Journal of accident & emergency medicine最新文献

{"title":"Journal scan","authors":"J. Wardrope, R. Russell","doi":"10.1136/emj.17.6.416","DOIUrl":"https://doi.org/10.1136/emj.17.6.416","url":null,"abstract":"Missed diagnosis of acute cardiac ischaemia in the emergency department J H Pope, T P Aufderheide, R Ruthazer et al N Engl J Med 2000;342:1163–70 Objectives—To describe the incidence of, factors related to, and clinical outcome of a failure to admit patients with acute cardiac ischaemia. Methods—10 689 patients attending 10 US emergency departments with chest pain or other symptoms suggestive of acute cardiac ischaemia were studied in a multi-centre prospective clinical trial. Patients that were sent home attended for repeat examination, ECG and CK-MB within 72 hours of discharge. Results—There was 99% follow up. A total of 1866 (17%) patients had acute cardiac ischaemia (8% MI, 9% unstable angina). Twenty seven per cent had stable angina or other cardiac problems. Fifty five per cent had non-cardiac pain. Nineteen (2.1%) of the 889 patients with acute MI and 22 (2.3%) of the 966 patients with unstable angina were sent home. Factors associated with mistaken discharge were female sex and age <55, non-white race, shortness of breath as main symptom and a normal or non-diagnostic ECG. Patients with acute MI who were sent home had the same crude mortality rates as those admitted to hospital (home 10.5%, hospital 9.7%) but when these rates were adjusted for various risk factors the mortality ratio was almost doubled (1.90). Those sent home with unstable angina did have both a higher crude mortality rate (home 9.8%, hospital 5.5%) and adjusted mortality ratio (1.7). Conclusions—Few patients are mistakenly discharged with acute cardiac ischaemia but their mortality is higher. Absence of typical symptoms or ECG changes are associated with mistaken discharge. Critique—This is an important problem. This paper aimed to identify the incidence of wrongful discharge along with the factors and consequences associated. The actual mortality rates of those sent home with acute MI and those admitted were similar although the risk adjusted mortality ratios were increased but the increases did not achieve statistical significance. Further explanation is required of the methodology of risk adjusted mortality ratios. Another weakness is that 929 patients were excluded from the study. No reason is given for these exclusions and this throws some doubt on the 99% follow up rate. Although excluded patients matched study patients for sex and race no explanation is given as to why they were omitted. There is no mention of the proportion from the overall population who were admitted. Obviously the lower the threshold for admission, the less likely there is to be an error. The study was carried out over seven months in 1993–4. No reason for the delay in publication is given. Further methods to identify acute ischaemia are now more widely available.","PeriodicalId":73580,"journal":{"name":"Journal of accident & emergency medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2000-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/emj.17.6.416","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"64231507","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Extracorporeal rewarming in a severely hypothermic patient using venovenous haemofiltration in the accident and emergency department.","authors":"K Spooner,&nbsp;A Hassani","doi":"10.1136/emj.17.6.422","DOIUrl":"https://doi.org/10.1136/emj.17.6.422","url":null,"abstract":"<p><p>Severe hypothermia is a medical emergency and requires active and occasionally rapid core rewarming to prevent cardiac arrhythmias and death. In the accident and emergency department rewarming is often limited to warmed intravenous fluids, heated blankets, gastric and bladder lavage. Extracorporeal methods, which rewarm core blood directly, for example haemodialysis and cardiopulmonary bypass, require expertise and equipment not always found in a district general hospital. Venovenous haemofiltration is now commonly found in district general hospitals around the country and can be used safely for core rewarming. A case is reported of a severely hypothermic elderly patient successfully rewarmed using venovenous haemofiltration, in an accident and emergency department, when other conventional methods had failed.</p>","PeriodicalId":73580,"journal":{"name":"Journal of accident & emergency medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2000-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/emj.17.6.422","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21927756","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Radiology case report: a nasty orbital abscess.","authors":"M E Papesch,&nbsp;J M Philpott","doi":"10.1136/emj.17.6.431","DOIUrl":"https://doi.org/10.1136/emj.17.6.431","url":null,"abstract":"","PeriodicalId":73580,"journal":{"name":"Journal of accident & emergency medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2000-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/emj.17.6.431","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21927761","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Snap without crackle or pop: a rude awakening. A case history of penile fracture.","authors":"P Gilligan,&nbsp;M Smith,&nbsp;F Todd,&nbsp;P Bradley,&nbsp;A Shenton","doi":"10.1136/emj.17.6.425","DOIUrl":"https://doi.org/10.1136/emj.17.6.425","url":null,"abstract":"<p><p>Penile fracture is a rare but worrying condition. The presentation to accident and emergency or primary care should not present difficulty in diagnosis but may cause concern with regard to initial treatment and definitive management. Emergency admission to a urologist is mandatory.</p>","PeriodicalId":73580,"journal":{"name":"Journal of accident & emergency medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2000-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/emj.17.6.425","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21927757","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary","authors":"K. Mackway-Jones","doi":"10.1136/emj.17.6.400","DOIUrl":"https://doi.org/10.1136/emj.17.6.400","url":null,"abstract":"Best evidence topic reports (BETs) summarise the evidence pertaining to particular clinical questions. They are not systematic reviews, but rather contain the best (highest level) evidence that can be practically obtained by busy practising clinicians. The search strategies used to find the best evidence are reported in detail in order to allow clinicians to update searches whenever necessary. The BETs published below were first reported at the Critical Appraisal Journal Club at the Manchester Royal Infirmary. Each BET has been constructed in the four stages that have been described elsewhere. The BETs shown here together with those published previously and those currently under construction can be seen at http:// www.bestbets.org. Six topics are covered in this issue of the journal:","PeriodicalId":73580,"journal":{"name":"Journal of accident & emergency medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2000-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/emj.17.6.400","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"64231442","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Biological tissue adhesive for multiple use in the accident and emergency department.","authors":"C Gerrard,&nbsp;S Moore,&nbsp;B Ryan","doi":"10.1136/emj.17.5.341","DOIUrl":"https://doi.org/10.1136/emj.17.5.341","url":null,"abstract":"<p><strong>Objective: </strong>To assess the strength of the glue and microbial contamination over 28 days from opening a vial of tissue adhesive in the accident and emergency setting, and to quantify cost savings of repeated use of the vials.