Evaluation of focussed assessment with sonography in trauma (FAST) by UK emergency physicians.

OBJECTIVES: To evaluate the introduction of a focussed assessment with sonography in trauma (FAST) scan into the early assessment of trauma patients in the UK. METHODS: The setting was an inner city teaching hospital emergency department (annual attendance 100,000). All patients aged 16 or over admitted to the resuscitation room after blunt trauma were included in a prospective observational study. Patients had a FAST scan performed at the end of the primary survey. Results were compared to results of other investigations, laparotomy, postmortem examination, or observation. RESULTS: 153 patients were entered into the study. The sensitivity of the FAST scan was 78% and specificity was 99%. CONCLUSION: FAST is a highly specific "rule in" technique and is useful in the initial assessment of trauma patients. Emergency physicians can perform FAST after a brief training period.

A pilot study of anabolic steroids in elderly patients with hip fractures.

OBJECTIVE: To determine the safety and efficacy of the anabolic steroid nandrolone in elderly patients with hip fractures. DESIGN: A randomized double-blind placebo-controlled trial. SETTING: The orthopedic ward of a university teaching hospital. PARTICIPANTS: 29 frail elderly females with hip fractures. INTERVENTION: Subjects received nandrolone 2 mg/kg (n = 15) or placebo (n = 14) by weekly injection for 4 weeks or until discharge. MEASURES: Baseline functional status was assessed by the Lawton-Brody ADL and IADL. Hemoglobin, transferrin, thyroid-binding prealbumin, albumin, liver function tests, creatinine, weight, MAMC, bioelectric impedance, standard anthropometrics and grip strength were measured at baseline and weekly intervals. Rehabilitation parameters and length of stay were recorded. RESULTS: The placebo and nandrolone groups were similar in age, although the control group had slightly higher baseline ADL scores. There was no difference between groups in biochemical parameters, anthropometrics, body composition, grip strength, rehabilitation end points or length of stay. One subject in the nandrolone group had a doubling of AST and was withdrawn from the study. CONCLUSIONS: Nandrolone can be given safely to frail elderly subjects with hip fractures but is likely to be of minimal benefit at the doses we employed.

An assessment of default and non-compliance in tuberculosis control in Pakistan.

Rates in particular for default from clinics and to a lesser degree non-compliance to treatment for patients with pulmonary tuberculosis have rarely been described quantitatively in the literature. In this report we describe studies in which an outpatient population in rural Pakistan was found retrospectively to have a default rate of 66%, and a non-compliance rate of 53% for P.A.S. and 60% for isoniazid measured by objective pharmacological tests. Suggestions are made for a change from the established out-patient approach, to intermittent high dose chemotherapy administered by health workers in the community.

Paradoxical sleep and depth perception.

It has been hypothesised that one possible function of paradoxical (REM) sleep is the maintenance of facilitation of co-ordinated eye movements. A prediction from this hypothesis is that binocular depth perception will be more accurate at the end of periods of paradoxical sleep than at the beginning. The results from previous studies are conflicting. Using two groups of eight healthy male volunteers in a two factor repeated measures design, it was found that for a period of paradoxical sleep in the second half of the night only, there was an improvement in binocular depth perception accuracy between the beginning and end of paradoxical sleep. The accuracy at the end of the paradoxical sleep was not significantly different to that on going to bed or on awakening in the morning; the effect was due to a large decrease in accuracy at the start of the REM period. There was no effect of paradoxical sleep on binocular depth perception in the early part of the night. Monocular depth perception accuracy was unaffected by paradoxical sleep.

Transcutaneous electrical nerve stimulation in acute hand infections.

Twenty-six patients with severe hand infections requiring operative drainage and admission to hospital were entered into a prospective, randomised, placebo-controlled trial. This was to test the use of a functioning transcutaneous electrical nerve stimulator and a non-functioning transcutaneous electrical nerve stimulator for pain relief in the first three postoperative days. Those patients with a functioning transcutaneous electrical nerve stimulator required significantly less analgesia. They also demonstrated highly significant improvement in their range of total active movement over those patients with a non-functioning transcutaneous electrical nerve stimulator. We recommend the use of transcutaneous electrical nerve stimulator after operation to reduce pain and improve mobility.

