Evaluation of focussed assessment with sonography in trauma (FAST) by UK emergency physicians.

OBJECTIVES: To evaluate the introduction of a focussed assessment with sonography in trauma (FAST) scan into the early assessment of trauma patients in the UK. METHODS: The setting was an inner city teaching hospital emergency department (annual attendance 100,000). All patients aged 16 or over admitted to the resuscitation room after blunt trauma were included in a prospective observational study. Patients had a FAST scan performed at the end of the primary survey. Results were compared to results of other investigations, laparotomy, postmortem examination, or observation. RESULTS: 153 patients were entered into the study. The sensitivity of the FAST scan was 78% and specificity was 99%. CONCLUSION: FAST is a highly specific "rule in" technique and is useful in the initial assessment of trauma patients. Emergency physicians can perform FAST after a brief training period.

Improvement in initial survival of spinal injuries: a 10-year audit.

A 10-year retrospective study of all spinal injuries presenting to the Leeds Teaching Hospitals between 1991 and 2001. The hospitals provide secondary care to a population of 750,000 and tertiary care to a population of 2-3 million. In total 1119 spinal injuries were studied. The overall survival rate was 89%. The commonest age group for presentation was 25-29 years with a secondary peak in the seventh decade, a mean overall of 43 years. 66% of injuries occurred in males. The commonest cause was a fall from a height (44%), with road traffic accidents (RTA) causing 43%. Pedestrians were most at risk within the road traffic group, making up 63% of cases. Isolated cervical spine injuries made up 37% of all cases. Cervical fractures were most associated with neurological injury (50%). Immediate survival has increased over the decade from 83% in 1991 to 93% in 2001. The probability of survival was significant at P = 0.006 and actual survival at P = 0.012 (Pearson correlation). The causal analysis has not been carried out but it is thought likely that improved quality of care is responsible.

Head injuries in Leeds: changes in epidemiology and survival over 12 years.

OBJECTIVES: To map the pattern of survival and epidemiology of patients admitted to accident and emergency, at a regional neurosciences unit with an isolated head injury, over a 12 year period. METHODS: The TARN database of a regional neuroscience referral centre was analysed to identify patients who where admitted after a significant, isolated head injury between January 1990 and December 2001. Demographic data about the patient and nature and cause of the injury were extracted and survival was mapped over the time period. Statistical analysis was performed to identify change in survival. RESULTS: There were 810 eligible patients. The most common cause of injury was road traffic accident (47%) with an average of 42.6% patients transferred from other hospitals. The most common disposal of patients was to an intensive care unit (35%). There was an overall increase in the number of patients but survival did not increase over the time period. Mean survival was 81.8% and overall survival decreased from 95.0% in 1990 to 81.6% in 2001, although this did not represent significant change (p = 0.990). CONCLUSIONS: Short term survival after significant head injury has not changed significantly over the 12 year period studied. No subset of patients is having a disproportionate effect on survival but in patients aged over 75, survival increased significantly. Further multicentre work is indicated to map a more accurate clinical picture of head injury survival.

Ultrasound by emergency physicians to detect abdominal aortic aneurysms: a UK case series.

Early identification of abdominal aortic aneurysms in some patients can be difficult and the diagnosis is missed in up to 30% of patients. Ultrasound cannot be used to identify a leak, but the presence of an aneurysm in an unstable patient is conclusive. With minimal training emergency physicians can easily identify the aorta and thus in the early phase of resuscitation an aneurysm can be confidently excluded. The purpose of the examination is not to delineate the extent of the aneurysm, but to identify those patients that will need emergency surgery. A series of patients presented to the department in an unstable condition with equivocal abdominal signs. An ultrasound scan in the resuscitation room by members of the emergency department revealed an aneurysm, which was enough to convince the vascular surgeons to take the patient straight to theatre with good results. In patients who are stable, computed tomography will continue to be used to evaluate the extent of the aneurysm and identify a leak.

Echoes of things to come. Ultrasound in UK emergency medicine practice.

