Interhospital trauma transfers: room for improvement?
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Emergency Medical Services↗
Biomedical subjects
Colin A Graham
Publications and source records attributed to Colin A Graham.
CPR for children: one hand or two?
AIMS: Current guidelines for chest compressions in CPR advocate a one handed technique in children (1-8 years old) and a two handed technique in adults (>8 years old). No previous study has examined whether these two techniques generate different compression pressures. This study assesses the relative difference in intrathoracic compression pressures generated by one- and two handed chest compression techniques in a paediatric manikin. METHODS: Randomised crossover design. Subjects performed both types of chest compressions on an adapted paediatric resuscitation manikin connected to a pressure transducer and personal computer. Ethical approval was granted. RESULTS: A 30 volunteer subjects (9 male, 21 female) participated in the study. Their mean age was 30.8 years (S.D. 8.6), and mean weight was 70.5 kg (S.D. 12.8). The mean compression pressure was 86.6 mmHg (S.D. 13.68) for two handed and 75.1 mmHg (S.D. 12.02) for one handed (P < 0.001, paired t-test). The average peak compression pressure was 133.5 mmHg (S.D. 26.36) for two handed and 116.8 mmHg (S.D. 21.48) for one handed (P = 0.001, paired t-test); 29 found the two handed technique easier to perform. CONCLUSION: Two handed chest compression CPR seems to be easier to perform on a paediatric resuscitation manikin and produces significantly higher mean and peak pressures. Further work is needed to determine the comparative effects on children and which technique produces better clinical outcomes.
Adult↗
Infrequent mutations of Archipelago (hAGO, hCDC4, Fbw7) in primary ovarian cancer.
OBJECTIVE: Archipelago (AGO, also known as hCdc4, Fbw7, or Sel-10) is an F-box containing component of the SCF complex implicated in the ubiquitination and proteolysis of cyclin E and c-Myc, and found to be mutated in 16% of endometrial carcinomas. We have previously reported somatic mutations in AGO in 3/10 ovarian cancer cell lines, but the frequency of such mutations in primary ovarian cancer is unknown. METHODS: The coding sequence of AGO was analyzed in 95 primary sporadic ovarian tumors and 16 cases of familial ovarian cancer, and correlated with levels of cyclin E and c-Myc protein expression. Constructs encoding mutations in AGO were transfected into an AGO-null cell line to directly test their ability to regulate cyclin E and c-Myc levels. RESULTS: Mutations were present in only 2 of 95 sporadic cases: a premature stop within the WD domain (471 Ter) and a missense change near the F-box (S245T). Both primary tumor specimens containing these mutations showed high levels of cyclin E and c-Myc, but reconstitution of an AGO-null cell line with constructs encoding these mutations showed 471 Ter to be inactive in regulating endogenous cyclin E and c-Myc levels, while the S245T mutant was indistinguishable from wild-type. No germ-line mutations were found in familial cases of ovarian cancer. CONCLUSION: Somatic AGO mutations are infrequent in primary ovarian cancers and are unlikely to contribute to familial ovarian cancer. Reconstitution experiments, rather than measuring tumor levels of cyclin E and c-Myc, provide an effective approach to determine the functional significance of AGO mutations identified in human cancers.
Cell Cycle Proteins↗
Emergency department airway management in the UK.
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Airway Obstruction↗
Scottish urban versus rural trauma outcome study.
BACKGROUND: Outcome following trauma and health care access are important components of health care planning. Resources are limited and quality information is required. We set the objective of comparing the outcomes for patients suffering significant trauma in urban and rural environments in Scotland. METHOD: The study was designed as a 2 year prospective observational study set in the west of Scotland, which has a population of 2.58 million persons. Primary outcome measures were defined as the total number of inpatient days, total number of intensive care unit days, and mortality. The participants were patients suffering moderate (ISS 9-15) and major (ISS>15) trauma within the region. The statistical analysis consisted of chi square test for categorical data and Mann Whitney U test for comparison of medians. RESULTS: There were 3,962 urban (85%) and 674 rural patients (15%). Urban patients were older (50 versus 46 years, p = 0.02), were largely male (62% versus 57%, p = 0.02), and suffered more penetrating traumas (9.9% versus 1.9%, p < 0.001). All prehospital times are significantly longer for rural patients (p < 0.001), include more air ambulance transfers (p < 0.001), and are characterized by greater paramedic presence (p < 0.001). Excluding neurosurgical and spinal injuries transfers, there was a higher proportion of transfers in the rural major trauma group (p = 0.002). There were more serious head injuries in the urban group (p = 0.04), and also a higher proportion of urban patients with head injuries transferred to the regional neurosurgical unit (p = 0.037). There were no differences in length of total inpatient stay (median 8 days, p = 0.7), total length of stay in the intensive care unit (median two days, p = 0.4), or mortality (324 deaths, moderate trauma, p = 0.13; major trauma, p = 0.8). CONCLUSION: Long prehospital times in the rural environment were not associated with differences in mortality or length of stay in moderately and severely injured patients in the west of Scotland. This may lend support to a policy of rationalization of trauma services in Scotland.
