a significantly increased probability of death associated with a weekend emergency admission compared with admission on a weekday (unadjusted OR 1.27, 95% CI 1.26 to 1.28, p<0.0001; adjusted for year of admission, gender, age, deprivation quintile and number of comorbidities OR 1.42, 95% CI 1.40 to 1.43, p<0.0001). ConclusionsDespite a general reduction in mortality over the last 11 years, there is still a significant excess mortality associated with weekend emergency admissions. Further research should be undertaken to identify the precise mechanisms underlying this effect so that measures can be put in place to reduce patient mortality.

Evaluation of the self-inflating bag-valve-mask and non-rebreather mask as preoxygenation devices in volunteers [RESEARCH]

Fri, 26 Oct 2012 00:00:00 +0000

ObjectiveTo evaluate and compare the effectiveness and tolerability of preoxygenation with the self-inflating bag-valve-mask (BVM) and non-rebreather mask (NRM) as are used before emergency anaesthesia. DesignDevice performance evaluation. SettingExperimental study. Participants12 male and 12 female healthy volunteers (age range 24-47) with no history of clinically significant respiratory disease. InterventionsEnd-expiration oxygen measurements (FEO2) after 3 min of preoxygenation with BVM (without mechanical assistance) and NRM devices. Mask pressures were measured and subjective difficulty of breathing was also assessed with a visual analogue score (VAS). Primary and secondary outcome measuresThe final FEO2 achieved was 58.0% (SD 7.3%) for the NRM compared to 53.1% (SD 13.4%) for the BVM (p=0.072). Preoxygenation was associated with small increases in FECO2 that were greater for the BVM (0.50%; 95% CI 0.48 to 0.52) than the NRM (0.29%; 95% CI 0.31 to 0.28); this difference was statistically significant (p=0.028). Both devices were well tolerated on VAS assessment of difficulty of breathing although this was higher for the BVM than the NRM (median VAS 1.85/10 compared to 1.1/10; p=0.041). Inspiratory and expiratory mask pressures were higher for the BVM. ConclusionsIn healthy volunteers, the NRM performs comparably to the BVM in terms of the degree of denitrogenation achieved although neither performed well. Although it was well tolerated, the BVM was subjectively more difficult to breathe through and was associated with greater mask pressures and a small increase in FECO2 consistent with hypoventilation or rebreathing. Our results suggest that preoxygenation with the NRM may be a preferable approach in spontaneously breathing patients.

Health service use in adults 20-64 years with traumatic brain injury, spinal cord injury or pelvic fracture. A cohort study with 9-year follow-up [RESEARCH]

Fri, 26 Oct 2012 00:00:00 +0000

ObjectivesTo estimate the health service use over 9 years after the injury year for patients with traumatic brain injury (TBI), spinal cord injury (SCI) and pelvic fracture (PF), and compare with non-injured. DesignA register-based cohort design with a 9-year follow-up period. SettingThe Danish population. ParticipantsThe study included 434, 100 and 278 hospital-treated incident patients with TBI, SCI and PF, respectively, among 20-year-olds to 64-year-olds identified using the National Patient Register. Controls for each patient group were drawn from the population register, matched by age, sex and health service use during 1995. All were followed during 1996-2005 by linkage to national health registers. The observations were excluded when the patients left Denmark or died. Outcome measuresThe use of hospital treatments, contacts with general practitioners and the use of physiotherapy. ResultsCompared to the controls, more patients with TBI and SCI were hospital admitted all 9 years after the injury year, on average 0.36 and 0.50 times annually, respectively. For patients with PF hospital admissions returned to baseline year 2 after the injury year. For patients with SCI the use of general practitioner services remained at an increased level year 9 after the injury year, while it returned to baseline level year 4 after the injury year for patients with TBI and year 2 for patients with PF. For patients with SCI physiotherapy use remained increased over 9 years after the injury year, while it returned to baseline the fifth year for patients with TBI and the third year after for patients with PF. ConclusionsTBI and SCI increase the use of health services over 9 years after the injury year, while most health service use after PF returned to baseline 2 years after the injury year.

