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  1. Jonathan Wyatt1,
  2. Crispin Porter2
  1. 1Accident and Emergency Department, Royal Cornwall Hospital, Truro, Cornwall TR1 3LJ, UK; jonathan.wyatt{at}rcht.swest.nhs.uk
  2. 2Accident and Emergency Department, Frenchay Hospital, Bristol, UK; cjporter{at}doctors.org.uk

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    Edited by Jonathan Wyatt; this scan coordinated by Crispin Porter

    Lactate: a predictive marker after shock related injury ▸

    This prospective observational study compared the ability of plasma lactate with the lactate/pyruvate ratio at the time of hospital presentation to predict shock related outcome after injury. The study also examined the effect of ethanol on the obtained results. Plasma lactate alone was found to be a better predictor than the lactate/pyruvate ratio of post-injury shock related outcome. In addition, lactate/pyruvate ratio interpretation was confounded by increased plasma ethanol.

    This study is important in that it seems to be the first to demonstrate the confounding effect of ethanol on the interpretation of lactate/pyruvate ratio. It is the largest to date to support plasma lactate as being superior to the lactate/pyruvate ratio as a predictor of outcome in injured patients. Development of near-patient testing of parameters such as lactate may have a future role in assessing haemodynamic status and guide clinical intervention as well as being a useful outcome audit tool.

    Boxer's fractures: a new angle? ▸

    Fracture of the fifth metacarpal neck is a common hand injury presenting to emergency departments. The starting point of this study was that in the absence of rotational deformity or functional deficit caused by pseudoclawing, the decision to treat “boxer's” fractures surgically or conservatively is usually based on the degree of angulation at the fracture site. It was hypothesised that the reliability of measurement of fracture angulation is poor. Three fellowship trained orthopaedic hand surgeons evaluated the anteroposterior, oblique, and lateral radiographs of 32 consecutive patients on two separate occasions and formulated management plans.

    The reliability of the measurement of fracture angulation between the three different observers was only “slight” and even the reproducibility of measurements of a single observer was only “fair”. Based on assessment of the radiographs, there was significant variability in the recommended treatment plans.

    This study demonstrated that interpretation of fracture angle at the fifth metacarpal head is difficult and subject to interobserver and intraobserver variability. In the UK only anteroposterior and oblique radiographs are performed routinely when “radiograph of the hand” is requested. It is important to remember that a true lateral view may be required to accurately assess the angulation of any metacarpal fracture. However, the majority of even angulated boxer's fractures are now treated conservatively and the important crucial step in assessing these injuries is clinical examination, rather than radiological investigation. Assessment of hand function, neurovascular supply, rotational deformity and whether or not there is an open fracture (especially a “reverse bite”) are key determinants in the management of metacarpal fractures. The results of this study may therefore be of limited significance.

    Fracture of the penis: a growing problem ▸

    Over the past 65 years, more than 1600 cases of fracture of the penis have been recorded in medical journals. In this comprehensive literature review of the 183 available publications (comprising 1331 cases) the clinical features, aetiology, investigations, pathology, treatment, and complications are discussed in detail. Even taking into account reporting bias, the authors believe that the incidence of fracture of the penis is rising and may increase further after the introduction of effective treatments for erectile dysfunction.

    They emphasise that fracture of the penis should be considered to be a clinical diagnosis (sudden penile pain, detumescence, voiding difficulties, penile swelling, penile deviation occurring during coitus, or other penile manipulation). Radiological investigations have been advocated in certain circumstances, but may delay definitive treatment (prompt urological referral for early surgical repair).

    Etomidate: an alternative to midazolam? ▸

    The use of etomidate in rapid sequence induction has been well reported. In this (mostly retrospective) study, etomidate was used as a “procedural sedative” in the emergency department to facilitate procedures such as DC cardioversion and orthopaedic reductions. A total of 134 patients (aged between 6 and 93 years) underwent 150 procedures receiving a mean dose of 0.2 mg/kg etomidate. In 32% of cases, “moderate sedation” was achieved (somnolent) and in 68% “deep sedation” (verbal unresponsiveness) occurred, with 95% recovering fully after 30 minutes. Overall, there were no significant changes in blood pressure, pulse or oxygen saturation. In five patients (3.3%) aged over 55 years, there was a significant fall in oxygen saturation: all made a full recovery, but four required bag-valve-mask ventilation. Some 4% of patients experienced nausea or vomiting. The authors conclude that etomidate is well tolerated and provides effective and brief sedation, with procedural amnesia, but without haemodynamic compromise. They acknowledge that significant respiratory depression may occur, especially if used in older patients at higher doses.

    The use of sedative/anaesthetic agents by emergency physicians to assist with the performance of various procedures remains highly controversial for a number of reasons. Etomidate certainly has an attractive profile as far as adverse haemodynamic effects are concerned. However, many would argue that what the authors described in this study as “deep sedation” (characterised by verbal unresponsiveness), may actually be more properly considered to be general anaesthesia. In the prevailing mood, it is hard to envisage that etomidate will be used increasingly by non-anaesthetists.

