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Sophia is aware that nail varnish can spell trouble with pulse oximetry, but what of artificial acrylic nails? A trial reported in Resuscitation (2007;74:75–82) compared two different pulse oximeters on intensive care patients to determine whether false nails affected the readings. Each patient had a pulse oximeter applied to a natural nail and to an acrylic nail, and the results were compared with an arterial blood gas measurement of oxygen saturations. The two oximeters tested emitted slightly different wavelengths of light and this may explain why one of them gave inaccurate readings when applied to false nails. The authors recommend that if false nails are in place, the oximeter probe be placed at 90° to the usual position so that the light does not pass through the nail (the alternative is spending 30 minutes soaking the nail off in acetone).
A US study of more than 1000 patients reports the influence of chronic comorbidity on survival after out‐of‐hospital VF arrest due to heart disease. The odds of survival to hospital discharge were inversely associated with the increasing count of chronic conditions Heart (2007:93:728–31).
Sophia reported in July on the three‐point Simplified Motor Score (SMS) as an alternative to the Glasgow Coma Score (GCS) in head injury. Inter‐rater reliability was found to be better using the SMS. A further study in the Annals of Emergency Medicine (2007;50:18–24) aims to validate the SMS in an American trauma population of over 20000 patients. The SMS compared favourably with the GCS in predicting the four important outcomes of emergency intubation, clinically significant brain injury, need for neurosurgical intervention and mortality.
Debate over imaging in suspected scaphoid fracture continues. The role of early computed tomography in avoiding unnecessary plaster immobilisation is investigated in a small study published in Emergency Medicine Australasia (2007;19:223–8). The authors report a negative predictive value of 97% and a positive predictive value of 100%. This would be extremely impressive, except that the confidence intervals are very wide. As ever, a larger study is suggested.
Resuscitation (2007;74:27–37) presents a systematic review to determine whether flumazenil should be used in suspected benzodiazepine overdose. Seven small studies comparing flumazenil with placebo were included in the review, which concluded that flumazenil was effective in reversing coma in overdose patients. Major side effects of seizures, arrhythmias and death were no more likely in the treatment group, but overall numbers may have been too small to demonstrate risks accurately. The authors conclude flumazenil should not be used in polydrug overdose or in chronic benzodiazepine users.
Clinical skills teaching, such as on ATLS and APLS courses, is undertaken in a didactic style using a four‐step approach. A study in Emergency Medicine Australasia (2007;19:241–5) compares the efficacy of this approach with the use of an instructional DVD when teaching the insertion of a paediatric intraosseous needle. Eighteen candidates were assigned to each group (20 minute four‐step approach, or 10 minute DVD and 10 minutes of practice on a mannequin) and their performance was assessed by a blinded examiner. DVD‐based teaching appeared to be more effective.
A Scottish emergency department reports on the computed tomography thorax findings of blunt trauma patients over a year. Of 134 patients, 15 pneumothoraces were detected as an incidental finding, having been missed clinically and on plain x‐rays. Six of these were managed with intercostal drain insertion as they required mechanical ventilation. Those who were managed conservatively made uncomplicated recoveries (European Journal of Emergency Medicine 2007;14:65–7).
A study in Thorax (2007;62:536–40) quantifies the incidence of unsuspected pulmonary embolism (PE) in inpatient multidetector computed tomography scans. Overall, 5.7% of patients scanned had incidental emboli. The incidence increased further with age. Most emboli were peripheral, raising the issue of whether they need treatment.
741 elderly people attending the ED with an acute illness were asked how they rated their overall health. During 18 months of follow‐up, those who rated their health as “fair” or “poor” were more than three times more likely to have died than those who had “excellent” health at the outset. Self‐rated health has been shown to be more sensitive than traditional risk factor assessment as a predictor of mortality and morbidity in the elderly in the community. A simple question may usefully identify high‐risk patients who warrant further geriatric assessment (Emergency Medicine Australasia 2007;19:196–202).
Hamstring strain is a common sporting injury. The British Journal of Sports Medicine (2007;41:460–1) reports the case of a 24 year old female long distance runner whose posterior thigh pain diagnosed clinically as hamstring pain was found on magnetic resonance imaging to be due to a circumflex femoral vein thrombosis. The authors assert that this is the first reported case of a deep venous thrombosis in this vein.
Urine dipstick tests are very frequently performed on febrile infants in the emergency department, but how confident can we be in a negative result? A study published in the online journal BMC Paediatrics (2007;7:24) involved 2249 infants with a normal bedside urinalysis. Although 1.8% of them had a positive urine culture, none developed bacteraemia or meningitis.