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To determine the effect of helium-oxygen inhalation on relieving symptoms and distress in children with croup as measured by the croup score, and to identify areas of uncertainty for future research. Systematic review of prospective randomised and non-randomised controlled trials of children with the clinical diagnosis of croup, comparing the effect of helium-oxygen mixtures with placebo or any active treatment. Outcome measures were change in croup score, physiological parameters, hospital admission rates, need for intubation and adverse events. All records as identified by a systematic search strategy were assessed independently by two reviewers. Two trials were identified for inclusion assessing the effect of helium-oxygen inhalation in children with croup in an emergency department. In one trial the control group received humidified oxygen and in the other nebulised epinephrine. An improvement in the mean croup score over time was seen in the control and intervention groups of both trials, with no significant difference between the groups. Significant methodological and clinical heterogeneity in the design of the trials precluded a meaningful meta-analysis. At present there is no evidence to support the use of helium-oxygen therapy in children with croup. Methodologically well-designed and adequately powered randomised controlled trials are needed to determine whether helium-oxygen inhalation as part of the initial treatment in croup alters outcome. To examine if observational pain assessment can be used for purposes of triage in children aged >3 years. A prospective, single blind, controlled trial was undertaken in children who presented to the emergency department (ED) with pain. Pain was assessed in the waiting room and again at triage before any treatment was administered using the Alder Hey Triage Pain Score (AHTPS), an observational tool designed for triage, and a self-report tool, either the Wong-Baker Faces Pain Rating Scale (WBS) for 3–7-year-old children or a visual analogue scale (VAS) for 8–15-year-old children. Scores were compared by instrument (observational and self-report) and ED location (waiting room and triage room). 75 children (29 aged 3–7 years and 46 aged 8–15 years) were enrolled in the study. The AHTPS scores were significantly lower than the scores measured by the WBS/VAS (p<0.001). The level of pain measured by both methods (self-report, observational) was lower in the triage room. Compared with the AHTPS, the WBS and VAS scored significantly lower in the triage room than in the waiting room (p<0.042 and p<0.006, respectively). Observational pain assessment underestimates children’s perception of pain and should not be recommended in children aged >3 years. Triage has a calming effect on children. A recent update suggested that the National Institute for Health and Clinical Excellence (NICE) guidance on head injury had led to safe early discharge, evidence of a reduction in the numbers of admitted patients and cost savings in some centres. The aim of this study was to use national Hospital Episodes Statistics (HES) data to determine whether admissions with head injury have changed since the NICE guidance was introduced. HES data coded as S00–S09 "Injuries to the head" from 1998–9 to 2006–7 were examined for admissions, age and length of stay. Admissions rates did not change markedly until 2003 when the NICE head injury guidelines were issued. From 2003, admissions increased for all adult age groups but not for children. Mean length of stay remained constant between 1998 and 2007, so bed days increased in proportion to admission rates. Adult head injury admissions in England have increased markedly since the introduction of the NICE guidelines. Given that there is little evidence that hospital admission is beneficial for patients with minor head injury, NICE head injury guidance appears to have failed to promote cost effective care. Interhospital transfers are one of the critical points of the emergency system, which often cause overcrowding of the emergency department (ED) and limit its effectiveness. A retrospective study was carried out, analyzing the clinical case files concerning the ED of the Policlinico "Umberto I" in Rome (Latium region, Italy) with the aim of establishing the reasons for the numerous unjustified transfers. From 1 January to 30 June 2006, 77 597 admissions to the ED occurred, and 861 patients (1.1%) were sent from other hospitals. 361 patients out of 861 (41.9%) were transferred with critical clinical conditions. The remaining 500 patients (58.1%) were transferred requiring specialised care. The need for specialised care was confirmed in 230 cases (46.0%) and therefore these transfers could be considered justified. The other 270 transfers (54.0%) were unjustified: 138 patients remained in the hospital to which they had been sent, contributing to crowding of the ED; 132 patients were returned, thereby placing them at additional risk. Unfamiliarity with the regulations governing interhospital transfers is the main cause of scantly justified transfers and the consequent reduction in efficiency of the ED in the receiving hospital. Lack of knowledge of an NHS trust’s major incident policies by clinical staff may result in poorly coordinated responses during a mass casualty incident (MCI). To audit knowledge of the major incident policy by clinical staff working in a central London major acute NHS trust designated to receive casualties on a 24-h basis during a MCI. A 12-question proforma was distributed to 307 nursing and medical staff in the hospital, designed to assess their knowledge of the major incident policy. Completed proformas were collected over a 2-month period between December 2006 and February 2007. A reply rate of 34% was obtained, with a reasonable representation from all disciplines ranging from nurses to consultants. Despite only 41% having read the policy in full, 70% knew the correct immediate action to take if informed of major incident activation. 