Emergency Medicine Journal

Published by BMJ Publishing Group
Online ISSN: 1472-0213
Publications
Baseline parameters prior to crystalloid infusions 
Article
To compare the effectiveness and side effects of lactated Ringer's solution (LR) and 0.9% saline (NS) in the treatment of rhabdomyolysis induced by doxylamine intoxication. In this 15-month-long prospective randomised single-blind study, after excluding 8 patients among 97 doxylamine-intoxicated patients, 28 (31%) patients were found to have developed rhabdomyolysis and were randomly allocated to NS group (n = 15) or LR group (n = 13). After 12 h of aggressive hydration (400 ml/h), urine/serum pH was found to be significantly higher in the LR group, and serum Na+/Cl- levels to be significantly higher in the NS group. There were no significant differences in serum K+ level and in the time taken for creatine kinase normalisation. The amount of sodium bicarbonate administered and the frequency administration of diuretics was significantly higher in the NS group. Unlike the NS group, the LR group needed little supplemental sodium bicarbonate and did not develop metabolic acidosis. LR is more useful than NS in the treatment of rhabdomyolysis induced by doxylamine intoxication.
 
Article
Background Emergency Care Practitioners (ECPs) arose from an ambulance-service initiative to provide an alternative response to patients who may not need transporting to hospital. ECPs are recruited from paramedic, nursing, and other clinical backgrounds. They are trained to assess and treat patients with minor or moderate health problems or refer them to an appropriate care provider. ECPs are working in different health care settings (eg, GP out-of-hours, 999 ambulance, and urgent care). Methods As part of the National Evaluation of Emergency Care Practitioners (NEECaP) Trial, we conducted interviews with 20 ECPs working in five different models of service delivery. The interviews were guided by a semi-structured interview schedule, tape recorded and transcribed. The texts were processed thematically according to the principles of framework analysis for applied policy research. Results The requirement of the ECP role to work across traditional organisational and professional boundaries raised significant challenges for integration into existing health care teams. Tensions operated at an ?individual? and ?collective? level. These were attributed to lack of understanding about what ECPs are and what they can do, inter-professional jealousies, protecting self-interest, fear of losing resources, perceived differences in pay, education, qualifications, and in clinical competence. The strategies used by ECPs to smooth their integration can be conceptualised as a combination of military (?numbers of ECPs on the ground?), (?behind the lines?) and diplomatic (?winning hearts and minds?; ?building relationships?, ?foreign aid?) actions. However, the experience of reshaping existing teams were also associated with weakening the traditional employer-employee links, and straining relationships between ECPs and those who they had previously regarded as colleagues working for the same organisation (?feelings of being in no-man's land?). Conclusions Successful integration of ECPs depends on strategic vision, and effective organisational partnerships at senior management level backed up operationally and supported by clear lines of communication to all stakeholders.
 
Article
Background Intravenous morphine is the preferred drug for the treatment of moderate to severe pain by paramedics. Nausea and vomiting are believed to be frequent side-effects and routine co-administration of metoclopramide is common. In the absence of pre-hospital data to support this practice, we sought to determine the incidence of peri-opiate nausea and vomiting in an ambulance service which does not administer anti-emetics. Methods This prospective observational study is currently assessing the incidence of emesis in 400 patients attended by the North East Ambulance Service, aged above 17 years and receiving morphine, using a patient-scored Nausea and Vomiting Score (NVS: 0=no nausea or vomiting, 1=slight nausea, 2=moderate nausea, 3=severe nausea, 4=vomited once, 5=vomited twice or more). Results To date 145 patients have been recruited. Median NVS before morphine was 0 (range 0 to 6, inter-quartile range (IQR) 0 to 1): 54/141 (38%) of patients had some degree of nausea or vomiting. Median NVS on hospital arrival (after morphine) was 0 (range of 0 to 6, IQR 0 to 1): 54/130 (42%) patients had some degree of nausea or vomiting. The differences pre- vs. post-morphine in median NVS (p=0.98) and proportion of patients suffering nausea and vomiting are not statistically significant (p=0.98 and p=0.54 respectively). There were no significant correlations between pre-morphine pain score and pre-morphine NVS; post-morphine pain score and post-morphine NVS; pre-morphine NVS and total morphine dose; and post-morphine NVS and total morphine dose (Spearman's rank correlation 0.09, p=0.274; 0.07, p=0.44; 0.10, p=0.25; and 0.10, p=0.24 respectively). Conclusion and recommendations To date this study has found no evidence that pre-hospital administration of morphine is associated with an increased incidence or severity of nausea and vomiting and therefore does not appear to support the routine co-administration of metoclopramide.
 
Article
Patients with dementia and traumatic injury require prompt and adequate pain relief. However we hypothesised that they may be at risk of under-treatment with analgesia in the emergency setting. We identified patients over 70 who attended our ED with acute musculoskeletal injuries and were either referred to the Orthopaedics/Trauma surgeons on call or the fracture clinic. Using clinical records and discharge diagnosis coding, 61 injured patients with dementia were identified. 84 injured patients over 70 without dementia were also studied. Their ED prescription records were examined and whether analgesia was given or not, together with the time interval from arrival to administration of first analgesic was noted. Kaplan-Meier curves were constructed from the time-interval data. Significance testing was by the log rank test. 62% of the patients with dementia had acute fractures. 77% of controls had acute fractures. The remaining patients (21% overall) had soft tissue injuries or joint dislocations. 50% of injured patients with dementia received analgesia in the ED phase of their care, compared with 56% of controls. There was a trend to delayed administration of analgesia to patients with dementia compared to controls (p=0.074, log rank). (Figure 1 for Kaplan-Meier curves). Our findings suggest that injured patients with dementia are less likely to receive timely analgesia in the ED than patients without dementia. Further work is needed to identify the reasons behind this inequity and intervene accordingly. Abstract 022 Figure 1Kaplan-Meier plot of time interval from ED arrival to first analgesic; patients with dementia (upper curve) vs. controls (lower curve); p=0.074.
 
