One hundred years on: Ypres and ATLS
"Hemorrhage, hemorrhage, hemorrhage—blood everywhere—clothes soaked in the blood, pools of blood in the stretchers, streams of blood dropping from the stretchers to the floor" Robertson OH, unpublished WWI diaries.1 In the sombre predawn darkness at 03:50 hours on the morning of 31July 1917; British, French and Belgian Forces advanced along the ridges and fields of the Gheluvelt plateau. So began the Third Battle of Ypres. Their objective was a small village called Passchendaele only 13 km away. However, it would take 3 months and over half a million casualties to get there. Two medical officers; both...
Source: Emergency Medicine Journal - October 23, 2017 Category: Emergency Medicine Authors: Parker, R. S., Parker, P. J. Tags: In perspective Source Type: research

BET 2: Should children with sport-related concussion observe strict physical rest until symptom-free?
A short cut review was carried out to establish whether strict physical rest following sports related concussion in children is better than normal activity in reducing post-concussional symptoms. two recent systematic reviews presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that children who present with a sport-related concussion should have a brief period of cognitive and physical rest followed by a gradual increase in activity. Further ...
Source: Emergency Medicine Journal - October 23, 2017 Category: Emergency Medicine Authors: Kline, A. C. Tags: EMJ Best evidence topic reports Source Type: research

Towards evidence based emergency medicine: Best BETs from the Manchester Royal Infirmary
Best Evidence Topic reports (BETs) summarise the evidence pertaining to particular clinical questions. They are not systematic reviews, but rather contain the best (highest level) evidence that can be practically obtained by busy practicing clinicians. The search strategies used to find the best evidence are reported in detail in order to allow clinicians to update searches whenever necessary. Each BET is based on a clinical scenario and ends with a clinical bottom line which indicates, in the light of the evidence found, what the reporting clinician would do if faced with the same scenario again. The BETs published below ...
Source: Emergency Medicine Journal - October 23, 2017 Category: Emergency Medicine Authors: Mackway-Jones, K. Tags: EMJ Best evidence topic reports Source Type: research

BET 1: Does the use of emollients prevent frostbite to the face?
A short cut review was carried out to establish whether routine use of emollients on the face reduced the incidence of frostbite in cold environments. 126 papers were found using the reported searches, of which three presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that the use of emollients on the face is not a good protection against frostbite and may even result in a higher risk (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - October 23, 2017 Category: Emergency Medicine Authors: De Buck, E. Tags: EMJ Best evidence topic reports Source Type: research

Abstracts from international Emergency Medicine journals
Editor’s note: EMJ has partnered with the journals of multiple international emergency medicine societies to share from each a highlighted research study, as selected by their editors. This edition will feature an abstract from each publication. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - October 23, 2017 Category: Emergency Medicine Tags: EMJ Primary survey Global Emergency Medicine Highlights Source Type: research

Use of a 23-hour emergency department observation unit for the management of patients with toxic exposures
Conclusion Most patients admitted to the EDOU were successfully managed and medically cleared within 23 hours, including those with a severe PSS. The EDOU appears to be a suitable alternative to inpatient admission for selected patients. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - October 23, 2017 Category: Emergency Medicine Authors: Mong, R., Arciaga, G. J., Tan, H. H. Tags: Original article Source Type: research

Introduction of a new imaging guideline for suspected renal colic in the ED reduces CT urography utilisation
Background Patients presenting to the ED with suspected renal colic are frequently imaged with CT urography (CTU), which rarely alters diagnosis or management. To reduce use of CTU in this population, we instigated a new imaging and management guideline in our ED. Methods This was a quasi-experimental prospective study, whereby a new guideline was commenced at the intervention site (Monash Medical Centre) and the existing guideline continued at the control site (Dandenong Hospital). The new guideline promotes focused ultrasound for diagnosing renal colic and restricts CT to those with poor response to analgesia or ‘...
Source: Emergency Medicine Journal - October 23, 2017 Category: Emergency Medicine Authors: Blecher, G., Meek, R., Egerton-Warburton, D., McCahy, P. Tags: Original article Source Type: research

