Jonathan Wyatt

Children presenting to hospital with acute alcohol intoxication

Aims: To investigate the problem of children presenting to hospital with alcohol intoxication. Methods: An observational study was conducted over 18 months profiling children who presented to hospital with acute alcohol intoxication, proved by laboratory tests on blood alcohol levels (BALs). The study was part of a multicentre-funded injury prevention project based on the widely accepted Canadian Hospital Injury Reporting and Prevention Programme. Results: 62 children (31 boys), mean age 14.5 years, presented with alcohol intoxication proved by BALs. The mean BAL was 203 mg/dl (standard deviation (SD) 80.7). As a point of reference, 56 (90%) children had BAL above the UK legal driving limit of 80 mg/dl. The most common type of alcohol consumed was spirits, in the form of whisky, gin, vodka and tequila. No significant association was seen between age and BAL. Children with high alcohol levels were much more likely to have lower Glasgow Coma Scores (p<0.001), but in contrast with conventional teaching, there was no association between blood glucose levels and BALs. The median Glasgow Coma Score on admission to the emergency department was 12. 15 (24%) children had a score ⩽8/15. Injuries were present in 21 (34%) children, most of which were minor injuries. Minor head injury was most common, accounting for 42% of the injuries. The most common cause of injury was a fall. Discussion: The results of this study confirm the heavy use of alcohol by some young children. This highlights a definite problem, which needs to be dealt with by a variety of measures, giving particular consideration to the ease of access to alcohol by children.

The electrocardiogram in hypothermia

OBJECTIVE Hypothermia is known to adversely affect the electrocardiogram (ECG) in many cases. This study set out to determine the incidence of defined cardiac dysrhythmias, J waves, and conduction abnormalities in urban hypothermia. METHODS A prospective, multicenter study was carried out to determine the incidence of defined cardiac rhythms in patients suffering from accidental urban hypothermia. The ECGs were independently analyzed by 2 of the authors and placed into 1 of 6 rhythm categories. RESULTS Seventy-three ECGs were analyzed. Normal sinus rhythm was the most common rhythm (41%). Overall mortality was 36% (26/73). J waves occurred in 36% of survivors and 38% of non-survivors and were, therefore, not prognostic. Shivering artifact was present in 66% of survivors and 38% of nonsurvivors. Although there was no statistically significant association between J waves and survival (P = .21), the presence of shivering artifact was associated with survival in severe hypothermia (P = .047). Atrial fibrillation and junctional bradycardia were both associated with high mortality. CONCLUSIONS This study confirms that the ECG is abnormal in the majority of patients suffering from accidental hypothermia. J waves do not appear to be independently prognostic in hypothermia. The results suggest that the inability to mount a shivering response may be associated with a poorer outcome; this finding requires further study.

A five year study of high falls in Edinburgh.

High falls are a common cause of death and disability. The aim of this study was to obtain an epidemiologically complete picture of all high falls over a 5 year period in Edinburgh, Scotland. Prospectively collected data on hospital survivors and hospital deaths was collected from the Scottish Trauma Audit Group (STAG) database. Data on prehospital deaths was obtained from autopsy reports and detailed police enquiry reports. There were 341 patients in the study, of whom 82% were male. Seventy-four percent survived to hospital discharge. Sixty-three percent of the total deaths appeared to be suicides. Head and chest injuries were responsible for the majority of deaths. Pelvis, limb and vertebral injuries predominated in survivors. In conclusion, prevention may be the most effective method of reducing prehospital deaths. Abdominal injuries were associated with a poor outcome, but survival might improve with immediate surgical exploration in haemodynamically unstable patients.

Do you really need to ask me that now?: a self-audit of interruptions to the 'shop floor' practice of a UK consultant emergency physician.

