A report from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) examines the quality of care of patients who died in UK hospitals from acute kidney injury, and makes several recommendations that are consistent with previous reports into acute hospital admissions.
Recommendations include:
checking electrolytes on all acute admissions
better physiological monitoring
senior medical review of acute patients
adequate critical care, diagnostic, and nephrological services for acute hospitals
Data were collected on 53 episodes of paraldehyde use in tonic-clonic status epilepticus, which showed it appeared to be effective at terminating seizures in 33 of 53 cases. The median dose was 0.79 ml/kg, in keeping with current APLS guidelines (0.4 ml/kg of paraldehyde plus 0.4 ml/kg olive oil given per rectum) Review of the efficacy of rectal paraldehyde in the management of acute and prolonged tonic-clonic convulsions Arch Dis Child. 2009 Sep;94(9):720-3
‘THE MISFITS’ is a popular mnemonic to assist in identifying the cause of critical illness in the neonatal period.
T = Trauma (Accidental and Non Accidental)
H = Heart Disease, Hypovolemia, Hypoxia
E = Endocrine (Congenital Adrenal Hyperplasia, Thyrotoxicosis)
M = Metabolic (Electrolyte Imbalance)
I = Inborn Errors of Metabolism
S = Sepsis (Meningitis, Pneumonia, UTI)
F = Formula Mishaps (Under or Over dilution)
I = Intestinal Catastrophes (Intussusception, Volvulus, Necrotizing Enterocolitis)
T = Toxins / Poisons
S = Seizures
From: Tonia J. Brousseau, Ghazala Q. Sharieff Neonatal Emergencies http://cme.medscape.com/viewarticle/557824 accessed 29/12/09
Infants whose weight does not increase as normally expected or those who lose weight should be investigated for four different causes1: insufficient intake, inability to absorb, increased caloric need, and inability to metabolise.
History, examination, and bedside investigations can often identify which group(s) of causes should be considered 1.Krugman SD, Dubowitz H. Failure to thrive. Am Fam Physician 2003;68:879-84.
A randomised controlled trial on 200 anaesthetised, tracheally intubated adults compared four methods of nasogastric tube placement, looking at success rates, time to insertion, and complications.
The four groups were: control, using a ureteral guidewire as stylet, a slit endotracheal tube as an introducer, and head flexion with lateral neck pressure. All intervention groups were more successful than the control group. The time necessary to insert the NG tube was significantly longer in the slit endotracheal tube group, which also had the highest bleeding rate. Complications were fewest in the flexion group. Nasogastric tube insertion using different techniques in anesthetized patients: a prospective, randomized study Anesth Analg. 2009 Sep;109(3):832-5
37 patients with blunt traumatic cardiac arrest underwent attempted resuscitation by a HEMS crew over a four year period. Chest decompression was performed in 18 cases (17 thoracostomy, one needle decompression). The procedure revealed evidence of chest injury in 10 cases (pneumothorax, haemothorax, massive air leak) and resulted in return of circulation and survival to hospital in four cases. All four cases died of associated major head injury, although one became a heart beating organ donor. Only half of the cases found to have pneumothorax demonstrated clinical signs of one prior to chest decompression.
The authors state: ‘Relying on clinical signs of the thorax alone will not identify all patients with these injuries, and our data support extending the practice into all patients with a suitable mechanism of injury together with external evidence of chest injury.’ Chest decompression during the resuscitation of patients in prehospital traumatic cardiac arrest Emerg Med J. 2009 Oct;26(10):738-40
Success rates with the bone injection gun were 71% (10 out of 14) in children <16 years and 73% (19 out of 26) in adults. Less encouraging data than that seen with the EZ-IO device, and consistent with the experience of some other services. Prehospital Intraosseus Access With the Bone Injection Gun by a Helicopter-Transported Emergency Medical Team J Trauma. 2009 Jun;66(6):1739-41
British military physicians reported the outcomes of patients sustaining penetrating neck injury from the Iraq and Afghanistan conflicts. Three quarters were injured in explosions, one quarter from gunshots.
Of 90 patients, only 1 of the 56 survivors to reach a surgical facility sustained an unstable cervical spine injury that required surgical stabilisation. This patient later died as result of a co-existing head injury. The authors conclude that penetrating ballistic trauma to the neck is associated with a high mortality rate, and their data suggest that it is very unlikely that penetrating ballistic trauma to the neck will result in an unstable cervical spine in survivors. In a hazardous environment the risk/benefit ratio of mandatory spinal immobilisation is unfavourable and may place medical teams at prolonged risk, and cervical collars may hide potential life-threatening conditions. Learning the lessons from conflict: Pre-hospital cervical spine stabilisation following ballistic neck trauma Injury. 2009 Dec;40(12):1342-5
Patients admitted to a level 1 trauma centre with traumatic brain injury whose end-tidal CO2 was kept with the Brain Trauma Foundation recommended limits of 30-35 mmHg (3.9-4.6 kPa) had a lower mortality than those whose CO2 was outside this range. The group in which the target was not achieved had a greater injury severity, which may have contribute to the difficulty in optimising ETCO2. Prehospital Hypocapnia and Poor Outcome After Severe Traumatic Brain Injury J Trauma. 2009 Jun;66(6):1577-82
