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.

Comparison of oral and intravenous morphine following acute injury in children.

The objective of this research was to examine the speed of onset and effectiveness of pain relief between oral and intravenous morphine in acutely injured children. An observational study of children aged 3 to 13 years with closed forearm fractures was performed in three accident and emergency departments. The study gathered information on age, gender, body weight, time of arrival, dose, route and time of morphine administration. Pain assessment using a Faces Scale was documented on arrival and repeated at 10, 30 and 60 minutes after morphine was given. Forty-seven children were studied. Of these, 25 were given intravenous morphine, 22 were given oral morphine. There was no statistically significant difference in age, body weight or time until morphine was administered. The change in median pain scores was analysed using the Mann-Whitney U test. This showed that there was a statistically significant reduction in pain score in the intravenous group compared with the oral group between arrival and 10 minutes after giving morphine and between arrival and 60 minutes after giving morphine. Intravenous morphine appears to give more rapid onset and more prolonged pain relief than oral morphine for children with acute injuries. We recommend that in accident and emergency departments where staff are experienced in paediatric cannulation, morphine should be given via the intravenous route in acutely injured children. However we do not advocate inexperienced staff attempting multiple venepunctures in a child resulting in increased anxiety.

A five year study of high falls in Edinburgh.

High falls are a common cause of death and disability. The aim of this study was to obtain an epidemiologically complete picture of all high falls over a 5 year period in Edinburgh, Scotland. Prospectively collected data on hospital survivors and hospital deaths was collected from the Scottish Trauma Audit Group (STAG) database. Data on prehospital deaths was obtained from autopsy reports and detailed police enquiry reports. There were 341 patients in the study, of whom 82% were male. Seventy-four percent survived to hospital discharge. Sixty-three percent of the total deaths appeared to be suicides. Head and chest injuries were responsible for the majority of deaths. Pelvis, limb and vertebral injuries predominated in survivors. In conclusion, prevention may be the most effective method of reducing prehospital deaths. Abdominal injuries were associated with a poor outcome, but survival might improve with immediate surgical exploration in haemodynamically unstable patients.

Suicidal high falls.

There are few data on committing suicide by jumping from a height. Information on suicidal high falls in southeast Scotland was prospectively gathered over 7 years (1992-1998). Data sources included ambulance, police, hospital and forensic records. Injuries sustained were scored according to the Abbreviated Injury Scale, generating Injury Severity Scores (ISS). Sixty-three individuals (50 males), appeared to have committed suicide by falling from a height. The backgrounds were diverse, but 44 individuals had known previous psychiatric illness, 18 having attempted suicide before. The most common locations were high bridges, with two accounting for 23 deaths (37%). Only nine individuals (14%) reached hospital alive. ISS range was 16-75, including 22 scores of 75. These individuals had a total of 24 injuries acknowledged to be unsurvivable, comprising 10 thoracic aortic ruptures, eight massive brain/brainstem injuries, four cardiac injuries, and two high spinal cord transections. The high rate of prehospital death reflects the heights of the falls and consequent major injuries. Prevention of suicide is acknowledged to be difficult - these results suggest that hospital treatment of injuries sustained has little to offer in terms of reducing the death rate from suicidal high falls.

Closed eye techniques of intracapsular cataract extraction with intraocular lens implantation.

The advantages of a corneal incision are discussed and the general trend toward closed eye surgery, as well as the reasons for the trend, are defined and reviewed. The mechanics involved in my method are presented as well as the theory and use of the lens glide. Finally, the Beale Continuous Corneal Closure method is discussed. Though this suture may take as long as 8 to 10 minutes to place properly, when it is completed it provides the patient with total mobility and the surgeon with total peace of mind.

A surgical stereo-video microscope.

In our lifetime, electronic photography, that is television, has replaced optical film photography in many areas and has opened new fields in other areas. The surgical optical microscope is a closed, limited system. Television can revolutionize this by converting the optical picture into an electronic picture which can be sent down a cable, through the air, or recorded on magnetic tape to be seen now or at a later time. The Stereo-Video Microscope offers a new surgical instrument which provides the surgeon with greater ease of viewing and other numerous advantages over optical microscopy.