Journal of accident & emergency medicine
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Comment Letter
Empirical thrombolysis in catastrophic pulmonary embolism.
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Inflammatory "one hit" and "two hit" models have recently been proposed to account for the development of multiple organ failure (MOF) in trauma and critically ill surgical patients when no source of infection can be found. In the "one hit" model, the initial insult is so massive that a systemic inflammatory response syndrome is triggered and leads rapidly to MOF. In the "two hit" scenario, initially less severely injured patients eventually develop MOF as a result of a reactivation of their inflammatory response caused by an adverse and often minor intercurrent event. ⋯ The "two hit" model is furthermore mirrored at the cellular level. Inflammatory cells are indeed susceptible of being primed by an initial stimulus and reactivated subsequently by a relatively innocuous insult. However, in the absence of clinical and biological corroboration based on cytokine secretion patterns, these models should not be accepted uncritically.
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In 1996-97 there were 623,000 emergency (999) calls made to the London Ambulance Service (LAS) and this represents a 30% increase over the previous five years. The reasons for this increase, which is also observed nationally, remain unknown. It has been suggested that some callers may be using the 999 service "inappropriately" but no data are available from the ambulance service. ⋯ This study suggests that while the majority of 999 calls were "appropriate", part of the 999 workload could be dealt with by other services. More research is required to clarify why people contact the 999 service for non-emergency incidents and also to establish the views of GPs and other agencies as to the role and function of the IAS.
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The Manchester triage system (MTS) is now widely used in UK accident and emergency (A&E) departments. No clinical outcome studies have yet been published to validate the system. Safety of triage systems is related to the ability to detect the critically ill, which has to be balanced with resource implications of overtriage. ⋯ The MTS is a sensitive tool for detecting those who subsequently need critical care and are ill on arrival in the A&E department. It did fail to detect some whom deteriorated after arrival in A&E. Most errors were due to training problems rather than the system of triage. Analysis of critically ill patients allows easy audit of sensitivity of the MTS but cannot be used to calculate specificity.