Use of cardiocerebral resuscitation or AHA/ERC 2005 Guidelines is associated with improved survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis [RESEARCH]

Wed, 3 Oct 2012 00:00:00 +0000

ObjectiveTo determine whether the use of cardiocerebral resuscitation (CCR) or AHA/ERC 2005 Resuscitation Guidelines improved patient outcomes from out-of-hospital cardiac arrest (OHCA) compared to older guidelines. DesignSystematic review and meta-analysis. Data sourcesMEDLINE, EMBASE, Web of Science and the Cochrane Library databases. We also hand-searched study references and consulted experts. Study selectionDesign: randomised controlled trials and observational studies. PopulationOHCA patients, age >17 years. Comparators Control' protocol versus Study' protocol. Control' protocol defined as AHA/ERC 2000 Guidelines for cardiopulmonary resuscitation (CPR). Study' protocol defined as AHA/ERC 2005 Guidelines for CPR, or a CCR protocol. OutcomeSurvival to hospital discharge. QualityHigh-quality or medium-quality studies, as measured by the Newcastle Ottawa Scale using predefined categories. ResultsTwelve observational studies met inclusion criteria. All the three studies using CCR demonstrated significantly improved survival compared to use of AHA 2000 Guidelines, as did five of the nine studies using AHA/ERC 2005 Guidelines. Pooled data demonstrate that use of a CCR protocol has an unadjusted OR of 2.26 (95% CI 1.64 to 3.12) for survival to hospital discharge among all cardiac arrest patients. Among witnessed ventricular fibrillation/ventricular tachycardia (VF/VT) patients, CCR increased survival by an OR of 2.98 (95% CI 1.92 to 4.62). Studies using AHA/ERC 2005 Guidelines showed an overall trend towards increased survival, but significant heterogeneity existed among these studies. ConclusionsWe demonstrate an association with improved survival from OHCA when CCR protocols or AHA/ERC 2005 Guidelines are compared to use of older guidelines. In the subgroup of patients with witnessed VF/VT, there was a threefold increase in OHCA survival when CCR was used. CCR appears to be a promising resuscitation protocol for Emergency Medical Services providers in increasing survival from OHCA. Future research will need to be conducted to directly compare AHA/ERC 2010 Guidelines with the CCR approach.

A metric-based analysis of structure and content of telephone consultations of final-year medical students in a high-fidelity emergency medicine simulation [RESEARCH]

Thu, 13 Sep 2012 00:00:00 +0000

ObjectivesIn this study we aimed to analyse the structure and content of telephone consultations of final-year medical students in a high-fidelity emergency medicine simulation. The purpose was to identify any areas of deficiency within structure and content in the effective transfer of clinical information via the telephone of final-year medical students. DesignAn educational study. SettingSimulation centre in a medical school. Participants113 final-year medical students. Primary and secondary outcomesThe primary outcome was to analyse the structure and content of telephone consultations of final-year medical students in a high-fidelity emergency medicine simulation. The secondary outcome was to identify any areas of deficiency within structure and content in the effective transfer of clinical information via the telephone of final-year medical students. ResultsDuring phone calls to a senior colleague 30% of students did not positively identify themselves, 29% did not identify their role, 32% did not positively identify the recipient of the phone call, 59% failed to positively identify the patient, 49% did not read back the recommendations of their senior colleague and 97% did not write down the recommendations of their senior colleague. ConclusionsWe identified a deficiency in our students skills to communicate relevant information via the telephone, particularly failure to repeat back and write down instructions. We suggest that this reflects a paucity of opportunities to practice this skill in context during the undergraduate years. The assumption that this skill will be acquired following qualification constitutes a latent error within the healthcare system. The function of undergraduate medical education is to produce graduates who are fit for purpose at the point of graduation.

