The PAWS score: validation of an early warning scoring system for the initial assessment of children in the emergency department.

OBJECTIVE: To devise a physiology-based scoring system for assessment of children presenting to the emergency department (ED) and to validate the system retrospectively. STUDY DESIGN: Age-dependent physiological parameters designed to reflect the cardiovascular, respiratory and neurological status of patients presenting to the ED were included in a scoring system called the Paediatric Advanced Warning Score (PAWS). A retrospective pilot evaluation was performed to validate PAWS. SETTING AND PATIENTS: PAWS scores were calculated retrospectively for 46 consecutive children who required admission from the ED to the paediatric intensive care unit (PICU) and for 49 control children who were admitted from the ED to the general paediatric ward. MAIN OUTCOME MEASURES: To validate the PAWS score, we determined if this score was able to identify patients who require admission to the PICU and were therefore significantly unwell. RESULTS: The PAWS score area under the receiver operating characteristic curve was 0.86. Using a trigger score of 3 or above, PAWS was able to identify patients requiring PICU admission with a sensitivity of 70% and a specificity of 90%. CONCLUSIONS: This pilot study has shown that a physiology-based scoring system can help to identify children in the ED requiring PICU admission. Future prospective validation of PAWS is necessary to assess its ability to identify all children in need of urgent assessment in the ED.

Role of thrombolytic agents in cardiac arrest.

The prognosis of patients having a cardiac arrest is generally poor, with a few exceptions. Interventions that aim to improve outcome in cardiac arrest have proved to be disappointing. In particular, no drug has been reliably proved to increase survival to discharge after cardiac arrest. Given that coronary thrombosis in situ and pulmonary thromboembolism are implicated in a large proportion of patients with cardiac arrest, the use of thrombolytic agents has been suggested. Case reports and animal studies have shown favourable results, and have proposed plausible mechanisms to explain them. This is a review of the current literature focusing on the use of thrombolysis during cardiac arrest. A comprehensive literature search was carried out on Medline from 1966 to January 2006, Embase from 1988 to January 2006 and the Cochrane Library, using the Ovid interface. Six articles were selected for review. Although some results are encouraging, all the studies currently available are limited by size and flaws in design.

Removal of C-spine protection by A&E triage nurses: a prospective trial of a clinical decision making instrument.

OBJECTIVE: To investigate if triage nurses could safely apply a set of clinical criteria, removing hard collars and spinal boards at initial triage assessment. METHODS: The Nexus clinical decision rules were applied by trained triage nurses to patients who attended the department with cervical collars and/or on spinal boards. Patients were excluded if they were felt to be in need of immediate medical assessment. Data were collected on the time to nursing assessment, time to medical assessment and time spent restrained. Patients were followed up until discharge and their radiological diagnosis confirmed. Hospital records were checked to ensure that no patients re-presented with injuries that had been missed at initial assessment. RESULTS: In total, 112 patients were included in the study. Clinical criteria were met in 59 patients and their collar removed at triage assessment. For low risk patients, this reflects a mean reduction in time spent restrained of 23.3 minutes (p<0.005; 95% confidence interval 20.18 to 26.54). No patient who had a collar removed was found to have a significant injury. CONCLUSIONS: Simple criteria can be applied by accident and emergency triage nurses to allow safe removal of cervical collars and spinal boards. The reduced time patients spent immobilised represents an important improvement in patient care.

A structured competency based training programme for junior trainees in emergency medicine: the "Dundee Model".

Recent changes in medical training prompted by Modernising Medical Careers and the New Deal requires a more structured, competency based training programme. This paper describes the development of such a programme in an emergency medicine department of a teaching hospital. It describes the process of design and the various aspects incorporated to develop a balanced system of training, appraisal, and assessment.

Difference in injury pattern between drivers and front seat passengers involved in road traffic accidents in Scotland.

OBJECTIVES: To investigate the frequency and pattern of injury in front seat passengers as compared with drivers, in Scotland. METHODS: Using the Scottish Trauma Audit Group (STAG) database from 1994 to 2000, a search for injuries to eight anatomical body regions was performed. Injuries were identified and selected by their abbreviated injury score code. A comparison of injury frequency between drivers and front seat passengers was then made. RESULTS: There were 4189 drivers and 954 front seat passengers included in the study. Mortality was higher in the "front seat passengers" group (6.6% compared with 5.3% p = 0.13). Seven of the eight body regions selected showed higher rates of injury in front seat passengers. There were significantly more injuries to cervical spine (6.0% compared with 3.3% p

Hypothermia in elderly patients presenting to accident & emergency during the onset of winter.

It is well established that the elderly population is vulnerable to hypothermia, leading to increased morbidity. A prospective observational study took place between 1 October 1999 and 31 December 1999 in a large teaching hospital Accident and Emergency department. Core temperature was assessed at presentation using a tympanic probe on patients over 65 years of age. A total of 1543 eligible patients attended during the study period. Complete data was available on 958 patients. Forty-eight patients (5%) were found to be hypothermic (core temperature < 35 degrees Celcius). There were two peaks in hypothermic presentations; these corresponded to periods of cold weather. The incidence of hypothermia was higher in non-ambulant patients and those with co-morbidity; the majority of patients lived in relatively deprived areas by a postcode derived deprivation index. Mortality was 34% in patients hypothermic at presentation. Hypothermia contributes to mortality and morbidity in elderly patients; its incidence may be higher than previously reported.

P-R segment depression: an early diagnostic feature in acute pericarditis: a telephone survey of UK accident and emergency departments.

P-R segment depression is an early ECG change in the evolution of acute pericarditis. This is widely recognized in the USA and appears in several major emergency medicine texts. A telephone survey was conducted to gain an overview of the knowledge of accident and emergency career doctors in the UK. We hope to use the results to highlight this potentially useful sign. One hundred accident and emergency departments, listed in the 1999 British Association for Accident and Emergency Medicine as seeing more than 40,000 new patients per year, were contacted in a telephone survey. The registrar, staff grade or consultant on call was asked to respond to a brief questionnaire. One hundred accident and emergency (A&E) specialist doctors were contacted--60 specialist registrars, 23 consultants and 17 staff grades. Of those questioned, 24% had a background in general medicine. The remainder had trained in surgery, A&E medicine or anaesthetics. None of the doctors questioned volunteered knowledge of P-R depression when asked an open question. Six doctors (6%) admitted, when prompted, to having previously heard of this sign. Knowledge of P-R segment depression is not widespread amongst UK A&E specialists. It is a potentially useful early electrocardiogram change in the evolution of acute pericarditis. Its recognition may aid diagnosis and prevent the inappropriate administration of thrombolytic therapy.