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  1. J P Wyatt1,
  2. L Freeman2
  1. 1Department of Accident and Emergency, Royal Cornwall Hospital, Treliske, Truro, Cornwall TR1 3LJ, UK
  2. 2Department of Accident and Emergency, Northumbria Healthcare NHS Trust, UK
  1. Correspondence to:
 Mr J P Watt; 
 jonathan.wyatt{at}rcht.swest.nhs.uk

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Edited by Jonathan Wyatt; this scan coordinated by Louise Freeman

Angioplasty is better than thrombolysis for acute myocardial infarct ▸

This review follows previous similar work on this subject published in this journal. It aimed to provide an updated quantitative analysis of the results of randomised trials of primary percutaneous transluminal coronary angioplasty (PTCA) compared with thrombolytic therapy for patients suffering from acute ST segment elevation myocardial infarction (AMI). The authors sought to identify all randomised trials comparing PTCA with thrombolysis, including unpublished data. They combined study results of 23 trials (involving 7739 patients) to calculate overall outcome measures including mortality, reinfarction, recurrent ischaemia, stroke, and major bleeding for each treatment group. Combined analysis showed that patients in the PTCA group had significantly lower morbidity and mortality rates than the thrombolysis group.

It seems ironic that thrombolysis may not be the “gold standard” for the treatment of AMI given the current quest for the UK National Service Framework 20 minute thrombolysis target. However, at present in the UK, emergency interventional cardiology is not widely available. The review specifically examined data from five trials in which transfer to another hospital for PTCA was compared with on-site thrombolysis. This continued to show significant decreases in morbidity such as non-fatal reinfarction, although there was not a significant decrease in mortality. None of the five trials were based in the UK, so further work may be needed to ascertain whether emergency PTCA should be the goal for patients with AMI in the UK.

Early corticosteroids do help acute asthma ▸

The stated objective of this review was to determine the effect of any form of systemic corticosteroids administered early in the course of treatment for patients presenting to the emergency department with acute asthma. The reviewers included all randomised, controlled trials in which patients aged over two years presenting with asthma to an emergency department were given systemic corticosteroids within an hour of arrival. The main outcome measure studied was the rate of admission to hospital. There were 12 studies of appropriate design and quality included. Overall, the results showed a significant reduction in admission for patients receiving early corticosteroids.

It is reassuring to learn that early corticosteroid treatment helps patients with acute asthma. Patients with more severe asthma seemed to benefit most, although clinical improvement was not maximal until four to six hours after corticosteroid administration. This implies that admission may be avoided in this group of patients if the decision to admit is delayed for longer than is usual practice. A notable variance from UK practice was the high dose of corticosteroids used in most of the included trials, which may limit direct application of the findings.

Self inflicted abdominal stab wounds ▸

All emergency departments occasionally see patients with self inflicted abdominal stab wounds. This study retrospectively reviewed 23 cases admitted to two level 1 centres in the US over a 10 year period and attempted to define the clinical profile of this patient group. Unsurprisingly, there was a definite association between self inflicted stab wounds and psychiatric morbidity. The investigators also found that one third of the stab wounds did not result in organ injury. They conclude that local exploration of wounds followed by observation is safe in the small group of patients with the absence of a peritoneal breach.

No role for nebulised β agonists or epinephrine in bronchiolitis ▸

This study directly investigated the issue of whether nebulised β2 agonists or epinephrine have any role in the treatment of previously well infants with bronchiolitis. Children were randomised to receive either epinephrine, albuterol, or placebo saline nebulisers. The primary outcome measure was length of stay in hospital. The study was double blind and powered to detect a mean decrease of 24 hours in length of hospital stay. The results revealed no significant difference between any of the intervention groups. The authors recommend that normally well infants admitted to hospital with acute bronchiolitis should be given oxygen and supportive fluids. Notably, the study did not include children directly admitted to the intensive care unit, so the results cannot necessarily be extrapolated to severely unwell babies.

Splints for some wrist fractures ▸

This study compared the treatment of minimally displaced fractures of the distal radius with a lightweight removable (“Futuro”) splint or a standard plaster cast. The trial was performed prospectively on 76 adult patients of whom 86% completed 12 weeks of follow up. Various measures of outcome were used including anatomical alignment, pain scores, mobility of wrist/hand, and patient satisfaction. The authors conclude that a Futuro splint provides an “acceptable, comfortable and economic alternative to Plaster of Paris” without resulting in malunion of the fracture. A factor in the study that may have implications when considering using this for patients in A&E is that randomisation only occurred at the first fracture clinic appointment. The time delay from initial attendance to first fracture clinic was not specified, so there was a possible source of bias in selection of clinic dates, affecting treatment choice. Notwithstanding these concerns, the data presented here for adults are in keeping with previous research involving children. Immobilisation of some distal radial fractures in a splint rather than a cast may prove to be both economic and comfortable.

