Back pain as the presenting symptom of generalised tetanus.

Back pain is a common presenting symptom in emergency departments and primary care across the UK. The extensive differential diagnosis includes mechanical, infective, thoracic, abdominal and vascular causes. This case report describes a patient who presented with lower back pain with a rare diagnosis, which is becoming more common in certain population groups, and emphasises the importance of clinical skills and insuring adequate tetanus prophylaxis.

Prehospital trauma management: a national study of paramedic activities.

OBJECTIVES: The benefits of prehospital trauma management remain controversial. This study aimed to compare the processes of care and outcomes of trauma patients treated by paramedics, who are trained in advanced prehospital trauma care, with those treated by ambulance technicians. METHODS: A six year prospective study was conducted of adult trauma patients attended to by the Scottish Ambulance Service and subsequently admitted to hospital. Prehospital times, interventions, triage, and outcomes were compared between patients treated by paramedics and those treated by technicians. RESULTS: Paramedics attended more severely injured patients (16.5% versus 13.9%, p<0.001); they attended a higher proportion of patients with penetrating trauma (6.6% versus 5.7%, p = 0.014) and had longer prehospital times. Patients managed by paramedics were more likely to be taken to the intensive care unit, operating theatre or mortuary, (11.2% versus 7.8%, p<0.001) and had higher crude mortality rates (5.3% versus 4.5%, p = 0.07). However, no difference in mortality between the two groups was noted when corrected for age, Glasgow coma score and injury severity score. CONCLUSIONS: This large scale national study shows that paramedics show good triage skills and clinical judgement when managing trauma patients. However, the value of the individual interventions they perform could not be ascertained. Further controlled trials are necessary to determine the true benefits of advanced prehospital trauma life support.

Appointment of a Resuscitation Training Officer is associated with improved survival from in-hospital ventricular fibrillation/ventricular tachycardia cardiac arrest.

OBJECTIVE: To determine if the appointment of a Resuscitation Training Officer improves survival to discharge from in-hospital ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest. DESIGN: A 22-month prospective study. SETTING: A 1100-bed teaching hospital. SUBJECTS: All inpatients suffering ventricular fibrillation or ventricular tachycardia cardiorespiratory arrests. INTERVENTIONS: Appointment of a Resuscitation Training Officer at start of study, who introduced coordinated resuscitation training for all staff. MAIN OUTCOME: Survival to discharge. RESULT: Improvement in survival to discharge of 20-75% (P<0.03, Spearman Rank Correlation test). CONCLUSION: Appointment of a Resuscitation Training Officer is associated with improved survival to discharge in ventricular fibrillation and ventricular tachycardia in-hospital cardiac arrest.

Survival from cardiac arrest in an accident and emergency department: the impact of out of hospital advisory defibrillation.

A prospective 1-year audit of cardiac arrests treated in the Accident and Emergency department of the Royal Infirmary, Edinburgh is presented. During the period January 1st, 1991 to December 31st, 1991, 325 patients with cardiac arrest were treated. Two-hundred ninety-seven of these were 'out-of-hospital' and 28 were 'in-department' arrests. Of patients with 'out-of-hospital' ventricular fibrillation/pulseless ventricular tachycardia 22.8% were discharged. Survival rates for patients with asystole or electromechanical dissociation were very poor. The impact of semiautomatic out-of-hospital defibrillation upon the survival and number of patients presenting to the department is discussed.

Evaluation of outcome following cardiac arrest in patients presenting to two Scottish emergency departments.

OBJECTIVES: To compare and contrast outcomes following cardiac arrest managed in two Accident and Emergency departments, and to identify factors which might account for such differences. DESIGN: Prospective 1-year evaluation of patients sustaining an out-of-hospital cardiac arrest. SETTING: The Accident and Emergency departments of the Edinburgh (ERI) and Glasgow (GRI) Royal Infirmaries which serve two large urban municipalities. PATIENTS: All patients sustaining a prehospital cardiac arrest and brought to ERI or GRI were included. Children (< 13 years), those declared dead on arrival at the scene, and events related to poisoning, near drowning, trauma and pregnancy were excluded. MEASUREMENTS AND MAIN RESULTS: There were 297 prehospital arrests from ERI, and 158 from GRI. Eighty-two (27.6%) were admitted as 'in-patients' to ERI and 23 (14.6%) to GRI (P < 0.01). Thirty-nine (13.1%) survived to hospital discharge from ERI; 13 (8.2%) survived to discharge from GRI (NS). The proportion of VF/VT:Asystole observed was significantly different between the two centres--162:98 from ERI, 54:73 from GRI (P < 0.001). Significantly more prehospital arrests were witnessed and received bystander CPR in those brought to ERI (P < 0.02). For the combined VF/VT/Asystole groups the ERI ambulance response times were significantly shorter (P < 0.01). However, there was no significant difference in the collapse to EMS arrival at the scene times between ERI and GRI. Two survivors from ERI had asystole as their initial observed rhythm. From GRI, one survivor had asystole, one had electromechanical dissociation and in another the initial rhythm was unknown. No survivor to discharge had severe neurological disability. CONCLUSIONS: Patients suffering out-of-hospital cardiac arrests in Edinburgh have a significantly better chance of being admitted to a ward. There is a trend favouring better survival to discharge in Edinburgh, but with the numbers investigated this does not achieve statistical significance. Amongst those factors which contribute to survival there are fewer witnessed arrests, less bystander CPR and slower ambulance response times in those brought to GRI. There is a need to investigate the environment in which patients collapse, to train the public in CPR, and to review the efficiency and resourcing of the ambulance service.

