Prehospital clearance of the cervical spine: does it need to be a pain in the neck?

Prehospital cervical spine (c-spine) immobilisation is common, despite c-spine injury being relatively rare. Unnecessary immobilisation results in a significant burden on limited prehospital and emergency department (ED) resources. This study aimed to determine whether the incidence of unnecessary c-spine immobilisation by ambulance personnel could be safely reduced through the implementation of an evidence-based algorithm. Following a training programme, complete forms on 103 patients were identified during the audit period, of which 69 (67%) patients had their c-spines cleared at scene. Of these, 60 (87%) were discharged at scene, with no clinical adverse events reported, and 9 (13%) were taken to the local ED with non-distracting minor injuries, all being discharged home the same day. 34 (33%) patients could not have their c-spines safely cleared at scene according to the algorithm. Of these, 4 (12%) patients self-discharged at scene and 30 (88%) were conveyed to an ED as per the normal procedure. C-spine clearance at scene by ambulance personnel may have positive impacts on patient care, efficient use of resources and cost to healthcare organisations.

Admissions to intensive care units from emergency departments: a descriptive study.

OBJECTIVES: To describe the case mix, activity, and outcome for admissions to intensive care units (ICUs) from emergency departments (EDs). DESIGN: An observational study using data from a high quality clinical database, the Case Mix Programme Database, of intensive care admissions, coordinated at the Intensive Care National Audit & Research Centre (ICNARC). SETTING: 91 adult ICUs in England, Wales, and Northern Ireland, 1996-99. SUBJECTS: 46,587 intensive care admissions. MAIN OUTCOME MEASURES: Ultimate hospital mortality. RESULTS: Admissions from EDs constituted 26% of total admissions to ICU, 77% of which were direct admissions to ICU from EDs. Direct admissions from EDs, indirect admissions from EDs, and non-ED admissions presented to ICU with different conditions and severity of illness. Indirect admissions from EDs presented in the ICU with the more severe case mix (older age, more acute severity of illness, more likely to have a chronic illness) compared with direct admissions to ICU from EDs. Compared with ICU admissions not originating in EDs, unit and hospital mortality were higher for admissions from EDs, with indirect admissions experiencing the highest hospital (46.4%) mortality. For ICU survivors, indirect admissions stayed longest in the ICU. CONCLUSIONS: A large proportion of admissions to ICU (26%) originate in EDs, and differ from those not originating in EDs in terms of both case mix and outcome. Additionally, those admitted directly to ICU from EDs differ from those admitted indirectly via a ward. The observed differences in outcome between different admission routes require further investigation and explanation.

Long-term use of the low molecular weight heparin tinzaparin in haemodialysis.

Fifty-two patients with chronic renal failure undergoing hospital haemodialysis were given a single bolus dose of tinzaparin (Innohep, Leo Laboratories, UK) into the arterial side of the dialyser, for up to 43 consecutive dialyses. The mean tinzaparin dose at the beginning was 2,139 IU anti-Xa and at the end 2,186 IU anti-Xa. Overall, tinzaparin proved a satisfactory anticoagulant for 1,370 (96.0%) out of 1,427 dialyses. Significant clot formation was prevented in 1,326 (92.8%) out of 1,429 dialyses. The clinically effective dose was associated with a mean plasma anti-Xa activity 1 h after dosing of 0.4 IU/ml and suppressed fibrinopeptide A formation for up to 4 h. Bleeding, from the skin or mucous membranes, was recorded at 27 (1.9%) of 1,408 dialyses. Prolonged fistula bleeding on completion of dialysis was recorded on only 20 occasions. Other haemorrhagic events included haematemesis, bruising and subconjunctival haemorrhage (each in 1 patient) and epistaxis (2 patients). Three patients died during the study of causes considered unrelated to tinzaparin therapy, myocardial infarction (2 patients) and multiple myeloma. Other adverse events reported included vomiting (3 patients) and hypotension (3 patients). Three patients ceased treatment due to haematemesis, prolonged bleeding from fistula puncture and thrombosis of the arteriovenous access, respectively. A small, but statistically significant, increase within the normal reference range was recorded in the mean values for aspartate aminotransferase and alanine aminotransferase.

Report on management of renale failure in Europe, XXVI, 1995. Rare diseases in renal replacement therapy in the ERA-EDTA Registry.