Can more appropriate support and services be provided for people who attend the emergency department frequently? National Health Service staff views
Conclusion Interventions to address frequent attendance should focus on redirection to and liaison with more appropriate services, located on the hospital site or in the community, tailored to each identified patient group. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - October 23, 2017 Category: Emergency Medicine Authors: Ablard, S., Coates, E., Cooper, C., Parry, G., Mason, S. M. Tags: Original article Source Type: research

Dimple on the shoulder after a ski injury
Clinical introduction A 74-year-old woman was brought to the ski clinic shortly after a fall on her left shoulder while skiing. She did not remember the exact fall mechanism. She felt a popping sensation in her left shoulder and was unable to move her left arm due to severe pain. Her medical and social histories were unremarkable. On physical examination, she had a deformity in her left shoulder (figure 1). Her neurovascular examination was intact. Figure 1Photograph of the left shoulder on arrival showing an anterior ‘dimple’. Question What is the most likely diagnosis of the injury? An acromioclavicu...
Source: Emergency Medicine Journal - October 23, 2017 Category: Emergency Medicine Authors: Khodaee, M., Vidal, A., Gutierrez, G. Tags: EMJ Image Challenge Source Type: research

Effect of patient weight on first pass success and neuromuscular blocking agent dosing for rapid sequence intubation in the emergency department
Objectives The primary objective of this study was to determine the association between patient weight and first pass success (FPS) during rapid sequence intubation (RSI) in the ED. The secondary objective was to evaluate the association between patient weight and neuromuscular blocking agent (NMBA) dosing. Methods This was a retrospective cohort study conducted in a tertiary care academic ED. Consecutive adult patients who underwent RSI in the ED between January 2014 and June 2016 were included. Data were collected on patient, operator and procedural characteristics. The cohort was categorised into the following weight strata:
Source: Emergency Medicine Journal - October 23, 2017 Category: Emergency Medicine Authors: Patanwala, A. E., Sakles, J. C. Tags: Original article Source Type: research

Randomised clinical simulation designed to evaluate the effect of telemedicine using Google Glass on cardiopulmonary resuscitation (CPR)
Conclusions Telematics support by an expert through GG improves success rates and completion times while performing CPR in simulated clinical situations for nurses in simulated scenarios. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - October 23, 2017 Category: Emergency Medicine Authors: Perez Alonso, N., Pardo Rios, M., Juguera Rodriguez, L., Vera Catalan, T., Segura Melgarejo, F., Lopez Ayuso, B., Marti{-}nez Riquelme, C., Lasheras Velasco, J. Tags: Original article Source Type: research

Relationship between non-technical skills and technical performance during cardiopulmonary resuscitation: does stress have an influence?
Background Non-technical skills, such as task management, leadership, situational awareness, communication and decision-making refer to cognitive, behavioural and social skills that contribute to safe and efficient team performance. The importance of these skills during cardiopulmonary resuscitation (CPR) is increasingly emphasised. Nonetheless, the relationship between non-technical skills and technical performance is poorly understood. We hypothesise that non-technical skills become increasingly important under stressful conditions when individuals are distracted from their tasks, and investigated the relationship betwee...
Source: Emergency Medicine Journal - October 23, 2017 Category: Emergency Medicine Authors: Krage, R., Zwaan, L., Tjon Soei Len, L., Kolenbrander, M. W., van Groeningen, D., Loer, S. A., Wagner, C., Schober, P. Tags: Open access, Editor's choice Original article Source Type: research

Building a visual aid for a triage tool in a developing health service
Resources in the modern day emergency department are often stretched, and this holds true more so in developing services. With limited manpower, it is essential that efficient tools are created so that processes can be run safely. Here we pilot the use of a vital signs matrix in a medical camp in Dhaka to screen patients at triage. We further modified this matrix to include the National Early Warning Score as our recording of the NEWS have remained poor in triage. A trial and validation study for the use of this matrix in an NHS setting is currently underway. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - October 23, 2017 Category: Emergency Medicine Authors: Ahmad, M. S., Wood, D. R. Tags: Swing shift: innovations in emergency medicine Source Type: research

