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Sepsis after major trauma
Analysis of the large Trauma Registry of the German Society for Trauma Surgery between 1993 and 2008 revealed that the rate of sepsis among patients with major trauma decreased significantly during the study period. Sepsis remains an important complication, with 3042 patients developing sepsis out of 29 829 on the registry (Crit Care Med 2011;39:621–8).
More ventilated burns
A study from The Netherlands reports an increase in the proportion of patients with extensive burn injuries whose initial care involved mechanical ventilation (J Trauma 2011;70:611–15). A doubling in the rate of ventilation coincided with more aggressive initial resuscitation and adoption of the Advanced Trauma Life Support training course.
European guidelines on atrial fibrillation
Recently published guidelines by the European Society of Cardiology on the management of atrial fibrillation are the focus of attention in the BMJ (2011;342:989–90). In keeping with previous guidance, the top priority for management remains the prevention of stroke. The direct thrombin inhibitory agent dabigatran is of considerable potential interest in this respect as, unlike warfarin, it does not require therapeutic monitoring and it appears to have lower associated risks of bleeding.
Glucose control and acute coronary syndrome
Hyperglycaemia is known to be a strong predictor of both short-term and long-term adverse events in patients who present with acute coronary syndrome (ACS). This raises the question as to whether or not tightly controlling blood glucose in this situation might improve outcome. A prospective randomised trial from Madrid compared intensive glycaemic control with conventional (standard) control, with respect to platelet aggregation. Intensive (tight) control of blood glucose in patients presenting with ACS was found to significantly reduce platelet reactivity (Heart 2011;97:803–9).
Left bundle branch block and myocardial infarction
Attempting to determine the relevance of left bundle branch block (LBBB) in patients presenting with chest pain is notoriously difficult. The issue has teased emergency practitioners for a number of years. A retrospective analysis of data from 892 patients from the Mayo Clinic's ST-elevation myocardial infarction network yielded some interesting results (Am J Cardiol 2011;107:1111–16). The authors conclude that while new or presumed new LBBB in patients suspected of having an acute myocardial infarction (MI) identifies a high-risk subgroup, only a small proportion actually turn out to have an acute MI. Many clinicians have relied upon the Sgarbossa criteria, but although they were shown to have high specificity, their sensitivity was depressingly low.
Antibiotic prophylaxis for endocarditis?
Prophylactic antibiotics have traditionally been advised for patients with congenital and heart valve disease, but latest guidance from the National Institute for Health and Clinical Excellence (NICE) goes against this. This issue is explored in an editorial in the Journal of the Royal Society of Medicine (2011;104:138–40). NICE are concerned about the quoted risk of 20 per million risk of fatal anaphylaxis among patients receiving oral penicillin.
Undergraduate ultrasound
With the ever-increasing use of ultrasound in the acute setting, the acquisition of this skill may become a core competency of future professionals. A study from Cambridge investigated the ability of undergraduates in the UK to achieve the College of Emergency Medicine standard for aortic scanning (The Clinical Teacher 2011;8:3–7). Based on their results, the authors argue that it is feasible to train inexperienced undergraduates to satisfactorily scan the abdominal aorta and question whether it is time for this skill to be part of undergraduate training requirements. Perhaps portable ultrasound equipment will become as commonplace as the stethoscope.
Transthoracic sonography
A review article in Critical Care Medicine (2011;39:839–45) examines the ability of transthoracic sonography to diagnose all sorts of thoracic pathology, ranging from pneumothorax to pneumonia. The article outlines the areas of practice enhanced by the use of transthoracic sonography along with the limitations, identifying where further investigation is required. With the increasing role of ultrasound in the acute assessment of patients, this article helps define the place of the investigation in these settings with regard to chest pathology.
Child passenger safety
There is now a wealth of evidence to show that relatively simple measures can significantly improve the safety of children travelling as passengers in cars. Recommendations based on this evidence are presented in a policy statement by the American Academy of Pediatrics published in Pediatrics (2011;127:788–93). Of interest, rear-facing seats are advised for children aged <2 years, and it is recommended that all children younger than 13 years travel in the rear seat of vehicles.
Paediatric head injury guidelines
The Scottish Intercollegiate Guidelines Network has published comprehensive guidance for the management of head injuries in children, which are similar to those published by the National Institute for Health and Clinical Excellence. A retrospective study from Edinburgh has shown that these guidelines are not currently being followed, at least as far as the threshold for obtaining a CT scan is concerned, with far fewer patients undergoing a scan than would be expected (The Surgeon 2011;9:83–7). There is understandable concern about the dose of radiation from CT, but reasons for the discrepancy between the guidelines and clinical practice are not clear and are certainly worthy of further investigation.