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  1. Jonathan Wyatt1,
  2. Walid Alsalim2
  1. 1Department of Accident and Emergency, Royal Cornwall Hospital, Treliske, Truro, Cornwall TR1 3LJ, UK
  2. 2Department of Accident and Emergency, Norfolk and Norwich Hospital, Colney Lane, Norwich NR4 7UY, UK
  1. Correspondence to:
 Mr J P Wyatt; 
 jonathan.wyatt{at}rcht.swest.nhs.uk

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Edited by Jonathan Wyatt; this scan coordinated by Walid Alsalim

Wernicke’s encephalopathy: room to improve recognition and treatment ▸

This review considers the management of one of the more difficult clinical problems among a notoriously difficult group of accident and emergency (A&E) patients, namely Wernicke’s encephalopathy in alcoholics. The authors hope to raise awareness of Wernicke’s encephalopathy, which they claim is currently significantly underdiagnosed among A&E patients (often for reasons that are entirely understandable). They argue for what appears at first sight to be quite an aggressive set of guidelines of prevention and treatment. Although implementation of these guidelines would have quite a significant impact upon the working practice of many A&E departments, it does seem to be appropriately supported by relevant research.

Corticosteroids and head injury ▸

This paper comprised the abstract of one of the Cochrane Database of Systematic Reviews together with a commentary regarding the possible routine role of corticosteroids in improving outcome among patients with head injury. Given the magnitude of the problem of head injury, even a small improvement in outcome associated with corticosteroids would have a dramatic effect. At the present time, the available data do not justify corticosteroid use, but there is a relative paucity of evidence in this area. Hopefully, the Corticosteroid Administration After Significant Head Injury (CRASH) study will change this and provide an evidence based pointer to guide future treatment.

Corticosteroids and spinal cord injury ▸

In contrast with the management of head injury, there are well established guidelines advocating the use of corticosteroids as part of the early management of spinal cord injury. Given the amount of time and effort that is being directed towards seeking an answer to the possible role of corticosteroids after head injury, it might seem rather perverse if parallel available guidelines for the management of spinal cord injury were not being followed. Yet this was the finding from this observational study from the UK Royal National Orthopaedic Hospital. The authors report that of 100 consecutive patients admitted to this regional spinal injuries centre, only 25 were given corticosteroids by the referring hospital according to the guidelines. The authors claim that the vast majority of referrals emanated from orthopaedic surgeons, who were statistically less likely to adhere to guidelines than neurosurgeons. Orthopaedic surgeons remain, as ever, an easy target for criticism, but presumably some responsibility for the management plan should reside with clinicians at the admitting hospital as well as the referring hospital. Unfortunately, it is not clear from the paper at what stage patients were referred to the regional spinal injuries centre, and whether or not this centre was involved in formulating the early treatment plan. Taking into account the fact that guidelines advocating early corticosteroid use appear in current standard textbooks and seem to be generally well known, it might be reasonable to speculate that clinicians are deliberately choosing to ignore the guidelines. Certainly, the research that underpins the guidelines has received some criticism—perhaps it is time for yet more research!

More hope for injured geriatric patients ▸

This group of Los Angeles based researchers deserve some credit for raising the profile of the injured elderly patient in their previous publications. Their latest paper analyses data collected over a nine year period, from which they conclude that activation of the trauma team combined with early intensive treatment improves survival of elderly injured patients (defined as over 70 years old). Their findings are certainly in keeping with similar results from other parts of the world. However, the methods that they used fail to exclude other alternative explanations. In particular, given that they analysed data for a considerable time before and after an intervention (introduction of modified criteria for trauma team activation to include age over 70 years), they failed to consider the possibility that the results might be explained simply on the basis of gradually improving trauma care.

Planning for major burns incidents ▸

The Delphi process has recently gained prominence in the medical literature. It is a useful technique for attempting to establish consensus among experts. In this three round Delphi study, experts address issues that surround planning for both the prehospital and hospital management of a major burns incident in the UK. The result is well worth reading. Many of the recommendations apply to generic major incident planning, but there is particular emphasis on the special care of burns.