Catchment Area, Health↗
Stridor after ingestion of dettol and domestos.
Dettol (4.8% chloroxylenol, 9% pine oil and 12% isopropyl alcohol) has previously been reported to cause delayed upper airway obstruction when ingested, despite the product being labelled as non-poisonous. Domestos (1-5% sodium hypochlorite) is used as a household and toilet cleaner. This paper reports a rare case in which both agents were consumed together in significant quantities, and caused stridor and impending airway obstruction requiring endotracheal intubation in the emergency department. Patients who have ingested this combination of cleaning agents are at high risk of acute airway compromise, and should have expert upper airway evaluation and control as soon as possible after admission.
Administration, Oral↗
Emergency physicians and rapid sequence intubation: a survey of Scottish teaching hospitals.
OBJECTIVES: Emergency definitive airway management is a fundamental skill for physicians in the emergency department. The aim of this survey was to determine the perceived confidence in the assessment and control of the emergency airway, including rapid sequence intubation, among physicians in Scottish teaching hospital emergency departments. METHODS: A postal survey of senior and middle-grade physicians in seven Scottish teaching hospital emergency departments. RESULTS: The response rate was 78% (47/60). A total of 98% of physicians rated their confidence at assessing the difficult airway as 'reasonable' to 'very high'; 79% were confident concerning their ability to administer drugs to facilitate emergency intubation; 47% had used drugs for emergency intubation within the month preceding the survey, and 72% had done so within the 6 months before the survey. Consultants were more confident than trainees, as were those possessing the Fellow of the Royal College of Anaesthetists qualification or a Diploma in Anaesthetics (UK). Those possessing the Fellowship of the Royal College of Anaesthetists qualification had all performed a rapid sequence intubation within the past month. CONCLUSION: Physicians in Scottish teaching hospital emergency departments have high levels of self-rated confidence in assessment and their ability to secure the emergency airway utilizing drugs to facilitate emergency intubation. Consultants and those with anaesthetic qualifications are more confident than trainees and those without such a qualification.
Clinical Competence↗
Discharge from the accident and emergency department after smoke inhalation: influence of clinical factors and emergency investigations.
OBJECTIVES: Smoke inhalation has become the principal cause of death in burns patients. There are few guidelines for the management of smoke inhalation in the accident and emergency department. The aim was to identify what factors influence immediate management. METHODS: A retrospective case note review using data from three west of Scotland accident and emergency departments in 1999. Computerized record systems were used to identify suitable patients. RESULTS: Of 120 patients, 63 patients had incomplete data and were excluded. A total of 57 patients were classified into one of five categories: no burns, normal vital signs and examination (group 1, n=23); no burns, abnormal vital signs or examination (group 2, n=26); minor burns (<15% total body surface area) with or without abnormal vital signs or examination (group 3, n=5); major burns (>15% total body surface area) (group 4, n=2); in cardiac arrest on arrival (group 5, n=1). In groups 1 and 3, the result of two investigations significantly influenced management. In group 2, arterial blood gases and carboxyhaemoglobin levels were abnormal in 25% of cases, but only on one occasion did it influence an admission decision. CONCLUSION: Arterial blood gases, chest radiography and carboxyhaemoglobin estimation rarely influence immediate management. Patients presenting with normal vital signs and examination and short smoke exposure may be safe to discharge from the accident and emergency department without further investigation.
Adolescent↗
Rapid sequence intubation of trauma patients in Scotland.
BACKGROUND: Endotracheal intubation remains the gold standard for trauma airway management. Rapid sequence intubation (RSI) has traditionally been performed by anesthesiologists but increasingly, emergency physicians are also undertaking RSI. We aimed to compare success and complication rates for trauma intubations for the two specialties. METHODS: Two year, prospective multi-center descriptive study of trauma RSI in seven Scottish urban emergency departments. RESULTS: 439 trauma patients were identified, including 233 RSIs. Patients intubated by emergency physicians had a higher median ISS (p < 0.001) and lower median RTS (p < 0.001) compared with anesthesiologists. For RSI, anesthesiologists had more grade I & II views at laryngoscopy (p = 0.051) and more successful first attempt intubations (p = 0.034) but there was no difference in the number of patients suffering complications (emergency physicians 10.0%, anesthesiologists 10.6%). CONCLUSION: There is no significant difference in complication rates for trauma RSI between emergency physicians and anesthesiologists in Scottish urban centers. A collaborative approach to the critical trauma airway is vital. Emergency physicians should consult with senior anesthesiologists before RSI when intubation is predicted to be difficult.
