Emergency medicine journal : EMJ
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Multicenter Study
Risk factors and outcomes associated with post-traumatic headache after mild traumatic brain injury.
To determine the prevalence and potential risk factors of acute and chronic post-traumatic headache (PTH) in patients with mild to moderate traumatic brain injury (TBI) in a prospective longitudinal observational multicentre study. Acute PTH (aPTH) is defined by new or worsening of pre-existing headache occurring within 7 days after trauma, whereas chronic PTH (cPTH) is defined as persisting aPTH >3 months after trauma. An additional goal was to study the impact of aPTH and cPTH in terms of return to work (RTW), anxiety and depression. ⋯ PTH is an important health problem with a significant impact on long-term outcome of TBI patients. Several risk factors were identified, which can aid in early identification of subjects at risk for PTH.
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Recent studies suggest that approximately one per thousand paediatric ED attendances may require some sort of critical procedure, with intubation being by far the most common. It is unknown how often critical non-airway procedures such as chest decompression, CPR, ED thoracotomy, defibrillation, pacing, and advanced vascular access techniques are performed by paediatric emergency clinicians. ⋯ More than half of the paediatric emergency clinicians surveyed had performed CPR and inserted an intraosseous needle within the last 12 months. Performance of other non-airway critical procedures was less common, and associated with less procedural confidence.
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Despite successful vaccination programmes meningococcal disease (MD) remains the leading infectious cause of septicaemia and death in children in the UK and Ireland.1,2 The early diagnosis of MD significantly improves outcomes with reduced morbidity and mortality.1,2 The early stages of MD are often indistinguishable from a simple viral illness making an early positive diagnosis of MD difficult.1 Hibergene have developed a commercially available bedside Loop-mediated isothermal AMPlification PCR (LAMP-MD) test that is a highly sensitive 0.89 (95%CI 0.72-0.96) and specific 1.0 (95%CI 0.97-1.0) for identifying children with invasive MD (4) (figure 1).emermed;34/12/A895-a/F1F1F1Figure 1 AIMS: The aims of this RCEM funded study were:Assess the ease of use and suitability for the EDDetermine the time taken to perform the testIndependently verify LAMP-MD performance against TaqMan quantitative PCR. ⋯ Meningitis Research Foundation. Meningococcal Meningitis and Septicaemia Guidance Notes2014.Ó Maoldomhnaigh, et al. Invasive meningococcal diseasein children in Ireland. PMID: 27566800.NICE. Management of petechial rash.Bourke TW, et al. Diagnostic accuracy of loop-mediated isothermal amplification as a near-patient test for meningococcal diseasein children. PMID: 25728843.
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The benefit of antiplatelet medication in confirmed acute coronary syndrome (ACS) is well established. In the Emergency Department (ED) diagnostic uncertainty may lead to over-treatment, with consequent risks (e.g., bleeding), or under-treatment, compromising clinical outcomes. Clinicians must subjectively balance the anticipated risks and benefits with their perceived probability of ACS in order to decide whether to prescribe these medications. We aimed to construct a clinical model to optimise and personalise recommendations for anti-platelet prescription in this context. ⋯ Systematic review identified three relevant original studies, and three sub-studies. After extracting data, we constructed two separate models, based on clinical outcomes after 30 days and 12 months. Aspirin alone led to greater net utility at probabilities below 7.4%, whereas treatment with ticagrelor led to greater net benefit when the probability of ACS exceeded 8.3% (figures 1 and 2). Sensitivity analyses including 10,000-fold Monte Carlo simulations demonstrated that the models were robust to a wide range of assumptions (figure 3).emermed;34/12/A870-a/F1F1F1Figure 1Acute coronary syndrome risk thresholds of treatment strategy superiority. (Clopidogrel and ticagrelor treatment strategies included the use of aspirin at ACS treatment)emermed;34/12/A870-a/F2F2F2Figure 2Net expected utility of anti-platelet therapy in 12 months combined outcome modelemermed;34/12/A870-a/F3F3F3Figure 3A monte carlo simulation (n=10,000) - net expected utility of anti-platelet therapy in 12 month combined outcome model - varying risk and utility outcomes CONCLUSION: This work suggests that treatment with ticagrelor yields greater net benefit for patients when the probability of ACS exceeds 8.3%. This has potential to improve clinical outcomes when used alongside a prediction model, such as the Manchester Acute Coronary Syndromes (MACS) decision aid, which calculates each patient's individual probability of ACS. The clinical and cost effectiveness of this novel 'precision Emergency Medicine' approach should now be evaluated in clinical studies.
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It is hypothesised that a single injection fascia iliaca compartment block (FICB) administered in the pre-operative setting provides better analgesic control for traumatic hip fractures and is not associated with major adverse effects. Systemic analgesics, whilst effective, could lead to cardiovascular, respiratory and cognitive impairment. As a consequence, undertreatment of acute pain remains prevalent in adult patients with hip fractures, with a consistent decline seen in analgesic administration with age. ⋯ Out of 3757 citations, eight RCTs were included in the final quantitative analysis, comprising of 645 participants. Acute pain was significantly reduced in FICB during positioning and movement, standardised mean difference (SMD)=-1.82 (95% CI:-2.26 to -1.38, p<0.00001) but was variable at rest (p=0.20). There was a reduced incidence of analgesia breakthrough (n=57 versus n=73), drowsiness/sedation (n=1 versus n=22), desaturation (n=0 versus n=4) and nausea and vomiting (n=3 versus n=7) in the FICB arm. There were similar numbers of patients across both arms that reported localised bruising (n=3). Only one study was at low risk of bias.emermed;34/12/A891-a/F1F1F1Figure 1emermed;34/12/A891-a/F2F2F2Figure 2 CONCLUSIONS: FICB is superior in controlling acute pre-operative pain in adult patients with traumatic hip fractures. The benefit is more evident during positioning and mobilisation of the limb. FICB has a better safety profile and reduces dependency on systemic analgesia.