Critical care in the emergency department: shock and circulatory support.

Effective resuscitation includes the rapid identification and correction of an inadequate circulation. Shock is said to be present when systemic hypoperfusion results in severe dysfunction of the vital organs. The finding of normal haemodynamic parameters, for example blood pressure, does not exclude shock in itself. This paper reviews the pathophysiology, resuscitation, and continuing management of the patient presenting with shock to the emergency department.

Aeromedical retrieval to a university hospital emergency department in Scotland.

Rural and island areas of Scotland benefit from the availability of the Scottish Ambulance Service paramedic staffed helicopter for transfers and primary scene responses. There are a small number of patients who require advanced airway management, invasive procedures, or critical care interventions to stabilise them before transport to definitive care. At present these additional skills are provided on an ad hoc basis by senior medical staff drawn from intensive care and emergency medicine at the receiving hospitals. Given the potential difficulties of training paramedics to use these infrequently used skills it may be preferable to establish a formalised system to access suitably trained medical staff. This case series illustrates the clinical challenges and potential benefits of such a service and discusses the practicalities involved.

Rapid sequence intubation in Scottish urban emergency departments.

OBJECTIVE: Airway care is the cornerstone of resuscitation. In UK emergency department practice, this care is provided by anaesthetists and emergency physicians. The aim of this study was to determine current practice for rapid sequence intubation (RSI) in a sample of emergency departments in Scotland. METHODS: Two year, multicentre, prospective observational study of endotracheal intubation in the emergency departments of seven Scottish urban teaching hospitals. RESULTS: 1631 patients underwent an intubation attempt in the emergency department and 735 patients satisfied the criteria for RSI. Emergency physicians intubated 377 patients and anaesthetists intubated 355 patients. There was no difference in median age between the groups but there was a significantly greater proportion of men (73.2% versus 65.3%, p=0.024) and trauma patients (48.5% versus 37.4%, p=0.003) in the anaesthetic group. Anaesthetists had a higher initial success rate (91.8% versus 83.8%, p=0.001) and achieved more good (Cormack-Lehane Grade I and II) views at laryngoscopy (94.0% versus 89.3%, p=0.039). There was a non-significant trend to more complications in the group of patients intubated by emergency physicians (8.7% versus 12.7%, p=0.104). Emergency physicians intubated a higher proportion of patients with physiological compromise (91.8% versus 86.1%, p=0.027) and a higher proportion of patients within 15 minutes of arrival (32.6% versus 11.3%, p<0.0001). CONCLUSION: Anaesthetists achieve more good views at laryngoscopy with higher initial success rates during RSI. Emergency physicians perform RSI on a higher proportion of critically ill patients and a higher proportion of patients within 15 minutes of arrival. Complications may be fewer in the anaesthetists' group, but this could be related to differences in patient populations. Training issues for RSI and emergency airway care are discussed. Complication rates for both groups are in keeping with previous studies.

The dangers of taking 'T in the country'.

'T in the Park' is the largest annual music festival in Scotland. This paper reports on how an increased attendance and change of location for the 1997 event altered the workload. The influences that affected the pattern of patient presentations and the adaptations made in the medical service provided are discussed.

Increased survival after serious injury in patients admitted directly to critical care areas from the accident and emergency department.

OBJECTIVES: We hypothesised that, in the subgroup of seriously injured patients who receive early critical care in the operating theatre or intensive care unit, there would be a greater actual survival rate than that statistically predicted using trauma scoring techniques. METHODS: 1031 seriously injured patients on a national trauma database were analysed. The numbers of survivors in 3 initial destination groups [intensive care unit (ICU), theatre and ward] were compared with the average number of survivors statistically predicted for similar groups of patients using the TRISS methodology. W statistics were then used to test for statistical significance. RESULTS: 77/122 patients admitted to an ICU survived (predicted number 66, W stat 8.8 [2.6-15.0]). 129/178 patients transferred to theatre survived (predicted number 113, W stat 8.8 [4.2-13.5]). 296/348 patients admitted to a ward survived (predicted number 292, W stat 1.3 [-1.9-4.4]). CONCLUSIONS: The number of patients who survive after severe injury is significantly greater than the number predicted to survive by current trauma scoring methods if the patient is sent directly to theatre or are admitted directly to the ICU. Survival is as predicted if the patient is sent initially to a ward.

The dangers of taking 'T in the Park'.

This paper describes how medical cover was provided for a large music festival attended by 70,000 people. The organisational structure of the team and the workload encountered are related. As well as illustrating the value of on-site medical cover in minimising the workload for local health services, some specific hazards of such events are discussed.

Unexplained pneumoperitoneum in association with basic cardiopulmonary resuscitation efforts.

During the mouth to mouth ventilation of basic life support, the high inflation pressures generated may result in later complications. Pulmonary barotrauma may result in pneumothorax or pneumomediastinum, and high pressures applied to the gastrointestinal tract may lead to gastric rupture and pneumoperitoneum. A case is reported of pneumoperitoneum in the absence of pneumothorax, pneumomediastinum or gastrointestinal perforation and the literature relating to this unusual condition is reviewed.

Plasma catecholamine responses in acute severe asthma.

Twenty patients presenting to an A&E department with acute severe asthma were studied. Despite clinically severe airway obstruction few had raised catecholamine levels. However several patients with impending respiratory arrest had markedly elevated catecholamine levels, and relationships are demonstrated between these levels and other measures of disease severity.