A 24-h helpline for access to expert management advice for food allergy-related anaphylaxis in children: protocol for a pragmatic randomised controlled trial [PROTOCOL]

Thu, 16 Aug 2012 00:00:00 +0000

ObjectivesAnaphylaxis is an important, potentially life-threatening paediatric emergency. It is responsible for considerable morbidity and, in some cases, death. Poor outcomes may be associated with an inability to differentiate between milder and potentially more severe reactions and an associated reluctance to administer self-injectable adrenaline. This study aims to assess the effectiveness of a 24-h telephone access to specialist paediatric allergy expert advice in improving the quality of life of children and their families with potentially life-threatening food allergy (ie, anaphylaxis) compared with usual clinical care. Methods and analysisChildren aged less than 16 years with food allergy and who carry an adrenaline autoinjector will be recruited from the Paediatric Allergy Clinic at Cork University Hospital, Ireland and baseline disease-specific quality of life will be ascertained using the validated Food Allergy Quality of Life Questionnaire (FAQLQ). Participants will be randomised for a period of 6 months to the 24-h telephone specialist support line or usual care. The primary outcome measure of interest is a change in FAQLQ scores, which will be assessed at 0, 1 and 6 months postrandomisation. Analysis will be on an intention-to-treat basis using a 2x3 repeated measures within-between analysis of variance. Although lacking power, we will in addition assess the impact of the intervention on a range of relevant process and clinical endpoints. Ethics and disseminationThis trial protocol has been approved by the Clinical Research Ethics Committee of the Cork Teaching Hospitals. The findings will be presented at international scientific conferences and will be reported on in the peer-reviewed literature in early 2013.

Reductions in hospital admissions and mortality rates observed after integrating emergency care: a natural experiment [RESEARCH]

Wed, 1 Aug 2012 00:00:00 +0000

ObjectivesReducing emergency admissions is a priority for the NHS. A single hospital's emergency care system was reorganised with the principles of front-loaded investigations, integration of specialties, reduced duplication, earlier decision making by senior clinicians and a combined emergency assessment area. The authors relocated our Medical Assessment Unit into our emergency department in 2006. The authors evaluated changes in admissions and mortality before and after 2006, compared with other similar hospitals. DesignQuasi-experimental before and after study using routinely collected data. Setting and participants1 acute hospital in England, the intervention site, was compared with 23 other English hospitals between 2001 and 2009. Outcome measuresOur outcome measures were hospital standardised mortality ratios (HSMRs) for non-elective admissions and standardised admission ratios (SARs). ResultsThe authors observed a statistically and clinically significant decrease in HSMR and SAR. The intervention hospital had the lowest HSMR and SAR of all the hospitals in our sample. This was statistically significant, p=0.0149 and p=0.0002, respectively. ConclusionIntegrating emergency care in one location is associated with a meaningful reduction in mortality and emergency admissions to hospital.

Antiemetic treatment for acute gastroenteritis in children: an updated Cochrane systematic review with meta-analysis and mixed treatment comparison in a Bayesian framework [RESEARCH]

Thu, 19 Jul 2012 00:00:00 +0000

ObjectiveTo assess the evidence for the safety and effectiveness of antiemetics on gastroenteritis-induced vomiting in children and adolescents. DesignSystematic review. Data SourcesThe Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE searched from 1980 to March 2012. MethodsMethods included comprehensive searches, data synthesis, meta-analysis and mixed treatment comparisons (MTC). Review methodsReference lists were checked, and missing or inconsistent data were sought from trial investigators. Randomised controlled trials comparing antiemetics in participants younger than 18 years and who were vomiting due to acute gastroenteritis. Four meta-analyses and three MTC were carried out. Results10 trials (1479 participants) and five treatments were included: dexamethasone, dimenhydrinate, granisetron, metoclopramide and ondansetron. There was clear evidence that ondansetron (oral or intravenous) compared with placebo increased the proportion of patients with cessation of vomiting (orally administered) (RR 1.44, 95% CI 1.29 to 1.61), reduced the immediate hospital admission rate (orally administered) (RR 0.40, 95% CI 0.19 to 0.83) and the need for intravenous rehydration therapy (orally administered) (RR 0.41, 95% CI 0.29 to 0.59). No significant difference was noted in the revisit rates, but ondansetron was associated with an increase in episodes of diarrhoea. There was no evidence for the use of dexamethasone or metoclopramide and limited evidence that dimenhydrinate or granisetron increased the cessation of vomiting. The MTC analysis suggested that ondansetron was the most likely treatment to stop the child vomiting. Nine studies were carried out in secondary care and one in primary care. ConclusionsThis systematic review used a method novel to this clinical area and found clear evidence that ondansetron was the most likely treatment to allow oral rehydration therapy to commence. Given the significance of these results, the authors urge healthcare policy makers to consider the wider use of ondansetron in secondary care. Furthermore, randomised controlled trials are needed to investigate the effectiveness of antiemetic treatment in primary care (including ambulatory care interventions).

