Atropine-resistant bradycardia due to hyperkalaemia

Symptomatic sinus bradycardia is routinely treated in the emergency department with atropine and pacing. Two cases are presented that illustrate the importance of considering hyperkalaemia, particularly in the presence of atropine-resistant symptomatic bradycardia. The administration of calcium in such cases acts to stabilise the myocardium and resolve the bradycardia. Blood gas analysis provides a rapid estimate of serum potassium concentrations, facilitating timely treatment.

Randomised trial of a vibrating bladder stimulator--the time to pee study

This randomised, non-blinded study evaluated a vibrating bladder stimulator to facilitate collection of a urine sample from pre-continent children. The use of a bladder stimulator produced no significant time improvements in any of the analysed parameters (n = 97). We identify a population of patients who may benefit from some form of bladder stimulation.

Tele-education in emergency care

The use of telemedicine is becoming routine and accepted in certain limited areas such as electrocardiogram and radiograph/computed tomographic scan telemetry. Tele-education has thus far had limited applications although in emergency medicine it has been shown to be an effective medium for the education of senior house officers and emergency nurse practitioners in remote or peripheral units. Despite apparent clinical and cost benefits and government support, the full potential of two way video conferencing and tele-presence has yet to be realised by the clinician, educator and manager.

Lower limb amputation with CPR in progress: recovery following prolonged cardiac arrest

Intravenous drug users (IVDUs) often present to the emergency services with the medical complications of drug use. We report a case in which an acutely ischaemic lower limb of one such patient was thought to be the cause of cardiac arrest occurring during treatment in the emergency department (ED). Amputation of the limb was performed with cardiopulmonary resuscitation (CPR) in progress, spontaneous cardiac output was restored, and the patient made an excellent neurological recovery despite a total arrest time of 85 minutes. Possible causes of cardiac arrest, in relation to the release of potassium and metabolic toxins are discussed, as well as the decision making processes of the involved clinicians and other possible management strategies.

Prevalence and healthcare burden of illegal drug use among emergency department patients

OBJECTIVES

Illegal drug use is common in emergency department (ED) patients, but previous prevalence studies have relied upon approaches that may underestimate the true extent of the problem. The aim of this study was to examine illegal drug use in a typical adult ED.

METHODS

We employed an independent researcher to prospectively and anonymously interview patients attending an inner city adult ED throughout all 168 hours of a typical week. Additional information collected from the treating clinician indicated whether each presentation was directly or indirectly related to illegal drug use.

RESULTS

We found that 6.9% of all patient attendances were directly or indirectly related to illegal drug use, and hospital admission was required in nearly half of these. The majority of drug related problems were acute injuries, overdose, and the medical complications of drug use.

CONCLUSIONS

This suggests that the emergency healthcare burden related to illegal drug use is substantial, and higher than previously reported.

Automatic external defibrillation in a 6 year old

A case is reported in which an automatic external defibrillator (AED) was used during the successful resuscitation of a 6 year old child in out-of-hospital cardiac arrest, despite the fact that these devices are not recommended in children under 8 years. The interpretation of resuscitation protocols is discussed and new developments in this area reported.

Nitrous oxide in emergency medicine

Safe and predictable analgesia is required for the potentially painful or uncomfortable procedures often undertaken in an emergency department. The characteristics of an ideal analgesic agent are safety, predictability, non-invasive delivery, freedom from side effects, simplicity of use, and a rapid onset and offset. Newer approaches have threatened the widespread use of nitrous oxide, but despite its long history this simple gas still has much to offer. "I am sure the air in heaven must be this wonder-working gas of delight". Robert Southey, Poet (1774 to 1843)

The effect of resolution, compression, colour depth and display modality on the accuracy of accident and emergency telemedicine

There are no current recommendations regarding the minimum technical specification for realtime telemedicine consultation in accident and emergency (A and E) practice. We assessed the effect of image resolution, compression, colour depth and display modality on perceived image quality and telediagnosis. Test sets of digitized radiographs and clinical images were subjected to a series of standardized manipulations and the resulting output files were evaluated by an expert panel using image scoring and receiver operating characteristic (ROC) analysis. For telemedicine in A and E work, the minimum technical specification should be regarded as images containing at least 250,000 pixels, compressed at up to JPEG 50 (or GIF for colour images) and displayed on a high-resolution computer monitor. These specifications resulted in average file sizes of 17 kByte for digital images and 9 kByte for radiographs.