The UK: as violent as ever? ▸

This study began from the (not unreasonable) premise that there is a significant amount of violence related injury in the UK that does not involve the police, or appear in crime surveys. Examination of the computerised records of 58 major A&E departments over a five year period was carried out to identify trends in violence. A total of 353 442 violence related attendances were identified. The results contrast with the media perception that the UK is an increasingly dangerous place to live, in that there was no overall increase in violence related A&E attendance from 1995 to 2000. The only group showing an increased rate of violence related A&E attendance was females aged 11–17 years—no specific reason for this increase was identified in the study. Otherwise, the study confirmed that the population groups most likely to present to A&E departments with violence related injury were those aged 18–30 years and those living in the northern or western regions of England and Wales. It was hypothesised that economic factors could account for the regional variation. The authors propose that A&E data could prove useful in tackling local trends in violence (such as episodes related to particular entertainment establishments).

Femoral nerve block for fractured hip ▸

This well designed trial describes the use of a three in one nerve block by emergency medicine staff for analgesia in patients with fractured neck of femur presenting to a UK emergency department. Potential benefits of a nerve block compared with intravenous opioid analgesia are possible reduction in opoid requirements and prolonged action of the block, resulting in better analgesia. The study demonstrated that patients receiving the nerve block were likely to require less opioid and achieved lower pain scores more quickly than the opioid group. The most interesting element of this trial was that the doctors administering the block were all grades of emergency medicine staff and not “expert” anaesthetists or skilled practitioners. The authors have shown that it is possible to train junior medical staff in the safe use of this technique in the UK district hospital environment. A minor caveat could be that confused patients with a fractured neck of femur might not be suitable for a nerve block as they could be unable to communicate pain resulting from intraneural injection.

Analgesia before assessment of patients with acute abdominal pain? ▸

It is now accepted practice in the UK to provide analgesia for patients with undiagnosed abdominal pain before the surgical team examines them. The authors of this paper reviewed the evidence behind the theory that analgesia does not obscure the findings of physical examination. Only seven full trials were identified with variable patient selection, intervention, and end points. None of the studies were ideal in terms of avoidance of bias. However, the authors conclude that these disparate studies do not show that analgesia is harmful and therefore recommend that pain should continue to quickly relieved. It is surprising that such a comparatively recent and widespread innovation does not have “scientific” validation—perhaps emergency medicine doctors should clarify this issue further.

Approach to children with first urinary tract infection ▸

The risk of renal scarring in small children with ascending urinary tract infection is well known and various strategies have been devised to detect anatomical or functional renal tract abnormalities before scarring occurs. This US study describes the findings and implications of early renal tract imaging as part of a large multicentre study comparing the use of oral and intravenous antibiotics in children aged under 2 years with fever. The investigators obtained renal ultrasound and technetium scans on children with fever and pyuria or bacteriuria within 24 hours of the diagnosis of their first febrile urinary tract infection. The children also underwent micturating cystourethrography one month later and repeat technetium scanning six months later. The authors conclude that none of the imaging investigations were likely to result in improved outcome in children who have undergone prenatal ultrasound in the third trimester. Notably, the practice of administering long term prophylactic antibiotics to children with confirmed vesicoureteric reflux is not supported by evidence, according to the authors of this study. They suggest that an aggressive policy of obtaining urine samples for culture in all febrile episodes in infants who have previously suffered a urinary tract infection would suffice (in other words, imaging in all these children is not initially required).

Partial rotator cuff tears ▸

All emergency departments will be familiar with the presentation of adults with a painful shoulder, with or without a history of minor injury. This review attempts to provide an overview of the pathology, diagnosis, and treatment of patients with partial thickness tears of the rotator cuff. The cause of this condition appears to be multifactorial with tissue degeneration, trauma, poor blood supply, and impingements all playing a part. Various imaging modalities have been used for diagnosis of partial tears but neither arthrography, bursography, ultrasound, or MRI has proved to be sufficiently sensitive to exclude the condition. It is unsurprising, perhaps, given his background, that the surgeon who wrote this review concludes that surgical intervention in the form of debridement and acromioplasty have given generally satisfactory results. He does, however, acknowledge that difficulties with diagnosis have resulted in a lack of robust trials of conservative treatment physiotherapy or corticosteroid injections, or both. The overall message from this review seems to be that an upper limb specialist should review the patient with a persistently painful shoulder to assess whether operative intervention would be beneficial.

Infection after haematoma block ▸

This case report describes a staphylococcal osteomyelitis of the distal radius of a 78 year old women after the reduction of a fracture under haematoma block. There was no focus of infection to account for haematogenous spread as a source. Haematoma block is perceived as a comparatively low risk substitute for other forms of anaesthesia in the reduction of distal radial fractures. This report illustrates that the “theoretical” conversion of a closed fracture to an open fracture by the use of a haematoma block can really result in destructive bone and joint infection. Another concern (not highlighted by the authors) was the potentially cardiotoxic effect of the bupivicaine used in the haematoma block.

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