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ObjectivesThe Manchester Acute Coronary Syndromes ECG (MACS-ECG) prediction model calculates a score based on objective ECG measurements to give the probability of a non-ST elevation myocardial infarction (NSTEMI). The model showed good performance in the emergency department (ED), but its accuracy in the pre-hospital setting is unknown. We aimed to externally validate MACS-ECG in the pre-hospital environment.MethodsWe undertook a secondary analysis from the Pre-hospital Evaluation of Sensitive Troponin (PRESTO) study, a multi-centre prospective study to validate decision aids in the pre-hospital setting (26 February 2019 to 23 March 2020). Patients with chest pain where the treating paramedic suspected acute coronary syndrome were included. Paramedics collected demographic and historical data and interpreted ECGs contemporaneously (as ‘normal’ or ‘abnormal’). After completing recruitment, we analysed ECGs to calculate the MACS-ECG score, using both a pre-defined threshold and a novel threshold that optimises sensitivity to differentiate AMI from non-AMI. This was compared with subjective ECG interpretation by paramedics. The diagnosis of AMI was adjudicated by two investigators based on serial troponin testing in hospital.ResultsOf 691 participants, 87 had type 1 AMI and 687 had complete data for paramedic ECG interpretation. The MACS-ECG model had a C-index of 0.68 (95% CI: 0.61 to 0.75). At the pre-determined cut-off, MACS-ECG had 2.3% (95% CI: 0.3% to 8.1%) sensitivity, 99.5% (95% CI: 98.6% to 99.9%) specificity, 40.0% (95% CI: 10.2% to 79.3%) positive predictive value (PPV) and 87.6% (87.3% to 88.0%) negative predictive value (NPV). At the optimal threshold for sensitivity, MACS-ECG had 50.6% sensitivity (39.6% to 61.5%), 83.1% specificity (79.9% to 86.0%), 30.1% PPV (24.7% to 36.2%) and 92.1% NPV (90.4% to 93.5%). In comparison, paramedics had a sensitivity of 71.3% (95% CI: 60.8% to 80.5%) with 53.8% (95% CI: 53.8% to 61.8%) specificity, 19.7% (17.2% to 22.45%) PPV and 93.3% (90.8% to 95.1%) NPV.ConclusionNeither MACS-ECG nor paramedic ECG interpretation had a sufficiently high PPV or NPV to ‘rule in’ or ‘rule out’ NSTEMI alone.

BackgroundTemporary lower limb immobilisation following injury is a risk factor for symptomatic venous thromboembolism (VTE). Pharmacological thromboprophylaxis can mitigate this risk but it is unclear which patients benefit from this intervention. The Aberdeen VTE risk tool was developed to tailor thromboprophylaxis decisions in these patients and this evaluation aimed to describe its performance in clinical practice. Secondarily, diagnostic metrics were compared with other risk assessment methods (RAMs).MethodsA prospective cohort service evaluation was conducted. Adult patients (≥16 years) managed with lower limb immobilisation for injury who were evaluated with the Aberdeen VTE risk tool prior to discharge from the ED were identified contemporaneously between February 2014 and December 2020. Electronic patient records were scrutinised up to 3 months after removal of immobilisation for the development of symptomatic VTE or sudden death due to pulmonary embolism (PE). Other RAMs, including the Thrombosis Risk Prediction for Patients with cast immobilisation (TRiP(cast)) and Plymouth scores, were assimilated retrospectively and diagnostic performance compared.ResultsOf 1763 patients (mean age 46 (SD 18) years, 51% women), 15 (0.85%, 95% CI 0.52% to 1.40%) suffered a symptomatic VTE or death due to PE. The Aberdeen VTE tool identified 1053 (59.7%) patients for thromboprophylaxis with a sensitivity of 80.0% (95% CI 54.8% to 93.0%) and specificity of 40.4% (95% CI 38.1% to 42.6%) for the primary outcome. In 1695 patients, fewer were identified as high risk by the TRiP(cast) (33.3%) and Plymouth (24.4%) scores, but with greater specificity, 67.0% and 75.6%, respectively, than dichotomous RAMs, including the Aberdeen VTE tool.ConclusionRoutine use of the Aberdeen VTE tool in our population resulted in an incidence of symptomatic VTE of less than 1%. Ordinal RAMs, such as the TRiP(cast) score, may more accurately reflect VTE risk and permit more individually tailored thromboprophylaxis decisions but prospective comparison is needed.

Background: Traumatic brain injury (TBI) is a common cause of disability and mortality and is associated with alcohol consumption. On 1st May 2018, the Scottish Government introduced Minimum Unit Pricing (MUP) legislation which set the floor price at which alcohol can be sold to 50 pence per unit. While MUP has led to a 7.6% decrease in off trade alcohol purchases, there are limited studies investigating the clinical impact of this legislation. This study aims to explore the impact of MUP on traumatic brain injury in Scotland. Methods: Retrospective cohort study using routinely collected national data collated by the Scottish Trauma Audit Group. Data were requested for all TBI incidents from 1st May to 31st December for both 2017 and 2018. Primary outcome was alcohol-related TBI. Secondary outcomes were injury mechanism, injury severity, clinical course, and short-term mortality. Analysis was conducted using multiple regression models adjusted for age, sex, season, and deprivation. Results: A total of 1166 patients (66% male, and 46% in the 60–79-year bracket) were identified. Alcohol-related TBI was evident in 184 of 509 (36%) patients before MUP and in 239 of 657 (36%) patients injured after its implementation (p = 0.638). Further, there was no change in injury mechanism, injury severity, hospital course and short-term mortality of TBI after MUP. Conclusions: MUP has not resulted in a change in alcohol-related TBI nor in the mechanism and severity of TBI. Limitations in two-point analysis mean that findings should be interpreted with caution and further studies investigating the clinical outcomes of MUP must be conducted.

