Jonathan Benger

Airway management outside the operating room: hazardous and incompletely studied.

Purpose of review The review examines recent knowledge regarding techniques and complications of airway management in hospitals, outside the operating room. The review does not consider airway management at the time of cardiopulmonary resuscitation as this is a separate topic. Recent findings There is a relative paucity of high-quality and interventional studies with most being observational in nature. The available data confirm the high-risk nature of airway management outside the operating room. Recent studies indicate that complications, particularly in intensive care, occur more frequently after airway placement than at the time of placement. Avoidable harm due to lack of appropriate personnel, equipment and monitoring, most notably capnography, is noted. Although airway management outside the operating room remains a high-risk procedure, the optimal organizational structure, rescue procedures, algorithms and appropriate personnel have yet to be adequately defined. Summary The notably high rate of failure of primary intubation attempts and high complication rates of airway procedures create a strong argument for increased research focus in this area of high-risk and incomplete knowledge.

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.

Atropine-resistant bradycardia due to hyperkalaemia.

Symptomatic sinus bradycardia is routinely treated in the emergency department with atropine and pacing. Two cases are presented that illustrate the importance of considering hyperkalaemia, particularly in the presence of atropine-resistant symptomatic bradycardia. The administration of calcium in such cases acts to stabilise the myocardium and resolve the bradycardia. Blood gas analysis provides a rapid estimate of serum potassium concentrations, facilitating timely treatment.

Self-inflating bag or Mapleson C breathing system for emergency pre-oxygenation?

Background: A crossover study was performed in healthy volunteers to compare the efficacy of a self-inflating bag with the Mapleson C breathing system for pre-oxygenation. Method: 20 subjects breathed 100% oxygen for 3 min using each device, with a 30 min washout period. The end tidal oxygen concentration and subjective ease of breathing were compared. Results: There was a statistically significant difference in performance between the two devices, with the Mapleson C providing higher end expiratory oxygen concentrations at 3 min. The mean (SD) end expiratory oxygen concentration was 74.2 (3.8)% for the self-inflating bag (95% CI 72.4% to 75.9%) and 86.2 (3.7)% for the Mapleson C system (95% CI 84.5 to 88.0); p<0.0001. The 95% CI of the difference between the mean values for end expiratory oxygen concentration at 3 min was 10.0% to 14.2%. There was also a statistically significant difference in the subjective ease of breathing, favouring the Mapleson C system. Conclusion: The Mapleson C breathing system is more effective and subjectively easier to breathe through than a self-inflating bag when used for pre-oxygenation. However, these benefits must be weighed against the increased level of skill required and possible complications when using a Mapleson C breathing system.

The case for urban prehospital thrombolysis

This is the first part in a debate on the benefits and disadvantages of urban prehospital thrombolysis. I put the case for prehospital thrombolyis in the urban environment and argue that it is a rational development that will save lives and reduce long term morbidity.

Response to radiation incidents and radionuclear threats: medical treatment should be given only when safe to do so.

EDITOR—Turai et al reviewed the medical response to radiation incidents and radionuclear threats.1 Puzzlingly, they say that providing care for a patient in a life threatening condition always has priority over decontamination from radioactive materials or those …

Why do we shine lights in the eyes of conscious patients after head injury

Pupil examination is a standard part of the neurological assessment of patients after head injury. The internationally recognised Advanced Trauma Life Support course teaches that Glasgow Coma Scale (GCS) score and pupillary responses should be assessed in all patients with head injuries.1 Similarly, the National Institute for Health and Care Excellence (NICE) recommends that, after initial assessment in the emergency department, a patient who is normally alert (with a GCS score of 15) after head injury should have their GCS and pupils assessed half hourly for two hours, then hourly for four hours, then two hourly thereafter.2 The rationale for pupillary assessment is that changes in pupil size and reaction can indicate a rise in intracranial pressure and can help to identify the location of …

Diagnosis by exclusion: take time to talk to patients and offer information and explanations

Ali raises an important point regarding the implications of diagnosis by exclusion.1 The online version of his article begins “Having completed attachments in acute medicine and cardiology, I have seen quite a few patients presenting with chest pain,” an entirely reasonable statement. However, the print …