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The Valsalva manoeuvre is an internationally recommended treatment for supraventricular tachycardia, but cardioversion is rare in practice (5–20%), necessitating the use of other treatments including adenosine, which patients often find unpleasant. We assessed whether a postural modification to the Valsalva manoeuvre could improve its effectiveness. We did a randomised controlled, parallel-group trial at emergency departments in England. We randomly allocated adults presenting with supraventricular tachycardia (excluding atrial fibrillation and flutter) in a 1:1 ratio to undergo a modified Valsalva manoeuvre (done semi-recumbent with supine repositioning and passive leg raise immediately after the Valsalva strain), or a standard semi-recumbent Valsalva manoeuvre. A 40 mm Hg pressure, 15 s standardised strain was used in both groups. Randomisation, stratified by centre, was done centrally and independently, with allocation with serially numbered, opaque, sealed, tamper-evident envelopes. Patients and treating clinicians were not masked to allocation. The primary outcome was return to sinus rhythm at 1 min after intervention, determined by the treating clinician and electrocardiogram and confirmed by an investigator masked to treatment allocation. This study is registered with Current Controlled Trials (ISRCTN67937027). We enrolled 433 participants between Jan 11, 2013, and Dec 29, 2014. Excluding second attendance by five participants, 214 participants in each group were included in the intention-to-treat analysis. 37 (17%) of 214 participants assigned to standard Valsalva manoeuvre achieved sinus rhythm compared with 93 (43%) of 214 in the modified Valsalva manoeuvre group (adjusted odds ratio 3·7 (95% CI 2·3–5·8; p<0·0001). We recorded no serious adverse events. In patients with supraventricular tachycardia, a modified Valsalva manoeuvre with leg elevation and supine positioning at the end of the strain should be considered as a routine first treatment, and can be taught to patients. National Institute for Health Research.

ObjectiveA new prognostic model has been developed and externally validated, the aim of which is to assist in the management of the blunt chest wall trauma patient in the emergency department (ED). The aim of this trial is to assess the feasibility and acceptability of a definitive impact trial investigating the clinical and cost-effectiveness of a new prognostic model for the management of patients with blunt chest wall trauma in the ED.DesignStepped wedge feasibility trial.SettingFour EDs in England and Wales.ParticipantsAdult blunt chest wall trauma patients presenting to the ED with no concurrent, life-threatening injuries.InterventionA prognostic model (the STUMBL score) to guide clinical decision-making.Outcome measuresPrimary: participant recruitment rate and clinicians’ use of the STUMBL score. Secondary: composite outcome measure (mortality, pulmonary complications, delayed upgrade in care, unplanned representations to the ED), physical and mental components of quality of life, clinician feedback and health economic data gathering methodology for healthcare resource utilisation.ResultsQuantitative data were analysed using the intention-to-treat principle. 176 patients were recruited; recruitment targets were achieved at all sites. Clinicians used the model in 96% of intervention cases. All feasibility criteria were fully or partially met. After adjusting for predefined covariates, there were no statistically significant differences between the control and intervention periods. Qualitative analysis highlighted that STUMBL was well-received and clinicians would support a definitive trial. Collecting data on intervention costs, health-related quality of life and healthcare resource use was feasible.DiscussionWe have demonstrated that a fully powered randomised clinical trial of the STUMBL score is feasible and desirable to clinicians. Minor methodological modifications will be made for the full trial.Trial registration number ISRCTN95571506; Post-results.

The combination of the Easter weekend (EW) being followed by a further long weekend, due to the Royal Wedding (RW), led to concerns that emergency departments (EDs) may be overwhelmed.

Concerns over greenhouse gas emissions are driving governments and the automotive industry to seek out ways of reducing vehicle CO₂ emissions. Engine friction reduction is one means of reducing CO₂ emissions, through fuel consumption improvements. Of the different systems within the engine, the camshaft timing drive can contribute around 5 to 10% of the overall engine friction. It is therefore a system that can benefit from careful optimisation. MAHLE has undertaken a motored friction-testing program on a 2.2 litre turbocharged diesel engine with the following different types of camshaft timing drive: • Chain drive with hydraulic tensioner. This is the standard configuration for this engine. • Chain drive with friction tensioner • Wet belt drive • Dry belt drive Testing was conducted to allow the differences in friction between the different drive configurations to be calculated, by comparing each camshaft drive against the standard chain drive system. Using the frictional differences as a basis, the changes in fuel consumption from the standard configuration were predicted for a drive cycle. Changes in CO₂ emissions were then calculated. Experimental uncertainly levels were assessed during the analysis of the results. This paper considers the approach to the testing, the testing process and the test results.