76% knew the correct stand-down procedure. 56% knew the correct reporting point but less than 25% knew that an action card system was utilised. Nurses had significantly (p<0.01) more awareness of the policy than doctors. In view of the heightened terrorist threat in London, knowledge of major incident policy is essential. The high percentage of positive responses relating to immediate and stand-down actions reflects the rolling trust-wide MCI education programme and the organisational memory of the trust following several previous MCI in the capital. There is still scope for an improvement in awareness, however, particularly concerning knowledge of action cards, which are now displayed routinely throughout clinical areas and will be incorporated into induction packs. Fractures of the mandible are common facial injuries. Patients frequently require hospitalisation, surgical intervention and extended periods of convalescence. A prospective database of patients presenting to the Oral and Maxillofacial Surgery service at Christchurch Hospital during an 11-year period was reviewed. 1045 patients with mandibular fractures were identified. Variables examined included demographic data, type of fractures, mode of injury and treatment delivered. More than 90% of patients were men, with 64% in the 15–29 years age group. Interpersonal violence accounted for 49% of fractures, followed by sports (16%), falls (13%) and motor vehicle accidents (10%). The condyle was the most frequent fracture site (34%) and multiple fractures were seen in 37% of patients. Hospitalisation was required for 53% of patients with 89% of these treatments being open reduction and internal fixation. Mandibular fracture is a common facial injury. The incidence is highest in young men who are victims of interpersonal violence. Alcohol is a major contributing factor. Management involved hospitalisation and surgical intervention for more than half of those presenting. Ureteric colic is a common presentation in the emergency department and accounts for approximately 1% of all hospital admissions. Diagnosis depends on a typical history, clinical examination and the presence of haematuria. Intravenous urography has traditionally been used as the means of investigation, but over recent years this has been superseded by CT urography. This latter investigation gives potentially more information and may detect alternative or additional pathology which would otherwise be missed on intravenous urography. 100 consecutive patients attending the emergency department with a provisional diagnosis of ureteric colic undergoing CT urography were studied to detect the incidence of alternative or incidental pathology. Stone disease was found in 58% of patients, with obstruction present in 43%. The most common site of obstruction was the vesicoureteric junction. Significant incidental or alternative pathology was found in 16% of patients. It was estimated that, in 12%, these findings would not have been detected by intravenous urography. The use of non-contrast CT urography is recommended in the initial investigation of patients with ureteric colic. "Heelys", or shoes with an integral wheel embedded into the heel, are becoming increasingly popular among children in the UK. Despite the manufacturer’s claims about their safety, increasing numbers of patients are attending the emergency department with "Heely"-related injuries. To assess the number and type of "Heely"-related injuries seen in the emergency department in a busy district general hospital and to assess the number of school days lost as a result of these injuries as a secondary measure of the impact on education and lifestyle. Medical staff working in the emergency department completed proformas for all children attending the department with "Heely"-related injuries between 26 December and 26 April 2007. Data collected included age, sex, mechanism of injury, diagnosis and number of days off school as a result of the injury. 35 patients with "Heely"-related injuries of mean age 9.6 years (range 6–15) were identified during the study period. The most common mechanism of injury was a fall onto an outstretched hand (20/35, 57%). Other mechanisms of injury identified were lateral upper limb injury (7/35), traumatic lower limb injury (2/35), rotational lower limb injury (2/35), head injury (2/35) and back injury (2/35). The most common diagnosis was fracture of the distal radius (10/35), two of which had an associated distal ulna fracture. Two tibial fractures and one nasal fracture were also seen. The average number of days off school was 4.5 days (range 0–20). None of the children included in this study were using safety equipment at the time of the injury. The number of "Heely"-related injuries seen in one department over a 4-month period suggests a much higher incidence of injuries than the 46/100 000 found by the manufacturers based on Consumer Product Safety Commission data in the USA. The discrepancy is almost certainly due to the reluctance of UK children to use safety equipment and to follow the manufacturer’s safety advice. Larger scale studies are needed to confirm the incidence of "Heely"-related injuries in emergency departments across the UK. If the