Dressings of the nailbed following nail avulsion.

Dressings of the raw nailbed tend to adhere and to be difficult and painful to remove. We have compared three types of dressing: polyurethane sponge, paraffin-gauze and replacement of the finger-nail. Assessment of adherence and pain showed that replacement of the nail had significant advantages over the other dressings.

Controlled study of the use of local steroid injection in the treatment of trigger finger and thumb.

A controlled double-blind prospective study of injection of methylprednisolone acetate plus local anaesthetic against a control injection of a local anaesthetic in the treatment of trigger finger and thumb has shown a 60% success rate for the steroid injection against 16% for the control group (p less than 0.05). This is the first controlled trial of local steroid therapy in this condition.

Antibiotics in open fractures of the distal phalanx?

A prospective trial was undertaken on 85 adult patients with open fractures of the distal phalanges of less than 6 hours duration, treated by conventional surgery. They either received no antibiotic therapy, or cephradine in short or long courses. The infection rate was 30% in the group without antibiotics and less than 3% in the treated groups. Three different antibiotics regimes were compared, with no difference in the infection rate: therefore the simplest and surest method, a single pre-operative dose and a single post-operative dose, is recommended.

Head injuries in Leeds: changes in epidemiology and survival over 12 years.

OBJECTIVES: To map the pattern of survival and epidemiology of patients admitted to accident and emergency, at a regional neurosciences unit with an isolated head injury, over a 12 year period. METHODS: The TARN database of a regional neuroscience referral centre was analysed to identify patients who where admitted after a significant, isolated head injury between January 1990 and December 2001. Demographic data about the patient and nature and cause of the injury were extracted and survival was mapped over the time period. Statistical analysis was performed to identify change in survival. RESULTS: There were 810 eligible patients. The most common cause of injury was road traffic accident (47%) with an average of 42.6% patients transferred from other hospitals. The most common disposal of patients was to an intensive care unit (35%). There was an overall increase in the number of patients but survival did not increase over the time period. Mean survival was 81.8% and overall survival decreased from 95.0% in 1990 to 81.6% in 2001, although this did not represent significant change (p = 0.990). CONCLUSIONS: Short term survival after significant head injury has not changed significantly over the 12 year period studied. No subset of patients is having a disproportionate effect on survival but in patients aged over 75, survival increased significantly. Further multicentre work is indicated to map a more accurate clinical picture of head injury survival.

Ultrasound by emergency physicians to detect abdominal aortic aneurysms: a UK case series.

Early identification of abdominal aortic aneurysms in some patients can be difficult and the diagnosis is missed in up to 30% of patients. Ultrasound cannot be used to identify a leak, but the presence of an aneurysm in an unstable patient is conclusive. With minimal training emergency physicians can easily identify the aorta and thus in the early phase of resuscitation an aneurysm can be confidently excluded. The purpose of the examination is not to delineate the extent of the aneurysm, but to identify those patients that will need emergency surgery. A series of patients presented to the department in an unstable condition with equivocal abdominal signs. An ultrasound scan in the resuscitation room by members of the emergency department revealed an aneurysm, which was enough to convince the vascular surgeons to take the patient straight to theatre with good results. In patients who are stable, computed tomography will continue to be used to evaluate the extent of the aneurysm and identify a leak.

Survival from cardiac arrest in the Accident and Emergency Department.

One hundred consecutive patients who were treated in an Accident and Emergency Department for 'cardiac arrest' were studied prospectively. Of these 30% had arrested within the community, 21% in transit and 49% in hospital. The immediate outcome was that 40 left the A&E Department alive; of these, 13 left hospital alive. The 'survivors' included 3 cases of documented asystole. Patients who were over the age of 65, who arrested out of hospital and at night, were found to have a poor prognosis. The time between arrest and arrival of the ambulance was found to affect outcome. Patients with ventricular fibrillation had the best prognosis and those with electromechanical dissociation the worst.

