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Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96–1·28). No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. National Institute for Health Research Health Services and Delivery Research Programme.

Acute renal colic has been challenging and has brought many concerns for physicians and patients for centuries. This study aimed to evaluate the analgesic effect and safety of a combination of papaverine and ketorolac against ketorolac and placebo in treating acute renal colic. This randomized clinical trial was performed in patients with renal colic from May 2018 to May 2020 in Ahvaz, Iran. Patients with colic pain due to sand or kidney stones underwent clinical examination. The pain intensified based on the visual analog scale (VAS) and the patients' need for rescue analgesia are considered as primary outcomes at various times after treatment. Patients were equally divided into two groups: A (ketorolac plus papaverine) and B (ketorolac plus placebo) by block balanced randomization method. Student test, the Chi square, and ANOVA tests were used for statistical analyses, which were performed by SPSS 19.0. P<0.05 was considered significant. A significant difference was observed in 280 patients (140 patients in each group) in pain intensity between both groups at 45 and 60 min. VAS scores in groups A and B were 5.08±1.23 and 5.56±1.11 in 45 min and 3.35±1.47 and 3.92±1.31 in 60 min (P=0.001, P=0.002), respectively. In subgroup analysis, the VAS score significantly decreased after taking the drug for middle and proximal ureteral stones at 45 and 60 min (P<0.001). Rescue analgesics were required in 7 (5%) and 21 (15%) patients in groups A and B, respectively (P=0.005). Side effects were similar in the two groups. In this study, ketorolac, along with papaverine, was effective in acute renal colic control, and combination therapy with ketorolac and papaverine was associated with reduced use of other rescue analgesics. IRCT20190217042738N1.

Background Fatal trauma is one of the leading causes of death in Western industrialized countries. The aim of the present study was to determine the preventability of traumatic deaths, analyze the medical measures related to preventable deaths, detect management failures, and reveal specific injury patterns in order to avoid traumatic deaths in Berlin. Materials and methods In this prospective observational study all autopsied, direct trauma fatalities in Berlin in 2010 were included with systematic data acquisition, including police files, medical records, death certificates, and autopsy records. An interdisciplinary expert board judged the preventability of traumatic death according to the classification of non-preventable (NP), potentially preventable (PP), and definitively preventable (DP) fatalities. Results Of the fatalities recorded, 84.9 % ( n  = 224) were classified as NP, 9.8 % ( n  = 26) as PP, and 5.3 % ( n  = 14) as DP. The incidence of severe traumatic brain injury (sTBI) was significantly lower in PP/DP than in NP, and the incidence of fatal exsanguinations was significantly higher. Most PP and NP deaths occurred in the prehospital setting. Notably, no PP or DP was recorded for fatalities treated by a HEMS crew. Causes of DP deaths consisted of tension pneumothorax, unrecognized trauma, exsanguinations, asphyxia, and occult bleeding with a false negative computed tomography scan. Conclusions The trauma mortality in Berlin, compared to worldwide published data, is low. Nevertheless, 15.2 % ( n  = 40) of traumatic deaths were classified as preventable. Compulsory training in trauma management might further reduce trauma-related mortality. The main focus should remain on prevention programs, as the majority of the fatalities occurred as a result of non-survivable injuries.

Background The short-term safety and efficacy of insertion of a self-expandable metallic colonic stent followed by elective surgery, bridge to surgery (BTS), for malignant large-bowel obstruction (MLBO) have been well described. However, long-term oncological outcomes are still debated. Hence, this study is conducted to evaluate long-term outcomes of colonic stent insertion followed by surgery for MLBO. Methods A comprehensive electronic literature search through May 2014 was performed to identify studies comparing long-term outcomes between BTS and emergency surgery for MLBO. The main outcome measures were overall survival (OS), disease-free survival (DFS), and recurrence. A meta-analysis was performed using random-effects models to calculate risk ratios (RRs) with 95 % confidence intervals (95 % CIs). Results There were 11 studies that matched the criteria for inclusion, yielding a total of 1136 patients, of whom 432 (38.0 %) underwent BTS and 704 (62.0 %) underwent emergency surgery. In OS analyses of all patients and patients who underwent curative resection, BTS was similar to emergency surgery [(RR = 0.95; 95 % CI 0.75–1.21; P  = 0.66) (RR = 0.96; 95 % CI 0.67–1.37; P  = 0.82), respectively]. DFS (RR = 1.06; 95 % CI 0.91–1.24; P  = 0.43) and recurrence (RR = 1.13; 95 % CI 0.82–1.54; P  = 0.46) did not differ significantly between the BTS and emergency surgery groups. Conclusions Results of this meta-analysis on long-term as well as well-described short-term outcomes suggest that BTS could be a promising alternative strategy for MLBO patients.