BackgroundLidocaine patches, applied over rib fractures, may reduce pulmonary complications in older patients. Known barriers to recruiting older patients in emergency settings necessitate a feasibility trial. We aimed to establish whether a definitive randomised controlled trial (RCT) evaluating lidocaine patches in older patients with rib fracture(s) was feasible.MethodsThis was a multicentre, parallel-group, open-label, feasibility RCT in seven hospitals in England and Scotland. Patients aged ≥65 years, presenting to ED with traumatic rib fracture(s) requiring hospital admission were randomised to receive up to 3×700 mg lidocaine patches (Ralvo), first applied in ED and then once daily for 72 hours in addition to standard care, or standard care alone. Feasibility outcomes were recruitment, retention and adherence. Clinical end points (pulmonary complications, pain and frailty-specific outcomes) and patient questionnaires were collected to determine feasibility of data collection and inform health economic scoping. Interviews and focus groups with trial participants and clinicians/research staff explored the understanding and acceptability of trial processes.ResultsBetween October 23, 2021 and October 7, 2022, 206 patients were eligible, of whom 100 (median age 83 years; IQR 74–88) were randomised; 48 to lidocaine patches and 52 to standard care. Pulmonary complications at 30 days were determined in 86% of participants and 83% of expected 30-day questionnaires were returned. Pulmonary complications occurred in 48% of the lidocaine group and 59% in standard care. Pain and some frailty-specific outcomes were not feasible to collect. Staff reported challenges in patient compliance, unfamiliarity with research measures and overwhelming the patients with research procedures.ConclusionRecruitment of older patients with rib fracture(s) in an emergency setting for the evaluation of lidocaine patches is feasible. Refinement of data collection, with a focus on the collection of pain, frailty-specific outcomes and intervention delivery are needed before progression to a definitive trial.Trial registration number ISRCTN14813929.

Tension gastrothorax is a rare life-threatening condition that needs early decompression of the stomach either by nasogastric tube, endoscopy or in extremis by needle decompression. 1 Following repair of a grade IV hiatus hernia, she successfully stopped all inhalers and fully recovered.

Patients with attacks of re-entrant supraventricular tachycardia (SVT) frequently present to the emergency department (ED). The Valsalva manoeuvre (VM) is the most effective and safe vagal manoeuvre and advocated as the first-line treatment in stable patients but has a relatively low cardioversion success rate. Improving its efficacy would reduce patients’ exposure to the side effects and complications of second-line treatments and has other potential benefits. We describe a modification to the VM, which is currently being studied, and present the case of a 23-year-old patient who was successfully treated with this modified VM after a previous near-fatal complication of direct current (DC) cardioversion.

A boy aged 7 years presented with his parents to the emergency department (ED). He had a known diagnosis of paroxysmal supraventricular tachycardia (SVT) and was under the care of paediatricians. He had been suffering episodes of palpitations and chest pain for over a year and had been prescribed atenolol 25 mg ON, though the side effects meant he had not taken it for a month prior to presentation. He had 2 previous confirmed episodes of SVT, one that reverted with Valsalva manoeuvres, and the other with intravenous adenosine. In the ED, an ECG was recorded showing SVT at 180 bpm. Aside from his tachycardia, he was haemodynamically stable. The postural modification of the Valsalva technique was performed within 5 min of arrival, with reversion to sinus rhythm occurring during the leg-lift phase on the first attempt. After 30 min of observation, the child remained stable and was discharged home.

BackgroundThe IPED study showed that use of a smartphone-based event recorder (AliveCor) in ED patients presenting with palpitation or pre-syncope, increased the number of patients in whom an ECG was captured during symptoms over five-fold to more than 55% at 90 days (Reed MJ et al. Lancet eClinical Medicine 2019; 8: 37–46). The pocket sized AliveCor (now Kardia) mobile (AliveCor, San Francisco, USA) is a monitoring device that requires the patient to trigger the ECG recording. With minimal training, two fingers from each hand are placed on the monitor (which can be connected to the back of a smartphone) for 30 s to take an ECG recording.This pre-planned analysis looked at the time to symptomatic rhythm detection in the intervention (AliveCorgroup)to determine the optimum AliveCor device monitoring period in the outpatient setting.Method and resultsPre-planned sub study analysis of a randomised controlled multi-centre trial. Participants ≥16 years old presenting to 10 UK hospital EDs with palpitation or pre-syncope whose underlying ECG rhythm during these episodes remained undiagnosed after ED assessment were enrolled. Time to symptomatic rhythm detection was recorded and analysed.Conclusions243 participants were recruited over an 18-month period. A symptomatic rhythm was detected at 90 days in 69 (n=124; 55.6%; 95% CI 46.9–64.4%) participants in the intervention (AliveCor) group.92.8% of patients who recorded a symptomatic rhythm during the 90 day period recorded this rhythm during the first 28 days (figure 1/table 1).Abstract 023 Figure 1Time to symptomatic rhythm detection in the intervention (AliveCor) group (n=69)Abstract 023 Table 1Cumulative symptomatic rhythm detection in the intervention (AliveCor) group (n=69)Conclusion: ED palpitation patients discharged with a smartphone-based event recorder such as the AliveCor should be reviewed after 4 weeks to enable efficient device usage and timely treatment if required. Patients in whom a diagnosis has not been made can be re-reviewed at 90 days. (1541 characters/285 words)