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ATLS IN 2005
Welcome to 2005 and the first of the now monthly EMJ. We begin the year acknowledging that ATLS is 26 years old and is currently launching its seventh edition in the UK. This icon of postgraduate education is nevertheless at a cross roads in its evolution—should it remain a primarily US orientated course or become more international? An editorial and commentaries by Nolan, McKeown, and Davis explore the pros and cons of these options. Many readers will also have strong opinions and we would like to hear them (http://www.emjonline.com). See pages 2, 3, 5, 6
The trauma theme continues through the rest of this edition. The review by Leigh-Smith et al shows how the classic description of a tension pneumothorax presentation applies mainly to those being positively ventilated. In contrast, spontaneously breathing patients have a more gradual onset of respiratory rather than cardiovascular signs. The article discusses the physiological changes underlying these symptoms and produces recommendations on improving the diagnosis of this life threatening condition. See page 8
MANAGING SHOCK AND PRACTICAL ADVICE ON THORACOTOMIES
Graham et al from Scotland start off the critical care series by discussing the dilemmas in assessing and managing shock in the emergency department using a case presentation format. A team of UK trauma practitioners provide good practical advice on thoracotomies and dealing with that heart sinking feeling of “now what do I do?” as you look into an open chest in the resuscitation room. See pages 17, 22
In 2004, the BAEM national audit findings showed there was considerable room for improvement in pain control in UK emergency departments. Several articles in this edition are therefore pertinent to all those reviewing their current set up. Evans et al from Southampton describe a randomised controlled trial (RCT) of patient controlled analgesia (PCA). They found it to be at least as effective as titrated intravenous injections of morphine in trauma patients. However, further studies will be required to fully explore the strengths and weaknesses of using PCA in the emergency department. In another RCT, Tarsia et al from the United States found that regional local anaesthesia was more effective than percutaneous injection when dealing with facial laceration. Boyd et al from Australia continue with the soft tissue theme by investigating analgesia in paediatric minor or moderate musculoskeletal injuries. They found that nurse initiated oral analgesia protocols significantly increase analgesia provision and decrease the time of its administration. See pages 25, 37, 30
IMAGING INFANTS WITH HEAD INJURY
The NICE head injury protocols were introduced last year and have been the subject of much discussion in this and other journals. Using retrospective data, Browning et al consider the role of plain skull radiology in infants. Their recommendations are that such films should only be used when there are visible signs of head injury or in cases of non-accidental injury. See page 33
TRAUMA MANAGEMENT, SECURING THE AIRWAY, AMBULANCE SERVICE WORKLOAD, AND AEROMEDICAL RETRIEVALS
From the prehospital arena we have a national review on trauma management activities by paramedics from Sukumaran et al. Securing the airway is obvious a key skill in the paramedics’ armamentarium and this was explored further by Deakin et al. Under optimal conditions with an anaesthetised patient paramedics had a success rate of 71% using endotracheal intubation compared with 88% using a laryngeal mask. Peacock et al quantify the oft discussed increase in workload in their overview of the London Ambulance Service between 1989 to 1999. They found a doubling of demand that did not seem to be dependent on any particular age group. It will be interesting to see how this develops with the change in GP out of hours service. At the other side of the UK, Caldow et al describe the aeromedical retrievals to the Southern General Hospital in Glasgow.
One of the main aims of the EMJ is to provide readers with comprehensive and comprehensible assessments of published work dealing with relevant emergency topics. To this end the now regular SOCRATES section from the West Yorkshire group joins the Journal Scan and BETs. See pages 50, 41, 43