Article
Background Out-of-hospital cardiac arrest (OHCA) remains a leading cause of mortality and severe neurological disability. Survival from OHCA depends on good quality cardiopulmonary resuscitation from EMS personnel. The 'time on the chest' and interruption time for defibrillation have recently been shown to be pivotal to survival. Electrocardiograph impedance analysis software allows retrospective quality control and feedback to EMS crews after a resuscitation attempt. Whilst this technique has been used by several EMS services worldwide, routine use and acceptance has yet to be established. Aims To establish the feasibility of using impedance software for pre-hospital resuscitation quality control and to gain baseline data on pre-hospital resuscitation practice in the Lothians region of Scotland. Methods Prospective, observational pilot study. After a resuscitation attempt the attending EMS crew was asked to consent to the ECG trace from the defibrillator being downloaded onto a research computer. The impedance trace was then analysed using computer software (Codestat - Physio Control) and a report on the resuscitation attempt generated. Results 9 OHCA were included in the pilot. All EMS crews agreed to the download from the defibrillator and all found viewing the trace informative. Downloading the ECG trace was straightforward in all cases. The mean time of the resuscitation attempt spent performing chest compressions was 50%. The mean chest compression rate was 141 min. The mean time from cessation of chest compressions to delivery of defibrillatory shock was 46 s. Conclusion ECG impedance analysis is a straightforward, accurate, accepted method of assessing quality of pre-hospital resuscitation by EMS personnel. Baseline data from our region suggests that the quality of advanced life support could be improved by focussing on basic elements of resuscitation. Using software-generated resuscitation reports could be useful for EMS personnel feedback and monitoring effectiveness of training programmes. Further research is warranted on the widespread use of this technique.
 
Age of patients at randomisation. 
Article
To test the design and feasibility of a large scale multicentre randomised controlled trial evaluating the efficacy and safety of a high dose corticosteroid infusion after head injury. To assess whether large numbers of patients could be enrolled and treated within eight hours from injury and then followed up at six months. Randomised placebo controlled multicentre trial of a 48 hour corticosteroid infusion after significant head injury. All head injured adults who were observed while in hospital to have GCS of 14 or less (out of a maximum score of 15), and who were within eight hours of the injury, were eligible for trial entry. Analysis of baseline and outcome data (for both treatment groups combined) for 1000 patients enrolled in the pilot phase of the MRC CRASH Trial. Fifty two hospitals in 14 countries participated in the pilot phase, recruiting an average of one patient per hospital per month. Of the 1000 randomised patients, 330 (33%) had mild head injury, 289 (29%) had moderate head injury, and 381 (38%) had severe head injury. Seven hundred and nine (71%) patients were randomised within three hours of injury. Outcome at two weeks from injury was known for 991 (99%) patients, of whom 170 (17%) patients died. At the time of writing, six month follow up for the first 500 patients was nearly complete. Vital status was known for 465 (93%) of the 500 patients, of whom 97 (21%) had died. Functional status based on the Glasgow Outcome Scale was known for 438 (88%) of the 500 patients: 21% were dead, 17% were severely disabled, 22% were moderately disabled, and 34% had made a good recovery. The trial procedures proved practicable and a wide variety of patients were recruited in the emergency department within eight hours of injury. Using simple outcome measures, large numbers of patients can be successfully followed up.
 
Article
A short cut review was carried out to establish whether levels of S-100b were predictive of long-term disability after head injury. 200 papers were found using the reported searches, of which 12 presented the best evidence to answer the clinical question. The author, date, and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that a raised level of S-100b is a marker of poorer long-term outcome after both major and minor head injury.
 
Article
Cranial CT (CCT) is the gold standard to rule out traumatic brain injury. The serum level of the protein S-100B has recently been proposed as promising marker of traumatic brain injury. We prospectively investigated whether it might be a reliable tool for CCT triage in mild brain injury at a peripheral trauma centre with limited CT resources. Patients with mild head injury and a Glasgow Coma Score of 13-15 admitted to the emergency department of a peripheral trauma centre were enrolled. Blood samples for S-100B analysis were obtained after clinical evaluation. The cut-off level for positive S-100B was 0.105 μg/l. All patients underwent CCT. The relationship between clinical findings, CCT results and S-100B levels was evaluated. 233 patients were enrolled. Median time between injury and sampling was 137 min. CCT was positive in 22 (9%) patients. Of these, 19 (8%) had positive serum S-100B levels. Overall, S-100B had a specificity of 12.2% and a sensitivity of 86.4%, with a positive predictive value of 12.8% and a negative predictive value of 85.7% as a selection tool for CCT triage in patients with mild head injury. The S-100B serum level showed a high sensitivity and negative predictive value in the screening of patients with mild head injury. The use of serum S-100B as a biomarker for CCT triage may improve patient screening and decrease the number of CCT scans performed. This would reduce unnecessary radiation exposure and free up capacity in the emergency rooms of peripheral hospitals to enable them to cope better with multiple admissions.
 
Article
Unscheduled tetanus prophylaxis (UTP) used in the emergency room (ER) in patients with wounds who are unaware of their vaccination history is erroneous in 40% of cases. Evaluation of bedside tetanus immunity with the Tétanos Quick Stick (TQS) test may improve UTP. To show that (1) a positive TQS result reflects immunity to tetanus; and (2) TQS is reproducible by ER workers. In a prospective concordance study, immunity to tetanus of patients with wounds was assessed by two techniques: (1) TQS at the bedside, which detects specific tetanus antitoxins at concentrations > or =0.2 IU/ml in whole blood or > or =0.1 IU/ml in serum; (2) ELISA in the laboratory (threshold >0.1 IU/ml). The study comprised three groups: (A) healthcare personnel self-tested with the two techniques to determine the effect of training; (B) selected patients with wounds were double-tested with TQS by two healthcare providers whose readings were compared to test reproducibility; and (C) all patients with wounds aged > or =15 years were consecutively included. Of 1018 individuals included, 60 were in group A, 50 were in group B and 908 were in group C. 403 patients who were not included were similar to those included for age, vaccination history and types of wounds. The reproducibility of the test was 98%. TQS sensitivity was 83.0%, specificity 97.5%, positive predictive value 99.6% and negative predictive value 42.9%. TQS reliably predicts tetanus immunity and is reproducible by healthcare providers. Although it may not accurately discriminate between patients with ongoing and declining immunity, it is currently the most sensitive and specific tool for guiding tetanus prophylaxis and should be included in current guidelines on UTP.
 