Acute toxicity caused by illicit substance use is a common reason for emergency department (ED) presentation. Knowledge of the substances involved is helpful for predicting and managing potential toxicity, but limited information is available about the accuracy of patient-reported substance exposure. This study assessed the accuracy of the history of exposure in those reporting use of a single substance by comparison with those identified by detailed toxicological analysis, focusing on synthetic cannabinoid receptor agonists (SCRA). Adults (≥16 years) presenting between March 2015 and July 2021 to participating UK hospitals with toxicity after reporting use of a single illicit substance were included. Exposure details were documented from medical records and blood and/or urine samples analysed using high-resolution accurate mass liquid chromatography-mass spectrometry (HRAM LCMS). Sensitivity, specificity, and positive and negative predictive values of the exposure history were calculated by comparison with biological sample analysis (“gold standard”). Single substance exposure was reported for 474 (median age 33 years, IQR: 18 range 16–75, 80% males) patients. Analysis commonly identified multiple substances (Median 3, IQR 2–5). A history of exposure was documented for 121 of 151 patients where a SCRA or metabolite was detected on analysis (sensitivity 80.1%, 95% CI 72.9, 86.2%). Corresponding proportions were lower for 3,4-methylenedioxymethamphetamine (MDMA, 44/70, 62.9%., 95% CI 50.5%, 74.1%), heroin 41/108 (38.0% 95% CI 28.8–47.8%) and cocaine (22/56, 31.3%, 95% CI 20.9, 43.6%). Multiple undeclared substances were detected analytically in most patients reporting single substance use. Clinicians should be alert to the potential presence and toxicity of unreported substances when managing patients presenting after substance misuse.

Study objective To determine whether risk stratification in the out-of-hospital setting could identify patients with chest pain who are at low and high risk to avoid admission or aid direct transfer to cardiac centers. Methods Paramedics prospectively enrolled patients with suspected acute coronary syndrome without diagnostic ST-segment elevation on the ECG. The History, ECG, Age and Risk Factors (HEAR) score was recorded contemporaneously, and out-of-hospital samples were obtained to measure cardiac Troponin I (cTnI) level on a point-of-care device, to allow calculation of the History, ECG, Age, Risk Factors, and Troponin (HEART) score. HEAR and HEART scores less than or equal to 3 and greater than or equal to 7 were defined as low and high risk for major adverse cardiac events at 30 days. Results Of 1,054 patients (64 years [SD 15 years]; 42% women), 284 (27%) experienced a major adverse cardiac event at 30 days. The HEAR score was calculated in all patients, with point-of-care cTnI testing available in 357 (34%). A HEAR score less than or equal to 3 identified 32% of patients (334/1,054) as low risk, with a sensitivity of 84.9% (95% confidence interval [CI] 80.7% to 89%), whereas a score greater than or equal to 7 identified just 3% of patients (30/1,054) as high risk, with a specificity of 98.7% (95% CI 97.9% to 99.5%). A point-of-care HEART score less than or equal to 3 identified a similar proportion as low risk (30%), with a sensitivity of 87.0% (95% CI 80.7% to 93.4%), whereas a score greater than or equal to 7 identified 14% as high risk, with a specificity of 94.8% (95% CI 92.0% to 97.5%). Conclusion Paramedics can use the HEAR score to discriminate risk, but even when used in combination with out-of-hospital point-of-care cTnI testing, the HEART score does not safely rule out major adverse cardiac events, and only a small proportion of patients are identified as high risk.

BackgroundCardiac sounding chest pain represents about 5% of all Emergency Department (ED) attendances in the United Kingdom (UK), often via 999 ambulance.Much work has focused on the rapid distinction of the 1 in 5 patients without ST elevation on ECG, who are suffering from a non ST elevation myocardial infarction (NSTEMI). Pre-hospital translation of such work may allow improved access to specialist treatment for patients with NSTEMI and also identify a low risk population suitable for management without immediate ambulance transfer to hospital.The objective was to determine the accuracy of a wholly paramedic calculated pre-hospital HEART score to predict a 30-day Major Adverse Cardiac Event (MACE). The potential implications of pre-specified low-risk and high-risk cut offs were also to be determined.Method and resultsProspective diagnostic accuracy study in Northeast Scotland (UK) on adult (>18 yr) patients with cardiac sounding chest pain, attended by a paramedic ambulance and who had no ST elevation on initial ECG.A real time paramedic HEAR score was calculated and blood drawn for analysis with a POC cTn assay and later with both laboratory based contemporary and high-sensitivity cTn assays. Normal care then ensued and patients were followed up to 30 days for development of MACE.ConclusionsBetween Nov 2014 and April 2018, 1275 patients agreed to participate in the ambulance and 1056 later gave informed consent with 1054 completing 30 day follow up.358 patients had complete Paramedic HEART scores with all 3 assays and 969 patients with the 2 lab based assays (figure 1)Abstract 013 Figure 1Patient flow diagramSensitivities and specificities (95% CI) for the HEART scores vs MACE will be calculated and ROC curves generated. Diagnostic properties at different score cut-offs will be presented and analysis of the impact of the different cTnI assays presented.Apologies: Independent AMI adjudication due to complete next week, so no full results yet.

