Emergency medicine journal : EMJ
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Facial injuries are a common presentation to the ED with data suggesting that this may be as high as 4%. There is little data on the epidemiology of paediatric facial injuries and how these are managed by the ED team. The exposure of structures such as the eyes, brain and thyroid to ionising radiation may be potentially harmful and at present there are no nationally agreed guidelines on which patients require imaging in the ED. The aim of this study was to look at the patterns of imaging in a cohort of paediatric facial injuries presenting to an ED in the West Midlands.emermed;31/9/782-b/SA13EMERMED2014204221TB1T1sa13-EMERMED2014204221TB1 A comparison of the imaging requests for the paediatric and adult facial injuriesCT HeadCT FacePA MandibleOPGTMJOMOrbitChild8117404864Adult100241714022669411 METHODS: A retrospective note review of all facial injuries presenting to any one of the three sites that make up the Heart of England NHS Foundation Trust in 2012 was conducted. Electronic records were examined to look for the mechanism of injury, disposal as well if any imaging had been performed during the initial presentation. Where imaging was performed the actual imaging as well as formal radiology reports were accessed to ascertain for the presence or absence of a facial fracture. ⋯ The study highlights that paediatric facial injuries are less common than adult facial injuries and that facial fractures make up only 1.5% of all paediatric facial injuries. Clinicians should consider this when requesting facial X-rays given the potential harm of ionising radiation to the head and neck region. Further studies are in progress to develop evidence based guidelines for imaging children with facial injuries within the ED.The table refers to the total number of different imaging requests and not the number of patients imaged. Some patients had more than one type of imaging requested.
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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.
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Emergency and urgent care workload is becoming unsustainable.(1 2) NW London has higher than average use of unscheduled care;(3) significant proportion with low acuity conditions.(2 4 5) As a paediatric emergency care provider, Imperial College Healthcare (ICHT) recognise a need to become proactive in tackling this challenge. ICHT collaborated with a professional puppet company to produce Fix Freddie!(6) A pilot tour ran in NW London March and April 2014. Objectives included:better understanding of how local community accesses unscheduled caregathering professionals across the whole system to support families in feeling confident to navigate system and care for their children's health needsreducing pressures on unscheduled care system ⋯ Fix Freddie! has provided a fun and engaging way to make connections across the whole system, facilitating co-design of local solutions to problems of healthcare accessibility and confidence in self management. Local CCG commissioners are keen to fund a wider local tour and we are looking at next steps to broaden the reach of events.
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Emergency Departments (ED) typically offer walk-in services for minor injuries, and patients arriving at peak times may experience delays. Other NHS services (e.g. GP, dentists and GUM) utilise booked appointments even for urgent problems.We wished to ascertain whether patients attending our ED (a DGH with a very large rural catchment area) with minor injuries would find an appointment system accessed via phone/internet acceptable, and also their views on perhaps being asked to return for an appointment later the same (or following) day, should they arrive when waiting times are unacceptably long. ⋯ This study confirms acceptance of the concept of ED offering appointments to minor injury patients. Participants would prefer pre-booked appointments over being asked to return later or next day, but they would accept either in preference to enduring excessive delays.
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The relationship between age and presenting Glasgow Coma Scale (GCS) in adults with traumatic brain injury (TBI) has not so far been explored in detail. We have previously reported a trend for higher GCS in elderly patients presenting to our major trauma centre with isolated TBI compared with younger adults. The aim of this study was to confirm and define this relationship using a national trauma registry and to evaluate potential contributory factors. emermed;31/9/775-c/SA2EMERMED2014204221TB1T1sa2-EMERMED2014204221TB1 Table 1 Isolated Head AIS 3+ patients 1988-2014 N(total 13547) Adults*mean (95% CI), **median (IQR) N(total 2485) Elderly*mean (95% CI), **median (IQR) Male 10410 76.8% (76.1%-77.6%) 1368 55.1% (53.1%-57.0%) Age* *26.1 (15.9-42.0) *77.6 (71.0-84.0) ISS** **16 (13-25) **17 (16-25) AIS head** **4 (3-5) **4 (4-5) Presenting GCS** **14 (9-15) Underwentprocedure* 1681 12.4% (11.9%-13.0%) 200 8.0% (7.0%-9.1%) 30 day mortality* 1072 7.9% (7.5%-8.4%) 732 29.5% (27.7%-31.2%) Injury mechanism Blast 4 0.0% (0%-0.1%) 0 Blow 1862 13.7% (13.2%-14.3%) 53 2.1% (1.6%-2.7%) Other 1664 12.3% (11.7%-12.8%) 96 3.9% (3.1%-4.6%) Fall <2 m 2073 15.3% (14.7%-15.9%) 1244 50.1% (48.1%-52.0%) Fall >2 m 2382 17.6% (16.9%-18.2%) 524 21.1% (19.5%-22.7%) RTC 5553 41.0% (40.2%-41.8%) 567 22.8% (21.2%-24.5%) Stabbing/shooting 9 0.1% (0%-0.1%) 1 0.0% (0%-0.1%) ⋯ We believe that this is the first study to demonstrate that elderly patients present with a higher GCS than younger adults for a given anatomical severity of TBI. This difference is not confined to any particular mechanism of injury nor any type of intracranial injury. These findings may have profound implications for prehospital trauma triage tools, outcome prediction methodologies and neurosurgical decision-making.