Article
Objectives: Although prehospital treatment algorithms have changed over the past years, the prehospital time of multiple trauma patients of some 70 min and the on-scene-treatment time (OST) of some 30 min have not changed since 1993. The aim of this study was to critically assess specific interventions and conditions at the scene in relation to their impact on prehospital rescue intervals. Methods: We performed a retrospective data analysis of all multiple injured patients from the TraumaRegister DGU (English: German Trauma Society) from January 1993 to December 2010. Exclusion criteria were missing or implausible data regarding prehospital timelines. With OST as an independent variable, different models of multivariate regression were performed to identify parameters with relevant impact on the OST. Results: 15 103 datasets were included in this study. Based on the mean OST of 32.7 (± 18.6) min and a constant absolute term of 16.2 (± 1.5) min, we identified seven procedures and nine environmental parameters with significant impact on OST. Intubation (9.3 ± 0.8 min) and being a car occupant (8.0 ± 0.8 min) were associated with the most prolonged OSTs. A Glasgow Coma Scale ≤ 8 (-4.5 ± 0.7 min) and cardiopulmonary resuscitation (-2.8 ± 1.7 min) resulted in its most relevant reduction. Admission to a Level III facility led to a reduced overall prehospital time (60.0 ± 24.6 min) compared with Level I (70.0 ± 28.5 min) and II (66.8 ± 27.4 min) trauma centres. Conclusions: This study identified characteristic interventions and conditions with significant impact on prehospital treatment times. Current treatment concepts should be re-evaluated with respect to these results.
 
Article
Some patients attempt to conceal human bites with factitious mechanisms of injury. Follow up questioning allows patients to modify their histories. This practice was prospectively audited. Patients with cutaneous wounds who did not present with a history of human bite were asked a follow up question. Those who then gave a history of human bite were noted. Certain groups of patients with human bites were significantly more likely to provide a factitious history and/or delay presentation. Follow up questioning dramatically increased the case-detection rate, prompting specific management.
 
Article
Acute epiglottitis in adult is a potentially life-threatening condition that may be underdiagnosed. The present study reports the clinical features, management and patient outcomes in an acute hospital in Hong Kong over a seven-year period. All adult patients aged 18 years or above admitted to Tuen Mun Hospital between July 1999 and June 2006 with the diagnosis of acute epiglottitis were included in this retrospective study. The diagnosis of acute epiglottitis was established by direct visualisation of inflamed epiglottis during laryngoscopic examination. 106 patients were identified. A total of 21 patients (20%) had co-morbidities, with diabetes mellitus (11%) being the most common. Five patients had a history of nasopharyngeal carcinoma and three patients had a previous history of acute epiglottitis. The majority (94%) of patients presented with sore throat as their major complaint. Blood cultures were collected from 15 patients and all were negative. A combination of cefotaxime and metronidazole was the most common empirical antibiotic regimen prescribed. Seven patients required active airway intervention (six with endotracheal intubation and one failed intubation with emergency tracheostomy performed). No mortality was reported. Acute epiglottitis in adults is not a rare entity and vigilance for this condition is needed. In general, the prognosis is good with antimicrobial therapy, close monitoring and selective airway intervention.
 
Article
This paper reviews the current evidence available on the practice of spinal immobilisation in the prehospital environment. Following this, initial conclusions from a consensus meeting held by the Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh in March 2012 are presented.
 
Article
A case is presented in which a knife wound to the head was initially assessed as inconsequential and later proved to be significant. This case illustrates the necessity of exploring scalp wounds to assess for possible skull fractures and of using the history to direct management. It also highlights the requirement for thorough guidelines for use by junior staff and for the staff to apply them with some degree of latitude.
 
Mechanisms of injury in 76 children. Numbers (percentages) of children in each category 
Three radiographic projections of the cervical spine: (A) lateral, (B) anteroposterior, and (C) open mouth odontoid (peg) projections.
Findings on clinical assessment before radiography in 76 children. Numbers (percentages) of children in each category 
Article
To assess the effectiveness of cervical spine radiography in injured children under 11 years old, and suggest improvements. Retrospective survey of radiographs and accident and emergency records for children examined during a one year period in a large teaching hospital. No cervical spine fractures occurred in this age group during the year. The recorded clinical findings did not always justify radiography. Clinical examination appears undervalued by those assessing injured children and is poorly recorded. Radiography can be used more selectively. Initial assessment using a single lateral projection can be followed in doubtful cases by cross sectional imaging.
 
Article
This article on management within the emergency department discusses capital planning, the workings of the coroner court and inquest, and the impact on the department of a major incident.
 
Article
Craniopharyngiomas are reported to be the commonest non-glial tumours of childhood. The classic presentation is typically progressive, commonly manifested as visual field defects, growth abnormalities and/or endocrine disturbance. We report a case of an 11-year-old girl presenting in acute confusional state, with few historical factors suggestive of an intracranial mass lesion and no objective localising signs on examination. Although initially treated as encephalitis, neuroimaging revealed a large craniopharyngioma with acute hydrocephalus and bilateral frontal lobe compression. She was transferred immediately to the local neurosurgical unit and underwent reservoir drainage of the cystic tumour within 24 h. This resulted in immediate symptomatic resolution. This case highlights the importance of early cerebral imaging in the paediatric patient with diagnostic uncertainty and suggests a high index of suspicion for space-occupying lesions in children, despite perceived duration of symptoms.
 