Adult↗
Pharmacological therapy of acute cardiogenic pulmonary oedema in the emergency department.
This paper critically reviews the major drug types that are currently used in the management of acute cardiogenic pulmonary oedema. As decompensated heart failure becomes an increasingly common problem in emergency departments in the developed world, optimization of emergency drug therapy for these critically ill patients is essential. The evidence base for 'routine therapy' in the ED is considered. The review also briefly considers emerging pharmacological therapies that may have an impact on future management of cardiogenic pulmonary oedema.
Acute Disease↗
Editorial comment--Transient cerebral ischemia demands urgent evaluation.
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Causality↗
Blunt cervical spine injuries in Scotland 1995-2000.
BACKGROUND: In the Accident and Emergency Department, the management of patients who have sustained head injuries (HI) is often made more complicated by the suspicion of a cervical spine injury (CSI). This study aimed to evaluate the incidence of CSI in patients sustaining blunt head injuries in a Scottish population. METHODS: Retrospective analysis of prospectively collected data for a 5-year period from the Scottish Trauma Audit Group (STAG) database. Logistic regression and other comparisons were used to investigate the relationship between Glasgow coma score/scale (GCS) and the incidence of CSI. RESULTS: A total of 5154 patients met the criteria for the study and 273 of the HI patients had associated CSI giving an overall incidence of 5.3%. Patients presenting with GCS of 3 were almost three times more likely to have a CSI compared to patients with an initial GCS of 4 or more (12.5% versus 4.4%, chi(2)=62.9, d.f.=1, P<0.001). When patients with GCS of 3 were excluded, there was no evidence of an increase in the incidence of CSI with a lower GCS (logistic regression chi(2)=0.09, d.f.=1, P=0.75). CONCLUSION: The risk of CSI in patients with blunt head trauma and an admission GCS of > or =4 does not decrease as GCS increases. Patients with blunt head injuries who present with a GCS of 3 are much more likely to have a concomitant CSI. The overall incidence of 5.3% compares with published series from other countries.
Adolescent↗
Is spinal immobilisation necessary for all patients sustaining isolated penetrating trauma?
INTRODUCTION: Previous work suggests that patients with isolated penetrating trauma rarely require spinal immobilisation. This study aimed to identify the incidence of mechanically unstable, or potentially mechanically unstable, spinal column injuries in penetrating trauma patients. The study also aimed to identify the incidence of spinal cord injury as a result of penetrating trauma in Scotland. DESIGN: Retrospective analysis of prospectively collected data from the Scottish Trauma Audit Group (STAG). METHODS: Study patients were identified from the period 1992-1999. Patients coded for both penetrating trauma and spinal column or spinal cord injury were included. Case records, theatre notes and post mortem information were also examined. RESULTS: 34903 patients were available for study. Twenty-seven patients were coded as having had penetrating trauma and concurrent spinal injury. 15 were excluded as they also had a major blunt mechanism of injury or had no actual injury to the spinal cord or column. In the remaining 12 patients, four cervical, one combined cervical and thoracic and seven thoracic spinal cord injuries were identified. 11 were male and 11 were assaulted. One assault was due to a gunshot wound; 10 resulted from sharp weapons. Four complete cord transections and nine partial cord lesions were identified. All 12 patients with spinal cord injury associated with isolated penetrating trauma either had obvious clinical evidence of a spinal cord injury on initial assessment or were in traumatic cardiac arrest. All had spinal immobilisation. CONCLUSION: Fully conscious patients (GCS=15) with isolated penetrating trauma and no neurological deficit do not require spinal immobilisation.
Cervical Vertebrae↗
Ambulance paramedic activities in North Ayrshire: a five-year review.
BACKGROUND: Ambulance paramedics have been practising in North Ayrshire for some time. The aim of this study was to determine the range and number of procedures that are undertaken by paramedics, and whether they are performed in accordance with standard operating procedures. METHODS: A five-year prospective observational study of patients attended by paramedics in a mixed urban/rural area of south-west Scotland. Data were collected on all procedures undertaken in the prehospital arena. A single investigator decided whether each procedure was performed in accordance with standard operating procedures in the light of available information. RESULTS: Data on 6600 patients were available, a mean of 42 patients per paramedic per year. Oxygen administration increased significantly and the number of occasions when excess time was spent on scene decreased significantly during the study. Paramedics treated significantly fewer patients requiring intravenous cannulation, intubation, defibrillation and cardiopulmonary resuscitation in year 5 compared with year 1. Paramedics administered drugs in accordance with standard operating procedures in almost all cases. CONCLUSION: Paramedic exposure to extended skills is low in this region, leading to concerns about advanced skills retention. Paramedics can administer drugs appropriately according to protocol. Increasing paramedic experience, possibly augmented by feedback via audit, may be influencing paramedic decision making.
