Emergency medicine journal : EMJ
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This first of two practice reviews addresses pulmonary embolism (PE) diagnosis considering important aspects of PE clinical presentation and comparing evidence-based PE testing strategies. A companion paper addresses the management of PE. Symptoms and signs of PE are varied, and emergency physicians frequently use testing to 'rule out' the diagnosis in people with respiratory or cardiovascular symptoms. The emergency clinician must balance the benefit of reassuring negative PE testing with the risks of iatrogenic harms from over investigation and overdiagnosis.
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Forearm fractures in children often require closed reduction in the emergency setting. The choice of anaesthesia influences the degree of pain relief, which determines the success of reduction. Main methods of anaesthesia include procedural sedation and analgesia, haematoma block, intravenous regional anaesthesia (IVRA) and regional nerve blocks. However, their comparative effectiveness is unclear. This study aims to synthesise peer-reviewed evidence and identify the most effective, in terms of pain reduction, and safest anaesthetic method. ⋯ Few randomised controlled trials compared anaesthetic methods in the closed reduction of paediatric forearm fractures. High heterogeneity precluded meta-analysis. Overall, current data are insufficient to guide the choice of anaesthetic method in emergency settings. More adequately powered trials, conducted using standardised methods, are required.
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Patients with lower limb injuries are commonly discharged from the ED with the affected area immobilised. Rigid casting of the lower limb is known to be a risk factor for the development of venous thromboembolism (VTE), making thromboprophylaxis in this population an important consideration for clinicians in the ED. The use of structured risk assessment methods (RAMs) to evaluate VTE risk and recommend thromboprophylaxis to those at higher risk is widespread in the UK. However, the evidence informing this practice is nearly exclusively based on studies of patients with rigid lower limb casts but many patients with knee injuries, including some with significant thrombotic risk factors, are managed in semi-rigid ('cricket') knee splints. These are both removable and allow free movement of the ankle, but the baseline risk of VTE and the performance of different RAMs in this population are not known. ⋯ In our cohort of patients managed in semi-rigid removable knee splints, the risk of symptomatic VTE was low, about 1 in 250, and current methods of VTE risk assessment did not prove clinically useful.