Protocol for an observation and implementation study investigating optimisation of the management of stroke and transient ischaemic attack (TIA) [PROTOCOL]

Mon, 25 Jun 2012 00:00:00 +0000

IntroductionPatients benefit from early and intensive treatment in both acute ischaemic stroke and transient ischaemic attack. Recent audits of acute stroke/transient ischaemic attack care suggest that although standards have improved, current services still fall short of optimal care. The aim of this study is to establish a database of patients accessing stroke services. Data will be collected and analysed to provide individualised feedback to healthcare professionals who can then use these findings to develop strategies for service improvement. Methods and analysisThis longitudinal observational study will evolve with the ongoing findings from the research output. The project will consist of three phases: assessment of current practice, feedback of findings and evaluation of service change. Consecutive patients will be recruited from participating hospitals, and identifiable data will be collected to link records from the Primary Care, Secondary Care and Emergency Services. As this study focuses on observation of current practice, a sample size calculation is not deemed appropriate. Patients will be sent follow-up questionnaires examining quality of life at 3 and 12 months post-event. Qualitative interviews will examine the care pathway through the experiences of patients, their carers, healthcare personnel and commissioners. Collected data will be used in economic analyses, which will evaluate the impact of current care and service redesign on the NHS costs and patient outcomes (death and quality of life). Ethics and disseminationEthical approval for this study has been obtained from the National Research Ethics Committee (reference; 09/H0716/71), and site-specific R&D approval has been acquired from the relevant NHS trusts. All findings will be presented at relevant healthcare/academic conferences and written up for publication in peer-reviewed journals. Results will be fed back to patients and participating trusts through a series of reports and presentations. These will be used to facilitate discussions about service redesign and implementation.

Self-reported cocaine use, emergency physician testing and outcomes in suspected acute coronary syndromes: a nested matched case-control study [RESEARCH]

Sat, 2 Jun 2012 00:00:00 +0000

ObjectivesThe primary purpose was to compare the odds of acute coronary syndrome-pertinent diagnostic testing between self-reported cocaine users and non-users at the turn of the century. The secondary purpose was to compare the odds of acute coronary syndrome outcomes between cocaine users and non-users. DesignNested matched case-control study using data from the Internet Tracking Registry of Acute Coronary Syndromes. SettingExtracted data of patients from eight US institutions composed of six academic and two community hospitals, with census varying between 10 000 and 160 000 visits per year. Participants249 cases of self-reported cocaine users and 249 matched controls. Matching was based on age, race, sex and any history of known coronary artery disease. Exclusion criteria were new ST elevations on initial ECG and initial physician impression of acute myocardial infarction. Primary and secondary outcome measuresPrimary outcome was the conditional odds of undergoing non-invasive and invasive testing for coronary artery disease. Secondary outcome was the occurrences of adverse cardiac outcomes within 30 days. ResultsCocaine users underwent diagnostic testing at similar rates compared with non-users (9.6% vs 8.0%, OR 1.24, CI 0.65 to 2.34). Adverse cardiovascular outcomes occurred in four (1.6%) cocaine users and in seven (2.8%) controls. ConclusionsThere was no increase in tendency for testing associated with self-reported history of cocaine use between 1999 and 2001. This suggests that even 10 years ago, cocaine use already had only a limited role in the Emergency Department (ED) physician's decision-making process. Similar data analyses of detailed registries can offer important contextual information that can better direct resources for future comparative effectiveness research.

