Propofol for adult procedural sedation in a UK emergency department: safety profile in 1008 cases.

BACKGROUND: Concerns exist regarding the safe use of propofol by Emergency Physicians for procedural sedation. The World SIVA International Sedation Task Force has recently created an adverse event tool, in an effort to standardize reporting. We present a safety analysis of our use of propofol using this tool. METHOD: Propofol was given according to a previously published guideline. We analysed our dedicated departmental sedation database between December 2006 and March 2012 and cross-examined the original sedation chart for each case recorded. We stratified the identified adverse events according to consensus agreement. RESULTS: Of the 1008 consecutive cases, we identified 11 sentinel (5 cases of hypoxia, 6 of hypotension), 34 moderate, 25 minor, and 3 minimal risk adverse events. There were no adverse outcomes. CONCLUSIONS: Our large series of propofol sedations performed by emergency physicians supports the safety of this practice. The sentinel adverse event rate of 1% that we identify prompts review: we will in future emphasize adherence to the reduced 0.5 mg kg(-1) propofol dose in the elderly, and reconsider our use of metaraminol. We believe that our application of the World SIVA adverse event tool sets a benchmark for further studies.

Routine pain scoring does not improve analgesia provision for children in the emergency department.

BACKGROUND: Scoring pain should lead to providing better analgesia for children attending the emergency department (ED). Our ED found that it offered analgesia to only 75% of children with painful injuries-36% of them receiving opiates, while scoring pain in 74%. This report describes what happened when we tried to ensure every child had their pain scored in an effort to improve analgesia provision. METHODS: We ensured mandatory pain scoring at triage during the introduction of our computerised notes system, backing this up with extra training of new staff and increased publicity of pain scoring tools. A retrospective audit was conducted after the intervention looking for completion of a pain score, provision of and type of analgesia. The study included children with long bone fractures or partial or full-thickness burns attending the ED. RESULTS: Following the intervention, we found that of 163 children, 97% had their pain scored on a zero-to-10 scale but only 66% received analgesia and only 10% were given opiates. CONCLUSIONS: The intervention was effective at achieving nearly universal early assessment and documentation of pain. This did not translate to an improvement in analgesic provision. Other means of changing behaviour need to be studied, possibly using the computerised record again to obligate analgesia provision.

Is propofol a safe and effective sedative for relocating hip prostheses?

OBJECTIVE: To explore the safety and efficacy of propofol as a sedative for the relocation of hip prostheses in the emergency department. METHODS: A prospective observational study was performed in 100 patients aged 37-93 years who received sedation with propofol in the emergency department for hip prosthetic relocation. All patients received intravenous titrated morphine prior to radiography, followed by a 1 mg/kg bolus of propofol after adequate preoxygenation. At 60 s, joint relocation was attempted by an independent physician. Data for each patient were recorded, with particular attention given to adverse outcomes. RESULTS: Two patients were excluded because of protocol violation. The use of propofol achieved hip relocation in 94 of the remaining 98 patients (96%). The four unsuccessful cases required general anaesthesia with muscle relaxation. Eight patients experienced a fall in oxygen saturation, four responding to airway repositioning and four requiring brief supplemental ventilation. Four patients became hypotensive and required titrated intravenous boluses of a vasopressor (metaraminol) to restore normal blood pressure. 42 patients required additional doses of propofol, 36 for inadequate sedation and 6 for prolonged reduction attempts. CONCLUSIONS: Significant adverse effects of propofol in this case series were uncommon (12/98 patients) and readily countered. This case series suggests that propofol is a safe and effective sedative for relocating hip prostheses.

Delivery of local anaesthetic via a sternal catheter to reduce the pain caused by sternal fractures: first case series using the new technique.

Sternal fractures cause considerable pain, and a proportion of patients require admission for analgesia. Local anaesthetic techniques have been used to reduce the pain from chest wall injuries and may reduce complications from these injuries. The use of a local anaesthetic delivered via a sternal catheter over a fractured sternum has been described in a patient whose pain was inadequately controlled with opiates. This technique was recently offered to patients in the emergency department at the Royal Devon and Exeter Hospital, Exeter, UK, and the experiences of patients and doctors are reported. Findings from this first case series suggest that the technique seems to be effective, well tolerated and acceptable to patients.

Synthesis and characterization of the silver maleonitrilediselenolates and silver maleonitriledithiolates [K([2.2.2]-cryptand)]4[Ag4(Se2C2(CN)2)4], [Na([2.2.2]-cryptand)]4[Ag4(S2C2(CN)2)4].0.33MeCN, [NBu4]4[Ag4(S2C2(CN)2)4], [K([2.2.2]-cryptand)]3[Ag(Se2C2(CN)2)2].2MeCN, and [Na([2.2.2]-cryptand)]3[Ag(S2C2(CN)2)2].

