Emergency medicine journal : EMJ
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Early recognition and treatment of sepsis in the emergency department (ED) has been shown to reduce mortality. At present, we are able to identify patients who satisfy the septic shock criteria. However, many patients admitted to the intensive care unit (ICU) do not satisfy the shock criteria whilst in the ED yet have a mortality rate of approximately 30% (unpublished internal data). The Mortality In Severe Sepsis in the Emergency Department (MISSED) score was derived and validated in ED patients admitted to the ICU. This score enables identification of patients at high risk of death. The score has now been simplified. The simplified MISSED score is made up of three independent variables which predict mortality in sepsis. They are, age >65 years, a serum albumin <27 g/l and an INR of >1.3. The score ranges from 0 to 3 depending on the number of variables present at presentation in the ED. The simplified MISSED score has been internally validated in 674 ED patients admitted in 2012. The aim of this study is to identify the mortality rate associated with the simplified MISSED score at one year from the index admission. ⋯ In patients admitted with an infection, increasing simplified MISSED scores in the ED were associated with significantly increased mortality rates at one year. emermed;31/9/784-c/EMERMED2014204221F11F1EMERMED2014204221F11 Kaplan Meier plot illustrating the one-year survival associated with the simplified MISSED score.
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Intraosseous (IO) access is becoming increasingly accepted in adult populations as an alternative to peripheral vascular access, however there is still insufficient evidence in large patient groups supporting its use. ⋯ Intraosseous access can be used for the infusion of a wide variety life saving medications, quickly, easily with low complication rates. This highlights its valuable role as an alternative method of obtaining vascular access, vital when resuscitating the critically injured trauma patient.
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Until January 2014, The National Institute of Clinical Excellence (NICE) Head Injury Guidelines (CG56) issued to clinicians advised anticoagulated patients with a head injury should only receive CT imaging if loss of consciousness or amnesia was experienced. These guidelines have recently been updated to advise CT imaging for all anticoagulated patients. We aimed to investigate how closely the 2007 guidelines were followed and whether the guideline update will mean considerable changes to existing practice. ⋯ The majority of patients that fulfilled the NICE 2007 criteria did have CT imaging performed (82%). However, a significant number of patients not fulfilling the criteria also had CT imagining performed. Overall, 60% of the anticoagulated patient cohort had CT imaging, this will need to increase considerably to follow the updated NICE 2014 guidelines of CT imaging for all patients.
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Pain is the commonest reason that patients present to an Emergency Department (ED), but is often not treated effectively. Patient controlled analgesia (PCA) is used in other hospital settings but there is little evidence to support its use in emergency patients. This study (one of two parallel trials) aimed to assess the effectiveness and cost-effectiveness of PCA in emergency patients with traumatic injuries. ⋯ Provisional results indicate that there is no statistically significant reduction in pain using PCA compared to routine care for emergency department patients with traumatic injuries. Further analyses are in progress, in particular, of total morphine consumption and cost-effectiveness.
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The safety of intravenous ketamine in procedural sedation is well described.(1 2) Guidelines produced by NICE(3) and the College of Emergency Medicine(4) are used by Emergency Departments (ED) nationwide. To avoid cannulation, opioids are frequently administered to children intranasally(5), avoiding first-pass metabolism.(6) Intranasal ketamine (INK) is an effective analgesic in children(7) and has been successfully utilised in prehospital and military settings.(8 9) However, a recent survey revealed that INK is not currently in use in UK paediatric EDs.(10)To determine the current level of evidence of the use of INK in procedural sedation in children we developed a clinical scenario and three part question.A 4 year old child presents with a lip laceration. Options for closure are under procedural sedation in the ED or general anaesthetic in theatre. You feel he would be suitable for procedural sedation. Your department's policy is intravenous ketamine. However the child is very upset and you feel the trauma of cannulation will adversely affect quality of sedation. Would INK be an alternative? ⋯ In [children undergoing procedural sedation] does [intranasal ketamine] result in [rapid onset, safe, effective sedation without prolonged recovery]?Using the search strategy outlined in table 1, seven relevant papers were identified.(11-18) RESULTS: EfficacyINK can be successfully used to sedate children for dental procedures at 3-6 mg/kg.(11-13) 5 mg/kg facilitates cannulation prior to induction of anaesthesia.(14-16) An ED based double-blinded RCT compared sedation with 3,6 and 9mg/kg INK(17). The study was small and was terminated early due to high sedation failures.SafetyAll studies demonstrated 3-9 mg/kg INK is safe, with no serious adverse events.EfficiencyAt 3-9mg/kg, time to onset ranged from 3.6-9.4 minutes with recovery time between 30-69 minutes.(11-17) CONCLUSION: An ideal agent for procedural sedation in the Paediatric ED is safe, easily delivered with rapid onset and recovery. The limited but growing evidence supports the use of INK to achieve this, although ideal dose is still unclear. All published studies to date have varying flaws with strict protocols defining adequate sedation and a lack of validated dissociative sedation scale potentially limiting reported success. More studies are emerging with a recent proposal presented to the PERUKI group. INK may still make its way into Paediatric EDs in the not too distant future.