Five instruments were testedfor their capacity to monitor heparin therapy on whole blood at the bedside. The instruments were 512 Coagulation Monitor (Ciba-Corning), Thrombotrack (Nycomed), Automated Coagulation Timer (Hemotec), Hemochron-ACT and Hemochron-APTT (International Technidyne Corporation). Fifty subjects with various levels of heparinisation were tested on each instrument and were also assayed for antithrombin Ill, fibrinogen, haematocrit, platelet count and plasma heparin level. The results were compared with a reference APTT performed on the Automated Coagulation Laboratory 300R (Instrumentation Laboratories). The Hemochron-ACT correlated least well. The Hemotec and Thrombotrack were unsuitable in a clinical setting because of pipetting requirements, although the Thrombotrack did correlate well with the reference parameters. The 512 Coagulation Monitor was the simplest to use, but its maximum response corresponded to the midpoint of the reference APTT therapeutic range. The Hemochron-APTT was simple to use, had an adequate response range and correlated well with reference parameters.

Medicine regards the prevention of death as an important priority. Yet patients may have a range of priorities of equal or greater importance. These other priorities are often not discussed or appreciated by treating doctors. ObjectivesWe sought to identify priorities of care for patients attending an advance care planning (ACP) clinic and among the general population, and to identify factors associated with priorities other than prolonging life.MethodsWe used a locally developed survey tool ‘What Matters Most’ to identify values. Choices presented were: maintaining dignity, avoiding pain and suffering, living as long as possible, and remaining independent. Participants rated the importance of each and then selected a main priority for their doctor. Participant groups were a purposive sample of 382 lay people from the general population and 100 attendees at an ACP clinic.ResultsLiving as long as possible was considered to be less important than other values for ACP patients and for the general population. Only 4% of ACP patients surveyed and 2.6% of our general population sample selected ‘living as long as possible’ as their top priority for medical treatment.Conclusions‘Living as long as possible’ was not the most important value for ACP patients, or for a younger general population. Prioritisation of other goals appeared to be independent of extreme age or illness. When end of life treatment is being discussed with patients, priorities other than merely prolonging life should be considered.

SummaryA case of refractory hypotension following propanolol overdose is reported. Management included isoprenaline, glucagon and extracorporeal circulatory support using femoral vein-femoral artery bypass. The unreliability of neurological observations, especially unreactive pupils, in the presence of drug overdose is reiterated. Key wordsSympathetic nervous system, 8-adrenergic antagonists; propanolol. Complications. Case historyA 20-year-old woman was admitted to the Accident and Emergency Department having ingested approximately 50 of her mother's propanolol tablets (total 2 gm) and 10 Mersyndol tablets (paracetamol 45 mg, codeine 9.7 mg, doxylamine 5 mg). Three hours before admission, her mother reported that she was well. However, in the hour before admission, the daughter told friends of her action and they induced her to vomit. Some tablets were seen in the vomitus. After half an hour, she became drowsy and an ambulance was called. The ambulance crew found her unresponsive, with focal fitting, dilated but sluggishly reacting pupils, no recordable blood pressure and a slow capillary refill time, but she was breathing spontaneously. She was given oxygen by mask and transferred in the lateral decubitus position.Her past medical history included mild asthma as a child. She had no psychiatric history. She lived with her mother and had a 2-year-old child. Recent relationship problems with her boyfriend had precipitated her overdose.She was unrousable on admission, intermittently fitting and peripherally cyanosed. No pulses were palpable and blood pressure was unrecordable. The ECG showed a broad QRS complex and bradycardia of 40 beats per minute. Blood gases during resuscitation were pH 6.96, Paco, 4.72 kPa, Pao, 73.0 kPa, base deficit 20.7. Urea and electrolytes were normal. Blood glucose was 6.5 mmol/litre. Paracetamol level was 33 mmol/litre; no tricyclics were detected. Subsequently propanolol levels were found to be greater than 4589 ng/ml. She was initially oxygenated by mask ventilation, followed by tracheal intubation and ventilation with 100% oxygen. External cardiac massage was initiated and continued throughout her subsequent resuscitation (total of 4 hours). Gastric lavage was performed, but no tablets were recovered. Activated charcoal was instilled into the stomach. Clonazepam 1 mg was given to relieve seizure activity and atropine 1.2 mg was administered for bradycardia. During the first hour, she received two boluses of isoprenaline 200 pg followed by an infusion of 20 pg per minute and two boluses of adrenaline 1 mg, followed by an infusion of 25 pg per minute. She also received 2 litres of intravenous colloid. There was no improvement in her pulse or blood pressure, and her central venous pressure was 35 cmH20. Glucagon was given as it became available, to a total of 9 mg over 90 minutes. Her carotid pulse became intermittently faintly palpable following glucagon administration. Her ECG continued to show a bizarre broad complex bradycardia of 30 to 40 beats per minute. Transvenous cardiac pac...

