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  1. J P Wyatt1,
  2. L Jones2
  1. 1Department of Accident and Emergency, Royal Cornwall Hospital, Treliske, Truro, Cornwall TR1 3LJ, UK
  2. 2Department of Accident and Emergency, Derriford Hospital, Plymouth, Devon, 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 Lewis Jones

Emergency medical technicians outperform anaesthetists! ▸

Participants were asked to perform bag-valve-mask ventilation for three minutes on a mannikin using a facemask and a two litre self inflating bag. Tidal volumes were measured and recorded by computer. The effectiveness of bag-valve-mask (defined as the proportion of ventilation attempts that achieved a tidal volume of >434 ml) was significantly greater for emergency medical technicians than for anaesthetists (p<0.001). Six of the 27 anaesthetists, but none of the 29 emergency medical technicians, were unable to produce even one “effective” tidal volume of at least 434 ml. The paper concludes that emergency medical technicians are able to perform adequate bag-valve-mask ventilation.

Prehospital intubation for trauma? ▸

Prehospital care practitioners will read this controversial paper from the United States with interest. The authors prospectively collected data on 191 patients who presented with a Glasgow Coma Scale of less than 9 and a “head” Abbreviated Injury Scale score of more than two. They compared outcomes according to whether or not patients received prehospital intubation (usually by paramedics who were trained to use some anaesthetic drugs). The results indicated significantly increased morbidity and mortality associated with prehospital intubation. The authors do acknowledge some limitations in their study design—their call for a randomised controlled trial seems eminently sensible.

Straddling—a solution for tracheal intubation on the ground ▸

Prehospital personnel who have struggled to intubate patients lying on the ground will find this Canadian study interesting. The authors studied the pressures required to perform oral tracheal intubations using a variety of rescuer positions on a mannikin with a modified Macintosh laryngoscope. Based upon their findings, the authors recommend a straddling position (where the rescuer’s right knee is between the supine patient’s left arm and chest, and the rescuer’s left foot is planted above the patient’s right shoulder).

Cosmetic outcome after different types of wound closure ▸

This commentary aimed to answer the questions “Are tissue adhesives (TA) as effective as standard wound closure (SWC) for cosmetic outcomes of traumatic lacerations in children and adults? Are some tissue adhesives better than others?”

The review found nine randomised control trials. Eight of these compared TA with SWC (sutures, staples and adhesive strips) and one compared two different TAs. The results showed no difference between the TA or SWC groups for cosmesis at 1–3 or 9–12 months. Patients treated with TAs had lower pain scores, the procedure time was 5.7 minutes less and there was less erythema around the wounds. However, there was a greater rate of wound dehiscence in the TA treated groups. The one study that compared butylcyanoacrylate with octycyanoacrylate showed no difference between the two adhesives. What this review did not consider was the size of the wounds treated or their position on the body. Further commentary or subgroup analysis would be helpful.

Assaults with bar glasses and bottles—time for plastic? ▸

This paper reviewed 1288 Criminal Injury Compensation Authority applications following reported assaults with bar glasses and bottles. The nature and severity of injuries differed according to the causative agent. Bottles caused less serious injury than bar glasses and resulted in less compensation cost. This was due mainly to the larger number of eye injuries in the bar glass group. National strategies need to be developed to reduce these types of injuries—perhaps we will all be drinking out of plastic soon.

Assessment of Achilles disorders ▸

Achilles tendinopathy can be a disabling problem for those involved in sporting activity and assessment can be difficult for the A&E or sports physician. This paper investigated the imaging modalities available for assessment of Achilles tendon disorders in 45 sportsmen and women with a total of 57 painful Achilles tendons. The results showed that ultrasound identified abnormalities in only 65% of abnormal tendons and normal morphology in only 68% of clinically “normal” tendons. The ultrasound findings had no predictive value towards 12 month outcomes. Magnetic resonance imaging identified abnormal morphology in only 56% of abnormal tendons but normal morphology in 94% of “normal” tendons. Both ultrasound and magnetic resonance imaging showed only moderate correlation with clinical history and examination, which remains the gold standard.

SARS in Hong Kong ▸

This paper describes the clinical presentation and course of 10 related patients (aged between 38 and 72 years) with severe acute respiratory syndrome (SARS) presenting to a Hong Kong hospital between 22 February and 22 March 2003. The incubation period was 2 to 11 days. All patients presented with a fever and most had rigor, cough, dyspnoea, malaise, and hypoxia. The physical examination of their chests revealed dullness to percussion and crackles on auscultation. Laboratory investigations revealed lymphopaenia in nine patients, an increased serum aspartate aminotransferase in six, but all had normal creatinine concentrations. The chest radiographs showed progressive air space shadowing. Microbiological tests were negative for all atypical pathogens. Patients were treated with corticosteroids and ribavirin and eight had received conventional antibiotic therapy. The paper gives a good clear account of the symptoms, signs, and clinical findings of SARS, even if some of the discussion regarding the causative agent and treatment is now already out of date in this fast moving field.

Charcoal—occasionally too much of a good thing ▸

The case notes of 878 patients who had been given oral activated charcoal in repeated doses were reviewed by an expert panel for any evidence of complications after this treatment. Five (0.6%) patients had clinically important pulmonary aspiration, although none died and none had residual problems persisting to discharge. Hypernatraemia was reported in 53 cases (6%) and hypermagnesaemia was seen in 27 (3.1%). Most bizarrely perhaps, repeated charcoal was held to be responsible for one patient suffering a corneal abrasion. Charcoal is widely used in a single dose for gastric decontamination, but repeated dose activated charcoal has comparatively few specific indications. It is well to recognise that it is a drug and is not without potential side effects, especially in patients with lowered levels of consciousness and tenuous airway protection.

Rh immune globulin in early first trimester abortion ▸

The prophylactic use of Rh immune globulin has successfully protected women who are potentially at risk from exposure to the Rh(D) antigen. Rh(D) immunoprophylaxis has been extended from women with term pregnancies to all women with miscarriages, abortions, and ectopic pregnancies. This article reviews the existing medical literature to assess the risks of foetomaternal haemorrhage and Rh isoimmunisation after complications of a first trimester pregnancy, induced abortion, or ectopic pregnancy. The authors conclude that the evidence to support the use of Rh immune globulin in the first trimester is sparse, but acknowledge that there is theoretical evidence to support its use. Given this, and the apparently low risk associated with its use, the authors make a good case for current practice to continue.

Limitations of ultrasound in blunt abdominal trauma ▸

Establishing what is the best form of investigation for haemodynamically stable patients after blunt abdominal trauma has been the subject of much debate. This study compared ultrasound with computed tomography in 205 patients. The authors conclude that in this group of patients, ultrasound is highly sensitive for the detection of free fluid, but not for the identification of organ injuries.

Non-invasive ventilation in patients with acute asthma ▸

Non-invasive ventilation has a reasonably established role for patients with pulmonary oedema and chronic obstructive pulmonary disease, but its value in acute asthma is unclear. This preliminary study from Israel randomised 30 patients to either receive or not receive three hours of bilevel positive pressure ventilation combined with conventional treatment. The control group comprised patients who had a bilevel positive pressure ventilation circuit applied to their faces with holes in the connecting tubing to release the positive pressure. Spirometry, oxygen saturations, blood pressure, and heart rate were measured throughout the trial period and one hour after finishing the study intervention. The use of bilevel positive pressure ventilation was associated with improved lung function tests and more rapid clinical improvement. Clearly, larger studies will need to follow.

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