A retrospective cohort study examining 18 months of historical data collated by the Queensland Ambulance Service TRT, the Pathology Queensland Central Transfusion Laboratory, the Royal Brisbane and Women's Hospital and the Princess Alexandra Hospital Trauma Services was undertaken.

Over an 18-month period (1 January 2011 to 30 June 2012), 71 trauma patients were administered pRBCs by the TRT. Seven patients (9.9%) died on scene and 39 of the 64 patients (60.9%) transported to hospital survived to hospital discharge. 57 (89.1%) of the transported patients had an Injury Severity Score (ISS) > 15, with a mean ISS, Revised Trauma Score (RTS) and Trauma-Injury Severity Score of 32.11, 4.70 and 0.57, respectively. No patients with an RTS < 2 survived to hospital discharge. 53 patients (82.8%) received additional pRBCs in hospital with 17 patients (26.6%) requiring greater than 10 units pRBCs in the first 24 h. 47 patients (73.4%) required surgical or interventional radiological procedures in the first 24 h.

There is a potential role for prehospital pRBC transfusions in an integrated civilian trauma system. The RTS calculated using the initial set of observations may be a useful tool in determining in which patients the administration of prehospital pRBC transfusions would be futile.

The study enrolled patients with cardiogenic cardiac arrest who were admitted to an intensive care unit after ROSC with PCAS. We investigated the association of the following factors with outcome: age, gender, witness to event present, bystander cardiopulmonary resuscitation (CPR) performed, ECG waveform at the scene, time interval from receipt of call to arrival of emergency personnel, time interval from receipt of call to arrival at hospital, prehospital defibrillation performed, special procedures performed by emergency medical technician, and time interval from receipt of call to ROSC, coronary angiography/percutaneous coronary intervention (PCI) and therapeutic hypothermia performed.

The study enrolled 227 patients with PCAS. Compared with the poor neurological outcome group, the good neurological outcome group had a statistically significant higher proportion of the following factors: younger age, male, witness present, bystander CPR performed, first ECG showed ventricular fibrillation/pulseless ventricular tachycardia, defibrillation performed during transportation, short time interval from receipt of call to ROSC, coronary angiography/PCI and therapeutic hypothermia performed. Of these factors, the only independent factor associated with good neurological outcome was the short time interval from receipt of the call to ROSC.

In the present study, shortening time interval from receipt of call to ROSC was the only important independent factor to achieve good neurological outcome in patients with PCAS.

We conducted semistructured qualitative interviews with a purposive sample of independent-living individuals aged 55 years and older from urban and rural settings. We developed an interview guide based on the constructs of the Theory of Planned Behaviour, which elicits salient attitudes, social influences and control beliefs potentially influencing CPR training and performance. Interviews were recorded, transcribed verbatim and analysed until achieving data saturation. Two independent reviewers performed inductive analyses to identify emerging themes, and ranked them by way of consensus.

Demographics for the 24 interviewees: mean age 71.4 years, women 58.3%, urban location 75.0%, single dwelling 58.3%, CPR training 79.2% and prior CPR on real victim 8.3%. Facilitators of CPR training included: (1) classes in a convenient location; (2) more advertisements; and (3) having a spouse. Barriers to taking CPR training included: (1) perception of physical limitations; (2) time commitment; and (3) cost. Facilitators of providing CPR included: (1) 9-1-1 CPR instructions; (2) reminders/pocket cards; and (3) frequent but brief updates. Barriers to providing CPR included: (1) physical limitations; (2) lack of confidence; and (3) ambivalence of duty to act in a large group.

We identified key facilitators and barriers for CPR training and performance in a purposive sample of individuals aged 55 years and older.

We designed a study to assess the ‘best’ way to orientate the glove when drawing a face on it. A prospective study was performed in the authors’ institution, where all children between the ages of 2 and 8 years presenting during the study period were given the option of playing with one of two glove balloons with a face drawn on it in two different ways.

149 paediatric patients were assessed, of whom 136 picked a glove, 75 picked the ‘Jedward’ version and 61 the ‘Mohawk’ version.

A standard hospital glove, inflated as a balloon with a face drawn on it, is a useful distraction for children with an acute injury. The face drawn should be drawn ‘Jedward’ style.

Retrospective review and logistic regression of HIs found in emergency department records for three groups of men, those: (1) who were chronically homeless with drinking problems (CHDP) (n=50), (2) in the general homeless population (GH) (n=60) and (3) in low-income housing (LIH) (n=59).

The proportion of individuals with non-minimal HIs documented in the previous year were 28%, 3% and 5% with annual rates of 0.47, 0.017 and 0.037 among the CHDP, GH and LIH groups (p<0.0001). In the multivariate model, independent associations with having an HI included: an HI in the previous year (OR 11.8, 95% CI 3.83 to 36.4), drug dependence (OR 3.67, 95% CI 1.11 to 12.13) and seizures (OR 3.50, 95% CI 1.13 to 10.90), while mood-disorders were protective. Homelessness had a crude risk increase of HI (OR 3.15, 95% CI 1.21 to 8.23) but was not significant in the multivariate model. Among those with HIs, chronic homelessness with drinking problems was associated with a higher rate of HI. With each successive HI, the time interval to another HI was 12 days shorter (p=0.0004). The chronic subdural haematoma incidence in the under-65-year-old CHDP group was 11 per 1000 (95% CI 2.8 to 45).

Having an HI is better predicted by previous head injuries, drug dependence or a seizure disorder than a history of homelessness or alcohol dependence. HIs may become more frequent with time.

In a prospective observational study over a 3-month period, we identified characteristics of patients with a history of active IDU presenting to the ED.

From 1 January 2010 to 31 March 2010, 146 patients with a history of IDU were identified. These contributed to 222 acute presentations to the ED. Baseline characteristics revealed that patients were predominantly male, of Irish nationality, with high levels of homelessness, unemployment and lack of stable family or intimate partner relationships. 45% of presentations occurred as a result of infection (95% CI 38.5% to 51.5%). Trauma, pure toxicological issues, thromboembolic phenomena and psychiatric issues comprised the other common acute diagnoses. The burden of comorbid medical illness was substantial with high rates of hepatitis C infection (74%) and HIV infection (13.8%). Healthcare utilisation indices for this cohort are extreme on multiple measures. We found an ED attendance rate of 445 per 100 patient-years, an admission rate of 68.8 per 100 patient-years and mortality rate of 4.86 per 100 patient-years.

Our study characterises the emergency presentations of active IDUs. We describe considerable acute and chronic medical consequences and high healthcare utilisation associated with IDU. This study is of particular relevance to any institution that provides acute medical care to this group of patients.

To use National Health Insurance claims data to track the work status and work places of emergency physicians compared with other specialists. To examine the hypothesis that emergency physicians leave their specialty more frequently than other hospital-based specialists.

Three types of specialists who work in hospitals were enrolled: emergency physicians, surgeons and radiologists/pathologists. Every physician was followed up until they left the hospital, did not work anymore or were censored. A Kaplan–Meier curve was plotted to show the trend. A multivariate Cox regression model was then applied to evaluate the adjusted HRs of emergency physicians compared with other specialists.

A total of 16 666 physicians (1584 emergency physicians, 12 103 surgeons and 2979 radiologists/pathologists) were identified between 1997 and 2010. For emergency physicians, the Kaplan–Meier curve showed a significantly decreased survival after 10 years. The log-rank test was statistically significant (p value <0.001). In the Cox regression model, after adjusting for age and sex, the HRs of emergency physicians compared with surgeons and radiologists/pathologists were 5.84 (95% CI 2.98 to 11.47) and 21.34 (95% CI 8.00 to 56.89), respectively.

Emergency physicians have a higher probability of leaving their specialties than surgeons and radiologists/pathologists, possibly owing to the high stress of emergency medicine. Further strategies should be planned to retain experienced emergency physicians in their specialties.

A modified Delphi method was used to develop a set of reference vignettes. Delphi participants completed a 2-round consensus-building process, and independently assigned triage acuity ratings to 100 written vignettes unaware of the ratings given by others. Triage acuity ratings were summarised for all vignettes, and only those that reached 80% consensus during round 2 were included in the reference set. Triage ratings for the reference vignettes given by two independent experts using the SATS were compared with the ratings given by the international Delphi panel. Measures of sensitivity, specificity, associated percentages for over-triage/under-triage were used to evaluate the construct of triage acuity (as measured by the SATS) by examining the association between the ratings by the two experts and the international panel.

On completion of the Delphi process, 42 of the 100 vignettes reached 80% consensus on their acuity rating and made up the reference set. On average, over all acuity levels, sensitivity was 74% (CI 64% to 82%), specificity 92% (CI 87% to 94%), under-triage occurred 14% (CI 8% to 23%) and over-triage 12% (CI 8% to 23%) of the time.

The results of this study provide an alternative to evaluating triage scales against the construct of acuity as measured with the SATS. This method of using 80% consensus vignettes may, however, systematically bias the validity estimate towards better performance.

This study evaluated whether the difference between systolic blood pressure (SBP), heart rate (HR), respiratory rate (RR) and shock index (SI) taken in the emergency department (ED) and prehospital can predict 48 h mortality postadmission following trauma.

Retrospective cohort was obtained from the Trauma Audit and Research Network. Subjects were excluded if head or spinal injuries, prehospital intubation or CPR were present. Main outcome was 48 h mortality. The difference (delta, ) between ED and prehospital values were used as study variables (ie, SI=SI-ED minus SI-prehospital). Accuracy was assessed using area under receiver operator characteristic curve (AUROC). AUROC coordinates were used to identify 95% specificity cut points and described further using sensitivity and likelihood ratios (LRs).

Significant AUROC statistics were revealed for SBP (0.57) and RR (0.56) for the full sample, SBP (0.62) and SI (0.65) for moderate, and RR (0.6) for severe injury. Best LRs were 3.4 and 2.4 for RR and SI, respectively, but sensitivities were low (<=26%). Cut point values for SBP, RR and SI were 37 mm Hg, 8 breaths/min and 0.2, respectively.

SBP and RR performed best overall, but SI performed best in the moderate injury group, suggesting earlier identification with SI. Use of values result in good rule-in of 48 h mortality and may supplement trauma treatment decisions.

The bibliographic data of Iranian authors on the ‘emergency medicine’ field during the years 2001–2011 were retrieved from the Science Citation Index Expanded database. Co-occurrence matrices were made by BibExcel and were imported to Ucinet and NetDraw to delineate coauthorship network. To detect structural patterns among authors, we considered some measures of social network analysis, such as density, centralisation indices, component analysis and cut-points. Lastly, subject experts separately analysed the content of papers.

Of 116 papers published, the network was composed of 10 components, with the largest component having 25 authors. Using social network analysis measures, we identified science bottlenecks in knowledge sharing, hub authors and accelerators of information flow. Topic analysis showed ‘Wounds and Injuries’ as the most recent theme in all components because of existence of national registry for trauma, high burden of road traffic injuries and research priority of injuries in Iran.

because of Iranian low productivity in the emergency medicine field, social network analysis seems to be a proper option for bibliometrics to identify central authors and detect knowledge structure in this field.

We selected cases that had the greatest discrepancy between observed mortality and predicted probability of mortality from seven hospitals involved in validation of the DAVROS risk-adjustment model. Reviewers at each hospital assessed hospital records to determine whether the discrepancy between predicted and actual mortality could be explained by the healthcare provided.

We received 232/280 (83%) completed review forms relating to 179 unexpected deaths and 53 unexpected survivors. The healthcare system was judged to have potentially contributed to 10/179 (8%) of the unexpected deaths and 26/53 (49%) of the unexpected survivors. Failure of the model to appropriately predict risk was judged to be responsible for 135/179 (75%) of the unexpected deaths and 2/53 (4%) of the unexpected survivors. Some 10/53 (19%) of the unexpected survivors died within a few months of the 7-day period of model prediction.

We found little evidence that deaths occurring in patients with a low predicted mortality from risk-adjustment could be attributed to the quality of healthcare provided.

To determine whether chest compressions delivered on a bed adjusted to rescuer's knee height are as effective as those delivered on the floor.

A total of 20 fourth-year medical students participated in the study. The students performed chest compressions for 2 min each on a manikin lying on the floor (test 1) and on a manikin lying on a bed (test 2). The average compression rate (ACR) and the average compression depth (ACD) were compared between the two tests.

The ACR was not significantly different between tests 1 and 2 (120.1 to 132.9  vs 115.7 to 131.2 numbers/min, 95% CI, p=0.324). The ACD was also not significantly different between tests 1 and 2 (51.2 to 56.6 vs 49.4 to 55.7 mm, 95% CI, p=0.058).

The results suggest that there may be no significant differences in compression rate and depth between CPR performed on manikins placed on the floor and those placed at a rescuer's knee height.

Patients were recruited from the emergency department of an academic teaching hospital. Informed consent and the entire treatment protocol was administered by a study physician. Nitric oxide was administered using a commercial device (Inovent) and a custom-made non-rebreathing face mask. The NO concentration was increased at 1 ppm/min (parts per million) until a maximum of 25 ppm and continued for 120 min and then weaned at 1 ppm/min. Dyspnoea was assessed with the Borg score, oxygenation by pulse oximetry, and haemodynamic status by shock index (HR/SBP).

Eight patients were enrolled. All patients tolerated the entire protocol without adverse events, and all had decreased numerical Borg score by >50%. The changes from baseline to 155 min were as follows: Borg score 7.5±2.5 to 2.3±1.9 (p=0.06, Signed rank test), SaO2% 93±5 to 97±3 and shock index 1.0±0.11 to 0.86±0.09. No patient experienced worsening during weaning.

Inhaled NO reduced dyspnoea without adverse events in eight patients with severe submassive PE. This protocol can serve as the basis for a phase II trial or for a compassionate use protocol.

An SCT-ECG was developed. The test was administered to medical students, residents and emergency physicians. Scoring was based on data from a panel of 12 emergency physicians. The statistical analyses assessed the internal reliability of the SCT (Cronbach's α) and its ability to discriminate between the different groups (ANOVA followed by Tukey's post hoc test).

The SCT-ECG was administered to 21 medical students, 19 residents and 12 emergency physicians. The internal reliability was satisfactory (Cronbach's α=0.80). Statistically significant differences were found between the groups (F_0.271=21.07; p<0.0001). Moreover, significant differences (post hoc test) were detected between students and residents (p<0.001), students and experts (p<0.001), and residents and experts (p=0.017).

This SCT-ECG is a valid tool to assess clinical reasoning in a context of uncertainty due to its high internal reliability and its ability to discriminate between different levels of expertise.

To determine what proportion of children in different age groups falls outside the limits of the Broselow tape, how their weight compares with that of the adults and what correlates most strongly with weight in these children.

This was a population-based prospective observational study of Chinese children up to 12 years old, from schools in Hong Kong. Weight was measured to the nearest 0.2 kg, and the height, foot-length and mid-arm circumference (MAC) were measured to the nearest 0.1 cm.

40% of 10-year olds and 70% of 11-year olds were too tall for the tape. Their median weight was 41.9 kg. This was significantly less than the median weight of 18-year olds (55 kg, p<0.0001) in Hong Kong. The strongest correlate with weight in these children was MAC.

The Broselow tape is inappropriate for use in most children over 10 years old. Children too tall for the tape cannot be assumed to be of adult weight; to do so would imply an average overestimate of 30%. Weight estimates in older children could be based on MAC.

Questionnaire surveys of medical graduates of 1993, 1996, 1999, 2000, 2002, 2005, 2008 and 2009 from all UK medical schools.

EM was specified as a first choice of career by 4.2% of graduates in postgraduate year 1, 4.8% in year 3, and 3.8% in year 5. Graduates who chose EM were much less likely to be certain about their choice than those who chose other specialties. Of those who specified EM as their first choice of career in year 1, only 26% still had it as their first choice in year 5. Of those who gave EM as their first career choice in year 5, only 27% had given EM as their first choice in year 1. Switches to EM were made, notably, by doctors who previously favoured surgical specialties, hospital physician-led specialties and anaesthetics.

Early career choices for EM are less predictive of career destinations than choices for other specialties, and, compared with many other specialties, doctors who pursue it may turn to it relatively late. Training policies on transferable competencies should enable clinical trainees in other related specialties to bank some of their skills if they transfer to EM, rather than necessarily having to start core training in year 1 of EM specialty training.

We undertook a cross-sectional questionnaire survey of 300 patients attending the ED with minor injuries on weekdays between 9:00 and 17:00. Participants completed a questionnaire asking which tests and treatments they expected, which they consequently received, whether explanations were given for tests and treatments, and how they rated satisfaction with care.

The most frequently expected interventions were x-ray, analgesia and bandage/strapping. In each case the proportion expecting intervention was significantly higher than the proportion receiving intervention: x-ray (58% vs 47%, p<0.001); analgesia (40% vs 20%, p<0.001); bandage/strapping (39% vs 22%, p<0.001). There were no significant differences between the proportions expecting and receiving other interventions. At least one unmet expectation was reported by 208/300 patients (69%) but an explanation was received in 151/208 cases (73%). Conversely, 106 (35%) received an unexpected intervention, of whom 79/106 (74%) received an explanation. Patients with unmet expectations tended to rate the satisfaction lower, but the difference was not statistically significant (p=0.187).

Patients often expect interventions for minor injuries that they do not receive, but in most cases an explanation was given. We were unable to demonstrate an association between unmet expectations and reduced satisfaction with care.

Senior emergency physicians attended a 3 h teaching session. Following this, they independently reported adult CT head scans between 22:00 and 08:00 using a pro forma. CT head examinations performed in this ‘out of hours’ period were formally reported by a consultant radiologist on the following morning. Data were collected in a blinded fashion over an 8-month period.

405 adult CT head examinations were performed. 360 pro formas were available for analysis, and the rest were excluded either because a consultant radiologist had been rung to discuss the results (five patients) or because the pro forma was not completed (40 patients). Concordance between consultant radiologists and emergency physicians was found in 339 (94%) of the cases ( coefficient 0.78). None of the discordant cases was managed inappropriately or had an adverse clinical outcome. All cases of extradural, subdural and subarachnoid haemorrhage were detected by emergency physicians.

In conclusion, we feel that this model can be employed as a safe and long-term alternative provided that the radiology department are committed to providing ongoing teaching and that a database is maintained to highlight problem areas. Emergency physicians need to remember that the clinical status of the patient must never be ignored, irrespective of their CT head findings.

Two retrospective clinical audits were carried out over a monthly period (May 2011 and January 2012) using electronic and paper NEAS patient records.

This audit confirmed that a range of basic and/or advanced airway management techniques are being successfully used to manage the airways of cardiac arrest patients. I-gel is emerging as a popular choice for maintaining and securing the airway during prehospital cardiopulmonary resuscitation. Success rates for i-gel insertion are higher (94%, 92%) than endotracheal (ET) tube insertion (90%, 86%). Documentation of the airway management method was poor in 11% of the records. The Quality Improvement Officers addressed this by providing individual feedback.

I-gel shows a higher success rate in cardiac arrest patients compared to the ET tube. Staff who chose to use methods other than i-gel indicated this was a confidence issue when using new equipment. The re-audit indicated an upward trend in the popularity of i-gel; insertion is faster with a higher success rate, which allows the crew to progress with the other resuscitation measures more promptly. Airway soiling and aspiration beforehand have been reasons staff resort to ET intubation. It is anticipated by the authors that i-gel will emerge as the first choice of airway management device in prehospital cardiac arrests.

A multicentre prospective observational study enrolled patients undergoing assessment for possible ACS. TIMI and mTIMI scores were calculated. The study outcome was a composite of all-cause death, myocardial infarction or coronary revascularisation within 30 days.

Of the 1666 patients, 219 (13%) reached the study outcome. Area under the receiver operating characteristic curve for the composite outcome was 0.80 (0.76 to 0.83) for the mTIMI score compared with 0.71 (0.67 to 0.74) for the standard TIMI score, p<0.001, but there was no significant difference for death or revascularisation outcomes. Sensitivity and specificity for the composite outcome were 0.96 (0.92 to 0.98) and 0.23 (0.20 to 0.26), respectively, at score 0 for TIMI and mTIMI. At score <2, sensitivity and specificity were 0.82 (0.77 to 0.87) and 0.53 (0.51 to 0.56) for mTIMI, and 0.74 (0.68 to 0.79) and 0.54 (0.51 to 0.56) for standard TIMI, respectively.

mTIMI score performs better than standard TIMI score for ED risk stratification of chest pain, but neither is sufficiently sensitive at scores >0 to allow safe and early discharge without further investigation or follow-up. Observed differences in performance may be due to incorporation bias.

International literature from Medline, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL), ProQuest, Scopus and grey literature from 1990 were included. Articles about any prehospital emergency care provider trained with extra skill(s) beyond their baseline competencies and evaluated in practice were included. Specific procedures for certain conditions and the extensively evaluated UK Emergency Care Practitioner role were excluded.

8724 articles were identified, of which 19 met the inclusion criteria. 14 articles considered paramedic patient assessment and management skills, two articles considered paramedic safeguarding skills, two health education and learning sharing and one health information. There is valuable evidence for paramedic assessing and managing patients autonomously to reduce Emergency Department conveyance which is acceptable to patients and carers. Evidence for other paramedic skills is less robust, reflecting a difficulty with rigorous research in prehospital emergency care.

This review identifies many viable extra skills for paramedics but the evidence is not strong enough to guide policy. The findings should be used to guide future research, particularly into paramedic care for elderly people.

This is a prospective, multicentre and observational cohort study. The study included general medical and surgical patients admitted to the EDs of three education and research hospitals during a period of 6 months. The primary outcome of the study is the admission of the patient to a ward/an intensive care unit (ICU)/high dependency unit (HDU) and in-hospital mortality. Receiver operating characteristics (ROC) curve analysis was performed to evaluate and compare the performances of two scores.

Total patients were 2000 (51.95% male, 48.05% female). The mean age was 61.41±18.92. Median MEWS and REMS values of the patients admitted to the ICU/HDU from ED were 1 and 6, respectively; and there was a significant difference in terms of REMS values, compared with patients discharged from ED. REMS (area under the curve (AUC): 0.642) was found to have a better predictive strength than MEWS (AUC: 0.568) in discriminating in-patients and discharged patients. Additionally, REMS (0.707) was superior to MEWS (AUC 0.630) in terms of predicting in-hospital mortality of patients presenting to ED.

