Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children.

OBJECTIVE: To determine whether full elbow extension as assessed by the elbow extension test can be used in routine clinical practice to rule out bony injury in patients presenting with elbow injury. DESIGN: Adults: multicentre prospective interventional validation study in secondary care. Children: multicentre prospective observational study in secondary care. SETTING: Five emergency departments in southwest England. PARTICIPANTS: 2127 adults and children presenting to the emergency department with acute elbow injury. INTERVENTION: Elbow extension test during routine care by clinical staff to determine the need for radiography in adults and to guide follow-up in children. MAIN OUTCOME MEASURES: Presence of elbow fracture on radiograph, or recovery with no indication for further review at 7-10 days. RESULTS: Of 1740 eligible participants, 602 patients were able to fully extend their elbow; 17 of these patients had a fracture. Two adult patients with olecranon fractures needed a change in treatment. In the 1138 patients without full elbow extension, 521 fractures were identified. Overall, the test had sensitivity and specificity (95% confidence interval) for detecting elbow fracture of 96.8% (95.0 to 98.2) and 48.5% (45.6 to 51.4). Full elbow extension had a negative predictive value for fracture of 98.4% (96.3 to 99.5) in adults and 95.8% (92.6 to 97.8) in children. Negative likelihood ratios were 0.03 (0.01 to 0.08) in adults and 0.11 (0.06 to 0.19) in children. CONCLUSION: The elbow extension test can be used in routine practice to inform clinical decision making. Patients who cannot fully extend their elbow after injury should be referred for radiography, as they have a nearly 50% chance of fracture. For those able to fully extend their elbow, radiography can be deferred if the practitioner is confident that an olecranon fracture is not present. Patients who do not undergo radiography should return if symptoms have not resolved within 7-10 days.

Early goal-directed therapy: a UK perspective.

The surviving sepsis campaign developed guidelines in 2003 that were designed to increase physician awareness of sepsis and to develop a series of recommendations for the management of the patient with sepsis. The guidelines had the support of 11 international professional organisations across a variety of specialties, and advocate aggressive, early goal-oriented resuscitation in appropriate patients.

Simplifying thrombolysis decisions in patients with left bundle branch block.

OBJECTIVES: To redesign and simplify an existing decision algorithm for the management of patients who present to the emergency department with chest pain and left bundle branch block (LBBB) based on the Sgarbossa criteria. To compare its reliability with the current algorithm. METHODS: A simplified algorithm was created and tested against the existing algorithm. Electrocardiograms (ECGs) of patients with LBBB were presented to 10 emergency department doctors with both old and new algorithms a week apart. Six ECGs displayed the relevant criteria for thrombolysis and had proven acute myocardial infarction (AMI) based on a gold standard of enzyme measurements. Subjects were asked whether or not they would thrombolyse a patient presenting with the given ECG using each of the algorithms as a guide. RESULTS: The new algorithm has demonstrated improvements in terms of an increase in appropriate thrombolysis and a reduction in inappropriate thrombolysis. Specificity for AMI rose from 0.85 to 0.99 and sensitivity from 0.38 to 0.6. kappa score showed greater agreement with the gold standard. CONCLUSION: Patients with AMI and LBBB have a significantly poorer outcome than those without LBBB. Despite this, thrombolysis is less likely to be given to patients with AMI and LBBB. This study demonstrates that in part this is because of cognitive difficulties using the current algorithm. The proposed proforma addresses these issues and provides a simple tool to aid appropriate treatment in this group of patients.

A comparative study of evaluation of radiographs, CT and 3D reformatted CT in facial trauma: what is the role of 3D?

A panel of 17 trainee maxillofacial surgeons viewed 23 cases of facial trauma, demonstrated on radiographs, axial CT images and three-dimensional (3D) reformatted CT images in a standardized viewing format under standard conditions. Their diagnostic interpretation, extraction of information relevant to surgical management and subjective evaluation of each modality were recorded by standard questionnaire and compared with a gold standard evaluation by a consultant radiologist and surgeon reading based on results of clinical management. There were clear and measurable differences in the viewers' evaluations of radiographs, CT and 3D reformatted images. Overall, surgeons showed more accurate diagnostic reading of radiographs and 3D reformatted images. This was in contrast to their subjective assessment of the clinical value of each modality, which showed a strong preference for 3D over all other techniques and for CT over radiographs. However the perceived benefit of axial CT images over radiographs was not reproduced on objective testing in this group; surgeons appear to perform less well in interpreting CT images than their subjective response to the modality would suggest. This work has supported the view that surgeons value 3D imaging as a front-line tool in the evaluation and management of selected cases of acute facial trauma. We have demonstrated that the perceived benefits of 3D reformatted CT to surgeons appear real.

Heliox for asthma in the emergency department: a review of the literature.

January 2002 saw the relaunch by BOC of Heliox, a gaseous mixture of helium and oxygen, for the use in a wide range of respiratory conditions. Despite a lapse of over 65 years since it was first used, and a large number of studies and case reports advocating its use, it remains an enigma, its use sporadic, and its role undefined. This paper reviews the discovery of helium and early medical use of helium oxygen mixtures and outlines areas where Heliox already has confirmed benefit as well as one or two areas that are currently under investigation. It will also look specifically at the use of Heliox in acute exacerbations of asthma and perform a thorough review of the current literature.