Article
An 11 year old boy walked into our accident and emergency department with his mother having woken up with headache four hours ago. He was known to have mild learning difficulties for speech and language, but was otherwise previously fit and healthy. He was not on any medications, and he did not have any history of trauma. He had vomited twice at home. On initial examination, he did not have a high temperature, rash, or meningeal symptoms, and his Glasgow Coma Scale score was E4 M6 V5. He had no neurological signs or papilloedema and the pupils were normal. He had no neck stiffness or meningeal signs. His pulse …
 
Article
Introduction During 2011/12, East Midlands Ambulance Service (EMAS) received 776,000 emergency 999 calls of which 36% (277,000) did not require transportation to hospital. Inappropriate calls can be due to public misunderstanding of when it is appropriate to ring 999. NHS 111 is an alternative free telephone service that enables the public to access health care advice or resources when the matter is urgent but not a 999 emergency. However knowing which service to telephone is not always easy and such a decision can be particularly difficult for older people as symptom presentation across complex co-morbidities can be atypical. A mixed method scoping project was carried out to explore the understanding, use and experiences of emergency (999) and urgent services (NHS 111) by older people aged 65 and over. Here, we report findings from the qualitative workstream. Methods Semi-structured interviews and focus groups (n=25) using a topic guide were carried out with a purposive sample of older people who had used the 999 ambulance service and/or the NHS 111 service in the East Midlands. Results We found a lack of awareness as to the remit of NHS 111 and confusion as to when this number should be phoned. Older people's expectations of 111 seemed to be analogous to other primary care services. As a consequence, participants were often dissatisfied with the service response; it neither provided useful advice nor reassurance. Greater satisfaction was reported with the call handling process and hospital transportation through EMAS (999) and older people's reported rationale for phoning 999 would seem to suggest appropriate service use. Conclusion Developing a greater understanding of how older people decide to contact a service would support future policy and practice implementation. If the remit of a service is unclear and accompanying publicity confusing, older people will continue to dial 999.
 
On scene physician provisional diagnosis 
False positive cases 
Article
The accuracy of the Danish police operated "112" emergency call system was studied. Dispatch of the anaesthesiologist staffed mobile emergency care unit (MECU) to acute coronary syndrome (ACS) cases was used as an indicator of accuracy of dispatch to life threatening emergencies. This was an observational cohort study of patients given a 112 system report of heart attack and patients with a provisional diagnosis of ACS made on scene by the MECU. Sensitivity, specificity, and positive predictive value with 95% confidence intervals (CI) were calculated. There were 341 reports of "heart attack" and 205 patients with ACS. Sensitivity was 75% (95% CI 68% to 80%) specificity 90% (89% to 92%) and positive predictive value 45% (40% to 50%). The accuracy of 112 dispatch of the MECU was found to be moderate. We suggest more training of dispatch staff and medical supervision.
 
Article
As in many other developing countries, emergency medical services, especially pre-hospital emergency care, has long been neglected in Pakistan. Consequently, patients are brought to the emergency departments by relatives or bystanders in private cars, taxis or any other readily available mode of transportation. Ambulances, where they exist, have barely a stretcher and arrangements for oxygen supply. Modern emergency services are considered too costly for many countries. A model of pre-hospital emergency services, called Rescue 1122 and established in Punjab province of Pakistan, is presented. The system is supported by government funding and provides a quality service. The article describes the process of establishment of the service, the organisational structure, the scope of services and the role it is currently playing in the healthcare of the region it serves.
 
Article
Objectives: The quality of chest compressions along with defibrillation is the cornerstone of cardiopulmonary resuscitation (CPR), which is known to improve the outcome of cardiac arrest. We aimed to investigate the relationship between the compression rate and other CPR quality parameters including compression depth and recoil. Methods: A conventional CPR training for lay rescuers was performed 2 weeks before the 'CPR contest'. CPR anytime training kits were distributed to respective participants for self-training on their own in their own time. The participants were tested for two-person CPR in pairs. The quantitative and qualitative data regarding the quality of CPR were collected from a standardised check list and SkillReporter, and compared by the compression rate. Results: A total of 161 teams consisting of 322 students, which includes 116 men and 206 women, participated in the CPR contest. The mean depth and rate for chest compression were 49.0±8.2 mm and 110.2±10.2/min. Significantly deeper chest compression depths were noted at rates over 120/min than those at any other rates (47.0±7.4, 48.8±8.4, 52.3±6.7, p=0.008). Chest compression depth was proportional to chest compression rate (r=0.206, p<0.001), but there were significantly more incomplete chest recoils at the rate of over 120/min than at any other rates (9.8%, 6.3%, 25.6%, p=0.011). Conclusions: The study showed conflicting results in the quality of chest compression including chest compression depth and chest recoil by chest compression rate. Further evaluation regarding the upper limit of the chest compression rate is needed to ensure complete full chest wall recoil while maintaining an adequate chest compression depth.
 
Article
To assess the response time and the details of the operating procedure of the Beijing 120 Emergency Medical Service (EMS). Between June and December 2005, 51 918 EMS cases recorded in the Dispatch Center of the Beijing Emergency Medical Center were analysed. The median response time of the 51 918 cases was 16.5 min; the cumulative proportions were 2.28%, 9.64% and 18.04% for less than 5 min, 8 min and 10 min of response time respectively, whereas the proportion was 19.20% for more than 30 min of response time. On the basis of this analysis, the response time of the Beijing 120 EMS system was found to be longer than that indicated by the national standards.
 
Article
The aims of this study were to present the demographics and mechanisms of facial injury in UK children, and to establish the nature and anatomical location of facial injury in this age group. Patient data were collected retrospectively over 1 year from a paediatric Emergency Department in South East Scotland. Medical notes were examined for all patients coded on the electronic patient record as having any facial injury. 593 patients attended with a facial injury. The median age of patients was 4.7 years. (IQR 2.4-7.5 years.), and the male to female ratio of facial injuries was 2:1. Injuries were predominantly from falls. Assault or violence was uncommon. Most common sites of facial injury were the lower third of the face and dento-alveolar injury. Facial fractures were rare and radiographic facial imaging was infrequently performed. Only eight facial fractures were diagnosed. 4.5% of all patients were admitted to hospital; 23% of the children were referred on to other specialities for follow-up, of these over half were to a dentist. A large number of children presented with facial injuries during the study period. Facial lacerations, oral trauma and dental trauma were the most common injuries. The majority of patients were dealt with without admission or referral to another speciality.
 