The proportion of centres returning the ERA-EDTA Registry questionnaires has decreased considerably in recent years. Demographic information, based on the response rate of centres in 1994 (44%), does not allow reasonable projections for management of renal failure in Europe. To encourage the participation of non-responding centres, the timing was right to show the powerful impact of the ERA-EDTA Registry as a supra-national registry, by studying patients in renal replacement therapy (RRT) suffering from rare diseases. Four such diseases, Fabry's disease, nephropathy due to cyclosporin (CsA), nephropathy due to cisplatin and scleroderma, were studied using the records of 440665 patients on file up to 31 December 1993. There were 83 patients with Fabry's disease (0.0188%), 85 patients with CsA nephropathy (0.0193%), 120 patients with cisplatin nephropathy (0.0272%) and 625 patients with scleroderma (0.142%). Scleroderma was introduced as a primary renal disease (PRD) in the ERA-EDTA Registry in 1977. Seven patients were accepted for RRT in that year, whereas the number increased to over 50 new patients per year after 1986. More than half of the patients were aged over 55 years, and 68% of them were women. Survival rate of dialysis patients suffering from scleroderma was 22% at 5 years, compared to 51% in patients with standard primary renal diseases. The main causes of death were cardiovascular complications (41%), cachexia (15%) and infection (10%). Survival of first graft in a small number of 28 patients was 44% at 3 years, compared to 60% in standard PRD. Patient survival after first transplant, however, was higher by 32% at 3 years compared to that of dialysis patients. Cisplatin nephropathy was introduced as a PRD in the ERA-EDTA Registry in 1985, and since then six to 19 new patients have been accepted for RRT each year. The main reason for undergoing cisplatin treatment was ovarian (32%) and testicular cancer (21%), and the mean interval from treatment to RRT was 21.5 months, ranging widely from 0.1 to 131 months. Patient survival on dialysis was 22% at 5 years, compared to 51% in patients with standard PRD. Malignancy and cachexia accounted for over 60% of the total number of deaths. CsA nephropathy was introduced as a PRD in the ERA-EDTA Registry in 1985 and, despite its rarity, is of particular interest as a new iatrogenic entity resulting from CsA administration, mainly in solid organ transplantation. In 1985, two new patients commenced RRT in Europe, and the number increased to 59 in 1991-93. The main reason for undergoing CsA treatment was heart (68%) and liver transplant (22%), and the mean interval from treatment to RRT was 50.2 months, ranging from 5 to 90 months. Patient survival on dialysis was 46% at 4 years, compared to 58% in patients with standard primary nephropathies. Cardiovascular causes (48%) and infection (17%) were the main causes of death. Fabry's disease was introduced as a PRD in the ERA-EDTA Registry in 1985, and since the four to 13 new patients per year have commenced RRT in Europe. It is a sex-linked recessive disorder primarily affecting males (87%), and the mean age at start of RRT was 38 years. Proteinuria, skin lesions and painful paresthesiae were the most common presenting symptoms, and over 70% of the patients were hypertensive and had significant cardiovascular problems at RRT. Patient survival on dialysis was 41% at 5 years, compared to 68% in patients with standard primary nephropathies. Cardiovascular complications (48%) and cachexia (17%) were the main causes of death. Graft survival at 3 years in 33 patients was not inferior to that of patients with standard nephropathies (72% vs 69%), and patient survival after transplantation was comparable to that of patients under 55 years of age with standard PRD. (ABSTRACT TRUNCATED)

Improving the prognosis in acute renal and respiratory failure.

We have achieved smooth homeostasis in patients with acute renal and respiratory failure by means of machine-controlled, continuous ultrafiltration and simultaneous bicarbonate hemodialysis with a polysulfone, biocompatible membrane (CUPID). No adverse effects were seen, even after 22 days of continued treatment. Mortality was reduced (7/14) when compared to that of a similar group given short conventional daily acetate hemodialysis and ultrafiltration with a cuprophane membrane (12/18).

A semi-automatic method of measuring leucocyte movement.

A semi-automatic system has been developed for measuring the migration of leucocytes within a micropore filter. The distance in micrometers is displayed digitally or analysed on-line by a digital computer. These improvements have resulted in considerable saving in time, permitting the full potential of the micropore method to be utilised. To illustrate this technique we report results from experiments to measure dose-response relationships of leucocytes to casein and the variation in response to Staphylococcus aureus and casein of cells from normal human subjects.

Concerning the ionic basis of presynaptic inhibition.

The superfused rat cuneate nucleus has been used to investigate the sensitivity of primary afferent terminals and of evoked primary afferent depolarization (PAD) to alterations in extracellular K+ and Cl- ions levels. Results indicate that PAD is caused by an efflux of Cl- from primary afferent terminals rather than by an increase in extracellular K+.