Objective To determine whether the management of head injuries differs between patients aged >65 years and those < 65. Design Prospective observational national study over four years. Setting 25 Scottish hospitals that admit trauma patients. Participants 527 trauma patients with extradural or acute subdural haematomas. Main outcome measures Time to cranial computed tomography in the first hospital attended, rates of transfer to neurosurgical care, rates of neurosurgical intervention, length of time to operation, and mortality in inpatients in the three months after admission. Results Patients aged >65 years had lower survival rates than patients < 65 years. Rates were 15/18 (83%) v 165/167 (99%) for extradural haematoma (P=0.007) and 61/93 (66%) v 229/249 (92%) for acute subdural haematoma (P < 0.001). Older patients were less likely to be transferred to specialist neurosurgical care (10 (56%) v 142 (85%) for extradural haematoma (P=0.005) and 56 (60%) v 192 (77%) for subdural haematoma (P=0.004)). There was no significant difference between age groups in the incidence of neurosurgical interventions in patients who were transferred. Logistic regression analysis showed that age had a significant independent effect on transfer and on survival. Older patients had higher rates of coexisting medical conditions than younger patients, but when severity of injury, initial physiological status at presentation, or previous health were controlled for in a log linear analysis, transfer rates were still lower in older patients than in younger patients (P < 0.001). Conclusions Compared with those aged under 65 years, people aged 65 and over have a worse prognosis after head injury complicated by intracranial haematoma. The decision to transfer such patients to neurosurgical care seems to be biased against older patients.
Eclampsia is defined as the occurrence of seizures in pregnancy or within 10 days of delivery, accompanied by at least two of the following features documented within 24 hours of the seizure: hypertension, proteinuria, thrombocytopenia or raised aspartate amino transferase. Eclampsia complicates approximately one in 2,000 pregnancies in the United Kingdom and it remains one of the main causes of maternal death. Up to 38% of cases of eclampsia can occur without premonitory signs or symptoms of pre-eclampsia-that is, hypertension, proteinuria, and oedema. Only 38% of eclamptic seizures occur antepartum; 18% occur during labour and a further 44% occur postpartum. Rare cases of eclampsia have occurred over a week after delivery. Outcome is poor for mother and child. Almost one in 50 women suffering eclamptic seizures die, 23% will require ventilation and 35% will have at least one major complication including pulmonary oedema, renal failure, disseminated intravascular coagulation, HELLP syndrome, acute respiratory distress syndrome, stroke, or cardiac arrest. Stillbirth or neonatal death occurs in approximately one in 14 cases of eclampsia. Up to one third of eclamptic seizures occur out of hospital. For this reason, initial management may involve accident and emergency departments. Early involvement of senior obstetric staff is crucial. Optimal emergency management of seizures, hypertension, fluid balance and subsequent safe transfer is essential to minimise morbidity and mortality.
Aim: Airway management is a core aspect of emergency medicine. The technique of rapid sequence intubation (RSI) creates continuing debate between anaesthetists and emergency physicians in the UK, although similar complication rates for emergency department (ED) RSI have been shown for both specialties. This study examined prospectively collected data on every ED RSI performed in a university hospital in Glasgow over 5 years. Methods: Data were prospectively recorded for every attempted RSI in the ED on a dedicated form (as used in previous studies) between January 1999 and December 2003. Immediate complications were specifically sought in the questionnaire, as was the immediate destination on leaving the ED. The x 2 test was used for categorical data. Results: On average, 51 ED RSI were performed annually (range 42-60). Emergency physician RSI for trauma increased from 32% (7/22) in 1999 to 75% (21/28) in 2003 (x 2 = 9.32, df = 1, p = 0.002) and for non-trauma from 62% (18/29) in 1999 to 79% (23/29) in 2003 (x 2 = 2.08, df = 1, p = 0.15). Complication rates for emergency physician RSI decreased from 43% (3/7) to 14% (3/21) for trauma (x 2 = 2.55, df = 1, p = 0.11) and from 28% (5/18) to 4% (1/ 23) for non-trauma (x 2 = 4.44, df = 1, p = 0.035). This compares with mean complication rates for anaesthetists for trauma of 17% and for non-trauma of 22%. Incidence of hypotension decreased in all groups; however, oxygen desaturation is now the most common complication. The rate of ED RSI prior to computed tomography (CT) scans increased in both the trauma (79% v 42%; x 2 = 7.42, df = 1, p = 0.0065) and non-trauma (48% v 17%; x 2 = 5.85, df = 1, p = 0.016) groups. Conclusion: Emergency physician performed ED RSI is increasingly common but is not associated with overall higher numbers of RSIs being performed in the ED. Effective pre-oxygenation should be emphasised during training. R apid sequence intubation (RSI) is a continuing source of debate between anaesthetists and emergency physicians. The debate has primarily focused on success and complication rates and the possibility that emergency physician RSI will increase the numbers of inappropriate intubations.1-3 Previous studies have shown that similar complication rates for RSI are seen in both specialties. No previous UK study has examined trends in the practice of RSI in the emergency department (ED) over an extended period of time. This study examines prospectively collected data on every RSI performed in the ED of a single teaching hospital in Glasgow over 5 years to identify trends and to determine how ED RSI has evolved in this centre during that time. METHODSThe study was undertaken in an ED seeing 45 000 new patients annually. Data were prospectively recorded for every attempted RSI in the ED on a dedicated proforma identical to that used in previous studies.2 4 Data were collected between January 1999 and December 2003. The questionnaire specifically sought to identify immediate complications resulting from the procedure, and the patient's immediate destinat...
Blood cultures taken in our emergency department rarely yield bacterial growth and over 2 years, only four seemed to directly influence patient management. Better guidelines are required for targeted use of blood cultures in the emergency department.
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