Article
Practitioners dealing with emergencies in older adults in the community must be able to recognise the atypical presentation of illness in older people and have a high index of suspicion that apparently innocent symptoms can be the presentation of serious underlying pathology. It must also be remembered that the common medical emergencies of younger adults generally occur more frequently in older adults and require similar treatment. Necessary skills include clear communication with patients although on occasions witnesses must be used to obtain relevant information. A focussed examination including a mental state test is often necessary when dealing with non-specific illness in the older patient and when determining if someone can be left at home. A home visit allows assessment of the patient's social circumstances and emergency practitioners might sometimes need to make adjustments to ensure the safety of the patient in their surroundings if they are to be left at home or subject to a delay in transfer. Evidence of neglect by the patient or by others should also be looked for when attending the patient at home. The combination of social and medical assessment, linked to knowledge of the services available locally will determine where the patient's care will be best delivered. With an older patient it is safer to err on the side of caution to avoid denying patients a specialist assessment. For many this will need to be a comprehensive Geriatric assessment performed after the emergency episode has passed.
 
Rapid-sequence intubation group versus awake transfer group 
Article
To identify the incidence of intracranial pathology in a population of patients with trauma with an on-scene Glasgow Coma Score (GCS) of 13 or 14, and the proportion that required prehospital intubation and ventilation. A retrospective review of a prehospital trauma database was carried out over a 12-month period, and 81 patients were reviewed. All had a traumatic mechanism of injury and had an on-scene GCS of 13 or 14 recorded by a prehospital doctor. 43 patients required prehospital rapid-sequence intubation. Overall, 31.5% of patients with a GCS of 13 or 14 had an abnormal computed tomography scan of the head and 20.5% had an intracranial haemorrhage. For this group of patients with trauma with a drop of only one or two points on the GCS, the incidence of intracranial pathology was almost one in three and that of intracranial haemorrhage was one in five.
 
Continued Percentages of statements considered by respondents to be true 
Article
Section 136 of the Mental Health Act 1983 empowers the police to detain those suspected of being mentally ill in public places, and convey them to a place of safety. In practice, accident and emergency (A&E) departments are often used. The authors assessed levels of knowledge of section 136 between A&E doctors, senior nurses, and police constables. Doctors and senior nurses in all (A&E) departments in the Yorkshire region were asked to complete a multiple choice tick box type questionnaire, as were police constables from the Humberside Police Force. 179 completed questionnaires were returned, of which 16 were completed by consultants, 14 by SpRs, 24 by SHOs, 33 by senior nurses, and 92 by police officers. Some 24.1% of A&E staff and 10.9% of police failed to recognise that a person has to appear to be suffering from a mental disorder to be placed on a section 136; 40.2% of police did not know that section 136 is a police power; 55.2% of A&E staff and 14.1% of police incorrectly thought that a person could be placed on a section 136 in their own home; 43.75% of consultants and 50% of SpRs did not consider A&E departments to be a place of safety; 49.4% of A&E staff and 29.3% of police thought that patients could be transferred on a section 136. Only 10.3% of A&E staff and 22.8% of police had received any formal training. The knowledge among A&E staff and the police of this difficult and complex piece of mental health legislation is poor and requires action through formal education and training. This study not only reflects the levels of knowledge within the groups, it may also reflect the different perceptions of each group as to their role and duties within section 136 of the Mental Health Act 1983.
 
Article
Neurological emergencies are seen relatively common by the community practitioner and require careful assessment in order to identify potential serious pathology. Headache presents a particular diagnostic challenge and a good history and examination is vital to avoid missing potentially life-threatening conditions such as subarachnoid haemorrhage. This article aims to provide a system to guide assessment and management, however, it is clear that in most cases patients will require secondary care assessment. Neurological conditions are extremely frightening for both patients and carers who often fear they may be having a stroke or brain tumour, therefore reassurance and support is a crucial part of the primary care professionals role.
 
Article
A 14-year-old boy presented to the emergency department with pain and swelling over the lumbar area after blunt trauma of his lower back 2 h previously (after falling from a horse). On examination, there was a voluminous swelling (20×15 cm) over the lumbar area, overlying …
 
Article
To determine the emergency department (ED) environmental factors associated with patient satisfaction. A prospective, observational study in a university-affiliated tertiary-referral ED and associated observation unit (OU). The ED environment was evaluated with a structured questionnaire, scored using a 100-mm visual analogue scale. Patients who stayed in the ED over 8 h (long-stay ED; LSED) were compared with those who stayed less than 4 h (short-stay ED; SSED) and with a control group admitted to the OU. A total of 233 patients was enrolled, overall satisfaction in SSED was 81% (95% CI 70.1 to 88.7), 69% in LSED (95% CI 57.4 to 78.7) and 84% in OU (95% CI 73.6 to 91.0). The most important environmental factors were cleanliness (median importance 95, interquartile range (IQR) 81-98) and communication with medical staff (94, IQR 80-98) and family (92, IQR 74-98). The least important factors were access to nature (38, IQR 19-65), a natural light source (50, IQR 24-74) and ability to sit out of bed (52, IQR 26-75). Factors rated high for importance but low for satisfaction were ED noise levels (median difference 40, IQR 3-70), ED trolley comfort (19, IQR 6-50) and food quality (12, IQR -4-29). Patients who spend over 8&emsp14;h in the ED are less satisfied with their environment than either those who spend less than 4 h or patients in an OU. Importantly, distinct, amenable factors can be identified. These should be addressed to improve patients' overall ED management and satisfaction.
 
