Pre-hospital intubation for head injury: ?no benefit

A systematic review of pre-hospital intubation for head injured patients failed to show evidence of benefit of tracheal intubation or invasive ventilation. The authors acknowledge the lack of methodological quality in the studies reviewed and the predominance of US paramedic-delivered intubations without the use of anaesthetic drugs.

Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence
Br J Anaesth. 2009 Sep;103(3):371-86

Pre-hospital intubation ‘success’ at a US centre

Of 203 patients attending a US Level 1 trauma centre who had pre-hospital airway management, 25 (12%) had unrecognised oesophageal intubations.

Patients were treated in the field by fire rescue personnel of various municipalities and with different experience levels. Patients transported by air were significantly more likely to be successfully intubated than those transported by ground, perhaps due to both increased experience and the use by air crews of succinylcholine. The authors in their discussion contrast these results with those of European studies which report higher success rates with pre-hospital systems that employ emergency physicians and anaesthetists.

Prehospital intubations and mortality: a level 1 trauma center perspective
Anesth Analg. 2009 Aug;109(2):489-93

Vehicle Rollover

Vehicle rollover as an indicator of mechanism of injury was investigated in a study examining accident databases and the medical literature. Only 2.4% of crashes involved rollovers but they accounted for one third of occupant deaths.

Some facts on vehicle rollover from the article:

  • Rollover is defined as a vehicle overturned by at least one quarter turn (at least onto its side).
  • Some rollovers involve many quarter turns and the final resting position may be on the vehicle’s side, roof, or back on its wheels.
  • Factors that cause a vehicle to roll over include trajectory (i.e., turning vs. straight), vehicle type, and speed (precrash velocity may be the most predictive factor)

The importance of vehicle rollover as a field triage criterion
J Trauma. 2009 Aug;67(2):350-7

Myocardial infarction not so common in LBBB?

An observational cohort study of 7937 ED visits by patients presenting with chest pain or ‘ischemic equivalent’ (shortness of breath for which ACS was considered a possible cause) was done to examine the relationship between left bundle branch block (LBBB) on the ECG and the incidence of acute myocardial infarction (AMI). No difference was observed in the rates of AMI in patients with new or presumed new LBBB, old LBBB, and no LBBB. The authors suggest that this large cohort of undifferentiated ED patients may be more reflective of the true prevalence of AMI in LBBB (7.3% in this study) and question the appropriateness of a liberal fibrinolytic strategy for such patients. Another argument for primary PCI?

Lack of association between left bundle-branch block and acute myocardial infarction in symptomatic ED patients
Am J Emerg Med. 2009 Oct;27(8):916-21

How to spot paediatric myocarditis

The most common aetiology of heart failure in previously well children is myocarditis. A review of 62 cases whose final diagnosis was viral myocarditis showed that common features included:

  • multiple visits / evaluations before the diagnosis was made
  • initial misdiagnosis as respiratory disease (eg. pneumonia, asthma)
  • presenting symptoms of shortness of breath, vomiting, poor feeding, lethargy, fever
  • signs included hepatomegaly (50%), tachypnoea, respiratory distress
  • although a normal heart rate for age was found in 41(66%) patients, ALL patients had an abnormal ECG
  • Most had abnormal chest x-rays

The take home messages regarding this rare disease are that initial misdiagnosis is common, do not expect a resting tachycardia, look for hepatomegaly, CXR signs, and particularly ECG abnormalities.

Pediatric myocarditis: presenting clinical characteristics
Am J Emerg Med. 2009 Oct;27(8):942-7

12 Lead ECG Features of Proximal LAD Occlusion

An ECG pattern is described in chest pain patients which signifies proximal LAD artery occlusion found at angiography: precordial ST-segment depression at the J-point followed by peaked, positive T-waves. Lead aVR displays also displayed slight ST-segment elevation in the majority of cases.
A letter in response points out that this finding was first reported in 1947.

Persistent precordial “hyperacute” T-waves signify proximal left anterior descending artery occlusion
Heart 2009;95;1701-1706