OBJECTIVE: To determine the characteristics of primary care attenders to St Mary's Hospital accident and emergency (A&E) department, evaluate the effects of the introduction of general practitioners (GPs) on patient care in A&E, and make recommendations for the provision of GPs in appropriate A&E departments. DESIGN: Prospective survey over a six week period. METHODS: Data collected from the attendances of 970 consecutive patients triaged with "minor" primary care problems, whether seen by A&E doctors or by GPs working in A&E, were analysed. RESULTS: During the study period 1078 patients (16.6%) were triaged as suitable for primary care. The A&E GPs saw 58.4% of these patients. The majority of primary care patients were young British residents, 71.1% of whom were registered with a GP. Sixty per cent of patients lived within St Mary's catchment area. Of those registered patients asked why they attended A&E, 27.1% thought their problem inappropriate for their GP. A&E doctors were more likely to investigate patients and arrange hospital follow up than GPs, who arranged community follow up in 80% of patients needing further care. CONCLUSIONS: The demand for primary care at St Mary's necessitates the provision of a primary care service, albeit for the first visit only. This can be provided by GPs in A&E. The features of the patients using the service suggests that discouraging first attendance is unrealistic, but using the visit to educate patients and return them to the care of the community is not.
A 23-year-old Asian lady presented with a hard indurated midline neck swelling of 2 months duration without any upper aerodigestive tract or systemic symptoms of note. Her inflammatory markers were elevated and she was commenced on antibiotics. Ultrasound scan and fine needle aspiration cytology (FNAC) were inconclusive. A CT scan showed an ill-defined soft tissue mass anterior to and not well demarcated from the thyroid, and contiguous with a superior and anterior mediastinal mass. Incisional biopsy revealed necrosis and pockets of purulent material.
Microbiology suggested a chronic pyogenic abscess negative for acid fast bacilli. She was treated with antituberculous therapy without resolution. She developed a discharging lateral neck mass with progressive increase of the mediastinal mass. She subsequently required a neck exploration and mediastinoscopy. Repeat mediastinal biopsies confirmed the diagnosis of Hodgkin’s disease and no organisms on culture. She was commenced on chemotherapeutic treatment with a satisfactory outcome.
OBJECTIVE--To compare the sociodemographic characteristics, diagnoses, and mode of referral of people and emergency admissions between an accident and emergency department in inner London and one in a town outside London. DESIGN--Standardised questionnaire completed prospectively over two weeks by field-workers in each accident and emergency department. SETTING--Accident and emergency departments in an inner London teaching hospital and an associated teaching hospital outside London. SUBJECTS--3039 adults newly attending the departments, 1476 in inner London and 1563 outside London. MAIN OUTCOME MEASURES--Sociodemographic characteristics, diagnosis, mode of referral, and whether the patient was admitted. RESULTS--General practitioner referrals accounted for similar proportions of the adult attendances (12% in inner London, 15% outside London). People attending at the inner London department were more likely to be tourists or long distance commuters (12% (179/1476) v 6% (95/1563)), single (43% (643) v 32% (505)), to live alone (24% (360) v 14% (225)), to have moved recently (13% (194) v 7% (107)), or to be homeless (3.3% (48) v 0.6% (10)). Broad clinical groupings of patients were similar in both departments. 291 people were admitted in inner London and 284 outside London. The proportions admitted from each sociodemographic group were similar in the two hospitals. CONCLUSION--Differences in sociodemographic characteristics were more important than general practice referral patterns in determining the differences in people attending at accident and emergency departments inside and outside London. Many of these characteristics are likely to be found in other inner city populations. A strategy to improve acute care in inner London should take account of the needs of these sociodemographically different groups.
Basilar artery thrombosis (BATS) is a progressive disorder which may present with fluctuating neurological signs of varying degrees of severity. Unless the diagnosis is considered, the confused young patient may be thought to be under the influence of drugs or to be psychologically ill, and indeed the Munchausen syndrome may be considered. The more elderly patient may be diagnosed simply as having had a cerebrovascular accident. This paper presents the cases of three patients admitted through the accident and emergency (A&E) department of St Mary's Hospital, London with basilar artery thrombosis during a 6-month period. All these patients demonstrated the classic triad for this syndrome of: (1) long tract neurological signs, (2) impaired conscious level, and (3) complex ocular signs. The concern is that, for patients with more subtle signs, a diagnosis of BATS may not be considered, and a neurological opinion may be thus delayed and no treatment with anticoagulants or thrombolytic agents would be given. Two of the three patients were treated with anticoagulants and improved, while in the third patients anticoagulation was judged inappropriate and the patients died from progression of the disease with respiratory complications.