Comparison of prehospital triage and five-level triage system at the emergency department
Conclusion The current prehospital triage system is insufficient and inappropriate in classifying patients transported to the ED. The present study offers supporting evidence for the introduction of a five-level triage system to prehospital EMS systems. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - October 23, 2017 Category: Emergency Medicine Authors: Tsai, L.-H., Huang, C.-H., Su, Y.-C., Weng, Y.-M., Chaou, C.-H., Li, W.-C., Kuo, C.-W., Ng, C.-J. Tags: Original article Source Type: research

Validity of triage systems for paediatric emergency care: a systematic review
Conclusions There is some evidence to corroborate the validity of the MTS, PedCTAS and ESI v.4 for paediatric emergency care in their own countries or near them. Efforts to improve the sensitivity and to minimise the undertriage rates should continue. Cross-cultural adaptation is necessary when adopting these triage systems in other countries. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - October 23, 2017 Category: Emergency Medicine Authors: de Magalhaes-Barbosa, M. C., Robaina, J. R., Prata-Barbosa, A., Lopes, C. d. S. Tags: Review Source Type: research

Five-level emergency triage systems: variation in assessment of validity
Conclusion Previous studies applied various reference standards and measures to validate five-level triage systems. They either created their own reference standard or used a combination of severity/resource measures. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - October 23, 2017 Category: Emergency Medicine Authors: Kuriyama, A., Urushidani, S., Nakayama, T. Tags: Review Source Type: research

How good is triage, and what is it good for?
Two papers in this month’s issue of EMJ systematically examine the validity of triage systems for adults and children1, while Tsai et al analyse the performance of prehospital triage criteria in Taiwan.2 Few emergency physicians have the luxury of being able to see all patients immediately and thus not needing triage. Firstly, before we can find a good triage system, we need to consider why we triage. The underlying principle of triage is a utilitarian ethic of maximising the overall good, originally described in the military setting: ‘those who are dangerously wounded should receive the first at...
Source: Emergency Medicine Journal - October 23, 2017 Category: Emergency Medicine Authors: Challen, K. Tags: Commentary Source Type: research

Highlights from this issue
Relationship between non-technical skills and technical performance during cardiopulmonary resuscitation: does stress have an influence? This paper looks at the impact of potential distractors affects Cardiopulmonary performance, an essential task to save life. The results of this simulation study were that there was considerable impact on the effectiveness of cardiopulmonary resuscitation when there were distracting features in the near environment. This has implications for the delivery of CPR and highlights the importance of the team leader keeping control, as far as possible, to the healthcare environment whe...
Source: Emergency Medicine Journal - October 23, 2017 Category: Emergency Medicine Authors: Maconochie, I. K. Tags: EMJ Primary survey Source Type: research

Correction: Exploring why 'primary care problems end up receiving ambulance treatment: early findings from a pre-hospital ethnographic study
Matthew Booker, Rebecca Barnes, Alison Heawood, et al. Exploring why ‘primary care’ problems end up receiving ambulance treatment: early findings from a pre-hospital ethnographic study. Emerg Med J 2017;34:697. doi:10.1136/emermed-2017-207114.5. The name of the first author, Matthew Booker, is misspelled in the author list. The correct list of authors is: Matthew Booker, Rebecca Barnes, Alison Heawood. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - October 23, 2017 Category: Emergency Medicine Tags: Miscellaneous Source Type: research

Correction: Investigating the population characteristics, processes and outcomes of pre-hospital psychiatric and self-harm emergencies in Scotland: a national record linkage study
E Duncan, C Best, N Dougall, et al. Investigating the population characteristics, processes and outcomes of pre-hospital psychiatric and self-harm emergencies in scotland: A national record linkage study. Emerg Med J 2017;34:695. doi:10.1136/emermed-2017-207114.1. The name of the first author, Edward Duncan, is missing from the author list. The correct list of authors is: Edward Duncan, Catherine Best, Nadine Dougall, Silje Skar, David Fitzpatrick, Josie Evans, Andrew Corfield, Isabella Goldie, Margaret Maxwell, Helen Snooks, Cameron Stark, Chris White, Wojtek Wojcik. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - October 23, 2017 Category: Emergency Medicine Tags: Miscellaneous Source Type: research

