Biomedical subjects

Anna Holdgate

Publications and source records attributed to Anna Holdgate.

11 recordsLinked to original sources

PubMed2006

Variability in agreement between physicians and nurses when measuring the Glasgow Coma Scale in the emergency department limits its clinical usefulness.

OBJECTIVE: To assess the interrater reliability of the Glasgow Coma Scale (GCS) between nurses and senior doctors in the ED. METHODS: This was a prospective observational study with a convenience sample of patients aged 18 or above who presented with a decreased level of consciousness to a tertiary hospital ED. A senior ED doctor (emergency physicians and trainees) and registered nurse each independently scored the patient's GCS in blinded fashion within 15 min of each other. The data were then analysed to determine interrater reliability using the weighted kappa statistic and the size and directions of differences between paired scores were examined. RESULTS: A total of 108 eligible patients were enrolled, with GCS scores ranging from 3 to 14. Interrater agreement was excellent (weighted kappa > 0.75) for verbal scores and total GCS scores, and intermediate (weighted kappa 0.4-0.75) for motor and eye scores. Total GCS scores differed by more than two points in 10 of the 108 patients. Interrater agreement did not vary substantially across the range of actual numeric GCS scores. CONCLUSIONS: Although the level of agreement for GCS scores was generally high, a significant proportion of patients had GCS scores which differed by two or more points. This degree of disagreement indicates that clinical decisions should not be based solely on single GCS scores.

Adult↗

PubMed2005

Is there a role for antimuscarinics in renal colic? A randomized controlled trial.

PURPOSE: We determined whether the addition of hyoscine butylbromide (Buscopan) reduces the amount of opioid analgesia required and the need for ongoing opioid analgesia in acute renal colic. MATERIALS AND METHODS: Patients with a clinical diagnosis of acute renal colic were prospectively randomized to receive Buscopan or placebo in addition to morphine and intravenous fluids, with or without indomethacin. Observations and pain scores were recorded 15 every minutes during the first hour then hourly thereafter. Morphine was administered in 2.5 mg increments until pain relief was achieved. Recordings were ceased at 4 hours or on discharge from the emergency department, whichever occurred first. The diagnosis of renal colic was confirmed by computerized tomography. The dose of morphine (mg/kg) and the proportion of patients who required further morphine were compared between the 2 groups. RESULTS: Of the 192 patients randomized, data were available for 178 on an intent to treat basis. A total of 85 patients received Buscopan while 93 received placebo in addition to standard therapy. Patients in the Buscopan group required a median of 0.12 mg/kg of morphine while those in the placebo group received a median of 0.11 mg/kg, and this difference was not significant (p =0.4). There was also no significant difference in the proportion of patients who required additional morphine, 33% in the Buscopan group and 38% in the placebo group (p =0.5). Subgroup analysis of the 138 patients with a confirmed stone also showed no difference between the groups. CONCLUSIONS: There is no evidence that Buscopan reduces opioid requirements or the need for ongoing opioid analgesia in acute renal colic.

Adolescent↗

PubMed2005

Impact of an early pregnancy problem service on patient care and Emergency Department presentations.

AIM: To examine the impact of a 'next day' outpatient clinic, the Early Pregnancy Problem Service, on patients presenting to the Emergency Department with pain or bleeding in the first trimester of pregnancy. This clinic was established in June 1996. METHODS: This was a retrospective study involving patients presenting to the Emergency Department with pain or bleeding in early pregnancy. Data was collected from the Emergency Department Information System and the medical records and then compared over the same 2-month periods in different years. These were in, 1996 (preclinic), 1997, 2000 and 2003. The primary outcome was length of stay in the Emergency Department for women with first trimester pain or bleeding that did not require hospital admission. Secondary outcomes were the proportion of such patients presenting and re-presenting to the Emergency Department. RESULTS: Following establishment of the clinic there was a significant reduction in the median length of stay in the Emergency Department for patients who were discharged (136 mins in 1996 vs 107 mins in 2003; P < 0.001). There were non-significant reductions in the proportion of patients presenting to the Emergency Department (1.5% in 1996 vs 1.1% in 2003; P = 0.09) and the number re-presenting (16% in 1996 vs 7% in 2003; P = 0.15). CONCLUSION: Following the introduction of the Early Pregnancy Problem Service, women presenting with first trimester pain or bleeding who did not require emergency hospital admission spent significantly less time in the Emergency Department.