Focused sonographic examination of the heart, lungs and deep veins in an unselected population of acute admitted patients with respiratory symptoms: a protocol for a prospective, blinded, randomised controlled trial [PROTOCOL]

Wed, 30 May 2012 00:00:00 +0000

IntroductionPatients admitted to hospital with acute respiratory symptoms remain a diagnostic challenge for the emergency physician. The use of focused sonography may improve the initial diagnostics, as most of the diseases, commonly seen and misdiagnosed in patients with acute respiratory symptoms, can be diagnosed with sonography. The protocol describes a prospective, blinded, randomised controlled trial that aims to assess the diagnostic impact of a pragmatic implementation of focused sonography of the heart, lungs and deep veins as a diagnostic modality in acute admitted patients with respiratory symptoms. Methods and analysisThe primary outcome of the study is the number of patients with a correct presumptive diagnosis within 4 h of admission to the emergency department. The patient is randomised to either an intervention or a control group. In the intervention group, the usual initial diagnostic work up is supplemented by focused sonographic examination of the heart, lungs and deep veins of the legs. In the control group, usual diagnostic work up is performed. The {chi}2 test, alternatively the Fischer exact test will be used, to establish whether there is a difference in the distribution of the total number of patients with a correct/incorrect 4 h' presumptive diagnosis in the control group and in the intervention group. Ethics and disseminationThis clinical trial is performed according to the Declaration of Helsinki and has been approved by the Regional Scientific Ethical Committee for Southern Denmark and the Danish Data Protection Agency. The results of the trial will be published according to the CONSORT statement with the extension for pragmatic trials. The results of the trial will be published in a peer-reviewed scientific journal regardless of the outcome. Trial registration numberThis study is registered at http://clinicaltrials.gov, registration number NCT01486394.

Templates for reporting pre-hospital major incident medical management: systematic literature review [PROTOCOL]

Thu, 3 May 2012 00:00:00 +0000

IntroductionIn 2010, a total of 385 natural disasters killed more than 297 000 people worldwide and affected over 217 million others. More standardised reporting of major incident management have been advocated in the previous years. Prevention, mitigation, preparedness and major incident response may be improved through collection and analysis of high-quality standardised data on medical management of major incidents. Standardised data may elevate the level of scientific evidence within disaster medicine research. Methods and analysisA systematic literature review will be conducted to identify templates for reporting pre-hospital major incident medical management. The first set of entry terms aims to describe major incidents published during the last 20 years. The second set aims to focus the number of search results from the first set to those publications that describe templates based on data collections from these major incidents. Predefined free search phases will be combined with the first two sets. Ethics and disseminationThe results will be submitted for publication in an open access, peer-reviewed scientific journal. The PRISMA checklist will be applied. No ethics approval is considered indicated, as this is a literature review only. Registration detailsThis review is registered in PROSPERO (registration number: CRD42012002051).

Effects of the Great East Japan Earthquake and huge tsunami on glycaemic control and blood pressure in patients with diabetes mellitus [RESEARCH]