The efficiency of REMS was found to be superior to MEWS as a predictor of in-hospital mortality and hospitalisation in medical and surgical patients admitted to ED.

To test the hypothesis that the general public might start ECC more often if they used an automated device rather than a manual massage.

Web-based public opinion survey based on two short videos, one showing manual ECC and the other automated ECC (Autopulse, Zoll, France). Advantages and disadvantages (perceived efficacy, reproducibility, hazard, apprehension and acceptability) of the two techniques were evaluated on a visual analogue scale (VAS). A VAS of 1–3 was considered to indicate preference for manual ECC, 8–10 for automated ECC and 4–7 for no clear preference. The final global score was the difference between advantage and disadvantage scores.

Overall, 1769 persons answered the questionnaire. The median VAS score for each variable was as follows: 7 (25–75 percentiles, 5–9) for efficacy, 8 (3–10) for reproducibility, 5 (3–8) for hazard, 5 (2–8) for apprehension and 5 (2–8) for acceptability. The overall median score indicated that 1034 persons (58%) preferred use of the device, 618 (35%) preferred manual ECC and 117 (7%) had no preference. There was no significant difference in the preference according to gender, education and training in first aid. However, older persons (0) preferred the use of device.

The better ‘advantages over disadvantages’ score for the automated ECC device over manual ECC indicated that the general public might envisage use of the device. This could contribute to increase the frequency of resuscitation attempts by bystanders.

We invited eight emergency physicians to answer eight script concordance tests. Interviews were tape-recorded and qualitatively analysed using predetermined categories until saturation.

Emergency physicians mainly mobilised intuition and non-Bayesian reasoning to incorporate biomarkers for diagnosis or treatment strategies.

Although biomarkers have been developed to be used in a Bayesian approach, emergency physicians mainly use other analytical and non-analytical cognitive processes to introduce these tools in their clinical reasoning.

Five EPs enrolled consecutive patients with a CFB over 3 months. One blinded EP reviewed patients after 3 days. The study end points were: change in visual acuity; visual analogue pain scale (VAS) score at 12 and 24 h; satisfaction rating; symptoms at follow-up; and rate of complications.

54 patients were enrolled: 28 had SLA removal and 26 NSLA removal; 52 were male; 22 had undergone previous CFB removal; six were wearing eye protection at the time of injury. Forty-three patients were reviewed: 26 by attendance and 18 by telephone. There was no difference in any end points at review. However, patients in the SLA group had median VAS scores that were 1.5 cm lower after 24 h than patients in the NSLA group (p=0.43, 95% CI –2.0 to 1.0). One patient in the SLA group developed keratitis.

We show that patient satisfaction ratings, complications and visual acuity were similar for the two methods. There was a trend for increased pain in the NSLA group at 12 and 24 h. Slit-lamp biomicroscopy and the use of magnification to remove CFBs remains the gold standard of care, and more intensive training should be given to EPs at the departmental level, particularly in EDs that receive patients with eye injuries.

To explore and understand patient and carer decision making around calling an ambulance for primary care-appropriate health problems.

Semistructured interviews were conducted with patients and carers who had called an ambulance for a primary care-appropriate problem. Participants were identified using a purposive sampling method by a non-participating research clinician attending ‘999’ ambulance calls. A thematic analysis of interview transcripts was undertaken.

A superordinate theme, patient and carer anxiety in urgent-care decision making, and four subthemes were explored: perceptions of ambulance-based urgent care; contrasting perceptions of community-based urgent care; influence of previous urgent care experiences in decision making; and interpersonal factors in lay assessment and management of medical risk and subsequent decision making.

Many calls are based on fundamental misconceptions about the types of treatment other urgent-care avenues can provide, which may be amenable to educational intervention. This is particularly relevant for patients with chronic conditions with frequent exacerbations. Callers who have care responsibilities often default to the most immediate response available, with decision making driven by a lower tolerance of perceived risk. There may be a greater role for more detailed triage in these cases, and closer working between ambulance responses and urgent primary care, as a perceived or actual distance between these two service sectors may be influencing patient decision making on urgent care.

A qualitative approach was employed to capture data through two focus group interviews. Sixteen APs were invited to participate in this study. Both focus groups were audio recorded, transcribed and analysed using Attride–Stirling's framework for thematic network analysis.

The global theme ‘Understanding Barriers to the Prehospital Management of Acute Pain in Children’ emerged from three organising themes as follows: AP education and training; current clinical practice guidelines for paediatric pain management; realities of prehospital practice. Limited exposure to children in the prehospital setting, difficulty assessing pain intensity in small children, and challenges in administering oral or inhaled analgesic agents to distressed and uncooperative children were highlighted by participants. Short transfer times to the emergency department, and a ‘medical’ cause of pain were also implicated as examples of when children are less likely to receive analgesia from practitioners.

The pathway to improving care must include an emphasis on improvements in practitioner education and training, offering alternatives to assessing pain in preverbal children, exploring the intranasal route of drug delivery in managing acute severe pain, and robustly developed evidence-based guidelines that are practitioner friendly and patient-focused.

A self-completed questionnaire was developed to explore paramedic perceptions and barriers to undertaking prehospital trials based upon a review of existing research and semistructured qualitative interviews with five paramedics. The questionnaire was distributed by ‘research champions’ to 300 paramedics at randomly selected ambulance stations in Yorkshire.

Responses were received from 96/300 participants (32%). Interest in clinical trials was reported, but barriers were recognised, including perceptions of poor knowledge and limited use of evidence, that conducting research is not a paramedics’ responsibility, limited support for involvement in trials, concerns about the practicalities of randomisation and consent, and time pressures. No association was found between training route and perceived understanding of trials (p=0.263) or feeling that involvement in trials was a professional responsibility (p=0.838). Previous involvement in prehospital research was not associated with opinions on importance of an evidence base (p=0.934) or gaining consent (p=0.329). The number of years respondents had been practicing was not associated with opinions on personal experience versus scientific evidence (p=0.582) or willingness to receive training for clinical trials (p=0.111). However, the low response rate limited the power of the study to detect potential associations.

Paramedics reported interest and understanding of research, but a number of practical and ethical barriers were recognised that need to be addressed if prehospital clinical trials are to increase.

Pulmonary cement emboli can occur in up to 23% of percutaneous vertebroplasty.1 This procedure is widely used making emergency practitioner recognition of complications important. Most complications are related to leakage of the bone cement into the venous system. Pulmonary migration can be asymptomatic and difficult...]]> 2013-03-19T00:01:24-07:00 info:doi/10.1136/emermed-2013-202432 hwp:master-id:emermed;emermed-2013-202432 British Association for Accident and Emergency Medicine 2013-03-19 Images in emergency medicine http://emj.bmj.com/cgi/content/short/emermed-2012-201465v1?rss=1 Introduction

Many studies have demonstrated a rise in troponin and brain natriuretic peptide (BNP) levels following prolonged and/or strenuous exercise. Only one study looked at athletes who collapse and this showed no difference in cardiac biomarkers between those who collapsed and those who completed without requiring medical attention. We set out to describe and quantify the changes in troponin and BNP in three groups of non-elite runners at the 2009 London marathon: those with and without known structural heart disease (SHD) and those who collapsed on completion.

The first group (recruited group, RG) was recruited at the prerace exhibition. This group had two subsets, runners with SHD and without (non-SHD). A second group was recruited from those who collapsed (collapsed group, CG). Blood was taken for troponin I (TnI), troponin T (TnT), high sensitivity TnT (HSTnT) and BNP.

Cardiac biomarker levels increased in all groups following the marathon. No statistically significant difference was seen between the SHD and non-SHD subgroups. When comparing the RG and CG the number and degree of rise was greater in those who collapsed. A trend for the degree of rise of HSTnT was demonstrated.

We identified runners with troponin levels that, in other circumstances, would raise concern for myocardial necrosis. However absence of adverse clinical sequelae would suggest this rise is physiological. The cause and clinical significance of the increased HSTnT levels seen in those that collapsed is yet to be fully elucidated.

We performed a prospective cohort study of all trauma patients admitted to our emergency room over a 1-year period to evaluate the utility of this tool for emergency physicians to detect significant haemorrhage in the trauma patient. Shock grades were prospectively assigned to patients by the trauma team as part of the primary survey, and followed up to assess for outcomes. The primary outcome was a composite endpoint of clinical, radiological and operative findings consistent with significant haemorrhage. Data were analysed using linear and logistic regression to assess predictive ability and receiver operator characteristic curve to assess overall diagnostic accuracy.

The overall sensitivity of the shock grading tool was 83%. The diagnostic accuracy based on area under receiver operator characteristic curve was 0.86. There was also a significant association between increasing shock grade and both injury severity score (β coefficient 7.0, p<0.001, 95% CI 6.2 to 7.8) and the presence of significant haemorrhage (OR 5.1, p<0.001, 95% CI 3.6 to 7.3).

We conclude that a simple ATLS based clinical tool that objectively categorises haemorrhagic shock is a useful part of the primary survey of the trauma patient, although a larger study with higher statistical power is required to evaluate this conclusion further.

To explore the lived experience of lay presence during an adult CPR attempt in primary (out-of-hospital) and secondary (inhospital) environments of care.

Hermeneutical phenomenological study.

Semistructured, face-to-face interviews with 8 ambulance staff and 12 registered nurses. The interviews were audio-recorded and subjected to thematic analysis.

Participants provided insight into situations where lay presence during adult CPR came about either spontaneously or as a planned event. Their accounts portrayed a mixture of benefits and concerns. Familiarity of working in the presence of lay people, practical experience in emergency care and personal confidence were important antecedents. Divergent practices within and across the contexts of care were revealed. The concept of exposure emerged as the essence of this phenomenon. Overall, the study findings serve to challenge some of the previously reported attitudes and opinions of emergency care staff.

Improved intraprofessional and interprofessional collaboration is essential to overcoming the barriers associated with lay presence during adult CPR. The future of this practice is dependent on initiatives that seek to bring about attitudinal change. Priority should be given to further exploring this phenomenon in the context of patient and family centred end-of-life care.

To determine whether a single NEWS on emergency department (ED) arrival is a predictor of outcome, either in-hospital death within 30 days or intensive care unit (ICU) admission within 2 days, in patients with sepsis.

Data were collected over a 3-month period as part of a national audit in 20 EDs in Scotland. All adult patients who were admitted for at least 2 days or who died within 2 days were screened for sepsis criteria. Patients with  systemic inflammatory response syndrome criteria were included. An EWS was calculated based on initial physiological observations made in the ED using the NEWS.

Complete data were available for 2003 patients. Each rise in NEWS category was associated with an increased risk of mortality when compared to the lowest category (5–6: OR 1.95, 95% CI 1.21 to 3.14), (7–8: OR 2.26, 95% CI 1.42 to 3.61), (9–20: OR 5.64, 95% CI 3.70 to 8.60). This was also the case for the combined outcome (ICU and/or mortality).

An increased NEWS on arrival at ED is associated with higher odds of adverse outcome among patients with sepsis. The use of NEWS could facilitate patient pathways to ensure triage to a high acuity area of the ED and senior clinician involvement at an early stage.

Searches for the period 2002–2012 were performed in PubMED, Cochrane database, EMBASE, Google Scholar and hand search.

Twenty-five case reports and case series articles were identified, 53 described children with acute and 23 with neglected THD. Overall, 42 (55%) were male and 73 (96%) sustained a posterior dislocation. Forty-eight (63%) had THD following a low-energy trauma. Eight (11%) reported associated injuries. Twenty-one (39.6%) acute dislocations were reduced in the ED without complications. AVN was identified in 3 (5.7%) children, who underwent reduction ≥10 h after dislocation. Redislocation occurred in 3 (5.7%) children and coxa magna developed in 5 (9.4%). Long-term functional outcome of 42 patients resulted in full recovery, and it was fair to good in 3 (including 2 children with AVN). All neglected cases (≥4 weeks from trauma) needed open reduction in the operating room (OR). AVN was identified in 11 children (47.8%). Hip function was completely recovered in 16 (70%) patients.

THD in this age group mainly occurs with low-energy trauma and leads to posterior dislocations. Urgent closed reduction of acute cases are done in the OR, or the ED. ED reduction appears to be safe. Neglected THDs need open reduction.

Intrasubject comparisons between the CPR techniques were made during multiple 2-min intervals of induced fibrillation in 17 porcine subjects. Arterial pO₂, cardiac output, carotid blood flow, coronary perfusion pressure (CPP), minute alveolar ventilation (MAV), end-tidal CO₂, and time from defibrillation to the return of spontaneous circulation (ROSC) were recorded. Organ damage was assessed by necropsy.

Compared with CC-CPR, OAC-CPR had higher pressure and ventilation metrics with increased relative CPP (+16 mm Hg), MAV (+75/ml/min/kg) and a lower reduction in arterial pO₂(–22% baseline), but suffered from lower carotid flows (–9.3 ml/min). No significant difference was found comparing cardiac outputs. Furthermore, resuscitation was qualitatively more difficult after OAC-CPR, with a longer time to ROSC (+70 s). No abdominal damage was observed over short periods of OAC-CPR.

Although OAC-CPR appeared superior to CC-CPR by pressure and ventilation metrics, lower carotid flow and longer delay until ROSC raise concerns about overall performance. These paradoxical observations suggest that the evaluation of efficacious alternative CPR techniques may require more direct measurements of vital organ perfusion.

Prospective cohort study. Patients hospitalised due to influenza virus infection were recruited. We collected information on sociodemographic characteristics, pre-existing medical conditions, vaccinations, toxic habits, previous medications, exposure to social environments, and EuroQoL-5D (EQ-5D). Severe pneumonia with multilobar involvement and/or shock (SPAS) was the primary outcome of interest. We constructed two multivariate logistic regression models to explain the likelihood of developing SPAS and to create a clinical prediction rule for developing SPAS that includes clinically relevant variables.

Laboratory-confirmed A(H1N1)pdm09, EQ-5D utility score 7 days before admission, more than one comorbidity, altered mental status, dyspnoea on arrival, days from onset of symptoms, and influenza season were associated with SPAS. In addition, not being vaccinated against seasonal influenza in the previous year, anaemia, altered mental status, fever and dyspnoea on arrival at hospital, difficulties in performing activities of daily living in the previous 7 days, and days from onset of symptoms to arrival at hospital were related to the likelihood of SPAS (area under the curve value of 0.75; Hosmer–Lemeshow p value of 0.84).

These variables should be taken into account by physicians evaluating a patient affected by influenza as additional information to that provided by the usual risk scores.

This was a prospective, multicentre, observational study including all patients attending in 2011. Age groups were: I, <50; II, ≥50–64; III, ≥65–74; IV, ≥75–84; V, ≥85 years. Univariate and multivariate analyses were performed.

Of 125 478 attendances, 20 845(16.6%) were of patients aged ≥65 years. Multivariate analysis found significant predictors for ED-LOS (C-statistics 0.79, p<0.0000001) to be: arrival mode (ambulance, OR 1.13 (95% CI 1.08 to 1.18)); acuity level (level 4, OR 1.24 (95% CI 1.21 to 1.28); level 1–3, OR 1.54 (95% CI 1.5 to 1.59)); haematological examinations (OR 3.34 (95% CI 3.15 to 3.56)); intravenous treatment (OR 1.58 (95% CI 1.47 to 1.69)); monitoring of vital signs (OR 1.89 (95% CI 1.69 to 2.10)); x-ray examinations (OR 1.53 (95% CI 1.45 to 1.61)); CT/MRI/ultrasound (OR 2.60 (95% CI 2.39 to 2.82)); and specialist advice (OR 1.39 (95% CI 1.30 to 1.48)). For EDOU-LOS (C-statistics 0.81, p<0.0000001) we found: age group (II, OR 1.19 (95% CI 1.16 to 1.22); III, OR 1.42 (95% CI 1.38 to 1.46); IV, OR 1.69 (95% CI 1.65 to 1.74); V, 2.01 (95% CI 1.96 to 2.07)); acuity level (level 4, OR 1.31 (95% CI 1.27 to 1.35); level 1–3, OR 1.71 (95% CI 1.66 to 1.77)); haematological examinations (OR 7.81 (95% CI 7.23 to 8.43)); intravenous treatment (OR 1.95 (95% CI 1.8 to 2.12)); x-ray examinations (OR 1.95 (95% CI 1.85 to 2.06)); CT/MRI/ultrasound (OR 6.74 (95% CI 5.98 to 7.6)); specialist advice (OR 2.24 (95% CI 2.07 to 2.42)); admission to a medical or surgical ward (OR 0.61 (95% CI 0.54 to 0.68)); and transfer (OR 1.79 (95% CI 1.54 to 2.07)).

Whereas ED-LOS and EDOU-LOS seem to be directly related to patients’ acuity and complexity, notably the need for diagnostic and therapeutic interventions, only EDOU-LOS was significantly associated with age and proposed care pathways. We propose that EDOU-LOS measurement should be made in EDs with an OU.

We examined the abstracted data from the Japanese Diagnosis Procedure Combination database, and included patients with ICD-10 code S141 who were admitted on an emergency basis between 1 July and 31 December in 2007–2009. The investigation evaluated the patients’ sex, age, comorbidities, Japan Coma Scale, hospital volume and the amount of methylprednisolone administered. One-to-one propensity-score matching between high-dose methylprednisolone group (>5000 mg) and control group was performed to compare the rates of in-hospital death and major complications (sepsis; pneumonia; urinary tract infection; gastrointestinal ulcer/bleeding; and pulmonary embolism).

We identified 3508 cervical SCI patients (2652 men and 856 women; mean age, 60.8±18.7 years) including 824 (23.5%) patients who received high-dose methylprednisolone. A propensity-matched analysis with 824 pairs of patients showed a significant increase in the occurrence of gastrointestinal ulcer/bleeding (68/812 vs 31/812; p<0.001) in the high-dose methylprednisolone group. Overall, the high-dose methylprednisolone group demonstrated a significantly higher risk of complications (144/812 vs 96/812;OR, 1.66; 95% CI 1.23 to 2.24; p=0.001) than the control group. There was no significant difference in in-hospital mortality between the high-dose methylprednisolone group and the control group (p=0.884).

Patients receiving high-dose methylprednisolone had a significantly increased risk of major complications, in particular, gastrointestinal ulcer/bleeding. However, high-dose methylprednisolone treatment was not associated with any increase in mortality.

A retrospective case-control study was conducted in a paediatric ED.

Two cohorts of patients who underwent UC were compared, 164 female infants who were sedated with midazolam (case subjects) and 173 who were not (controls). Cases and controls had a mean temperature of 38.3°C and 38.2°C, respectively. One hundred and forty-one patients were treated with oral midazolam and 23 received the drug intranasally. Cases and controls had a UCC rate of 20/164 (12%) and 45/173 (26%), respectively. Compared with controls, cases had lower odds of UCC (OR=0.39, 95% CI 0.21 to 0.73).Serious adverse events related to midazolam were not recorded. Case subjects and controls had a mean ED length of stay of 2.96 h and 2.50 h, respectively. The difference between the groups was statistically significant (p<0.014, 95% CI 0.10 to 0.90 for difference between means).

In this cohort of febrile infants, sedation with oral or intranasal midazolam reduced the risk of culture contamination during UC without causing serious adverse events. However, patients who were treated with sedation had longer length of stay in the ED.

Following a web-based learning module and 3 h of proctored practical training, emergency medicine trainees were evaluated in technical and interpretative skills in estimating left ventricular function, detection of pericardial effusion and inferior vena cava (IVC) diameter measurements using bedside-focused echocardiography on emergency department patients. An inter-rater agreement analysis was performed between the trainees and a board-certified cardiologist.

100 focused echocardiography examinations were performed by nine emergency medicine trainees. Agreement between the trainees and the cardiologist was 93% (K=0.79, 95% CI 0.773 to 0.842) for visual estimation of left ventricular function, 92.9% (K=0.80, 95% CI 0.636 to 0.882) for quantitative left ventricular ejection fraction by M-mode measurements, 98% (K=0.74, 95% CI 0.396 to 1.000) for the detection of pericardial effusion, and 64.2% (K=0.45, 95% CI 0.383 to 0.467) for IVC diameter assessment. The Bland–Altman limits of agreement for left ventricular function was –9.5% to 13.7%, and a Pearson's correlation yielded a value of 0.82 (p<0.0001, 95% CI 0.734 to 0.881). The trainees detected pericardial effusion with a sensitivity of 60%, specificity of 100%, positive predictive value of 100% and negative predictive value of 97.9%.

Emergency medicine trainees were found to be able to perform and interpret focused echocardiography reliably after a short duration of training.

Speakers were identified through the organising committee and a database constructed using the internet to determine the presence and activity of speakers on social media platforms. We also examined the use of Twitter by attendees and non-attendees using an online archiving system. Researchers tracked and reviewed every tweet produced with the hashtag #ICEM2012. Tweets were then reviewed and classified by three separate authors into different categories.

Of the 212 speakers at ICEM 2012, 41.5% had a LinkedIn account and 15.6% were on Twitter. Less than 1% were active on Google+ and less than 10% had an active website or blog. There were over 4500 tweets about ICEM 2012. Over 400 people produced tweets about the conference, yet only 34% were physically present at the conference. Of the original tweets produced, 74.4% were directly related to the clinical and research material of the conference.

ICEM 2012 was the most tweeted emergency medicine conference on record. Tweeting by participants was common; a large number of original tweets regarding clinical material at the conference were produced. There was also a large virtual participation in the conference as multiple people not attending the conference discussed the material on Twitter.

Adult trauma patients admitted due to assault between 1999 and 2009 were identified through the hospital based trauma registry at an inner city major trauma centre in Sydney. Demographic data, incident details, clinical evidence of alcohol intoxication, injury severity scores and injury related outcomes were collected. Population based incidences were calculated and outcomes compared between intoxicated and non-intoxicated patients. Major trauma was defined as a composite outcome of severe injury (injury severity score>15), intensive care admission or in-hospital mortality.