BACKGROUND: Paracetamol overdose is common but patient stratification is suboptimal. We investigated the usefulness of new biomarkers that have either enhanced liver specificity (microRNA-122 [miR-122]) or provide mechanistic insights (keratin-18 [K18], high mobility group box-1 [HMGB1], and glutamate dehydrogenase [GLDH]). The use of these biomarkers could help stratify patients for their risk of liver injury at hospital presentation.METHODS: Using data from two prospective cohort studies, we assessed the potential for biomarkers to stratify patients who overdose with paracetamol. We completed two independent prospective studies: a derivation study (MAPP) in eight UK hospitals and a validation study (BIOPAR) in ten UK hospitals. Patients in both cohorts were adults (≥18 years in England, ≥16 years in Scotland), were diagnosed with paracetamol overdose, and gave written informed consent. Patients who needed intravenous acetylcysteine treatment for paracetamol overdose had circulating biomarkers measured at hospital presentation. The primary endpoint was acute liver injury indicating need for continued acetylcysteine treatment beyond the standard course (alanine aminotransferase [ALT] activity >100 U/L). Receiver operating characteristic (ROC) curves, category-free net reclassification index (cfNRI), and integrated discrimination index (IDI) were applied to assess endpoint prediction.FINDINGS: Between June 2, 2010, and May 29, 2014, 1187 patients who required acetylcysteine treatment for paracetamol overdose were recruited (985 in the MAPP cohort; 202 in the BIOPAR cohort). In the derivation and validation cohorts, acute liver injury was predicted at hospital presentation by miR-122 (derivation cohort ROC-area under the curve [AUC] 0·97 [95% CI 0·95-0·98]), HMGB1 (0·95 [0·93-0·98]), and full-length K18 (0·95 [0·92-0·97]). Results were similar in the validation cohort (miR-122 AUC 0·97 [95% CI 0·95-0·99], HMGB1 0·98 [0·96-0·99], and full-length K18 0·93 [0·86-0·99]). A combined model of miR-122, HMGB1, and K18 predicted acute liver injury better than ALT alone (cfNRI 1·95 [95% CI 1·87-2·03], p

The aim of this study was to describe the aetiology and severity of head injury in an infant (age1 year) population presenting to a Scottish Paediatric Emergency Department (PED) and to discern preventable risk factors. The records of infants who presented to the PED of the Royal Aberdeen Children's Hospital between September 2010 and December 2011 with isolated head trauma were reviewed, patient demographics were extracted and information on aetiology, including nonaccidental injury (NAI), was recorded. Of 1574 attendances, 233 suffered isolated head injury. The majority (97%) were minor; six patients suffered skull fractures, three had traumatic intracranial haemorrhage and only three were considered to have sustained an NAI. The most common mode of injury was fall from a height (37%). Infants commonly present to the PED with head injury, many of which should be easily preventable. The number of cases because of NAI in our population is smaller than previously published figures.

Toddler's fracture (TF) occurs in young children after minor trauma. Clinical diagnosis can be challenging and initial radiological evidence may be lacking. The aim of this study was to compare the management and outcomes of clinically diagnosed TF patients with and without initial radiological evidence. A retrospective cohort study of patients aged between 9 and 36 months treated for TF in a Scottish Paediatric Emergency Department was conducted. Patients with a radiologically confirmed TF were more likely to be placed in a cast than those with a presumptive clinical TF diagnosis (92 vs. 47%; P

A 66-year-old man suffered a ventricular fibrillation cardiac arrest after an episode of chest pain. Despite advanced life support, his condition deteriorated; the situation was considered irrecoverable and resuscitation was discontinued. The patient was observed for about 5 min with irregular agonal gasping respirations evident but no palpable pulse. A gradual increase in the regularity of breathing pattern heralded the return of spontaneous circulation. An inferior myocardial infarction was diagnosed. Primary percutaneous coronary intervention was performed. The patient was discharged from hospital after 9 days with no neurological sequelae. There are several possible mechanisms to explain the Lazarus phenomenon including auto-positive end expiratory pressure and delayed drug actions, but cases are rarely reported in the medical literature. After discontinued resuscitation, we suggest consideration should be given to a period of continued monitoring. However, evidence is limited and prospective studies would be welcome to allow firmer recommendations.

SummaryBackgroundParacetamol poisoning is common worldwide. It is treated with intravenous acetylcysteine, but the standard regimen is complex and associated with frequent adverse effects related to concentration, which can cause treatment interruption. We aimed to ascertain whether adverse effects could be reduced with either a shorter modified acetylcysteine schedule, antiemetic pretreatment, or both.MethodsWe undertook a double-blind, randomised factorial study at three UK hospitals, between Sept 6, 2010, and Dec 31, 2012. We randomly allocated patients with acute paracetamol overdose to either the standard intravenous acetylcysteine regimen (duration 20·25 h) or a shorter (12 h) modified protocol, with or without intravenous ondansetron pretreatment (4 mg). Masking was achieved by infusion of 5% dextrose (during acetylcysteine delivery) or saline (for antiemetic pretreatment). Randomisation was done via the internet and included a minimisation procedure by prognostic factors. The primary outcome was absence of vomiting, retching, or need for rescue antiemetic treatment at 2 h. Prespecified secondary outcomes included a greater than 50% increase in alanine aminotransferase activity over the admission value. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov (identifier NCT01050270).FindingsOf 222 patients who underwent randomisation, 217 were assessable 2 h after the start of acetylcysteine treatment. Vomiting, retching, or need for rescue antiemetic treatment at 2 h was reported in 39 of 108 patients assigned to the shorter modified protocol compared with 71 of 109 allocated to the standard acetylcysteine regimen (adjusted odds ratio 0·26, 97·5% CI 0·13–0·52; p