Fri, 13 Apr 2012 00:00:00 +0000

ObjectiveTo examine the effects of a huge tsunami resulting from the Great East Japan Earthquake on blood pressure (BP) control and glycaemic control in diabetic patients. DesignA retrospective study. SettingTohoku University, Japan. Participants63 patients were visiting Rikuzentakata Hospital for diabetic treatment before the earthquake and returned to the clinic in July after the earthquake, and they were analysed in the present study. The subjects were divided into two groups: those who were hit by the tsunami, the Tsunami (+) group (n=28), and those who were not, the Tsunami (-) group (n=35), and the groups' parameters and their changes were compared. Primary outcome measureChanges of HbA1c. Secondary outcome measuresChanges of BP, body mass index. ResultsHbA1c and both BP increased, while the numbers of most drugs taken decreased in both groups. Parameter changes were significantly greater in the Tsunami (+) group. All medical data stored at the hospital was lost in the tsunami. The Tsunami (+) patients also had their own records of treatment washed away, so it was difficult to replicate their pre-earthquake drug prescriptions afterwards. In comparison, the Tsunami (-) patients kept their treatment information, making it possible to resume the treatment they had been receiving before the earthquake. The BP rose only slightly in men, whereas it rose sharply in women, even though they had not been directly affected by the tsunami. BP rose markedly in both genders affected by the tsunami. ConclusionsAll medical information was lost in the tsunami, and glycaemic and BP controls of the tsunami-affected patients worsened more than those of patients who had been affected by the earthquake alone. Women may be more sensitive to changes in the living environment that result from a major earthquake than are men.

A meta-analysis to determine the effect on survival of platelet transfusions in patients with either spontaneous or traumatic antiplatelet medication-associated intracranial haemorrhage [RESEARCH]

Thu, 5 Apr 2012 00:00:00 +0000

ObjectivesThe aim of this study was to evaluate by meta-analysis the current level of evidence in order to establish the impact of a platelet transfusion on survival in patients on pre-injury antiplatelet agents who sustain an intracranial haemorrhage (either spontaneous or traumatic). DesignThis was a meta-analysis; the MEDLINE Database was searched using the PubMed interface and the Ovid interface. CINAHL and EMBASE Databases were also searched. The search was performed to identify randomised controlled trials (RCT)'s case-controlled studies or nested case-controlled studies. Comparing the outcome (death or survival) of patients with intracranial haemorrhage (ICH) and pre-injury antiplatelet agents who received a platelet transfusion against a similar cohort of patients who did not receive a platelet transfusion. Results499 citations were obtained from the PubMed search. 31 full articles were reviewed from 34 abstracts. 6 studies were found suitable for the meta-analysis. No randomised controlled studies were identified. 2 of the six studies were in patients with spontaneous ICH. The remaining four studies were in patients with traumatic intracranial haemorrhage. Significant heterogeneity was present between the studies, I2=58.276. The random effects model was therefore the preferred model, this produced a pooled OR for survival of 0.773 (95% CI 0.414 to 1.442). ConclusionsThe results of this meta-analysis has shown, based upon six small studies, that there was no clear benefit in terms of survival in the administration of a platelet transfusion to patients with antiplatelet-associated ICH. Further work is required in order to establish any potential benefit in the administration of a platelet transfusion in patients with spontaneous or traumatic intracranial haemorrhage who were on pre-injury antiplatelet agents.

Emergency and surgery services of primary hospitals in the United Republic of Tanzania [RESEARCH]

Fri, 3 Feb 2012 00:00:00 +0000

ObjectiveThe primary objective was to evaluate the capacity of first-referral health facilities in Tanzania to perform basic surgical procedures. The intent was to assist in planning strategies for universal access to life-saving and disability-preventing surgical services. DesignCross-sectional survey. SettingFirst-referral health facilities in the United Republic of Tanzania. Participants48 health facilities. MeasuresThe WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was employed to capture a health facility's capacity to perform basic surgical (including obstetrics and trauma) and anaesthesia interventions by investigating four categories of data: infrastructure, human resources, interventions available and equipment. The tool queried the availability of eight types of care providers, 35 surgical interventions and 67 items of equipment. ResultsThe 48 facilities surveyed served 18.6 million residents (46% of the population). Supplies for basic airway management were inconsistently available. Only 42% had consistent access to oxygen, and only six functioning pulse oximeters were located in all facilities surveyed. 37.5% of facilities reported both consistent running water and electricity. While very basic interventions (suturing, wound debridement, incision and drainage) were provided in nearly all facilities, more advanced life-saving procedures including chest tube thoracostomy (30/48), open fracture management (29/48) and caesarean section delivery (32/48) were not consistently available. ConclusionsBased on the results in this WHO country survey, significant gaps exist in the capacity for emergency and essential surgical services in Tanzania including deficits in human resources, essential equipment and infrastructure. The information in this survey will provide a foundation for evidence-based decisions in country-level policy regarding the allocation of resources and provision of emergency and essential surgical services.

