Ian Sammy

Emergency oxygen therapy for the breathless patient. Guidelines prepared by North West Oxygen Group

Based on a systematic review of the scientific literature, the North West Oxygen Group have developed guidelines for oxygen therapy for patients who present with acute breathlessness. The above emergency medicine physicians, chest physicians and intensive care physicians have gained approval from their regional societies to have this document accepted as the agreed regional guidelines for the use of oxygen in the immediate care of breathless patients in the North West of England. Flow charts are also currently being developed, based on these guidelines, for use by ambulance and emergency department staff in the area. It is recognised that the present use of oxygen across these specialties is inconsistent. This protocol will help us to deliver standardised oxygen therapy to breathless patients by paramedics, doctors and nurses. This will also improve the consistency of medical training across these disciplines in the North West. It is crucial to provide optimal oxygen therapy while the acutely breathless patient is being transferred to hospital, assessed in the emergency department and treated for their disease. For most such patients, the main concern is to give sufficient oxygen to support their needs. The major risk is giving too little oxygen (hypoxia). Insufficient oxygen therapy can lead to cardiac arrhythmias, tissue damage, renal damage and, ultimately, cerebral damage. However, excessive oxygen therapy can be dangerous for some patients with respiratory failure. Patients who present acutely with breathlessness will have varying requirements for oxygen therapy depending on the underlying cause of their symptoms. Most acutely breathless patients will have conditions such as asthma, heart failure, pneumonia, pleural effusions, pulmonary embolism or pneumothorax and some may be victims of major trauma. These patients require high concentration oxygen therapy. For most of these patients, 40%–60% oxygen will be sufficient to maintain satisfactory oxygenation (for example, 4–10 l/min from a …

Necrotising fasciitis as a complication of steroid injection.

Necrotising fasciitis is described as a complication of steroid injection of a painful shoulder in a previously well female. This case highlights a very rare life threatening emergency after steroid injection. Early recognition, resuscitation, and aggressive surgical management are essential to prevent mortality in this condition.

The International Federation for Emergency Medicine framework for quality and safety in the emergency department

All emergency departments (EDs) have an obligation to deliver care that is demonstrably safe and of the highest possible quality. Emergency medicine is a unique and rapidly developing specialty, which forms the hub of the emergency care system and strives to provide a consistent and effective service 24 h a day, 7 days a week. The International Federation of Emergency Medicine, representing more than 70 countries, has prepared a document to define a framework for quality and safety in the ED. Following a consensus conference and with subsequent development, a series of quality indicators have been proposed. These are tabulated in the form of measures designed to answer nine quality questions presented according to the domains of structure, process and outcome. There is an urgent need to improve the evidence base to determine which quality indicators have the potential to successfully improve clinical outcomes, staff and patient experience in a cost-efficient manner—with lessons for implementation.

An open prospective randomised trial to reduce the pain of blood glucose testing: ear versus thumb

The assessment of random blood glucose concentration is one of the most commonly performed procedures in clinical practice. Traditionally, a digit is used—for accessibility and rich blood supply. The digits, however, are very sensitive, resulting in pain for some patients. Previous work showed that sampling from the side of the thumb was less painful than lancet sampling from the finger or from venepuncture at the elbow.1 During that study the earlobe was suggested as an alternative sample site, as it is also accessible and vascular. We tested the null hypothesis that there would be no difference in pain score between lancet skin puncture sites on the thumb and on the earlobe. We conducted the study in a university hospital emergency department over three weeks; we received approval from the Salford and Trafford Health Authoritys research ethics committee. We excluded patients aged under 16 years, …

Is the APLS formula used to calculate weight-for-age applicable to a Trinidadian population?

BackgroundIn paediatric emergency medicine, estimation of weight in ill children can be performed in a variety of ways. Calculation using the ‘APLS’ formula (weight = [age + 4] × 2) is one very common method. Studies on its validity in developed countries suggest that it tends to under-estimate the weight of children, potentially leading to errors in drug and fluid administration. The formula is not validated in Trinidad and Tobago, where it is routinely used to calculate weight in paediatric resuscitation.MethodsOver a six-week period in January 2009, all children one to five years old presenting to the Emergency Department were weighed. Their measured weights were compared to their estimated weights as calculated using the APLS formula, the Luscombe and Owens formula and a “best fit” formula derived (then simplified) from linear regression analysis of the measured weights.ResultsThe APLS formula underestimated weight in all age groups with a mean difference of −1.4 kg (95% limits of agreement 5.0 to −7.8). The Luscombe and Owens formula was more accurate in predicting weight than the APLS formula, with a mean difference of −0.4 kg (95% limits of agreement 6.9 to −6.1%). Using linear regression analysis, and simplifying the derived equation, the best formula to describe weight and age was (weight = [2.5 x age] + 8). The percentage of children whose actual weight fell within 10% of the calculated weights using any of the three formulae was not significantly different.ConclusionsThe APLS formula slightly underestimates the weights of children in Trinidad, although this is less than in similar studies in developed countries. Both the Luscombe and Owens formula and the formula derived from the results of this study give a better estimate of the measured weight of children in Trinidad. However, the accuracy and precision of all three formulae were not significantly different from each other. It is recommended that the APLS formula should continue to be used to estimate the weight of children in resuscitation situations in Trinidad, as it is well known, easy to calculate and widely taught in this setting.

