Highlights from the literature
Sophia recommends a supplement in the British Journal of Surgery (2012;99(Suppl 1)) devoted to trauma care. Advances in surgical approaches and the use of tourniquets, haemostatic dressings and novel intravenous fluids are discussed in an article heralding the beginning of the end for damage control surgery (2012;99(Suppl 1):10–11). Following on, a review of trauma induced coagulopathy speculates that future treatment may be based upon a combination of systemic antifibrinolytics, local haemostatics, and individualised point of care guided rational use of coagulation factor concentrates (Suppl 1:40–50). Indicators of the quality of trauma care are considered later in the supplement (Suppl 1:97–104). Traditional markers of quality have relied upon rates of death/survival in hospital, but it is now acknowledged that these are rather crude measures. Work is under way to develop measures of performance which include morbidity, functional long-term outcomes as well as mortality.
Propofol for painful procedures
A randomised prospective study compared propofol with ketamine/midazolam sedation in the ED for painful orthopaedic manipulations. Specific comparisons included recovery time, total sedation time, adverse events and the level of analgesia induced. The study included 60 patients and found that propofol reduced both the average total sedation time and recovery time compared with ketamine/midazolam (Journal of Bone and Joint Surgery American 2011;93:2255–62).
Spinal cord and brachial plexus injuries
Injuries to both the spinal cord and brachial plexus in the same patient have previously been considered to be very rare. However, a study from Minnesota, USA, warns that this combination of injuries may be less unusual than previously thought. In a retrospective analysis of 255 adult patients presenting with traction injuries to the brachial plexus over a 9-year period, 31 had associated spinal cord injury. The findings suggest that Horner's sign and/or phrenic nerve dysfunction may be useful clinical pointers to the combination of brachial plexus and cord injuries (J Bone Joint Surg Am 2011;93:2271–7).
Hip pain due to obturator hernia
A case report in the British Journal of Hospital Medicine (2011;72:714–15) describes how an elderly man presented with left hip pain due to a Richter's type small bowel hernia in the left obturator canal. Given the rarity of obturator hernias, knowledge of specific physical signs may be of little more than academic interest. Relevant signs include the Howship-Rhomberg sign (pain radiating down the medial thigh during extension and abduction) and the Haddington-Kiff sign (absence of the adductor tendon reflex on the affected side).
Autoresuscitation after asystole
How long should we wait after resuscitation ceases before a patient can be declared dead and the organs used for transplant? Guidelines have previously suggested five minutes of asystole before confirmation of death. However, in a study in Critical Care Medicine (2012;40:158–61), no patient ‘autoresuscitated’ within 2 min.
Syncope in the elderly
A study of 242 patients over the age of 65 with transient loss of consciousness found that after 2 years, the recurrence of syncope was 33% and mortality 17%. Mortality was related to increasing age and comorbidity, whereas recurrence was related to increasing age and disability. Cardiac syncope was more frequent in deceased than survivor patients, and syncope recurrence was high despite a low incidence of unexplained syncope (Age and Ageing 2011;40:696–702).
Suicide and mental illness
Researchers from Manchester present the findings of 15 years of data from the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness in the British Medical Bulletin (2011;100:101–21). The database includes completed suicides from individuals who had been in contact with mental health services in the preceding 12 months. Rates of suicide vary according to age, sex and clinical features (of mental illness). Risk assessment remains a considerable challenge.
Excited delirium syndrome
Descriptions of ‘excited delirium syndrome’ have traditionally been used in forensic practice to describe individuals who may be aggressive, agitated, hyperthermic and exhibit ‘superhuman strength’. There is a strong association with cocaine use. The condition is of particular relevance to both forensic and emergency practitioners, especially considering the large number of deaths attributed to it. Relatively little is understood about it, which has prompted scrutiny from a group of experts (Journal of Clinical Forensic Medicine 2012;19:7–11).
Violence in the ED
A considerable amount of violence in the workplace is experienced in the ED. This affects staff morale, retention and physical health, costing the NHS an estimated £69 million per year. It seems that verbal aggression is rarely reported and only a third of staff report physical violence. An article in the British Journal of Hospital Medicine (2011;72:664–5) concludes that a multi-factorial approach to reducing and preventing violence in the ED is needed. Perhaps lessons can be learnt from business, psychology and marketing for solutions.
Painful procedures in children
Taking blood from children can be distressing for all involved. Despite the availability of topical and systemic analgesics, routine medical care involving painful procedures (particularly those involving needles) continues to cause distress. Following experiences as children, approximately 10% of adults are needle phobic and so do not attend for dental care, vaccinations and other routine medical procedures. An article in the Archives of Diseases in Childhood (2012;97:1–4) looks to introduce a guideline to reduce distress, optimise staff competencies, minimise use of restraint and identify when other agencies (eg, play specialists) should be involved, thereby making procedures more tolerable for all.