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GMC knife advice
New guidance from the General Medical Council (GMC) relating to stab injuries is reported in the BMJ. At the present time, emergency physicians are required to report all gunshot wounds to the police. The revised GMC guidance, which came into force in October 2009, now requires doctors to report attacks with a knife/blade or sharp instrument, whether the patient is an adult or a child. A representative from the GMC states that they are not asking doctors to force patients to speak to the police, but they are asking them to pass on information which will assist the police in helping to protect patients, the public and staff from risks of serious harm. BMJ (2009;339:b4004)
Speed bumps
It has been estimated that by 2020, road traffic collisions will have moved from ninth to third in the world disease burden ranking. A Cochrane review analysed whether area-wide traffic calming interventions actually do help to prevent traffic related crashes, injuries and deaths or whether they merely serve as a frustration for drivers trying to get to work. Twenty-two controlled before and after studies of area-wide traffic calming schemes were analysed. The authors conclude that traffic calming may have the potential to reduce death and serious injury, but more research is needed. It looks like speed bumps are here to stay! (Cochrane Review DOI:10.1002/14651858.CD003110).
Trauma and blood glucose
It has been well documented that hyperglycaemia is associated with a poor outcome in patients with traumatic brain injury and in critically ill patients. A retrospective study from Switzerland analysed the impact of admission blood glucose on the outcome of surviving patients with multiple injuries, (defined as an Injury Severity Score of over 16 and more than one severely injured organ system). After analysis of data from 555 trauma patients, the authors conclude that hyperglycaemia on admission is strongly associated with increased morbidity (especially infections), prolonged intensive care unit and hospital length of stay, independent of injury severity, gender, age and various biochemical parameters (J Trauma 2009;67:704–8).
An ECG pattern to beware
A single centre observational study published in Heart describes the occurrence of a distinct electrocardiogram pattern in patients with acute proximal left anterior descending coronary artery occlusion: a persistent ST-segment depression at the J-point with upsloping ST-segments, continuing into tall, symmetrical T waves in the precordial leads. The incidence of this ECG pattern was seen in approximately 2% of all anterior myocardial infarctions admitted to a dedicated prehospital triage system. The study emphasises the need for emergency care physicians and cardiologists to recognise this distinct ECG pattern, so they can triage such patients for immediate reperfusion therapy. Heart (2009;95:1701–6)
Sudden death post MI
Emergency practitioners are well aware that the rate of death, in particular sudden cardiac death, is highest in the early days after myocardial infarction. However, current guidelines do not recommend the use of an implantable cardioverter defibrillator within 40 days after a myocardial infarction for the prevention of sudden death. A randomised prospective multicentre trial sought to test the hypothesis that patients at an increased risk of sudden cardiac death, who are treated early with an implantable cardioverter defibrillator (ICD) will live longer than those who receive optimal medical therapy alone. The results indicated that early ICD implantation did not reduce overall mortality in these patients (N Engl J Med 2009;361:1427–36).
Vital signs in children
Measuring vital signs is standard clinical practice for children presenting to an emergency department with suspected acute infections. However, the predictive value of vital signs in identifying children with serious infections in the emergency setting has not been established. A study found that the presence of one or more of high fever, decreased oxygen saturations, tachycardia or tachypnoea to be moderately sensitive (80%) for identifying children with serious or intermediate infection. This sensitivity is comparable to more complicated triage systems such as the Manchester triage score and the NICE traffic light system of clinical risk. The diagnostic value of combined vital signs and the NICE traffic light system remains unknown (Arch Dis Child 2009;94:888–93).
Retinal haemorrhages and NAI
Convulsions may be the first presenting sign of ‘shaken baby syndrome’, but many infants present to the ED with convulsions as a result of other systemic illnesses. A recent study aimed to establish the prevalence of retinal haemorrhages in infants presenting with a diagnosis of first convulsions and whether this finding is always associated with non-accidental injury. The study found that the prevalence of retinal haemorrhages in infants with convulsions was less than 0.017, but all the infants found to have retinal haemorrhages were later diagnosed as being abused. These findings reinforce that non-accidental injury must always be excluded as the most likely diagnosis in infants found to have retinal haemorrhages after a convulsion. (Arch Dis Child 2009;94:873–5)
Beware the glass thermometer
Many studies have described potential hazards of using glass thermometers. Initiatives to ban the imports or sale of glass thermometers throughout Europe have resulted. However, a recent retrospective study from Boston reports that patients (especially children aged less than four years) still present to the ED each year with glass thermometer related injuries. Glass thermometers carry a dual threat of injury from broken glass as well as mercury exposure. The recommendation to use alternative thermometers is reiterated – so all parents should clear out their cupboards now! (Pediatr Emery Care 2009;25:645–7)