Reaction of AgBF(4), KNH(2), K(2)Se, Se, and [2.2.2]-cryptand in acetonitrile yields [K([2.2.2]-cryptand)](4)[Ag(4)(Se(2)C(2)(CN)(2))(4)] (1). In the unit cell of 1 there are four [K([2.2.2]-cryptand)](+) units and a tetrahedral Ag(4) anionic core coordinated in mu(1)-Se, mu(2)-Se fashion by each of four mns ligands (mns = maleonitrilediselenolate, [Se(2)C(2)(CN)(2)](2)(-)). Reaction of AgNO(3), Na(2)(mnt) (mnt = maleonitriledithiolate, [S(2)C(2)(CN)(2)](2)(-)), and [2.2.2]-cryptand in acetonitrile yields [Na([2.2.2]-cryptand)](4)[Ag(4)(mnt)(4)].0.33MeCN (2). The Ag(4) anion of 2 is analogous to that in 1. Reaction of AgNO(3), Na(2)(mnt), and [NBu(4)]Br in acetonitrile yields [NBu(4)](4)[Ag(4)(mnt)(4)] (3). The anion of 3 also comprises an Ag(4) core coordinated by four mnt ligands, but the Ag(4) core is diamond-shaped rather than tetrahedral. Reaction of [K([2.2.2]-cryptand)](3)[Ag(mns)(Se(6))] with KNH(2) and [2.2.2]-cryptand in acetonitrile yields [K([2.2.2]-cryptand)](3)[Ag(mns)(2)].2MeCN (4). The anion of 4 comprises an Ag center coordinated by two mns ligands in a tetrahedral arrangement. Reaction of AgNO(3), 2 equiv of Na(2)(mnt), and [2.2.2]-cryptand in acetonitrile yields [Na([2.2.2]-cryptand)](3)[Ag(mnt)(2)] (5). The anion of 5 is analogous to that of 4. Electronic absorption and infrared spectra of each complex show behavior characteristic of metal-maleonitriledichalcogenates. Crystal data (153 K): 1, P2/n, Z = 2, a = 18.362(2) A, b = 16.500(1) A, c = 19.673(2) A, beta = 94.67(1) degrees, V = 5941(1) A(3); 2, P4, Z = 4, a= 27.039(4) A, c = 15.358(3) A, V = 11229(3) A(3); 3, P2(1)/c, Z = 6, a = 15.689(3) A, b = 51.924(11) A, c = 17.393(4) A, beta = 93.51(1) degrees, V = 14142(5) A(3); 4, P2(1)/c, Z = 4, a = 13.997(1) A, b = 21.866(2) A, c = 28.281(2) A, beta = 97.72(1) degrees, V = 8578(1) A(3); 5, P2/n, Z = 2, a = 11.547(2) A, b = 11.766(2) A, c = 27.774(6) A, beta = 91.85(3) degrees, V = 3772(1) A(3).

Syntheses and characterization of the metal maleonitrilediselenolates [K([2.2.2]-cryptand)]2[M(Se2C2(CN)2)2] (M = Ni, Pd, Pt) and [Ni(dmf)(5)Cl]2[Ni(Se2C2(CN)2)2].

Reaction of KNH(2), K(2)Se, Se, [2.2.2]-cryptand, and a metal source yields the metal bis(maleonitrilediselenolates) [K([2.2.2]-cryptand)](2)[M(Se(2)C(2)(CN)(2))(2)] (M = Ni, 1; Pd, 2, Pt, 3). These compounds are isostructural and crystallize with four formula units in the monoclinic space group P2(1)/c in cells at T = 153 K with parameters (a (A), b (A), c (A), beta (deg), V (A(3))) of 12.220(1), 15.860(2), 15.306(1), 107.64(2), 2827(1) for 1; 12.291(1), 15.669(1), 15.548(1), 108.55(1), 2839(1) for 2; and 12.292(3), 15.671(3), 15.569(3), 108.59(3), 2842(1) for 3. The cation of 1 has been substituted to yield [Ni(dmf)(5)Cl](2)[Ni(Se(2)C(2)(CN)(2))(2)] (4). [Ni(dmf)(5)Cl](2)[Ni(Se(2)C(2)(CN)(2))(2)] (4) crystallizes with one molecule in the triclinic space group P1 in a cell with parameters (T = 153 K) of a = 8.842(2) A, b =13.161(3) A, c = 13.831(3) A, alpha = 110.08(3) degrees, beta = 95.23(3) degrees, gamma = 93.72(3) degrees, V = 1484(1) A(3). The electronic absorption and infrared spectra are characteristic of metal maleonitrilediselenolates. Cyclic voltammetry shows that the maleonitrilediselenolate (mns) complexes are more easily oxidized than their maleonitriledithiolate (mnt) analogues.