A study of cases of retropharyngeal abscess in Nigerian children was carried out. It occurred most commonly in children under the age of 6 months and in more male children than female in a ratio of 5:3.
Most children seen at the Lagos University Teaching Hospital were brought in late with the upper airway already obstructed. A diagnostic tool of soft-tissue x-ray examination of the neck is not foolproof. In fact, 22.58 percent of soft-tissue x-ray examinations of the neck in this study produced false-positive results. Factors contributing to these results are discussed.
Bacteriology showed the main organisms to be Hemophilus influenzae (45.84 percent) and Streptococcus pyogenes (33.33 percent). All cases were found to be secondary to upper respiratory tract infection.
Problem: An initial audit of the care provided to emergency asthma patients by the ambulance service was carried out in 1996. Some under-recognition and under-treatment of severe asthma was found as well as a lack of documentation of patient condition on scene. A re-audit was undertaken in 1999.
Design: A multidisciplinary advisory group was reconvened. The same method was adopted as for the first audit. Patients included were those administered nebulised salbutamol by crews in the catchment areas of four hospitals and those diagnosed with asthma at the Accident & Emergency (A&E) departments of those hospitals between January and March 1999.
Setting: London Ambulance Service.
Key measures for improvement: (1) Accuracy of diagnosis and appropriateness of treatment, and (2) adherence to protocol.
Strategies for change: Following the first audit, treatment protocols were widened and brought into line with the British Thoracic Society guidelines for care of acute asthma patients. The results were widely disseminated within the service and training was initiated for all operational staff.
Effects of change: The number of patients included in the re-audit more than doubled (audit 1: n = 252, audit 2: n = 532). The increase occurred exclusively in those administered nebulised salbutamol by ambulance crews but diagnosed with conditions other than asthma in A&E (audit 1: n = 15, audit 2: n = 161). The proportion of patients diagnosed with asthma in A&E who were administered nebulised salbutamol by their attending crew rose from 58% to 75%. However, 43 asthma patients were not treated; several of these were not recognised as suffering from asthma and others fell within the changed protocols for treatment. Adherence to protocol for administration of salbutamol remained high. Pre-hospital documentation of key observations did not improve.
Lessons learnt: Messages from the first audit seem to have been acted upon selectively. Implementing change is complex, and re-audit is necessary to understand the effects of the changes made.
During 1984, 23 patients in whom a diagnosis of viral haemorrhagic fever was considered presented to the accident and emergency department at St Thomas's Hospital. There were no confirmed cases of viral haemorrhagic fever. Nine patients were transferred to Coppett's Wood Hospital, the nearest specially designated high security isolation unit. Malaria was the final diagnosis in 14, and in six this diagnosis was confirmed only after examining repeated smears at Coppett's Wood Hospital. Transferral of patients to such units is time consuming, expensive, and often unnecessary. Specially designated isolation units in district general hospitals and all teaching hospitals would simplify and improve the care not only of patients with a possible viral haemorrhagic fever but also patients with tuberculosis, multiply resistant staphylococcal infections, and viral infections that may be hazardous if transmitted to immunocompromised patients.
Over the 3 years from 1982 to 1984, a total of 34 patients were seen in the Accident and Emergency Department of St Thomas' Hospital, London, as a result of the London Marathon. Clinical details are discussed. Considering the number of annual runners who take part, the casualties from the finish of this event are low. This short report suggests that the 3 years' preparation and organization for the finish of the London Marathon were consistently effective.