Introduction and aims Traditionally, neurologically pristine patients with a thunderclap headache are investigated with a non-contrast computed tomography (CT) brain scan, which if negative is followed by a lumbar puncture (LP) to exclude important secondary causes, particularly subarachnoid haemorrhage (SAH). However, misdiagnosis of such patients is still a cause of significant human and financial cost and a regular reason for medical litigation. This study explores the approach of emergency medicine and acute medicine clinicians to the investigation of a patient with thunderclap headache. Methods Clinicians were invited to complete an online survey based on a clinical vignette of a 45-year-old man presenting with a thunderclap headache who had a pristine neurological examination. Results A total of 160 clinicians responded. The majority (89%) elected to perform a non-contrast CT brain as their first investigation, though five clinicians discharged the patient without investigation. If the CT was negative, only 84% would then proceed to LP, but 20% would undertake this investigation before 12 hours from headache onset. Conclusions Most clinicians investigate neurologically intact patients with thunderclap headache following a CT/LP strategy, but deviations from recommended practice are common.

Background and aims The emergency department of Aberdeen Royal Infirmary receives around 68,000 new adult admissions annually. All poisoning cases are admitted to a 14-bedded short-stay ward, except those admitted to intensive care or immediately discharged. This study aimed to analyse epidemiological trends and management of short-stay ward admissions for poisonings. Method and results Adult (>13 years) poisoning presentations admitted to the emergency department short-stay ward of Aberdeen Royal Infirmary from 1 January–31 December 2009 were retrospectively reviewed using patient discharge summaries. During 2009, there were 1062 poisoning cases, of which repeat episodes were responsible for 15%. The mean age of presentation was 33.9 years (SD 14.4) and there was a female preponderance (62%). Almost half of poisonings were polypharmacy, alcohol was involved in 40% of cases and overdoses most commonly involved paracetamol (43%). Management involved basic observations only (66%), N-acetylcysteine (24%), naloxone (4%) and activated charcoal (1%). Liaison psychiatry reviewed 84% presentations and admitted 9% to the psychiatric unit. Conclusions The short-stay ward is important for acute management of poisonings and the data gained from this study should help to direct patient services appropriately.

Acetaminophen (paracetamol-APAP) is the most common cause of drug-induced liver injury in the Western world. Reactive metabolite production by cytochrome P450 enzymes (CYP-metabolites) causes hepatotoxicity. We explored the toxicokinetics of human circulating APAP metabolites following overdose. Plasma from patients treated with acetylcysteine (NAC) for a single APAP overdose was analyzed from discovery (n = 116) and validation (n = 150) patient cohorts. In the discovery cohort, patients who developed acute liver injury (ALI) had higher CYP-metabolites than those without ALI. Receiver operator curve (ROC) analysis demonstrated that at hospital presentation CYP-metabolites were more sensitive/specific for ALI than alanine aminotransferase (ALT) activity and APAP concentration (optimal CYP-metabolite receiver operating characteristic area under the curve (ROC-AUC): 0.91 (95% confidence interval (CI) 0.83-0.98); ALT ROC-AUC: 0.67 (0.50-0.84); APAP ROC-AUC: 0.50 (0.33-0.67)). This enhanced sensitivity/specificity was replicated in the validation cohort. Circulating CYP-metabolites stratify patients by risk of liver injury prior to starting NAC. With development, APAP metabolites have potential utility in stratified trials and for refinement of clinical decision-making.

OBJECTIVES The 'clinical scaphoid fracture' remains a common problem faced by emergency physicians. Early magnetic resonance imaging (MRI) has been used to routinely investigate such patients presenting to the emergency department of Aberdeen Royal Infirmary since 2002. The aim of this study was to evaluate the effectiveness of this strategy in the diagnosis of occult scaphoid fracture. METHODS This was a retrospective cohort study of patients presenting with symptoms and signs suggestive of scaphoid injury and normal initial radiographs. Patients undergoing MRI evaluation of a suspected scaphoid injury between September 2002 and June 2008 were identified from records. The number of patients with scaphoid fractures and other significant pathology diagnosed on MRI was recorded. RESULTS A total of 651 patients were included in the study. A scaphoid fracture was diagnosed in 11% of patients. Using the χ test, there was evidence of an association between sex and type of injury (χ=58.0, P

Coeliac axis dissection as a result of blunt abdominal trauma is rare. This case report describes a 31-year-old male who after losing control of his motorbike sustained a coeliac axis dissection diagnosed on initial trauma pan-CT. This was managed non-operatively. In the context of blunt trauma, coeliac axis dissection is a marker of significant injury and is rarely found in isolation. The diagnosis of these injuries requires a high index of suspicion. Successful management needs to be tailored to each patient individually, though many can be managed non-operatively.