Ultrasound is widely used in the US and continental Europe in the immediate assessment of patients after blunt abdominal trauma. There are also now other recognised "primary" indications for ultrasound in emergency medicine. In this paper current evidence supporting the implementation and use of emergency ultrasound in these primary conditions and possible other indications are assessed. The issues surrounding introduction of the technology into the practice of emergency medicine in this country are considered. It is accepted that further debate is necessary but the establishment of a robust evidence base in the UK will help to clarify the place of ultrasound.

Cortical bone cyst following a greenstick radial fracture.

There are only a few reports of well defined cystic lesions of the peripheral skeleton following fracture. In children, these lesions are mostly small cortical defects affecting the distal radial metaphysis after a greenstick or torus fracture. A cyst is reported complicating a greenstick fracture, together with a brief review of published reports confirming that these are asymptomatic lesions which can be managed conservatively without further investigation.

Performance of the "house doctor". Effect of physician-to-patient ratio on follow up in long-term care facilities.

Do physicians with many patients in a long-term care facility provide more timely follow up of their drug orders than those with only a few? We reviewed 60 charts at random in three intermediate care facilities. Physician practices fell into two distinct groups. Those with more than 17 patients followed up sooner than those with fewer than six. We recommend a "house doctor" model of care for patients whose follow up is poor.

A pilot study of anabolic steroids in elderly patients with hip fractures.

OBJECTIVE: To determine the safety and efficacy of the anabolic steroid nandrolone in elderly patients with hip fractures. DESIGN: A randomized double-blind placebo-controlled trial. SETTING: The orthopedic ward of a university teaching hospital. PARTICIPANTS: 29 frail elderly females with hip fractures. INTERVENTION: Subjects received nandrolone 2 mg/kg (n = 15) or placebo (n = 14) by weekly injection for 4 weeks or until discharge. MEASURES: Baseline functional status was assessed by the Lawton-Brody ADL and IADL. Hemoglobin, transferrin, thyroid-binding prealbumin, albumin, liver function tests, creatinine, weight, MAMC, bioelectric impedance, standard anthropometrics and grip strength were measured at baseline and weekly intervals. Rehabilitation parameters and length of stay were recorded. RESULTS: The placebo and nandrolone groups were similar in age, although the control group had slightly higher baseline ADL scores. There was no difference between groups in biochemical parameters, anthropometrics, body composition, grip strength, rehabilitation end points or length of stay. One subject in the nandrolone group had a doubling of AST and was withdrawn from the study. CONCLUSIONS: Nandrolone can be given safely to frail elderly subjects with hip fractures but is likely to be of minimal benefit at the doses we employed.

Controlled study of the use of local steroid injection in the treatment of trigger finger and thumb.

A controlled double-blind prospective study of injection of methylprednisolone acetate plus local anaesthetic against a control injection of a local anaesthetic in the treatment of trigger finger and thumb has shown a 60% success rate for the steroid injection against 16% for the control group (p less than 0.05). This is the first controlled trial of local steroid therapy in this condition.

Prescribing Strategies for the Frail Elderly: Patient function as an indispensable end point.

Current recommendations for prescribing for the frail elderly can be supplemented by others of value to family physicians. Minimization or simplification of medication regimens, proof of medication efficacy, vigilance for adverse drug reactions, and knowledge of aging and medications are important. Compliance is critical for the community-dwelling frail elderly but is rarely a problem in long-term care facilities. High-yield, high-risk conditions with presentations different from the "geriatric giants" must be recognized. Less medication is not necessarily the best treatment. Routine surveillance and frequent follow up are essential to adequate pharmacotherapy of frail elderly people.

Prilocaine for Bier's block: how safe is safe?