OBJECTIVES: To report on the extent and nature of acute MDMA (ecstasy) related problems presenting to a large London hospital's accident and emergency (A&E) department. METHOD: The computerised attendance records for all patients attending the A&E department over a 15 month period were retrospectively screened. Potential cases thus identified had their case notes systematically reviewed to confirm the history of MDMA use and to extract other relevant data. RESULTS: Forty eight consecutive MDMA related cases were identified. All were in the 15-30 year age group with the majority presenting in the early hours at weekends and having consumed the drug at a night club. The mean number of tablets consumed was two and almost 40% had taken MDMA before. Polydrug use was common with half of the sample having concurrently taken another illicit substance--most commonly other stimulants (amphetamines and cocaine). A wide range of adverse clinical features was found. The most common symptoms were vague and non-specific such as feeling strange or unwell, however many patients had collapsed or lost consciousness. The most common signs elicited were related to sympathetic overactivity, agitation/disturbed behaviour, and increased temperature. The more serious complications of delirium, seizures, and profound unconsciousness (coma) were commoner when MDMA was used in combination with other substances. CONCLUSIONS: For young adults presenting late at night at weekends and exhibiting symptoms of sympathetic overactivity, disturbed behaviour, and increased temperature ("Saturday night fever") the use of stimulant dance drugs especially MDMA should be suspected. As MDMA use does not appear to occur in isolation, the clinical picture is likely to be complicated by multiple rather than single drug ingestion. This poses increased diagnostic and management challenges for A&E staff who typically represent the front line response to dance drug related problems.
Head and neck squamous cell carcinoma of the upper aerodigestive tract is well known for its frequently late presentation and diagnosis at an advanced stage. In addition, it is well recognized that it may arise in multiple sites, either synchronously or metachronously. Thus it should be imperative to endoscopically screen the upper aerodigestive tract of patients at risk for head and neck squamous cell carcinoma with a new diagnostic tool, especially due to the fact that early lesions are very difficult to detect even by multiple passes with a standard endoscopy, if they are ≤ 1 cm in diameter. Lugol chromoendoscopy, which is mainly used in the oesophagus, is not suitable for the head and neck region due to severe mucosal irritation. Herein, narrow-band imaging is described, a diagnostic tool already proved as a useful screening method in other endoscopic fields, and its application in the early detection of head and neck squamous cell carcinoma is reviewed, as reported by previous studies in the otolaryngologic literature. Narrow-band imaging relies on the principle of depth of penetration of light, with the narrow-band blue light having a short wavelength (415 nm) penetrating into the mucosa and highlighting the superficial vasculature. Furthermore, the blue filter is designed to correspond to the peak absorption spectrum of haemoglobin to enhance the image of capillary vessels on surface mucosa. Thus, superficial mucosal lesions that would be missed by regular white light endoscopy, are identified, in view of their neoangiogenetic pattern of vasculature, using the blue light of the narrow-band imaging. Narrow-band imaging has been used extensively in the lower aerodigestive system, yet there are only 2 reports of applications in the region of the head and neck, specifically the oropharynx and the hypopharynx. However, these are not the only sites that can benefit from narrow-band imaging. Herewith, the uses and importance are highlighted of narrow-band imaging as a future diagnostic tool in otolaryngology, in the pre-, intra- and post-operative settings.
Upper aero-digestive tract; Malignant tumours; Diagnosis; Endoscopy; Narrow-band imaging
A retrospective survey of over 2000 patients with inversion injuries of the ankle joint was undertaken to examine the validity of criteria commonly used in an accident and emergency department to assess severity. Swelling alone is an unreliable indicator of the severity of the injury. Patients with severe pain and inability to weight bear show a high incidence of fractures and must be X-rayed. Conversely, a combination of minimal pain and swelling, and ability to bear weight are indicative of a soft-tissue injury. Young people sustain most inversion injuries and have a lower incidence of significant fractures of the lateral malleolus. Analysis of presenting features did not reveal any reliable indicants which could be used to reduce the number of radiographs requested, without substantially increasing the risk of missing patients with significant fractures. However, it has been possible to formulate guidelines for the more rational and consistent use of X-rays in the initial assessment of patients with ankle sprains.