The treatment of isolated sternal fractures (ISF) throughout the world is heterogeneous. This study aimed to identify the incidence, morbidity, and mortality associated with isolated fractures of the sternum and describe current practice for diagnosis and management of ISF and cardiac injury at a level I trauma center in the UK. A retrospective cohort study of adult patients (>16 years) with ISF presenting from 2006 to 2010 was conducted. Eighty-eight patients with ISF were identified. Most patients (88%, 77) were admitted to hospital with 66% (58) of them discharged within 48 hours. Two (2%) patients had an ER EKG with abnormality but both resolved to normal sinus rhythm within 6 hours of follow-up. Serum CEs were drawn from 55 (63%) patients with only 2 (2%) having a rise in serum troponin >0.04; however, in both of these patients troponin quickly normalized. Six (7%) patients underwent echocardiograms without significant findings. In all 88 patients with ISF, no cases of clinically significant cardiac injury were identified. Patients presenting with an isolated sternal fracture with no changes on EKG or chest X-ray do not warrant an admission to hospital and may be discharged from the ER.

Acute abdominal pain is a common reason for emergency presentation to hospital. Despite recent medical advances in diagnostics, overall clinical decision-making in the assessment of patients with undifferentiated acute abdominal pain remains poor, with initial clinical diagnostic accuracy being 45-50%. Computer-aided decision support (CADS) systems were widely tested in this arena during the 1970s and 1980s with results that were generally favourable. Inception into routine clinical practice was hampered largely by the size and speed of the hardware. Computer systems and literacy are now vastly superior and the potential benefit of CADS deserves investigation. An extensive literature search was undertaken to find articles that directly compared the clinical diagnostic accuracy prospectively of medical staff in the diagnosis of acute abdominal pain before and after the institution of a CADS programme. Included articles underwent meta-analysis with a random-effects model. Ten studies underwent meta-analysis that demonstrated an overall mean percentage improvement in clinical diagnostic accuracy of 17.25% with the use of CADS systems. There is a role for CADS in the initial evaluation of acute abdominal pain, which very often takes place in the emergency department setting.

Patients commonly present to the Emergency Department with sudden onset acute severe headache, but exclusion of significant secondary causes, particularly subarachnoid haemorrhage (SAH), is vital. The misdiagnosis of SAH is most likely in patients with a normal neurological examination, and the consequences can be disastrous. A noncontrast computed tomography (CT) brain scan is the initial investigation of choice, and most would recommend that, if negative, this be followed by a lumbar puncture (LP) and cerebrospinal fluid (CSF) analysis. Many hospitals in the UK have developed Clinical Decision Unit (CDU) pathways to provide a standardized approach to the investigation and management of neurologically normal patients with headache suggestive of SAH.The aims of this study were to describe the prevalence of SAH and to evaluate the performance of CT and LP in a CDU population with sudden onset acute severe headache.A retrospective review of neurologically pristine patients admitted to a CDU pathway for exclusion of SAH was conducted. Structured case notes were reviewed; patient demographics, investigation results and clinical outcomes were recorded in each case.The overall prevalence of SAH in this population was 14/517 (2.7%). A noncontrast CT of the brain had a negative predictive value of 99.8%, reducing the post-test probability of having an angiogram-positive SAH detected by LP and CSF analysis to 0.21% (95% confidence interval 0.04-0.36%).The management of neurologically pristine patients with sudden onset severe headache on a CDU pathway is feasible. In light of the low prevalence of SAH in this population, the decision to follow a negative CT with an LP in all cases needs careful consideration, as CSF results may only rarely confer therapeutic benefit to patients suspected of SAH.

Objectives & Background Cardiac sounding chest pain is one of the commonest reasons for presentation to the Emergency Department (ED) or acute medical receiving. An electrocardiogram (ECG) can rapidly identify those patients suffering from an ST elevation acute coronary syndrome (ACS) but the differentiation of patients with non ST elevation ACS from those with non cardiac chest pain or stable cardiac disease is often not straightforward and encompasses historical, clinical and biochemical factors. Effective early risk stratification of this group of non ST elevated ACS patients may streamline care pathways for those at high risk and lead to effective use of resources and early discharge in those in whom ACS is unlikely. Methods A prospective cohort study of adult patients presenting to the ED or acute medical receiving unit of Aberdeen Royal Infirmary with cardiac sounding chest pain and an a non-diagnostic ECG. A necessary sample size of 1000 patients was calculated and recruitment began in December 2014. HEART, GRACE and TIMI scores were calculated from data obtained on patient attendance, with subjective aspects entered by the attending medical practitioner in real time. Patients were followed up to 30 days for the development of a MACE. Receiver Operated Characteristic (ROC) curves were plotted to determine discriminative power of each of the three scores to detect MACE. Sensitivities and specificities (with 95% CIs) for each score (at different cut-offs) were calculated. Results Preliminary results are available on 605 patients. Ages ranged from 20–95 years (mean 61.8 years), 360 (59.5%) were male and 108 patients (17.9%) patients suffered a MACE at 30 days. Area under the ROC curves demonstrated that HEART (0.86) had a greater ability to discriminate patients going on to develop a MACE than TIMI (0.71) and GRACE (0.76) scores. Within the HEART low risk group 1.2% of patients developed a MACE and within the high risk group over 60% developed a MACE. Conclusion The HEART score out performs GRACE and TIMI in predicting MACE in patients presenting to the ED with cardiac sounding chest pain. It rapidly identifies a low-risk population that may be suitable for early discharge or ambulatory management from the ED and higher risk patients may be promptly prioritised for invasive management.