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ObjectivesReport the implementation, user evaluation and key outcome measures of an educational intervention—the iValidate educational programme—designed to improve engagement in shared decision-making by health professionals caring for patients with life-limiting illness (LLI).DesignProspective, descriptive, cohort study.ParticipantsHealth professionals working in acute care settings caring for patients with an LLI.Main outcomes measuredParticipant evaluation of learning outcomes for communication skills and shared decision-making; demographic data of participants attending education workshops; and documentation of patients with LLI goals of management, including patient values and care decision based on area in acute care and seniority of doctor.ResultsThe programme was well accepted by participants. Participant evaluations demonstrated self-reported improved confidence in the areas of patient identification, information gathering to ascertain patient values and shared decision-making. There was strong agreement with the course-enhanced knowledge of core communication skills and advanced skills such as discussing mismatched agendas.ConclusionsWe described the educational pedagogy, implementation and key outcome measures of the iValidate education programme, an intervention designed to improve person-centred care for patients with an LLI. A targeted education programme could produce cultural and institutional change for vulnerable populations within a healthcare institution. A concurrent research programme suggests effectiveness within the current service and the potential for transferability.

Minitracheostomy is a valuable technique in patients with sputum retention. However, insertion 0/ a minitracheostomy tube over a dilator passed through an incision through the cricothyroid membrane (the suggested method o/insertion o/the 'Mini-trach II', [Portex]), can prove difficult. A Seldinger method is described which results in easier and more reliable placement in difficult cases.

Summary

Ethnicity may be considered a factor when considering what size endotracheal tube to insert. In particular it has been suggested that Chinese patients have a smaller tracheal diameter, justifying the selection of smaller endotracheal tubes. We systematically evaluated transverse tracheal diameters in Chinese and Caucasian patients, utilising archived computer tomography images. A convenience sample of 100 Caucasian patients from Australia was compared with 100 Chinese patients from Hong Kong. Patients over 18 years of age who had undergone a computerised tomography scan of the neck and thorax, and also had accurate body height and weight recorded, were studied. The mean transverse diameter of the trachea measured at three levels was similar between the Chinese and Caucasian patients. At the narrowest measurement point, the immediate subcricoid transverse diameter, the unadjusted mean difference between male Chinese and Caucasian patients was small (1 mm, standard deviation 0.83 mm, P=0.01), and similarly small between female Chinese and Caucasian patients (1.5 mm, standard deviation 0.8 mm, P <0.01). Multivariate analysis demonstrated only a small influence related to ethnicity (12% relative contribution to the overall variance [R2] of the model), but substantial influence of height (40%) and sex (41%). Our findings do not support the practice of routinely selecting a smaller endotracheal tube size for Chinese patients on the basis that there is a difference related to the Chinese ethnic phenotype. Considerations regarding choice of endotracheal tube size should rather focus on patient sex and height.