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  1. J P Wyatt1,
  2. A Wakai2
  1. 1Department of Accident and Emergency, Royal Cornwall Hospital, Treliske, Truro, Cornwall TR1 3LJ, UK;
  2. 2Department of Emergency Medicine, St James’s Hospital, Dublin 8, Ireland

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    Prehospital tracheal intubation in trauma ▸

    In this Danish observational study conducted between 1998 and 2000, 74 severely injured patients underwent prehospital intubation. Of these, 84% (62/74) received anaesthetics. Twelve intubations were performed without anaesthesia. Fifty eight per cent (36 of 62) of patients who were given anaesthetics and 8% (1 of 12) of patients who were not given anaesthetics survived at least six months (p<0.05). The authors compare their results to previously published work from London that found 0.2% (1 of 486) survival among trauma patients who underwent prehospital tracheal intubation without anaesthesia or muscle relaxants. Although this Danish study was small, its comparatively higher (though still poor) survival in patients who underwent prehospital tracheal intubation without anaesthesia may be related to differences in the trauma systems of Denmark and the UK. In the UK, paramedics perform tracheal intubation without the use of anaesthetic drugs on trauma patients when the airway is compromised and basic airway manoeuvres have failed. In Denmark, ambulance crews do not intubate. Furthermore, (accident and) emergency medicine is not a separate specialty. Anaesthetists work in emergency care in and out of hospitals. Despite these differences in trauma systems, the prognosis of all trauma patients intubated without the use of drugs is poor in both systems and the value of this practice is questionable. Clearly, to be able to permit easy passage of a tracheal tube without anaesthetic drugs, a patient must be profoundly unconscious with a high likelihood of death.

    Acute myocardial infarction may follow blunt chest trauma ▸

    Rugby is regarded by some as somewhat dangerous, and this report may add fuel to the flames. It describes coronary artery dissection with resultant myocardial infarction in a 21 year old after blunt chest trauma in a tackle. Although initial electrocardiogram (ECG) and echocardiogram showed transient ST segment elevation and anterolateral hypokinesia, cardiac catheterisation reportedly showed normal coronary arteries. A diagnosis of myocardial contusion was made and the patient discharged after three days. Chest pain recurred the afternoon after hospital discharge, and the patient returned. Repeat cardiac catheterisation showed a proximal left anterior descending artery dissection extending into mid-artery. Careful review of the initial cardiac catheterisation study showed an intimal tear. The patient made an uneventful recovery. The authors conclude that in comparatively minor blunt chest trauma, the presence of ECG changes, along with segmental wall motion abnormalities should alert the clinician to the presence of coronary artery injury.

    Transfer for primary coronary angioplasty is superior to on-site fibrinolysis ▸

    This Danish multicentre randomised study on fibrinolytic therapy versus acute coronary angioplasty in AMI (DANAMI-2) is noteworthy for its randomised design, its practical approach, and its careful consideration of the time between the onset of symptoms (in addition to arrival at the hospital) and reperfusion in its comparisons of strategies and treatment centres. This study confirms the findings of previous trials comparing transfer for primary percutaneous coronary intervention with on-site fibrinolytic therapy. Despite the delay necessary for patient transfer (43 minutes on average), primary percutaneous coronary intervention was associated with significant reductions in rates of death, non-fatal re-infarction, and stroke. The findings of this study have several important implications for clinical practice. Most importantly, considering the logistics associated with interhospital patient transfer, an integrated approach to reperfusion therapy is crucial. Transfer to a centre capable of performing angioplasty may be the best option when fibrinolytic therapy is contraindicated or unsuccessful, when cardiogenic shock ensues, when the transfer delay will be less than 60 minutes, or when more than three hours have elapsed since symptoms began.

