Gavin Lloyd

Is propofol a safe and effective sedative for relocating hip prostheses

Objective: To explore the safety and efficacy of propofol as a sedative for the relocation of hip prostheses in the emergency department. Methods: A prospective observational study was performed in 100 patients aged 37–93 years who received sedation with propofol in the emergency department for hip prosthetic relocation. All patients received intravenous titrated morphine prior to radiography, followed by a 1 mg/kg bolus of propofol after adequate preoxygenation. At 60 s, joint relocation was attempted by an independent physician. Data for each patient were recorded, with particular attention given to adverse outcomes. Results: Two patients were excluded because of protocol violation. The use of propofol achieved hip relocation in 94 of the remaining 98 patients (96%). The four unsuccessful cases required general anaesthesia with muscle relaxation. Eight patients experienced a fall in oxygen saturation, four responding to airway repositioning and four requiring brief supplemental ventilation. Four patients became hypotensive and required titrated intravenous boluses of a vasopressor (metaraminol) to restore normal blood pressure. 42 patients required additional doses of propofol, 36 for inadequate sedation and 6 for prolonged reduction attempts. Conclusions: Significant adverse effects of propofol in this case series were uncommon (12/98 patients) and readily countered. This case series suggests that propofol is a safe and effective sedative for relocating hip prostheses.

Communication skills training for emergency department senior house officers—a qualitative study

Objective—To identify common weaknesses in senior house officer-patient consultation skills, and evaluate direct observation with feedback and negotiation of educational contracts, as a teaching tool in an emergency department setting. Method—Common weaknesses were identified through review of feedback charts by three trained observers. Alteration in clinical and learning behaviour, as well as senior house officer and observer perceptions of the teaching were evaluated qualitatively by a combination of semi-structured interviews and focus groups. Results—Several common weaknesses were identified, notably the use of closed questions, and poor negotiation and explanation of treatment plan and follow up. The senior house officers perceived improvement in their clinical practice, welcomed feedback, and subsequently set, though did not complete educational contracts. While comfortable with this style of teaching, the observers felt that it did not make efficient use of teaching time. Conclusions—This study identifies common weaknesses in the consultation skills of emergency department senior house officers and confirms the need for training in this area. Direct observation is effective in changing behaviour to this end, though self directed learning is not necessarily stimulated. Video recorded consultations with group feedback may be a more effective teaching tool.

Routine pain scoring does not improve analgesia provision for children in the emergency department

Background: Scoring pain should lead to providing better analgesia for children attending the emergency department (ED). Our ED found that it offered analgesia to only 75% of children with painful injuries—36% of them receiving opiates, while scoring pain in 74%. This report describes what happened when we tried to ensure every child had their pain scored in an effort to improve analgesia provision. Methods: We ensured mandatory pain scoring at triage during the introduction of our computerised notes system, backing this up with extra training of new staff and increased publicity of pain scoring tools. A retrospective audit was conducted after the intervention looking for completion of a pain score, provision of and type of analgesia. The study included children with long bone fractures or partial or full-thickness burns attending the ED. Results: Following the intervention, we found that of 163 children, 97% had their pain scored on a zero-to-10 scale but only 66% received analgesia and only 10% were given opiates. Conclusions: The intervention was effective at achieving nearly universal early assessment and documentation of pain. This did not translate to an improvement in analgesic provision. Other means of changing behaviour need to be studied, possibly using the computerised record again to obligate analgesia provision.

Door to relocation time for dislocated hip prosthesis: multicentre comparison of emergency department procedural sedation versus theatre-based general anaesthesia

Background: Dislocation of a hip prosthesis is a painful event which has an incidence of 4% for primary total hip arthroplasty. Relocation is traditionally performed under general anaesthesia in the operating theatre, but relocation using sedation in the emergency department (ED) has been reported, with a limited success rate of 62%. A study was undertaken to compare door to relocation times for ED sedation and theatre general anaesthesia. Methods: The notes of all patients attending five centres in the south west of England with prosthetic hip dislocation over a 12-month period between 2005 and 2006 were retrospectively reviewed using standardised data collection forms. Results: Successful ED reduction was significantly quicker than failed ED reduction and theatre-based general anaesthesia (2 h 21 min vs 8 h 32 min; p<0.001). No statistical difference was found between failed ED reduction and theatre general anaesthesia. Conclusions: Reduction of dislocated hip prostheses in the ED saves nearly 6 h compared with theatre-based general anaesthesia and is therefore advocated.

Tachycardia due to atrial flutter with rapid 1:1 conduction following treatment of atrial fibrillation with flecainide

Flecainide can “organise” atrial fibrillation into atrial flutter with 1:1 conduction, leading to cardiovascular compromise.

Clinical management of injured patients with ankylosing spondylitis.

Patients with ankylosing spondylitis are prone to low impact fractures. Maintain a low threshold for medical imaging

Capnography for procedural sedation in the ED: a systematic review

Introduction Procedural sedation and analgesia (PSA) is commonplace in the ED. Previous studies have identified capnography as a reliable indicator of PSA-induced respiratory depression. This review investigates the potential effect on patient safety of the use of capnography in addition to standard monitoring for adult patients undergoing PSA in the ED. Methods MEDLINE, Embase, Scopus, CINAHL and Google Scholar were searched systematically for ED studies using capnography during PSA. Data extraction was performed by two independent authors. Using MedCalc V.13.3.3 and Meta-DiSc V.1.4, data were aggregated under the random-effects model and heterogeneity was assessed using Cochrans Q-test and the I2 statistic. Results Of the 737 studies that were screened, 7 studies met the eligibility criteria, representing a total of 662 patients. The aggregate diagnostic accuracy for capnography identifying an adverse event included a diagnostic OR of approximately 6 (OR: 5.87; 95% CI 2.41 to 14.3; p<0.001), sensitivity 0.82 (95% CI 0.76 to 0.87), specificity 0.6 (95% CI 0.55 to 0.64), negative likelihood ratio 0.3 (95% CI 0.12 to 0.75) and positive likelihood ratio 1.89 (95% CI 1.53 to 2.34). There was a lack of statistical evidence for a difference in the proportion of adverse events detected when capnography was used in addition to standard monitoring (48.8% (95% CI 32.85 to 64.92)) compared with chance alone (50%). Conclusions There is no firm evidence that capnography provides additional safety compared with standard monitoring alone during PSA in adults in the ED. There is a paucity of published research involving preoxygenated patients who remain on high-flow oxygen throughout PSA. Well-powered randomised controlled trials, employing an accepted adverse event reporting tool in such patients, are required. Until then, we advocate continued compliance with current professional recommendations for the use of capnography during PSA in adults in the ED.

Procedural sedation: what would the patient like?

Imagine breaking your ankle. Worse still having a fracture/dislocation of your ankle that you recognise needs manipulation. What are your thoughts preprocedure? How confident are you of a painless (and hopefully successful) reduction? Might we assume that deep down, you dread an uncomfortable experience and its recall? In similar circumstances what are patients’ genuine experiences? Analysis of the emergency medicine literature reveals widely varying recall rates: 7%,1 12%–13%,2 12%–16%,3 65%4 and 90%.5 More importantly, patients reporting painful recall of the procedure on return to baseline mental status has been recorded as 2%–6%,2 10%–14%3 and 30%.4 In a randomised controlled …