This study was designed to assess the possible superiority of intravenous lidocaine to morphine for pain management. This was a randomized double blind controlled superiority trial, carried on in the emergency department (ED). Traumatic patients older than 18-year-old with the complaint of acute pain greater than 4 on a numeric rating scale (NRS) from 0 to 10 on their extremities were eligible. One group received IV lidocaine (1.5 mg/kg), and the other received IV morphine (0.1mg/kg). Pain scores and adverse effects were assessed at 15, 30, 45 and 60 minutes and patients' satisfaction was evaluated two hours later. A minimum pain score reduction of 1.3 from baseline was considered clinically significant. Fifty patients with the mean age of 31.28±8.7 were enrolled (78% male). The demographic characteristics and pain scores of the two groups was similar. The on-arrival mean pain scores in two groups were, lidocaine: 7.9±1.4 and morphine: 8.0±1.4 (p=0.57) and after 1 hour were, lidocaine: 2.28±1.2 and morphine: 3.2±1.7. Although the pain score decreased significantly in both group (p=0.027), there were not any clinically and statistically significant difference between the two groups (p=0.77). Patients' satisfaction with pain management in both groups were almost similar (p=0.49). The reduction in pain score using IV lidocaine is not superior to IV morphine in adult ED patients with traumatic limb pain.

This study describes 11,920 in-flight medical emergencies on the basis of consultations from five major airlines to a physician-directed communications center. In nearly half the emergencies, physicians on board provided assistance, and in 7.3%, the aircraft was diverted. Commercial airlines serve approximately 2.75 billion passengers worldwide annually. When in-flight medical emergencies occur, access to care is limited. Physicians and other medical professionals are often called on to assist when traveling, despite limited training or experience with these situations. 1 Airlines partner with health care institutions to deliver real-time medical advice from an emergency call center to airline personnel, in an effort to improve the quality of care provided to passengers. There is limited information on the incidence and characteristics of in-flight medical emergencies. 2 Although previous studies of these events have characterized the incidence, categories of symptoms, rates of aircraft . . .

Emergency airway management in children is generally considered to be challenging, and endotracheal intubation requires a high level of personal skills and experience. Immobilization of the cervical spine is indicated in all patients with the risk of any cervical spine injury but significantly aggravates endotracheal intubation. The best airway device in this setting has not been established yet, although the use of videolaryngoscopes is generally promising. Seventy-five moderately experienced paramedics of the Emergency Medical Service of Poland performed endotracheal intubations in a pediatric manikin in three airway scenarios: (A) normal airway, (B) manual in-line cervical immobilization, and (C) cervical immobilization using a Patriot cervical extrication collar and using two airway techniques: (1) McGrath videolaryngoscope and (2) Macintosh blade in a randomized sequence. First-attempt intubation success rate, time to intubation, glottis visualization, and subjective ease of intubation were investigated in this study. Intubation of difficult airways, including manual in-line and cervical collar immobilization, using the McGrath was significantly faster, with a higher first-attempt intubation success rate, better glottic visualization, and ease of intubation, compared to Macintosh-guided intubation. In the normal airway, both airway techniques performed equal. Conclusion: Our manikin study indicates that the McGrath may be a reasonable first intubation technique option for endotracheal intubation in difficult pediatric emergencies. Further clinical studies are therefore indicated. What is known : • Airway management in pediatrics is challenging and requires a high level of skills and experience. Cervical immobilization is indicated in all patients with any risk of cervical spine injury, but it significantly aggravates endotracheal intubation in these patients. Videolaryngoscopes have been reported to ease intubation and provide better airway visualization in the regular clinical setting. What is new: • The McGrath is an easy-to-use and clinically often used videolaryngoscope, but it has never been investigated in pediatrics with an immobilized cervical spine. In the normal airway, the McGrath provided better airway visualization compared to Macintosh laryngoscopy. However, better visualization did not lead to decreased time to intubation and a higher success rate of the first intubation attempt. In difficult airways, the McGrath provided better airway visualization and this led to faster intubation, a higher first-attempt intubation success rate, and better ease of intubation compared to Macintosh-guided intubation.

Zoë Fritz and colleagues discuss new approaches to resuscitation decisions that incorporate broader goals of care