At the deep end: towards a social emergency medicine.

People experiencing the highest levels of social deprivation are more likely to present to emergency care across the spectrum of disease severity, and to have worse outcomes following acute illness. Emergency medicine in the UK and Europe has lagged behind other regions in incorporating social emergency medicine into practice. There is evidence that emergency clinicians have the potential to mitigate health inequalities, through advocacy and intervention supported by high-quality research, while also acknowledging the limitations intrinsic to the environment in which they work.

Haemorrhagic and thrombotic complications in pregnant women with acquired and congenital cardiac disease.

BACKGROUND: Pregnant patients with cardiac disease have significantly higher predicted maternal morbidity and mortality compared to the general obstetric population. Published guidelines on optimal management of these patients recommend multidisciplinary care provision. There are few published data on the incidence of haematological complications in pregnant women with cardiac disease, although the data that does exist suggests a relatively high rate of bleeding and thrombotic events. AIMS: To determine the outcomes in terms of haematological morbidity occurring within a cohort of pregnant women with cardiac disease in the setting of multidisciplinary care provision. METHODS: Patients were identified from a database compiled by the obstetric cardiology service listing all cardiac patients managed in the Rotunda maternity hospital during the period from 2004 to 2011. Data were obtained from the medical and obstetric case notes relating to details of perinatal care and the occurrence of antenatal and postnatal complications. RESULTS: During the 8-year review period, 451 women with cardiac disease were assessed. Fifty-nine were determined to have moderate to high-risk disease. Each received consultant-delivered multidisciplinary care, where written management strategies were agreed by collaborating senior colleagues either preconceptually or in early pregnancy. No venous thromboembolic events occurred and a modest rate of post-partum haemorrhage (approximately 5%) was recorded. There were no maternal deaths. CONCLUSION: The relatively favourable outcomes observed within our institution highlight the importance of a multidisciplinary approach to the management of pregnant women with cardiac disease, particularly in scenarios where limited published evidence exists to guide management.

The role of ultrasonography in obstetric anesthesia.

Ultrasonography is increasingly being viewed as an everyday tool in obstetric anesthesia. For the administration of spinal or epidural anesthesia, it reduces needle redirection attempts in patients with difficult anatomy. In the less frequent scenario of a collapsed patient, it helps with assessment in the form of transthoracic echocardiography. Abdominal blocks require ultrasound guidance for safe and anatomically correct placement. Accurate assessment of gastric volume status with ultrasound would be a useful everyday skill if it is adopted into mainstream practice. We provide a summary of current opinions on the role of ultrasound in practice and highlight the potential for its future use in obstetric anesthesia.

Surgical site infection after cesarean section: implementing 3 changes to improve the quality of patient care.

BACKGROUND: Surgical site infection (SSI) is an important complication of cesarean section (CS) delivery and a key quality indicator of patient care. METHODS: A baseline assessment was undertaken to determine SSI rates, and subsequently a quality improvement program was introduced, followed by repeat surveillance. Data were collected during in-hospital stays and for up to 30 days after CS during both periods. Interventions in the quality improvement program included the use of nonabsorbable sutures for skin closure, use of clippers instead of razors, and use of 2% ChloraPrep for skin disinfection before incision. RESULTS: A total of 710 patients were surveyed before the interventions, and 824 patients were surveyed after the interventions. Of these, 114 (16%) had an SSI before the interventions, and 40 (4.9%) had an SSI after the interventions (P < .001; odds ratio, 0.27), with 90% and 83%, respectively, detected after hospital discharge. In multivariate analysis, obesity (P = .002) and the use of absorbable suture materials for skin closure (P = .008) were significantly associated with a higher SSI rate before the interventions; however, only obesity was associated with a higher SSI rate after the quality program. CONCLUSION: Surveillance of SSI rates after CS followed by 3 interventions contributed to a significant reduction in SSI rate and improved patient care.

Dissociative mental state in a patient with an intrathecal drug administration system.

IMPLICATIONS: We describe a patient with acute mental status changes, which resolved on removal of medication from the reservoir of a Synchromed intrathecal pump. This report highlights the potential adverse mental affects of chronic spinal infusions for pain therapy and discusses pitfalls in toxicology analysis using immunoassay.