Abdominal Pain↗

PubMed2005

Review of branch aortic injuries in blunt chest trauma.

OBJECTIVES: To review the incidence, mechanisms of injury, diagnosis and treatment of injuries to the major branches of the thoracic aorta within the thoracic cavity following blunt trauma. METHODS: Medline, Embase and Cochrane were searched using appropriate key word and MeSH headings. Full text articles were retrieved where there was any information relating to the mechanism of injury, incidence of injury, diagnosis, treatment or outcome in patients with injuries to the brachiocephalic, subclavian or carotid arteries within the thoracic cavity following blunt chest trauma. RESULTS: The reported incidence of these injuries varied widely, most injuries were related to rapid deceleration injuries or falls. Diagnosis depends on a high level of clinic suspicion and appropriate investigations include helical CT scanning and arteriography. Treatment options have expanded in recent years with the use of endovascular stents; however, the optimal treatment remains uncertain. CONCLUSIONS: Aortic branch injuries must be actively excluded in patients with suspicious mechanisms of injury. Guidelines determining appropriate investigative pathways and methods of treatment should be developed at all trauma centres.

Aorta↗

PubMed2004

Systematic review of the relative efficacy of non-steroidal anti-inflammatory drugs and opioids in the treatment of acute renal colic.

OBJECTIVE: To examine the relative benefits and disadvantages of non-steroidal anti-inflammatory drugs (NSAIDs) and opioids for the management of acute renal colic. DATA SOURCES: Cochrane Renal Group's specialised register, Cochrane central register of controlled trials, Medline, Embase, and reference lists of retrieved articles. REVIEW METHODS: Randomised controlled trials comparing any opioid with any NSAID in acute renal colic if they reported any of the following outcomes: patient rated pain, time to pain relief, need for rescue analgesia, rate of recurrence of pain, and adverse events. RESULTS: 20 trials totalling 1613 participants were identified. Both NSAIDs and opioids led to clinically important reductions in patient reported pain scores. Pooled analysis of six trials showed a greater reduction in pain scores for patients treated with NSAIDs than with opioids. Patients treated with NSAIDs were significantly less likely to require rescue analgesia (relative risk 0.75, 95% confidence interval 0.61 to 0.93). Most trials showed a higher incidence of adverse events in patients treated with opioids. Compared with patients treated with opioids, those treated with NSAIDs had significantly less vomiting (0.35, 0.23 to 0.53). Pethidine was associated with a higher rate of vomiting. CONCLUSIONS: Patients receiving NSAIDs achieve greater reductions in pain scores and are less likely to require further analgesia in the short term than those receiving opioids. Opioids, particularly pethidine, are associated with a higher rate of vomiting.

Analgesia↗

PubMed2004

Enteral vs intravenous rehydration therapy for children with gastroenteritis: a meta-analysis of randomized controlled trials.

