PRIMARY SURVEY

Commentary: all that glistens is not gold

TOP Commentary: all that glistens... Best BETS: use of... Spontaneous compartment syndrome... Potential for quality... Communicating risk to emergency... Covering our backs: ambulance... Acute epiglottitis in adults:...

The authors of this commentary suggest that prehospital and emergency medicine practitioners are too eager to "trial" new devices and to "have a go". They suggest that this approach does not make financial sense and quote as an example of this the early adoption in many hospital emergency departments and prehospital care of mechanical chest compression devices. This has led to the directors of clinical care of ambulance services and the joint Royal Colleges Ambulance Liaison Committee taking the unprecedented step of writing a brief note which identified the need for further research and consequently recommended that no further devices were purchased, unless it was to support an appropriately designed and approved clinical trial, and that currently available devices should only be used in the context of approved research. The authors suggest we are a gift to industry representatives seeking opportunities (see page 251).

Best BETS: use of IV on aminophylline in addition to beta-2 agonists and steroids in acute asthma

TOP Commentary: all that glistens... Best BETS: use of... Spontaneous compartment syndrome... Potential for quality... Communicating risk to emergency... Covering our backs: ambulance... Acute epiglottitis in adults:...

Recent updates in the British Thoracic Society/SIGN guidelines on the management of asthma have suggested that there is little evidence base for the use of aminophylline. Some of the older members of the medical community (and I include myself in this) have used intravenous aminophylline for many years and felt the patients benefited from this intervention. When high quality evidence-based reviews come up with a lack of evidence for an intervention which a clinician has felt has been beneficial, it is always tempting to wonder if this is merely a lack of evidence that the intervention works rather than that the intervention does not work. Here is a review of the use of aminophylline in addition to beta-2 agonists and steroids in acute asthma. There is still no evidence that aminophylline works and I will leave it up to you to decide whether or not there is still a lack of evidence (see page 289).

Spontaneous compartment syndrome in association with simvastatin-induced myositis

TOP Commentary: all that glistens... Best BETS: use of... Spontaneous compartment syndrome... Potential for quality... Communicating risk to emergency... Covering our backs: ambulance... Acute epiglottitis in adults:...

The number of prescriptions for statins has increased considerably in the last few years and those of us who prescribe them on a regular basis are aware of the fact that these drugs are not without their side effects. The authors of this paper describe what is relatively an extremely rare side effect namely myositis necessitating a fasciotomy, and describe an interesting patient journey before the clinical conclusions were eventually reached (see page 305).

Potential for quality improvement of acute stroke management in a district general hospital

TOP Commentary: all that glistens... Best BETS: use of... Spontaneous compartment syndrome... Potential for quality... Communicating risk to emergency... Covering our backs: ambulance... Acute epiglottitis in adults:...

I’ve already made reference to my advancing years in this primary survey and now feelings of déjè vu come over me as I read this interesting article on the potential for quality improvement of acute stroke management in a district general hospital. The authors report on the management of 171 acute stroke patients and report that failure to thrombolise eligible patients led to increased disability in 6 patients and the loss of independent living in 2 patients. These findings bring to mind the difficulties that had to be gone through before standards for thrombolysis became nationally accepted. Hopefully the introduction of this treatment in acute stroke management will benefit from our experiences in the management of myocardial infarction (see page 270).

Communicating risk to emergency department patients with chest pain

TOP Commentary: all that glistens... Best BETS: use of... Spontaneous compartment syndrome... Potential for quality... Communicating risk to emergency... Covering our backs: ambulance... Acute epiglottitis in adults:...

How good are we at communicating a risk to our patients? When we do try to do this are there ways of presenting information which are more readily understood by patients? The authors used the risks and benefits of thrombolytic therapy for acute myocardial infarction to examine patients’ understanding, having had the frequency of side effects expressed in percentages or descriptive language. By reading this article you may improve the communication of such information to patients (see page 276).

Covering our backs: ambulance crews’ attitudes to clinical documentation when 999 patients are not conveyed to hospital

TOP Commentary: all that glistens... Best BETS: use of... Spontaneous compartment syndrome... Potential for quality... Communicating risk to emergency... Covering our backs: ambulance... Acute epiglottitis in adults:...

Up to 30% of people who call for an emergency ambulance are, for various reasons, not conveyed to hospital. Previous studies have suggested that documentation does not get completed for a large proportion of non-conveyed patients. In this qualitative study from one large ambulance service trust, crews’ attitudes to documentation for non-conveyed patients were explored. The results of this study highlight the reasons that crews do not complete documentation. Perhaps addressing these could lead to a decrease in clinical risk and adverse litigation if things go wrong (see page 292).

Acute epiglottitis in adults: a retrospective review of 106 patients in Hong Kong

TOP Commentary: all that glistens... Best BETS: use of... Spontaneous compartment syndrome... Potential for quality... Communicating risk to emergency... Covering our backs: ambulance... Acute epiglottitis in adults:...

We all worry about the potential airway problems in patients with acute epiglottitis. In this retrospective study of 106 patients identified from admissions to an acute hospital in Hong Kong over a 7-year period, the authors look at comorbidities, presentation, blood culture findings, antibiotic management and the need for active airway intervention including intubation and emergency tracheostomy. The authors conclude that acute epiglotitis in adults is not a rare entity and we need to be vigilant with regard to this condition. The prognosis is good with antimicrobial therapy close monitoring and selective airway intervention (see page 253).

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