high incidence of injuries among users is confirmed, primary and secondary prevention methods could be considered to reduce injuries. Reduction in admissions is an important aim of emergency department working policy to overcome the problems of a shortage of inpatient beds, overcrowding, rising costs and exhausted resources. A new policy was instituted in the emergency department of a hospital in Kuwait with the following components: (1) an admission avoidance team of emergency department doctors; (2) implementation of disease management guidelines; and (3) maximising the use of an emergency department observation unit. The effects of this policy on reduction in admission rates for total medical admissions and for chest pain, bronchial asthma, heart failure, pneumonia and pyelonephritis as selected samples of common medical conditions were prospectively studied over a period of 3 years from institution of the policy and compared with the 3-year period before the policy was instituted. There was a significant reduction in admission rates after institution of the new policy, with a relative reduction of 35.9% for total medical admissions, 52.7% for chest pain, 49.2% for bronchial asthma, 34.7% for heart failure, 59.1% for pneumonia and 43.3% for pyelonephritis compared with the period before the policy was instituted. A multidisciplinary emergency department policy, using as much available evidence as possible, was successful in significantly reducing medical hospital admissions in spite of the rising numbers of patients visiting the emergency department and observation unit. To examine the effectiveness and safety of the sedative agents used in the emergency department following the introduction of ketamine as an agent for procedural sedation A 2-year prospective audit of sedation practice was undertaken. This specifically examined the rationale behind a doctor’s choice of sedative agent, the depth of sedation achieved, adverse events and the time taken to regain full orientation. 210 patients were included of whom 85 (40%) were given ketamine, 107 (51%) midazolam and 18 (9%) propofol. The median time to full orientation was 25 min for ketamine, 30 min for midazolam and 10 min for propofol. Complications occurred in 15.9% of sedations overall (14.6% of those given ketamine, 15.8% given midazolam and 22.2% given propofol). Apnoea and hypoxia most often occurred with midazolam and propofol, while hypertension and hypertonicity were encountered more frequently with ketamine. In addition, 19.5% of patients given ketamine suffered the re-emergence phenomenon. The association between deep sedation with no response to pain and adverse events encountered with midazolam does not occur with ketamine. Ketamine is both safe and effective and compares favourably with midazolam as an agent for procedural sedation in the emergency department. Although the re-emergence phenomenon occurred, no psychological sequelae were encountered after return to full orientation. Ketamine may be particularly useful in groups of patients at high risk of adverse effects with midazolam. Adenosine deaminase (ADA) is found in most tissues including lymphoid cells and lymph nodes. It is a marker of T lymphocyte activation. The role of type 1 and type 2 T helper cells in appendicitis has been investigated experimentally. Serum ADA levels in acute appendicitis have not previously been studied. To assess the serum levels of ADA in patients with acute appendicitis. Serum levels of ADA were investigated in 30 cases with acute appendicitis (mean age 26 years; male/female 17/13) and 21 healthy controls (mean age 40 years; male/female 11/10). Levels of ADA were compared in patients with acute appendicitis and healthy controls. Correlation analysis between ADA and other inflammatory markers (C-reactive protein (CRP), high-sensitivity CRP, erythrocyte sedimentation rate and white blood cell count) was also performed. Mean (SD) serum ADA levels were significantly higher in those with acute appendicitis than in the control group (13.41 (3.56) U/l vs 9.39 (1.22) U/l; p<0.001). There was no correlation between ADA and the other inflammatory markers investigated. Although serum levels of ADA do not correlate with other known inflammatory markers, its serum level is increased in acute appendicitis and it has a higher positive predictive value. The administration of analgesics to patients with acute abdominal pain due to acute appendicitis is controversial. A study was undertaken to assess the analgesic effect of morphine in patients with acute appendicitis. A randomised double-blind clinical trial was conducted in Sina hospital, a general teaching hospital, from January 2004 to March 2005. Patients scheduled for appendectomy were randomised to receive 0.1 mg/kg morphine sulfate or saline (0.9%) to a maximum dose of 10 mg over a 5 min period. Patients were examined by surgeons not involved in their care before and after drug administration and their pain intensity and signs were recorded at each visit. The physicians were also asked to indicate their own treatment plan. The main outcome measures were pain intensity using a visual analogue scale (VAS) and signs of acute appendicitis. A favourable reduction in VAS score was defined as a change of >13 mm. Of the 71 patients enrolled in the study, 35 were allocated to receive morphine and 36 to receive placebo. One patient left the hospital before receiving morphine. No significant differences were seen between the two groups with regard to age, sex and initial VAS score. A more favourable change in VAS score was reported in the morphine group with a significantly greater reduction in the median VAS score than in the placebo group. Morphine administration did not cause significant changes in patients’ signs or in the physicians’ plans or diagnoses. No adverse events were seen in either group. Morphine can reduce pain in patients with acute appendicitis without affecting diagnostic accuracy. NCT00477061. To evaluate the hypothesis that using an automated external defibrillator (AED) with video telephony-directed cellular phone instructions for untrained laypersons would increase the probability of successful performance of AEDs. Real-time communication with visual images can provide critical information and appropriate instructions to both laypersons and dispatchers. A prospective observational study was undertaken. 