    Body surface mapping for acute myocardial infarction with left bundle branch block ▸

    Early diagnosis of acute myocardial infarction (AMI) in the presence of left bundle branch block (LBBB) in patients with acute ischaemic type chest pain is notoriously tricky. Difficulties in early diagnosis translates into this subset of patients being less likely to receive a fibrinolytic agent, which has been shown to impact adversely on mortality. Body surface mapping (BSM) has enabled identification of prior MI in those with LBBB, but its use in AMI has been limited by technical difficulties. With advances in bioengineering and a novel self adhesive electrode harness, BSM is now recorded in a similar time as that taken to record a 12 lead ECG. The findings of this study using BSM are encouraging, with sensitivity for AMI significantly superior to that of 12 lead ECGs. Although specificity was reduced, it was within acceptable limits to allow BSM to be clinically useful. The results suggest BSM (a practical and non-invasive tool) has the potential to become a useful addition to the armamentarium for the diagnosis of AMI in the presence of LBBB.

    High dose mannitol for head injured patients with operable acute intracranial haematomas ▸

    The objectives of this systematic review were to assess the effects of different mannitol therapy regimens, to compare mannitol with other intracranial (ICP) lowering agents, and to quantify the effectiveness of mannitol administration given at other stages after acute traumatic brain injury. The reviewers concluded that high dose mannitol seems to be preferable to conventional dose mannitol in the preoperative management of patients with acute intracranial haematomas. However, there is little evidence about the use of mannitol as a continuous infusion in patients with raised ICP but no operable intracranial haematoma. Mannitol therapy for raised ICP may have a beneficial effect on mortality when compared with pentobarbital treatment. ICP directed treatment shows a small beneficial effect compared with treatment directed by neurological signs and physiological indicators. There are insufficient data on the effectiveness of prehospital administration of mannitol to judge the effect on mortality.

    Computed tomography should replace radiographs in suspected cervical spine trauma ▸

    Quick on the heels of recently issued guidance in the UK (by NICE) on the role of computed tomography (CT) in head injury, this US study advocates an increasing role for CT in suspected cervical spine injury. Altogether 1199 blunt trauma patients underwent both conventional radiographic imaging and CT evaluation of the cervical spine. Cervical injuries were identified in 116 patients (9.5%). Both methods successfully identified the injury in 75 of these patients. The remaining 41 (3.2%) patients had injuries not seen on plain radiographs, but seen only on CT scan. The authors conclude that CT scan in a trauma patient population identified more bony injuries in the cervical spine than standard conventional radiographs. More importantly, all injuries missed by cervical spine radiographs required treatment. The authors therefore suggest that there does not seem to be any role for cervical spine radiography in the clearance of blunt cervical spine injury. The data from this study have led to an adjustment in practice protocol at the authors’ institution, with CT scan alone used for the initial screening of adult patients at risk for blunt cervical spine injury. However, such a protocol needs to be prospectively validated before it becomes universal practice.

    Insulin is a drug of misuse in body builders ▸

    This case report adds to the rather limited clinical literature on insulin misuse by athletes. It describes the presentation to the emergency department of a spontaneously breathing 31 year old man with a Glasgow coma score of 6/15. Vital signs were within normal limits. Bedside glucometer reading was “low” (confirmed as blood glucose 0.6 mmol/l). He showed immediate clinical improvement after intravenous administration of 50 ml of dextrose 50% and subsequently made an uneventful recovery. He revealed he was not a diabetic, but admitted regularly using insulin three times weekly to help increase his muscle bulk. The extent of insulin misuse may be underestimated by the limited literature on this issue. In some respects, insulin is an ideal drug of misuse for high performance athletes, having a short half life and its various forms being indistinguishable. Emergency physicians need to be aware of a potentially emerging problem.

    Immunochemical based and guaiac based faecal occult blood tests have comparable performance ▸

    Faecal occult blood (FOB) testing is still often used in the evaluation of gastrointestinal complaints. Commonly used guaiac based tests (which detect heme pseudoperoxidase activity in stool) have comparatively low specificity and positive predictive values necessitating many follow up investigations (either barium enema or colonoscopy), which often yield no important findings. Newer, more expensive, immunochemical based tests promise higher specificity because they only detect human haemoglobin from the lower gastrointestinal tract. This study compared the diagnostic performance of guaiac based FOB tests and newer immunochemical based tests in a general medical clinic for colorectal cancer screening or for symptom evaluation. Overall, immunochemical based and guaiac based FOB tests had comparable diagnostic performance, so there is no evidence to choose one over another.