There were 2380 patients analysed. Clinical evidence of alcohol intoxication was documented in 12% (287/2380) of cases. There was a marked peak in incidence of hospital admissions due to assault which occurred between 2000 and 2002. Overall, the rate of hospital admissions due to assault decreased during the study period (incident rate ratios 0.94, 95% CI 0.90 to 0.99, p<0.001). The odds of major trauma were three times higher in patients with clinical evidence of intoxication compared to those that did not (adjusted OR 2.9, 95% CI 2.1 to 4.0, p<0.001).

There was a peak in hospital admissions due to inner city assault around 2000–2002 associated with an overall decline in hospital admissions at this trauma centre over 10 years. Clinical evidence of alcohol intoxication in patients admitted for assault appears to be associated with more severe injury, including severe head injury.

The bibliographic databases EMBASE, MEDLINE, CINAHL and Maternity and Infant Care were searched from 1991 to 2012 for relevant English language publications using key words and Medical Subject Heading (MeSH) terms. Data were extracted with respect to study design, incidence of BBAs, attendance of paramedics, complications and recommendations.

Fourteen studies were selected for inclusion arising from the US, UK and Europe. While all studies acknowledged paramedics attend BBAs, seven reported the incidence of BBAs attended by paramedics, and two discuss issues specifically encountered by paramedics. Paramedics attended between 28.2% and 91.5% of all BBAs. While the articles reviewed noted that most of the births encountered by paramedics were uncomplicated, they all reported maternal or neonatal complications. Eight articles reported the most common maternal complication was excessive bleeding after birth, and nine reported the most frequent neonatal complication was hypothermia regardless of gestation.

Paramedics need to be adequately educated and equipped to manage BBAs at both undergraduate and graduate levels. Protocols should be developed between health and ambulance services to minimise risks associated with BBAs. A dearth of information surrounds the incidence of BBAs attended and the management performed by paramedics highlighting the need for further research.

Top 100 frequent callers to YAS were analysed using population comparison, case control and multiple regression methods. 7808 calls were made by the frequent callers, and data were analysed to predict total number of calls made, and explore characteristics of frequent callers.

Six call codes were associated with a higher number of calls. Frequent callers were assigned slower response levels, or often no call code. Calls increased during the times of 4:00–9:00, 16:00–20:00 and 22:00–2:00, and in the months of December, January and February. Men and patients with all but the very highest conveyance rates had a higher number of different reasons for calling. Patients with a medical diagnosis were more likely to be conveyed, while patients with a psychiatric classification had a higher number of different reasons for calling, were older and were more likely to call for ‘assault/sexual assault’ or ‘haemorrhage/laceration’.

Frequent callers to YAS were a heterogeneous group that differed from the overall population served, resulting in numerous implications for the delivery of services for this group of patients. Further research is required to determine if and how frequent callers differ from frequent attenders at emergency departments.

Prospective study in ED patients with severe sepsis and septic shock (high-risk cohort), or suspected infection (low-risk cohort). Outcome: 28-day mortality. Prognostic performance of PIRO, sepsis category and clinical judgement were assessed with Cox regression analysis with correction for quality of ED treatment and disposition. Illness severity measures were divided into four groups with the lowest illness severity as reference category; discrimination was quantified by receiver operator characteristics with area under the curve (AUC) analysis.

Death occurred in 72/323 (22%, high-risk) and 23/385 (6%, low-risk) patients. For the low-risk cohort, corrected HRs (95% CI) for categories 2–4 were 2.0 (0.4 to 11.9), 4.3 (0.8 to 24.7) and 17.8 (2.8 to 113.0: PIRO); 0.5 (0.05 to 5.4), 2.1 (0.2 to 21.8) and 7.5 (0.6 to 92.9: sepsis category). Patients discharged home (category 1) all survived. HRs were 4.5 (0.5 to 39.1) and 13.6 (4.3 to 43.5) for clinical judgement categories 3–4. Prognostic performance was consistently better in the low-risk than in the high-risk cohort. For PIRO AUCs were 0.68 (0.61 to 0.74; high-risk) and 0.83 (0.75 to 0.91; low-risk); for sepsis category AUCs were 0.50 (0.42 to 0.57; high-risk) and 0.73 (0.61 to 0.86; low-risk); for clinical judgement AUCs were 0.69 (0.60 to 0.78; high-risk) and 0.84 (0.73 to 0.96; low-risk).

The accuracy and discriminative performance of the PIRO score and clinical judgement are similar, but better than the sepsis category. Prognostic performance of illness severity scores is less in high-risk cohorts, while in high-risk populations a risk stratification tool would be most useful.

Retrospective study of registry data from a large UK teaching hospital ED. Consecutive adult patients (aged 16 years and over) in whom ASA grade could be calculated, with an isolated dislocation of a hip prosthesis between 8 September 2006 and 16 April 2010 were included for analyses (n=303). The primary outcome measure was association between ASA and complication rate (any of desaturation <90%; apnoea; vomiting; aspiration; hypotension <90 mm Hg; cardiac arrest). Secondary outcome measures were relationship between ASA grade and procedural success, choice of sedative agent and sedation depth, and complications and choice of sedative agent, arrival time and sedation depth.

There was no significant difference between ASA grade and the risk of complication (p=0.800). Moreover, there was no significant difference between ASA grade and procedural success (p=0.284), ASA and choice of sedative agent (p=0.243), or ASA and sedation depth (p=0.48). There was no association between complications and sedative agent (p=0.18), or complications and arrival time (p=0.12). There was a significant difference between sedative depth and complications (p<0.001).

There is no clear association between a patient's physical status (ASA grade) and the risk of complications, chance of procedural success or choice of sedative agent in relocation of hip prostheses. There is a higher rate of complications with higher levels of sedation (p<0.001).

Data were collected prospectively by four emergency medicine doctors trained in emergency ultrasonography. FAST scans were performed by one ED doctor and timings, scan result and disposition were recorded. Patient haemodynamic stability was assessed by the emergency doctor performing the scan; subjectively at the time of scanning and objectively using calculation of the shock index. All scan results were subsequently verified by a second ED doctor in a blinded fashion and by CT scanning or operative intervention when clinically indicated.

166 FAST scans were conducted of which 36 (21.7%) were positive. Mean age was 30.6 years (SD 12.8). 74.1% of patients sustained blunt traumatic injury. Doctors’ subjective haemodynamic stability assessments had higher specificity, sensitivity and predictive values than shock index alone. Haemodynamic instability and a positive FAST result were significantly related (p=0.004). Sensitivities and specificities of FAST scans for blunt and penetrating trauma were 93.1% and 100%, and 90.0% and 100%, respectively. Corresponding values for pneumothoraces were 84.6% and 100%.

This study showed a valuable role for FAST in all traumas, particularly in haemodynamic compromise. As an addition to the physician's repertoire of bedside assessment tools, it improves diagnostic capabilities in comparison with simple haemodynamic assessments alone.

A retrospective study of all trauma activation patients requiring inpatient admission at a single inner city major trauma centre in Australia between 2007 and 2011 was conducted. Logistic regression was used to derive a multivariable model for the outcome of SSA (length of stay ≤2 days excluding deaths or intensive care unit admission). Model discrimination was tested using area under receiver operator characteristic curve analyses and calibration was tested using the Hosmer-Lemeshow test statistic. Validation was performed by splitting the dataset into derivation and validation datasets and further tested using bootstrap cross validation.

A total of 2593 patients were studied and 30% were classified as SSAs. Important independent predictors of SSA were injury severity score ≤8 (OR 7.8; 95% CI 5.0 to 11.9), Glasgow coma score 14–15 (OR 3.2; 95% CI 1.8 to 5.4), no need for operative intervention (OR 2.2; 95% CI 1.6 to 3.2) and age < 65 years. (OR 1.7; 95% CI 1.2 to 2.6). The overall model had an area under receiver operator characteristic curve of 0.84 (95% CI 0.82 to 0.87) for the derivation dataset. After bootstrap cross validation the area under the curve of the final model was 0.83 (95% CI 0.81 to 0.84).

We report a prediction rule that could be used to establish admission criteria for a trauma short stay unit. Further studies are required to prospectively validate the prediction rule.

This randomised double-blind study compared the efficacy of intravenous 1 gm paracetamol, 50 mg dexketoprofen and 0.1 mg/kg morphine in patients with acute mechanical LBP. Visual analogue scale (VAS) was used for pain measurement at baseline, after 15 and after 30 min.

A total of 874 patients were eligible for the study, and 137 of them were included in the final analysis: 46 patients from the paracetamol group, 46 patients in the dexketoprofen group and 45 patients in the morphine group. The mean age of study subjects was 31.5±9.5 years, and 60.6% (n=83) of them were men. The median reduction in VAS score at the 30th minute for the paracetamol group was 65 mm (95% CI 58 to 72), 67 mm (95% CI 60 to 73) for the morphine group and 58 mm (95% CI 50 to 64) for the dexketoprophen group. Although morphine was not superior to paracetamol at 30 min (difference: 3.8±4.9 (95% CI –6 to 14), the difference between morphine and dexketoprofen in reducing pain was 11.2±4.7 (95% CI 2 to 21). At least one adverse effect occurred in 8.7% (n=4) of the cases in the paracetamol group, 15.5% (n=7) of the morphine group, and 8.7% (n=4) of the dexketoprophen group (p=0.482).

Intravenous paracetamol, dexketoprofen and morphine are not superior to each other for the treatment of mechanical LBP in ED.

The objectives of this study were to compare the diagnostic decisions of APs with emergency medicine (EM) physicians, and to investigate if APs, as currently trained, can predict the requirement for hospital admission.

A prospective study was initiated, whereby each emergency ambulance call received via the statutory 999 system was recorded by the attending AP. The AP was asked to provide a clinical diagnosis for each patient, and to predict if hospital admission was required. The data was then cross-referenced with the working diagnosis of the receiving emergency physician and the hospital admission records.

A total of 17 APs participated in the study, and 1369 emergency calls were recorded over a 6-month period. Cases where a general practitioner attended the scene were excluded from the concordance analysis. Concordance with the receiving emergency physician represents 70% (525/748) for all cases of AP diagnosis, and is mirrored with 70% (604/859) correct hospital admission predictions.

AP diagnosis and admission prediction for emergency calls is similar to other emergency medical services systems despite the relative recency of the AP programme in Ireland. Recognition of non-concordance case types may identify priorities for AP education, and drive future AP practice in areas such as ‘treat and refer’.

The primary purpose was to compare the undertriage and overtriage rates in the PATS and pre-PATS study periods.

Data were collected from 5 April 2010 to 1 May 2011 for the PATS and compared with a database of patients triaged from 1 October 2009 to 24 March 2010 for the pre-PATS. Data included patient disposition outcomes, demographics and triage level assignments.

14 706 (pre-PATS) and 25 243 (PATS) patient visits were reviewed. Overall, overtriage rates improved from 53% (pre-PATS) to 38% (PATS) (p<0.001); likewise, undertriage rates improved from 47% (pre-PATS) to 16% (PATS) (p<0.001). Statistically significant decreases in both rates were found when paediatric and adult cases were analysed separately. PATS was more predictive of inpatient admission, Intensive Care Unit (ICU) admission and death rates in the A&E than was the pre-PATS. The lowest acuity category of each system had a 0.6% (pre-PATS) and 0% (PATS) chance of death in the A&E or ICU admission (p<0.001). No change in death rate was seen between the pre-PATS and PATS, but ICU admission rates decreased from 0.35% to 0.06% (p<0.001).

PATS is a more predictive triage system than pre-PATS as evidenced by improved overtriage, undertriage and patient severity predictability across triage levels.

Retrospective audit of ERD-related presentations from 1 January 2008 to 31 December 2010 at two tertiary hospital EDs. Variation in presentations across years was tested using a two-tailed test for proportions. Univariate and multivariate logistic regressions were used to compare sociodemographic and clinical characteristics across groups.

Most of the 1347 presentations occurred on weekends, 24:00–06:00. Most patients arrived by ambulance (69%) from public places (42%), private residences (26%) and licensed venues (21%). Ecstasy-related presentations decreased from 26% of presentations in 2008 to 14% in 2009 (p<0.05); -hydroxybutyrate (GHB) presentations were most common overall. GHB presentations were commonly related to altered conscious state (89%); other presentations were due to psychological concerns or nausea/vomiting. Compared with GHB presentations, patients in ecstasy-related presentations were significantly less likely to require intubation (OR 0.04, 95% CI 0.01 to 0.18), but more likely to result in hospital admission (OR 1.77, 95% CI 1.08 to 2.91). Patients in amphetamine-related cases were older than those in GHB-related cases (median 28.4 years vs 23.9 years; p<0.05), and more likely to have a history of substance use (OR 4.85, 95% CI 3.50 to 6.74) or psychiatric illness (OR 6.64, 95% CI 4.47 to 9.87). Overall, the median length of stay was 3.0 h (IQR 1.8–4.8), with most (81%) patients discharged directly home.

Although the majority of ERD-related presentations were effectively treated, with discharge within a short time frame, the number and timing of presentations places a significant burden on EDs. ERD harm reduction and improved management of minor harms at licensed venues could reduce this burden.

All patients receiving PtcCO₂ monitoring in the ED were included. We excluded paediatric patients, patients with no ABGA results during a hypotensive event, patients whose ABGA was not performed simultaneously with PtcCO₂ monitoring, and patients who received sodium bicarbonate for resuscitation. The included patients were classified into hypotensive patients and normotensive patients. A hypotensive patient was defined as a patient showing a mean arterial pressure under 60 mm Hg. The agreement in measurement between PaCO₂ tension (PaCO₂) and PtcCO₂ were investigated in both groups.

The mean difference between PaCO₂ and PtcCO₂ was 2.1 mm Hg, and the Bland–Altman limits of agreement (bias±1.96 SD) ranged from –15.6 to 19.7 mm Hg in the 28 normotensive patients. The mean difference between PaCO₂ and PtcCO₂ was 1.1 mm Hg, and the Bland–Altman limits of agreement (bias±1.96 SD) ranged from –19.5 to 21.7 mm Hg in the 26 hypotensive patients. The weighted values were 0.64 in the normotensive patients and 0.60 in the hypotensive patients.

PtcCO₂ monitoring showed wider limits of agreement with PaCO₂ in urgent situations in the ED environment. However, acutely developed hypotension does not affect the accuracy of PtcCO₂ monitoring.

Emergency department patients with acute elbow injury were recruited. Practitioners used their usual judgement to assess whether x-ray examination was required. Radiographs were reported on by radiologists blind to clinical assessment. Patients not x-rayed were followed-up at 7 days by telephone interview, and those with ongoing pain were recalled for assessment. Recursive partitioning was used to derive a maximally sensitive decision tool. Inter-rater variability for significant discriminators was subsequently evaluated by a cohort of 20 emergency department clinicians.

492 patients were recruited (May 2006–November 2008): 50.4% were male; 26.8% were children; 444 (90.2%) had an x-ray; 167 (37.6%) showed abnormality. A follow-up telephone interview was conducted with 28; none were recalled. Thirteen could not be contacted, none of whom returned within 3 months. Sixteen patients with fractures were able to fully extend their elbow. The sensitivity of elbow extension alone was 84% (95% CI 77% to 88%), with specificity of 54% (95% CI 53% to 58%). A 100% sensitive (95% CI 97% to 100%) decision rule for adults (n=348) was derived based on (1) inability to fully extend the elbow, (2) tenderness over radial head, olecranon or medial epicondyle, and (3) presence of bruising (specificity 24% (95% CI 19% to 30%)). A similar rule for children could not be derived.

A simple and highly sensitive clinical decision rule for adult elbow fracture was derived in our cohort. A validation study in a second population is now required. At present, we are unable to recommend a rule-out strategy for elbow injuries in children.

This 4-week study was undertaken in Cork University Hospital, Ireland, for all admissions from the emergency department (ED). A panel independently reviewed patients with suspected ADRs. Causality assessment was performed using the Naranjo ADR probability scale and the Hallas criteria was used to assess preventability of the ADRs.

During the study period, 1258 patients were admitted from the ED; of these, 856 patients were included in the study; 75 patients (8.8%) had an ADR-related admission. Over half were deemed to be ‘possibly’ or ‘definitely’ avoidable. The level of agreement between reviewers using the Naranjo and Hallas criteria was very low.

In the ADR group (n=75), 50.7% were men compared with 53.1% in the non-ADR group (n=781). The median age for patients in the ADR group was 73 years compared with 45 years in the non-ADR group. The average number of prescribed drugs per patient in the ADR group was 7.5 (SD±3.8) compared with 2.4 (SD±3.6) in the non-ADR group. Classified by drug type, 74.2% of the ADRs were attributed to cardiovascular and central nervous system drugs.

This study estimated the incidence of ADR-related admissions to an Irish hospital at 8.8%, with 57.3% of these deemed to have been potentially avoidable. Older patients were more likely to have an ADR-related admission. Prescribers must be aware of this increased likelihood of an ADR when prescribing new drugs to this patient population, and regularly review treatment.

In this prospective controlled observational study, we included patients referred to a stroke centre if their ground transport time exceeded 30 min, or they were transported by a secondarily dispatched, physician-staffed helicopter. The primary endpoint was time from telephone contact to triaging neurologist to arrival in the stroke centre. Secondary endpoints included modified Rankin Scale at 3 months, 30-day and 1-year mortality.

A total of 330 patients were included; 265 with ground transport and 65 with helicopter, of which 87 (33%) and 22 (34%), received thrombolysis, respectively (p=0.88). Time from contact to triaging neurologist to arrival in the regional stroke centre was significantly shorter in the ground group (55 (34–85) vs 68 (40–85) min, p<0.01). The distance from scene to stroke centre was shorter in the ground group (67 (42–136) km) than in the helicopter group (83 (46–143) km) (p<0.01). We did not detect significant differences in modified Rankin Scale at 3 months, in 30-day (9.4% vs 0%; p=0.20) nor 1-year (18.8% vs 13.6%; p=0.76) mortality between ground and helicopter transport.

We found significantly shorter time from contact to triaging neurologist to arrival in the regional stroke centre if stroke patients were transported by primarily dispatched ground ambulance compared with a secondarily dispatched helicopter.

A multicentric, prospective, observational, longitudinal, cohort study involving 15 Spanish EDs. Inclusion: consecutive patients with chest pain (<12 h) finally diagnosed of NSTEACS. Measurements: copeptin and troponin at arrival. Cut-off point for copeptin: 25.9 pmol/l. Follow-up: within 2 months after ED attendance to identify 30-day adverse events. Discriminatory capacity of copeptin and troponin was compared by receiver operating characteristic (ROC) curves.

We included 377 patients with NSTEACS. Adverse events: 11 (2.9%) patients died, 27 (7.2%) had an adverse coronary event, 14 (3.7%) had a stroke, and 48 (12.7%) a composite endpoint. The initial copeptine value was over 25.9 pmol/l in 114 patients, and they presented a higher mortality rate (OR: 4.2, (95% CI 1.2 to 14.8); p=0.03). This association disappeared after adjusting by clinical variables or troponin level. No significant differences were found for the remaining endpoints. The area under the curve  of the ROC curve of 30-day mortality was 0.73 (95% CI 0.58 to 0.87) for copeptin, and 0.80 (95% CI 0.73 to 0.87) for troponin.

In patients with NSTEACS, determination of copeptin at presentation to the ED is associated with risk of death during the subsequent month. This association, however, disappears after adjusting by baseline features or troponin level, so copeptin does not add complementary prognostic information over that provided by troponin.

Eight paramedics were selected to undergo advanced training in resuscitation and non-technical skills. Simulation and video feedback was used during training. The designated TC2 paramedic manned a regular ambulance service response car and attended emergency calls in the usual manner. Emergency medical dispatch centre dispatchers were instructed to call the TC2 paramedic directly on receipt of a possible OHCA call. Call and dispatch timings, quality of cardiopulmonary resuscitation and return-of-spontaneous circulation were all measured prospectively.

Establishing a specialist, second-tier paramedic response was feasible. There was no overall impact on ambulance response times. From the first 40 activations, the TC2 paramedic was activated in a median of 3.2 min (IQR 1.6–5.8) and on-scene in a median of 10.8 min (8.0–17.9). Bimonthly team debrief, case review and training sessions were successfully established. OHCA attended by TC2 showed an additional trend towards improved outcome with a rate of return of spontaneous circulation of 22.5%, compared with a national average of 16%.

Establishing a specialist, second-tier response to OHCA is feasible, without impacting on overall ambulance response times. Improving non-technical skills, including prehospital resuscitation team leadership, has the potential to save lives and further research on the impact of the TOPCAT2 pilot programme is warranted.

To determine if there are productivity differences between residents and MLPs, as defined by patients seen (pt/h) and RVUs generated per hour (RVU/h), in a high-acuity area of the ED.

This is a retrospective review of emergency medicine residents and MLPs assigned to a high-acuity area of a single 45 000 volume community ED. Number of patients seen and RVUs generated were recorded, and pt/h, RVU/h and RVU/pt were calculated. Two-tailed t test was used to compare resident and MLP performance.

55 MLP and 98 emergency medicine residency shifts were included for comparison. During the study period, MLPs saw 1.56 pt/h (CI±0.14), while residents saw 1.23 pt/h (CI±0.06, p<0.0001). MLPs generated 3.19 RVU/h (CI±0.29), while residents generated 3.33 RVU/h (CI±0.17, p=0.43). Residents generated 2.73 RVU/pt (CI±0.09), while MLPs generated 2.05 RVU/pt (CI±0.09, p<0.0001). In comparing the subgroup of postgraduate year 3 residents (PGY3s) with MLPs, MLPs still saw significantly more patients (1.30 vs 1.56, p=0.003), but PGY3s generated 3.58 RVU/h compared with 3.19 RVU/h for MLPs (p=0.06). PGY3s generated 2.79 RVU/pt compared with 2.05 for MLPs (p<0.0001).

In a high-acuity area of the ED, MLPs see more patients per hour than residents, but generate fewer RVUs per patient. This suggests that residents may document more thoroughly than MLPs. Alternatively, MLPs may elect to see less sick patients even when working in a high-acuity area.

Retrospective review of the clinical logbook for an Emergency Medicine trainee during a 12-month attachment with an Air Ambulance service in the UK. IBTPHEM assessment tools were completed to complement the clinical logbook. Clinical experience and the degree of clinical supervision were compared with the standards published by the IBTPHEM.

