Emergency medicine journal : EMJ
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Paediatric patients with suspected cervical spine injury (CSI) are routinely immobilised on a firm surface using a hard collar, which results in excessive flexion of the cervical spine due to the relatively large size of the occiput. The objective of this study was to determine whether the use of a thoracic elevation device (TED) results in a more neutral cervical spine position and reduces the occurrence of cervical spine hyperflexion. ⋯ A total of 76 patients were identified at site A and site B. There were four exclusions at each site for poor quality images. 51 patients in the site A group were found to be in neutral position (71%), compared to 29 patients in the site B group (43%) (p=0.001). One patient (1%) who had a TED was found to be hyperflexed (>10 degrees), whereas 12 (18%) patients at site B were hyperflexed (p=0.001). CONCLUSIONs: The use of a TED appears to produce a greater proportion of neutral cervical spine films in children < or =10 years of age presenting for suspected CSI.
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Case Reports
Intraosseous administration of thrombolysis in out-of-hospital massive pulmonary thromboembolism.
Pulmonary thromboembolism has an incidence of more than 69/100 000 population but may be underdiagnosed because of the non-specific character of its symptoms and difficult differential diagnosis. The prognosis is worse if the pulmonary thromboembolism is massive and associated with haemodynamic instability, whereupon mortality rises to over 50%. Cardiogenic shock supervenes and cardiopulmonary arrest is often inevitable. ⋯ The case history is described of a 25-year-old woman in cardiogenic shock leading to prehospital cardiac arrest in which intravenous access was impossible. Resuscitation drugs were given by the intraosseous route and, with a suspected diagnosis of massive pulmonary thromboembolism, it was decided to start thrombolysis by the same route before transport to hospital. The treatment was a complete success, and the patient was discharged from hospital with no sequelae after 39 days.
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An ongoing comprehensive paediatric procedural sedation (PPS) training and credentialing programme to improve patient safety was introduced into emergency departments (EDs) at a tertiary children's hospital (Royal Children's Hospital; RCH) and a suburban mixed ED (Sunshine Hospital; SH) in Melbourne, Australia. The study aimed to establish whether changes in practice had been sustained 3 years after implementation of the PPS programme. ⋯ Based on an analysis of proxy markers of sedation safety significant changes over pre-implementation sedation care were maintained 3 years after implementation of a PPS programme. Documentation of sedation safety markers decreased over the study period, more so at the community hospital. To maintain educational gains and system change in sedation safety requires ongoing resources.
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An adult man was brought into the emergency department after deliberate ingestion of dinitrophenol: an agent that uncouples mitochondrial oxidative phosphorylation. The patient rapidly developed a hyper-metabolic state with fever, respiratory failure and died within a few hours after admission. Dinitrophenol is used in the manufacture of dyes, pesticides and explosives. ⋯ Although remaining unlicensed as a drug, dinitrophenol is widely available through mail-order websites and online pharmacies, which promote it as an anti-obesity treatment. This case highlights the need for awareness of possibly increasing rates of accidental poisoning with a growing obesity prevalence and availability of this unlicensed drug through the internet. Additionally, we discuss the use of dantrolene in dinitrophenol poisoning and question whether current Toxbase/UK National Poison Information Service treatment guidelines regarding the indication and dosing of this drug, the only relatively specific treatment in dinitrophenol poisoning presently recommended, could be revised.