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Most cardiac arrests occur in the out of hospital setting. A Finnish study (Eur J Emerg Med 2007;14:75–81) assessed the prehospital care after return of spontaneous circulation in the out of hospital setting. It found that only 40% of patients received care in accordance with established guidelines. Failure to follow guidelines correlated with a lower rate of survival to hospital discharge. The results emphasise that return of spontaneous circulation is really only the beginning in the management of these patients, and that what happens next is just as critical.
It is widely acknowledged that the stress hormones play a role during resuscitation. A pilot study in the American Journal of Emergency Medicine (2007;25:318–25) examines the use of hydrocortisone in the resuscitation of non‐traumatic out‐of‐hospital cardiac arrest patients. Administration of hydrocortisone during resuscitation was associated with an improvement in return of spontaneous circulation from 39% (placebo group) to 61% (steroid group). Disappointingly, it had no significant effect upon one and seven day survival rates, or the rate of those surviving to hospital discharge.
A study in the American Journal of Emergency Medicine (2007;25:263–7) reports favourably upon use of the laryngeal tube device in the emergency setting (both in‐hospital and prehospital) by practitioners with varying airway management skills. It reports it to be extremely useful in airway management, even in challenging cases, requiring only a minimum of training.
A case report in the Journal of Emergency Medicine (2007;32:275–8) reports the ability of methadone to induce prolonged QTc and subsequent Torsades de Pointes, in an apparently dose‐dependent fashion. The authors warn of the potential cardiotoxicity of methadone. They urge caution in its use, particularly when any additional medication which the patient may be receiving could inhibit metabolism of the drug.
Human factors are acknowledged to be most important in causing road traffic collisions, and these include a variety of physical illnesses. However, meningitis had not been implicated, until a report in the Journal of Forensic and Legal Medicine (2007;14:175–7).
More and more procedures are being undertaken within the emergency department, often involving sedation. An overview of procedural sedation and the risks involved is presented in the Annals of Emergency Medicine (2007;49:454–61). The consensus of assembled experts yields some interesting and useful recommendations. In particular, specific recommendations are provided regarding fasting and limits for sedation depth and length, depending on the individual risk stratification of each patient.
It is a tribute to the Glasgow Coma Scale (GCS) that it has survived for so long without significant challenge. The scale has been used for many years as a helpful tool for the emergency practitioner in the assessment of patients with reduced conscious level. However, its reliability and practicality have often been questioned. A recent study (Ann Emerg Med 2007;49:403–7) compares it against a new tool, the Simplified Motor Score (SMS). This consists of three levels of motor assessment only: “obeys commands”, “localises pain”, and “no response”. Previous studies have identified this as the most sensitive and useful part of the GCS. The study assessed the inter‐rater reliability of the SMS compared with the GCS and two other simple scores in common use. Although it concludes that the SMS had the best inter‐rater reliability in the assessment of these patients, it will surely take a lot before the GCS is replaced.
Even more uses for the emergency department ultrasound machine are emerging. The latest involves the use of ultrasound in determining whether a patient has elevated intra‐cranial pressure. This is achieved by measuring the optic nerve sheath diameter using the ultrasound probe over the closed orbit (Ann Emerg Med 2007;49:508–14). Another suggested use is as an aid in confirming placement of the intraosseous needle. Insertion of these devices can prove to be tricky and it is often difficult to be certain of correct positioning. Using ultrasound, the flow of fluid in the intraosseous space can be observed and thus the needle used with confidence (Ann Emerg Med 2007;49:515–19).
Progesterone is known to have neuroprotective properties. A recent pilot clinical trial (Ann Emerg Med 2007;49:391–402) reports the use of progesterone in patients with acute traumatic brain injury. It found no serious adverse events in those randomised to receive progesterone. Further, those who did receive progesterone had a lower 30 day mortality, and those with moderate brain injury had a better outcome than those in the placebo group. However, there was no benefit in neurological outcome in those with severe brain injury. More studies will follow.
Sophia wishes to draw attention to a useful review in Injury (2007;38:272–9), which considers abdominal compartment syndrome in detail. It emphasises the importance of prompt haemorrhage control and careful fluid resuscitation in those with serious traumatic injuries, citing “indiscriminate crystalloid resuscitation of uncontrolled bleeding” as an important cause of the post‐injury secondary abdominal compartment syndrome. It also suggests that abdominal compartment syndrome may occur early enough to present in the emergency department and that early recognition is vital for an optimal outcome.