Supervision rates were similar to those in other pilots (17.33%). Clinical workload was comparable with that reported in other organisations. More advanced procedures (eg, conscious sedation/prehospital anaesthetics) were completed than in IBTPHEM pilot programmes. The vast majority of curriculum elements detailed by the IBTPHEM were fulfilled.

The experiences of an Emergency Medicine trainee in pilot programme at a regional Air Ambulance in the UK compared favourably with the results of formal pilots of the IBTPHEM programme conducted at other centres. The IBTPHEM assessment tools are appropriately designed and sufficient in number to ensure that fulfilment of the curriculum elements can be recorded and trainee development monitored. Areas for future developments in training and support, notably in curriculum areas regarding the management of obstetric prehospital emergencies, are suggested.

Prospective cohort study of a convenience sample of shifts by volunteering emergency physicians (EP) at two urban tertiary care Canadian EDs. EPs completed standardised forms on all patients for whom a consultation was requested. Medical chart reviews and secondary analyses of administrative databases were also performed. Factors associated with longer LOS were determined through linear regression modelling.

1180 patients received at least one consultation during study shifts and EPs completed data collection on 841 (71%) of these. Median patient age was 54 years, 53.3% were male, and 2.9% had documented dementia. Admitted patients receiving consultations had a longer overall LOS compared to discharged patients. Median time from triage to consultation request accounted for approximately 28% of the total median LOS in admitted patients compared to 46% for discharged patients. Consultation decision time accounted for 33% and 54% of the LOS for admitted and discharged patients, respectively. Linear regression modelling revealed that advanced age, longer latency between arrival and first consultation request, history of dementia and multiple consultations were significantly associated with longer LOS. Conversely, undergoing procedures while in the ED was associated with a shorter LOS.

Consultation decision time contributes significantly to ED LOS. Further efforts are needed to validate these results in other ED settings and improve this aspect of ED throughput.

To analyse the mission profiles and interventions performed during rescues involving the winching of a physician in the Greater Sydney Area HEMS (GSA-HEMS).

All winch missions involving a physician from August 2009 to January 2012 were identified from the prospectively completed GSA-HEMS electronic database. A structured case sheet review for a predetermined list of demographic data and physician-only interventions (POIs) was conducted.

We identified 130 missions involving the winching of a physician, of which 120 case sheets were available for analysis. The majority of patients were traumatically injured (90%) and male (85%) with a median age of 37 years. Seven patients were pronounced dead at the scene. A total of 63 POIs were performed on 48 patients. Administration of advanced analgesia was the most common POI making up 68.3% of interventions. Patients with abnormal RTS_c² scores were more likely to receive a POI than those with normal RTS_c² (84.8% vs 15.2%; p=0.03). The performance of a POI had no effect on median scene times (45 vs 43 min; p=0.51).

Our high POI rate of 40% (48/120) coupled with long rescue times and the occasional severe injuries support the argument for winching Physicians. Not doing so would deny a significant proportion of patients time-critical interventions, advanced analgesia and procedural sedation.

The authors completed a retrospective case analysis of the first 100 patients brought directly to UHS by helicopter. Data were obtained from ED notes and helicopter provider databases. Analysis was conducted on the type of incident and appropriateness of referral. Incident locations were plotted geographically.

100 patients arrived at UHS ED by helicopter between 17 November 2011 and 31 March 2012. Of these, 79 were primary helicopter emergency medical service (HEMS) missions and 21 were secondary transfers from other hospitals. Of the HEMS patients, 38 were likely to have been transported to another hospital, had there not been an onsite helipad at UHS. 29 passed another suitable receiving hospital en route and therefore may have come to UHS for speciality services.

The provision of an onsite, 24 h helipad facility at UHS has resulted in a significant number of patients being transported to the hospital by helicopter who might otherwise have attended an alternative hospital.

This multicentre study included adults with severe TBI (GCS ≤8) or haemorrhagic shock (SBP ≤70 mm Hg, or (SBP 71–90  mm Hg and heart rate ≥108 bpm)). We compared patients receiving out-of-hospital AAM with those receiving emergency department AAM. We evaluated the associations between airway strategy and patient outcomes (28-day mortality, and 6-month poor neurologic or functional outcome) and airway strategy, adjusting for confounders. Analysis was stratified by (1) patients with isolated severe TBI and (2) patients with haemorrhagic shock with or without severe TBI.

Of 2135 patients, we studied 1116 TBI and 528 shock; excluding 491 who died in the field, did not receive AAM or had missing data. In the shock cohort, out-of-hospital AAM was associated with increased 28-day mortality (adjusted OR 5.14; 95% CI 2.42 to 10.90). In TBI, out-of-hospital AAM showed a tendency towards increased 28-day mortality (adjusted OR 1.57; 95% CI 0.93 to 2.64) and 6-month poor functional outcome (1.63; 1.00 to 2.68), but these differences were not statistically significant. Out-of-hospital AAM was associated with poorer 6-month TBI neurologic outcome (1.80; 1.09 to 2.96).

Out-of-hospital AAM was associated with increased mortality after haemorrhagic shock. The adverse association between out-of-hospital AAM and injury outcome is most pronounced in patients with haemorrhagic shock.

To estimate the association of obesity with death risk among drivers of passenger vehicles aged ≥16 and to examine effect modification by driver sex, driver seat belt use, vehicle type and collision type.

We conducted a matched-pair cohort study using data from the Fatality Analysis Reporting System. WHO body mass index (BMI) categories were calculated. Data were analysed using conditional Poisson regression.

Estimated risk ratios (RRs) were slightly raised for underweight drivers (RR=1.19, 95% CI 0.86 to 1.63). RR increased with higher BMI categories and were 1.21 (0.98 to 1.49) for BMI 30–34.9, 1.51 (1.10 to 2.08) for BMI 35–39.9 and 1.80 (1.15 to 2.84) for BMI ≥40. Estimated BMI effects varied by gender. We found no meaningful variation across levels of vehicle type, collision type or seat belt use.

Findings from this study suggest that obese vehicle drivers are more likely to die from traffic collision-related injuries than non-obese occupants involved in the same collision. Education is needed to improve seat belt use among obese people, as is research to understand the potential role of comorbidities in injury outcomes.

250 CO poisoning cases that were diagnosed and treated by the emergency department of Wonju Christian Hospital from January 2006 to February 2012 were retrospectively reviewed.

Fifty (20%) out of 250 patients with CO poisoning developed myocardial injury. Among those with elevated troponin I (Tn I), peak levels occurred at 11.0 (IQR, 4.5–18.5) h normalising by 65.0 (IQR 44.0–96.0) h. CO exposure time, and total and ICU admission length was longer (7.5 (IQR 3.7–10.0) h vs 3.0 (IQR 1.0–7.5) h, p<0.001; 3.5 (IQR 0.0–7.0) days and 0.0 (IQR 0.0–1.25) days vs 0.0 (IQR 0.0–2.0) days and 0.0 (IQR 0.0–0.0) days, p<0.001, respectively) in the myocardial vs non-myocardial injury group. The predictors of myocardial injury were male gender, Glasgow Coma Scale (GCS) ≤14, and CO exposure time ≥2 h (OR (95% CI) of 3.341 (1.171 to 9.531), 9.920 (3.763 to 26.150), and 7.743 (1.610 to 37.238), respectively).

Myocardial injury developed in 20% of CO poisoned patients. Time to normalisation and of peak Tn I level in elevated Tn I group was 65.0 (IQR 44.0–96.0) h and 11.0 (IQR 4.5–18.5) h. Presence of myocardial injury was associated with poorer prognosis. Predictors of myocardial injury included male gender, GCS of 14 or less, or CO exposure times greater than 2 h.

Retrospective cohort study involving 270 patients admitted for acute PE. Collected data: past medical history, analytic/gasometric parameters, admission ECG and echocardiogram, thoracic CT angiography. Patients followed for 6 months. An analysis was performed in order to clarify whether history of AF, irrespective of its timing, helps predict intrahospital, 1-month and 6-month all-cause mortality.

Patients with history of AF, irrespective of its timing (n=57, 21.4%), had higher intrahospital (22.8% vs 13.1%, p=0.052, OR 2.07, 95% CI 0.98 to 4.35), 1-month (35.1% vs 16.9%, p=0.001, OR 3.16, 95% CI 1.61 to 6.21) and 6-month (45.6% vs 17.4%, p<0.001, OR 4.67, 95% CI 2.37 to 9.21) death rates. The prognostic power of AF was independent of age, NT-proBNP values, renal function and admission blood pressure and heart rate and additive to mortality prediction ability of simplified PESI (AF: p=0.021, OR 2.31, CI 95% 1.13 to 4.69; simplified PESI: p=0.002, OR 1.47, CI 95% 1.15 to 1.89). The presence of AF at admission added prognostic value to previous history of AF in terms of 1-month and 6-month all-cause mortality prediction, although it did not increase risk for intrahospital mortality.

The presence of AF, irrespective of its timing, may independently predict mortality in patients with acute PE. These data should be tested and validated in prospective studies using larger cohorts.

All telephone enquiries to and user sessions for TOXBASE, the NPIS on-line information resource, related to methoxetamine (and synonyms ‘MXE’, ‘mket’ and ‘2-(3-methoxyphenyl)-2-(ethylamino)cyclohexanone’) were reviewed from 1 April 2010 to 1 August 2012. Data were compared for the 3 months before and after the TCDO.

There were 47 telephone enquiries and 298 TOXBASE sessions regarding methoxetamine during the period of study. Comparing the 3 months before and after the TCDO, TOXBASE sessions for methoxetamine fell by 79% (from 151 to 32) and telephone enquiries by 80% (from 15 to 3). Clinical features reported by enquirers were consistent with case reports of analytically confirmed methoxetamine toxicity and typical toxidromes were of stimulant (36%), reduced consciousness (17%), dissociative (11%) and cerebellar (6.4%) types, but also particularly featured acute disturbances in mental heath (43%).

Structured NPIS data may reveal trends in drugs of abuse use and toxicity when interpreted within their limitations. Since April 2012, there have been fewer enquiries to NPIS from clinicians, indicating reduced presentations with suspected methoxetamine toxicity to healthcare services. It is unclear if this is related to the TCDO made on 5 April 2012.

We set up a free access internet website for German-speaking countries, with an anonymous reporting system for emergency medical services personnel. After a 7-year study period, an expert team analysed and classified the incidents into staff related, equipment related, organisation and tactics, or other.

845 reports were entered in the study period. Physicians reported 44% of incidents, paramedics 42%. Most patients were in a life-threatening or potentially life-threatening situation (82%), and only 53% of all incidents had no influence on the outcome of the patient. Staff-related problems were responsible for 56% of the incidents, when it came to harm, 78% of these incidents were staff related.

Incident reporting in prehospital emergency medicine can identify system weaknesses. Most of the incidents were reported during care of patients in life-threatening conditions with a high impact on patient outcome. Staff-related problems contributed to the most frequent and most severe incidents.

Cohort study.

Secondary care.

All emergency medical admissions to Dumfries and Galloway Royal Infirmary between 1 January 2008 and 31 December 2010.

We examined 7 and 30 day mortality for all weekend and for all public holiday admissions, using all weekday and non-public holiday admissions, respectively, as comparators. We adjusted mortality for age, gender, comorbidity, deprivation, diagnosis and year of admission.

771 (3.8%) of 20 072 emergency admissions died within 7 days of admission and 1780 (8.9%) within 30 days. Adjusted weekend mortality in the all weekend versus all other days analysis was not significantly higher at 7 days (OR 1.10, 95% CI 0.92 to 1.31; p=0.312) or at 30 days (OR 1.07, 95% CI 0.94 to 1.21; p=0.322). By contrast, adjusted public holiday mortality in the all public holidays versus all other days analysis was 48% higher at 7 days (OR 1.48, 95% CI 1.12 to 1.95; p=0.006) and 27% higher at 30 days (OR 1.27, 95% CI 1.02 to 1.57; p=0.031). Interactions between the weekend variable and the public holiday variable were not statistically significant for mortality at either 7 or 30 days.

Patients admitted as emergencies to medicine on public holidays had significantly higher mortality at 7 and 30 days compared with patients admitted on other days of the week.

A prospective, observational clinical trial with ethics and MHRA approval was conducted in a single centre. Patients with diagnosed pneumothorax (including tension pneumothorax) and pleural effusion were consented and recruited. The ease of device introduction, penetration and ease of use were evaluated. Clinical and radiological improvements were the clinical endpoints and operator feedback was analysed.

20 procedures were performed on patients (mean age: 63.4 years (range: 30–90 years) with 75% male subjects) recruited between September 2008 and August 2009. Nine patients had pneumothorax (tension pneumothorax n=4) and 11 had pleural effusions. 19 patients completed the study with symptomatic and radiological resolution. One patient was withdrawn due to poor pain threshold disproportionate to the procedure. No complications were encountered. 68% had complete clinical and radiological resolution and 32% had partial resolution (these patients needed a definitive drain and hence were not aspirated to completion). The operator feedback in the study rated the device as very good or excellent in 90% patients.

Our study found the use of ThoraQuik II to be safe and easy in draining pneumothorax and pleural effusions. The changes to ThoraQuik II made it more user friendly.

We sought to determine the incidence of haemorrhage requiring PCC administration in our cohort of patients, and to assess compliance with current national guidelines regarding their storage and use. We searched our database for all patients that received PCCs, or met current guidelines for their administration, and followed them through to hospital discharge. We also conducted a telephone survey of all hospitals served by the EMRS to determine compliance with national standards.

During the 42-month study period, 1170 retrieval missions were conducted. Twenty-six retrieved patients had a congenital or acquired clotting factor deficiency and seven met criteria for PCC administration. Of these, only three received PCCs prior to transfer to definitive care. Telephone survey revealed that all the rural general hospitals were served by the EMRS stock PCCs, but only one out of 15 GP-led community hospitals had access to PCCs.

In the remote and rural setting where access to definitive care may be limited or delayed, timely administration of PCCs in appropriate patients may improve outcomes. As many rural hospitals do not have access to PCCs, the ability of the EMRS to provide this treatment may improve patient care.

A retrospective database review of all missions between October 2010 and January 2012 was carried out. Any RSI or intubation carried out was included, regardless of age or indication. Patients who were intubated by Ambulance Service personnel prior to the arrival of the East Anglian Air Ambulance (EAAA) team were excluded.

The team was activated 1156 times and attended 763 cases. A total of 88 RSIs occurring within the study period were identified as having been carried out by the EAAA team and meeting inclusion criteria for review. There were no failed intubations that required a rescue surgical airway or the placement of a supraglottic airway device. For road traffic collisions (RTCs), the overall on-scene time for patients who required an RSI was 40 min (range 15–72 min). For all other trauma, the average on-scene time was 48 min (range 25–77 min), and for medical patients, the average time spent at scene was 41 min (range 15–94 min).

We have demonstrated the successful introduction of a prehospital care SOP, already tested in the urban trauma environment, to a rural and suburban air ambulance service operating a fulltime doctor-paramedic model. We have shown a zero failed intubation rate over 16 months of practice during which time over 750 missions were flown, with 11.5% of these resulting in an RSI.

A quality improvement report on the design, implementation and evaluation of a specialised service and structured training programme to detect and manage DA presentations within an emergency medicine department.

The study was set in the ED at the Northern General Hospital, Sheffield, UK.

Key measures for improvement included introducing a service within the ED to help staff manage DA and coordinate responses; improve staff confidence in detecting DA; develop a structured and consistent process by which to manage DA presentations.

An Independent Domestic Violence Advocate service was introduced into the department in July 2011 through a multiagency agreement. A structured training and education programme was delivered to ED staff. A ‘communications form’ was developed for DA risk assessment and case management. The process was reviewed quarterly.

One hundred and seventy-two referrals were made to the service (121 distinct clients) over a 12-month period. Staff reported greater confidence in detecting DA, and community partners highlighted the role the service had in improving DA detection and care quality within the city.

Strong leadership and prioritising the issue within the department has facilitated the development of the process and contributed substantially to its success. Support from community partners has been invaluable in tailoring the service and education programme to the needs of staff and patients within the department.

ELISA is a five-category nursing triage algorithm. Intrarater agreement was tested by comparing triage levels attributed to the same clinical scenarios at two different times. Interrater agreement was investigated by comparing triage categories attributed to clinical cases by different triage nurses. Finally, validity was estimated by studying the correlations between the triage ranking assigned by the nurse and actual resource consumption and patient outcome.

The distribution of the difference between nurse classification at the two times was statistically unrelated to which nurse carried out the evaluation. Regarding interrater agreement, assigned classifications were compared to the reference assignment. Cohen's coefficient revealed an almost perfect agreement between classification by nurses and the reference. Finally, statistical analysis revealed a strong relation between ELISA and the overall need for supplementary clinical testing. Outcomes were also significantly correlated with ELISA.

The need for a specific, French-language triage tool in our ED led us to develop a new triage scale. This study demonstrates that the scale is a valid triage tool with high interrater and intrarater agreement and considerable efficiency.

Forty-five ambulance workers from the London Ambulance Service, UK, were studied. Trauma exposure, post-traumatic stress disorder and depression symptoms were assessed using self-report measures. Positive and negative appraisals were measured in relation to two previous call-outs: one during which they coped well and one during which they did not.

Enhanced coping was associated with making more positive appraisals during the call-out. Better coping was also related to greater levels of objectivity during these call-outs. Coping less well was associated with the use of more negative appraisals during the call-out.

Ambulance workers may benefit from psychological interventions, which focus on cognitive reappraisal and enhancing objectivity to improve coping and resilience.

A systematic search of the Pubmed and Cochrane Library databases was performed. Eligible studies compared trauma patients managed with selective CT scanning with patients who underwent immediate full-body scanning. Using random effects modelling, the pooled OR was used to calculate the effect of routine full-body CT on mortality while the pooled weighted mean difference was used to analyse the difference in ED time.

Five studies (8180 patients) provided mortality data while four studies (6073 patients) provided data on ED time. All were non-randomised cohort studies and were prone to several sources of bias. There was no mortality difference between groups (pooled OR=0.68; 95% CI 0.43 to 1.09, p=0.11). There was a significant reduction in the time spent in the ED when patients underwent full-body CT (pooled effect size of weighted mean difference=–32.39 min; 95% CI –51.78 to –13.00; p=0.001).

We eagerly await the results of randomised controlled trials. Firm clinical outcome data are expected to emerge in the near future, though data on cost and radiation exposure will be needed before definitive conclusions can be made.

Prospectively and consecutively collected 5684 trauma patients’ data over a 10-year period at a regional level I trauma centre were reviewed. Four modified TRISS (mTRISS) models using Age coefficient from reclassifications of the Age variable according to their correlation with survival by logistic regression on the local dataset were acquired. RTS and ISS coefficients were derived from the local dataset and then applied to the mTRISS models. mTRISS models were compared with the existing Major Trauma Outcome Study (MTOS)-derived TRISS (eTRISS) model. Model 1=Age effect taken as linear; Model 2=Age classified into two groups (0–54, 55+); Model 3=Age classified into four groups (0–15, 16–54, 55–79, 80+) and Model 4=Age classified into two groups (0–69, 70+). Performance measures including sensitivity, specificity, accuracy and area under the Receiver Operating Characteristic (ROC) curve were used to assess the various models. The cross-validation procedure consisted of comparing the P_S obtained from mTRISS Models 1 and 2 with the P_S obtained from the MTOS derived from eTRISS.

A 5147 blunt trauma patients’ dataset was reviewed. Model 1, where Age was taken as a scale variable, demonstrated a substantial improvement in the survival prediction with 91.6% accuracy in blunt injuries as compared with 89.2% in the MTOS-derived TRISS. The 95% CI for ROC derived from mTRISS Model 1 was (0.923, 0.940), when compared with the hypothesised ROC value 0.886 obtained from eTRISS, it clearly indicated a significant improvement in predicting survival at 5% level. Furthermore, ROCs have shown clearly the superiority of Model 1 over Model 2, and of Model 2 over MTOS-derived TRISS. The recategorisation of the Age variable (Models 3 and 4) also demonstrated improved performance, but their strength was not as intense as in Model 1. Overall, the results point to the adoption of Model 1 as the best model for P_S. Cross-validation analysis has further assured the validity of these findings.

The present study has demonstrated that (1) having the Age variable being dichotomised (cut-off at 55 years) as in the eTRISS, but with the application of a local dataset-derived coefficients give better TRISS survival prediction in Asian blunt trauma patients; (2) improved performance are found with certain recategorisation of the Age variable and (3) the accuracy can further be enhanced if the Age effect is taken to be linear, with the application of local dataset-derived coefficients.

This was a retrospective cohort study conducted in a tertiary care emergency department in the USA. Consecutive adults who received intravenous morphine 4 mg for pain were included. Patients were categorised into three groups based on body mass index (BMI): non-obese (18.5–29.9 kg/m²); obese (30.0–39.9 kg/m²); and morbidly obese (≥40 kg/m²). Baseline and post-dose pain scores were recorded. Pain was measured on a 0–10 numerical rating scale (0=no pain; 10=worst possible pain). Analgesic response was defined as the difference between the initial pain score and post-dose pain score.

300 patients were included in the study (100 in each group). The median baseline pain scores were 8.5, 8 and 8.5 in the non-obese, obese and morbidly obese groups, respectively (p=0.464). The median analgesic response after morphine administration was 2, 3 and 2 in the non-obese, obese and morbidly obese groups, respectively (p=0.160). In the linear regression analysis (R²=0.006), BMI was not predictive of analgesic response (coefficient –0.020; p=0.199).

Obesity status did not influence analgesic response to a fixed dose of morphine. This suggests that obese and morbidly obese patients do not require a higher dose of morphine for acute pain reduction compared to non-obese patients.

Consecutive patients presenting with traumatic lacerations at three diverse emergency departments were prospectively enrolled and 27 variables were collected at the time of treatment. Patients were followed for 30 days to determine the development of a wound infection and desire for scar revision.

2663 patients completed follow-up and 69 (2.6%, 95% CI 2.0% to 3.3%) developed infection. Infected wounds were more likely to receive a worse cosmetic rating and more likely to be considered for scar revision (RR 2.6, 95% CI 1.7 to 3.9). People with diabetes (RR 2.70, 95% CI 1.1 to 6.5), lower extremity lacerations (RR 4.1, 95% CI 2.5 to 6.8), contaminated lacerations (RR 2.0, 95% CI 1.2  to 3.4) and lacerations greater than 5 cm (RR 2.9, 95% CI 1.6 to 5.2) were more likely to develop an infection. There were no differences in the infection rates for lacerations closed before 3% (95% CI 2.3% to 3.8%) or after 1.2% (95% CI 0.03% to 6.4%) 12 h.