A study was made of all 587 new patients attending an accident and emergency department in the East End of London during one week. Two hundred and twenty-six (39%) cases were not accidents or emergencies; of these, 67% were self-referrals who had not previously seen their general practitioner (GP) and 21% were self-referrals who had previously seen their GP. The four main reasons that these self-referred patients had for attending were that they thought their condition needed immediate attention; they were insufficiently organized to see their GP; they were not registered with a GP; or they wanted a second opinion. Twenty-eight (12%) of the cases which were not accidents or emergencies were referred by a GP. Sixty-nine (12%) of all cases were not registered with a GP. The frequency of cases who were not accidents or emergencies was significantly higher in those not registered than in those registered (0.01 greater than P greater than 0.001). Nineteen (3%) patients were living rough or in hostels. Little abuse of the ambulance service was found.
A retrospective review of 201 patients with stab wounds admitted to an East London Hospital over a period of six years was performed. There was no striking increase in the annual incidence of these injuries over the period reviewed. The majority of patients were young males who arrived at the Accident and Emergency Department after 1800 h on a Friday, Saturday, or Sunday and had consumed alcohol prior to admission. There were 47 abdominal injuries (23%), 69 thoracic (34%), 51 limb injuries (25%) and 34 injuries involving the head and neck (17%). Forty patients (20%) had injuries involving more than one site. Abdominal stabbings were managed by a selective approach resulting in 28 laparotomies of which only 2 (7%) were negative. Evisceration of small bowel or omentum was always associated with significant intraperitoneal injury.
Blunt trauma neck to larynx is an uncommon injury that results in a wide spectrum of damage to endolaryngeal soft tissues as well as underlying cartilaginous skeleton leading to upper airway obstruction requiring emergency tracheostomy. A case report of blunt trauma neck anterior is presented who developed upper airway obstruction necessitating tracheostomy. Indirect Laryngoscopy and fibre optic examination identified vocal cord paralysis as primary cause of upper airway obstruction although X ray soft tissue neck and CT neck revealed fracture hyoid as well as hematoma surrounding the laryngeal frame work. Emergency tracheostomy was done and patient recovered uneventfully.
Blunt trauma; Vocal cord paralysis; CT neck; Tracheostomy
Malignancy of the upper aerodigestive tract is not always associated with obvious localizing symptoms. Presentation may then only be prompted by the appearance of a hard mass in the neck, a metastasis to a cervical lymph node. Neck exploration without a prior diligent search for an occult head and neck primary tumour is to be avoided as it compromises subsequent treatment. The diagnostic investigation of 112 patients complaining solely of a painless and enlarging neck swelling is reviewed. An otolaryngologic examination identified an asymptomatic malignancy of the head and neck in 72 patients (64%). Excision biopsy of the neck mass was required to achieve a diagnosis in only 29 (29%) of those patients who had not already undergone surgery. These results are presented to emphasize the need for a specialist examination of the head and neck prior to embarking on excision of any suspicious neck mass.
A 25-year-old man presented to the Emergency department in a rural South African hospital after a left, submental neck stab with a knife. Examination was deemed unremarkable, and the patient was discharged, but re-attended 2 days later complaining of a painful, swollen neck. Further examination identified Horner's syndrome, and further investigation revealed that the blade of the knife had remained in the patient's neck. This was successfully removed in theatre.
This case illustrates the importance of careful history, examination and diagnostic imaging in the management of penetrating neck injuries. Horner's syndrome can be easily missed in a busy Emergency department and may indicate life-threatening pathology in the context of neck trauma. The difficulties in assessing and managing this type of injury are discussed.
OBJECTIVE: To examine the clinical presentations and management of patients presenting to an accident and emergency (A&E) department with an AIDS defining illness (ADI). METHODS: Presentations of patients in the A&E department with ADI were reviewed retrospectively. The age, sex, ethnic origin, risk factor for HIV infection, route of referral to hospital, presenting complaint, triage category, referral from A&E, admission under medical specialists, diagnosis, and survival from ADI were noted for each patient. RESULTS: 133 patients were registered at St Mary's Hospital in London with ADI during 1994. A significant minority of these patients (25/133) presented to the hospital without prior knowledge of their HIV positive status. Thirty two patients presented to the A&E department with their ADI. Of these, 13/32 (41%) were unaware of the HIV serostatus. All 13 patients had an acute respiratory disease (Pneumocystis carinii pneumonia or pulmonary tuberculosis). In contrast, patients aware of their HIV positive status (19/32) presented to the A&E department with a wide range of non-pulmonary ADI. CONCLUSIONS: The study emphasises the importance of respiratory complications in patients who present with a ADI to emergency departments but are unaware of their HIV positivity. These patients presented solely with Pneumocystis carinii pneumonia or pulmonary tuberculosis, conditions in which early diagnosis and treatment significantly reduce morbidity and mortality.