Disaster-related injury and predictors of health complaints after exposure to a natural disaster: an online survey [RESEARCH]

Tue, 20 Dec 2011 00:00:00 +0000

ObjectivesTo study short- and long-term effects of experiencing a disaster in repatriated injured survivors and the differential effect of injury, need for medical treatment, loss of loved ones and danger to life on both physical and mental health. DesignProspective online study. SettingOpen online survey among Dutch survivors of the 2004 Asian tsunami. ParticipantsOf the estimated total of 464 Dutch survivors, the authors recruited 144 unique respondents (59 men and 85 women) with a total of 175 assessments made in various time periods. Main outcome measuresHealth outcomes were Symptom Checklist 90 (SCL-90), Impact of Event Scale (original version, in Dutch) and Beck Depression Inventory II. Correlations were calculated with socio-demographic as well as disaster-related factors: physical injury, medical care, loss of loved ones and duration of threat to life. Assessments were clustered in four post-disaster time periods (0-3, 4-6, 7-30 and 31-48 months). ResultsAcross these periods, SCL-90 scores were significantly higher than the reference population (p<0.001), with a significant linear downward trend between the groups over time (p=0.001). The same pattern occurred for the Impact of Event Scale (p<0.001) and the Beck Depression Inventory II (p=0.002). Physical injury, medical care or loss of loved ones was not associated with higher total SCL-90 scores or somatic subscores. Both duration of threat to life and female sex were correlated with all measured outcome parameters. ConclusionsExposure to the 2004 Asian tsunami had significant short- and long-term impacts on health complaints in a group of repatriated Dutch tsunami victims. Cross-sectionally, there was a trend towards recovery over 4 years, although 22% still reported high psychological and physical distress 4 years post-disaster. Duration of danger to life and female sex were associated with more physical and mental health complaints. In this study, neither disaster-related injury nor loss of loved ones resulted in negative health outcomes.

Will our junior doctors be ready for the next major incident? A questionnaire audit on major incident awareness across three NHS Trusts in Wales [RESEARCH]

Fri, 2 Sep 2011 00:00:00 +0000

AimThe aim was to assess junior doctors' understanding of their role in the Major Incident Contingency Plan at their hospital, and to evaluate the effectiveness of a teaching intervention on increasing awareness. BackgroundIn this audit, junior doctor' refers to the first 2 years of work after qualifying from medical school. Once a major incident is confirmed, junior doctors should go to their ward, contact the senior nurse in charge and compile a list of the patients who could safely be discharged from the hospital. This action is standard across NHS Trusts in Wales. MethodA questionnaire was given to 89 junior doctors across three NHS Trusts in Wales. It involved general aspects of a major incident, as well as ascertaining perceptions of their role as junior doctors. They then received formal teaching by Emergency Planning Faculty. Following this, a repeat questionnaire was completed. Results91% felt they did not know what would be expected of them during a major incident; 47% would initially go to the Emergency Department; 27% were unclear where to go; 31% were unaware who to contact on hearing of a major incident; and 16% would telephone switchboard. Junior doctors believe their primary role would be triage (16%); clerking in the emergency department (36%); clerking in Medical Assessment Unit/Surgical Assessment Unit (17%); and practical work (15%). Only 3% would first go to their ward; 12% believe their primary role would involve patients on the ward; and only 1% would list patients for discharge. 90% of completed questionnaires included a request for teaching. Following teaching, 97% knew who to call, where to go and what to do during a major incident. ConclusionJunior doctors' awareness of major incidents within Wales was near absent prior to teaching. This teaching is vital to help ensure smooth running of the hospital on the day.