Letter to editor: Best estimations of the effects of alcohol on emergency department attendance
We thank Parkinson and colleagues for their recent interesting study1 which found that alcohol-related attendance at their ED to be 12%–15% with marked variation in attendance by time and demographics. We performed a similar retrospective study looking at a calendar year's worth of data (2013) from Poole Hospital Foundation Trust's ED. Collating all of the attendances that had been recorded as ‘related to alcohol’ by the discharging clinician, we analysed these records and their demographics. The estimates of cost were taken from the hospital's data and coding department. Of 60 908 attendances, we fo...
Source: Emergency Medicine Journal - May 24, 2017 Category: Emergency Medicine Authors: Welch, M., Waseem, H., Catton, A., Barratt, J. Tags: PostScript Source Type: research

EMJ Global Highlights June 2017
Editor’s note: EMJ has partnered with the journals of multiple international emergency medicine societies to share from each a highlighted research study, as selected by their editors. This edition will feature an abstract from each publication. African journal of emergency medicine The official journal of the African Federation for Emergency Medicine, the Emergency Medicine Association of Tanzania, the Emergency Medicine Society of South Africa, the Egyptian Society of Emergency Medicine, the Libyan Emergency Medicine Association, the Ethiopian Society of Emergency Medicine Professionals, the Sudanese Emergency...
Source: Emergency Medicine Journal - May 24, 2017 Category: Emergency Medicine Authors: Weber, E. J. Tags: Primary survey Source Type: research

BET 3: In septic patients requiring fluid resuscitation can the bedside lung ultrasound be used to assess the pulmonary fluid status?
A short cut review was carried out to see if the presence of ‘B lines’ detected on lung ultrasound could be used to guide the volume of fluid replacement necessary in the resuscitation of the patient with sepsis. Four papers with some degree of relevance were found in the literature search. The author, date and country of publication, patient group studied, study type, relevant outcomes, results study weaknesses of these papers are tabulated. Although a promising concept, the remains a paucity of good quality evidence sufficient to recommend this approach. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - May 24, 2017 Category: Emergency Medicine Authors: Judith, A., St-Onge, M. Tags: Best evidence topic reports Source Type: research

BET 2: Pre-hospital finger thoracostomy in patients with chest trauma
A short cut review was carried out to see if ‘finger’ thoracostomy is a safe and effective method of treating a tension pneumothorax in a pre-hospital setting. Five relevant papers were found looking at this technique in the pre-hospital setting. The author, date and country of publication, patient group studied, study type, relevant outcomes, results study weaknesses of these papers are tabulated. This technique appears to be safe and effective when performed by trained physicians in a pre-hospital setting. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - May 24, 2017 Category: Emergency Medicine Authors: Jodie, P., Kerstin, H. Tags: Best evidence topic reports Source Type: research

Toward evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary
Best Evidence Topic reports (BETs) summarise the evidence pertaining to particular clinical questions. They are not systematic reviews, but rather contain the best (highest level) evidence that can be practically obtained by busy practicing clinicians. The search strategies used to find the best evidence are reported in detail in order to allow clinicians to update searches whenever necessary. Each BET is based on a clinical scenario and ends with a clinical bottom line which indicates, in the light of the evidence found, what the reporting clinician would do if faced with the same scenario again. The BETs published below ...
Source: Emergency Medicine Journal - May 24, 2017 Category: Emergency Medicine Authors: Ferguson, C. Tags: Best evidence topic reports Source Type: research

