Head injury attenders in the emergency department: the impact of advice and factors associated with early symptom outcome.

PRIMARY OBJECTIVE: Many who attend hospital after head injury are not admitted to a hospital bed. This study explores the views of hospital attenders about advice received, predictors of memory for and compliance with advice and factors associated with early symptom persistence and outcome that might identify those requiring follow-up. DESIGN: A single group prospective follow-up design. METHODS AND PROCEDURE: Relationships between information obtained by emergency department (ED) staff during admission and about satisfaction with and memory for advice and about symptom persistence was compared in 200 attenders with head injury who were not admitted to hospital. The telephone interview comprised a structured interview and the Post-Concussional Symptoms Checklist. RESULTS: Satisfaction with advice was high. Despite this, a minority remembered advice (alcohol/drugs 44%; medication 38%; rest/sleep 56%; work 36%; sport 36%). At follow-up, symptom complaints were not predicted by information obtained in the ED. Attenders with retrospectively assessed post-traumatic amnesia (PTA) for more than 5 minutes reported more symptoms and poorer memory for advice at follow-up. CONCLUSIONS: Although satisfaction with advice was high, memory for advice was relatively poor and was associated with longer durations of PTA. Attenders with PTA > 5 minutes should be targeted for follow-up or inpatient admission.

The significance of post-traumatic amnesia as a risk factor in the development of olfactory dysfunction following head injury.

OBJECTIVE: To test the following hypothesis in the assessment of head injury PATIENTS: only patients with 5 min or more of post-traumatic amnesia (PTA) are at risk of acute olfactory dysfunction (OD). METHODS: This was a retrospective comparative study of olfactory status in head injury patients seen at a head injury clinic at Glasgow Royal Infirmary from 1985 to 2003. Of 828 clinic attenders, 101 had acute OD. These subjects were compared with a randomly selected control group of 102 patients with head injury but normal olfactory function. The main outcome measure was a significant likelihood of patients with PTA lasting for 5 or more minutes having acute OD compared with those with PTA of less than 5 min. RESULTS: The likelihood of patients with a PTA of 5 min or more having acute OD compared to those with PTA of less than 5 min is clinically significant with an odds ratio of 9.6 (p<0.01). CONCLUSION: Examination of patients with 5 min or more of PTA should include a simple test of sense of smell. Patients with impaired smell sensation should be aware of their condition prior to discharge from hospital. In addition, the need for a CT brain scan and appropriate follow up should be considered.

CPR '98: a practical multimedia computer-based guide to cardiopulmonary resuscitation for medical students.

This paper describes an initiative to build a multimedia computer-based teaching package for cardiopulmonary resuscitation. The project resulted from a perceived gap in the undergraduate medical curriculum allied to concern from medical students. The software application was designed to be networked and used as an adjunct to taught life support courses for undergraduate medical students. The package comprises tutorials and test questions in basic and advanced life support. It incorporates sound, video, graphics and animation to illustrate the techniques involved and is distributed on CD ROM for the PC. The content is based on the 'Advanced Life Support Manual', produced by the Resuscitation Council (UK) and incorporates all changes to the guidelines made during 1997 and 1998. The basic life support section has been networked locally, and has been tested on more than 60 third year medical students attending a local basic life support course. It was found that students who used the package performed significantly better in theoretical assessments than those who did not.

Prolonged resuscitation in accidental hypothermia: use of mechanical cardio-pulmonary resuscitation and partial cardio-pulmonary bypass.

We report a case of profound accidental hypothermia with asystolic cardiac arrest which was reversed after 5.5 hours of mechanical cardio-pulmonary resuscitation. Rewarming was achieved by the use of partial cardio-pulmonary bypass.

The general practitioner's use and expectations of an accident and emergency department.

In an attempt to establish what the general practitioner expects from an accident and emergency department, and how closely the service provided correlates with that view, a 12-point questionnaire was sent to the general practitioners in the Glasgow Royal Infirmary catchment area. Out of the 61.2% of general practitioners who replied, the majority wish to have responsibility for their own patients for conditions which are neither accidents nor emergencies. There is less agreement as to how much should be done within an accident and emergency department and on the appropriate modes of referral and communication between the general practitioner and the hospital service. Further consultation and cooperation are necessary to interpret and resolve these differences.

Unplanned re-attendance in the accident and emergency department.

The notes of patients who re-attended the Accident and Emergency Department with a problem for which they had already been seen and treated were reviewed over a five-week period. Such patients comprised 2.5% of total attendances. The commonest reason for re-attendance was persistent pain following an injury and of such patients, about a half required a significant change in management. It was estimated that two-thirds of re-attendances were unavoidable. Twenty patients were admitted following re-attendance, and of these, two had serious medical conditions which were missed on initial presentation. The role of senior Accident and Emergency doctors is discussed in the light of these findings.

Who cares for the patient with head injury now?