Article
Much effort has been put in the past years to create and assess accurate tools for the management of febrile infants. However, no optimal strategy has been so far identified. A sequential approach evaluating, first, the appearance of the infant, second, the age and result of the urinanalysis and, finally, the results of the blood biomarkers, including procalcitonin, may better identify low risk febrile infants suitable for outpatient management. To assess the value of a sequential approach ('step by step') to febrile young infants in order to identify patients at a low risk for invasive bacterial infections (IBI) who are suitable for outpatient management and compare it with other previously described strategies such as the Rochester criteria and the Lab-score. A retrospective comparison of three different approaches (step by step, Lab-score and Rochester criteria) was carried out in 1123 febrile infants less than 3 months of age attended in seven European paediatric emergency departments. IBI was defined as isolation of a bacterial pathogen from the blood or cerebrospinal fluid. Of the 1123 infants (IBI 48; 4.2%), 488 (43.4%) were classified as low-risk criteria according to the step by step approach (vs 693 (61.7%) with the Lab-score and 458 (40.7%) with the Rochester criteria). The prevalence of IBI in the low-risk criteria patients was 0.2% (95% CI 0% to 0.6%) using the step by step approach; 0.7% (95% CI 0.1% to 1.3%) using the Lab-score; and 1.1% (95% CI 0.1% to 2%) using the Rochester criteria. Using the step by step approach, one patient with IBI was not correctly classified (2.0%, 95% CI 0% to 6.12%) versus five using the Lab-score or Rochester criteria (10.4%, 95% CI 1.76% to 19.04%). A sequential approach to young febrile infants based on clinical and laboratory parameters, including procalcitonin, identifies better patients more suitable for outpatient management.
 
Continued
Article
(1) investigate risk factors associated with repeated deliberate self-harm (DSH) among patients attending the emergency department due to DSH, (2) stratify these patients into risk categories for repeated DSH and (3) estimate the proportion of repeated DSH within 12 months. A consecutive series of individuals who attended one of Scandinavia's largest emergency departments during 2003-2005 due to DSH. Data on sociodemographic factors, diagnoses and treatment, previous DSH at any healthcare facility in Sweden (2002-2005) and circumstances of the index DSH episode were collected from hospital charts and national databases. A nationwide register based on follow-ups of any new DSH or death by suicide during 2003-2006. Repeated DSH episode or suicide. 1524 patients were included. The cumulative incidence for patients repeating DSH within 12 months after the index episode was 26.8% (95% CI: 24.6 to 29.0). Risk factors associated with repeating DSH included previous DSH, female gender, self-injury as a method for DSH and if the self-injury required a surgical procedure, current psychiatric or antidepressant treatment and if the patient suffered from a substance use disorder or adult personality disorder or did not have children under the age of six. Patients attending an emergency department due to DSH have a high risk of repeating their self-harm behaviour. We present a model for risk stratification for repeated DSH describing low-risk (18%), median-risk (28% to 32%) and high-risk (47% to 72%). Our results might help caretakers to direct optimal resources to these groups.
 
Article
Introduction: This paper describes the first 16-months experience of prehospital rapid sequence intubation (RSI) in a rural and suburban helicopter-based doctor-paramedic service after the introduction of a standard operating procedure (SOP) already proven in an urban trauma environment. Method: A retrospective database review of all missions between October 2010 and January 2012 was carried out. Any RSI or intubation carried out was included, regardless of age or indication. Patients who were intubated by Ambulance Service personnel prior to the arrival of the East Anglian Air Ambulance (EAAA) team were excluded. Results: The team was activated 1156 times and attended 763 cases. A total of 88 RSIs occurring within the study period were identified as having been carried out by the EAAA team and meeting inclusion criteria for review. There were no failed intubations that required a rescue surgical airway or the placement of a supraglottic airway device. For road traffic collisions (RTCs), the overall on-scene time for patients who required an RSI was 40 min (range 15-72 min). For all other trauma, the average on-scene time was 48 min (range 25-77 min), and for medical patients, the average time spent at scene was 41 min (range 15-94 min). Conclusions: We have demonstrated the successful introduction of a prehospital care SOP, already tested in the urban trauma environment, to a rural and suburban air ambulance service operating a fulltime doctor-paramedic model. We have shown a zero failed intubation rate over 16 months of practice during which time over 750 missions were flown, with 11.5% of these resulting in an RSI.
 
Article
SAVES, the name used to describe a register of survivors of out-of-hospital cardiac arrest (OHCA), was established in rural Northwest Ireland in 1992. From 1992 to 2008, 80 survivors were identified (population 239,000 (2006)). Most incidents were witnessed (69/70) and all were in shockable rhythm at the time of first rhythm analysis (66/66). Of 66 patients who could be traced, 46 were alive in December 2008. Average survival rates appeared to increase over the lifetime of the database. SAVES has also contributed to the development of a national OHCA register.
 
Response rates for each follow up period 
Change in mean score of PTSD symptoms over time and repeated measures analysis of variance 
Article
To determine the prevalence of post-trauma psychological problems among a cohort of male accident and emergency department patients admitted to hospital. To identify the changes in their psychological symptoms over an 18 month follow up period. A prospective cohort study of male accident and emergency department patients who were admitted for treatment of an injury. Baseline interview recorded demographic details and accident details. Standardised questionnaires measured baseline psychological state and personality type. Follow up at six weeks, six months, and 18 months after injury was by face to face interview or postal questionnaire and recorded progress since injury, and documented psychological status through the use of standardised questionnaires to detect psychiatric disorder and symptoms of post-traumatic stress disorder (PTSD). 210 male patients were recruited into the study. Psychiatric disorder was identified in 47.6% of responders at six weeks, and 43.4% at six months after injury. This improved significantly at 18 months. PTSD symptoms were moderate in 25%-30% and severe in 5%-14% and did not change significantly over the study period. A significant relation was found between previous psychiatric history and psychological symptoms at 18 months after injury. No relation was identified between injury severity and psychological status after injury. This study finds a high prevalence of psychological distress in male accident and emergency department patients after injury. Although some symptoms resolve over the follow up period, a proportion remain and may be related to previous psychiatric history. There was no relation identified between severity of injury and psychological morbidity.
 