BET1: Pre-hospital finger thoracostomy in patients with traumatic cardiac arrest
A short cut review was carried out to see if ‘finger’ thoracostomy was a safe and effective procedure to use in the pre-hospital setting in patients with traumatic cardiac arrest. Three relevant papers were found describing the use of this technique in the pre-hospital setting. The author, date and country of publication, patient group studied, study type, relevant outcomes, results study weaknesses of these papers are tabulated. Finger thoracostomy appears to be an acceptable and effective technique for trained physicians in the pre-hospital setting. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - May 24, 2017 Category: Emergency Medicine Authors: Jodie, P., Kerstin, H. Tags: Best evidence topic reports Source Type: research

A systematic review of patients', parents' and healthcare professionals' adrenaline auto-injector administration techniques
Discussion There was wide variation in administration techniques reported. However, studies designed using before-and-after training show that even a brief demonstration and educational intervention can improve technique. Further studies are required to design and pilot acceptable and cost-effective educational materials. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - May 24, 2017 Category: Emergency Medicine Authors: El Turki, A., Smith, H., Llewellyn, C., Jones, C. J. Tags: Review Source Type: research

Chest compression fraction in ambulance while transporting patients with out-of-hospital cardiac arrest to the hospital in rural Taiwan
Conclusions The chest compression fraction was low for patients with out-of-hospital cardiac arrest in a moving ambulance, irrespective of the number of providers. Reasons for this observation, as well as the effectiveness of the one-handed chest compression require further evaluation. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - May 24, 2017 Category: Emergency Medicine Authors: Hung, S.-C., Mou, C.-Y., Hung, H.-C., Lin, I.-H., Lai, S.-W., Huang, J. Y. Tags: Prehospital care Source Type: research

A man with fever and posterior neck pain
Clinical introduction A 40-year-old man presented with a 5-day history of severe posterior neck pain and fever of 38.3°C. He also had odynophagia. Physical examination revealed a normal active range of motion in neck anteflexion but limited extension and left rotation. Laboratory tests showed elevated white cell count (12 x109/L) and C reactive protein (8.70 ng/dL). Cerebrospinal fluid analysis was normal. A lateral cervical radiograph was performed (figure 1). Question What is the most likely diagnosis? A. Retropharyngeal abscess B. Meningitis C. Crowned dens syndrome D. Acute calcific tendinitis of the longus co...
Source: Emergency Medicine Journal - May 24, 2017 Category: Emergency Medicine Authors: Suyama, Y., Shirakawa, T., Hagiwara, K. Tags: Image Challenge Source Type: research

Development of a trigger tool to identify adverse events and harm in Emergency Medical Services
Discussion The Emergency Medical Services Trigger Tool (EMSTT) may be used as a sampling strategy similar to the Global Trigger Tool, to identify and measure AE and harm over time, and monitor the success of improvement initiatives within the Emergency Medical Services setting. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - May 24, 2017 Category: Emergency Medicine Authors: Howard, I. L., Bowen, J. M., Al Shaikh, L. A. H., Mate, K. S., Owen, R. C., Williams, D. M. Tags: Original article Source Type: research

Emergency department syndromic surveillance to investigate the health impact and factors associated with alcohol intoxication in Reunion Island
This study demonstrated the interest of syndromic surveillance to monitor non-infectious diseases. Time-series models showed a robust association between ED visits for AI and several factors. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - May 24, 2017 Category: Emergency Medicine Authors: Vilain, P., Larrieu, S., Mougin-Damour, K., Marianne Dit Cassou, P.-J., Weber, M., Combes, X., Filleul, L. Tags: Original article Source Type: research

A systematic review of management strategies for childrens mental health care in the emergency department: update on evidence and recommendations for clinical practice and research
Conclusions Lower-quality data suggest benefits to the use of specialised resources and services for paediatric mental health care in general and paediatric EDs. Experimental evaluation of strategies and the inclusion of patient-reported outcomes will improve confidence in these findings. Additional psychometric studies are needed for the HEADS-ED tool to be considered well established. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - May 24, 2017 Category: Emergency Medicine Authors: Newton, A. S., Hartling, L., Soleimani, A., Kirkland, S., Dyson, M. P., Cappelli, M. Tags: Original article Source Type: research