Prehospital clinical spinal clearance ▸

Immobilisation of the spine is one of the most frequently performed prehospital procedures, yet the proportion of patients who ultimately turn out to have spinal injury is comparatively low. Quite apart from the time and resources required, rigid spinal immobilisation is uncomfortable for patients. Based upon data from retrospective studies, the authors of this multicentre project attempted to prospectively validate prehospital clinical spinal clearance criteria. They hoped that absence of five clinical criteria would enable the spine to be safely “cleared”. These five criteria were: altered mental status, neurological deficit, spine pain/tenderness, intoxication, suspected extremity fracture. In the group of 8975 patients studied, 295 were ultimately shown to have spinal injury. The potential for spine injury was identified in 280 of these 295 injuries. Most of the 15 spinal injuries “missed” by the criteria were comparatively minor and stable, but they did include one odontoid peg fracture, underlining the potential difficulties of producing safe protocols. However, the authors hope that their criteria may form the basis of a safe prehospital spinal clearance protocol, which if successfully introduced, would be welcomed by both patients and clinicians.

Facial injury in children and adolescents ▸

This retrospective study attempted to investigate the epidemiology of facial injury to children and young adults. The authors seem to have only reviewed the notes of those patients treated by the oral and maxillofacial surgical team and not included those seen, treated, and discharged by A&E clinicians. The epidemiological value of the results therefore seems somewhat questionable. Having said this, the results were more or less in keeping with what might be predicted. Falls were the most common mechanism resulting in facial injury, accompanied by dog bites among younger children and interpersonal violence among adolescents.

Ibuprofen for irritable hip ▸

This small double blind study randomised 40 children with transient synovitis of the hip to receive either placebo or ibuprofen syrup. Patients were reviewed at between 48 and 72 hours and thereafter as clinically indicated. The end point of the study was defined as when each child was no longer experiencing pain and had returned to normal activity. Overall, symptoms resolved in more than 80% of children within seven days, but the median duration of symptoms was significantly shorter in those who had received ibuprofen. There is currently considerable variation in the A&E management of children with transient synovitis, but this study reinforces the potential role of ibuprofen.

Identifying ventriculoperitoneal shunt block in children ▸

Cerebrospinal fluid shunts remain the mainstay of treatment of hydrocephalus in the paediatric population. The aim of this prospective observational study was to evaluate the predictive value of symptoms, signs and radiographic findings accompanying presumed ventriculoperitoneal shunt malfunction, by comparing presentation with operative findings and subsequent clinical course. All 53 children referred to a paediatric neurosurgical centre over an eight month period with a diagnosis of presumed shunt malfunction were studied. The results showed that drowsiness was by far the best clinical predictor of ventriculoperitoneal shunt blockage. An increase in ventricle size on CT scan was found to be highly suggestive of shunt blockage, but the absence of any change did not exclude the diagnosis.

Outcome of head injured patients with preinjury anticoagulation ▸

Some previous research papers investigating the influence of pre-existing anticoagulation in patients who sustain head injuries have reported counter-intuitive results. In contrast, this paper from Michigan quite definitely reports what might be expected, namely that head injured patients who are already anticoagulated have a significantly increased risk of death compared with non-anticoagulated patients. Interestingly, this increased risk appeared to extend from anticoagulation with warfarin even through to aspirin.

N-acetylcysteine affects prothrombin time ▸

This retrospective study demonstrated that N-acetylcysteine can interact with clotting factors, thereby affecting the prothrombin time. Patients treated with N-acetylcysteine for paracetamol poisoning may develop an increased prothrombin time in the absence of impending liver failure, so changes in prothrombin times in these patients need to be interpreted in the light of other findings.

Primary angioplasty or prehospital thrombolysis for acute myocardial infarction? ▸

This multicentre French trial randomised patients with acute myocardial infarction to receive either prehospital thrombolysis (with transfer to a hospital with facilities for possible rescue angioplasty) or primary angioplasty. Unfortunately, because of a lack of funding the 840 patients enrolled did not match the 1200 planned. The results did not reveal any statistical differences in outcome. Arguments regarding what constitutes the best management of acute myocardial infarction are bound to continue. In the meantime, at a local level, treatment is likely to be dictated by the availability of resources.

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