Emergency medicine journal : EMJ
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Traumatic cardiac arrest (TCA) has traditionally been described as futile, with poor outcomes. Reported survival rates vary widely, with higher rates observed from mechanisms leading to a respiratory cause of traumatic cardiac arrest (e.g., drowning and hanging). Currently there is little evidence regarding outcomes following TCA in children. The primary aim of our study was to describe 30 day survival following TCA. Secondary aims were to provide an analysis of injury patterns (severe haemorrhage or traumatic brain injury), describe the functional outcome at discharge and to report the association between survival and interventions performed. ⋯ Although a rare event, this study has demonstrated that resuscitation of children in traumatic cardiac arrest is not futile with overall outcomes comparable to survival rates seen in adults. Survival from pre-hospital traumatic cardiac arrest is possible and the early identification and aggressive management of these patients is advocated.
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Recent studies suggest that approximately one per thousand paediatric ED attendances may require some sort of critical procedure, with intubation being by far the most common. It is unknown how often critical non-airway procedures such as chest decompression, CPR, ED thoracotomy, defibrillation, pacing, and advanced vascular access techniques are performed by paediatric emergency clinicians. ⋯ More than half of the paediatric emergency clinicians surveyed had performed CPR and inserted an intraosseous needle within the last 12 months. Performance of other non-airway critical procedures was less common, and associated with less procedural confidence.
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There has been a recent drive to implement rapid rule-out strategies which allow the early discharge of low-risk patients with suspected cardiac chest pain directly from the Emergency Department (ED). Previously, such patients would have been admitted to a hospital bed for observation and delayed biomarker testing. While the drive to implement rapid rule-out strategies comes from healthcare providers, there has been little assessment of patient perspectives on early discharge, in what is known to be a high-anxiety presentation. We aimed to explore patient perspectives on the acceptability of early discharge strategies. ⋯ Most patients would be satisfied with a rapid rule-out strategy, however, it should be acknowledged that patients receive reassurance from hospital admission and over 10% of patients would be dissatisfied with discharge direct from ED. Improved patient information and shared decision making is required when rapid discharge strategies are incorporated into practice.
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It is hypothesised that a single injection fascia iliaca compartment block (FICB) administered in the pre-operative setting provides better analgesic control for traumatic hip fractures and is not associated with major adverse effects. Systemic analgesics, whilst effective, could lead to cardiovascular, respiratory and cognitive impairment. As a consequence, undertreatment of acute pain remains prevalent in adult patients with hip fractures, with a consistent decline seen in analgesic administration with age. ⋯ Out of 3757 citations, eight RCTs were included in the final quantitative analysis, comprising of 645 participants. Acute pain was significantly reduced in FICB during positioning and movement, standardised mean difference (SMD)=-1.82 (95% CI:-2.26 to -1.38, p<0.00001) but was variable at rest (p=0.20). There was a reduced incidence of analgesia breakthrough (n=57 versus n=73), drowsiness/sedation (n=1 versus n=22), desaturation (n=0 versus n=4) and nausea and vomiting (n=3 versus n=7) in the FICB arm. There were similar numbers of patients across both arms that reported localised bruising (n=3). Only one study was at low risk of bias.emermed;34/12/A891-a/F1F1F1Figure 1emermed;34/12/A891-a/F2F2F2Figure 2 CONCLUSIONS: FICB is superior in controlling acute pre-operative pain in adult patients with traumatic hip fractures. The benefit is more evident during positioning and mobilisation of the limb. FICB has a better safety profile and reduces dependency on systemic analgesia.
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Review Meta Analysis
1 Patient acceptability and feasibility of HIV testing in emergency departments in the UK - a systematic review and meta-analysis.
NICE 2016 HIV testing guidelines now include the recommendation to offer HIV testing in Emergency Departments, in areas of high prevalence,1 to everyone who is undergoing blood tests. 23% of England's local authorities are areas of high HIV prevalence (>2/1000) and are therefore eligible.2 So far very few Emergency Departments have implemented routine HIV testing. This systematic review assesses evidence for two implementation considerations: patient acceptability (how likely a patient will accept an HIV test when offered in an Emergency Department), and feasibility, which incorporates staff training and willingness, and department capacity, (how likely Emergency Department staff will offer an HIV test to an eligible patient), both measured by surrogate quantitative markers. ⋯ For an Emergency Department considering introducing routine HIV testing, this review suggests an opt-out publicity-lead strategy. Utilising oral fluid and blood tests would lead to the greatest proportion of eligible patients accepting an HIV test. For individual staff who are consenting patients for HIV testing, it may be encouraging to know that there is >50% chance the patient will accept an offer of testing.emermed;34/12/A860-a/T1F1T1Table 1Summary table of data extracted from final 7 studies, with calculated acceptability and feasibility if appropriate, and GRADE score. Studies listed in chronological order of data collection. GRADE working group evidence grades: 4= high quality, 3= moderate quality, 2= low quality, 1 or below = very low quality. (*study conclusion reports this figure is inaccurate)emermed;34/12/A860-a/F1F2F1Figure 1Patients accepting HIV tests, and being offered HIV tests, as a proportion of the eligible sample REFERENCES: National Institute for Health and Care Excellence, Public Health England. HIV testing: Increasing uptake among people who may have undiagnosed HIV. 2016 1 December 2016.Public Health England. HIV prevalence by Local Authority of residence to end December 2015. Table No.1: 2016. Public Health Engand; 2016.