Can surf-lifeguards perform a quality cardiopulmonary resuscitation sailing on a lifeboat? A quasi-experimental study
Conclusion Surf-lifeguards are able to deliver good-quality CPR even on a moving IRB, but their performance is lower than onshore. This fact should be considered in real cases to balance the risk and benefits of CPR on board. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - May 24, 2017 Category: Emergency Medicine Authors: Barcala-Furelos, R., Abelairas-Gomez, C., Palacios-Aguilar, J., Rey, E., Costas-Veiga, J., Lopez-Garcia, S., Rodriguez-Nunez, A. Tags: Original article Source Type: research

Violence-related ambulance call-outs in the North West of England: a cross-sectional analysis of nature, extent and relationships to temporal, celebratory and sporting events
Conclusion Ambulance call-out data can provide a wealth of information to understand violence and subsequently inform about violence prevention and response activity. Ambulance services and staff could play a key role in preventing violence through sharing data and identifying and supporting victims. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - May 24, 2017 Category: Emergency Medicine Authors: Quigg, Z., McGee, C., Hughes, K., Russell, S., Bellis, M. A. Tags: Original article Source Type: research

The Royal College of Emergency Medicine composite pain scale for children: level of inter-rater agreement
Conclusion The Ladder score could be omitted from this composite tool as it has poor inter-rater agreement in comparison with the other indicators. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - May 24, 2017 Category: Emergency Medicine Authors: James, F., Edwards, R., James, N., Dyer, R., Goodwin, V. Tags: Original article Source Type: research

What is an ROC curve?
The paper by Body et al is concerned with the evaluation of decision aids, which can be used to identify potential acute coronary syndromes (ACS) in the ED. The authors previously developed the Manchester Acute Coronary Syndromes model (MACS) decision aid, which uses several clinical variables and two biomarkers to ‘rule in’ and ‘rule out’ ACS. However, one of the two biomarkers (heart-type fatty acid bindingprotein, H-FABP) is not widely used so a revised decision aid has been developed (Troponin-only Manchester Acute Coronary Syndromes, T-MACS), which include a single biomarker hs-cTnT. In this is...
Source: Emergency Medicine Journal - May 24, 2017 Category: Emergency Medicine Authors: Hoo, Z. H., Candlish, J., Teare, D. Tags: Editor's choice Concepts Source Type: research

Diagnosing a painful abdominal hernia
Clinical introduction An 83-year-old man with a longstanding incisional hernia presented to the ED with a 48-hour history of vomiting and constipation. His medical history included thrombotic stroke, congestive cardiac failure, hypertension, chronic obstructive pulmonary disease and large bowel resection. The patient was tachypnoeic. All other observations were stable. Examination revealed a distended abdomen with a hernia protruding beneath a midline laparotomy scar. The superior portion of the hernia was reducible and the edges of the wide defect palpable. However, inferiorly there was a firm, irreducible tender knuckle ...
Source: Emergency Medicine Journal - May 24, 2017 Category: Emergency Medicine Authors: Nagra, N. S., Cox, M. P., Nana, G. R., Isherwood, J. Tags: EMJ Image Challenge Source Type: research

Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid: single biomarker re-derivation and external validation in three cohorts
Conclusions T-MACS could ‘rule out’ ACS in 40% of patients, while ‘ruling in’ 5% at highest risk using a single hs-cTnT measurement on arrival. As a clinical decision aid, T-MACS could therefore help to conserve healthcare resources. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - May 24, 2017 Category: Emergency Medicine Authors: Body, R., Carlton, E., Sperrin, M., Lewis, P. S., Burrows, G., Carley, S., McDowell, G., Buchan, I., Greaves, K., Mackway-Jones, K. Tags: Open access, Editor's choice, Drugs: cardiovascular system, Acute coronary syndromes Original article Source Type: research

Highlights from this issue
This month’s editor’s choice is actually a pair of papers: one, a study on the diagnostic characteristics of the T-MACS chest pain risk stratification score AND the other, a paper explaining a key methodological concept used in this and other studies of diagnostic tests, the receiving operator characteristic ROC) curve (Richard Body (an associate editor of EMJ) and colleagues previously developed the MACS rule, which classifies patients as very low risk or very high risk after the results of an initial set of biomarkers are known, TMACS relies on obtaining both high sensitivity troponin and heart-type fatty aci...
Source: Emergency Medicine Journal - May 24, 2017 Category: Emergency Medicine Authors: Dawood, M. Tags: Primary survey Source Type: research