52 public officers with no previous experience in the use of a defibrillator were presented with a scenario in which they were asked to use an AED on a manikin according to the instructions given to them by cellular phones with video telephony. The proportion who successfully delivered a shock and the time interval from cardiac arrest to delivery of the shock were recorded. Placement of the electrode pads was performed correctly by all 52 participants and 51 (98%) delivered an accurate shock. The mean (SD) time to correct shock delivery was 131.8 (20.6) s (range 101–202). Correct pad placement and shock delivery can be performed using an AED when instructions are provided via video telephone because a dispatcher can monitor every step and provide correct information. To examine the correlation between the AMPDS prioritisation category at dispatch and the use of alternative clinical dispatch using data from an emergency care practitioner (ECP) service dispatching on likely clinical need. Data for a 12-month period were reviewed for all 999 calls seen by an ECP and comparison was made between AMPDS code/category and outcome of the patient. 3955 cases were reviewed with all but two AMPDS code groups represented. All categories showed alternative pathways to the emergency department used by ECPs: category A, 36%; category B, 52%; category C, 44%. Clinically directed dispatch for ECPs allows utilisation of alternative pathways across all AMPDS categories, suggesting that AMPDS alone is not a good predictor of potential for avoiding emergency department attendance and possible hospital admission. Streptococcus suis is a common pathogen in swine and infection in humans is rarely reported. When it does occur, it is considered an occupational risk associated with the handling of carcasses. Meningitis is one of the most life-threatening manifestations of S suis infection. This case of meningitis in a butcher is reported to create awareness of this zoonotic disease. The report highlights the importance of an occupational history and a meticulous general physical examination looking for cuts and abrasions in patients with suspicion of meningitis. A 37-year-old woman presented following a trampolining accident with neck pain and paraesthesia of the left arm. Cervical spine radiographs were normal and a provisional diagnosis of whiplash was made. Three hours later she developed rotational vertigo and then cerebellar signs. Magnetic resonance angiography and magnetic resonance imaging of the brain confirmed the diagnosis of vertebral artery dissection (VAD) with cerebellar embolic infarcts. She was anticoagulated and symptoms resolved over one week. VAD is a relatively common cause of posterior circulation stroke in young people. It usually presents following (often minor) trauma, with headache, neck pain, cerebellar, sensory and cranial nerve signs. However, it remains a diagnosis that is frequently missed or misdiagnosed. Symptomatic sinus bradycardia is routinely treated in the emergency department with atropine and pacing. Two cases are presented that illustrate the importance of considering hyperkalaemia, particularly in the presence of atropine-resistant symptomatic bradycardia. The administration of calcium in such cases acts to stabilise the myocardium and resolve the bradycardia. Blood gas analysis provides a rapid estimate of serum potassium concentrations, facilitating timely treatment. Cholestyramine carries a risk of hyperchloraemic metabolic acidosis. Being cognisant of this drug-induced adverse event may reduce diagnostic delays. Emergency physicians should be alert about this condition, in particular among patients with pre-existing chronic kidney disease, or who are taking spironolactone. Phrenic nerve palsy has previously been associated with brachial plexus root avulsion; severe unilateral phrenic nerve injury is not uncommonly associated with brachial plexus injury. Brachial plexus injuries can be traumatic (gunshot wounds, lacerations, stretch/contusion and avulsion injuries) or non-traumatic in aetiology (supraclavicular brachial plexus nerve block, subclavian vein catheterisation, cardiac surgeries, or obstetric complications such as birth palsy). Despite the known association, the incidence and morbidity of a phrenic nerve injury and hemidiaphragmatic paralysis associated with traumatic brachial plexus stretch injuries remains ill-defined. The incidence of an associated phrenic nerve injury with brachial plexus trauma ranges from 10% to 20%; however, because unilateral diaphragmatic paralysis often presents without symptoms at rest, a high number of phrenic nerve injuries are likely to be overlooked in the setting of brachial plexus injury. A case report is presented of a unilateral phrenic nerve injury associated with brachial plexus stretch injury presenting with a recalcitrant left lower lobe pneumonia.
