Editor,—Working in accident and emergency (A&E), we are used to patients presenting with injuries sustained during punching. Some of these injuries are sustained by people while in nightclubs, and almost invariably the “punch” is not welcomed by the nightclub management. We wish to …
Objectives—To assess pain in young children presenting to an accident and emergency (A&E) department. To evaluate the use of the toddler-preschooler postoperative pain scale (TPPPS) and the use of analgesia in these children. Methods—100 children aged 1–5 years presenting to an A&E department were assessed for pain. Pain assessments were carried out using a modified form of the TPPPS; a visual analogue scale by parents and a numerical scale by nursing staff. Results—The majority of children were assessed as having pain: 60 by the TPPPS, 58 by the nurses and 63 by parents. Only 30 children, however, received analgesia. Children with the highest pain scores as assessed by nursing staff or using the TPPPS all received analgesia. Conclusions—The pain scale appears suitable for use in young children in A&E departments. The subsequent management of pain in young children could be improved.
Objective-To determine factors associated with vomiting after minor head injury in a paediatric population with the intention of defining the role of vomiting in management decisions.Methods-A prospective study of all patients presenting with minor head injury to the Royal Hospital for Sick Children, Edinburgh, between 1 May and 30 June 1997. Information regarding basic demographics, features of the head injury and past and family history was noted on a proforma. This included mechanism of injury, site of impact, presence or absence of scalp haematoma, skull fracture or brain injury and intrinsic factors such as age, family history of migraine and a personal history of migraine, its childhood variants and associated conditions. The relation between vomiting and these features was analysed using chi(2) and Fisher's exact tests.Results-563 children aged from birth to 13 years presented with minor head injury. Complete data were obtained on 463 patients. Some 15.8% vomited after minor head injury. Comparing vomiters with non-vomiters the only associated factors that could be identified were a past history of recurrent vomiting or motion sickness (p = 0.0035, p = 0.036 respectively).Conclusions-Vomiting after minor head injury seems to be related to individual intrinsic factors rather than specific features of the head injury and its role in management decisions needs to be explored further.
Descriptive statistics are used to summarise numerical information so that it is in a more manageable form. There are a variety of ways of carrying this out depending upon what type of data we are dealing with. There is also a choice when presenting data. Graphical and tabular formats are possible but each have strengths and weaknesses. Selection therefore needs to take these into account along with the format of the presentation and the type of data.
Editor,—I read with interest the article by Turner et al , providing an update on carbon monoxide poisoning.1 The authors correctly point out that hyperbaric therapy remains controversial, and that no controlled clinical trial had been conducted comparing hyperbaric oxygen (HBO) with normobaric oxygen (NBO). Since the date of acceptance of their paper a prospective, blinded, randomised trial comparing NBO with HBO has been published.2 This …
Report by Claire Park, Medical Student Search checked by Katrina Richell-Herren, Research Fellow A 25 year old woman attends the emergency department having taken an overdose of amitriptyline. You wonder whether she will benefit from treatment with activated charcoal. In [adults who have taken …
Descriptive statistics are used to summarise numerical information so that it is in a more manageable form. There are a variety of ways of carrying this out depending upon what type of data we are dealing with. There is also a choice when presenting data. Graphical and tabular formats are possible but each have strengths and weaknesses. Selection therefore needs to take these into account along with the format of the presentation and the type of data.
This edition sees the second anniversary of the first publication of best evidence topic reports (BETs) from Manchester Royal Infirmary,1 the publication of the first ever “guest” BETs and the launch of the bestbets web site. The BETs were designed in 1997 as a method for appraising real clinical questions using published evidence.2 The BETs were never meant to be systematic reviews. They are a method of evidence retrieval, evaluation and collation easily achievable by busy emergency physicians. Although originally used to influence practice locally, publication in the JAEM has disseminated the information to a much wider audience. The BETs were based on the critically appraised topics (CATs) developed by Sackett et al .3, 4 CATs usually use one or two high quality papers to answer a specific question; this approach has been adopted in other …
Life threatening hyperkalaemia (> 7.0 mmol/l) is commonly associated with acute renal failure. Moderate hyperkalaemia (6.1-6.9 mmol/l) is also common and well tolerated in patients with chronic renal failure. Renal failure is the most common cause of hyperkalaemia although other causes to consider include drugs (potassium sparing diuretics, angiotensin converting enzyme inhibitors), hyperglycaemia, rhabdomyolysis and adrenal insufficiency. Hyperkalaemia affects the cardiac conducting tissue and can cause serious arrhythmias including ventricular fibrillation and asystolic arrest. Therefore it is important to treat hyperkalaemia promptly in the emergency department. This paper evaluates the therapeutic options available for treatment of hyperkalaemia.
