David Gabbott

Emergency treatment of anaphylactic reactions—Guidelines for healthcare providers

*The UK incidence of anaphylactic reactions is increasing. *Patients who have an anaphylactic reaction have life-threatening airway and, or breathing and, or circulation problems usually associated with skin or mucosal changes. *Patients having an anaphylactic reaction should be treated using the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. *Anaphylactic reactions are not easy to study with randomised controlled trials. There are, however, systematic reviews of the available evidence and a wealth of clinical experience to help formulate guidelines. *The exact treatment will depend on the patients location, the equipment and drugs available, and the skills of those treating the anaphylactic reaction. *Early treatment with intramuscular adrenaline is the treatment of choice for patients having an anaphylactic reaction. *Despite previous guidelines, there is still confusion about the indications, dose and route of adrenaline. *Intravenous adrenaline must only be used in certain specialist settings and only by those skilled and experienced in its use. *All those who are suspected of having had an anaphylactic reaction should be referred to a specialist in allergy. *Individuals who are at high risk of an anaphylactic reaction should carry an adrenaline auto-injector and receive training and support in its use. *There is a need for further research about the diagnosis, treatment and prevention of anaphylactic reactions.

The Acute Care Undergraduate TEaching (ACUTE) Initiative : consensus development of core competencies in acute care for undergraduates in the United Kingdom

BackgroundThe care of the acutely ill patient in hospital is often sub-optimal. Poor recognition of critical illness combined with a lack of knowledge, failure to appreciate the clinical urgency of a situation, a lack of supervision, failure to seek advice and poor communication have been identified as contributory factors. At present the training of medical students in these important skills is fragmented. The aim of this study was to use consensus techniques to identify the core competencies in the care of acutely ill or arrested adult patients that medical students should possess at the point of graduation.DesignHealthcare professionals were invited to contribute suggestions for competencies to a website as part of a modified Delphi survey. The competency proposals were grouped into themes and rated by a nominal group comprised of physicians, nurses and students from the UK. The nominal group rated the importance of each competency using a 5-point Likert scale.ResultsA total of 359 healthcare professionals contributed 2,629 competency suggestions during the Delphi survey. These were reduced to 88 representative themes covering: airway and oxygenation; breathing and ventilation; circulation; confusion and coma; drugs, therapeutics and protocols; clinical examination; monitoring and investigations; team-working, organisation and communication; patient and societal needs; trauma; equipment; pre-hospital care; infection and inflammation. The nominal group identified 71 essential and 16 optional competencies which students should possess at the point of graduation.ConclusionsWe propose these competencies form a core set for undergraduate training in resuscitation and acute care.

Communication between members of the cardiac arrest team - a postal survey

AIMS Effective communication enhances team building and is perceived to improve the quality of team performance. A recent publication from the Resuscitation Council (UK) has highlighted this fact and recommended that cardiac arrest team members make contact daily. We wished to identify how often members of this team communicate prior to a cardiopulmonary arrest. METHOD A questionnaire on cardiac arrest team composition, leadership, communication and debriefing was distributed nationally to Resuscitation Training Officers (RTOs) and their responses analysed. RESULTS One hundred and thirty (55%) RTOs replied. Physicians and anaesthetists were the most prominent members of the team. The Medical Senior House Officer is usually nominated as the team leader. Eighty-seven centres (67%) have no communication between team members prior to attending a cardiopulmonary arrest. In 33%, communication occurs but is either informal or fortuitous. The RTOs felt that communication is important to enhance team dynamics and optimise task allocation. Only 7% achieve a formal debrief following a cardiac arrest. CONCLUSION Communication between members of the cardiac arrest team before and after a cardiac arrest is poor. Training and development of these skills may improve performance and should be prioritised. Team leadership does not necessarily reflect experience or training.

Maternal cardiac arrest—Rarely occurs, rarely researched

In this edition of ‘Resuscitation’ a systematic review of ‘Cardiac rrest in Pregnancy’ is published.1 The data formed part of the LCOR 2010 ‘Consensus on Science Treatment and Recommendaions’ and contributed to the formation of new 2010 International esuscitation Guidelines.2 The authors are to be congratulated on ollating all the articles on science pertaining to resuscitation of he pregnant patient. Their results clearly show the dearth of good uality research in this area – no randomized trials evaluating the ffect of specialized interventions for cardiac arrest associated with regnancy could be identified. The main areas where the review ocumented good evidence for providing guideline recommendaions pertain to the use of perimortem caesarean section,3,4 the ptimal position of the pregnant patient for chest compressions5,6 nd a single study demonstrating that transthoracic impedance was ot altered significantly during pregnancy.7 Much of the science nd current recommendations concerning other aspects of sucessful maternal resuscitation are lacking and guidelines have been xtrapolated from non-pregnant patient based research. Maternal cardiorespiratory arrest is fortunately an infrequent vent. Maternal collapse however (which may or may not lead to ardiorespiratory arrest) occurs with a frequency of 3–6/1000 pregant mothers.8 In this stressful and emotive situation there are otentially two lives that may be lost. Triennial audits from the UK epeatedly confirm that major haemorrhage, thromboembolism, mniotic fluid embolism and hypertensive disease of pregnancy PET and eclampsia) account for the majority of direct obstetric elated deaths. Data from the latest Centre for Maternal and Child nquiry (CMACE) triennial report indicates a maternal mortality in he UK of 11.4/100,000 – a significant reduction from the previus report.9 For the first time, however, sepsis is the leading direct ause of death. Cardiac disease continues to be the leading indirect ause of death, which is attributed to the increased prevalence of ifestyle risk factors (obesity, smoking and increased maternal age) nd the increased number of women with pre-existing complex ongenital heart disease. The latest report again highlights the dire eed to routinely use a ‘Modified Early Obstetric Warning Score’ MEOWS) in order to detect initial signs of maternal critical illness or all causes. It is clear that physiological changes associated with advanced regnancy may alter management of the mother who has a cariorespiratory arrest and modifications to the well-documented ABC’ approach may be required. Laryngeal and tracheal oedema, he risk of aspiration from progesterone induced gastroesophageal reflux and difficulties with tracheal intubation all eed attention. Whilst the airway may be narrower in pregnant omen10 and the incidence of failed intubation higher, recent data

The influence of neck position on ventilation using the ‘Combitube’ airway

A Combitube airway was inserted into 40 patients undergoing general anaesthesia. A rigid cervical collar was then used to immobilise the neck of each patient. In all 40 subjects adequate ventilation of the lungs was possible in this position as assessed by chest movement and auscultation, measurement of expired tidal volume and maintenance of satisfactory arterial oxygen saturation. In 18/40 patients (45%), blood was present on the Combitube after removal. Reducing the volume of air injected into the proximal balloon of the Combitube appeared to reduce the incidence of airway trauma during insertion.

The system approach to trauma care

Trauma systems worldwide continue to develop. Prehospital care and transportation is being refined to ensure that the most severely injured are delivered rapidly to the most appropriate institutions. Hospital teams continue such care under the guidance of team leaders. Auditing of trauma care performance and defining standards of care remain prime objectives within any trauma system.