A review of telemedicine in accident and emergency: the story so far

Recent developments in information and communications technology have the potential to revolutionise health care. This has been recognised at government level, and plays a significant part in the new information strategy for the NHS "Information For Health". Telemedicine (literally, medicine at a distance) is one of the most successful techniques in this rapidly expanding field, and in preliminary studies has proved to be both successful and popular with patients and health care professionals. In the UK telemedicine has been mainly applied to two major areas of accident and emergency (A&E) practice. These are the transmission of computed tomography scans for urgent neurosurgical opinion and the ongoing support of minor injuries units. The latter also involves transmission and interpretation of radiographs, usually peripheral limb films. Telemedicine is not a medical subspecialty in itself, but a facilitator of all medical and surgical specialties. While recent modernisation initiatives have permitted A&E departments to purchase a range of telemedical equipment, overall progress is hampered by a lack of large or scientifically rigorous studies, and a complete absence of data on the economic implications of this new technique. This review introduces A&E telemedicine in terms that avoid jargon and complex technical details. After a brief consideration of the origins of the subject, attention is given to recent publications relating to minor injuries support and A&E teleradiology. The technical and clinical feasibility of A&E telemedicine are demonstrated, and a case is made for the transmission and interpretation of minor injuries radiographs using a relatively simple and inexpensive system, supported by timely radiological reporting. After a brief study of various legal and ethical issues, the likely developments of the future are discussed.

The 'Malone Group' meeting, October 1998

The diverse experiences and activities of seven UK units participating in telemedicine with minor injuries units is described. Not unexpectedly, ‘growing pains’ were experienced and pitfalls in implementation were identified. Difficulties in consensus emerged regarding the minimum equipment required and the most appropriate cases for teleconsultation, but there was general agreement on the need for clear protocols. Decreased utilization of telemedicine links over time proved to be a common trend; it was felt that this resulted from increasing staff experience and confidence at the peripheral sites. Overall, the telemedicine connection was considered successful. It promoted a close working relationship and supervision between units which were linked, although long-distance connection to ‘anonymous’ experts worked less well. With time, certain clinical permutations emerged that were less appropriate for a telemedicine link, such as deep hand and wrist injuries. Radiological interpretation comprised a large proportion of all teleconsultations.

Protocols for minor injuries telemedicine

Protocols are essential in a nurse-led minor injuries unit. They allow the identification of agreed steps that need to occur in a sequential and timely fashion for a given process. Protocols fall into four categories: (1) for the management of specific clinical conditions; (2) for ordering and interpreting radiographs; (3) for prescribing and dispensing medications; (4) for conducting the teleconsultation itself. Current examples are given which offer a clear demonstration of the types of protocol that are in use in the UK for minor injuries telemedicine and how they are presented.

A review of minor injuries telemedicine

Video support in the management of minor injuries was pioneered in the mid-1970s in the USA, but remained little more than a technical curiosity pending the development of acceptable equipment some 20 years later. Minor injuries telemedicine has developed very successfully over the last few years in the UK, the first reported UK minor injuries telemedicine link being set up in 1994. Peripheral services are generally staffed by emergency nurse practitioners, who can use a telemedicine link when required to obtain realtime advice from a doctor at a main hospital accident and emergency department. There is now a considerable body of experience to show that the technique is safe and effective, and also some limited data about its economic benefits. The majority of minor injuries teleconsultations involve transmission of radiographs and most minor injuries teleradiology is undertaken on the understanding that a definitive radiologist's report will be issued in due course. Studies show that satisfactory interpretation of plain radiographs is possible using a low-cost/low-resolution telemedicine link. This is supported by other studies which have shown that even a teleradiology system at reduced cost and technical specifications can yield adequate images. It seems likely that teleconsultation will become an essential component in the provision of accident and emergency services.