Diabetes, wound contamination, length greater than 5 cm and location on the lower extremity are important risk factors for wound infection. Time from injury to wound closure is not as important as previously thought. Improvements in irrigation and decontamination over the past 30 years may have led to this change in outcome.

Retrobulbar haemorrhage is a vision-threatening emergency. It is typically secondary to facial trauma or a surgical procedure. Without prompt recognition and treatment, the haemorrhage can expand and produce an orbital compartment syndrome. In orbital compartment syndrome, high intraocular pressure (IOP) damages the optic nerve and compromises vascular flow, resulting in retinal ischaemia.1 Total vascular insufficiency of only 60–120 min can produce permanent vision loss.2

Signs and symptoms indicative of high IOP may include painful proptosis, a difference in globe compressibility, ophthalmoplegia,...]]> 2013-01-12T00:02:03-08:00 info:doi/10.1136/emermed-2012-201975 hwp:master-id:emermed;emermed-2012-201975 British Association for Accident and Emergency Medicine 2013-01-12 Images in emergency medicine http://emj.bmj.com/cgi/content/short/emermed-2012-201672v1?rss=1 Purpose

The impacts of emergency work on firefighters have been well documented and summarised, but this is not the case for paramedics. This paper explores the literature regarding the impact of work stress on paramedics.

To identify the literature available on the effect of paramedics’ jobs on their health status.

Electronic database used: MEDLINE (Ovid, PubMed, National Library of Medicine) between 2000 and 2011. Key words used for the computer searches were: paramedics, emergency responders, emergency workers, shift workers, post-traumatic symptoms, obesity, stress, heart rate variability, physiological response, blood pressure, cardiovascular and cortisol. Exclusion criteria were: studies in which participants were not paramedics, participants without occupational exposure, physical fitness assessment in paramedics and epidemiological reports regarding death at work.

The electronic databases cited 42 articles, of which we excluded 17; thus, 25 articles are included in this review. It seems clear that paramedics accumulate a set of risk factors, including acute and chronic stress, which may lead to development of cardiovascular diseases. Post-traumatic disorders, sleeping disorders and obesity are prevalent among emergency workers. Moreover, their employers use no inquiry or control methods to monitor their health status and cardiorespiratory fitness.

More studies are needed to characterise paramedics’ behaviour at work. These studies could allow the development of targeted strategies to prevent health problems reported in paramedics.

During a 42-month period (Sept 2008–Feb 2012), we prospectively registered all prehospital cardiac arrest situations in which the LT-D had been applied by paramedics (from one emergency medical service in Germany).

During the defined period, 133 attempts, recorded on standardised data sheets, were enrolled into the investigation. Three were excluded from the study because of use during a trauma situation. Therefore, 130 patients were evaluated in this study. For this, the LT-D was used in 98% of all cases during resuscitation, and in about 2% of other emergencies (eg, trauma). With regard to resuscitation, adequate ventilation/oxygenation was described as possible in 83% of all included cases. In 66% of all cases, no problems concerning the insertion of the LT-D were described by the paramedics. No significant problems were reported in 93%. In 7% (n=9 cases), no insertion of the LT-D was possible. Instead of bag-mask-valve ventilation, the LT-D was used as a first-line airway device in about 66%. Between the two defined groups, no statistically significant differences were found (p>0.05).

As an alternative airway device during resuscitation, recommended by the ERC in 2005 and 2010, the LT-D may enable ventilation rapidly and, as in most of our described cases, effectively. Additionally, by using the LT-D in a case of cardiac arrest, a reduced ‘hands-off time’ and, therefore, a high chest compression rate may be possible. Our investigation showed that the LT-D was often used as an alternative to bag-mask-ventilation and to ETI as well. However, we were able to describe more problems in the use of the LT-D than earlier investigations. Therefore, in future, more studies concerning the use of alternative airway devices in comparison with ETI and/or video-laryngoscopy seem to be necessary.

Local fishermen, fish sellers/dealers/brokers, buyers and emergency department physicians were interviewed about the fishery and consumption facts of the puffer fish in the region, the number of cases reported in the regional state run hospitals and the 112 Emergency Medical Response Service, and the knowledge and practice of the doctors in the emergency departments.

General health organisations are unprepared for the serious health hazards caused by this fish, including fatalities. Health workers should have sufficient knowledge regarding the clinical manifestations, complications and management of puffer fish poisoning. Official authorities should make the public aware of the potential risk of consuming puffer fish.

This cross-sectional analysis evaluated how patient age affects length of ED stay. The study was conducted at an ED attached to Fujisawa City Hospital, Japan, between 1 November 2009 and 31 October 2010. Patients scheduled to visit for childbirth and patients under age 15 were excluded. The primary outcome measure was the relationship between length of ED stay and patient age. The secondary outcome was the relationship between patient age and patient dispositions indicated by column chart and 100% staked column chart.

Over the study period, there were 17 744 patient visits to the ED. The study included 15 840 (89.3%) patients. The mean (SD) age of these patients was 56.9 (21.5) years. In single and multiple linear regression analyses, mean patient age per day was an important factor in length of ED stay for the total number of patients visiting the ED (single linear regression analysis: regression coefficient=1.59 min/year, r²=0.005, p<0.001; multiple linear regression analysis: regression coefficient=0.72 min/year, r²=0.24, p<0.001). The ratio of admitted and transferred patients increased with patient age.

The increase in older patients visiting the ED has a direct significant negative effect on overcrowding in the ED.

Before and after study, by means of timeline measurements and questionnaires on satisfaction in two consecutive patient series (n=1808). Questionnaires covered aspects of provision of information, opportunity given to explain problems, waiting time and sorting out the problem. After implementation of MTS, patients were triaged between 12:00 and 22:00. Subanalysis was performed on triaging and non-triaging; and between urgency levels.

Waiting time did not decrease after implementation of the MTS, however, treatment time and LOS were significantly longer. Total LOS did not differ. After implementation, waiting time was better distributed over urgency levels.

Furthermore, after implementation, patient satisfaction scored significantly lower on the provision of information and opportunity to explain their problems, however, waiting time and the feeling that their problem had been sorted out scored better. No significant differences were found between triaged and non-triaged patients. Although not significant, patients in the lower urgency levels seemed more satisfied than patients in the higher urgency levels.

Implementing MTS on its own is not sufficient to improve efficiency and quality of EDs. More complex interventions including process redesigning that targets various groups of ED patients should be evaluated in the future by using rigorous research designs for quality improvement of EDs.

Adults, entered into the TraumaRegister DGU^® database between 2002 and 2011, were classified into reference ranges for heart rate (HR), systolic blood pressure (SBP) and Glasgow coma scale (GCS) according to the PHTLS classification of hypovolaemic shock. First, patients were grouped by a combination of all three parameters (HR, SBP and GCS) as suggested by PHTLS. Second, patients were classified by only one parameter (HR, SBP or GCS) according to PHTLS and alterations in the remaining two parameters were assessed. Furthermore, subgroup analysis for trauma mechanism and traumatic brain injury (TBI) were performed.

Out of 46 689 patients, only 12 432 (26.5%) could be adequately classified according to PHTLS if a combination of all three criteria was assessed. In TBI patients, only 12.2% could be classified adequately, whereas trauma mechanism had no significant influence. When patients were grouped by HR, there was only a slight reduction in SBP. When grouped by SBP, GCS dropped from 14 to 8, while no significant tachycardia was observed in any group. In patients with a GCS less than 12, HR was unaltered whereas SBP was slightly reduced to 114 (±42) mm Hg. On average, GCS in TBI patients was lower within all shock groups. In penetrating trauma patients, changes in HR and SBP were more distinct, but still less than predicted by PHTLS.

The PHTLS classification of hypovolaemic shock displays substantial deficits in adequately risk-stratifying trauma patients.

Between May 2009 and October 2010, 47 patients were admitted to our emergency department with snake bites, and as a control group 20 healthy volunteers were enrolled in this study. Serum, plasma, and erythrocyte components were prepared for all patients on admission and at the control after 1 month. Serum TOS/TAS levels were measured.

No correlation was observed among age, gender and the levels of TAS, TOS and OSI. TAS, TOS and OSI levels were higher in snake envenomation patients upon arrival at the emergency department than in the healthy control group. Upon admission, all levels of patients with snake envenomation were higher than the control levels taken after 1 month.

Serum TAS, TOS and OSI levels increase in snake envenomation patients. The results obtained in this study indicate that the snake bite was associated with a shift to an oxidative state, and oxidative stress plays an important role in the pathophysiology of snake envenomation.

All secondary retrievals undertaken by a national aeromedical critical care retrieval service were reviewed over a 48-month period.

In a mixed medical and trauma critical care population, 11 of 967 (1.1%) secondary retrievals required electrical intervention during aeromedical critical care retrieval. The median age of these patients was 77 years (range 32–86) and the median transport time was 70 min (range 40–100 min). All of these patients had an underlying primary cardiac condition and had been identified as high risk for developing an arrhythmia.

Electrical intervention in a transport environment brings unique challenges, particularly during aeromedical transport. Our study in a European model shows that there is a small but significant incidence of electrical intervention required during aeromedical flight for critically ill patients. There are potential safety issues with electrical intervention in aeromedical flight; therefore, any service involved in the transport of critically ill patients needs to have a robust procedure in place to deliver this safely.

A retrospective cohort study, examining 18 months of historical data collated by the Queensland Ambulance Service Trauma Response Team (TRT) and the Pathology Queensland Central Transfusion Laboratory was undertaken.

Over an 18-month period (1 January 2011–30 June 2012), of 500 pRBC units provided to the TRT, 130 (26%) were administered to patients in the prehospital environment. Of the non-transfused units, 97.8% were returned to a hospital blood bank and were available for reissue. No instances of equipment failure directly contributed to wastage of pRBCs. The cost of providing pRBCs for prehospital use was $A551 (£361) for each unit transfused.

It is feasible and practical to provide prehospital trauma teams with pRBCs for use in the field. Use of pRBCs in the prehospital setting is associated with similar rates of pRBC wastage to that reported in emergency departments.

We performed a retrospective data analysis of all multiple injured patients from the TraumaRegister DGU (English: German Trauma Society) from January 1993 to December 2010. Exclusion criteria were missing or implausible data regarding prehospital timelines. With OST as an independent variable, different models of multivariate regression were performed to identify parameters with relevant impact on the OST.

15 103 datasets were included in this study. Based on the mean OST of 32.7 (±18.6) min and a constant absolute term of 16.2 (±1.5) min, we identified seven procedures and nine environmental parameters with significant impact on OST. Intubation (9.3±0.8 min) and being a car occupant (8.0±0.8 min) were associated with the most prolonged OSTs. A Glasgow Coma Scale ≤8 (–4.5±0.7 min) and cardiopulmonary resuscitation (–2.8±1.7 min) resulted in its most relevant reduction. Admission to a Level III facility led to a reduced overall prehospital time (60.0±24.6 min) compared with Level I (70.0±28.5 min) and II (66.8±27.4 min) trauma centres.

This study identified characteristic interventions and conditions with significant impact on prehospital treatment times. Current treatment concepts should be re-evaluated with respect to these results.

A convenience sample of 216 patients, who presented to the emergency department for complaints unrelated to injury, requiring blood tests for their management was obtained. Using the Protetanus QuickStick® all samples were analysed.

No statistical difference between men and women in terms of tetanus immunity (p=0.94) but significant reduction in immunity with increasing age (p<0.001). Those non-immune tended to be older with mean age of 66 years compared to mean age of 46 year for immune. Using logarithmic regression analysis an increase in age of 10 years was associated with 50% reduction in immunity.

National guidelines should incorporate this data and explicitly advocate the use of booster doses of tetanus toxoid outside of the normal vaccination programme especially in the elderly.

A case-control study was conducted to retrospectively analyse the bacteraemic adults visiting the emergency department (ED) during the period between January 2005 and August 2006. The patients with occult bacteraemia were the case group. Two control groups (CGs) were selected for comparisons: CG I, those with bacteraemia and the same Pittsburgh bacteremia score who were admitted at the first ED visit temporally near a case patient; and CG II, those with bacteraemia admitted at their first ED visit, irrespective of the Pittsburgh bacteraemia score.

There were 119 adults composing of the case group, 119 matched adults as the CG I and 293 adults as the CG II. Demographic characteristics, clinical conditions and outcomes were retrieved from chart records. A lower 28-day death rate (5.0% vs 11.9%, p=0.03) and less critical illness (ie, Pittsburgh bacteremia score ≥4 points; 1.7% vs 22.2%; p<0.001) were noted among case patients compared with those in CG II. However, no difference in the 28-day death rate (5.0% vs 5.9%; p=0.77) between the case group and CG I was discovered. Among the case patients, thrombocytopenia (<100 000/mm³; OR, 8.87; p=0.03) and inappropriate antibiotic therapy at the second ED or outpatient-clinic visit (OR 7.59; p=0.045) were the independent factors of 28-day mortality in the multivariate analysis. Moreover, the survival curve revealed a significant difference in the survival rate between those with occult bacteraemia receiving inappropriate and appropriate antibiotic therapy after index bacteraemic-onset (p=0.02).

For adults with occult bacteraemia, a lower severity of illness and death rate than those of bacteraemic patients hospitalised for ED visit could be demonstrated, demonstrating the importance of appropriate antibiotic therapy.

This study aimed to determine the accuracy of a physician's olfactory sense for diagnosing alcohol intoxication.

Patients suspected of major trauma in the ED underwent an evaluation by the examining physician for alcohol odour and a blood alcohol level. Alcohol intoxication was defined as a serum ethanol level ≥80 mg/100 ml. Data were reported as means with 95% CI or proportions with IQR 25–75%.

151 patients (70% men) were enrolled, with a median age of 45 years (IQR 33–56). The prevalence of alcohol intoxication was 43% (95% CI 35% to 51%).

Physician assessment of alcohol intoxication: sensitivity 84% (95% CI 73% to 92%), specificity 87% (95% CI 78% to 93%), positive likelihood ratio 6.6 (95% CI 3.8 to 11.6), negative likelihood ratio 0.18 (95% CI 0.1 to 0.3) and accuracy 86% (95% CI 80% to 91%). 7.3% (95% CI 4% to 13%) of patients were falsely suspected of being intoxicated.

Although the physicians had a high degree of accuracy in identifying patients with alcohol intoxication based on their olfactory sense, they still falsely overestimated intoxication in significant numbers of non-intoxicated trauma patients.

We studied all of the ETI data at two urban emergency departments over a 5-year period. We assessed the intubator's specialty and training level, intubation method, device used, predicted airway difficulty and cause of ETIs. Univariate and multivariate logistic regression models were used to identify factors affecting the first-attempt success (FAS) of ETI in emergency departments.

A total of 1478 adult ETIs were analysed. A multivariate logistic analysis revealed that factors such as a non-difficult airway (OR=5.11; 95% CI 3.38 to 7.72), senior physicians (2nd-year to 4th-year resident and attending physicians) (OR=2.39; 95% CI 1.61 to 3.55) and the rapid sequence intubation/induction (RSI) method (OR=2.06; 95% CI 1.04 to 3.03) had significant associations with the FAS for emergency medicine (EM) physicians. For non-EM physicians, however, a non-difficult airway was the only independent predictor of FAS (OR=3.10; 95% CI 1.82 to 5.28).

The predicted airway difficulty was the major factor associated with FAS in emergency department ETI on adults regardless of intubator's specialty. Especially in EM physician group, level of training and using of RSI also affecting on first–attempt success. The overall ETI success rate on first attempt was 80.1%, but EM physicians had success rate of 87.3%. Systematic technical and non-technical airway skill training focused on RSI and continuous quality control and ETI recording could help non-EM physicians increase their FAS rate.

The NPIS telephone enquiry database, the UK Poisons Information Database, was interrogated for enquiries to the four NPIS units from 2004 to 2010. Search terms used were ‘snake’ and ‘snakebite’. Information from the national dataset was available from Cardiff and Edinburgh units from 2004 onwards, Birmingham from June 2005 and Newcastle from September 2006.

Five hundred and ten cases were identified, of which 69% were male and 31% female. Average age of cases was 32 years (±1 95% CI). The snake was identified as follows: British Adder in 52% of cases, an exotic species in 26%, unknown in 18% and another UK snake in 4%. 82% of cases occurred between the months of April and September. Cases peaked during August (19%). Forty-two per cent of enquiries involved features of envenoming. Eighty-five cases were assessed as requiring antivenom. Eighty-four cases received treatment with antivenom. No adverse reactions to the antivenom were reported and resolution of clinical features was reported in all treated cases. Advice to use an antidote was followed in 98.8% of cases.

Snakebites account for one to two NPIS cases per week. Adder bites account for over half of cases. A quarter of cases were due to non-UK snakes kept in captivity within the UK. Envenoming was said to have occurred in just under half of all cases. Advice given by the NPIS appears to closely reflect national practice guidelines.

In this retrospective cohort study, patients were identified using the hospital trauma registry and clinical information department. Data on analgesic method, outcomes and confounders were obtained from the medical record. Costing data were obtained from the case-mix department. The analysis used logistic regression for the primary outcome and a generalised linear model for the secondary outcomes to adjust for potential confounders.

227 patients were included. In the PCA group, 17/52 (33%) patients had a complication compared with 26/175 (15%) in the interval dosing group. The adjusted odds for a complication in patients receiving PCA was not significantly different from the adjusted odds in those receiving interval dosing (OR=1.2, 95% CI 0.3 to 4.6, p=0.83). The median LOS was 8.9 days in the PCA group and 4.6 days in the interval dosing group. The adjusted LOS for patients receiving PCA was 10% shorter than those receiving interval dosing (relative difference 0.9, 95% CI 0.6 to 1.3, p=0.52). The median hospital cost was $A11 107 in the PCA group (IQR $A7520–$A15 744) and $A4511 (IQR $A2687–$A8248) in the interval dosing group. The adjusted total hospital costs for patients receiving PCA was 10% higher than for those receiving interval dosing (relative difference 1.1, 95% CI 0.8 to 1.5, p=0.44).

PCA did not reduce complications, hospital LOS or costs compared with interval analgesic dosing.

An anonymous questionnaire (30 yes/no questions on demographics and FWR) was sent to all prehospital emergency staff (physicians, nurses and support staff) working for the 377 Mobile Intensive Care Units in France.

Of the 2689 responses received 2664 were analysed. Mean respondent age was 38±8 years, the male to female ratio was 1:2. 87% of respondents had already performed FWR and 38% had offered relatives the option to be present during resuscitation. Most respondents (90%) felt that FWR might cause psychological trauma to the family; 70% thought that FWR might impact on the duration of resuscitation and 68% on EMS team concentration. In the 28% of cases when relatives had asked to be present, 59% of respondents had acquiesced but only 27% were willing to invite relatives to be routinely present.

Prehospital EMS teams in France seems to support FWR but are not yet ready to offer it systematically to relatives. Following our survey, written guidelines are currently in development in our department. These guidelines could be the first step of a national strategy for developing FWR in France. We await results from other studies of family members’ opinions to compare prehospital practitioners’ and family members’ views to further develop our practice.

A medical record review of patients with an ED diagnosis of pericarditis conducted in an adult tertiary hospital over a 5-year period. Variables collected included pain characteristics, associated symptoms, physical examination findings, investigation results, ED treatment and disposition.

179 presentations were included, with 73.9% men and a mean age of 38.8 years. The majority of patients described pleuritic chest pain worse with inspiration with half characterising the pain as sharp or stabbing, with others describing tightness, dullness or cramping. Radiation to the left shoulder occurred in 2.8% and change of pain with posture occurred in 46.4%. A pericardial rub was documented in 19 presentations. All patients had an ECG recorded with ST segment elevation present in 69.3% and PR segment depression in 49.2%. Nearly 90% of patients had troponin testing but only 6.4% of these were positive. Only 8.1% of cases were treated with colchicine. No patients required pericardiocentesis. Patients with high-risk factors were more likely to have previous pericarditis, dyspnoea, nausea, abnormal investigation results, treatment with colchicine and admission to hospital. However, 16.9% of patients without risk factors were admitted, and 46.9% of patients with at least one risk factor were discharged.

Pericarditis may not follow the classical clinical description. Admission and discharge decisions appear to relate to individual clinical characteristics rather than known risk factors. Use of colchicine for treatment in ED is infrequent.

A case study incorporating questionnaire survey, analysis of routinely collected data and analysis of costs in the north-west England.

Children with acute illness referred for CCNT care.

Two CCNT provided care for 273 children during acute illness in order to reduce the number and duration of hospital admissions.

Costs of CCNT, other services and costs to families.

The objectives of both CCNT included shortening and avoiding hospitalisations. Most (45 (58%) in case A and 150 (77%) in case B) children were referred for infections. There were differences in the proportion of children who had been hospitalised (45 (57.7%) and 78 (40%)), the mean number of services used before referral to CCNT (1.6 and 2.2) and the staffing profile of the CCNT. There was a statistically significant difference in the overall mean cost to the NHS of CCNT care (£146 and £238, 95% CI for difference of means 7 to 184), associated with higher proportions of children having telephone-only contact (two (3%) and 46 (24%)) and children using almost twice as many other health services during care by one CCNT (means 0.27 and 0.51).

Costs of CCNT care can vary widely when all health service use is taken into account. Differences in the way CCNT are integrated with the urgent care system, and the way in which CCNT care is organised, could contribute to variations in costs.

A sample of patients with a non-haemorrhagic injury from the Trauma Audit and Research Network (TARN) was compared with a healthy, non-injury sample from the Health Survey for England (HSE) databases. Two-way analysis of variance with rank transformation of data was used to compare systolic blood pressure (SBP) and HR between the groups at different ages. In the injured group, the SBP and HR were also compared between spinally immobilised and non-immobilised patients.

There was a statistically significant difference between the groups for both HR and SBP (p<0.001). Median HR remained approximately 10 bpm higher in the TARN set when compared to the HSE set, irrespective of age. The difference for SBP was not considered clinically relevant (the highest was 5 mm Hg). There was no significant difference between immobilised and non-immobilised patients, for either HR or SBP (p=0.07 and 0.3, respectively).