A young woman with fever and low back pain
Clinical introduction A previously healthy, 20-year-old woman taking oral contraceptives presented to the Emergency Department (ED) with fever (body temperature, 39.2°C) and low back pain. Physical examination showed right costovertebral angle tenderness. Laboratory tests revealed elevated white blood cell count (13.2x109/L) and C-reactive protein level (9.75 mg/dL). Coagulation test results were unremarkable except for D-dimer level (1.5 μg/mL). Urinalysis results were normal. Abdominal CT with contrast was performed (figure 1). Question What is the most likely diagnosis?Renal infarction Acute focal bacte...
Source: Emergency Medicine Journal - April 19, 2017 Category: Emergency Medicine Authors: Suyama, Y., Inaba, H., Inokuchi, R. Tags: EMJ Image Challenge Source Type: research

Global emergency medicine highlights
Editor’s note: EMJ has partnered with the journals of multiple international emergency medicine societies to share from each a highlighted research study, as selected by their editors. This edition will feature an abstract from each publication. African journal of emergency medicine The official journal of the African Federation for Emergency Medicine, the Emergency Medicine Association of Tanzania, the Emergency Medicine Society of South Africa, the Egyptian Society of Emergency Medicine, the Libyan Emergency Medicine Association, the Ethiopian Society of Emergency Medicine Professionals, the Sudanese Emergency Medi...
Source: Emergency Medicine Journal - April 19, 2017 Category: Emergency Medicine Authors: Weber, E. J. Tags: Primary survey Source Type: research

Osseous injuries of the foot: an imaging review. Part 3: the hindfoot
Injuries to the foot are a common cause for presentation to the emergency department, and imaging is often used to aid in the diagnosis. The foot can be divided into three distinct anatomic regions: the forefoot, midfoot and hindfoot. Our manuscripts comprise a three-part imaging review in which we address the use of radiography as well as advanced imaging modalities. We provide pearls to radiographic interpretation and discuss prognostic implications and classification systems. Part 1 addresses forefoot injuries, part 2 reviews midfoot injuries and part 3 covers the hindfoot. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - April 19, 2017 Category: Emergency Medicine Authors: Kiener, A. J., Hanna, T. N., Shuaib, W., Datir, A., Khosa, F. Tags: Radiology, Clinical diagnostic tests, Radiology (diagnostics), Trauma Review Source Type: research

BET 2: Striking the right balance: anticoagulation and isolated distal deep vein thrombosis
A short-cut review was carried out to establish whether treatment of isolated distal deep vein thrombosis with therapeutic anticoagulation can reduce adverse clinical outcomes. A meta-analysis from 2011 and 11 subsequent directly relevant papers were found using the reported search strategy. Of these, 7 in total presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that patients diagnosed with isolated distal deep vein thrombosis should be...
Source: Emergency Medicine Journal - April 19, 2017 Category: Emergency Medicine Authors: Jones, T., Horner, D. Tags: Best evidence topic reports Source Type: research

Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary
Best Evidence Topic reports (BETs) summarise the evidence pertaining to particular clinical questions. They are not systematic reviews, but rather contain the best (highest level) evidence that can be practically obtained by busy practicing clinicians. The search strategies used to find the best evidence are reported in detail to allow clinicians to update searches whenever necessary. Each BET is based on a clinical scenario and ends with a clinical bottom line which indicates, in the light of the evidence found, what the reporting clinician would do if faced with the same scenario again. The BETs published below were firs...
Source: Emergency Medicine Journal - April 19, 2017 Category: Emergency Medicine Authors: Horner, D. Tags: Best evidence topic reports Source Type: research