The approach to the initial management of spontaneous pneumothorax differs markedly from centre to centre, and it is difficult in practice to establish a standard protocol. This article reviews the concepts behind the British Thoracic Society guidelines, and reports the varying opinions and alternative practices existing currently. There is a need for more evidence-based studies to identify what is the best approach. Based on a review of relevant recent reports, the author attempts to work out an unbiased practical approach that can be used safely and that can possibly give the best overall cost effective results.
Working in an accident and emergency (A&E) department inevitably involves dealing with the consequences of violence, and a knowledge of the laws of violence is a useful adjunct to the clinical practice of A&E medicine. The police and the Crown Prosecution Service decide whether or not to charge a suspect, and which charge is appropriate. All criminal offences are initially considered in the magistrates' court but the more serious offences may be committed to crown court. Specific offences include common assault, actual bodily harm, grievous bodily harm, and grievous bodily harm with intent. If the defendant is found guilty, an appropriate sentence is imposed.
Reading radiographs is one of the many skills senior house officers (SHOs) learn in accident and emergency (A&E). One of the more difficult aspects of radiological interpretation is that of children's radiographs. As the authors state the young doctor in the A&E department has only a sketchy idea of how very different children's fractures are from adults. The growing skeleton and the different nature of the bones make the nature of the injuries different and their interpretation very difficult. This book goes a long way to solving this conundrum.The general idea …
Report by Vincent Choudhery, Specialist Registrar Search checked by Sue Maurice Consultant A 3 year old boy is brought into the emergency department by his mother. She says that he swallowed a coin two hours earlier. The …
Report by Bruce Martin; Search checked by Martin SmithA 32 year old man presents to the emergency department following a fight. He complains of pain around the base of the right thumb metacarpal. Radiography reveals an undisplaced Bennett's fracture. You wonder …
Spinal cord injury without radiological abnormality is rare in adults. A case is described of a 61 year old man who fell 15 feet from a ladder striking his head on a wall who presented with neck pain and with motor and sensory neurological abnormalities in his limbs. Plain radiographs of the neck revealed no fractures or dislocations. Further imaging with computed tomography and magnetic resonance imaging revealed an osteophyte fracture with associated cord contusion at the C5 level. Careful neurological examination is essential in all cases of potential spinal injury.
Report by Kathryn Gow, Medical Student Search checked by Rob Williams, Clinical Fellow A 25 year old man attends the emergency department with a one day old wrist injury caused by falling onto his outstretched hand. He is tender in his anatomical snuff box and also on longitudinal thumb compression, but he is in very little pain on normal everyday movements. You send him for a scaphoid series of x rays …
The insertion of foreign bodies into the urethra is an unusual, though well documented, practice in which a wide variety of objects has been implicated.1–3 The activity principally occurs during pathological masturbation, intoxication, or as a consequence of psychiatric disturbance. The foreign body may disappear into the urethra or remain visible at the meatus. In the latter instance, we feel simple removal by traction is likely to be unsuccessful, if not harmful, as illustrated by the following two cases. A 36 year old man attended the accident …
OBJECTIVE:To study an established triage nurse x ray requesting system to determine whether sending defined groups of patients for radiography before assessment by doctors or emergency nurse practitioners (ENPs) resulted in shorter waiting times for patients without compromising quality of care.METHODS:Prospective randomised controlled study of "walking wounded" patients attending a district general hospital. Data were collected over two separate two week periods, six months apart, in the middle of two senior house officer appointment periods. A total of 675 patients were entered into the study. Analysis of results was achieved using standard statistical methods.RESULTS:Altogether 335 patients were in the nurse x ray group and 340 in the control group. The triage categories of the groups were similar. A 36% mean time reduction of 37.2 min (95% confidence interval 30.2 to 44.2, p=0.000) from time of triage to time of treatment decision was achieved in the nurse requested group. Triage nurses requested 8% (p=0.002) fewer x rays than doctors or ENPs and had a 6% higher positive "hit" rate (p=0.03). In 7.8% (26 cases), patients in the triage nurse group were judged to require radiographs or further views by the doctor or ENP; of these, 11 cases showed a positive finding on radiography. The time from triage to assessment by doctor or ENP was not lengthened by prior requesting of radiography (nurse x ray group 64.4 min, control group 63.7 min, p=0.79).CONCLUSIONS:A triage nurse x ray requesting system speeds up the progress of walking wounded patients through the department without compromising service quality. Further benefits are staff and patient satisfaction and a greater sense of team working for all staff.