Article
A 48-year-old male F-18 jet mechanic presented with a new floater in his right eye after a screw he was attempting to remove exploded. He was not wearing eye protection. He denied pain or any other vision changes. Anterior …
 
Article
The case of a 17-year-old girl brought into the emergency department (ED) having been found in a field semi-clad and overtly hypothermic is reported. A weak carotid pulse, agonal breathing and fixed dilated pupils were noted. On arrival in the ED she was in asystolic cardiopulmonary arrest. Initial core body temperature was 18 degrees C. After 4 h of closed cardiopulmonary resuscitation and rewarming using a haemofiltration circuit, she made a full recovery with no adverse neurological sequelae. In this case report, the importance of prolonged resuscitation in cardiopulmonary arrest secondary to acute severe environmental hypothermia and the successful use of a haemofiltration circuit to deliver active core rewarming are highlighted.
 
Article
Cholera was a much feared disease as it spread across Europe in 1829–1830. The Lancet on the 19 November 1831 charted its progress and even published a fold out map of Europe to allow its readers to monitor its approach.1 The epidemic reached Sunderland in October 1831. On the 3 December 1831 a Dr W B O’Shaughnessy delivered a lecture to the Westminster Medical Society on the “Blue epidemic cholera”, as it was then known. As there was still no known “remote” cause of the disease, he considered it legitimate to look at the effects of the disease and to treat these instead. He had observed that, “universal stagnation of the venous system, and rapid cessation of the arterialisation of the blood, are the earliest, as well as the most characteristic effects.”2 He then posed the question, “What is the best mode by which this artificial arterialisation can be effected ..?” At the time most physicians favoured venesection. Others, “Recommend the inhalation of oxygen gas, or of a mixture of oxygen and atmospheric air, or of the protoxide of azote, ... “laughing gas”...”2 He went on, “Now it might rationally be imagined that the success or failure of these methods should afford us a touchstone of some authority, in deciding on the rationality of the principles on which they are practised ...”2 and concluded that there was some evidence in favour of venesection, if done in time and no other problems were encountered. He found no evidence in favour of oxygenation and conceded that venesection might also fail. In vitro physiology studies had shown that venous blood could be arterialised by agitation in atmospheric air, or contact with highly oxygenised solids or fluids. This led him to suggest the idea of intravenous injection of nitrate or …
 
Article
Little has been published on the subject of civil ambulance services and their development from the mid-19th century in the UK until modern times. There is limited secondary literature available which provides useful background information on the subject and most organisations may give brief histories of their early days but these sources lack historical adequacy in terms of detail. This article shows part of the uncertain path which the history followed towards the service which we enjoy today. From the pages of the British Medical Journal and the Lancet and Hansard, the battle to set up the service is followed and an indication of the drivers towards change over the period is revealed in the attitudes expressed. In particular, the two World Wars are seen to be the stepwise stimuli to providing a necessary service to the British population where the will to achieve this had hitherto been lacking at a parliamentary level. The history of the London Ambulance Service is chosen because more is written about it in these journals but services in other British cities and the USA are mentioned since they played a part in influencing change.
 
Article
Prehospital care in the United Kingdom rarely lasts more than a few hours other than in exceptional circumstances (for example, mountain and cave rescue, oil rigs). In other parts of the world hospitals may be much more distant and in expeditions to remote areas, prehospital care may extend to days or even weeks. When this occurs, the boundaries between primary care and prehospital care blur.
 
Article
To determine the trend in the associations between socioeconomic status and gender with median age at death in England and Wales, from 1960 to 2009. Annual cross-sectional studies of all registered deaths from a motor vehicle collision in England and Wales, 1960-2009. There were 1647 deaths from a motor vehicle collision in 1960 and 964 deaths in 2009. The number of children aged 14 years or less who died in 1960 was 66 and this figure had reduced to 20 deaths by 2009. Individuals in non-manual occupations were consistently more likely to die above the median age of death than those in manual occupations during 1960-1963 (OR 1.66; 95% CI 1.50 to 1.84) and also during 1990-2000 (OR 1.54; 95% CI 1.44 to1.65). For 1960-1969, women had a higher risk of dying at above the annual median age of death (OR 1.72; 95% CI 1.62 to 1.82); for 2001-2009 the corresponding OR was 1.80 (95% CI 1.68 to 1.94). There has been a 41% decrease in annual deaths after motor vehicle collisions in England and Wales over the past 50 years. The number of individuals over the age of 74 years dying in motor vehicle collisions has increased slightly, while the number of children's deaths decreased by 70% over the same time period despite driving becoming more common. Involvement in motor vehicle collisions may contribute to the sex and social class gradients in life expectancy observed in England and Wales.
 
Article
The role of acute coagulopathy after severe trauma as a major contributor to exsanguination and death has recently gained increasing appreciation, but the causes and mechanisms are not fully understood. This study was conducted to assess the risk factors associated with acute traumatic coagulopathy together with quantitative estimates of their importance. Using the multicentre Trauma Registry of the German Society for Trauma Surgery, adult trauma patients with an Injury Severity Score ≥16 were retrospectively analysed for independent risk factors of acute traumatic coagulopathy on arrival at the emergency department (ED) by multivariate stepwise logistic regression analysis. Coagulopathy was defined as prothrombin time test (Quick's value) <70% and/or platelets <100,000/μl. A total of 1987 patients was eligible for further analysis. Independent risk factors for acute traumatic coagulopathy calculated by multivariate analysis were the Injury Severity Score, abdomen Abbreviated Injury Scale score, base excess, body temperature ≤35°C, presence of shock at the scene and/or in the ED (defined as systolic blood pressure ≤90 mm Hg), prehospital intravenous colloid:crystalloid ratio ≥1:2 and amount of prehospital intravenous fluids ≥3000 ml. The risk factors from multivariate analysis correspond to the current understanding that coagulopathy is influenced by several clinical key factors; for example, an ongoing state of shock (at the scene and in the ED) was associated with a threefold increased risk of developing coagulopathy. When adjusted for all factors including the amount of prehospital intravenous fluids, a high colloid:crystalloid ratio was still associated with coagulopathy on admission to the ED. The recognition, prevention and management of the mechanisms and risk factors of coagulopathy aggravating haemorrhage after trauma are critical in the treatment of the severely injured patient.
 