Median HR remained approximately 10 bpm higher in the TARN (injury) set compared to the HSE (non-injury, control) set, irrespective of age. Understanding that HR reacts in this way for mild to moderately injured patients is important as it will affect clinical interpretation during the initial assessment.

We instituted anonymous data sharing with the police to reduce community violence, and increased involvement with the local CSP. We measured the effectiveness of this approach with routinely collected data at the emergency department and the police. We used police data from 2009, and emergency department data from 2000.

Initially, the number of assault patients requiring emergency department treatment rose after we initiated data sharing. After improving the data flows, the number of assault patients fell back to the predata-sharing level. There was no change in the number of hospital admissions during the study period. There were decreases in the numbers of violent crimes against the person, with and without injury, recorded by the police.

We have successfully implemented data sharing in our institution without the support of an academic institution. This has been associated with reductions in violent crime, but it is not clear whether this association is causal.

Electronic searches of Medline and Cumulative Index of Nursing and Allied Health Literature were conducted for papers published between 1980 and 2011. In addition, hand searching was conducted for unpublished government and ambulance service documents and reports for the same period.

38 studies examined temporal patterns in ambulance demand. Six studies reported trends in overall workload and 32 studies reported trends in a subset of ambulance demand, either as a specific case type or demographic group. Temporal patterns in overall demand were consistent between jurisdictions for time of day but varied for day of week and season. When analysed by case type, all jurisdictions reported similar time of day patterns, most jurisdictions had similar day of week patterns except for out-of-hospital cardiac arrest and similar seasonal patterns, except for trauma. Temporal patterns in case types were influenced by age and gender.

Temporal patterns are present in ambulance demand and importantly these populations are distinct from those found in hospital datasets suggesting that variation in ambulance demand should not be inferred from hospital data alone. Case types seem to have similar temporal patterns across jurisdictions; thus, research where demand is broken down into case types would be generalisable to many ambulance services. This type of research can lead to improvements in ambulance service deliverables.

To explore patients’ and carers’ experiences of gaining access to acute stroke care and identify the factors that enabled or prevented stroke from being treated as a medical emergency.

Qualitative semi-structured interviews were conducted with 59 stroke survivors and carers who had received care at seven UK centres. The interviews were recorded and transcribed verbatim and thematic analysis was undertaken.

Themes emerging showed that participants recognised signs and symptoms, they were satisfied with access to emergency medical services (EMS), and they experienced setbacks in the emergency department and delays caused by the lack of availability of specialist services outside normal working hours. Awareness of the importance of time to treatment was generally attributed to the UK stroke awareness campaign, although some felt the message was not sufficiently comprehensive. This awareness led to increased frustration when participants perceived a lack of urgency in the provision of assessment and medical care.

The stroke awareness social marketing campaign has contributed to public knowledge and was perceived to assist in reducing prehospital delay. It has also resulted in an enhanced knowledge of the significance of rapid treatment on admission to hospital and raised public expectation of EMS and stroke services to act fast. More research is required to assist organisational change to reduce in-hospital delay.

To evaluate the potential benefit of introducing clinical assistants to a busy and crowded ED.

This was a retrospective cohort study at an urban, academic tertiary medical centre. We introduced one clinical assistant to each ED shift. The main task of clinical assistants was managing the flow of incoming ED patients. The case group consisted of all adult non-trauma emergency patients during the case period from 1 September to 30 November 2008. The first control group consisted of all adult non-trauma emergency patients between 1 June and 31 August 2008 and the second control group consisted of all patients treated between 1 September and 30 November 2007. The primary outcome was the ‘waiting time’, defined as the time from triage to the time of the first medical order entered into the computer system. The secondary outcome was the number of adult non-trauma emergency patients who left the ED without being seen.

There were 12 257 cases and 25 950 controls. The mean and median waiting times were significantly shorter in the case group. The mean waiting time of the case group was 20.86 min, which was 4.51 min (17.8%) shorter than that of the first control group and 7.41 min (26.2%) shorter than that of the second control group. The median waiting time of the case group was also significantly shorter than those of the control groups. The number of the patients who left without being seen was significantly smaller in the case period.

In a busy and crowded ED, the introduction of clinical assistants to an existing emergency health service effectively reduces patient waiting times and decreases the number of patients leaving without being seen.

The conventional method involved blind insertion through nasal orifices. The alternative method was insertion with Magill's forceps or long forceps under visualisation using a direct laryngoscope. The new method was performed as follows: (1) insertion of another endotracheal tube (ETT) orally into the oesophagus; (2) insertion of a temperature probe into the hole of the ETT; (3) removal of the ETT. To compare the success rates and procedure times according to the insertion method, we collected data retrospectively from the prospective Samsung Medical Centre hypothermia database and medical records.

A total of 91 cases were examined. Insertion was performed using the conventional method in 36 cases, the alternative method in 26, and the new method in 29. Rates of success on the first attempt were 63.9%, 65.4% and 100%, and procedure times were 33.2±13.6, 33.3±17.8 and 27.0±7.9 min, for the conventional, alternative and new methods, respectively. The initial success rates and procedure times were significantly different among the three groups (p<0.01).

The new ETP insertion method had a better first attempt success rate than the conventional method and the alternative method.

We performed an online survey of undergraduate and graduate students at a mid-sized, private university that has 37 AEDs located throughout its two campuses.

267 students responded to the survey. Almost all respondents could identify CPR (98.5%) and an AED (88.4%) from images, but only 46.1% and 18.4%, respectively, could indicate the basic mechanism of CPR and AEDs. About a quarter (28.1%) of respondents were comfortable using an AED without assistance, compared with 65.5% when offered assistance. Of those who did not feel comfortable, 87.7% indicated that they were ‘afraid of doing something wrong.’ One out of 6 (17.6%) respondents knew that a student centre had an AED, and only 2% could recall its precise location within the building. Most (66.3%) respondents indicated they would look for an AED near fire extinguishers, followed by the entrance of a building (19.6%).

This study found that most students at an American university can identify CPR and AEDs, but do not understand their basic mechanisms of action or are willing to perform CPR or use AEDs unassisted. Recent CPR/AED training and 9-1-1 assistance increases comfort. The most common fear reported was incorrect CPR or AED use. Almost all students could not recall where an AED was located in a student centre.

We conducted a retrospective cohort study using the Ontario Trauma Registry's Comprehensive Data Set for 2002–2009. Eligible patients were greater than 16 years of age, had an initial Glasgow Coma Score of less than 9 and were cared for by ground-based non-critical care paramedics. The primary outcome was mortality. Outcomes were compared between patients undergoing prehospital intubation versus basic airway management. Logistic regression analyses were used to quantify the association between prehospital intubation and mortality.

Of the 2229 patients included in the analysis, 671 (30.1%) underwent prehospital intubation. Annual rates of prehospital intubation declined from 33.7% to 14.0% (p_trend<0.0001) over the study period. Unadjusted death rates were 66.0% versus 34.8% in the intubation and basic airway groups, respectively (p<0.0001). Intubation in the prehospital setting was associated with a heightened risk of mortality (adjusted OR 2.8, 95% CI 1.1 to 7.6).

Prehospital non-drug assisted intubation for trauma is being performed less frequently in Ontario, Canada. Within our study population, paramedic non-drug assisted intubation or attempted intubation was associated with a heightened risk of mortality.

Retrospective case note review of all patients presenting to the Royal Infirmary of Edinburgh (RIE) Emergency Department (ED) for whom a blood component was requested and historic comparison. Improvement measures implemented between 2007 and 2011 included (1) formal staff education, (2) use of e-learning Module One Safe Transfusion Practice (traceability update, Medicines and Healthcare products Regulatory Agency (MHRA) traceability regulations and importance of returning completed blood component tags), (3) an ED resuscitation room blood fridge, (4) introduction of a dedicated ED transfusion consultant and ED transfusion link nurse and (5) the presence of an ED consultant on the Hospital Transfusion Group.

Between 1st January and 31st December 2011, blood components were requested for 255 patient episodes, totalling 1034 individual units. 687 units (66.4%) of blood component were transfused, 248 components (24.0%) were recycled, 90 components (8.7%) were discarded and nine units (0.9%) were unaccounted for. There was a 64% reduction in blood component ordering (3209 vs 1034 units), a 39% reduction in blood component transfusion (1131 vs 687 units) and a 96% reduction in unaccounted units (214 vs 9 units) between 2007 and 2011. There was a rise in the median age of the patient for whom a transfusion request was made from 63.9 years in 2007 to 67.0 years in 2011.

Blood component ordering, usage and traceability within the ED have improved significantly since 2007 following implementation of simple strategies. The age of ED transfusion recipients is increasing.

Ambulance staff participated in an online Delphi questionnaire, comprising 74 items (Round 1) on 7-point Likert scales. Second-round and third-round participants each received feedback based on the previous round, and responded to modified versions of the original items and to new items for clarification.

One hundred and two participants took part in Round 1; 47 statements (64%) achieved consensus. In Round 2, 72 people from Round 1 participated; 15 out of 39 statements (38%) achieved consensus. In Round 3, 49 people from Round 2 participated; 15 out of 27 statements (59%) achieved consensus. Overall, there was consensus in the following areas: ‘psychosocial needs of patients’ (consensus in 34/37 items); ‘possible sources of stress in your work’ (8/9); ‘impacts of distress in your work’ (7/10); ‘meeting your own emotional needs’ (4/5); ‘support within your organisation’ (2/5); ‘needs for training in psychosocial skills for patients’ (15/15); ‘my needs for psychosocial training and support’ (5/6).

Ambulance clinicians recognise their own education needs and the importance of their being offered psychosocial training and support. The authors recommend that, in order to meet patients’ psychosocial needs effectively, ambulance clinicians are provided with education and training in a number of skills and their own psychosocial support should be enhanced.

We explored experiences of patients, who had accessed the ambulance service for AMI or stroke, and clinicians regularly treating patients for these conditions in the prehospital setting.

A qualitative research design was employed to obtain rich and detailed data to explore and compare participants’ experiences of emergency prehospital care for AMI and stroke.

We conducted 33 semistructured interviews with service users and clinicians and one focus group with five clinicians. Four main themes emerged: communication, professionalism, treatment of condition and the transition from home to hospital. Patients focused on both personal and technical skills. Technical knowledge and relational skills together contributed to a perception of professionalism in ambulance personnel. Patients’ experience was enhanced when physical, emotional and social needs were attended to and they emphasised effective communication within the clinician–patient relationship to be the key. However, we found a discrepancy between paramedics’ perceptions of patients’ expectations and patients’ lack of knowledge of the paramedic role.

Factors that contribute to better patient experience are not necessarily understood in the same way by patients and clinicians. Our findings can contribute to the development of patient experience measures for prehospital care.

This was a retrospective cohort study conducted in a tertiary care emergency department (ED) in the USA. Consecutive adult patients intubated in the ED using succinylcholine or rocuronium for paralysis were included. Data collected included patient demographics, vital signs, medications used post-intubation and times of drug administration. Patients were divided into two groups based on the type of paralytic used for rapid sequence intubation: (1) rocuronium or (2) succinylcholine. All patients received etomidate for induction of sedation. Time between intubation and post-intubation sedative use was compared between the two groups using an unpaired Student's t test.

A total of 200 patients were included in the final analyses (100 patients in each group). There were no significant differences between the groups with regard to patient demographics, vital signs or other baseline characteristics. After intubation, 77.5% (n=155) of patients were initiated on a sedative infusion of propofol (n=148) or midazolam (n=7). The remaining patients received sedation as bolus doses only. Mean time between intubation and post-intubation sedative use was significantly greater in the rocuronium group compared with the succinylcholine group (27 min vs 15 min, respectively; p<0.001).

Patients intubated with rocuronium had greater delays in post-intubation sedative initiation compared with succinylcholine.

To develop and externally validate a fall risk screening tool for use in hospital EDs and to compare the tool's predictive ability to existing screening tools.

This prospective cohort study involved two hospital EDs in Sydney, Australia. Potential participants were people aged 70+ years who presented to the ED after falling or with a history of 2+ falls in the previous year and were subsequently discharged. 219 people participated in the tool development study and 178 people participated in the external validation study. Study measures included number of fallers during the 6-month follow-up period, and physical status, medical history, fall history and community service use.

31% and 35% of participants fell in the development and external validation samples, respectively. The developed two-item screening tool included: 2+ falls in the past year (OR 4.18, 95% CI 2.61 to 6.68) and taking 6+ medications (OR 1.89, CI 1.18 to 3.04). The area under the receiver operating characteristic curve (AUC) was 0.70 (0.64–0.76). This represents significantly better predictive ability than the measure of 2+ previous falls alone (AUC 0.67, 0.62–0.72, p=0.02) and similar predictive ability to the FROP-Com (AUC 0.73, 0.67–0.79, p=0.25) and PROFET screens (AUC 0.70, 0.62–0.78, p=0.5).

A simple, two-item screening tool demonstrated good external validity and accurately discriminated between fallers and non-fallers. This tool could identify high risk individuals who may benefit from onward referral or intervention after ED discharge.

Copeptin was measured at arrival in 65 consecutive patients (56±10 years, 45 men) suspected of ACS and no indication for immediate invasive angiography. All patients underwent coronary CTA without disclosure of the results to the treating physician, and outcomes were classified as obstructive CAD (>50% stenosis) or no obstructive CAD (≤50%) in one or more vessel.

The final diagnosis of ACS was established in 10 (15%) patients, 6 myocardial infarctions and 4 unstable angina pectoris. Coronary CTA detected obstructive CAD in all patients with ACS and in 10 (15%) patients with no ACS. Copeptin concentrations were higher in patients with ACS (median 7.42 pmol/l (IQR 3.71–18.72)) vs patients with no ACS (3.40 pmol/l (1.13–6.27), p=0.02). Copeptin was not higher in patients with obstructive CAD on coronary CTA (4.87 pmol/l (2.90–8.51) vs 3.60 pmol/l (1.21–6.23), p=0.20) compared with patients with no obstructive CAD.

Copeptin seems to be elevated in patients with ACS while there is no strong correlation with obstructive coronary disease on CTA.

This prospective, observational, pilot study was performed at an emergency room and general ward in ASAN Medical Centre, a 2680-bed teaching hospital. One hundred and six patients with severe sepsis or septic shock were enrolled and assigned to an intermittent monitoring group (n=53) or continuous monitoring group (n=53).

Within 6 h of the EGDT, interventions by the treating physicians were assessed, including intravenous fluid administration, use of vasopressors and compliance with SSC bundles. After 6 h of the EGDT, 41.5% of all goals (primary outcome) were achieved in the intermittent group and 35.8% in the continuous group (p=0.550). Intensive Care Unit (ICU) mortality, hospital mortality and length of ICU stay did not differ between groups.

During EGDT, intermittent ScvO₂ monitoring was not inferior to continuous ScvO₂ monitoring when delivered within the first 6 h of intervention.

A convenience sample of patients triaged to a fast-track unit were surveyed. Patient satisfaction was scored using a validated survey instrument, as well as a single overall care rating (poor to excellent). Median satisfaction scores were compared between each incremental hour of waiting time. Bivariate analysis was conducted between those who waited 1 h or less, and those who waited longer. Ordered logistic regression was used to determine predictors of improved overall care rating.

236 patients completed surveys (response rate of 74%). Of these, 84% rated their care as either very good or excellent. There was a linear decrease in median satisfaction scores for each incremental hour of waiting time associated with half the odds of higher overall care rating after adjusting for presenting problem type, triage category, and treating clinician type (OR 0.53 95% CI 0.37 to 0.75 p<0.001). English language (OR 2.43 95% CI 1.33 to 4.42 p=0.004) and initial consultation by a nurse practitioner (NP) (OR 1.81 95% CI 1.03 to 3.31 p=0.038) were also found to be significant predictors of improved overall care rating.

Waiting time was found to be highly predictive of patient satisfaction in an emergency fast-track unit with English language and NPs also associated with improved overall care rating. Future measures to improve patient satisfaction in fast-track units should focus on these factors.

Confidential, deidentified incident reports (IRs) were collected, and MEs were independently categorised by two investigators. Discordant responses were resolved by consensus.

MEs (597) accounted for 19% of all IRs, with reporting rates varying 25-fold across sites. Anti-infective agents were the most commonly reported, followed by analgesics, intravenous fluids and respiratory medicines. Of the 597 MEs, 94% were medication errors and 6% adverse reactions; further analyses are reported for medication errors. Incorrect medication doses were related to incorrect weight (20%), duplicate doses (21%), and miscalculation (22%). Look-alike/sound-alike MEs were 36% of incorrect medications. Human factors contributed in 85% of reports: failure to follow established procedures (41%), calculation (13%) or judgment (12%) errors, and communication failures (20%). Outcomes were: no deaths or permanent disability, 13% patient harm, 47% reached patient (no harm), 30% near miss or unsafe conditions, and 9% unknown.

ME reporting by the system revealed valuable data across sites on medication categories and potential human factors. Harm was infrequently reported. Our analyses identify trends and latent systems issues, suggesting areas for future interventions to reduce paediatric ED medication errors.

All data were collected prospectively and entered into the ED's centralised electronic patient record database (Qualicare, Switzerland) and retrospectively analysed. The database was scanned for the standardised key words: ‘sexual intercourse’ (German ‘Geschlechtsverkehr’) or ‘coitus’ (German ‘Koitus’).

A total of 445 patients were available for further evaluation; 308 (69.0%) were male, 137 (31.0%) were female. The median age was 32 years (range 16–71) for male subjects and 30 years (range 16–70) for female subjects. Two men had cardiovascular emergencies. 46 (10.3%) of our patients suffered from trauma. Neurological emergencies occurred in 55 (12.4%) patients: the most frequent were headaches in 27 (49.0%), followed by subarachnoid haemorrhage (12, 22.0%) and transient global amnesia (11, 20.0%). 154 (97.0%) of the patients presenting with presumed infection actually had infections of the urogenital tract. The most common infection was urethritis (64, 41.0%), followed by cystitis (21, 13.0%) and epididymitis (19, 12.0%). A sexually transmitted disease (STD) was diagnosed in 43 (16.0%) of all patients presenting with a presumed infection. 118 (43.0%) of the patients with a possible infection requested testing for an STD because of unsafe sexual activity without underlying symptoms.

Sexual activity is mechanically dangerous, potentially infectious and stressful for the cardiovascular system. Because information on ED presentation related to sexual intercourse is scarce, more efforts should be undertaken to document all such complications to improve treatment and preventative strategies.

To investigate the impact of a new pre-alert tool on current alerting practice and evaluate its ability to take the place of a prehospital early warning system.

Data were collected for a sample of patients brought by ambulance to the resuscitation area of Aberdeen Royal Infirmary ED over a 7-week period. Basic demographic information plus alert status and guidance prompt status was collected and compared with a pragmatic alert requirement. Analysis of ambulance crew alert decisions and the pre-alert guidance prompt advice was undertaken and compared.

Ambulance crew decisions to alert had a sensitivity of 72% (CI 62% to 80%), specificity of 50% (CI 27% to 73%), positive predictive value (PPV) of 90% and negative predictive value (NPV) of 22%. The pre-alert guidance alert prompt had a sensitivity of 99% (CI 94% to 100%), specificity of 64% (CI 39% to 84%), PPV of 95% and NPV of 90%. 28% of patients were under-alerted by ambulance crews, mostly medical patients presenting with chest pain.

The pre-alert guidance tool shows face validity and superior ability to advise a pre-alert than ambulance crew decisions. It supplements a practitioners’ clinical decision-making and has been regarded as having a positive impact on ED triage and utilisation of resources. Further levels of validity are expected to be achieved with continued audit and ongoing use of this tool.

We performed a chart review of all adult patients who were discharged from an urban ED in the USA, with an 88 000 annual visit volume. All charts of patients presenting with the three most common ED chief complaints (chest pain, abdominal pain and headache) were reviewed by two reviewers. Charts were coded as either symptomatic or pathological diagnosis based on the discharge diagnosis provided by the attending physician. Those with discrepant coding by the two reviewers were subject to review by a third adjudicator.

797 charts met the inclusion criteria. Five charts (0.6%) were coded differently by the two reviewers; a discussion with the third reviewer resulted in consensus in all cases. For patients presenting with chest pain, abdominal pain and headache, the proportion that received a pathological ED discharge diagnosis were 17%, 43% and 41%, respectively.

According to our pilot study, most patients are discharged from the ED without a pathological diagnosis that explains the likely cause of their symptoms. Future studies will investigate whether this finding is consistent across institutions, and whether provision of a pathological diagnosis affects clinical outcomes and patient satisfaction.

Four EDs were selected to take part in the study. A period of up to 3 days was spent in each ED in order to collect data. Mixed methods were utilised to capture data: incident report forms were examined to establish the reported incidence of violence/aggression, ethnographic observations were noted, and staff interviews were undertaken.

Staff defined violence as having both verbal and physical dimensions, and felt that verbal aggression was a regular occurrence. Staff communicated a number of reasons, which went beyond excessive alcohol consumption, as to why EDs are particularly susceptible to aggression/violence.

There was variation in reporting behaviour between departments and individuals. This appeared to be linked to the presence of security staff within the hospital, staff disillusionment with the reporting process, and issues with the incident report form itself.

This study adds to current evidence regarding how staff perceive and experience violence in the ED. Given the variation in reporting behaviour, national figures on violence within the NHS are likely to be underestimated. More research is needed to understand the true prevalence of violence occurring in the ED.

This was a prospective, non-blinded randomised controlled trial conducted in a university affiliated emergency department (ED). The inclusion criteria were (1) age ≥18 years; (2) anterior or posterior shoulder dislocation without fracture of the surgical neck of the humerus; (3) patient who is able to communicate and cooperate. Participants were randomly assigned using a computer generated random number sequence into one of two groups—either the traditional practice group or Oxford chair group. Administration of intravenous sedation was only permitted in the traditional practice group due to the concerns of sedation use in the sitting position while unsupported on the chair. The primary outcome measure was length of ED stay. The secondary outcome measures were length of time for the procedure, successful reduction rate, levels of pain experienced by patients in different time periods before and after the reduction.