Rapid sequence induction in the emergency department: a strategy for failure

Background: Rapid sequence induction (RSI) is increasingly used by emergency physicians in the emergency department. A feared complication of the technique is the inability to intubate and subsequently ventilate the patient. Current drills based on anaesthetic practice may be unsuitable for use in the emergency department. Objective: To construct a drill for failed adult intubation in the emergency department. Methods: Literature review and consensus knowledge. Results: A drill for failed adult intubation in the emergency department is given. Summary: Failure to intubate following RSI in the emergency department is a feared complication. Practitioners must have a predetermined course of action to cope with this event. The guidelines presented here are tailored for use by the emergency physician.

The use of whole-body computed tomography in major trauma: variations in practice in UK trauma hospitals

Introduction Whole-body CT (WBCT) use in patients with trauma in England and Wales is not well documented. WBCT in trauma can reduce time to definitive care, thereby increasing survival. However, its use varies significantly worldwide. Methods We performed a retrospective observational study of Trauma Audit and Research Network (TARN) data from 2012 to 2014. The proportion of adult patients receiving WBCT during initial resuscitation at major trauma centres (MTCs) and trauma units/non-designated hospitals (TUs/NDHs) was compared. A model was developed that included factors associated with WBCT use, and centre effects within the model were explored to determine variation in usage beyond that expected from the model. Results Of the 115 664 study participants, 16.5% had WBCT. WBCT was performed five times more frequently in MTCs than in TUs/NDHs (31% vs 6.6%). In the multivariate model, increased injury severity, low GCS, shock, comorbidities and triage category increased the chances of having a WBCT, but there was no consistent relation with age. High falls and motor vehicle collisions also increased WBCT usage. Adjusting for casemix, there was a 13-fold intrahospital variation in the use of WBCT between MTCs and a 30-fold variation between TUs/NDHs. The amount of variability between individual hospitals that could not be accounted for by the factors shown to impact on WBCT use was 26% (95% CI 17% to 39%) for MTCs and 17% (95% CI 13% to 21%) for TUs/NDHs. Conclusion There are significant variations in WBCT use between different hospitals in England and Wales, which require further investigation.

Trauma in the elderly in Trinidad and Tobago: a cross-sectional study

Little is known about trauma in the elderly in the developing world. This study compared injuries in older patients with those in younger adults in a Third World setting. This was a prospective observational study of trauma admissions to a tertiary hospital in Trinidad, comparing injury characteristics and patient outcomes in older versus younger adults. Falls were the most common mechanism of injury in the elderly, accounting for 71% of injuries. Older patients who fell sustained fractures more often and were most likely to injure the limbs and head. Elderly patients were more likely to be admitted to hospital. Trauma in the elderly in Trinidad is similar to that in the developed world. Public health measures in developing countries should be aimed at preventing falls in older persons. The burden of trauma in the elderly is likely to increase in developing countries as the population ages.

Information technology in accident and emergency departments.

The aim of this study was to assess the availability and use of information technology in accident and emergency departments (A&E) in the UK. A postal questionnaire was sent to every general A&E department in the UK which sees more than 25000 new attendances/year (n = 217). Responses were obtained from 159 (73.3%) departments, of which 129 (81.1%) were computerized. Computer data was used for administration in 96.9%, for audit in 79.1% and for research in only 41.1%. Most used several sources of toxicology information, but telephone advice from the poisons information bureau was the main source. Of the hospitals, 74.2% offered courses in computer technology to their staff. The availability of information technology varies widely between departments. If the most is to be made of available technology, staff training must be more widely available and more actively promoted.

Are first rib fractures a marker for other life-threatening injuries in patients with major trauma? A cohort study of patients on the UK Trauma Audit and Research Network database

Background First rib fractures are considered indicators of increased morbidity and mortality in major trauma. However, this has not been definitively proven. With an increased use of CT and the potential increase in detection of first rib fractures, re-evaluation of these injuries as a marker for life-threatening injuries is warranted. Methods Patients sustaining rib fractures between January 2012 and December 2013 were investigated using data from the UK Trauma Audit and Research Network. The prevalence of life-threatening injuries was compared in patients with first rib fractures and those with other rib fractures. Multivariate logistic regression was performed to determine the association between first rib fractures, injury severity, polytrauma and mortality. Results There were 1683 patients with first rib fractures and 8369 with fractures of other ribs. Life-threatening intrathoracic and extrathoracic injuries were more likely in patients with first rib fractures. The presence of first rib fractures was a significant predictor of injury severity (Injury Severity Score >15) and polytrauma, independent of mechanism of injury, age and gender with an adjusted OR of 2.64 (95% CI 2.33 to 3.00) and 2.01 (95% CI 1.80 to 2.25), respectively. Risk-adjusted mortality was the same in patients with first rib fractures and those with other rib fractures (adjusted OR 0.97, 95% CI 0.79 to 1.19). Conclusion First rib fractures are a marker of life-threatening injuries in major trauma, though they do not independently increase mortality. Management of patients with first rib fractures should focus on identification and treatment of associated life-threatening injuries.