“Sir William Osler (1849–1919) said, In science credit goes to the man who convinces the world, not to the man to whom the idea first occurs” The desire to provide the highest possible level of care to all our patients is one of the primary motivations of emergency physicians. The scope of our practice is such that we need to be aware of the developments in most other specialties. The Cochrane Database continues to provide the world with rigorous analysis of research and thus gives us the opportunity to use this information in the best interests of our patients. In this synopsis Of Cochrane Reviews applicable to emergency services (SOCRATES), we will look at the reviews that we found in our assessment of the output of the Cochrane Heart Group. The method used to find and summarise the reviews is as described previously. We found eight reviews from the Cochrane Heart Group that we thought were of particular relevance. ### Background The objective of this review was to determine whether active compression–decompression cardiopulmonary resuscitation (CPR) using a handheld suction device improved outcome (mortality) compared with standard manual CPR in adult patients with cardiac arrest. The secondary outcome measure was complications of CPR—for example, rib fractures or pneumothorax. ### Results Eight out-of-hospital studies (n = 4162), one in-hospital study (n = 53) and one study with both in-hospital and out-of-hospital components (n = 773) were included. No difference was found in mortality, survival to discharge or complications between the active compression–decompression CPR group and the standard manual CPR group. ### SOCRATES says Active compression–decompression CPR does not improve the outcome of adult patients with cardiac arrest when compared with standard manual CPR. ▸ Lafuente-Lafuente C, Melero-Bascones M. Active chest compression-decompression for cardiopulmonary resuscitation. (Cochrane Review). In: Cochrane Library, Issue 2. Oxford: Update Software, 2006 . ### Background Patients with atrial fibrillation and atrial flutter are at an increased risk of stroke. This review aimed to identify randomised controlled trials of drugs used to prevent thromboembolism in …

In the UK, many emergency departments (EDs) were built with dedicated theatres reflecting surgical origins. This study assessed the number and type of procedures performed in such a facility over a 16-year period. A retrospective cohort study of ED theatre usage was carried out in Aberdeen Royal Infirmary from 1995 to 2010. Cases were identified from theatre log books, and relevant demographics were extracted and analyzed. In total, 8785 procedures were performed, although this decreased from 1078 cases in 1995 to 214 cases in 2010. Common procedures included fracture manipulation, abscess drainage and foreign body removal. Use of ED theatre has reduced considerably. The reasons for this are complex, but may reflect a reduction in the surgical skill set of staff in the ED. Sound basic surgical skills are valuable to the emergency physician and further consideration should be given to how these are best acquired in the course of training.

Introduction and aims In the UK, specialist trainees in emergency medicine are required to pass the Fellowship of the College of Emergency Medicine (FCEM). This examination assesses clinical knowledge, attitudes and skills, management principles, critical appraisal, and the ability to search medical literature and synthesise information. The aims of this study were to ascertain what resources trainees felt were most valuable in preparation for the FCEM and to obtain trainee feedback on the running of the FCEM. Methods A questionnaire was developed in conjunction with the TSC into nine parts covering all aspects of preparation for and experience of sitting the FCEM. Email addresses of those trainees who had sat the FCEM examination in 2006 and 2007 were provided by the CEM and questionnaires were sent electronically to recipients. Responses were collated and analysed using Microsoft Excel. Results There was a response rate of 42% (86/203), of whom about three-quarters felt well prepared for the FCEM. The most highly valued resources for exam preparation were practice questions, private study and small group work. A yearly mock FCEM examination was felt to be important by those who had such access and local trainer involvement in exam preparation was perceived significant for success. Conclusions Training programmes should make sure that facilities and expertise are available at a local level to allow trainees to have access to everything that is considered important in order to pass the FCEM.

In 2002 it was highlighted that sledging results in serious injuries in the paediatric population and safety recommendations were made. The aim of this study was to re-examine the number, severity and aetiology of sledging-related trauma. This was a retrospective study performed in the Paediatric Emergency Department (PED) of the Royal Aberdeen Children's Hospital (RACH) during two periods totalling 12 days, when there was continuous snow ground cover. Records of all attendances were scrutinized to identify patients with sledging injuries. The nature, mechanism and severity of injury, and subsequent management were then analysed. Of 403 PED attendances, 45 (11%) were sledging related with 16 (36%) fractures and 13 (29%) head injuries. Eight patients (18%) were admitted to hospital and three (7%) required an operation. Collision with a stationary object was the most common reason for injury (51%), followed by the adoption of a dangerous sledging position or use of a stationary jump. No patients were wearing a helmet. In conclusion, there has been little change in the epidemiology and aetiology of paediatric sledging injuries since 2002. Work is needed to inform parents of the previously recommended safety measures that could reduce the morbidity of this activity without detracting from the enjoyment.

INTRODUCTION AND AIMS Patients with undifferentiated acute abdominal pain (AAP) frequently present to the Emergency Department (ED). The most common diagnosis is the nonspecific abdominal pain although missed occult surgical pathology in the haemodynamically stable patient with equivocal symptoms and signs is a potential source of morbidity. The objectives of this study were two-fold. Firstly, to ascertain the accuracy of ED clinicians in the diagnosis of AAP, and to delineate if there was a population of patients who would normally require admission to hospital that would be suitable to be managed on a Clinical Decision Unit (CDU) protocol. Secondly, to prospectively evaluate such a strategy by way of a pilot study. METHODS An initial retrospective cohort study of consecutive patients presenting to the ED with undifferentiated AAP were analysed. Data were extracted on admission, length of stay and the correlation between initial ED clinical diagnosis and final discharge diagnosis. Following this, a protocol was developed within our institution for the management of patients with stable AAP on a CDU pathway. This was then formally evaluated over a period of 25 months as part of a quality improvement exercise. RESULTS A total of 501 patients were analysed of whom 48% were admitted from the ED. The initial ED diagnosis was correct in 57% of patients, and 28% of admitted patients were discharged within 48 h with no specific intervention. During the period of the pilot study, 189 patients were entered on to the AAP CDU pathway, of which 85% were safely discharged directly from the CDU and 67% within 24 h. Of the 28 patients admitted only four required an operation. Use of the protocol in this population resulted in the initial ED assessment being correct in 69% of cases. CONCLUSION The management of stable AAP within the ED environment on a well-defined CDU pathway is feasible and can facilitate safe, efficient and effective care with early discharge and an increase in the accuracy of the final diagnosis.