    The Ottawa Ankle Rules: yet more revalidation ▸

    The Ottawa Ankle Rules were developed in Canada in 1992. Although well validated, some studies had raised concern that, in general, decision rules may not transport well between different countries and settings. In this study, the Ottawa Ankle Rules were compared with two decision rules currently used in the Netherlands (the Leiden and Utrecht ankle rules) in their ability to identify clinically significant fractures in patients presenting with painful ankle injuries. Altogether 647 consecutive patients were assessed according to all three ankle decision rules and subsequently all received radiological assessment. In terms of identifying clinically significant fractures, the specificities and sensitivities of each rule were respectively: Ottawa 26%, 98%; Leiden 57%, 88%; Utrecht 84%, 59%. Potential reduction in number of radiographs: Ottawa 24%; Leiden 54%; Utrecht 82%.

    Once again, the Ottawa Ankle Rules have been shown to achieve a near 100% sensitivity in identifying significant ankle fractures. One can only wonder if there is really any need to further revalidate the Ottawa Ankle Rules in adult patients? Repeat studies may only result in causing unnecessary radiographs that the rules were designed to prevent—perhaps it is time for researchers to turn their attention elsewhere.

    One more for the road? ▸

    A US national telephone survey of 943 adults, selected by random digit dialling techniques, assessed the public comprehension of the contribution of alcohol to unintentional traumatic death. Public opinions on alcohol control measures were also recorded. The study population made surprisingly accurate estimations of the proportion of victims who were legally drunk at the time of death resulting from a fall (32%), drowning (34%), or poisoning (29%). The proportion of drivers killed in motor vehicle accidents who were intoxicated was overestimated (42% rather than 33%). The proportion of fire deaths associated with victim alcohol intoxication was underestimated (29% rather than 42%). Some 78% of respondents did not believe that raising alcohol taxes would reduce fatal injuries, although 58% supported routine blood alcohol concentrations being taken on all seriously injured patients.

    In general, this survey suggests that US public awareness of the contribution of alcohol to traumatic death is high, but it is not clear whether or not this awareness extends to the subgroup most at risk of alcohol related traumatic death.

    Prehospital fluid administration: a military perspective ▸

    Administration of large amounts of fluid to trauma patients, without surgical control of blood loss, runs the risks of increasing bleeding, causing hypothermia and promoting coagulopathy. This study examines the effects of prehospital fluid administration given to military combat casualties on core body temperature and coagulation. Over a two year period, prospective data were collected on all 84 moderately and severely injured soldiers wounded in South Lebanon who survived to be evacuated to Israel. Mean intravenous fluid administration was 2.4 litres and the average evacuation time exceeded 100 minutes. On arrival at hospital, core temperature, prothrombin time, and partial thromboplastin time were recorded. There was no statistical correlation between any of these measurements and prehospital fluid treatment. The authors concluded that with proper control of external blood loss and avoidance of excessive fluid administration, their combat casualty population can be resuscitated with fluid volumes without causing hypothermia or coagulopathy.

    There are significant difficulties in conducting a clinical study in a combat environment. Prehospital recording of even the most basic vital signs may not be possible and there are significant priority differences between combat and peacetime prehospital casualty management. Although the results of this study may have reassured the authors that their own prehospital fluid administration policies are appropriate, the limitations of the study preclude the application of the results to other prehospital situations, including many other combat zones.

    Hypothermic resuscitation in trauma: can refrigeration save your bacon? ▸

    Hypothermic resuscitation has been reported to have benefits in certain circumstances, including during cardiopulmonary bypass, some neurosurgical procedures, and cardiac arrest. The authors of this study attempted to investigate the potential role of cold fluid resuscitation in trauma with haemorrhagic shock. Fourteen pigs were lightly anaesthetised with halothane, before uncontrolled haemorrhage was induced through a 5 mm aortotomy. The pigs were then randomly assigned to receive 500 ml Ringer's lactate solution at either 37°C or 4°C over 20 minutes through the external jugular vein. Five of the pigs in the 4°C infusion group survived until 240 minutes compared with only one of the 37°C infusion group. (All surviving pigs were killed at the 240 minute point).

    Despite some theoretical advantages, hypothermia during resuscitation can worsen metabolic acidosis, cause systemic vasoconstriction, promote cardiac arrhythmias, and interfere with clotting function. There is little evidence to support its routine use in the management of hypovolaemia attributable to trauma. Unfortunately, the methods used in this study did not promote hypothermia (the core temperature in the 4°C infusion group remained more than 35°C). So, while hypothermic trauma resuscitation is an interesting concept, at the moment that is really all it is.

    Anthrax: a comprehensive review ▸

    After the terrorist attacks in the USA in September 2001, there has been particular concern over the possible use of anthrax as a biological weapon. The more recent threat of “dirty” bombs has heightened this concern. The article has been produced as a consensus statement for the Working Group on Civilian Biodefense. It is a comprehensive review of current medical knowledge of bacillus anthracis and the current threat. While the emergency physician may hope to never need to refer to it, this paper deserves to be kept easily accessible.

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