What happens to acutely ill patients with acute kidney injury requiring in-hospital dialysis after their acute admission? How many recover and how many require chronic dialysis? A Canadian study of 3769 such patients followed up for an average of 3 years demonstrated that the incidence rate for chronic dialysis was only 2.63 per 100 person years, and that all cause mortality compared with matched controls was unchanged.
JAMA. 2009 Sep 16;302(11):1179-85
Immediate vs Delayed Intervention for NSTEACS
An early invasive strategy is recommended for high risk non-ST elevation acute coronary syndrome (ST/T wave changes, ongoing symptoms, or troponin rise) but how early is early? The French ABOARD study randomised 352 patients to an early (median time of randomisation to sheath insertion 70 mins) or delayed (21 hours) strategy. No difference in the primary outome measure of troponin elevation was observed. Good news for busy cardiologists who won’t have to get up at night for this type of patient.
JAMA. 2009 Sep 2;302(9):947-54
Clopidogrel and PPIs
PPIs such as omeprazole affect the pharmacodynamics of thienopyridines such as clopidogrel, but this does not seem to affect clinical outcomes for most patients. Pantoprazole and esomeprazole have less of an effect on the platelet response to clopidogrel.
Pharmacodynamic effect and clinical efficacy of clopidogrel and prasugrel with or without a proton-pump inhibitor: an analysis of two randomised trials
Lancet editorial (Lancet subscription required)
Sensitive troponin improves early detection of AMI
Newer sensitive troponin assays (detecting 0.04 ng/ml troponin I) showed better senstivity at detecting acute myocardial infarction at 0 amp; 3 hours compared with standard assays. Specificity was however slightly lower than standard assays, suggesting non-AMI pathologies that produce a degree of cardiomyocyte injury will also be detected. Senstivity and specificity for AMI at baseline were both around 90%. Troponin I 0.04 ng/ml was an independent risk factor for adverse events at 30 days.br /br /a href=”http://content.nejm.org/cgi/content/short/361/9/868″http://content.nejm.org/cgi/content/short/361/9/868/a
Paeds BVM for adult resus
Smaller self-inflating bags produce greater guideline consistent ventilation in simulated cardiopulmonary resuscitation
A comparison between two sizes of self-inflating resuscitation bags revealed improved adherence to resuscitation guidelines with the smaller bag. Student paramedics were more likely to produce suboptimal tidal volumes and ventilation rates with a 1500ml bag than a 1000ml bag during simulated ventilation of an artificial lung model.
BMC Emerg Med. 2009 Feb 20;9:4
http://www.ncbi.nlm.nih.gov/pubmed/19228432
Full text at http://www.biomedcentral.com/1471-227X/9/4
Prehospital management of severe traumatic brain injury
Prehospital management of severe traumatic brain injury
A review of current practice and evidence base of this important topic can be found at
BMJ. 2009 May 19;338:b1683
http://www.ncbi.nlm.nih.gov/pubmed/19454738
Full text http://www.bmj.com/cgi/content/full/338/may19_1/b1683
London's getting worse
The physician-led pre-hospital service London HEMS examined its penetrating trauma caseload between 1991 and 2006. Overall, stabbings rose annually by 23.2% and shootings by 11.0%.
Is the prevalence of deliberate penetrating trauma increasing in London? Experiences of an urban pre-hospital trauma service
Injury. 2009 May;40(5):560-3
http://www.ncbi.nlm.nih.gov/pubmed/19232594
Ad hoc resus teams less effective
During simulated cardiac arrest resuscitations, a comparision was made between those run by teams that had had time to form before the arrest, and those that had to be assembled ad hoc after the arrest occurred. 99 teams of three doctors, including GPs and hospital physicians were studied. ACLS algorithms were less closely followed in the ad hoc formed teams, with more delays to therapies such as defibrillation. Analysis of voice recordings revealed the ad hoc teams to make fewer leadership utterances (eg. ‘we should defibrillate’ or ‘the next countershock will be 360J’) and more reflective utterances (eg. ‘what should we do next?’). The authors suggest that team building is therefore to be regarded as an additional task imposed on teams formed ad hoc during CPR that may substantially impact on outcome. No surprise to those of us who banned ‘cardiac arrest teams’ from our emergency department resuscitation rooms many years ago!
Hands-on time during cardiopulmonary resuscitation is affected by the process of teambuilding: a prospective randomised simulator-based trial
BMC Emerg Med. 2009 Feb 14;9:3
http://www.ncbi.nlm.nih.gov/pubmed/19216796
Full text at http://www.biomedcentral.com/1471-227X/9/3
Population density & use of ambulance services
Does ambulance use differ between geographic areas? A survey of ambulance use in sparsely and densely populated areas
A lower use of emergency department health care services by rural residents as compared with urban residents has previously been described. This Swedish study examined the use of ambulance services in relation to geography, showing that patients from sparsely populated areas were sicker. required more treatment, and were assessed as not needing prehospital care less than half as often as their urban counterparts (16% vs 39%). Take home message is that population density is related to inappropriate use of ambulance services.
Am J Emerg Med. 2009 Feb;27(2):202-11
http://www.ncbi.nlm.nih.gov/pubmed/19371529
72000 retrievals by Flying Doctors
Over twelve years in Queensland the RFDS undertook over 72000 fixed wing retrievals, including over 4000 critically ill patients. Trauma was the commonest diagnostic category. There were only 90 primary retrievals, from locations without healthcare facilities – less than one per month on average. This fascinating service covers vast distances, low population density, and a high number of indigenous people.
Aeromedical retrieval for critical clinical conditions: 12 years of experience with the Royal Flying Doctor Service, Queensland, Australia
J Emerg Med. 2009 May;36(4):363-8
http://www.ncbi.nlm.nih.gov/pubmed/18814993