OBJECTIVE: A recent report on head injury management from the Royal College of Surgeons of England suggests that surgeons are unsuited to the inpatient care of head injuries (ICHI) and should hand over responsibility entirely to neurosurgeons and accident and emergency (A&E) specialists. This prompted a survey of A&E consultants to establish their opinions on the current and future practice of head injury care. METHODS: Questionnaires were sent to consultant members of the British Association for Accident and Emergency medicine. Of a possible 256 A&E departments from Great Britain and Ireland with over 20 000 annual new attenders 206 (80%) replied. RESULTS: General surgeons contribute to ICHI for adults in 107 of 206 hospitals (52%) compared with orthopaedic surgeons in 73 of 206 (35%) and A&E consultants in 71 of 206 (34%). There was frequent criticism that surgeons are uninterested in head injury care. Fifty nine units (30%) commented on the lack of neurosurgery beds and difficulties experienced in getting patients accepted. Few hospitals seem to have well integrated rehabilitation or follow up services targeted at head injury. One in six patients with head injury admitted to a general hospital or observation ward remain after 48 hours and one in 20 stay beyond one week. Of the 132 A&E units without responsibility for ICHI 54 (41%) either wish to take on this responsibility or are willing to do so if the necessary resources are first put in place. The perceived net revenue cost required to allow 67 A&E units to take on ICHI is about 12.5 million pounds per year. This does not include the cost of further care after 48 hours, follow up or rehabilitation. CONCLUSION: Only one third of A&E units at present have even part of the ICHI role recommended in the RCS report; another third are prepared to accept a new role if training and resources are provided and support is forthcoming from other specialists to take over the care after 48 hours; the remaining third are unwilling to accept responsibility for ICHI.

Inadvertent subclavian artery puncture in an intravenous drug abuser.

Arterial complications from inadvertent arterial puncture in intravenous drug abusers are well recognised. Most reports describe injury to the femoral artery with occasional reports of brachial and radial artery injury. A case of subclavian artery injury is described in this paper, and the pathophysiology and treatment of intraarterial drug injection discussed.

Electrocardiograph interpretation by junior doctors.

The object of this study was to assess the ability of junior doctors in the accident and emergency department to detect electrocardiographic (ECG) abnormalities. The ECG's performed in this department were monitored over a 4 week period. The initial diagnosis by the accident and emergency doctor was compared with the report from the cardiologist on 126 ECG's which showed abnormalities. The error rate was 19.8%. Of those abnormalities which were graded as clinically significant only 2 (4.4%) were missed. The danger of missing acute changes is emphasized and proposals discussed which may reduce their frequency.

The introduction of automatic blood pressure monitoring to an accident & emergency resuscitation room.

Machines for automatic non-invasive blood pressure (BP) monitoring are increasingly available in British accident and emergency departments. Our department recently acquired two machines with this capability for use in the resuscitation room. This provided us with an opportunity to compare the speed and frequency of automatic BP recording with the previously used manual method. We found no significant difference in either the median time to the first recording of BP or in the median number of documented recordings in the first hour. However, the overall frequency of BP recording did show a statistically significant increase. We conclude that automation alone does not improve standard practice in this area greatly.

Post-traumatic stress disorder symptoms following a head injury: does amnesia for the event influence the development of symptoms?

BACKGROUND: There is controversy as to whether PTSD can develop following a brain injury with a loss of consciousness. However, no studies have specifically examined the influence of the memories that the individuals may or may not have on the development of symptoms. AIMS: To consider how amnesia for the traumatic event effects the development and profile of traumatic stress symptoms. METHOD: Fifteen hundred case records from an Accident and Emergency Unit were screened to identify 371 individuals with traumatic brain injury who were sent questionnaires by post. The 53 subsequent valid responses yielded three groups: those with no memory (n = 14), untraumatic memories (n = 13) and traumatic memories (n = 26) of the index event. The IES-R was used as a screening measure followed by a structured interview (CAPS-DX) to determine caseness and provide details of symptom profile. RESULTS: Groups with no memories or traumatic memories of the index event reported higher levels of psychological distress than the group with untraumatic memories. Ratings of PTSD symptoms were less severe in the no memory groups compared to those with traumatic memories. CONCLUSIONS: Psychological distress was associated with having traumatic or no memories of an index event. Amnesia for the event did not protect against PTSD; however, it does appear to protect against the severity and presence of specific intrusive symptoms.

Head injuries at an inner city accident and emergency department.

A prospective study was carried out of 784 adults (aged 13 years and over) with recent head injuries who attended the Accident and Emergency Department of the Glasgow Royal Infirmary during an 11-week period (April-June 1978). One-third were caused by assault and only one-tenth by road traffic accidents. Half the patients had recently ingested alcohol, one-quarter of all patients had at least a brief period of post-traumatic amnesia (PTA). The overall admission rate was 28 per cent. Radiography of the skull was performed in 65 per cent and a fracture seen in 5 per cent of these. One-quarter of the patients had at least one unsatisfactory radiograph. Two patients whose fractures were initially missed on radiography were not admitted. Seven of the 24 patients with fractures had no clinical evidence of brain damage (no PTA, no impaired conscious level, no focal neurological signs or symptoms), but all had wounds of the scalp. One-third of all patients did not have radiography of the skull performed, nor were they admitted to hospital, yet one-quarter of these had some evidence of brain damage.