Background Despite a risk of harm, the past 20 years have seen dramatically increased participation in snow sports such as skiing, and particularly, snowboarding. This period has also seen revolutions in piste maintenance and paradigm developments in the use of safety equipment. Consequently, the numbers and characteristics of injury may be very different from those traditionally quoted. Purpose To compare and evaluate the injury patterns among skiers and snowboarders in a North American ski resort in 1996 and 2013. Study Design Cross-sectional study; Level of evidence, 3. Methods Questionnaire-based cross-sectional studies were carried out independently in a North American ski resort between the dates of March 6 and April 11 in both 1996 and 2013. Demographic data and information about incident circumstances were collected from injured patients who visited the local on-site clinic. Data were compared statistically to assess for significant changes in injury characteristics between the 2 time periods. Results The 1996 report consisted of 148 injured participants, and the 2013 study included 156 participants. Results from 2013 demonstrated significant increases in helmet use, the number of snowboarders injured, and shoulder injuries. Injury was also more likely in those aged 46 to 55 years, those never having had professional instruction, or those with rented equipment. Significant reductions were seen in those injured with other people close by and in the 36- to 45-year age group. Overall, the knee was the most commonly injured body part in both periods (1996: 31%, n = 38; 2013: 33%, n = 36), although upper limb injuries were predominant in snowboarders. Conclusion Snow sports injury characteristics of patients presenting to a ski resort medical clinic have changed between 1996 and 2013. These findings can be used to further inform safety recommendations and areas to target with further research.

Wound botulism is a rare infectious disease due to neurotoxin release from the anaerobic, spore-forming bacterium Clostridium botulinum that is becoming an ever more frequent complication of parenteral drug abuse in the Western world. Before the year 2000, no such cases had been reported in the UK and Ireland, but since then the number of proven and suspected cases of wound botulism occurring in parenteral drug users has increased markedly. The diagnosis is often difficult, based on a high degree of clinical suspicion and if not considered in the initial differential diagnosis, then considerable delays in treatment may result. This is the case report of a male heroin user who presented three times to an Emergency Department in the UK before a diagnosis of wound botulism was made and treatment commenced. It is important that emergency clinicians are aware of the possibility of wound botulism in parenteral drug users that present with unusual neurological or respiratory symptomatology.

Objective: To assess the effectiveness of a systematic examination of the ulnar collateral ligament (UCL) of the thumb metacarpophalangeal joint (MCPJ) prior to and post infiltration of local anaesthetic. Methods: During the study period from 24 October 2001 to 22 February 2002, 51 patients with clinical signs suggestive of UCL injuries were identified prospectively from initial ED attendances and attendances at a subsequent review clinic. Patients were formally assessed a mean of 6.6 days post injury. A single ED Senior House Officer carried out examination before and after direct infiltration of local anaesthetic around the site of injury. Stress radiography was also performed as the ‘gold standard’ diagnostic test of UCL instability. Results: Forty-seven patients were enrolled in the study. When reviewed by the single observer, examination prior to and post local anaesthetic infiltration revealed a degree of joint stability in 28% (95% CI 16–43%) and 98% (95% CI 88–100%) cases, respectively, compared to the gold standard. Post infiltration, this technique had a specificity of 100% (95% CI 94–100%) and a sensitivity of 87.5% (95% CI 74–95%) (P

Summary Kaposiform haemangiondothelioma (KHE) is a rare vascular tumour, predominantly of infancy and early childhood, that has a close association with Kasabach-Merritt syndrome. Despite benign histology, this tumour frequently behaves aggressively, causing significant morbidity and mortality as a result of the compression and invasion of surrounding structures as well as from associated haematological and lymphoproliferative syndromes. There is a need for a high index of suspicion when presented with large, enlarging or abnormal vascular lesions in infancy and, less commonly, in adulthood. An early diagnosis of KHE can lead to prompt treatment, which may be life saving. To date, there have been only four reported cases of KHE occurring in patients over the age of 18 years. We report an otherwise well 26-year-old woman who presented with a KHE of the left thigh, and briefly review the literature. We believe this to be the second reported case of KHE in the UK and the first in an adult patient.

Objective: To determine the accuracy of references in Emergency Medicine Journal during 2003. Materials and methods: All references cited in Emergency Medicine Journal during 2003 were examined carefully, and the accuracy of the citations was checked against reliable electronic and manual resources. References were categorised as correct or incorrect. The errors were classified as minor if the integrity of the reference was not greatly compromised and major if the error severely detracted from the quality of the reference. Results: Overall, errors were found in 19% of all citations checked (n = 2561), and in 8% the errors were major and markedly detracted from the quality of the reference. Conclusions: Citation errors reflect badly on authors and the publishing journal and may reflect underlying flaws in other areas of the research published. It is hoped that identification of this problem will lead to attempts to improve the accuracy of reference citation in the emergency medicine literature and to an improvement in the credibility of research in our specialty.

