Bomb blast imaging: bringing order to chaos.

Blast injuries are complex, severe, and outside of our everyday clinical practice, but every radiologist needs to understand them. By their nature, bomb blasts are unpredictable and affect multiple victims, yet require an immediate, coordinated, and whole-hearted response from all members of the clinical team, including all radiology staff. This article will help you gain the requisite expertise in blast imaging including recognising primary, secondary, and tertiary blast injuries. It will also help you understand the fundamental role that imaging plays during mass casualty attacks and how to avoid radiology becoming a bottleneck to the forward flow of severely injured patients as they are triaged and treated.

Single and multi-user virtual patient design in the virtual world.

This research addresses the need for the flexible creation of immersive clinical training simulations for multiple interacting participants and virtual patients by using scalable open source virtual world technologies. Initial development of single-user surgical virtual patients has been followed by that of multi-user multiple casualties in a field environment and an acute hospital emergency department. The authors aim to validate and extend their reproducible framework for eventual application of virtual worlds to whole hospital major incident response simulation and to multi-agency, pan-geographic mass casualty exercises.

Resuscitation room blood alcohol concentrations: one-year cohort study.

OBJECTIVE: To clarify the relationship between presenting clinical condition and blood alcohol concentration (BAC) among adult patients admitted to a resuscitation room (RR) of an emergency department (ED) in order to help guide clinical practice. METHOD: Single-site prospective cohort study of all patients admitted to the RR of an inner-city hospital over a one-year period. The study sample comprised all those aged 16 years and over from whom a blood sample was taken, with BAC (results not known to ED staff), pathology by International Classification of Diseases (ICD) version 10 coding, injury severity score for trauma, return visit to hospital and mortality during the subsequent 6-month period, being recorded. RESULTS: 291 (15%) of 1908 presentations had a positive BAC (ie, BAC >10 mg/100 ml) ranging from 11 to 574 mg/100 ml, of which almost 40% were over 240 mg/100 ml (ICD-10 code Y90.8). In addition to collapse from alcohol/drugs, almost half of those presenting following self-harm or assault had a positive BAC. Those with a positive BAC had a higher rate of ED re-attendance in the following 6 months. 10% of all presentations were due to trauma. CONCLUSION: The following five presentations to the RR are associated with a positive BAC: collapse from alcohol/drugs, self-harm, trauma, gastrointestinal bleeding (ICD-10 code K92.2) and non-cardiac chest pain (ICD-10 code R07). Patients with a positive BAC demonstrate a very wide range of pathology, some with severe levels of misuse. This highlights the opportunity for prompt feedback when sober, to ensure all is done to encourage patients to contemplate change in order to reduce re-attendance.

Clinicians taking pictures--a survey of current practice in emergency departments and proposed recommendations of best practice.

The primary objective of this survey was to establish current practice in emergency departments in the UK. Variation in obtaining consent, how image collection is achieved, and the images stored were considered to be important outcomes. An initial postal questionnaire followed by phone survey posed questions about practical and procedural issues when capturing clinical images in emergency departments in the UK. Altogether, 117 departments replied out of 150 surveyed. Only 21 departments have a written policy permitting medico-legal case photography. A total of 53 do take clinical photographs where no policy exists, seven of which actively take assault/domestic violence images, only four of which document consent. All departments with photographic facilities take images for clinical/teaching purposes. Thirty two of those without a policy attach the photograph to the clinical notes and so may be potentially called upon for medico-legal proceedings if relevant, which raises issues of adequate consent procedures, storage, and confidentiality. This is particularly pertinent with the increasing use of digital photography and image manipulation. A large variation in current practice has been identified in relation to a number of issues surrounding clinical image handling in emergency departments. Subsequently, recommendations for best practice have been proposed to protect both the patient and the clinician with regards to all forms of photography in the emergency department setting.

Modification of minitracheostomy technique to limit bleeding complications.

Minitracheostomy is a commonly performed procedure usually carried out by junior medical staff. Though there are few problems associated with the technique of minitracheostomy, bleeding is often encountered. We now present a brief case report demonstrating the problems associated with bleeding. We also outline an alteration in insertion technique with the 'Minitrach' designed to diminish the risks of serious bleeding, and report on our results with this technical modification.

Pacing thresholds of temporary epicardial electrodes: variation with electrode type, time, and epicardial position.

We compared the variation in pacing thresholds of two widely used temporary pacing electrodes at different epicardial sites in 67 patients after coronary artery operations performed with either cardioplegia or ventricular fibrillation. In 33 patients, a bare, braided pacing wire (DW) was placed on the right ventricle and a Medtronic localized epicardial electrode (MED), on each ventricle. In the other 34 patients, the DW wire was placed on the right atrium and a MED electrode, on each atrium. Pacing thresholds were measured at the time of placement; at 1 hour, 6 hours, and 12 hours postoperatively; and daily for 4 days. The pacing thresholds (mean +/- standard error of the mean) at implantation were as follows: DW wire = 0.93 +/- 0.08 V and MED electrode = 0.63 +/- 0.1 V in the ventricles and DW = 1.28 +/- 0.18 V and MED = 0.65 +/- 0.09 V in the atria. On the fourth postoperative day, the pacing thresholds were DW = 2.08 +/- 0.21 V and MED = 1.19 +/- 0.22 V in the ventricles and DW = 2.33 +/- 0.29 V and MED = 1.04 +/- 0.09 V in the atria. The pacing thresholds of both types of wire increased significantly over time, but this deterioration was more pronounced with the braided wire both on the ventricle and on the atrium. The pacing threshold patterns were not affected by chamber side or mode of myocardial preservation. The braided ventricular wire failed to capture after 24 hours in 9 of 30 patients, whereas the localized epicardial electrode captured in all instances (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Primary cardiac sarcomas. A report of three cases and a review of the current literature.

Primary cardiac sarcomas are uncommon but they may mimic a wide range of common cardiac pathologies by their modes of presentation. Surgery is the mainstay of treatment for non-metastatic disease however, the incidence of tumour recurrence and late metastases is high. For metastatic disease, the response to chemotherapy and radiotherapy is poor and surgery should be reserved for palliation where appropriate. The emphasis should be on early diagnosis of primary cardiac sarcoma, enabling prompt and relevant management.