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  1. J P Wyatt1,
  2. A Newton2
  1. 1Department of Accident and Emergency, Royal Cornwall Hospital, Treliske, Truro, Cornwall TR1 3LJ, UK
  2. 2Emergency Department, John Radcliffe Hospital, Oxford OX3 9DU, UK
  1. Correspondence to:
 Mr J P Wyatt;
 jonathan.wyattrcht.cornwall.nhs.uk

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Prehospital corticosteroids for spinal cord injury ▸

A position paper from the National Association of EMS Physicians in the US, this article reviews the literature, both human and animal, and concludes that there is no convincing evidence of benefit for the use of high dose corticosteroids in acute spinal cord injury. It also states that there is a significant potential for serious adverse effects. Overall the association recommends that high dose corticosteroids should no longer be used in the prehospital management of spinal cord injuries.

Prehospital guidelines for brain injuries ▸

Guidelines for prehospital management of traumatic brain injury have been developed by the Brain Trauma Foundation in the US. These focus on the prevention of secondary brain injury, by maintenance of the airway and oxygenation and maximising brain perfusion. This prospective study evaluated the implementation of these guidelines, assessing the areas of provider education, practice implementation, and patient outcome. Data were collected for five months before a two month educational programme. After the programme, a further five months of data were collected. The results showed a significant increase in knowledge of traumatic brain injury management after education. There was a significant decrease in the prehospital incidence of hypoxia and of those arriving at hospital hypotensive. The 30 day mortality for patients with moderate to severe brain injury fell significantly after implementation and the functional outcome in survivors significantly improved.

Colloid or crystalloid? ▸

This multicentred, double blinded intensive case based study compared fluid resuscitation with either 4% albumin or normal saline. A total of almost 7000 patients were recruited from 16 centres during the trial period. The allocated fluid was used for all resuscitation until discharge, death, or up to 28 days. The primary outcome measure of mortality at 28 days was similar in both groups—relative risk of death in the albumin group was 0.99 (95% CI 0.91 to 1.09). Secondary outcome measures of survival time during the 28 days, and new single or multiple organ failure were also similar between the two groups. The authors conclude that albumin and saline are equivalent for resuscitation of intensive care patients.

Trauma systems compared ▸

The systems of trauma care differ greatly between France and the US. In France the focus is on physician delivered prehospital care with triage to the most appropriate facility. In the US, prehospital care is regarded as less important than rapid delivery to a regional trauma centre. This interesting article outlines the historical background to both the systems and highlights the major differences. The authors admit there is lack of data to permit comparison of outcome between the two systems, although crude mortality rates for motor vehicle collisions are significantly lower in the US.

Current concepts in damage control ▸

This issue of Injury is dedicated to a review of damage control. The concept of damage control originated from the University of Pennsylvania and comprises a staged, planned strategy for injured patients. The four distinct phases are: early recognition of suitable patients, operation for haemorrhage and contamination control, intensive care management, and finally definitive repair operation. The concept originally targeted abdominal injury (for example, liver lacerations being initially packed and repaired later), but it has now been applied to injury to other anatomical areas. Each article in the journal covers a particular area of damage control.

Thoracotomy in the emergency department ▸

This study attempted to answer the question of whether it is better to perform an emergency thoracotomy in the emergency department (ED) or the operating theatre. This four year retrospective review of six American trauma centres included all thoracotomies performed within 60 minutes of presentation of a hypotensive patient. Death rates for stab wound and gunshot wounds were analysed separately. In an attempt to correct for the higher injury severity score and lower incidence of a detectable blood pressure in the ED thoracotomy group, a multivariate logistical regression analysis was performed. This showed no difference in death rates between thoracotomy in the ED or the operating theatre for those with stab wounds, but showed a mortality benefit in those with gunshot wounds treated with thoracotomy in the operating theatre. There were wide confidence intervals for the results (probably a consequence of low numbers), so they should be interpreted with caution. The authors conclude that gunshot wounds should have thoracotomy performed in theatre rather than in the ED. They advocate emergency department thoracotomy for a very select group of patients.

Ultrasound to detect rib fractures ▸

This small study compared the detection rate of rib fractures by ultrasound, plain radiography, and oblique views. Fourteen patients were radiologically assessed, and a total of 15 fractures were found in 10 of these patients. Ultrasound detected 14 of these, oblique films 13, and chest radiographs 10. One rib fracture was detectable only by oblique view and two were detectable only by ultrasound. The authors conclude that ultrasound is marginally better at detecting rib fractures, but is too painful and time consuming to be used routinely. This conclusion seems particularly reasonable, given that diagnosing an isolated rib fracture is unlikely to radically change the subsequent treatment.

