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  1. J Wyatt1,
  2. R Lynch2
  1. 1Department of Accident and Emergency, Royal Cornwall Hospital, Treliske, Truro, Cornwall TR1 3LJ, UK
  2. 2Department of Emergency Medicine, Cavan General Hospital, Cavan, Ireland
  1. Correspondence to:
 Mr J P Wyatt

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Effect of prehospital hypotension ▸

This large multicentre study set out to establish whether non-traumatic out of hospital hypotension (systolic blood pressure<90 mm Hg), confers an increased risk of in-hospital mortality. Of 10 807 consecutive patients, there was a 9% incidence of out of hospital hypotension. Out of hospital hypotension was associated with a mortality rate of 32% compared with 11% in patients without recorded hypotension. The effect was more even pronounced when sustained hypotension occurred. The next important question is whether prehospital practitioners can improve outcomes by interventions aimed at preventing hypotension.

Does anyone know how to treat anaphylaxis? ▸

This brief report, comprising 14 adults and 46 children, identified an alarming lack of knowledge among patients and their parents of both the indications for administering auto-injectable adrenaline (epinephrine) and how to use the devices. Only 14% of adults and 35% of parents knew how and when to administer injectable adrenaline. In addition, of 50 general practitioners interviewed, only one knew how to operate an adrenaline device and none instructed the patients on how or when to use these devices. Most delegated these duties to the practice nurse. Fifty two per cent of general practitioners did not consider it necessary for the patient to attend hospital after administering adrenaline. Further education is needed in all quarters regarding the indications for adrenaline and how to operate the devices.

Laryngeal mask airway for chemical and biological incidents ▸

The threat posed by chemical and biological warfare has prompted researchers in Israel to compare the ease and success rates of securing an airway while wearing special protective clothing. They identified that non-anaesthetic doctors may be as successful as anaesthetists in inserting LMA while wearing protective gear. Further work is required to assess the effectiveness of paramedics and emergency department doctors in this setting as they will be the providers of initial airway management in the setting of chemical and biological incidents. In a mass casualty setting, time is a critical factor, and the use of LMA may provide a satisfactory alternative to tracheal intubation.

Male paramedics’ hormones ▸

Stress responses of front-line healthcare staff have rightly been the subject of considerable scrutiny in recent times. This interesting Dutch study measured salivary cortisol concentrations in male paramedics in response to various stressful situations at various times of day and night. Significantly greater increases in salivary cortisol concentrations were found after exposure to more severely stressful situations, but patterns were different during the day and night. Interpretation of these results understandably involved considerable speculation. It is clear that much more is yet to be learned about the combined effects of stress and shift working.

Continuous nebulisers to treat acute asthma ▸

The authors of this Cochrane review support the use of continuous nebulised β agonists for patients with severe asthma, as compared with the traditional use of intermittent nebulisers. However, the overall quality of the 165 studies was poor. No double blinded randomised controlled trials were identified. The heterogeneous nature of treatment schedules, small patient numbers, and methodological quality of included studies preclude any reliable recommendation for or against the use of continuous β agonists in the treatment of acute asthma. Future high quality studies may investigate these issues together with its suitability for the management of asthma in the prehospital setting.

HIV post-exposure prophylaxis not available to general public ▸

Occupational HIV post-exposure prophylaxis (PEP) has been available to emergency physicians in the UK since 1996 to treat healthcare workers exposed to blood or body fluids. However, this service is not available for non-occupational exposure. Investigators in Rhode Island, USA, retrospectively reviewed more than six years of attendances to their emergency department for blood and body fluid exposures. They found that healthcare workers were significantly (p<0.001) more likely than members of the general public to receive HIV PEP after non-sexual exposures. There is a need for guidelines for non-occupational HIV post-exposure prophylaxis management.

Can patients detect their own aneurysms? ▸

In this interesting pilot study of 164 patients, the accuracy of self examination in the diagnosis of abdominal aortic aneurysm was assessed and compared with examinations conducted by vascular surgical doctors (specialist registrar/consultant) and a nurse. The sensitivity, specificity, positive predictive value, and negative predictive value of self examination were similar to those conducted by both vascular nurses and doctors. Self examination of the breast, testis, and thyroid has previously been promoted—perhaps the aorta will be added to the list.

Emergency department errors ▸

Twenty six randomly selected medical, surgical, and obstetrics residents were interviewed to assess their perceptions of medical error associated with emergency department (ED) care. No ED resident was interviewed. Most residents discussed cases involving misdiagnosis, misinterpreted radiographs, or inappropriate disposition from the ED. Two thirds of patients discussed either died or experienced delays in care. Residents most often held the ED responsible for errors, yet feedback to the ED was uncommon. In addition, residents deemed themselves, their teams, and lack of training as responsible. Long nights, heavy patient loads, and organisational systems were also cited as being important factors. Unfortunately, the aims of the study did not include correlation between these incidents and complaints or litigation. Recording of mishaps in patients’ charts was not routine, morbidity and mortality meetings were not commonly undertaken, incident reporting forms were rarely used, and few cases were discussed with the ED or other involved services. As a result, the ability to learn from errors was limited and no mechanisms were introduced to prevent repeat incidents. A risk manager’s worst nightmare...

Problems with foreign bodies ▸

Suspected foreign body ingestion is a common presenting complaint to emergency departments worldwide. Investigators in Hong Kong retrospectively studied more than a 1000 consecutive patients with suspected impacted foreign body. Complications were comparatively unusual, but 2.8% developed significant problems, including perforation and abscess. These complications were associated with presentation delayed for more than two days or where there was a visible abnormality on lateral neck radiograph. This study serves as a reminder of the need to investigate impacted foreign bodies in a timely fashion.

Interleukins as markers of trauma severity ▸

The search for laboratory markers of injury severity continues. In a prospective study, investigators in Germany identified that of 20 mediators studied, the severity of chest trauma strongly correlated with plasma interleukin 6 (IL6) concentrations and the extent of overall soft tissue trauma to interleukin 8, IL6, and creatine kinase levels. However, the sensitivity of these markers was not reported. The relevance of these markers in the management of the acutely traumatised patient is not clear.

When can I go home mum? ▸

Procedural sedation in paediatric patients in emergency departments has become routine in recent years. Emergency physicians are mindful of the potential for early and delayed adverse events. However, it is not known when it is safe to discharge these patients. A prospective study was conducted in a New York emergency department on 1341 consecutive paediatric patients undergoing sedation over a two year period. Admitted patients were excluded. It was found that 13.7% suffered an adverse event, 86% of which were “serious”. Only 8% of adverse events occurred after the procedure. The most commonly used drug combinations were midazolam/fentanyl and ketamine/midazolam/atropine. Seventy eight per cent of adverse events occurred with the use of the former drug regimen. Serious events rarely occurred more than 25 minutes after receiving the final drug dose and of those that occurred after this time, all were preceded by a similar adverse event. The authors thus suggest that in the absence of any adverse event, discharge is safe about 30 minutes after receiving the final dose of sedation. One problem with this study was a follow up rate of only 64%. Also, the accuracy of recorded times was questioned by the authors and this undermines the accuracy of the results. In addition, important information (grade and training of staff involved, number of procedures that were abandoned) is missing. Until more data are available, the conclusions of this study need to be treated with a degree of caution.