Prilocaine has become the agent of choice for Bier's block (or intravenous regional anaesthesia--IVRA), since 1983 when the product licence of bupivacaine was withdrawn for this purpose owing to fatal or serious complications. No serious complications have been documented in the literature relating to prilocaine in IVRA and we have conducted a survey within the U.K. which indicates that about 45,000 Bier's blocks have been carried out with prilocaine without convulsion, arrhythmia or fatality. This includes cases of accidental cuff deflation or even failure to inflate the cuff, resulting in bolus doses to the circulation. Prilocaine has now been in use since 1964 and the Committee for Safety of Medicines has no deaths on record over a 25-year period. (This includes other types of regional anaesthesia). We suggest that intravenous regional anaesthesia using prilocaine is a safe technique. It is highly unlikely that fatalities will occur, provided present guidelines are adhered to. We can find no reason to limit its use to trained anaesthetists only, but would recommend that a strict protocol is adhered to.

Benefits of early anti-inflammatory medication following acute ankle injury.

A total of 122 patients presenting with acute ankle injuries within 6 h of injury were entered into a double-blind study. Treatment consisted of a standardized regimen of physiotherapy and elastic support for all patients, who were then randomized into two groups. One group received immediate ibuprofen (2400 mg/day) while the other group received placebo medication for 48 h, followed by ibuprofen (2400 mg/day) from the 3rd day onwards, i.e. delayed antiinflammatory treatment. Assessments were made by means of a daily diary and also by clinical and radiological examination. The immediate treatment group demonstrated more rapid recovery by day 7 in terms of regression of swelling (P less than 0.01) and clinician's impression of severity (P less than 0.05). This group also tended to consider their ankle more able to bear weight at this stage (P = 0.05). In comparison with an earlier study, in which the only active treatment was an elastic support, a greater percentage of patients recovered earlier in the present study. The incidence of side-effects was low. Immediate high-dose ibuprofen is therefore recommended as treatment for moderate to severe acute ankle injuries.

Clinical benefits of early cold therapy in accident and emergency following ankle sprain.

One hundred and forty-three patients presenting with ankle sprains within 24 h of injury were entered into a double blind study. Treatment consisted of a standardized regime of high dose non-steroidal anti-inflammatory medication and an elastic support for all patients, who were then randomly allocated to two groups. One group received immediate cold therapy, the other received simulated therapy. Assessments made at 7 days showed a trend in favour of the group receiving cold therapy, although this did not reach significance. It is concluded that cold therapy together with compression may have a beneficial effect but that a single application in the accident and emergency department is not justified when a background therapy of non-steroidal anti-inflammatory medication is given.

Do we need to cross-match blood in closed fractures of the shaft of the femur?

A total of 50 patients with isolated closed fractures of the shaft of the femur are presented. Eleven per cent of the blood specimens were merely grouped and saved on arrival, and the remaining 39 (78 per cent) were crossmatched between 2 and 6 units. Overall, 138 units of blood were crossmatched and only 16 units were used (11.5 per cent), none of them actually in the accident and emergency department. We can find no record of blood being given for resuscitation. The use of blood appeared to depend on the occurrence and timing of operation. We suggest that local policy for crossmatching blood for such patients takes into account the orthopaedic surgical plan, but that the routine instruction to cross-match blood on arrival be abandoned.

The family physician and nursing-home care.

Nursing home patinets are becoming more numerous and now form a part of most family physicians' practices. Physicians wishing to do more nursing home care require guideliness for preventing unnecessary nursing home admissions, for scheduling visits, and for making transfers to hospital. Multi-disciplinary conferences and good basic documentation are valuable in the nursing home. Therapy with medication may be a problem, especially if changes in compliance and independence as a therapeutic end-point are not borne in mind. Serious ethical questions arise routinely in the care of nursing home patients, and a scheme for addressing these is presented, together with some of its limitations. Contrary to the current common wisdom, nursing home care may be challenging and rewarding.

Dressings of the nailbed following nail avulsion.

Dressings of the raw nailbed tend to adhere and to be difficult and painful to remove. We have compared three types of dressing: polyurethane sponge, paraffin-gauze and replacement of the finger-nail. Assessment of adherence and pain showed that replacement of the nail had significant advantages over the other dressings.