Deciding who doesn't need abdominal CT in trauma

A derivation then validation study on adults with blunt torso trauma found the absence of the following factors to be associated with a very low risk of significant (intervention-requiring) abdominal pathology and such patients were unlikely to benefit from abdominal CT scanning:

  • GCS score less than 14
  • costal margin tenderness
  • abdominal tenderness
  • femur fracture
  • hematuria level greater than or equal to 25 red blood cells/high powered field
  • hematocrit level less than 30%
  • abnormal chest radiograph result (pneumothorax or rib fracture)

Clinical Prediction Rules for Identifying Adults at Very Low Risk for Intra-abdominal Injuries After Blunt Trauma
Ann Emerg Med. 2009 Oct;54(4):575-8

New Guidelines for Care of Children in the Emergency Department

A joint policy statement from the American College of Emergency Physicians and the American Academy of Pediatrics lists guidelines and resources that should be in place for emergency departments to serve paediatric patients. Well worth a look through while asking yourself whether your ED ticks all the boxes.
Joint Policy Statement—Guidelines for Care of Children in the Emergency Department
Free full text access
A similar, even more comprehensive, document by these organisations’ UK counterparts was published in 2007
Services for Children in Emergency Departments
Free full text access

Effects of bed height on the performance of chest compressions

In a manikin study of CPR, there was a decrease in mean depth of chest compressions when the height of the bed was over 20cm above the knee height of the nurse doing the compressions.
The study has several limitations, but serves as a helpful reminder that adjusting the height of the bed to suit the rescuer is an option not to be forgotten. At least for those areas where manual CPR is still performed.
Effects of bed height on the performance of chest compressions
Emerg Med J. 2009 Nov;26(11):807-10

Paramedics apply cervical spine rule successfully

The Canadian C-Spine rule – a decision instrument designed to clinically rule out important cervical spine injuries in alert patients – was successfully and safely applied by Canadian paramedics in a study of 1949 patients. Any misinterpretation erred on the side of safety.
This important work could ultimately result in less stress, discomfort, and wasting of ambulance resources and time for this large subgroup of pre-hospital patients.
The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics
Ann Emerg Med. 2009 Nov;54(5):663-671

Tying the tracheal tube

After intubation it is critical to securely fasten the tracheal tube so it does not dislodge during transfer. Dedicated devices are available for this although mostly cloth tape is used.
Different knots have been compared although not found be significantly different in terms of security1. One favoured knot, which is easy to learn and to teach, is the lark’s head (also called cow’s hitch)2.
The tape is folded in half so there is a loop at one end and two free ends at the other. The loop is wrapped around the tube and the two free ends are fed through the loop, and then taped around the patient’s head. It has been suggested that this results in the tape gripping the tube over the widest possible area, thereby reducing the potential for slippage and displacement.

larks head knot
larks head knot

1.The insecure airway: a comparison of knots and commercial devices for securing endotracheal tubes
BMC Emerg Med. 2006 May 24;6:7 Open Access
2. A knotty problem resolved
Anaesthesia. 2007 Jun;62(6):637

Two new studies on ECMO

Extracorporeal Membrane Oxygenation (ECMO) for severe respiratory failure features in two important papers recently.
The first, the CESAR trial, is an RCT showing a improvement in six-month disability-free survival in patients referred to an ECMO centre. The complexity of the study and the potential confounding factors led an editorialist to say: ‘This study will likely provide ammunition for both those in favour and those against the use of ECMO in the adult population‘.
Perhaps the Australasians have their own ammunition. In a paper describing the use of ECMO for patients with H1N1, they treated 68 patients with ECMO in three months, the same number of patients that actually received ECMO in the five year CESAR study!
Maybe the Aussies need to do a bigger, better RCT than CESAR?
Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial
Lancet. 2009 Oct 17;374(9698):1351-63
Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome
JAMA. 2009;302(17) (Full text)
Further information on the impact of H1N1 on Australasian critical care services, and the 722 patients admitted to ICU with the disease, is published in the New England Journal:
Critical Care Services and 2009 H1N1 Influenza in Australia and New Zealand
N Engl J Med. 2009 Oct 8. [Epub ahead of print]

Educational resources

Basic airway management in adults
Basic airway management in children
Tracheal intubation in adults
Tracheal intubation in children
Rapid sequence induction in adults
Rapid sequence induction in children
Surgical airway
Securing tracheal tubes in adults
Securing tracheal tubes in children
Non-invasive ventilation in adults
Using a portable ventilator
Basics of mechanical ventilation
Breathing systems in the emergency department
Asthma case
Pneumothorax case
Pneumonia case
ARDS case
Post cardiac arrest case
Basic echo
The hypotensive patient
Vasoactive drugs in the ED
Seizures in adults
Seizures in kids
VP shunt case
Neuroprotection in the ED
Sepsis: definitions and basics
Interhospital transport

Decision instrument for head CT in children

A derivation then validation study was done on over 40000 children with head injuries to identify factors associated with clinically important brain injury. Prediction rules based on history and examination findings were developed for children younger than two years and for children two years and older. Both rules had high negative predictive values and may be useful tools in supporting the decision not perform a head CT.
Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study
Lancet. 2009 Oct 3;374(9696):1160-70

NIV after extubation prevented respiratory failure

Spanish investigators compared NIV for 24 hours with conventional oxygen therapy in patients with chronic respiratory disorders who were extubated after a successful spontaneous breathing trial. The NIV group had signficantly lower rates of post-extubation respiratory failure.
Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial.
Lancet. 2009 Sep 26;374(9695):1082-8