Injuries among samples of car accident cases attending the Accident & Emergency (A & E) department of a District General Hospital (DGH) in the year before and after the introduction of seat belt legislation were classified applying the Abbreviated Injury Scale using information recorded in the patient case notes. Those who died or did not attend an A & E department were not included in the sampling frame. The number of those who escaped injury increased by 40% and those with mild and moderate injuries decreased by 35% after seatbelt legislation. There was a significant reduction in soft tissue injuries to the head. Only whiplash injuries to the neck showed a significant increase.
To examine the mode of presentation, clinical course and treatment of acute epiglottitis in a series of adult patients.
All adults with acute epiglottitis admitted to teaching hospital over a period of 12 months were included in this retrospective study. The diagnosis of epiglottitis was eatablished by laryngoscopy and soft tissue X-ray neck lateral view.
Twelve patients were included. Three patients had concurrent acute tonsillitis. Blood cultures were negative in all the cases. Pathogens were isolated by throat swabs only in three patients with acute tonsillitis. Two patients underwent intubation for management of airway obstruction. A combination of coamoxy-clav and metronidazole was the most common antibiotic regimen used.
The rising incidence of acute epiglottitis in the adults necessitates the close observance on the part of the otolaryngologist. Selective airway intervention is recommended for patients with more than 50% airway obstruction.
Acute epiglottitis; Adult population; Haemophilus influenzae; Laryngoscopy
Trauma and foreign body residue occurring in different settings are common in the neck. Some small injuries go unrecognized, and vascular injuries caused by the sharp penetrating trauma of a foreign body are very dangerous. Without early diagnosis and treatment, foreign body residue remains a major cause of mortality.
A six-cm piece of wooden chopstick was not initially detected in the neck of a 24-year-old Chinese man presenting with a slight bleeding wound after a brawl accident. Three days later, the patient had an expanding neck hematoma and shortness of breath. Computed tomography revealed a dense shadow in the soft tissue of the left side of the patient’s neck, and surgical exploration found that a residual broken chopstick had resulted in a delayed rupture of the common carotid artery and internal jugular vein.
A residual foreign body should be seriously considered after neck trauma because it can result in a lethal hemorrhage originating from a delayed rupture of blood vessels.
Common carotid; Foreign body; Internal jugular vein; Trauma
BACKGROUND: Acute paediatric admissions have risen steadily over the past 20 years. During the same period, practice-based child health clinics have increased, although provision is less common in areas of deprivation where hospital use is greatest. AIM: To investigate the contribution of practice-based, preventive child health services to rates of hospital utilisation in children under five years of age. METHOD: A cross-sectional retrospective study examining practice variations in paediatric acute admissions, outpatient referrals, and accident and emergency (A&E) department attendances in the East London and the City Health authority, including all 164 practices in the inner-city boroughs of Hackney, Newham, Tower Hamlets, and the City of London. The main outcome measures were practice-based paediatric hospital attendance rates, for discrete age and sex bands, for the year to 31 March 1996. RESULTS: Hospital use varied with age and sex, with the rates being highest for the youngest children and for boys. The median A&E attendance rate (including reattendances) for boys up to one year of age was 897 per thousand children per practice. In east London, 62% of practices are registered for child health surveillance and 71% provide a child health clinic. Practice approval for child health surveillance, and the provision of child health clinics, did not account for differences between practices in hospital use, but proportionally greater health visiting hours were significantly related to lower rates of emergency hospital admission by young children. Multivariate analyses revealed that up to 23% of the variation between practice admission rates could be explained by health visiting hours. CONCLUSIONS: We found significant associations between the amount of health visiting time available to the practice population and rates of acute admission and outpatient referral among children up to five years of age. These findings suggest that increasing health visitor provision could contribute to lower paediatric emergency admission and outpatient referral rates. A small change would have a significant effect, particularly among the youngest children, given that during the study year 10,000 children under two years of age in east London were either admitted or referred to hospital.