Acute venous obstruction from a mediastinal cystic lymphangioma.

We report a case of acute symptomatic obstruction of the right innominate vein caused by mediastinal cystic lymphangioma, which was dissected completely free and excised from the surrounding tissues. The patient's postoperative course was uneventful. We stress the need for timely surgical excision of such masses upon diagnosis to prevent life-threatening clinical presentations resulting from sudden increase in the cyst size.

An objective analysis of an accident flying squad.

An objective evaluation of an accident flying squad, in relation to trauma call-outs during a six month period, was performed using the Injury Severity Score and the recently described Revised TRISS methodology. We have demonstrated improvement in patient survival for those trauma cases treated at the scene. This has not been previously documented. Objective evaluation of these squads in relation to medical emergencies is even more difficult. The profile of these call-outs is described. (11.1%) of those treated at the scene for cardiac arrest survived to leave hospital. Ventricular fibrillation was the primary arrhythmia recorded in this group of survivors. This supports the vogue for extended ambulance personnel training.

Implementing an in-house radiological equipment service program.

The pressure to control hospital costs extends to departments of radiology. One area of radiology in which costs may be reduced without cutting quality is equipment service. Equipment maintenance and repair expenditures can be lowered considerably through the implementation of an in-house service program. By developing an adequate data system to accompany the in-house service program, informed decisions can be made concerning vendor service contracts, lease options and equipment replacement.

Intact microtubules are required for rapid turnover of carboxyl-terminal tyrosine of alpha-tubulin in cell cultures.

In cultured muscle cells the carboxyl-terminal tyrosine of alpha-tubulin was shown to exchange rapidly with free tyrosine. The rapid turnover of this residue was dependent upon the presence of intact microtubules. Half-life determinations were made by two methods: (i) the cells were pulse-labeled in hypertonic medium, in which the major tyrosine incorporation was post-translational, and then chased with isotonic medium; and (ii) the cells were pulsed and chased in isotonic medium, and the post-translational component of the radioactivity of purified alpha-tubulin was calculated. Both methods yielded a half-life of 37 min or less for the terminal tyrosine residue, whereas the half-life of tubulin itself was shown to be greater than 48 hr.

Electrical burns--incidence and prognosis in Western Scotland.

A 10-year review of all patients admitted to the West of Scotland Regional Burns Unit with serious electrical burns indicated an incidence of only 2.6 cases per million of the population served by the Unit per year. Injuries following electrocution or electric flash, but excluding injuries caused by grasping the hot heating element of an electric fire, were suffered by 70 patients, 52 of whom sustained electrocution which was not immediately fatal. Ninety-one per cent of the patients were male. The patients who died in hospital did so as a result of sepsis rather than as a direct result of the electrical injury. All those patients who had ECG changes on admission recovered completely. In view of the very deep injuries, the amputation rate was high with 12 out of 52 patients (23 per cent) with electrocution injury requiring one or more amputations. The events preceding the serious electrical injury in our patients suggest that, 57 per cent of all the injuries could have been prevented, and in patients under 20 years of age this percentage rose to 91.

An audit of trauma deaths occurring in the accident and emergency department.

A retrospective study of all patients who died following trauma in the Accident and Emergency Department of the royal Infirmary of Edinburgh over a 4-year period revealed 50 patients (0.0002% of total attendances). Injury severity scores (ISS) and probabilities of survival (Ps) were calculated for all patients. Two-thirds had a Ps of zero while 7 (14%) had a Ps of 0.5 or more. From the information in the case records and at autopsy four deaths (8%) were considered to have been potentially avoidable on the basis of inadequate or inappropriate management. There were a further eight cases (16%) whose management appeared to have been unsatisfactory but who would have been expected to die even if given optimal treatment. These cases are discussed in detail. Difficulty in diagnosing thoracic injuries and delay in giving appropriate treatment were by far the commonest errors encountered. A protocol for the treatment of patients in cardiorespiratory arrest with thoracic injuries is presented. The importance of regular audit of trauma cases and deaths is emphasized.