Changes in variables over the study period 
Article
Performance of emergency departments in England and Wales has declined in recent years. Data from the authors' department has shown that junior doctors now see fewer patients and spend longer over their assessment than was the case previously. This study aimed to determine how the assessment of patients with isolated ankle injuries changed over an 11 year period. A retrospective case note review was conducted. Data regarding the duration of assessment, clinical information recorded, investigations, and treatments were retrieved. During the period studied 13 555 patients presented with isolated ankle injuries; case notes of 550 of these patients were reviewed in the present study. Linear regression demonstrated that the median length of time from arrival in the department until seen by a clinician increased (b = 3.0 min/year, 95% CI 0.7 to 5.2, p = 0.015), but the median length of time from seeing a clinician until leaving the department was unchanged (b = 0.6 min/year, 95% CI -1.3 to 2.5, p = 0.475). More clinical information was being recorded, but the proportion of patients having radiographs of the ankle (b = 0.24% per year, 95% CI -1.40% to 1.87%, p = 0.751) or in whom a fracture was diagnosed (b = -0.20% per year, 95% CI -1.59% to 1.19% per year, p = 0.752) remained unchanged. It appears from this study that the duration of assessment of patients with minor injuries is not changing although this result should be interpreted cautiously.
 
Article
Background In the UK, recruitment of adequate numbers of doctors to emergency medicine (EM) has been problematic. With this as background, we analysed data about career choice for, and progression in, EM in a large multi-purpose study of doctors’ careers. Methods Questionnaire surveys of medical graduates of 1993, 1996, 1999, 2000, 2002, 2005, 2008 and 2009 from all UK medical schools. Results EM was specified as a first choice of career by 4.2% of graduates in postgraduate year 1, 4.8% in year 3, and 3.8% in year 5. Graduates who chose EM were much less likely to be certain about their choice than those who chose other specialties. Of those who specified EM as their first choice of career in year 1, only 26% still had it as their first choice in year 5. Of those who gave EM as their first career choice in year 5, only 27% had given EM as their first choice in year 1. Switches to EM were made, notably, by doctors who previously favoured surgical specialties, hospital physician-led specialties and anaesthetics. Conclusions Early career choices for EM are less predictive of career destinations than choices for other specialties, and, compared with many other specialties, doctors who pursue it may turn to it relatively late. Training policies on transferable competencies should enable clinical trainees in other related specialties to bank some of their skills if they transfer to EM, rather than necessarily having to start core training in year 1 of EM specialty training.
 
Odds ratio of death adjusted for ISS90 RTS and age (all hospitals) n=83 929. 
Hospital Ws scores 1996-2000 (number of observed versus expected survivors per 100 trauma patients standardised for the database casemix) n=58 672. 
Ws scores by most senior doctor who managed the patient.
Article
To demonstrate trends in trauma care in England and Wales from 1989 to 2000. Database of the Trauma Audit and Research Network that includes hospital patients admitted for three days or more, those who died, were transferred or admitted to an intensive care or high dependency area. To demonstrate trends in outcome, severity adjusted odds of death per year of admission to hospital were calculated for all hospitals (n=99) and 20 hospitals who had participated since 1989 (adjustments are for Injury Severity Score, age, and Revised Trauma Score). The grade of doctor initially seeing the injured patient in accident and emergency and median prehospital times per year of admission were calculated to demonstrate trends in the process of care. Trend analyses were carried out using simple linear regression (odds ratio versus year). The analysis shows a significant reduction in the severity adjusted odds of death of 3% per year over the 1989-2000 time period (p=0.001). During the period 1989-1994 the odds of death declined most steeply (on average 6% per year p=0.004). Between 1994 to 2000 no significant change occurred (p=0.35). This pattern was mirrored by the 20 permanent members where the odds of death also declined more steeply over the 1989-1994 period. The percentage of severely injured patients (ISS >15) seen by a consultant increased from 29 to 40 from 1989-1994 but has remained static subsequently. Median prehospital times for severely injured patients have not changed significantly since 1994 (51 to 45 minutes). Most of the case fatality reduction for trauma patients reaching hospital over the 1989-2000 time period occurred before 1995 when there was most marked change in the initial care of severely injured patients.
 
Article
The acute work of the ambulance service is of two sorts. Emergencies result from 999 telephone calls usually made by members of the public. Urgent transfers follow a request by a general practitioner (GP) or other health care professional to take a patient to hospital. In recent years there has been a large increase in emergency calls to the ambulance service. This has not been associated with a reduction in severity of illness, as judged by patient disposal from the A&E department.1 We felt that some of the increasing emergency calls was caused by a reduction in urgent calls and tested this hypothesis by examining the workload of the Westcountry Ambulance Service …
 
Software systems in use in the 33 A&E departments 
A&E departments and health regions.
Assault patient attendance by region and sex 
Article
To identify overall, seasonal, sex and age specific national trends in community violence from an accident and emergency (A&E) department perspective. Prospective collection of national violence data from a stratified random sample of 33 A&E departments in England and Wales. Data were analysed for the three years from May 1995 to April 1998. Time series statistical methods were used to detect trends among those aged 0-10, 11-17, 18-30, 31-50 and 51 + years. 121475 assaults were identified: 89533 (74%) men sustained injury. Forty five per cent were aged 18-30. The significant trends were an increase in injured women and those aged 31-50. Significant seasonal trends were identified for both sexes and all age groups: peaks were found in July to September and troughs in February to April. There was no overall significant change in levels of violence between 1995-1998 from an A&E department perspective. Numbers of women injured and those aged 31-50 increased significantly. The incidence of injury sustained in community violence is biphasic: is highest during July to September and lowest during February to April. National A&E department violence surveillance provides a unique perspective.
 
Top-cited authors
Simon D Carley
  • Manchester Metropolitan University
Jonathan Benger
  • University of the West of England, Bristol
Lee A Wallis
  • University of Cape Town
Matthew W Cooke
  • The University of Warwick
Emanuel Rivers
  • Wayne State University