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  1. J P Wyatt1,
  2. D Alao2
  1. 1Department of Accident and Emergency, Royal Cornwall Hospital, Treliske, Truro, Cornwall TR1 3LJ, UK;
  2. 2Department of Accident and Emergency, Derriford Hospital, Derriford, Plymouth, Devon, UK

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    Suction for snakebites ▸

    Suction applied to the fang wounds after snakebite is a traditional immediate first aid measure that is embedded in folklore. Research in this area is inconclusive, with many previous studies being flawed in design. This new study had an interesting design, which was perhaps most remarkable for the way in which it involved eight human “volunteers” who were prepared to suffer mock envenomation with a mixture containing radioactive albumin! Having had this mixture injected into their lower leg, a mechanical suction pump was applied over the injection site and fluid was recovered and analysed. Only a tiny amount of radioactive mock venom was recovered, such that it appeared that the suction pump was ineffective as a first aid measure. Whether these results can be extended to the real situation is open to question. The authors only chose to use one puncture wound rather than the usual two resulting from bites from venomous snakes (perhaps this was to spare the volunteers additional discomfort). More importantly, the mock venom clearly only had a limited effect upon adjacent tissues, which is likely to be very different from true venom.

    Public education works for burns ▸

    Researchers from Auckland assessed the impact of a multi-media campaign to advise the public of the role of immediate continuous cool running water as first aid treatment of burns. They compared data obtained during the four months before the campaign with that obtained during the four months after it. They report that a significant improvement in the first aid treatment of burns after the intervention was associated with significant reductions in the numbers of patients requiring admission to hospital and undergoing surgical procedures. This underlines the considerable power of the media and the potential to harness this in a positive way on health issues.

    Community use of nasal/buccal midazolam in children ▸

    Families of children who have a history of prolonged seizures have traditionally been given diazepam to administer rectally in the event of a seizure. There are difficulties associated with both the administration and effect of rectal diazepam, such that a team in Glasgow introduced the option of nasal or buccal midazolam as an alternative. They attempted to analyse the new system, but the small telephone survey presented in this paper does not reflect the most robust science. In addition, midazolam is not currently licensed for use in the way described. In view of this, widespread use of midazolam in this way cannot be advocated at the present time.

    Clearance of the cervical spine in unconscious patients ▸

    It is generally acknowledged that patients who are unconscious after trauma may be harbouring significant injuries to the cervical spine despite normal initial investigations (plain radiographs and CT scan). It may sound potentially hazardous, but the idea of using fluoroscopic flexion and extension radiographs has some support and has even appeared as an option in some US guidelines. The authors of this study reject the technique, not on the grounds of patient safety, but because of technical difficulties visualising the lower cervical spine.

    Computed tomography without oral contrast in patients with abdominal trauma ▸

    Computed tomography with intravenous and oral contrast is regarded as standard practice in the evaluation of intra-abdominal injury. This study questions the routine use of oral contrast, suggesting that even blunt bowel and mesenteric injuries can be detected without it.

    Diagnosing acute appendicitis ▸

    This meta-analysis of 24 studies analysed the diagnostic value of elements of the disease history, findings on clinical examination, and laboratory test results in acute appendicitis. The author did face some difficulties, a significant one being that histopathological diagnosis is usually regarded as “gold standard”, but there are no universally accepted criteria for histopathological diagnosis of acute appendicitis. Results indicated that clinical and laboratory variables are weak discriminators when used in isolation. However, combining a history of migration of abdominal pain with clinical findings of peritoneal irritation and laboratory confirmation of an inflammatory response, does yield the most important diagnostic information. Acute appendicitis is often a difficult diagnosis to make. Perhaps the old adage has some merit: if a surgeon is right every time they operate on suspected acute appendicitis, then they are under-diagnosing the condition.

    Derivation of a syncope rule ▸

    Syncope is a relatively common reason for patients to present to accident and emergency. This paper is a bold attempt to develop a decision rule that would enable clinicians to identify patients with a significant underlying cause. By implication, this rule might play an important part in supporting the decision to discharge certain patients judged to be at “low risk” of subsequently developing serious problems. The following five criteria were deemed to indicate a “high risk” of serious outcome: an abnormal ECG, shortness of breath, a systemic blood pressure of less than 90 mm Hg, a packed cell volume of less than 30%, congestive heart failure. Adoption of this rule must await validation studies.

    Oral prednisolone for young children with viral respiratory infection ▸

    The role of systemic corticosteroids to treat pre-school children with acute wheezing is controversial. This randomised, double blind placebo controlled trial involved 230 children. Children were randomised to either receive a three day course of oral prednisolone or placebo. The authors claimed oral prednisolone reduced disease severity, length of hospital stay, and duration of symptoms.

    Playground injuries in children ▸

    This article reviewed published data on injuries to children occurring in playgrounds and examined them from a temporal perspective, with particular reference to safety interventions introduced after 1985. Fractures to the upper limbs are comparatively common in playgrounds. It is reassuring to learn that deaths in playgrounds are very rare, but severe head injuries occurred not infrequently in the past. The introduction of safety surfaces appeared to coincide with a reduction in the rate of these head injuries. The authors postulated that the impact absorbing surface may be sufficient in attenuating forces from impact after a fall at standing height, but may be insufficient from greater heights. There seems to be potential to further develop surfaces that protect children from both head injury and extremity fractures.