Emergency medicine journal : EMJ
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There is currently much debate about the relative roles of pharmacological reperfusion (ie, thrombolysis) and mechanical reperfusion (ie, primary percutaneous coronary intervention (PPCI) in the management of patients with acute ST segment elevation acute myocardial infarction (STEMI). Whilst the scientific debate is reaching some resolution in terms of appropriate interpretation of the evidence base, there are still significant resource issues within the UK that limit our ability to implement gold standard reperfusion therapy. Current evidence supports the use of one or other strategy in certain situations depending on various patient-related and logistical factors. ⋯ Cardiac networks throughout the UK are developing strategies to improve access to these interventions and this paper offers advice on the logical selection of interventions for reperfusion in the context of a clinical decision framework that is evidence-based, pragmatic and develops through a series of scenarios with increasing availability of resources. Four sequential scenarios are presented: the first to set the scene is largely consigned to history; the last, as of yet, is not robustly achievable within the UK, but represents the "optimum reperfusion pathway", to which most cardiac networks are striving. Most of us currently find ourselves in a period of change between the two and will relate to either scenario two or three.
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As "time is myocardium" in the settings of acute myocardial infarction, it is important to make the diagnosis as quickly as possible, and a high clinical suspicion is needed to avoid missing the diagnosis, resulting in unwarranted interventions. The electrocardiogram is a crucial tool in the identification of acute chest pain, enabling a detailed analysis of patterns of ST-segment elevation. We describe the case of a 22-year-old man who presented with fever, with dynamic electrocardiographic changes similar to the Brugada syndrome. These electrocardiographic anomalies disappeared when the temperature returned to normal.
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Comparative Study
The psychological effect of severe acute respiratory syndrome on emergency department staff.
The severe acute respiratory syndrome (SARS) outbreak in 2003 affected 29 countries. The SARS outbreak was unique in its rapid transmission and it resulted in heavy stress in first-line healthcare workers, particularly in the emergency department. ⋯ SARS was a traumatic experience for healthcare providers in Taiwan. Most staff in the emergency department and in the psychiatric ward had PTSD. Emergency department staff had more severe PTSD symptoms than staff in the psychiatric ward.
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A 30-year-old nurse presented with abdominal pain and tenderness. Her blood tests, including amylase, were normal. ⋯ The source of the increased urinary amylase was found to be the patient's saliva - she had spit into her urine sample. Subsequent investigation showed that she had Munchausen's syndrome.