Critical analysis of an accident and emergency ward.

OBJECTIVES: To describe the work, both qualitatively and quantitatively, of an accident and emergency (A&E) ward, and discuss some of the advantages and disadvantages associated with this ward. METHODS: An observational study was carried out of all patients admitted to the A&E ward of Glasgow Royal Infirmary from 1 January 1992 to 31 December 1992. Epidemiological and management data were collected for all patients admitted. RESULTS: There were 2460 admissions, of which 69% were related to trauma and 45% to head injury; 47% of the patients had consumed alcohol before admission. Accidental trauma was the commonest reason for admission (57%), followed by assault (33%). Ninety two per cent of admissions stayed for less than 3 d, but 33% of the workload was spent on a small number of patients admitted for longer than 7 d. CONCLUSIONS: This A&E ward presents a significant workload, and some of its most serious problems lie with those patients who stay longer than 72 h. The safe and effective use of the ward depends upon it being well resourced, along with the department it serves.

A study of stab wounds.

A study was made of patients with stab wounds who attended the Accident and Emergency Department of Glasgow Royal Infirmary during 1978 and 1983. There were 318 patients. The majority, 304 (96%), were males. A total of 87 (27%) were teenagers. The most common sites of the wounds were the chest (143 patients) and the abdomen (113 patients). The features of the patients and their wounds are compared with those of a previous study carried out at the same hospital in the early 1960s (Batey & MacBain, 1967). The post-mortem reports of 25 fatal stab injury cases occurring in Glasgow between 1971 and 1978 are also reviewed. Some aspects of diagnosis, management and prevention of stab wounds are discussed.

Management of minor head injuries in the accident and emergency department: the effect of an observation ward.

The management of 483 patients presenting with minor head injury to the accident and emergency (A&E) departments of two Scottish hospitals was studied prospectively. Such patients comprised 5.7 and 3.9% of the total attendances to each department. Of the 277 patients assessed in the former department, 83 (30%) fulfilled at least one of the currently accepted criteria for recommending admission to hospital and 49 (17.7%) patients were actually admitted. Patients in whom head injury was not the principal reason for admission were excluded from the study. In the same time period the second department dealt with 206 patients with minor head injury, 49 (24%) of whom had criteria for admission. However, significantly fewer, 10 (4.9%) patients, were actually admitted. The major relevant factor when comparing the two departments was the existence in the former of an observation ward. These results support the view that easy access to hospital beds is a major determinant of management in patients presenting with minor head injury to the A&E department and may be more influential than clinical findings.

An evaluation of open scalp wounds.

A retrospective study of 661 adult patients with open scalp wounds attending the Accident and Emergency Department of Glasgow Royal Infirmary, Glasgow, Scotland, was performed. Detailed information was recorded about history, nature of open wounds ('contused' or 'incised'), wound exploration and radiological findings. The commonest cause of injury was assault (40%), followed by falls (34%). Half of the patients had been drinking alcohol. The majority of scalp wounds were 'contused' (84%) resulting equally from assaults and falls; 'incised' wounds (16%) were more commonly due to assault. Although division of the occipitofrontalis aponeurosis was infrequent (18%), most (78%) of the skull fractures occurred in this group. Wound exploration detected nine fractures not evident on skull X-rays. To maximise fracture detection rate, careful wound exploration should be an important adjunct to skull radiography and, in particular, division of the occipitofrontalis aponeurosis should alert the casualty officer to the likelihood of a skull fracture.

Effect of Strathclyde police initiative "Operation Blade" on accident and emergency attendances due to assault.

OBJECTIVE: To review assault victim attendance at the accident and emergency department of Glasgow Royal Infirmary before and after a police initiative to curb knife carrying and tackle violent assaults ("Operation Blade"). METHODS: Assault victim attendance was reviewed for the month before the implementation of Operation Blade and for one month a year later. The number of victims requiring treatment in the resuscitation room for stab wounds before, during, and after Operation Blade was also reviewed as a crude indicator of the frequency of serious assaults in the city. RESULTS: There were no significant differences in the nature or number of assault victims attending this hospital one year after Operation Blade compared with the month before its implementation. Operation Blade reduced the number of serious stabbings for a period of 10 months, but subsequently numbers surpassed those prevailing before its implementation. CONCLUSIONS: Any attempt to combat this complex and multifactorial problem must be addressed through a combined public health and education initiative in conjunction with regular press and police campaigns to achieve a sustained effect.