Shock resuscitation ▸

This excellent review article discusses the limitations of traditional methods of resuscitation, and reviews current and future alternative methods of fluid therapy, haemorrhage control, and monitoring techniques. It covers issues regarding hypertonic saline, blood substitutes, procoagulants, and advanced monitoring techniques.

Visual analogue scores improve pain relief ▸

Visual analogue scales (VAS) are often used in the medical literature as a research tool, but this study investigates potential benefits in clinical practice. A total of 300 patients were randomised into three groups—either VAS recorded initially and at two hours (the control group); VAS every 12 minutes marked in a table; or VAS every 12 minutes marked in a graph. Patients and physicians were also asked about the usefulness of the VAS and their assessment of adequacy of pain relief. Results showed that although final VAS scores were similar in all groups, physicians were more aware of the patients’ VAS in the tabular and graphical groups and that those in the graphical VAS group received their analgesia quicker. Both patients and physicians found the VAS useful, and patients felt that it improved the adequacy of their pain relief. As the authors suggest, perhaps VAS should be regarded as the fifth “vital sign” and be recorded on observation charts.

Upper limb splints and driving ▸

An interesting study into an everyday question often faced in the emergency department—“can I drive with this thing on my hand, doctor?” The study was conducted in an occupational therapy department that fits about 2000 thermoplastic splints per year. A questionnaire with photographs depicting 12 different upper limb splints arranged in sequence progressing from mallet splint up to “aeroplane splint” of the axilla was given to patients, local GPs, the police, and the driver and vehicle licensing agency. They were asked to comment on whether or not it was safe to drive while wearing each of the splints. There were additional questions on whether the side worn was important and who has the ultimate responsibility to make the decision. For most splints, there was good consensus among both patients and GPs. However, there was considerable uncertainty in both groups regarding the Futura wrist splint. Only 10% of patients and 4% of GPs seemed to be aware that it is the patient’s responsibility to contact the driver and vehicle licensing agency if they have any concerns regarding their ability to drive. Interestingly, 60% of patients responded that they should have the ultimate responsibility—we need to remind them that they do!

Discharge of patients with normal troponin I ▸

This is the first study to report adverse event rates on those patients discharged from the emergency department with a normal troponin I (TnI) who do not have subsequent provocative testing. It comprised a retrospective chart review of all adult patients discharged after a normal TnI from a US emergency department over three years. A total of 663 patients were discharged after a normal TnI. Data were available on 89%. There were only two known incidences of adverse cardiac events within 30 days. On review one patient had an abnormal ECG on presentation, and the other had TnI checked after only 30 minutes of symptoms. The authors conclude that low risk patients with a normal ECG and a negative TnI at six to nine hours have a very low incidence of adverse events at 30 days. The results of this study are potentially important, but there were several important design limitations. Firstly, there was no uniform definition of who was regarded as low risk and suitable for discharge (25% of the patients studied had known coronary artery disease). Secondly, the authors only regarded death or AMI as adverse events. Finally, clinical details were absent and therefore there was no means of ascertaining whether this group of patients had largely typical or atypical symptoms.

Doubling the dose of inhaled corticosteroids during asthma exacerbations ▸

This well conducted multicentre trial from Canada examined the effect of doubling the dose of inhaled budesonide during an acute exacerbation of asthma. The study was undertaken in an outpatient setting, where asthmatic patients monitored their own peak expiratory flow rates. To be eligible, patients had to be stable on a regular inhaled corticosteroid for one month before the trial started. Exacerbations were strictly defined. When an exacerbation occurred, the patient took an additional inhaler—either budesonide or placebo. All patients suffering from an exacerbation were followed up for three months to assess asthma stability. Results on the 98 patients who experienced an exacerbation during the six month trial showed no difference in the rate of treatment failure (also strictly defined) between the two groups. Also, there was no difference in the number of subsequent exacerbations between the two groups during the three month follow up. The authors concluded that there was no benefit in doubling the dose of inhaled corticosteroid during an acute exacerbation of asthma. This supports the recommendations in the current BTS/SIGN guidelines.

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Footnotes

  • Edited by Jonathan Wyatt; this scan coordinated by Al Newton

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