TRIAGE AFTER TERROR ATTACKS

Triage decisions made during terrorist attacks can be inaccurate, according to a recent retrospective report (

) . The triage classification of patients in two large terrorist bombings made by experienced clinicians was compared to a retrospectively applied Injury Severity Score and Israeli Defence Forces injury severity score. The results of this paper raise interesting questions about the validity of field triage. However, as the authors concede, triage is a dynamic process, which is often performed in seconds in extreme circumstances.

STOPPING PREHOSPITAL RESUSCITATION

Identifying when it is reasonable to stop resuscitation attempts in the field following out of hospital cardiac arrest is an important issue. Three out of hospital termination of resuscitation rules were assessed in a Canadian study (

) . Analysis of prospectively collected data revealed high sensitivity and negative predictive value of all three rules, but specificity and transport rates varied greatly.

BURN FIRST AID

Knowledge of burn first aid treatment was tested in an Australian study (

) . Health care workers and non-health care workers were questioned about the immediate management of four clinical burns scenarios. Reassuringly, perhaps, correct responses were given more often by health care professionals. Both groups were more likely to give correct answers if they had attended a first aid course. However, the results serve as a reminder that first aid knowledge in both the general and health care population is not as good as it could be.

BURN PROGNOSIS USING LACTATE

Lactate measured on the first day in patients with severe burns is a useful prognosticator. A prospective observational study in a burns unit of 166 patients resuscitated initially using Parkland’s formula and then according to clinical parameters suggests that a high lactate level on day one can separate survivors from non-survivors. Whether this parameter can usefully be used in guiding fluid resuscitation in burns victims is worthy of further study (

) .

GLUCOSE AND COPD

Another ‘generic’ marker of poor outcome, hyperglycaemia has been investigated as a prognosticator in acute exacerbation of COPD (

) . A retrospective review of the first admission for all patients admitted with an exacerbation of COPD to a London teaching hospital was performed. The absolute risk of adverse outcomes (death or prolonged stay) was increased by 15% for each 1mmol/litre glucose above the normal range (using each patient’s highest recording). For those who had a measured, and elevated admission glucose, this figure was 31%.

GOAL DIRECTED THERAPY

Support for the practice of Evidence Based Medicine is to be found in a retrospective study establishing the effect of implementing an evidence based ‘care-bundle’ (including goal directed therapy, glycaemic control, steroids) in septic patients (

) . With 30 matched patients in each arm, a higher survival and more rapid recovery of organ function was observed in those patients treated according to the ‘care bundle’.

LIMITATIONS OF CLINICAL EXAMINATION

Further evidence of the fallibility of clinical examination is provided by a systematic review of the utility clinical signs in peripheral artery disease. The review included 17 studies comparing clinical examination to imaging studies. (

) .

PRE-ENDOSCOPY DISCHARGE

Traditional dogma dictates that upper gastrointestinal haemorrhage requires admission and endoscopy. This is supported by an observational study of pre-endoscopy discharge which suggests that using either a pre-endoscope Rockall score, or the Glasgow Blatchford Score may not be safe (

ACHILLES RUPTURE

The treatment of Achilles tendon rupture has seen much debate in relation to conservative versus operative treatment. Adding a new angle to this debate, researchers from East Anglia present data supporting immediate mobilisiation (rather than traditional non-weight bearing) for patients whether managed conservatively or surgically (

HUMIDITY FOR CROUP

Controversy over treatment of croup with humidity continues. A recent study of controlled delivery of humidity against mist therapy (

) did not support the use of humidity for moderate croup for patients treated in the emergency department.

BENEFITS OF CHOCOLATE

Sophia is always pleased to read research that has genuine potential to increase well-being and happiness in the general population. Swiss researchers studied the effects of dark chocolate on endothelial and platelet function in smokers. They suggest that the high antioxidant intake from a small quantity of dark chocolate may improve platelet function and flow-mediated dilatation (

) .

FROM COFFEE TO MEDITATION

A further selection of studies investigating the effects of lifestyle has also caught the eye of Sophia. A study into effects of coffee intake (

) suggests that slow caffeine metabolism (mediated by the CYP1A2 gene) increases the risk of non-fatal myocardial infarction in coffee drinkers. This risk starts to increase even with one cup per day. Further evidence to support the hypothesis that exercise decreases mortality from colorectal cancer has been published in

) . Physical activity is known to reduce the risk of developing the condition, but this study concludes that at least 20 minutes exercise per week improves the likelihood of survival from colorectal cancer, possibly mediated by increases in insulin-like growth factor. It also appears that a high body mass index worsens prognosis in those patients ventilated for acute lung injury, according to a retrospective cohort analysis of intensive care patients (

) . Lastly, it seems that the stresses inherent in practicing Emergency Medicine are unlikely to be reduced by meditation. Cochrane (www.cochrane.org/reviews/en/ab004998.html) has reviewed the treatment of anxiety disorders with meditation. The small number of trials performed reveals that relaxation therapies are as effective at reducing anxiety as mediation, adverse effects are not known, and therefore (yet again) more studies are needed.