Objectives To map interruptions encountered by a senior physician performing a variety of everyday tasks on an emergency department (ED) ‘shop floor’ in the UK in order to identify tasks most likely to be interrupted, modes of interruption and those interruptions most likely to result in breaks as suspension of the original task. Methods A self-observational audit study of interruptions was undertaken by a consultant emergency physician in a medium-sized ED over 25 separate shifts totalling 119 h. The main outcome measures were type and occurrence of interruption in relation to mode of original task. ‘Success’ of interruptions and number of outstanding tasks were also recorded. Results 718 interruptions were recorded, with an average of 6 per hour. A mean number of 2.44 outstanding tasks were recorded on each occasion of interruption. Verbal advice, telephone calls and interpretations of x-rays were the most common forms of interruption. 498 interruptions (69%) were successful, defined as interruptions that resulted in a task break (over-riding and suspension of the original task). The most successful interruptions were calls to the resuscitation room (95%). Interruptions from electronic telecommunications systems were extensive (33% of total) with success dependent on the type of communication system. Telephone conversations were rarely interrupted (16% compared with a mean of 69%). Conclusions Overt electronic communication systems may have a disproportionate impact in determining the likelihood for successful interruptions. Formal consideration of how to prioritise and manage interruptions from various channels could be usefully added to emergency medicine education and training.

Road traffic suicides

A prospective observational study of fatal road traffic collisions in south-east Scotland between 1993 and 2003 revealed 17 cases (2.8% of all road fatalities) which appeared to be the result of suicide. In all 17 cases the judgement that the death was the result of suicide reflected the combination of a consistent mechanism of injury with supporting background information. The 17 individuals comprised 13 car drivers and four pedestrians. Ten of the individuals had a past history of mental illness. Only three (18%) survived to reach hospital alive. Analysis of the injuries revealed nine individuals to have unsurvivable injuries (defined by Abbreviated Injury Scale of six, Injury Severity Score of 75). The number of road traffic suicides may be generally underestimated. They appear to be difficult to prevent.

Cardiac air gun pellet injury.

An 11 year old boy was brought to accident and emergency by ambulance with a history of having been struck by a “ricochet” from a 0.22 inch air rifle fired from approximately 10 metres away by a friend. He had reportedly been clammy at scene, but on arrival at hospital was undistressed, with an oxygen saturation of 100% on oxygen, pulse 100 per minute with no ectopic beats and blood pressure 108/57 mm Hg. A 0.5 cm wound was noted on the right anterior chest …

Survival after laceration of the superior vena cava from blunt chest trauma.

Laceration of the superior vena cava is an unusual result of blunt trauma and is almost invariably lethal. A case caused by a high speed road traffic accident is presented; the factors relating to survival are discussed.

ED, email, emess!

Email has transformed communication in the National Health Service. Handling a torrent of unfocused communication is a potential burden on the clinicians time and a source of stress at work. A prospective study of the number of emails, links and attachments received during a 14-day period by four doctors of an emergency department has revealed the large number of emails received, with consultants receiving more emails than registrars. The time required to merely read this mass communication is substantial. It is suggested that time needs to be allocated to handle emails and that doctors may benefit from training on how to handle them.

Highlights from the issue

In this issue of EMJ , several important subjects relevant to prehospital care are considered. Firstly, Kate Cantwell and colleagues from Victoria, Australia review the literature relating to the temporal demands on the ambulance service. They argue that whilst there are temporal patterns on ambulance demand, these do not necessarily match hospital demand, so need to be considered separately. Later in the issue, the (traditionally contentious) topic of prehospital tracheal intubation for trauma patients receives some attention. Christopher Evans and colleagues provide data from Ontario, from which they conclude that paramedic non-drug assisted tracheal intubation or attempted tracheal intubation for trauma was associated with a heightened risk of mortality. Interestingly, during the study period, the annual rates of prehospital tracheal intubation declined significantly. In amongst all of the quantitative studies, there is also a qualitative study focussing upon the experiences of patients who had accessed …

Highlights from the literature

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;342:989e90). 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.