Allied Health Personnel↗
Interleukin-12 p40 polymorphism and susceptibility to multiple sclerosis.
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Genetic Predisposition to Disease↗
Chromosome 7q21-22 and multiple sclerosis: evidence for a genetic susceptibility effect in vicinity to the protachykinin-1 gene.
Chromosome 7q21-22 and, in particular, the region surrounding D7S554 emerged from the recent American genome screen in multiple sclerosis (MS) as the most promising region genome-wide for harboring a disease susceptibility gene. We tested association between D7S554 and MS in 217 Sardinian trio MS families by the transmission disequilibrium test (TDT), and in a Northern Irish case-control study comprising 542 individuals. In both populations, we found evidence for significant allelic association (P(c)=0.04 and P(c)=0.0002, respectively). In a second stage, we analysed five microsatellite markers in a 4 megabase interval on chromosome 7q21-22 in the same set of Sardinian families. Parental transmission of a single allele of one of these markers, i.e. D7S3126, was significantly distorted (P(c)=0.008). D7S554 and D7S3126 are located at distances of, respectively, 40 and 81 kb 5' from the startcodon of the protachykinin-1 gene (TAC1), and occur in strong linkage disequilibrium (P<10(-7)). Our study indicates that the previous finding of linkage with D7S554 refers possibly to the presence of an MS susceptibility effect in vicinity to TAC1. In addition, a second independent association was uncovered between a microsatellite polymorphism in the plasminogen activator inhibitor-1 gene, i.e. D7S477, and MS. Overall, the analysis presented here may contribute to the increasingly refined genomic map of MS and underscores the requirement for a further high-resolution screening of chromosome 7q21-22.
Adult↗
Evaluation of a new method for the carotid pulse check in cardiopulmonary resuscitation.
BACKGROUND: The ability to determine the presence or absence of a central pulse remains a key skill in cardiopulmonary resuscitation (CPR) for healthcare providers, despite studies showing that they perform this poorly. The aim of this study was to evaluate a modified technique for palpation of the carotid pulse. METHODS: Sixty seven undergraduate dental students were taught the standard method of carotid pulse detection during a basic life support session and were also taught a modified method. Each student was asked to palpate the carotid pulse of a volunteer in two positions (neck neutral and neck extended) with the volunteer on the floor and on a trolley. The time taken to identify the pulse was measured and the scenarios compared. RESULTS: The time to detect the carotid pulse was reduced in three of the four scenarios (floor, neck extended P=0.0053, trolley neck neutral P=0.0070, trolley neck extended P=0.0024). The final scenario (floor, neck neutral) showed no improvement (P=0.36). CONCLUSION: The new method of carotid pulse palpation results in a more rapid determination of the carotid pulse when it is present in all positions except with the neck neutral on the floor. This will only be clinically significant if trauma is suspected.
Adult↗
Cardiopulmonary resuscitation training for undergraduate medical students: a five-year study.
BACKGROUND: Cardiopulmonary resuscitation (CPR) training for undergraduate medical students and junior doctors has been noted to be poor in the past. Attempts have been made over the last decade to improve CPR training for all health professionals. AIM: This study aimed to determine if CPR training for undergraduate medical students in a single institution improved after initial concerns in 1992, and to observe trends in CPR training over five years. METHODS: Prospective single centre observational cohort survey by means of a 2-page self completed questionnaire to final year undergraduate medical students at the University of Glasgow (1993-97 inclusive). RESULTS: Mean annual response rate 58% (range 48%-67%). 99% of responders had been trained in basic life support during undergraduate training. The use of simulated arrests for training increased significantly. CPR training was concentrated in the first and final years. Training in all aspects of advanced life support increased, as did the students' confidence in these techniques. Student satisfaction with the amount of basic life support training increased very significantly and there was a small, but significant increase in student satisfaction with advanced life support training. Overall confidence at the prospect of being a member of the resuscitation team on qualification did not increase. CONCLUSIONS: There has been a sustained improvement in CPR training at this institution since 1993. Improvements in the training of specific advanced life support techniques does not lead to improved overall confidence in using these skills on qualification. Advanced life support training requires further expansion.
Cardiopulmonary Resuscitation↗