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Emerg Med J. 2007 May; 24(5): 374.
PMCID: PMC2658508


When to fluid resuscitate in haemorrhagic shock

At present there is much debate about when is the best time to give fluids in haemorrhagic shock. The previous Advanced Trauma Life Support teaching of immediate and aggressive fluid resuscitation has been challenged. As a result, the practice of hypotensive resuscitation is being performed more frequently, particularly in the prehospital setting. However, a recent study from Taiwan using rats (Ann Emerg Med 2007;49:37–44) provides evidence to suggest that delayed fluid resuscitation may not guarantee the best long‐term outcome. Those rats who received delayed resuscitation greater than 45 mins had an increased production of pro‐inflammatory cytokines and reduced production of anti‐inflammatory cytokines. Perhaps limited fluid resuscitation may be the best option, avoiding the rebleeding from early over‐aggressive intravenous fluids and the cytokine effects from delayed resuscitation.

Pigs may fly!

Sophia was surprised to learn that pigs did fly in study reported in Resuscitation (2007;72:280–5). The study assessed the possible role of interventional lung assist (iLA) for acute respiratory failure in aero‐medical evacuation. It assessed pigs in various transport modalities including helicopters and a 7 hr flight in a Hercules aircraft. It concluded that iLA has the potential to maintain physiological arterial concentrations of CO2 and O2 at normal flight altitudes. The authors propose iLA as being a feasible option for intercontinental aero‐medical evacuations.

Ketofol for procedural sedation

Procedural sedation is commonly undertaken in the emergency department. Increasingly, propofol is being used as first line in conscious sedation, but it does not have good analgesic properties. A prospective evaluation of “ketofol” (ketamine/propofol mix in the same syringe) for procedural sedation is reported in the Annals of Emergency Medicine (2007;49:23–30). Ketofol is proposed as an effective and safe method of analgesia and sedation in the emergency department, combining rapid recovery with high patient satisfaction.

ABCD2: the future for TIAs

The subject of how to manage TIAs has not traditionally generated a huge amount of interest, but this is all changing. A study in the Lancet (2007;369:283–92) refines and validates a score for early prediction of stroke after TIA. It combines elements from the California score with the ABCD score to arrive at a better prognostic score – the ABCD2 score. This is a five factor score with good predictive value for stroke at day 2, 7 and 90. The score helps to identify those patients with TIAs that need to be most aggressively managed, probably as an inpatient.

MRI for stroke

Another Lancet study (2007;369:293–8) compared the use of CT with MRI in an emergency setting for diagnosing acute stroke. It concluded that MRI is more accurate at identifying acute ischaemia, but can also identify acute and chronic haemorrhage as accurately as CT.

Heart rate and pain

A prospective observational study of 975 patients examined the correlation between patient heart rate and acute pain. The results, interestingly, revealed poor correlation between a change in pain intensity and heart rate (J Emerg Med 2007;32:19–22).

Fracture risk

Patients often attend the emergency department concerned that they have re‐injured an old fracture site and sustained a re‐fracture, sometimes many years later. Is there any likelihood of this? A prospective cohort study (JAMA 2007;29:387–94) looked at the incidence of re‐fracture after an initial low‐trauma fracture. It discovered that an absolute risk of subsequent fracture persists for up to 10 years. This risk is similar for men and women and in virtually all fracture groups. Perhaps the patients are right to be concerned!

Crystals and septic arthritis

It may appear reassuring to receive a knee aspirate result showing crystals in the sample rather than a high synovial white blood cell count. However, a recent study (J Emerg Med 2007;32:23–6) urges caution: septic arthritis and acute crystal‐induced arthritis can occur simultaneously.

Organophosphate poisoning

Organophosphate poisoning is unusual in the UK, but there are concerns about its possible use in a chemical attack. However, poisoning from organophosphate is relatively common in some parts of the world, including India where an important study on optimal management has been reported (Lancet 2006;368:2136–41). The study compared the use of pralidoxime as a regular bolus treatment against a (high dose) continuous infusion. It was used together with standard treatment in the form of atropine and decontamination. The authors report that mortality was significantly lower in the high dose infusion group.

Cough suppressant abuse

Over the counter medications are sometimes regarded as safe and innocuous, but this is not necessarily the case. A recent paper from the US (Arch Pediatr Adolesc Med 2006;160:1217–22) highlights the rising trend of abuse of dextromethorphan, a drug used in cough suppressants and cold remedies, available over the counter (also in the UK). The most severe effects appear to be on the respiratory system and can be treated with naloxone, but may require intubation.

Non‐accidental head injury

A retrospective study from Australia reviewed 52 cases of head injuries in infants resulting from abuse. The focus was on the time period between assault and onset of resulting symptoms. It concluded that this period was usually brief and often immediate, going against the theory that a child can have a prolonged period of lucidity after a serious head injury (J Paediatrics and Child Health 2007;43:60–5).

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