Emergency medicine journal : EMJ
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To measure the sensitivity of modern CT in patients presenting to the emergency department and evaluated for possible subarachnoid haemorrhage, with particular attention to those presenting within 12 h of ictus. ⋯ While modern CT has a high sensitivity for the diagnosis of acute subarachnoid haemorrhage, particularly within 12 h of ictus, it is still not sufficient to act as the sole diagnostic tool, and patients with a negative CT will require further investigation with a lumbar puncture.
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Transfusion thresholds for upper gastrointestinal bleeding (UGIB) are controversial. Observational studies suggest associations between liberal red blood cell (RBC) transfusion and adverse outcome. A recent trial reported increased mortality following liberal transfusion. We delivered a cluster randomised trial to evaluate the feasibility and safety of implementing a restrictive (transfusion when haemoglobin (Hb) <8 g dL) vs liberal (transfusion when Hb <10 g/dL) RBC transfusion policy for UGIB. ⋯ Adherence to both policies was high, resulting in a reduction in RBC transfusion and separation in the degree of anaemia and RBC exposure. There was a trend towards improved safety in the restrictive policy. We have demonstrated that a large-scale cluster randomised trial is feasible and is now warranted to determine the effectiveness of implementing restrictive RBC transfusion for all patients with AUGIB.
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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care unit (ICU) do not satisfy the shock criteria whilst in the ED yet have a mortality rate of approximately 30% (unpublished internal data).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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Traumatic cardiac arrest (TCA) in children is associated with poor survival (<5% in the majority of studies) and even worse neurological outcome.Since 2003, over 600 seriously injured local national children have been treated at deployed UK military medical treatment facilities during the Iraq and Afghanistan conflicts. A number of these were in cardiac arrest after sustaining traumatic injuries.emermed;31/9/790-a/SA2EMERMED2014204221TB7T1sa2-EMERMED2014204221TB7 Mechanism of InjuryMechanismIED13GSW7MVC4Drowning4Other (RPG, UXO)4Total32Trauma care has continually advanced during the recent conflicts, leading to many unexpected survivors (1). The objective of this study was to define outcomes from paediatric TCA in this cohort. ⋯ Outcomes from this cohort show better survival rates in paediatric traumatic cardiac arrest compared to the most other studies. The reason for this is not known, although this mirrors the unexpected survivors previously reported in recent military series. Further work is necessary to define the optimal management of paediatric patients in TCA.
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Timely defibrillation and high-quality cardiopulmonary resuscitation (CPR) are the only pre-hospital interventions which have been demonstrated to save lives after OHCA (out-of-hospital cardiac arrest). Standard resuscitation using the advanced life support (ALS) algorithm specifies a period of two minutes of CPR after delivering a shock before re-assessing the rhythm and delivering a further shock if indicated. Recent work has focused on improving quality of CPR, but few studies have examined how effectively defibrillation is carried out in pre-hospital practice. This study aims to assess the timing of shocks during resuscitation after OHCA. ⋯ There were 189 cardiac arrests in the study period, with 70 cases eligible for inclusion. Mean time between shocks was 3:06 min (0:15 min-18:23 min, SD 1:54 min). 53% of inter-shock intervals were >2:30 min and 21% were <2:00 min. Only 26% of intervals were compliant with ALS guidelines. Figure 1 shows a scatter plot of the inter-shock intervals for each OHCA resuscitation episode. The red bar indicates the 'compliant' zone of 2:00-2:30 min. emermed;31/9/781-b/EMERMED2014204221F7F1EMERMED2014204221F7 CONCLUSION: The majority of intervals between shocks delivered in out-of-hospital cardiac arrest were non-compliant with current ALS guidelines. Whilst the underlying reasons for this finding remain unclear, the extreme outliers appeared to be related to transporting the patient from the scene of the arrest. It was still the case, however, that the majority of defibrillation attempts were delivered either earlier than 2 min or later than 2:30 min, which may reflect a loss of situational awareness in the distracting environment of an OHCA resuscitation. Further work needs to be done to establish the cause of this deviation from recommended shock timing in order to develop strategies to optimise practice.