OBJECTIVE: To review the relative efficacy and safety of enteral vs intravenous (IV) rehydration therapy in treating childhood gastroenteritis. DATA SOURCES: MEDLINE, EMBASE, and the Cochrane Controlled Trials Register databases were searched. Known investigators and expert bodies were contacted to locate unpublished and ongoing studies. STUDY SELECTION: Studies were selected based on the following criteria: randomized or quasi-randomized trials; children younger than 15 years with a clinical diagnosis of gastroenteritis of less than 1-week duration; interventions comprising enteral and IV treatment arms; and at least 1 of the following: major adverse event rates, treatment failure rates, weight gain with treatment, measurement of ongoing losses, length of hospital stay, costs of treatment, and satisfaction with treatment. DATA EXTRACTION: Data were extracted from eligible studies, which were then combined using a random-effects model. DATA SYNTHESIS: Sixteen trials involving 1545 children and conducted in 11 countries were identified. Compared with children treated with IV rehydration, children treated with oral rehydration had significantly fewer major adverse events, including death or seizures (relative risk, 0.36; 95% confidence interval [CI], 0.14-0.89), and a significant reduction in length of hospital stay (mean, 21 hours; 95% CI, 8-35 hours). There was no difference in weight gain between the 2 groups (mean, -26 g; 95% CI, -61 to 10 g). The overall failure rate of enteral therapy was 4.0% (95% CI, 3.0%-5.0%). CONCLUSIONS: For childhood gastroenteritis, enteral rehydration is as effective if not better than IV rehydration. Enteral rehydration by the oral or nasogastric route is associated with significantly fewer major adverse events and a shorter hospital stay compared with IV therapy and is successful in most children.

Child↗

PubMed2003

How accurate are emergency clinicians at interpreting noncontrast computed tomography for suspected renal colic?

OBJECTIVE: To assess the accuracy of emergency physicians and trainees in the interpretation of noncontrast helical computed tomography (NCHCT) for suspected renal colic by examining the interrater reliability between emergency department (ED) clinicians and radiologists. METHODS: Information was collected prospectively on all ED patients undergoing NCHCT for suspected renal colic over a 12-month period. Emergency physicians and trainees were asked to report the absence or presence of specific renal parameters (renal tract abnormality, calculus, hydroureter, hydronephrosis, perinephric stranding, and renal parenchymal edema) and nonrenal parameters (nonrenal abnormality, free gas, free fluid, and aortic diameter >3 cm). These reports were compared with the formal radiology report, which was used as the reference standard. The sensitivity, specificity, accuracy, and kappa coefficient were calculated for each of the parameters. RESULTS: Over the 12-month period, 212 patients underwent NCHCT for suspected renal colic, of whom 127 had both ED and formal radiological reporting. There was an excellent degree of interrater reliability between the ED clinicians and the radiologists (kappa > 0.75) for the presence of renal tract abnormality and renal tract calculus. There was intermediate interrater reliability (kappa 0.4-0.75) for nonrenal tract abnormalities, hydroureter, hydronephrosis, and perinephric stranding. Four patients had potentially significant nonrenal abnormalities missed by ED clinicians. CONCLUSIONS: Emergency clinicians are able to identify renal calculi with a high degree of accuracy but may miss important nonrenal abnormalities. Therefore, all patients without evidence of renal tract calculus on NCHCT must have early and appropriate follow-up.

Clinical Competence↗

PubMed2002

Nurse-initiated intravenous morphine in the emergency department: efficacy, rate of adverse events and impact on time to analgesia.

OBJECTIVES: The objectives of this study were: (i) to measure the analgesic efficacy and frequency of adverse events following autonomous nurse-initiated intravenous morphine in patients presenting with acute pain, awaiting medical assessment; and (ii) to determine whether such a process would improve the time to analgesia. METHODS: A prospective convenience sample of patients presenting in acute pain received titrated intravenous morphine by experienced emergency nurses. Pain scores on a 10.0 cm visual analogue scale and predetermined adverse events defined by physiological parameters were measured at regular intervals over the following 60 min. Demographic, diagnostic and waiting time data were also recorded. RESULTS: Three hundred and forty nine patients were enrolled over a 12-month period. The median initial pain score was 8.5 cm, with a reduction to 4.0 cm at 1 h. Respiratory rate, oxygen saturation, heart rate and blood pressure all showed small but statistically significant reductions over 60 min. There were 15 predefined adverse events, 10 episodes of hypotension and five episodes of oxygen desaturation. No intervention other than supplemental oxygen was required. There were no episodes of bradycardia, bradypnoea or reduced level of consciousness. The median time to narcotic was 18 min and the median time to be seen by a doctor was 52 min. CONCLUSION: Experienced emergency nurses can initiate effective intravenous narcotic analgesia for patients in acute pain awaiting medical assessment, with minimal change in physiological parameters. This process can improve the time to analgesia for patients in acute pain.