Sixty eligible patients were recruited, 30 in each group. The median lengths of stay in the ED in Oxford chair group (n=30) and traditional method group (n=30) were152 min and 173 min respectively (p=0.183). The median procedure time was 3 min for the Oxford chair group compared to 5 min in the traditional method group (p=0.179). The success rate for the Oxford chair method was 77% (23/30). There were no statistically or clinically significant differences of pain score at any point.

The chair method had a 77% success rate in reducing acute shoulder dislocations without sedation. There was no difference in pain level experienced by patients between the chair method and the traditional method. Patient factors, including patients who have had previous shoulder surgery and patients who have fracture dislocations, contribute to the reduced efficacy of the chair method. It remains possible that the chair method may reduce patient length of stay in the ED in uncomplicated patients.

We conducted a comprehensive search of the major databases (Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid PsycInfo, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews and Scopus) and references of potentially eligible articles and conference proceedings of major emergency medicine organisations through May 2012. We included all original research studies conducted in emergency departments on diagnostic performance of PERC. Two reviewers independently identified the eligible studies and extracted data. Sensitivity, specificity and likelihood ratios were calculated using contingency tables.

12 studies including 13 cohorts (three retrospective, 10 prospective) were included, comprising of 14 844 patients from six countries. 12 cohorts were urban and one was rural. Pooled (95% CI) sensitivity, specificity, positive and negative likelihood ratio were 0.97 (0.96 to 0.98), 0.22 (0.22 to 0.23), 1.22 (1.16 to 1.29) and 0.17 (0.13 to 0.23), respectively. The pooled (95% CI) diagnostic OR was 7.4 (5.5–9.8). On meta-regression analysis, there was no significant difference between PE prevalence and PERC diagnostic performance (coefficient (SE) of –0.032 (0.022), p=0.173) or on relative diagnostic OR (0.97, 95% CI 0.92 to 1.02). Significant heterogeneity was observed in specificity (I²=97.4%) and positive likelihood ratio (I²=89.1%).

Because of the high sensitivity and low negative likelihood ratio, PERC rule can be used confidently in clinically low probability population settings.

A prospective observational cohort study of prognosis in head-injured patients was undertaken in the emergency (ED) department of an adult tertiary hospital with a statewide neurosurgical service from 2008 to 2010. A convenience sample of patients taking warfarin, aspirin, clopidogrel or mixed therapy presenting to the ED with head trauma were included and followed-up over 3–18 months. Outcomes were severity of brain injury on neuroimaging, intensive care unit admission, intracranial surgery, intracranial complications, death in hospital, altered Glasgow Coma Score (GCS) on hospital discharge, and mortality and function scores on follow-up.

Overall, 345 patients were included in the study. Of these, 164, 70, 55 and 56 were taking aspirin, warfarin, clopidogrel and combination agents, respectively, with 250 having neuroimaging in the ED. Neuroimaging was significantly more likely to be undertaken in patients with a more urgent triage score (p<0.001), an abnormal GCS (p=0.004), older patients (p=0.039), and those taking warfarin (p<0.001). In patients receiving neuroimaging and admitted to hospital, the proportion with acute brain injury, poor hospital outcomes or overall poor outcomes were not statistically different between the agent groups.

A high proportion of patients taking warfarin underwent neuroimaging, but brain injury and admission rates were comparable between groups. There were no significant differences in short-term outcomes between the groups. The overall mortality is higher for patients on antiplatelet agents than warfarin.

Three groups of healthcare professionals were separately provided with brief supervised training in using the three devices. Afterwards the participants were asked to place the airway device. For every participant, the positioning of each device was recorded. The success rate and timing of insertion were measured. Furthermore, each insertion was scored for the ease of insertion, clinical and fibreoptic verification of the position and successful ventilation.

A total of 66 healthcare providers (22 paramedics, 22 nurse anaesthetists and 22 anaesthesia residents) participated in the study. The median time of insertion of both the laryngeal mask and the tube was significantly longer than for the I-gel for all professional groups (p<0.001). The success rate with the I-gel was higher than that with the laryngeal mask or tube (p<0.001). Except for the laryngeal mask, there were no differences among the professional groups regarding the fibreoptic evaluation.

In terms of both the time required for successful placement and the rate of successful placement, the I-gel is superior to the laryngeal mask and tube in paediatric resuscitation simulations by healthcare professional groups with different levels of experience with paediatric airway management.

A retrospective review of paediatric major trauma calls was performed between 1 April 2009 to 31 January 2010, before MTC status, and the same time period in 2010/11 when St George's Healthcare Trust was a designated adult MTC. The following variables were assessed; number of trauma calls, admissions to hospital, radiological services usage, inpatient stay, mechanism of injury and injury severity score (ISS)—calculated from abbreviated injury score.

There was a 200% increase in trauma calls between the two time periods and a 191% increase in admission to hospital. The usage of radiology increased 221% for CT and 161% for plain radiology. Mean inpatient stay decreased by 0.2 days. Mechanisms of injury were similar. Despite becoming a MTC the relative volume of major injuries (ISS>15) decreased between the two time periods by 1% with a relative increase in minor trauma (ISS<5) from 63% to 72%. These results may suggest at present paediatric trauma patients are being over triaged.

Major adult trauma centre status has a significant effect on paediatric trauma workload and hence resources. When reconfiguration of trauma services are being considered it is essential to take into account the impact on paediatric services alongside those of the adult population.

A questionnaire based survey of the perception of violence among nurses working in six tertiary hospitals’ EDs across five states in Nigeria was conducted.

81 nurses were interviewed with a male to female ratio of 1:4. Most were right about the definition of violence. About 88.6% of respondents have witnessed ED violence while 65.0% had been direct victims before. Nurses followed by doctors were the usual victims. The acts were carried out mostly by visitors to the ED. Men were usually responsible for the violence, which usually occurred in the evenings. Weapons were not commonly utilised: only 15.8% of the nurses had been threatened with a weapon over a 1-year period. The main perceived reasons for violence were overcrowded emergency rooms, long waiting time and inadequate system of security. All the institutions were lacking in basic strategies for prevention. While most of the nurses were not satisfied with the EDs that were considered not safe, few would wish for redeployment to other departments/units.

There is a need to make the EDs safer for all users. This can be achieved by a deliberate management policy of ‘zero’ tolerance to workplace violence, effective reporting systems, adequate security and staff training on prevention of violence.

Retrospective review of 203 ambulatory children, between 1 and 5 years old, presenting with femur fractures to an urban paediatric hospital over a 10-year period. ² And Student's t test were employed for statistical analysis.

The mean age was 36.6 months, with 155 (76.2%) being male. The most frequent mechanism of injury was fall from a height (n=62, 30.5%). The highest number of injuries occurred in 2–3-year-olds. The most common history in 1–2-year-olds was stumbling on/over something causing a fall. For 4–5 year olds it was road traffic accidents. Other additional physical findings were infrequent (14.3%) and not suspicious of inflicted injury. Child protective services concluded three of the cases to be likely non-accidental, and four cases were inconclusive but requiring close follow-up. Of these seven children, six occurred in 1–2-year-olds. No distinguishing feature was noted in fracture type or location.

Femur fractures can occur with low velocity injury whether from a short fall or twisting/stumbling injury in young healthy ambulatory children.

Non-traumatic OHCA occurring in paediatric patients aged less than 16 years were identified using the Victorian Ambulance Cardiac Arrest Registry and available coronial findings reviewed.

Between the years 2001 and 2009, emergency medical services (EMS) attended 26 974 non-traumatic OHCA of which 390 (1.4%) occurred in children less than 16 years of age. We successfully linked 301 patients with the coronial registry; excluding patients discharged alive from hospital (n=22) and patients with terminal illness (n=16), this represents 86% of OHCA attended by the ambulance. Agreement between the paramedic cause of OHCA and the coronial cause of death was 66.5% ( 0.16) for presumed cardiac, 74.4% ( 0.43) for sudden infant death syndrome (SIDS), 81.1% ( 0.17) for respiratory, 92.7% ( 0.18) for neurological and 98.3% ( 0.27) for drug overdose precipitants to OHCA. Undiagnosed congenital heart disease was a rare cause of OHCA (n=3, 1%). Intentional injury was found on autopsy in 13 cases; six cases were clinically thought to be SIDS and two cases presumed cardiac. Co-sleeping was found in 35 cases (39%) of SIDS.

This study highlights the limitations associated with ascribing the cause of OHCA on the basis of clinical details. Improved reporting is possible by linkage with coronial data. Such robust data inform EMS service providers but also the wider healthcare system where preventive, diagnostic and treatment strategies can be maximised.

Untrained laypersons were allocated to either the metronome sound-guided group (MG), who performed DA-COCPR with metronome sounds (110 ticks/min), or the control group (CG), who performed conventional DA-COCPR. The participants of each group performed DA-COCPR for 4 min using a manikin with Skill-Reporter, and the data regarding chest compression quality were collected.

The data from 33 cases of DA-COCPR in the MG and 34 cases in the CG were compared. The MG showed a faster compression rate than the CG (111.9 vs 96.7/min; p=0.018). A significantly higher proportion of subjects in the MG performed the DA-COCPR with an accurate chest compression rate (100–120/min) compared with the subjects in the CG (32/33 (97.0%) vs 5/34 (14.7%); p<0.0001). The mean compression depth was not different between the MG and the CG (45.9 vs 46.8 mm; p=0.692). However, a higher proportion of subjects in the MG performed shallow compressions (compression depth <38 mm) compared with subjects in the CG (median % was 69.2 vs 15.7; p=0.035).

Metronome sound guidance during DA-COCPR for the untrained bystanders improved the chest compression rates, but was associated more with shallow compressions than the conventional DA-COCPR in a manikin model.

We investigated the existence or absence of vomiting in stroke patients in the Kyoto prefecture cohort. We compared the characteristics of patients with and without vomiting. We calculated the HR for death in both types of patients, adjusted for age, sex, blood pressure, arrhythmia, tobacco and alcohol use and paresis.

Of the 1968 confirmed stroke patients, 1349 (68.5%) had cerebral infarction (CI), 459 (23.3%) had cerebral haemorrhage (CH) and 152 (7.7%) had subarachnoid haemorrhage (SAH). Vomiting was seen in 14.5% of all stroke patients. When subdivided according to stroke type, vomiting was observed in 8.7% of CI, 23.7% of CH and 36.8% of SAH cases. HR for death and 95% CI were 5.06 and 3.26 to 7.84 (p<0.001) when all stroke patients were considered, 5.27 and 2.56 to 10.83 (p<0.001) in CI, 2.82 and 1.33 to 5.99 (p=0.007) in CH and 5.07 and 1.87 to 13.76 (p=0.001) in SAH.

Compared with patients without vomiting, the risk of death was significantly higher in patients with vomiting at the onset of stroke. Vomiting should be an early predictor of the outcome.

The purpose of this study was to assess how Iranian ED residents deal with abuse. Awareness, educational programmes, reports, causes of abuse and ways to reduce this were considered in this survey.

In 2011, a cross-section survey was conducted at seven ED residencies of central hospitals in Tehran, Mashhad, Ahwaz and Tabriz. ED residents were asked about their age, sex, abuse time, awareness of abuse, educational programmes, reporting abuse, causes of reluctance to report, and how to reduce abuse. The data were analysed by SPSS V.20.

A total of 215 questionnaires were completed. Abuse was reported to have occurred most frequently during night shifts (n=89, 41.4%),  and most of the residents were abused by men rather than women (n=132, 61% vs n=22, 10%, p<0.05). About half the residents (n=107, 49.8%) were not aware of any abuse. Only 22% (n=46) had formal or informal education in abuse, and 74% (n=158) of them had not gone through any learning programmes. Most residents (n=175, 81%) did not know how to report abuse, and among respondents, most of the residents did not report the abuse (n=86, 40%), and the cause was mostly the uncertainty towards officials being able to solve the problem of abuse (n=67, 38%). Residents most often reported not to admit patients more than the hospital's capacity as the main solution to reduce abuse (n=61, 32%).

Being abused during residency is a universal problem, and there is a lack of awareness and the knowledge of how to deal with abuse, and reporting it among ED residents in Iranian hospitals.

To describe the incidence of hyponatraemia and assess its effect on outcome in patients with crush syndrome during the Wenchuan earthquake.

A retrospective study was conducted in 17 reference hospitals during the Wenchuan earthquake. We excluded patients younger than 15 years and those with missing sodium values within 3 days after being rescued from the ruins.

Hyponatraemia (serum sodium concentration <135 mmol/l) was seen in 91/180 (50.6%) patients on admission. Compared with patients with normonatraemia, those with hyponatraemia were younger, had more severe traumatic injury and renal failure, underwent more fasciotomies, received more blood transfusion and renal replacement therapy. In the multivariable-adjusted model, the number of extremity injuries (OR=1.59, 95% CI 1.08 to 2.33) and serum creatinine (OR=1.30, 95% CI 1.07 to 1.59) were independently associated with the occurrence of hyponatraemia. Covariate adjusted multiple logistic regression analysis showed an independent mortality risk rising with hyponatraemia (OR=5.74, 95% CI 1.18 to 28.00).

Hyponatraemia was common in the patients with crush syndrome during the Wenchuan earthquake and associated with poor prognosis. Water, commercial drinks and hypotonic intravenous fluids should be supplied carefully to patients with crush syndrome.

Consecutive children presenting to an Australian paediatric Emergency Department with HIs were enrolled. Published inclusion/exclusion criteria and predictor variables from the CDRs were collected prospectively. Using these we determined the frequency with which each CDR was applicable.

1012 patients (69.9%) were enrolled with 949 available for analysis. Mean age was 6.8 years (21% <2 years). 95% had initial Glasgow Coma Scale 15. CT rate was 12.8% and neurosurgery rate was 0.7%. No CDR was applicable to all patients. CHALICE was applicable to the most (97%, 95% CI 96% to 98%) and CATCH to the fewest (26%, 95% CI 24% to 29%). PECARN was applicable to 76% (95% CI 70% to 82%) aged <2 years, and 74% (95% CI 71% to 77%) aged 2–<18 years.

Each CDR is applicable to a different proportion of children with HI. This makes a direct comparison of the CDRs difficult. Prior to selection of any for implementation they should undergo validation outside the derivation setting coupled with an analysis of their performance accuracy, usability and cost effectiveness.

To evaluate whether alternative healthcare services could reduce the need for admissions to specialist care hospitals.

Prospective observational study of emergency referrals for admission to specialist care.

A single out-of-hours primary care centre (OPCC) in Norway.

Out-of-hours physicians registered their referrals for hospital admission and stated whether the admission could have been avoided given the availability of six other healthcare services.

Of 1083 registered encounters at the OPCC, 152 (14%) were referred for specialist care hospital admission. According to the referring physician, 32 (21%) of these referrals could have been avoided. The most eligible alternatives to such referrals were next-day appointments at a specialist outpatient clinic (11 of 32 referrals), or admission to a community hospital (21 of 32 referrals), or a nursing home (nine of 32 referrals). Respiratory (eight of 32 referrals) and gastrointestinal problems (12 of 32 referrals) were the most common among avoidable admissions.

The use of specialist care hospital admission can be reduced if appropriate alternatives are available.

This was a prospective cross-sectional study including all the haemodynamically stable, high-energy, blunt trauma patients with negative pelvic physical examination referring to our trauma centre during a 5-month period (May–September 2010). Pelvic radiographies were performed and reviewed for abnormalities. In those who had negative pelvic physical examination and the radiography was not revealing enough, CT imaging was requested and reviewed.

During the study period, 1679 high-energy blunt trauma patients referred to our centre out of which 389 were haemodynamically stable and had negative pelvic physical examination. Pelvic radiography was found to be normal in all the patients except one (0.25%) who had pelvic fracture. Only three patients required CT imaging out of which two (0.5%) were found to be normal.

Pelvic radiography could be eliminated from the primary survey protocol of the patients with high-energy blunt trauma who are haemodynamically stable and have negative pelvic physical examination.

The study design used was a retrospective longitudinal analysis based on medical chart review and a computer database. Except for a shorter list of complaints and some abnormal vital sign criteria modifications, the structure and triage process for applying Ped-TTAS was similar to that of the Paediatric Canadian Emergency Triage and Acuity Scale. Non-trauma paediatric patients presenting to the ED were triaged by well-trained triage nurses using the four-level Ped-TTS in 2008 and five-level Ped-TTAS in 2010. Hospitalisation rates and medical resource utilisation were analysed by acuity levels between the contrasting study groups.

There was a significant difference in patient prioritisation between the four-level Ped-TTS and five-level Ped-TTAS. Improved differentiation was observed with the five-level Ped-TTAS in predicting hospitalisation rates and medical costs.

The five-level Ped-TTAS is better able to discriminate paediatric patients by triage acuity in the ED and is also more precise in predicting resource utilisation. The introduction of a more accurate acuity and triage system for use in paediatric emergency care should provide greater patient safety and more timely utilisation of appropriate ED resources.

The National University Hospital operates the only ED for adults in the capital area of Reykjavik. The source of data was the electronic records for patients 18 years or older, who left AMA, who left WBS, who had the ICD-10 code Z53.2, or who completed their visits. ED visits, hospital admissions and the death registry are filed with the personal identification number, which enabled recognition of the index visit, and the outcomes, rates of return visits, hospitalisation and death.

Of 107 119 patients, 77 left AMA, 4471 left WBS and 423 had code Z53.2. The HR for returning to the ED within 30 days was 4.79 for AMA patients, 4.84 for WBS patients and 3.67 for Z53.2 patients. The HR for hospitalisation within 30 days was 6.90 for AMA patients, 1.09 for WBS patients and 1.07 for Z53.2 patients. The HR for death within 30 days was 10.97 for AMA patients, 0.84 for WBS and no deaths occurred among Z53.2 patients.

During 30 days follow-up, AMA and WBS patients had an increased rate of repeat ED visits compared with those patients who completed their ED visits. AMA patients also had an increased rate of hospitalisations.

This 1-year, prospective, observational, cohort study determined the daily percentage of patients leaving the ED in <4 h (ED quality and performance indicator; EDQPI). According to the median EDQPI two groups were defined: best-days and bad-days. Hospital and ED variables and time interval metrics were evaluated as predictors.

Data were obtained for 67 307 patients over 364 days. Differences were observed between the two groups in unadjusted analysis: number of daily visits, number of patients as a function of final disposition, number boarding in the ED, and time interval metrics including wait time to triage nurse and ED provider, time from ED admission to decision, time from decision to departure and length of stay (LOS) as a function of final disposition. Five variables remained significant predictors for bad-days in multivariate analysis: wait time to triage nurse (OR 2.36; 95% CI 1.36 to 4.11; p=0.002), wait time to ED provider (OR 1.93; 95% CI 1.05 to 3.54; p=0.03), number of patients admitted to hospital (OR 1.86; 95% CI 1.09 to 3.19; p=0.02), LOS of non-admitted patients (OR 9.5; 95% CI 5.17 to 17.48; p<0.000001) and LOS of patients admitted to hospital (OR 2.46; 95% CI 1.44 to 4.2; p=0.0009).

Throughput is the major determinant of EDQPI, notably time interval reflecting the work dynamics of medical and nursing teams and the efficacy of fast-track routes for low-complexity patients. Output also significantly impacted on EDQPI, particularly the capacity to reduce the LOS of admitted patients.

We used clinical and outcome data from a large international biomarker study (BACH trial) and analysed data of all 1557 patients of the European and US sites presenting with acute dyspnoea. Patients were discharged or transferred from the ED to different levels of care (general ward, monitoring unit, intensive care unit). This original patient disposition was compared with the hypothetical disposition based on an adapted method of net reclassification improvement (NRI), which upgraded or downgraded patients from one level of care to the other based on the MR-proADM test result.

MR-pro-ADM was significantly higher in patients who died during the follow-up than in survivors (p<0.0001). When applying the adapted NRI model, 30 additional patients from the European Union (EU) and 55 additional patients from USA were theoretically discharged (increase of 16.5%) if MR-proADM had been used for patient management. The overall NRI, adding up the rates of upgrades and downgrades, in the EU was 16.0% (95% CI 8.2% to 23.9%). A total of n=72 (9.9%) patients changed disposition when adding MR-pro ADM. In the USA, the overall NRI was 12.0% (5.7%–18.4%) and a total of n=81 (11.2%) patients changed disposition.

MR-proADM has the potential to guide initial disposition of undifferentiated ED patients with acute dyspnoea and might therefore be helpful to improve resource utilisation and patient care.

Compare the holding strength of each type of clamps by measuring the amount of kinetic energy absorbed, ask 20 physicians to evaluate the clamp placement using sutures or staples, and summarise the clamps effectiveness and complications in 10 patients.

Compared to sutured clamp, the needleless clamp was more secure. The needleless clamp was also significantly better with regard to ease of use, safety, perceived strength (p value <0.002), and insertion time was reduced by 63%. No adverse events or skin infections occurred while using the needleless clamps.

Without incurring complications or increasing risk to patients, the needleless clamp is secure and improves safety and efficiency for physicians.

A consecutive series of 1524 patients attending one of Scandinavia's largest emergency departments (ED) due to DSH during a 3-year period were included. Explanatory factors were collected from hospital charts and national databases. A nationwide register-based follow-up of new DSH episode or death by suicide within 6 months was used. We used logistic regression, area under the curve and classification trees to identify factors associated with repetition. To evaluate the ability of different decision rules to identify patients who will repeat DSH, we calculated the sensitivity and specificity.

Repeated DSH or suicide within 6 months.

The cumulative incidence for patients repeating within 6 months was 20.3% (95% CI 18.0% to 22.0%). Application of Manchester Self-Harm Rule to our material yielded a sensitivity of 89% and a specificity of 21%. The clinical decision rule based on four factors associated with repetition in the Swedish population yielded a sensitivity of 90% and a specificity of 18%.

Application of either rules, with high sensitivity, may facilitate assessment in the ED and help focus right resources on patients at a higher risk. Irrespective of the choice of decision rule, it is difficult to separate those who will repeat from those who will not due to low specificity.

This was a retrospective survey of children found to be vitamin D deficient after attending the emergency department from March 2009 until March 2010. These data were then subdivided according to their age, ethnic origin, presenting complaint and biochemical associated features.