Synovial sarcoma is a rare soft tissue sarcoma in the head and neck region and parapharyngeal space. There is no previous cytologic report of synovial sarcoma of parapharynx. The cytologic and immunocytochemical findings of a parapharyngeal biphasic synovial sarcoma together with diagnostic pitfalls are described.
A 21-year-old girl presented with a 6-month history of progressive right arm pain, neck mass and upper aerodigestive tract obstruction. On physical examination there was a large painless mass arising from the right-sided parapharyngeal space causing airway obstruction. Initial magnetic resonance imaging (MRI) revealed a large tumor in the right-sided parapharyngeal space. Fine needle aspiration through cervical region was performed and was reported as benign spindle cell tumor. Smears were cellular and composed mostly of tight and loose clusters of spindle cells. Epitheloid cells could also be identified intermingled with them. She underwent near total resection of the tumor. Pathologic report disclosed the diagnosis of synovial sarcoma. She then received postoperative adjuvant external radiotherapy.
Due to rarity of this tumor in this region and nonspecific cytologic features, we could not differentiate this tumor from the other more common spindle cell neoplasms. Considering synovial sarcoma in this region and immunocytochemistry can be helpful in rendering a correct initial diagnosis of this tumor.
Congenital spinal abnormalities can easily be misdiagnosed on plain radiographs. Additional imaging is warranted in doubtful cases, especially in a setting of acute trauma.
This patient presented at the emergency unit of our university hospital after a motor vehicle accident and was sent to our radiology department for imaging of the cervical spine. Initial clinical examination and plain radiographs of the cervical spine were performed but not conclusive. Additional CT of the neck helped establish the right diagnosis.
CT as a three-dimensional imaging modality with the possibility of multiplanar reconstructions allows for the exact diagnosis and exclusion of acute traumatic lesions of the cervical spine, especially in cases of doubtful plain radiographs and when congenital spinal abnormalities like absent cervical spine pedicle with associated spina bifida may insinuate severe trauma.
Objective. The demand and usage of button batteries have risen. They are frequently inadvertently placed by children in their ears or noses and occasionally are swallowed and lodged along the upper aerodigestive tract. The purpose of this work is to study the different presentations of button battery foreign bodies and present our experience in the diagnosis and management of this hazardous problem in children. Patients and Methods. This study included 13 patients. The diagnostic protocol was comprised of a thorough history, head and neck physical examination, and appropriate radiographic evaluation. The button batteries were emergently extracted under general anesthesia. Results. The average follow-up period was 4.3 months. Five patients had a nasal button battery. Four patients had an esophageal button battery. Three patients had a button battery in the stomach. One patient had a button battery impacted in the left external ear canal. Apart from a nasal septal perforation and a tympanic membrane perforation, no major complications were detected. Conclusion. Early detection is the key in the management of button battery foreign bodies. They have a distinctive appearance on radiography, and its prompt removal is mandatory, especially for batteries lodged in the esophagus. Physicians must recognize the hazardous potential and serious implications of such an accident. There is a need for more public education about this serious problem.
Stroke is a common and important condition in medicine. Effective early management of acute stroke can reduce morbidity and mortality.
A 63-year-old man presented to the Accident and Emergency department with a history of collapse and progressive right-sided weakness. Clinically this was a cerebrovascular accident affecting the left hemisphere of the brain causing right hemiplegia. Computed tomography scans, performed 3 days apart, showed the evolution of infarction in the brain caused by the thrombus in the left middle cerebral artery. This is one of the early signs for stroke seen on computed tomography imaging and it is called the hyperdense middle cerebral artery sign.
Patients admitted with a stroke, undergo CT brain within 24 hours. The scan usually takes place at admission into the hospital and is done to rule out a bleed or a space occupying lesion within the brain. A normal CT brain does not confirm a stroke has not taken place. When scanned early, the changes seen on the CT due to an infarction from a thrombus may not have taken place yet. This paper highlights the early changes that can be seen on the CT brain following a stroke caused by infarction due to a thrombus in the middle cerebral artery.