Toxicological screening in trauma.

OBJECTIVES: To determine the prevalence and patterns of alcohol and drug use in patients with major trauma. METHODS: Consecutive trauma patient enrollment, 24 hours a day, was envisaged with anonymised patient data on gender, age band, and mechanism of injury collected. The study group had surplus plasma quantitatively analysed for ethanol concentration, and urine samples were initially screened, via immunoassay, for opiates, cannabinoids, amphetamines, benzodiazepines, cocaine, and methadone. Confirmation and specification of individual positive results was then performed using thin layer or gas-liquid chromatography. Drugs of treatment given in the resuscitation room, if subsequently detected in the urine samples, were excluded from the final results. RESULTS: There were 116 eligible trauma patients assessed and treated in the resuscitation room over a six month period, of which 93 (80%) were enrolled. Altogether 27% of this trauma population had plasma ethanol concentrations greater than 80 mg/dl. There was a significantly higher prevalence of alcohol intoxication in the group not involved in a road traffic accident (RTA) compared with the group who were involved in a RTA. Initial screening of urine for drugs revealed a prevalence of 51%. After 12 exclusions due to iatrogenic administration of opiates, the final confirmed prevalence was 35% in this trauma population. The individual drug prevalence was 13% for cannabinoids, 11% for codeine, 8% for morphine, 6% for amphetamine, 6% for benzodiazepines, 3% for cocaine, 1% for dihydrocodeine, and 1% for methadone. CONCLUSIONS: There is a notable prevalence of drug and alcohol use in this British accident and emergency trauma population. A significantly higher prevalence for alcohol intoxication was found in the non-RTA group compared with the RTA group. The patterns of drug usage detected reflect local influences and less cocaine use is seen compared with American studies. The association between alcohol, drugs, and trauma, together with ethically acceptable methods of screening, are discussed.

What information do general practitioners want about accident and emergency patients?

OBJECTIVES: To establish what information general practitioners (GPs) want about their patients who attend accident and emergency (A&E) departments and the GPs' preferences for the type of communication and method of delivery. METHODS: Analysis of questionnaire sent to all 350 GPs in the catchment area of one A&E department. RESULTS: 219 completed questionnaires (63%) were returned. GPs requested information about most new attendances at A&E, but only 50% of GPs wanted details of every new A&E patient. Most GPs preferred a small computer generated letter or sticky label which included details of investigation results, diagnosis, treatment, and follow up arrangements. 47% of GPs requested delivery of letters by the pathology specimen service, but 25% preferred hand delivery by the patient or a relative. Individual GPs often had widely different preferences, especially about the type of communication and method of delivery. Most GPs would value a monthly list of all their patients who have attended A&E. CONCLUSIONS: GPs need prompt and appropriate information about their patients who attend A&E. A computerised records system should be arranged so that relevant information can be produced easily and quickly in a format suitable for filing in GP records. Good communications with GPs would improve the continuity of care for A&E patients.

The diagnosis of ectopic pregnancy in an accident and emergency department.

The correct diagnosis was initially suspected in 32 (53%) of 60 patients with ectopic pregnancy who attended an accident and emergency department. Incorrect diagnoses were made because ectopic pregnancy was not considered or because relevant symptoms and signs were missed or misinterpreted. Three patients had been 'sterilized'. Twenty-four patients (40%) had abdominal pain or vaginal bleeding for more than 1 week before attending. Fever and leucocytosis were wrongly attributed to pelvic infection. Pregnancy tests were positive in 56% of the patients tested.

Multiple casualties caused by a gale.

On 1 February 1983 severe westerly gales affected most of Britain. In Leeds wind speeds of up to 96 mph (43 metres/sec) were reported, 116 patients were treated in hospital for injuries caused by the wind and three people died. The majority of accidents occurred when people were blown over whilst walking outside. These might have been avoided had people been warned to stay inside.

Intravenous N-acetylcystine: the treatment of choice for paracetamol poisoning.

One hundred cases of severe paracetamol poisoning were treated with intravenous N-acetylcysteine (acetyl-cysteine). There was virtually complete protection against liver damage in 40 patients treated within eight hours after ingestion (mean maximum serum alanine transaminase activity 27 IU/1). Only one out of 62 patients treated within 10 hours developed severe liver damage compared with 33 out of 57 patients (58%) studied retrospectively who received supportive treatment alone. Early treatment and acetylcysteine also prevented renal impairment and death. The critical ingestion-treatment interval for complete protection against severe liver damage was eight hours. Efficacy diminished progressively thereafter, and treatment after 15 hours was completely ineffective. Intravenous acetylcysteine was more effective than cysteamine and methionine and noticeably free of adverse effects. It is the treatment of choice for paracetamol poisoning.