Effects of Cold and Compression on Edema.

In brief: A 40-minute cooling period was used to treat artificially induced acute inflammatory reactions in human tissue. Results showed no significant change in the volume of the inflammatory reaction at one hour, though a transient attenuation during the first 15 minutes was detected. The addition of mild pressure (10 mm Hg) to mild cooling (range, 15° to 25° C) produced a highly significant reduction in swelling from 15 minutes onward, This effect was sustained as long as swelling was detectable. Pressure alone (20 mm Hg) had a nonsignificant effect. The authors compare two cooling devices, an inflatable cooling cuff and an evaporative bandage, which were both found to be effective. The authors suggest that these devices could be used more routinely in emergency medicine.

Improvement in initial survival of spinal injuries: a 10-year audit.

A 10-year retrospective study of all spinal injuries presenting to the Leeds Teaching Hospitals between 1991 and 2001. The hospitals provide secondary care to a population of 750,000 and tertiary care to a population of 2-3 million. In total 1119 spinal injuries were studied. The overall survival rate was 89%. The commonest age group for presentation was 25-29 years with a secondary peak in the seventh decade, a mean overall of 43 years. 66% of injuries occurred in males. The commonest cause was a fall from a height (44%), with road traffic accidents (RTA) causing 43%. Pedestrians were most at risk within the road traffic group, making up 63% of cases. Isolated cervical spine injuries made up 37% of all cases. Cervical fractures were most associated with neurological injury (50%). Immediate survival has increased over the decade from 83% in 1991 to 93% in 2001. The probability of survival was significant at P = 0.006 and actual survival at P = 0.012 (Pearson correlation). The causal analysis has not been carried out but it is thought likely that improved quality of care is responsible.

The family physician and nursing-home care.

Nursing home patinets are becoming more numerous and now form a part of most family physicians' practices. Physicians wishing to do more nursing home care require guideliness for preventing unnecessary nursing home admissions, for scheduling visits, and for making transfers to hospital. Multi-disciplinary conferences and good basic documentation are valuable in the nursing home. Therapy with medication may be a problem, especially if changes in compliance and independence as a therapeutic end-point are not borne in mind. Serious ethical questions arise routinely in the care of nursing home patients, and a scheme for addressing these is presented, together with some of its limitations. Contrary to the current common wisdom, nursing home care may be challenging and rewarding.

Prescribing Strategies for the Frail Elderly: Patient function as an indispensable end point.

Current recommendations for prescribing for the frail elderly can be supplemented by others of value to family physicians. Minimization or simplification of medication regimens, proof of medication efficacy, vigilance for adverse drug reactions, and knowledge of aging and medications are important. Compliance is critical for the community-dwelling frail elderly but is rarely a problem in long-term care facilities. High-yield, high-risk conditions with presentations different from the "geriatric giants" must be recognized. Less medication is not necessarily the best treatment. Routine surveillance and frequent follow up are essential to adequate pharmacotherapy of frail elderly people.

Alcohol-induced bronchospasm.

A case of alcoholic beverage sensitivity is described which presented as acute bronchospasm. Such reactions in asthmatics are not uncommon, though their severity may be underestimated in the presence of intoxication. Indeed, such patients may be dismissed as suffering only from the effects of intoxication with obvious consequences.

Failed resuscitation in acute severe asthma: a medical indication for emergency thoracotomy?

A case is reported in which a 32-year-old man who had a cardiac arrest secondary to acute severe asthma was successfully resuscitated following an emergency thoracotomy when conventional external measures failed.

Inflatable splints--what are they doing?

The pressure to which splints were inflated was measured to determine whether splintage was effective and if vascular complications were likely. The prevalence of their use by the ambulance service was also investigated. The findings indicate that inflatable splints are in common use, and are rarely inflated to pressures likely to cause vascular complications. However, they are extremely inefficient in holding their pressure and rapidly become ineffective as splints. The therapeutic range between effective splinting and risk of complications is narrow and it is recommended that blow-off valves are incorporated into the manufacture of all such devices.