Emergency Service, Hospital↗

PubMedDate not supplied

Comparison of a verbal numeric rating scale with the visual analogue scale for the measurement of acute pain.

OBJECTIVES: To test the agreement between the visual analogue scale (VAS) and a verbal numeric rating scale (VNRS) in measuring acute pain, and measure the minimum clinically significant change in VNRS. METHODS: Patients scored their pain by the VAS and the VNRS, then re-scored their pain every 30 min for up to 2 h. Patients also recorded whether their pain had improved or worsened. Agreement between scores was evaluated, and where patients scored their pain as 'a bit worse' or 'a bit better' the mean change in VNRS was calculated. RESULTS: A total of 309 paired observations were obtained from 79 patients. The VAS and VNRS were highly correlated (r = 0.95, 95% CI 0.94-0.96). The VNRS was significantly higher than the VAS for the paired observations, with 95% of the differences between VAS and VNRS lying between -2.3 and 1.3 cm. The minimum clinically significant difference in VNRS was 1.4 cm (95% CI 1.2-1.6). CONCLUSIONS: The VNRS performs as well as the VAS in assessing changes in pain. However, although the VAS and VNRS are well correlated, patients systematically score their pain higher on the VNRS, with an unacceptably wide distribution of the differences.

Acute Disease↗

PubMedDate not supplied

Neonatal presentations to a Mixed Emergency Department.

AIMS: To investigate the characteristics of neonates presenting to a metropolitan Mixed Emergency Department (MED). To examine whether there are maternal and neonatal characteristics which increase the risk of presentation to the ED in the neonatal period. METHODS: A retrospective chart review was performed of all neonatal presentations occurring between July 2002 and June 2003 to Liverpool Hospital Emergency Department, a Level 6 MED located in south-western Sydney, New South Wales, Australia, seeing approximately 45,000 presentations annually of which 20% are paediatric. Comparisons of maternal and neonatal characteristics were made with Liverpool Hospital, Area Health Service and New South Wales Mothers and Babies data, and with other paediatric presentations to the MED. RESULTS: 179 neonates made 194 neonatal presentations. Compared with all paediatric presentations, the neonatal triage category assignment, admission and transfer proportions were significantly higher, although just over half had 'primary care type illnesses'. Mothers of neonates presenting to this MED were more likely to be younger and first time mothers in comparison to the general population of mothers and newborns. This study did not find an over-representation of neonates who were discharged within 48 h after birth. CONCLUSION: The implications of these results for practice include a consideration of the availability and appropriateness of after-hours service available to new mothers. Further studies investigating parental reasons for neonatal ED presentation are recommended.

Adolescent↗

PubMedDate not supplied

Randomized, single blinded control trial comparing haemolysis rate between two cannula aspiration techniques.

OBJECTIVE: Blood aspiration through i.v. cannulae is a common ED sampling method. It is, however, associated with increased haemolysis rates when compared with direct venipuncture. Our ED utilizes two common methods of sampling through cannulae. The aim of the present study was to examine the haemolysis rates for these two techniques. METHODS: A randomized, single blinded prospective study was performed. From a convenience sample patients were randomized to either 'Method one' (blood taken directly from cannula hub) or 'Method two' (blood taken using an Interlink device through cannula cap). For each group patient demographics, clinical information and haemolysis were analysed. chi(2)-analysis and a multivariate logistic regression model were applied to determine significant relationships. RESULTS: A total of 1390 patients were enrolled, 694 had blood collected by 'Method one' and 696 by 'Method two', with haemolysis rates of 6.5% and 7.2%, respectively. Univariate analysis showed ease of aspiration to be the only variable to have a strong association with haemolysis (P < 0.0001). After allowing for ease of aspiration the technique used did not significantly affect haemolysis rate (P = 0.7). CONCLUSIONS: The rate of haemolysis is unrelated to the technique of blood aspiration. However, haemolysis rates increase significantly with perceived difficulty of blood draw.

Adolescent↗