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The introduction of new advanced life support (ALS) guidelines requires resuscitation teams to expend a considerable amount of effort to ensure that resuscitation efforts are synchronised. Understandably, resuscitation team members often question the need for changes. An interesting pig study compared resuscitation between two groups of pigs, who were resuscitated according to the old and new guidelines respectively. Ventricular fibrillation was induced with the use of a transvenous pacing wire inserted into the right ventricle. Nineteen pigs were randomised to receive treatment according to either the 2000 or 2005 Resuscitation Council guidelines. Both algorithms recorded similar successful resuscitation rates, but animals treated with the 2000 guidelines restored a rhythm compatible with a pulse more quickly. Neurological outcome and long‐term survival were not evaluated (Resuscitation 2007;73:459–66).
It is a cause of continuing frustration that there are often significant delays before patients who are suffering from acute myocardial infarction receive treatment. Patients themselves are responsible for some important delays, by failing to promptly seek medical attention. An editorial in the BMJ (2007;335:3–4) addresses this issue and urges that patients with known ischaemic heart disease (or at high risk of myocardial infarction) should be taught to call for an emergency ambulance if chest pain unrelieved by glyceryl trinitrate persists for 5 minutes.
Alcohol use is associated with many different forms of injury. Evidence suggests that unaddressed alcohol problems result in recurrent injuries and/or death. The use of brief personalised motivational interventions or brief information and advice was assessed in a randomised clinical trial (J Trauma 2007;62:1102–12). The results revealed that brief interventions reduced the rate of injuries in at‐risk non‐dependent drinkers.
Millions of people use aspirin in varied doses to prevent cardiovascular disease. An interesting systematic review investigated relationships between doses, efficacy and safety of aspirin (JAMA 2007;297:2018–24). Current clinical data do not support routine long‐term use of dosages of aspirin greater than 75–81mg per day for the purpose of cardiovascular disease prevention. Higher doses do not provide additional prevention, but are associated with increased risk of gastrointestinal bleeding.
Taking warfarin significantly reduces the risk of stroke in patients who have atrial fibrillation. However, warfarin carries the obvious risk of major bleeding. The risk of major haemorrhage varies according to a variety of factors. In particular, being aged over 70 years, being female, having a remote bleed or a recent bleed, using alcohol, being diabetic, anaemic or using antiplatelet drugs increases the risk of a major bleed in patients taking warfarin for atrial fibrillation (Chest 2006;130:1390–6).
German researchers analysed injury patterns in cyclists with a view to implementing preventive measures (J Trauma 2007;62:1118–22). There was a low use of helmets and unsurprisingly a major issue with head injuries. The authors recommend extension of bicycle traffic lanes to increase the separation between cyclist and motorist to try to reduce injury rates.
A number of factors may cause delayed transfer of critically ill patients from the ED to the intensive care unit. The impact of delay was studied by the “DELAY‐ED study group” from the Albert Einstein College of Medicine in New York (Crit Care Med 2007;35:1477–83). Patients who waited for 6 hours or more to be transferred to intensive care had increased length of hospital stay as well as increased mortality. Further work is needed in order to investigate whether delayed transfer was actually responsible for worse outcomes.
Resuscitative mild hypothermia is believed to result in reduced damage to vital organs, particularly the brain. One way of achieving this is to use surface cooling with ice cold water. Austrian researchers investigated the safety and effect of transthoracic defibrillation after surface cooling in a pig model. Using pigs with induced ventricular fibrillation cardiac arrest, defibrillation was performed in dry and then in wet conditions. There was a tendency towards fewer shocks needed to achieve restoration of spontaneous circulation in wet conditions compared with dry conditions. Additionally, the authors concluded that defibrillation could be performed safely in wet conditions (Am J Emerg Med 2007;25:420–4).
Sometimes the diagnosis is most obvious in hindsight. A 12‐year‐old girl presented to an ED with diffuse abdominal pain. The pain lasted 3 days, but had been episodic in the preceding months in what appeared to be a cyclical pattern. She denied any sexual activity, and stated that she had never menstruated. She had breast buds and pubic hair, confirming the onset of puberty. Ultrasound and computed tomography revealed severe dilatation of the vagina and uterus. Perineal examination confirmed an imperforate hymen with retrograde menstruation—an unusual, but important, diagnosis which is usually obvious (admittedly sometimes in retrospect) from the history (Lancet 2007;369:1890).
It can be quite a challenge to determine whether patients presenting with breathlessness to the ED have an underlying cardiac or non‐cardiac cause. A study from Taiwan suggests that impedance cardiography may assist in this determination. The technique is non‐invasive and involves measuring beat to beat changes of thoracic bioimpedance via four sensors applied to the neck and chest (Am J Emerg Med 2007;25:437–41).