</p><p><strong>Method: </strong>(1) Strips of reinforced nylon and a specially constructed piece of apparatus designed to measure the force at which the glue gave way were used to measure the strength of the tissue adhesive at various times after the glue was opened to assess if the glue strength deteriorated over time. (2) Microbial contamination of the glue was assessed.</p><p><strong>Results: </strong>There was no deterioration in the glue strength over time. There was no evidence of microbial contamination of the glue.</p><p><strong>Conclusion: </strong>Cyanoacrylate tissue adhesive can safely be reused for a period of 28 days after opening with no risk of degradation of glue strength or contamination with micro-organisms. In our department this represents a potential saving of ł5400 per year.</p>","PeriodicalId":73580,"journal":{"name":"Journal of accident & emergency medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2000-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/emj.17.5.341","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21837496","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The capability of accident and emergency departments to safely decontaminate victims of chemical incidents.","authors":"P Horby,&nbsp;V Murray,&nbsp;A Cummins,&nbsp;K Mackway-Jones,&nbsp;R Euripidou","doi":"10.1136/emj.17.5.344","DOIUrl":"https://doi.org/10.1136/emj.17.5.344","url":null,"abstract":"<p><strong>Objectives: </strong>To evaluate the capability of accident and emergency (A&E) departments in six health regions of England to safely decontaminate casualties exposed to hazardous chemicals.</p><p><strong>Methods: </strong>In January 1999 a postal questionnaire was sent to the clinical director of all A&E departments in Trent, North and South Thames, South and West, North West and, Anglia and Oxford Health Regions. The questionnaire inquired about characteristics of the department, decontamination facilities and equipment, and staff training. Nonresponders were sent a second questionnaire and contacted by telephone if they failed to respond to the second mailing.</p><p><strong>Results: </strong>308 of 326 departments identified (94%) returned a questionnaire. There was no significant difference in response rate by region (p = 0.99). Analysis was restricted to 154 major departments seeing more than 20000 new attendances per year. Of these 154 departments, 109 (71%) had a written chemical incident plan but only 55 (36%) maintained a list of nearby industrial chemical sites. Fifty nine departments (38%) stated that members of staff had received training in the management of chemically contaminated casualties in the preceding year. Eighteen departments (12%) possessed the level of personal protective equipment (PPE) recommended for decontamination by the Ambulance Services Association. Ninety six departments (62%) had a designated decontamination room but only seven (7%) of them incorporated all the features generally considered necessary for safe decontamination. Forty one units (27%) had the capability to decontaminate casualties outside of the department either with warm water from a shower attachment or with a mobile decontamination unit. Thirty six departments (23%) had neither a decontamination room nor the ability to decontaminate casualties outside the department. Only 16 units (10%) had both adequate PPE and either a decontamination room or the capability to decontaminate outside the department.</p><p><strong>Conclusions: </strong>This study has identified deficiencies in the current NHS capability to respond to chemical incidents. To resolve this, nationally recognised standards for decontamination facilities, equipment and training should be formulated, agreed and implemented.</p>","PeriodicalId":73580,"journal":{"name":"Journal of accident & emergency medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2000-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/emj.17.5.344","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21837497","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Circ.com-plications.","authors":"J E Kennedy","doi":"10.1136/emj.17.5.384","DOIUrl":"https://doi.org/10.1136/emj.17.5.384","url":null,"abstract":"A 20 year old single man presented to the accident and emergency department after failing in an attempt to circumcise himself. He had previously normal anatomy, and a fully retractile foreskin. He had been “browsing” on the internet and had found a web site1 with written and pictorial instructions for self circumcision techniques. Using a non-sterile …","PeriodicalId":73580,"journal":{"name":"Journal of accident & emergency medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2000-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/emj.17.5.384","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21837950","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"An unusual cause of stridor.","authors":"P Gaffney,&nbsp;S Holbrook","doi":"10.1136/emj.17.5.386","DOIUrl":"https://doi.org/10.1136/emj.17.5.386","url":null,"abstract":"","PeriodicalId":73580,"journal":{"name":"Journal of accident & emergency medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2000-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/emj.17.5.386","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21837952","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Combined brachial plexus and vascular injury in the absence of bony injury.","authors":"A F MacNamara,&nbsp;A Ismail","doi":"10.1136/emj.17.5.378","DOIUrl":"https://doi.org/10.1136/emj.17.5.378","url":null,"abstract":"<p><p>Neurovascular injury to the axillary vessels is well described in association with fracture or dislocation involving the shoulder joint or the humerus. Such injury however can also occur in the absence of bony injury. A case is presented of damage to the axillary artery and brachial plexus following blunt trauma. This case demonstrates that complex neurovascular damage can occur in the absence of fracture or dislocation. The importance of a thorough clinical assessment is highlighted and priorities with regard to diagnosis and management are discussed.</p>","PeriodicalId":73580,"journal":{"name":"Journal of accident & emergency medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2000-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/emj.17.5.378","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21838611","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}