Objectives & Background Paracetamol poisoning is common worldwide. Standard intravenous N-acetylcysteine (NAC) therapy is complex, and commonly associated with concentration-related adverse effects and the potential for administration errors. We aimed to determine whether adverse effect incidence could be reduced by antiemetic pre-treatment and/or a simpler and shorter intravenous N-acetylcysteine regimen. Methods We delivered, in 3 centres, a randomised factorial trial comparing a modified 12 h (100 mg/kg over 2 h, 200 mg/kg over 10 h) with a standard 20.25 h NAC regimen (150 mg/kg 15 min, 50 mg/kg 4 h, 100 mg/kg 16 h) with and without pre-treatment with ondansetron (4 mg IV). The primary endpoint was absence of retching, vomiting or need for rescue antiemetic at 2 h; secondary endpoints included the incidence of anaphylactoid reactions, the need for medication or treatment interruption, and hepatic toxicity (ALT, INR). Results In 217 participants, retching and vomiting were less common with ondansetron than placebo (OR 0.406, 97.5% CI 0.205–0.803, p=0.0031) and with the modified compared to the conventional acetylcysteine regimen (OR 0.260, 97.5% CI 0.130–0.518, p Conclusion In patients with paracetamol poisoning requiring acetylcysteine, adverse effects were substantially reduced by ondansetron pre-treatment and by using a modified, shorter treatment regimen. Ondansetron, but not the modified regimen, increased the frequency of liver function abnormalities. If large effectiveness studies confirm the modified regimen is non-inferior to conventional then shorter and safer treatment would be possible for this common poisoning.

Sledging is one of the most enjoyed winter pastimes. In Britain the arrival of snow is usually heralded by an exodus of children to the local parks and hills. However, sledging can result in serious injury and attendance to the accident and emergency (A&E) department. Sledging accidents frequently involve children and can be fatal.1 The aim of this study was to establish the number of sledging related injuries presenting to our paediatric A&E department and to study the cause and patterns of these injuries to see if any preventative measures may reduce the number of accidents. The first snow of the winter in our area lay on the ground from the 22 December 2001 to the 6 January 2002. During this period the attendances to our paediatric A&E department were identified from computer records. The A&E cards and hospital notes were then examined retrospectively to determine those injuries that occurred as a result of sledging accidents. These cases were then studied in greater detail to establish the mechanism and extent of injury in each instance and to try to ascertain what safety measures could be recommended to try to reduce morbidity. During the 16 day study there were a total of 422 attendances at the paediatric A&E department. Of these 46 patients (10.9%) were identified as having suffered injuries as a result of sledging. There were 25 boys and 21 girls. The ages ranged from 2–13 years (mean 8.6 years) and …

Sir: We present a case demonstrating what we believe to be the original observation of an acute right lower motor neurone facial nerve palsy complicating meningococcal septicaemia. A previously healthy 14-year-old boy was admitted elsewhere with a 12-h history of fever, vomiting and headache together with generalised aches and pains. On examination he had an extensive purpuric rash consisitent with meningococcal septicaemia but no meningismus. He was given intravenous penicillin and cefotaxime prior to immediate transfer to Aberdeen. On arrival in our hospital he was hypotensive but responded within 12 h to fluid replacement and a dopamine infusion. Antibiotics were continued. Blood cultures were sterile but a urinary antigen test for Meningococcus Group C/W135 was positive (Wellcogen Bacterial Antigen Kit, Muirex). Lumbar puncture was not performed. Subsequently some of his purpuric areas became necrotic but he was otherwise stable. On day 9 of his illness he experienced a sudden onset right-sided lower motor neurone facial nerve palsy for which he was given a course of oral prednisolone (2 mg/kg per day) without benefit. There was no other neurological impairment. On followup the facial nerve palsy resolved after 6 months with no further intervention. Although it is not possible to establish without doubt that the lower motor neurone facial palsy in this child was related to the meningococcal septicaemia, the relationship in time is very strongly suggestive of an aetiological link. Although facial nerve palsies have been documented in meningococcal meningitis [1] they have so far not been described in meningococcal septicaemia alone. Although no lumbar puncture was performed, there was no clinical suggestion of meningitis in this child at any time. Seventh nerve palsy has been described as secondary to multiple causes including many infections [2, 4, 5, 6], however the timing of the event in this child after 9 days of antibiotics does not suggest a direct infective mechanism. Although late complications may occur due to antibody complex disease, the focal nature of this suggests a more mechanical cause. We suspect that the aetiology may have been associated with a local purpuric area in the facial canal which became necrotic and resulted in oedema with compression of the facial nerve. This case highlights that in addition to peripheral neuropathy [3, 7], which has rarely been described, peripheral cranial nerve lesions may complicate meningococcal septicaemia and make a full recovery.

SummaryAims:Clinically and intuitively, it is believed that the incidence of abdominal injuries is high when there is a combination of both thoracic and pelvic trauma. The aim of this study was to establish the true incidence of intra-abdominal injury in these patients.Methods:A retrospective analysis of the Scottish Trauma Audit Group (STAG) database for the 5-year period from 1997 to 2001 inclusive. Significant chest, abdominal and pelvic injuries were all defined as AIS≥2. The incidence of abdominal trauma was calculated for different combinations of severity of chest and/or pelvic trauma.Results:507/3644 (14%) patients with significant chest trauma but no pelvic trauma had concomitant abdominal injuries, compared to 111/1397 (8%) patients with pelvic trauma but no chest trauma. The likelihood of concomitant abdominal injury increased significantly if both chest and pelvis injuries were present (239/507, 47%; p