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  1. Jonathan Wyatt1,
  2. Liza Keating2
  1. 1Department of Accident and Emergency, Royal Cornwall Hospital, Treliske, Truro, Cornwall, TR1 3LJ, UK
  2. 2Department of Accident and Emergency, Oxford, UK
  1. Correspondence to:
 Department of Accident and Emergency, Royal Cornwall Hospital, Treliske, Truro, Cornwall TR1 3LJ, UK;

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Thomas tube holder in prehospital care ▸

Securing a tracheal tube has long been a challenge in the prehospital setting. This article advocates the use of a “Thomas tube holder”, which was designed to address the problems of inadvertent dislodgement and tube biting. The tube holder comprises a plastic mouthpiece and central tube-clamping hole and comes in adult and paediatric sizes. The author proposes its use with laryngeal mask airway in addition to tracheal tubes.

Treatment of pulmonary oedema ▸

This randomised controlled trial from Brazil compared continuous positive airway pressure (CPAP), non-invasive bilevel ventilation, and standard oxygen therapy on the tracheal intubation rate in patients with cardiogenic pulmonary oedema in the emergency department. The results revealed a significantly higher intubation rate in the group treated with standard oxygen therapy (42%) compared with the CPAP or bilevel (7% in both). However, the study was not powerful enough to be able to properly compare bilevel with CPAP in the treatment of cardiogenic pulmonary oedema.

Magnesium sulphate for asthma in children ▸

The role of intravenous magnesium sulphate in treating acute moderate to severe asthma in children remains controversial. The primary outcome measure considered in this meta-analysis was its effectiveness in preventing admission to hospital. A total of five trials from emergency departments were included, all of which were judged to be of good quality. The dosing regimes did vary across the studies, but the results indicated that magnesium sulphate was effective in preventing admission to hospital.

Procalcitonin as a marker of meningococcal sepsis ▸

This prospective observational study from Alder Hey Hospital examined the profiles of different inflammatory markers in 94 children with proven meningococcal sepsis. Lactate, C-reactive protein (CRP), and procalcitonin levels were measured. Plasma procalcitonin at admission was significantly higher in children with septic shock. The same was also true for those requiring ventilation and those whose hospital stay was greater than 10 days. Confusingly, however, the cut-off value chosen for an abnormal procalcitonin level varied. Procalcitonin was not significantly higher in survivors versus non-survivors and hence was not proven to be a reliable predictor of death as has previously been suggested. Lactate was a reliable predictor of septic shock and CRP did not reliably discriminate between any of these groups. The clinical implications of the study are not entirely clear, but there are interesting data from animal studies where the administration of procalcitonin antiserum appeared to increase survival in sepsis.

More evidence for primary angioplasty ▸

This piece of meta-analysis reveals that primary angioplasty for S-T elevation myocardial infarction in those with contraindications to thrombolysis is better than aspirin alone. The reduction in short term risk of death is around 44%. Perhaps not a surprising result.

Surgery for stroke ▸

Spontaneous supratentorial intracerebral haemorrhage occurs in about a fifth of all stroke patients and accounts for the highest morbidity and mortality. The treatment of this group remains controversial. This multicentre randomised trial compared early surgery with initial conservative treatment for patients with intracerebral haemorrhage. 1033 patients were recruited from 27 countries. The result showed no overall benefit from early surgery when compared with initial conservative treatment. Subgroup analysis showed a marginal benefit for early surgery in those with a haematoma closer to the cortical surface.

Bruising in children ▸

The authors of these two related papers review the difficult subject of bruising in children. Bruising is the commonest presenting feature of physical abuse in children, but it is also a normal finding in the majority of children. The authors reviewed the evidence and attempted to differentiate between patterns of normal and abnormal bruising. They were hampered by the poor quality of the available evidence. They conclude that patterns of bruising may be indicative of physical abuse, but the bruises should be assessed in the context of the medical, social, and developmental history, as well as the explanation given.

The second review by the same team urges caution to those commenting on bruising in cases of suspected child abuse. Their comprehensive review of the available literature suggests that it is not possible to reliably age a bruise from clinical assessment and that the practice has no scientific basis.

Fluid therapy for major burns ▸

This study aims to compare standard intravenous fluid therapy (based on the Baxter 4 ml/kg/% burn in the first 24 hours) for burns patients with that of “goal-directed therapy”. Fifty patients with greater than 20% burns were prospectively studied and randomised to receive either standard treatment (Baxter formula) or treated with goal-directed therapy (with the aim of preventing hypovolaemia, oliguria, etc) guided by invasive monitoring. The difference in fluid regimens in the first 24 hours was significantly different: a mean of 16.2 litres in the control group compared with 27.0 litres in the goal-directed group (p = 0.0001). The mortality in both groups was high (over 30%), and there was no significant difference in observed morbidity and mortality. Traditional arguments about intravenous fluid therapy seem certain to continue.

Nimodipine for subarachnoid haemorrhage ▸

Secondary ischaemia is a frequent cause of poor outcome in patients with subarachnoid haemorrhage (SAH). Its pathogenesis has not yet been fully elucidated, but it may be related to vasospasm. Trials have suggested that calcium antagonists can prevent vasospasm and have additional neuroprotective properties. This Cochrane review attempted to answer whether calcium antagonists improve outcome in patients with SAH. From an analysis of over 2800 patients from 12 trials, the authors conclude that oral nimodipine (60 mg every 4 hours) reduces the risk of a poor outcome. They warn that evidence for intravenous administration of calcium antagonists is currently not available.

Poor evidence for hyperbaric oxygen ▸

Poisoning with carbon monoxide remains an important cause of both deliberate and unintentional injury worldwide. The low threshold and widespread use of hyperbaric oxygen in the management of carbon monoxide poisoning appears to be based largely on the results of several unblinded non-randomised trials that have suggested that the use of hyperbaric oxygen may prevent long term neurological sequelae. This Cochrane review of published trials found conflicting, potentially biased, and generally weak evidence about the efficacy of hyperbaric oxygen in terms of the prevention of neurological symptoms. The duration of treatment, the timing, and the dose of hyperbaric oxygen varied greatly across the trials. None report clinically significant long term outcome measures. The authors suggest that this research question would be ideally suited to a multicentre randomised controlled trial.

Steroids do help acute exacerbations of chronic obstructive pulmonary disease (COPD) ▸

COPD is a major public health problem. Short term, high dose corticosteroid treatment is now widespread in the treatment of acute exacerbations of this condition. This Cochrane review looks at the efficacy of steroid treatment in COPD. They conclude from the ten included studies that treatment with oral or parenteral corticosteroids significantly reduces treatment failure and the need for additional medical treatment (odds ratio 0.48, 95% CI 0.34 to 0.68). Additionally the rate of improvement in lung function and dyspnoea in the first 72 hours is increased. Reassuring!

Lack of evidence for glucocorticoids in bronchiolitis ▸

Bronchiolitis remains a common cause of hospital admission in children. This Cochrane review includes 13 randomised controlled trials that met the selection criteria. The majority were set in hospital, with three being undertaken in the emergency department. Outcome measures included hospital length of stay and admission rates, along with clinical scores. This systematic review adds to a growing list of previous reviews that have failed to show any significant effect on clinically relevant outcomes for any of the treatments that are widely used in the treatment of bronchiolitis. These treatments now include glucocorticoids together with inhaled bronchodilators and epinephrine (adrenaline). Treatment remains supportive and many infants continue to be admitted because of the lack of a reliable tool to predict those at risk of apnoea or respiratory failure.

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