    Gastric lavage does not propulse poisons beyond the pylorus ▸

    This systematic review critically assessed the quality of the evidence for gastric lavage induced propulsion of poison into the small bowel. The search strategy used revealed only two studies, a randomised controlled trial and a human volunteer study. The RCT used radio-opaque polythene pellets and the human volunteer study used radio-labelled tap water, to determine propulsion of gastric contents into the small bowel. Neither study showed any increase in the amount of marker present in the small bowel after lavage compared with that present after no intervention. However, both studies had significant design or analytical limitations, or both. Both studies examined gastric lavage performed carefully in a controlled experimental setting, which may not translate into routine clinical relevance. Nevertheless, on the basis of available information, there is no evidence that lavage exacerbates self poisoning by increasing or speeding absorption via pushing the poison into the small bowel. The findings of this systematic review present an ideal opportunity for the conduct of large randomised controlled trials, comparing gastric lavage with no intervention.

    Tissue adhesives for paediatric scalp and facial wounds ▸

    The aim of this study was to compare the three tissue adhesives available in the UK: N-butyl-1,2-cyanoacrylate (Histoacryl blue), 2-octyl-cyanoacrylate (Dermabond) and enbucrylate (Indermil) regarding technique, wound healing, satisfaction, merits, and complications. Study participants were 51 children aged between 1 and 14 years presenting with isolated uncomplicated cuts to the scalp or face, of less than six hours duration and less than 2.5 cm in length. Seventeen children were treated with each tissue adhesive in an apparently non-randomised fashion. The adhesive effect was said to be similar for each of the three tissue adhesives. The authors reached further conclusions about the superiority of one tissue adhesive over another, even although there were no statistical differences between them. On this basis, the authors’ conclusions from this small apparently non-randomised trial are open to question.

    Aerosol therapy by hood is as efficient as by mask in wheezy infants ▸

    Infants and toddlers do not tolerate face masks well for the delivery of aerosol medications. More acceptable and patient friendly interfaces for improving aerosol delivery in infants are needed: hoods (head canopies) have been developed for this purpose. This study showed that clinical response to treatment, lung deposition fraction, and aerosol distribution are as good in infants managed with hood nebulisation as in those receiving conventional face mask nebulisers. Furthermore, hood treatment appeared to be more acceptable to infants and parents.

    Belt positioning booster seats for children aged 4 to 7 years ▸

    This cross sectional study of 3616 crashes involving 4243 children aged between 4 and 7 years has provided compelling evidence that belt positioning booster seats are associated with a reduced risk of injury compared with seat belts. Belt positioning booster seats function by raising a child up to the vehicle seat so that his/her seated height is more like that of an adult, permitting both portions of the belt to fit better. This information will be useful when educating parents and in advancing legislation.

    Resuscitation of newborn infants with ambient air seems to be safe ▸

    The optimal concentration of supplemental oxygen in newborn resuscitation remains contentious. Infant resuscitation with 100% oxygen (O2) may result in significantly higher oxidative stress up to a month after resuscitation. This international multicentre study (Resair 2), with 10 participating centres in Europe and Asia, recruited 609 newborn infants with birth weight over 1 kg, who at birth where resuscitated with either 21% or 100% O2. There were no significant differences in growth or neurological handicap at age 18 to 24 months in infants resuscitated with either 21% or 100% O2. Taking into account identical early (seven day) neonatal mortality in both groups, neonatal resuscitation with ambient air seems to be safe and efficient in most cases. However, the authors rightly caution that it cannot be concluded from this study that subgroups of newborn infants (for example, those with birth weight under 1 kg) would not need oxygen supplementation. Furthermore, this study does not establish whether or not 100% for newborn resuscitation is detrimental: large randomised controlled trials are needed to investigate this issue.

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