Basic fibroblast growth factor promotes subplate cell survival in explant cultures of embryonic mouse cortex.

Subplate neurons form a transient layer immediately below the embryonic cortex and die early in postnatal life. It has been suggested that trophic factors, perhaps coming from cortical afferents, maintain the initial survival of these cells. Later withdrawal of these factors may cause subplate cell death. We tested whether basic fibroblast growth factor (bFGF) has survival-promoting effects on subplate cells in organotypic cultures from the late embryonic mouse cortex. We found that the survival of subplate cells was promoted by adding bFGF to the cultures. By contrast, there was no effect of bFGF on the survival of overlying cortical neurons. These results indicate that bFGF may have a role in the regulation of subplate cell survival and death in vivo.

General practice: a secondment from emergency medicine--so what!

The Joint Committee for Higher Medical Training has issued a core curriculum for training in accident and emergency medicine. This article highlights some of the knowledge, skills, and attitudes one may usefully gain from a period of 6-12 months in general practice and how this can be integrated and adapted to a career in emergency medicine.

Interpretation of trauma radiographs by junior doctors in accident and emergency departments: a cause for concern?

OBJECTIVES: To investigate how well junior doctors in accident and emergency (A&E) were able to diagnose significant x ray abnormalities after trauma and to compare their results with those of more senior doctors. METHODS: 49 junior doctors (senior house officers) in A&E were tested with an x ray quiz in a standard way. Their results were compared with 34 consultants and senior registrars in A&E and radiology, who were tested in the same way. The quiz included 30 x rays (including 10 normal films) that had been taken after trauma. The abnormal films all had clinically significant, if sometimes uncommon, diagnoses. The results were compared and analysed statistically. RESULTS: The mean score for the abnormal x rays for all the junior doctors was only 32% correct. The 10 junior doctors were more experience scored significantly better (P < 0.001) but their mean score was only 48%. The mean score of the senior doctors was 80%, which was significantly higher than the juniors (P < 0.0001). CONCLUSIONS: The majority of junior doctors misdiagnosed significant trauma abnormalities on x ray. Senior doctors scored well, but were not infallible. This suggests that junior doctors are not safe to work on their own in A&E departments. There are implications for training, supervision, and staffing in A&E departments, as well as a need for fail-safe mechanisms to ensure adequate patient care and to improve risk management.

Cervical spine imaging in trauma patients: a simple scheme of rationalising arm traction using zonal divisions of the vertebral bodies.

OBJECTIVE: To evaluate the effectiveness of arm traction for cervical spine imaging in trauma patients and devise a scheme to predict the probability of visualising the C7/T1 level in trauma patients. METHODS: 98 trauma patients were studied. Each vertebral body was divided into three equal horizontal zones, the disc space between vertebral bodies being equivalent to one zone. The fifth cervical vertebra was used as the starting level (zone 1). Zones obtained pre and post arm traction on the lateral cervical spine radiographs were recorded. Results were analysed to show the probability of imaging the lower cervical spine, including the cervico-thoracic junction. RESULTS: If the initial film showed less than zone 10 (mid-C7 vertebra), the probability of showing zone 13 (upper body of T1) with arm traction was only 7.7%, that is, one success in every 13 pulls; or conversely, 12 failures in every 13 pulls. CONCLUSIONS: Unless an initial cervical spine radiograph includes the upper one third of the body of the C7 vertebra, the probability of attaining the C7/T1 level with arm traction is < 15%. It is suggested that all initial radiographs of the lateral cervical spine in major trauma patients be done with arm traction, and where the upper one third of the body of C7 vertebra is not seen, then computerised tomography, swimmer's, or oblique views be considered.

Unusual presentation of tuberculosis to the accident and emergency department.

A patient with localized, reactive tendinitis secondary to tuberculosis presented to the accident and emergency (A&E) department. Tendinitis is a relatively common complaint, and it is important to consider uncommon systemic causes, including tuberculosis.

Resuscitation training for cardiac patients and their relatives--its effect on anxiety.

It is feared by many doctors that teaching basic life support (BLS) to high risk cardiac patients or a member of the family increases their anxiety. We trained a group of patients with recurrent ventricular tachycardia in BLS together with a friend or family member. Measurement of anxiety before and three months after training demonstrated a reduction in anxiety in both groups. This suggests that basic life support training can be targeted to high risk groups without fear of increasing anxiety.