[Primary survey] Primary survey
[Editorial] The Clockwork ED
[Review] Use of helium-oxygen mixtures in the treatment of croup: a systematic review
[Miscellanea] Emergency Medicine Questions (EMQs)
[Original articles] Observational pain assessment versus self-report in paediatric triage
[Original articles] Hospital admissions with head injury following publication of NICE guidance
[Original articles] Scant justification for interhospital transfers: a cause of reduced efficiency in the emergency department
[Original articles] Mass casualty incidents: are NHS staff prepared? An audit of one NHS foundation trust
[Original articles] Epidemiology of mandibular fractures in a tertiary trauma centre
[Original articles] Benefits of CT urography in patients presenting to the emergency department with suspected ureteric colic
[Original articles] "Heely"-related injuries in children
[Original articles] Can a change in policy reduce emergency hospital admissions? Effect of admission avoidance team, guideline implementation and maximising the observation unit
[Original articles] Audit of the safety and effectiveness of ketamine for procedural sedation in the emergency department
[Original articles] Serum adenosine deaminase levels in diagnosis of acute appendicitis
[Original articles] Morphine analgesia in patients with acute appendicitis: a randomised double-blind clinical trial
[Critical appraisal series] Critical appraisal for emergency medicine 3: Evaluation of a therapy
[Best Evidence Topic reports] Towards evidence based emergency medicine: Best BETs from the Manchester Royal Infirmary
[Best Evidence Topic reports] BET 1. LACTATE CLEARANCE A BETTER PREDICTOR OF MORTALITY THAN INITIAL LACTATE LEVEL
[Best Evidence Topic reports] BET 2. STEROIDS IN CHILDREN WITH ERYTHEMA MULTIFORME
[Best Evidence Topic reports] BET 3. CHEST PHYSIOTHERAPY IS NOT USEFUL IN BRONCHIOLITIS
[Prehospital care] Performance of cellular phones with video telephony in the use of automated external defibrillators by untrained laypersons
[Prehospital care] AMPDS categories: are they an appropriate method to select cases for extended role ambulance practitioners?
[Prehospital care] Use of the pneumatic anti-shock garment
[Images in emergency medicine] Phantom tumour of the lung
[Prehospital care] From the prehospital literature
[Emergency casebook] Meningitis in a butcher
[Images in emergency medicine] Massive abdominal wall haematoma and haemothorax due to spontaneous rupture of an intercostal artery
[Emergency casebook] Neck pain and minor trauma: normal radiographs do not always exclude serious pathology
[Emergency casebook] Atropine-resistant bradycardia due to hyperkalaemia
[Emergency casebook] Hyperchloraemic metabolic acidosis
[Emergency casebook] Brachial plexus trauma: the morbidity of hemidiaphragmatic paralysis
[Miscellanea] EMQ answers
[PostScript] Demographics of workplace violence: methodology is the key
[PostScript] Authors' reply
[PostScript] The importance of journey times to hospital in urban areas
[PostScript] Authors' response
[PostScript] Ketamine use in prehospital critical care
[PostScript] Authors' response
[PostScript] Gut contamination of acutely poisoned patients: why is no one using the NICE guideline?
[PostScript] Administering a glyceryl trinitrate infusion: faster is better than slower
[PostScript] Textbook of pediatric emergency procedures, 2nd edition
[PostScript] Correction
[PostScript] Correction
[Miscellanea] Sophia
Basic Legal Guide
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