BET 1: A glass half full? Thrombolysis for the treatment of submassive pulmonary embolism
A short-cut review was carried out to establish whether thrombolysis in addition to therapeutic anticoagulation could be of benefit in submassive (intermediate risk) pulmonary embolism (PE). 64 directly relevant papers were found using the reported search strategy. Of these, three presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that there is insufficient evidence to support the routine use of adjuvant thrombolytic therapy at any dose...
Source: Emergency Medicine Journal - April 19, 2017 Category: Emergency Medicine Authors: Barrett, L., Horner, D. Tags: Best evidence topic reports Source Type: research

Post-operative shortness of breath
Clinical introduction A previously well 34-year-old woman presented to the ED in the evening following an elective arthroscopy of her right shoulder and removal of a paralabral cyst. She had undergone a general anaesthetic and right interscalene nerve block, and the operation had gone well. She presented with chest ‘heaviness’ and shortness of breath immediately postoperatively which failed to resolve upon returning home and so she had returned to the ED. Auscultation of her chest was normal, RR was 18  breaths per minute and oxygen saturations were 99% on room air. ECG showed normal sinus rhythm at 72 bea...
Source: Emergency Medicine Journal - April 19, 2017 Category: Emergency Medicine Authors: Haden, M. Tags: EMJ Image Challenge Source Type: research

Management of pregnancy and obstetric complications in prehospital trauma care: prehospital resuscitative hysterotomy/perimortem caesarean section
The need for prehospital resuscitative hysterotomy/perimortem caesarean section is rare. The procedures can be daunting and clinically challenging for practitioners. Maternal death can be averted by swift and decisive action. This guideline serves to inform prehospital practitioners about conducting maternal resuscitation following cardiac arrest, provides an evidence-based framework to support decision making and highlights areas for improvement in prehospital care. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - April 19, 2017 Category: Emergency Medicine Authors: Battaloglu, E., Porter, K. Tags: Concepts Source Type: research

Management of pregnancy and obstetric complications in prehospital trauma care: faculty of prehospital care consensus guidelines
This consensus statement seeks to provide clear guidance for the management of pregnant trauma patients in the prehospital setting. Pregnant patients sustaining trauma injuries have certain clinical management priorities beyond that of the non-pregnant trauma patients and that if overlooked may be detrimental to maternal and fetal outcomes. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - April 19, 2017 Category: Emergency Medicine Authors: Battaloglu, E., Porter, K., Abeysinghe, Bosanko, Cox, Chu, Crombie, Leech, Moss, Nash, Plaat, Ralph, Russell, Wyse, Johnston, Hinshaw, Paterson-Brown, Birks Tags: Original article Source Type: research

Does end-tidal capnography confirm tracheal intubation in fresh-frozen cadavers?
Conclusions Cadaveric oesophageal intubation did not result in a capnography waveform, simulating live patients. When present, ETCO2 following tracheal intubation showed normal morphology which was sustained for 2 min. However, ETCO2 was not present following tracheal intubation in all cadavers. These results represent instrumentation on the cadavers for the first time after thawing and further work should assess the repeatability of the findings with subsequent intubations. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - April 19, 2017 Category: Emergency Medicine Authors: Reid, C., Ferguson, I., Burns, B., Habig, K., Shareef, M. Tags: Resuscitation Short report Source Type: research

Widespread eruption in a patient with atopic dermatitis
Clinical introduction A 36-year-old woman at 12 weeks of pregnancy with a personal history of severe atopic dermatitis presented to the ED with a widespread and painful skin eruption. On physical examination, there were clusters of monomorphic blisters and crusts (see figures 1 and 2). Question Laboratory tests were within normal range. What is the most likely diagnosis?Disseminated herpes simplex virus (HSV) infection Disseminated varicella-zoster virus infection Severe atopic dermatitis flare-up Bullous impetigo Answer:A Tzanck smear showed multinucleated giant cells, and PCR confirmed an HSV type 1 infection. Staph...
Source: Emergency Medicine Journal - April 19, 2017 Category: Emergency Medicine Authors: Combalia, A., Ferrando, J., Mascaro, J. M. Tags: EMJ Image Challenge Source Type: research