This prospective observational study aimed to determine the rate of success of reduction of dislocated hip prostheses using conscious sedation. In 101 consecutive patients presenting to the emergency department between August 2000 and February 2003 with a dislocated hip prosthesis, reduction was attempted using conscious sedation. The outcome measures of the study were (a) rate of success of the attempted reductions (b) rate of complication of the sedation or the procedure, and (c) rate of success in the three subgroups (based on degree of dislocation). The overall success rate was 62% (95% CI 53% to 71%). There were six complications: five related to sedation and one was a mild foot drop. The mean time to attempted reduction using conscious sedation was 1.83 hours and for an equivalent group who were excluded and subsequently required general anaesthesia the mean time was 10.9 hours. Reduction of isolated unilateral prosthetic hip dislocation using conscious sedation in the emergency department is safe and has a reasonable success rate. Prosthetic hip reduction can be attempted more quickly using conscious sedation than when awaiting general anaesthesia. R eduction of dislocated hip prostheses is usually performed under general anaesthesia. Often there are significant delays waiting for theatre and controlling patients' pain in the interim can be difficult. A comprehensive literature search failed to identify any studies whose primary outcome was the rate of success of reduction under sedation. A single case report 1 was found in which etomidate was used to facilitate reduction instead of ''narcotics''.An pilot study 2 conducted in our department (1998-99; unpublished) demonstrated a success rate of 67% was possible using conscious sedation. Our aim in the present study was to prospectively establish the rate of success, and the nature and frequency of complications when reducing prosthetic hip dislocations using conscious sedation. METHODSWe included adult patients presenting to the emergency department with an isolated, unilateral dislocation of a prosthetic hip between August 2000 and February 2003. Exclusion criteria were American Society of Anesthesiologists (ASA) score .2; neurovascular deficit; dislocation .12 hours; previous failure using sedation; inability to consent; refusal; only one doctor on duty or when it was considered ''too busy''.It has been the usual practice within our accident and emergency department to attempt reduction of dislocated hip prostheses under sedation for the previous 15 years. Since this study was an attempt to establish the rate of success and nature and frequency of complications, and it did not involve introduction of a new practice, ethical approval was not obtained.Patients' demographic details were recorded contemporaneously on a proforma and the patients were given intravenous morphine to control their pain. Patients were examined fully and specifically for any neurovascular deficit of the affected leg. All patients had an anteroposterior x ray of the hemipelvis. We...

The details are presented of the first published case of a tension pneumothorax induced by an automatic compression-decompression (ACD) device during cardiac arrest. An elderly patient collapsed with back pain and, on arrival of the crew, was in pulseless electrical activity (PEA) arrest. He was promptly intubated and correct placement of the endotracheal tube was confirmed by noting equal air entry bilaterally and the ACD device applied. On the way to the hospital he was noted to have absent breath sounds on the left without any change in the position of the endotracheal tube. Needle decompression of the left chest caused a hiss of air but the patient remained in PEA. Intercostal drain insertion in the emergency department released a large quantity of air from his left chest but without any change in his condition. Post-mortem examination revealed a ruptured abdominal aortic aneurysm as the cause of death. Multiple left rib fractures and a left lung laceration secondary to the use of the ACD device were also noted, although the pathologist felt that the tension pneumothorax had not contributed to the patient's death. It is recommended that a simple or tension pneumothorax should be considered when there is unilateral absence of breath sounds in addition to endobronchial intubation if an ACD device is being used.

though tricksters, may yet be mentally, and sometimes physically, ill; and that we who are not can, as well as being clever, also be kind. How can cases of Munchausen syndrome be recognised early in the consultation? The clinician's suspicion remains all important.

A69-year-old woman with known hypertension presented to hospital with sudden onset severe central chest pain radiating between her shoulder blades and into her abdomen. This was associated with loss of power and sensation in her left leg lasting for 30 minutes. She complained of residual discomfort between her scapulae. Examination revealed a well-looking woman with unequal blood pressures in both arms: right 140/70 mmHg, left 100/80 mmHg, a pulse rate of 84/min and no audible murmurs. There was no vascular or neurological deficit in either leg. 12-lead electrocardiogram showed left ventricular hypertrophy by voltage criteria and chest radiograph was normal. Urgent spiral computed tomography of the chest and abdomen showed an extensive type A dissection of her aorta from her aortic valve to the abdominal aortic bifurcation (Figure 1). Despite attempts at haemodynamic resuscitation, she died in the ambulance en route to the regional cardiothoracic centre. Post mortem revealed a tense haemopericardium.

A 63-year-old women with a history of palpitations presented to the emergency department with a supraventricular tachycardia; the patient was cardiovascularly stable. Carotid sinus massage (CSM) was performed to help identify the underlying rhythm. During massage the patient had an immediate cerebrovascular accident, resulting in a left hemiplegia. Given the prevalence of atherosclerotic vascular disease in the general population and the safe alternatives available, it is recommended that CSM not be used for the termination of narrow complex tachycardia in the elderly population.

This study shows that limited extremity MRI can safely exclude clinically important injury. Significant symptoms do persist, however, for many patients with a normal MRI.

This study was to determine whether or not ED and ICU consultants would intubate an unstarved, haemodynamically unstable patient with a BCT requiring electrical cardioversion, and to determine the incidence of complications for both intubating and not intubating based on the responders personal experience. 174 postal questionnaires were sent to ED and ICU consultants in the Wessex and South West regions of England. They were asked whether or not they would intubate a patient that required electrical cardioversion for a BCT with hypotension. 139 responded: 77 (56%) elected to intubate the patient always or most of the time, 34 (24%) would rarely or never intubate the patient, and 28 (20%) would only do so sometimes. Responders were aware of significant complications from both intubating and not intubating such a patient. Intubation for an unstarved patient with a haemodynamically compromising BCT would seem to occur on a variable basis. ED consultants were more likely to sedate such a patient without intubation whereas ICU consultants were more likely to intubate them. It is a well established anaesthetic practice that unstarved patients require intubation when anaesthesia is required urgently in order to protect the airway from regurgitated stomach contents during a procedure.1 However, our personal experience of the airway management for unstarved, haemodynamically unstable patients because of a broadcomplex tachycardia (BCT) seems to vary between clinical practitioners. The United Kingdom Resuscitation Council guidelines 2001 2 state that for a BCT ''anaesthesia or appropriate sedation'' is necessary to facilitate electrical cardioversion. However, there is no further explanation for how this should be achieved. The UK Academy of Medical Colleges published a report on safe sedation, which states that if sedation is used, and verbal responsiveness is lost, the patient requires a level of care identical to that needed for general anaesthesia. 3 We reviewed the literature and found no papers that addressed this scenario.The aim of our survey was to determine whether Emergency Department (ED) and Intensive Care Unit (ICU) consultants would intubate an unstarved, unstable patient with a BCT. METHODSA questionnaire was posted to all ED and ICU consultants in the Wessex and South West regions of England in September 2003. The ED consultants were identified using the BAEM 2002 directory. The ICU consultants were identified by contacting the switchboard of all hospitals in this region and asking them for the names of the current intensive care consultants.The questionnaire described a hypothetical scenario in which a 76 year old male with a BCT was hypotensive. He was not starved, but predicted to be an easy intubation and had a potassium level of 4.5 mmol/l. He specifically required electrical cardioversion.The questionnaire asked if the responder would intubate the patient always, most of the time, sometimes, rarely, or never. Subsequent questions asked about complications they had experienced or known about from int...

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