We identified 89 patients with a low vitamin D level (total vitamin D levels less than 50 nmol/l), with 83% of those having very low vitamin D levels (less than 25 nmol/l). The most common presenting features were abdominal pain (19%), a seizure (17%) and limb pain (15%). The most common ethnic origins in our series were Pakistani (37%) followed by black African (11.2%).

Vitamin D deficiency should be considered in children with pigmented skin presenting with a range of symptoms. The detected vitamin D deficiency probably represents only a very small proportion of the vitamin D deficiency in children in Birmingham.

A national prospective, observational study was conducted over a 2-year period. All patients under 17 years of age referred to a neurosurgical service following TBI were included. Data on patient demographics, events surrounding injury, injury type and severity, patient management and outcome were collected from ‘on-call’ logbooks and neurosurgical admissions records.

342 patients were included. Falls were the leading cause of injury for both sexes. Boys’ injuries tended to involve greater energy transfer and involved more risk-prone behaviour resulting in a higher rate of other (non-brain) injury and a higher mortality rate. Intentional injury occurred only in boys. While injury severity was similar for boys and girls, significant gender differences in injury type were present; extradural haematomas were significantly higher in boys (p=0.014) and subdural haematomas were significantly higher in girls (p=0.011). Mortality was 1.8% for girls and 4.3% for boys.

Falls were responsible for most TBI, the home is the most common place of injury and non-operable TBI was common. These findings relate to all children. Significant gender differences exist from infancy. Boys sustained injuries associated with a greater energy transfer, were less likely to use protective devices and more likely to be injured deliberately. This results in a different pattern of injury, higher levels of associated injury and a higher mortality rate.

A retrospective chart review of medical records of 489 patients admitted due to poisoning in the 5-year period (2006–2010). The data included: age, sex, place of residence, nature of the substance, causes of poisoning, former use of psychoactive stimulants, accompanying self-mutilation and injuries and length of hospitalisation. Categorical variables were expressed as percentages, and continuous variables as mean and SD. The data were collected in a Microsoft Excel database. Statistical analysis was performed using the Statistical Programme for Social Sciences.

Out of 2176 hospitalised children, 489 were admitted because of poisoning. Out of these, 244 (49.9%) were hospitalised due to intoxication by alcohol. Only eight children used designer drugs. The mean age of all patients in our group was 12.86±5.04 years, of which 52.4% were male. Poisoning was intentional in 75.5%, and accidental in 24.5% of cases. Appearance of ‘designer drugs’ had no significant impact on the number and epidemiology of poisonings in our group.

We recruited 30 senior medical students with no previous experience of using flashlight-guided CPR to participate in this prospective, simulation-based, crossover study. The experiment was conducted in a simulated noisy situation using a cardiac arrest model without ventilation. Noise such as patrol car and fire engine sirens was artificially generated. The flashlight guidance device emitted light pulses at the rate of 100 flashes/min. Participants also received instructions to achieve the desired rate of 100 compressions/min. CPR performances were recorded with a Resusci Anne mannequin with a computer skill-reporting system.

There were significant differences between the control and flashlight groups in mean compression rate (MCR), MCR/min and visual analogue scale. However, there were no significant differences in correct compression depth, mean compression depth, correct hand position, and correctly released compression. The flashlight group constantly maintained the pace at the desired 100 compressions/min. Furthermore, the flashlight group had a tendency to keep the MCR constant, whereas the control group had a tendency to decrease it after 60 s.

Flashlight-guided CPR is particularly advantageous for maintaining a desired MCR during hands-only CPR in noisy environments, where metronome pacing might not be clearly heard.

This was a retrospective case note review over a 6-month period. Patients were included if their presentation was due to ingestion of Eric-3. Physiological data, symptoms, outcome and destination of the patient from the ED were collected. Postmortem toxicological analysis was obtained for one of the patients who died.

41 attendances were identified from 18 patients. Two patients died and five were admitted to ITU. Heart rate and temperature on arrival tended to be above normal (mean heart rate was 112 bpm, with an SD of 18; mean temperature was 37.45° with an SD of 0.95°). 63.4% of attendances included agitation and 34.1% choreiform movements. α-Methyltryptamine and 3-/4-flouroephedrine were found in the blood of one of the patients who died.

In this outbreak, Eric-3 gave symptoms similar to other stimulants. It may have been a novel substance 3-/4-flouroephedrine. It underlines the need for prospective data collection and information sharing.

All patients diagnosed with a thoracolumbar fracture presenting to the emergency department of a major trauma centre and having an initial GCS score of 15 were included in the study. Variables collected included type of fracture, mechanism of injury, the presence of pain or tenderness on log-roll, ethanol levels and prehospital opioid analgesia.

There were 536 patients with thoracolumbar fractures, of which 508 (94.8%) patients had either pain, tenderness or had received prehospital opioid analgesia. A small subgroup of 28 (5.2%) patients who received no prehospital opioid analgesia, did not complain of pain and had no tenderness to the thoracolumbar spine elicited on log-roll. This subgroup was significantly older (p=0.033) and a high proportion of patients (64.3%) had a concurrent fracture of the cervical spine. Within this subgroup, a clinically significant unstable thoracic fracture was present in three patients, with all three patients exhibiting symptoms and signs of neurological injury or having a concurrent cervical vertebral fracture.

In this population of blunt trauma patients with a GCS score of 15, not under the influence of alcohol or prehospital morphine administration, the absence of pain or tenderness on log-roll can exclude a clinically significant lumbar vertebral fracture, but does not exclude a thoracic fracture.

A prospective study was conducted including patients with acute ischaemic stroke, intracerebral haemorrhage and transient ischaemic attack admitted to hospital. Time intervals for prehospital delay, background data, severity, type of first medical contact and mode of transport were recorded. Univariate and multivariate analyses were performed to identify factors influencing prehospital delay.

A total of 440 patients were included, with a mean age of 71.4±13.0 years (44.3% female subjects), consisting of 65.9% patients with ischaemic stroke, 11.4% with intracerebral haemorrhage and 22.7% with transient ischaemic attack. The median time from symptom onset to admission was 3.0 h (179 min; IQR 77–542). The median decision delay was 1.5 h (92 min, IQR 25–405) and accounted for 55.1% (median value) of the prehospital delay. 310 (70.5%) patients arrived by ambulance. In the multivariate linear regression analysis, high National Institute of Health Stroke Scale score (p<0.001), transport by ambulance (p<0.001) and lower age (p=0.048) were significantly associated with early admission.

Severe strokes, use of ambulance and lower age are associated with reduced prehospital delay. The present study shows that more than half of the delay is caused by the hesitation to contact medical services. Public information campaigns should focus on fast symptom recognition and the importance of immediately contacting the Emergency Medical Services upon symptom onset.

Electronic abstract databases, trial registries, article reference lists and internet repositories were searched using the following search terms: ‘peripheral venous cannulation’, ‘peripheral venous access’. Studies meeting the following criteria were included: randomised controlled trial patients of all ages who required peripheral intravenous access; interventions were Ultrasound-guided versus standard cannulation technique; patients were identified as having difficult venous access; inclusion of at least one defined outcome (procedural success time to cannula placement; number of attempts).

7 trials were identified (289 participants). Ultrasound guidance increases the likelihood of successful cannulation (pooled OR 2.42; 95% CI 1.26 to 4.68; p=0.008). There were no differences in time to successful cannulation, or number of percutaneous skin punctures.

Ultrasound guidance increases the likelihood of successful peripheral cannulation in difficult access patients. We recommend its use in patients who have difficult venous access, and have failed venous cannulation by standard methods. Further randomised controlled trials (RCTs) with larger sample sizes would be of benefit to investigate if Ultrasound has any additional advantages in terms of reducing the procedure time and the number of skin punctures required for successful venous cannulation.

A multi-stage, 80x20 cluster sample randomized survey (1800 households) with probability proportional to size of households affected by the 2010 Indus river floods in Pakistan. The floods affected over 18 million households and led to more than 8 billion USD in response dollars.

Less than 20% of respondents reported being satisfied with response, though a small increase in satisfaction levels was observed over the three time periods of interest. Within the first month, receipt of hygiene items, food and household items was most strongly predictive of overall satisfaction. At 6 months, positive receipt of medicines was also highly predictive of satisfaction. The proportion of households reporting unmet needs remained elevated throughout the 6-month period following the floods and varied from 50% to 80%. Needs were best met between 1 and 3 months postflood, when response was at its peak. Unmet needs were the greatest at 6 months, when response was being phased down.

Access-limiting issues were rarely captured during routine monitoring and evaluation efforts and seem to be a significant predictor in dissatisfaction with relief efforts, at least in the case of Pakistan, another argument in favor of independent, population-based surveys of this kind. There is also need to better identify and serve those not residing in camps. Direct surveys of the affected population can be used operationally to assess ongoing needs, more appropriately redirect humanitarian resources, and ultimately, judge the overall quality of a humanitarian response.

62 Health science students performed 5 min of conventional CPR in accordance with the 2010 ERC guidelines. A SkillReporter manikin was used to objectively assess temporal change in determinants of CPR quality. Participants subjectively reported their end-fatigue levels, using a visual analogue scale, and the point at which they believed fatigue was affecting CPR delivery.

49 (79%) participants reported that fatigue affected their CPR performance, at an average of 167 s. End fatigue averaged 49.5/100 (range 0–95). The proportion of chest compressions delivered correctly decreased from 52% in min 1 to 39% in min 5, approaching significance (p=0.071). A significant decline in chest compressions reaching the recommended depth occurred between the first (53%) and fifth (38%) min (p=0.012). Almost half this decline (6%) was between the first and second minutes of CPR. Neither chest compression rate, nor rescue breath volume, were affected by rescuer fatigue.

Fatigue affects chest compression delivery within the second minute of CPR under the 2010 ERC guidelines, and is poorly judged by rescuers. Rescuers should, therefore, be encouraged to interchange after 2 min of CPR delivery. Team leaders should be advised to not rely on rescuers to self-report fatigue, and should, instead, monitor for its effects.

Cricothyroidotomy in 30 human cadavers performed by 30 first year anaesthesia residents. The set chosen for use was randomised: PCK-technique (n=15) and ST (n=15). Success rates, insertion times and complications were compared. Traumatic lesions were anatomically confirmed after dissection.

The ST-group had a higher success rate (100% vs 67%; p=0.04). There was no difference in time taken to complete the procedure (PCK 82 s. vs ST 95 s.; p=0.89). There was a higher complication rate in the PCK-group (67% vs 13%; p=0.04). Most frequent complication in the PCK-group was injury to the posterior tracheal wall (n=8), penetration to the oesophageal lumen (n=4) and injury to the thyroid and/or cricoid cartilage (n=5). In the ST-group in only 2 cases minor complications were observed (small vessel injury).

In this human cadaver study the PCK technique produced more major complications and more failures than the ST. In the hand of the inexperienced operator the standard surgical approach seems to be a safe procedure, which can successfully be performed within an adequate time. The PCK technique cannot be recommended for inexperienced operators.

114 patients with cardiac arrest who underwent chest CT after successful resuscitation from January 2006 to August 2009 were included in the study. To evaluate the area of the cardiac chambers subjected to external chest compression, the area of each cardiac chamber under the sternum was measured using cross-sectional CT at three different locations: the internipple line on the sternum (point A), halfway between point A and the sternoxiphoid junction (point B) and at the sternoxiphoid junction (point C).

The widest total heart area, total ventricular area and left ventricular area (LVA) were observed most frequently at point C (58%, 85% and 78% of all cases, respectively). Few cases (six in total heart area, one in total ventricular area and one in LVA) were observed as the widest at point A. Predicted compressed areas of the right and left ventricle were wider at point C than at points A or B (right ventricular area: 366±536 mm² at point A, 961±653 mm² at point B and 1383±689 mm² at point C, p<0.001; LVA: 65±236 mm² at point A, 365±506 mm² at point B and 1099±817 mm² at point C, p<0.001).

Only a small proportion of the ventricle is subjected to external chest compression when CPR is performed according to the current guidelines. Compression of the sternum at the sternoxiphoid junction might be more effective to compress the ventricles.

A retrospective analysis of suspected stroke patients who presented between November 2009 and November 2010, and had BUN and Cr levels measured by POCT-BUN/Cr, and the reference laboratory tests performed with the blood sample which was transferred to the central laboratory by an air-shoot system. Two assays were conducted on the whole blood (POCT) and serum (reference) by trained technicians. The time interval from arrival at the ED to reporting of the results was assessed for both assays via a computerised physician order entry system.

The mean standard deviation (SD) interval from arrival at the ED to reporting of the results was 11.4 (4.9) min for POCT-BUN/Cr and 46.8 (38.5) min for the serum reference laboratory tests (p<0.001). Intra-class correlation coefficient (ICC) analysis demonstrated a high level of agreement (the consistency agreement) between POCT and the serum reference tests for both BUN (ICC=0.914) and Cr (ICC=0.980).

This study suggests that POCT-BUN/Cr results correlate well with those of serum reference tests in terms of BUN and Cr levels and, in turn, predicting CIN. POCT-BUN/Cr is easily performed with a rapid turnaround time, suggesting its use in the ED may have substantial clinical benefit.

This retrospective study involved three dispatch centres in the UK and USA. We analysed 6 months of data involving chest pain/heart attack symptoms taken using the MPDS chest pain and heart problems/automated internal cardiac defibrillator protocols.

The EMDs successfully completed the ADxT on 69.8% of the 44 141 cases analysed. The patient's mean age was higher when the ADxT was completed, than when it was not (mean±SD: 53.9±19.9 and 49.9±20.2; p<0.001, respectively). The ADxT completion rate was higher for second-party than first-party calls (70.3% and 69.0%; p=0.024, respectively). A higher percentage of male than female patients took aspirin (91.3% and 88.9%; p=0.001, respectively). Patients who took aspirin were significantly younger than those who did not (mean±SD: 61.8±17.5 and 64.7±17.9, respectively). Unavailability of aspirin was the major reason (44.4%) why eligible patients did not take aspirin when advised.

EMDs, using a standardised protocol, can enable early aspirin therapy to treat potential ACS/AMI prior to responders' arrival. Further research is required to assess reasons for not using the protocol, and the significance of the various associations discovered.

We retrospectively reviewed the medical records of 37 387 inpatients. Among them, 883 (2.36%) cases of abdominal injury were deemed eligible and enrolled for analysis. The data analysed included demographics, category of abdominal injury, associated injury type, cause of injury, treatment and clinical outcome, as well as risk factors for death.

Abdominal injury was often accompanied with multiple injuries. Injury of the abdominal wall was the most frequent type of earthquake-related abdominal injury (32%). The spleen was the most commonly injured abdominal organ (18%). Of the 883 patients evaluated, 221 cases received operations and 41 cases died. The highest death rate was found in patients with haemorrhagic shock (28/41, 68.3%) caused by intra-abdominal bleeding.

Abdominal injuries are relatively uncommon in earthquake disasters and often present with associated injuries. A timely and complete diagnosis of both abdominal as well as associated injuries is of primary importance in the treatment of patients with abdominal injuries. Knowledge of different types of abdominal injury, and their relative proportions, prevalence of associated injuries, risk factors and final clinical outcomes observed in this study may be of valuable reference in dealing with major earthquake events in the future.

Manual chest compressions were compared with LUCAS 2, AutoPulse and animax mono devices using the Ambu Man Wireless MegaCode manikin (10 series each). The measurements were performed in a standard ambulance vehicle during transport on a predefined track of 5.0 km.

Mean compression frequencies in the manual group (117±18 min^–1) and in the animax mono group (115±10 min^–1) were significantly higher than in the LUCAS 2 group (100 min^–1, p=0.02) and the AutoPulse group (80 min^–1, p<0.01). Both mechanical devices worked absolutely constantly. Only the animax mono group reached with 51.2 mm the recommended compression depth. The quality of manual compressions decreased considerably during braking or change manoeuvres while the mechanical devices continued to work constantly.

During a patient transport with ongoing resuscitation, external mechanical compression devices may be a good alternative to manual compression because they increase the safety of the rescuer and patient. Yet, in this study only animax mono reached the guideline specifications regarding chest compressions' frequency and depth. Concerning constancy, the mechanical devices work reliably and more independently from motion influences. Further studies are necessary to evaluate the effectiveness of these devices in patient transport.

Senior medical students performed 12 sets of chest compressions following the guiding sounds, with three down-stroke patterns (normal, fast and very fast) and four rates (80, 100, 120 and 140 compressions/min) in random sequence. Repeated-measures analysis of variance was used to compare the average chest compression depth and duty cycle among the trials.

The average chest compression depth increased and the duty cycle decreased in a linear fashion as the down-stroke pattern shifted from normal to very fast (p<0.001 for both). Linear increase of average chest compression depth following the increase of the rate of chest compression was observed only with normal down-stroke pattern (p=0.004).

Induction of a shorter compression phase is correlated with a deeper chest compression during metronome-guided cardiopulmonary resuscitation.

This comparative cross-sectional study retrospectively assessed 28 289 digital chest x-rays and 2301 LODOX scans performed between 2006 and 2010 at a tertiary emergency centre. The radiographic appearance, image quality and location of ingested foreign bodies were evaluated in standard digital chest and LODOX radiography. The mean irradiation (μSv) and cumulative mean radiation dose per patient with the ingested foreign body were calculated according to literature-based data, together with the sensitivity and specificity for each modality.

A total of 62 foreign bodies were detected in 39 patients, of whom 19 were investigated with LODOX and 20 with conventional digital chest radiography. Thirty-three foreign bodies were located in the two upper abdominal quadrants, 21 in the lower quadrants—which are not visible on conventional digital chest radiography—seven in the oesophagus and one in the bronchial system. The sensitivity and specificity of digital chest radiography were 44.4% and 94.1%, respectively, and for the LODOX Statscan 90% and 100%, respectively. The calculated mean radiation dose for LODOX investigations was 184 μS, compared with 524 μS for digital chest radiography.

LODOX Statscan is superior to digital chest radiography in the diagnostic work-up of ingested foreign bodies because it makes it possible to enlarge the field of view to the entire body, has higher sensitivity and specificity, and reduces the radiation dose by 65%.

Ventilation was assessed with the Oxylator ventilator, as well as the consecutive self-contained underwater breathing apparatus (SCUBA) regulators using an anaesthetic test lung: Poseidon Cyklon 5000, Poseidon XStream, Apeks TX 100, Spiro Arctic, Scubapro Air2 and Buddy AutoAir.

Oxylator, Apeks TX 100, Arctic and Buddy AutoAir delivered reliable peak pressures and tidal volumes. In contrast, the ventilation parameters remarkably depended on duration and depth of pressing the purge button in Poseidon Cyklon 5000, Poseidon XStream and Scubapro Air2. Critical peak pressures occurred during ventilation with all these three regulators.

The use of Poseidon Cyklon 5000, Poseidon XStream and Scubapro Air2 regulators is consequently not recommended for in-water ventilation. With the limitation that the devices were tested with a test lung and not in a human field study, Apeks TX 100, Spiro Arctic and Buddy AutoAir might be used for emergency ventilation and probably ease in-water resuscitation for the dive buddy of the victim. Professional rescue divers could be equipped with the Oxylator and an oxygen tank to achieve an early onset of efficient in-water ventilation in drowning victims.

A survey tool was developed with reference to the human factors literature. Paramedics in a large Australian ambulance service were asked to recall an adverse event and to nominate factors that may have contributed to its occurrence. Responses were analysed using principal components analysis in order to identify contributory factors that could be statistically grouped together in meaningful patterns.

The survey yielded 370 responses. Eight key single contributors and 14 groups of contributory factors were identified. Of the groups, only two were strongly associated with serious patient outcomes, such as reported significant deterioration or death.

The deteriorating patient was identified as the leading single contributor to prehospital adverse events, and two perfect storm patient harm scenarios were found to contribute materially to adverse outcomes. This approach to identifying both single factors contributing to an incident and factors which could be grouped together in a pattern, appears useful in delineating risk in the acute prehospital setting, and warrants further exploration in this and other areas of patient safety.

The Victorian Ambulance Cardiac Arrest Registry records were used to identify survivors of OHCA that occurred between 2003 and 2008 in the 18-39 year-old age group. Survivors were administered a telephone questionnaire using Short Form (SF-12), EQ-5D and Glasgow Outcome Scale-Extended. Cerebral Performance Category (CPC) ascertained at hospital discharge from the medical record was recorded for the uncontactable survivors.

Of the 106 young adult survivors, five died in the intervening years and 45 were not contactable or refused. CPC scores were obtained for 37 (74%) of those who did not take part in telephone follow-up, and 7 (19%) of these had a CPC ≥3 indicating severe cerebral disability. The median follow-up time was 5 years (range 2.7- 8.6 years) for the 56 (53%) patients included. Of these, 84% were living at home independently, 68% had returned to work, and only 11% reported marked or severe disability. The majority of patients had no problems with mobility (75%), personal care (75%), usual activities (66%) or pain/discomfort (71%). However, 61% of respondents reported either moderate (48%) or severe (13%) anxiety.

The majority of survivors have good functional and quality of life outcomes. Telephone follow-up is feasible in the young adult survivors of cardiac arrest; loss to follow-up is common.

The two main objectives of this study were (1) to determine the perceived preparedness of acute care providers in New Zealand to respond to the healthcare demands of RWC 2011; and (2) to determine the factors associated with perceived strong preparedness among acute care providers in New Zealand.

A cross-sectional survey of 1500 doctors, nurses and ambulance officers working in acute care services in New Zealand was conducted between June 2010 and March 2011.

911 surveys were completed (response rate 60.7%). Only 12.7% of acute care providers felt they were prepared to deal with possible health issues arising from RWC 2011. Perceived preparedness was highest among ambulance officers and lowest among providers in intensive care units (16.3% vs 4.1%, p<0.01). Acute care providers who were aware of their role in a mass emergency were more likely to report preparedness with a prevalence OR of 3.5 and a 95% CI of 2.1 to 5.7.

Only 12.7% of acute care providers in New Zealand perceived preparedness for RWC 2011. Perceived preparedness followed a stepwise decline from prehospital services, emergency department, to surgery and then finally to intensive care services. This indicates that current preparedness activities are focusing on prehospital emergency services and neglecting surgical and intensive care services. Awareness about the role of acute care providers during emergencies, training and previous experience were associated with perceived strong preparedness for RWC 2011.