Emergency Medicine News

Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest
Although the benefits of mild therapeutic hypothermia (MTH) in selected patients after out-of-hospital cardiac arrest have been consistently demonstrated, no controlled trial of MTH in selected patients after in-hospital cardiac arrest (IHCA) has been published. This article sought to assess the benefit of MTH after IHCA in patients meeting our institutions IHCA MTH inclusion criteria. Overall it found no difference in neurological outcome at discharge was detected in predominantly non-shockable IHCA patients treated with MTH. This finding, if confirmed with further study, may define a population of patients for whom this costly and resource intensive therapy should be withheld.

Imaging and Insurance: Do the Uninsured Get Less Imaging in Emergency Departments?
On average, Americans without health insurance receive fewer health care services than those with insurance. The specific types of services for which the uninsured face access and utilization deficits are not well understood. The authors describe the use of imaging tests in hospital emergency departments (EDs) by nonelderly patients, comparing uninsured, Medicaid, and non-Medicaid insured individuals. Compared with comparable insured persons, nonelderly uninsured and Medicaid patients received fewer services in the ED (8% and 10%, respectively, P < .01), even after adjustment for level of acuity. These results suggest that insurance status influences how much imaging and the intensity of imaging patients receive. Further research is needed to understand whether insured patients receive unnecessary imaging or if uninsured and Medicaid patients receive too little imaging.

Stroke Mimics and Intravenous Thrombolysis
The necessity for rapid administration of intravenous thrombolysis in patients with acute ischemic stroke may lead to treatment of patients with conditions mimicking stroke. This article analyzed stroke patients treated with intravenous thrombolysis in our center to characterize cases classified as stroke mimics. It was found that Stroke mimics were infrequent among intravenous thrombolysis–treated stroke patients in this cohort, and their treatment did not lead to harmful complications.

Use Pulmonary Embolism Rule-Out Criteria 'With Confidence'
A clinical decision tool known as PERC (for Pulmonary Embolism Rule-out Criteria) is highly sensitive for excluding pulmonary embolism in patients with a low pretest probability, a new meta-analysis has shown. "Use of PERC could thus avoid the frequent expensive diagnostic imaging that typically results when a D-dimer result is positive," the investigators say.

Incidence of blunt cerebrovascular injury in low-risk cervical spine fractures
It has been suggested that specific cervical spine fractures (CSfx) (location at upper cervical spine [CS], subluxation, or involvement of the transverse foramen) are predictive of blunt cerebrovascular injury (BCVI). The authors sought to determine the incidence of BCVI with CSfx in the absence of high-risk injury patterns and found that all CS fracture patterns warrant screening for BCVI.

Oral and Tympanic Membrane Temperatures are Inaccurate to Identify Fever in Emergency Department Adults
Identifying fever can influence management of the emergency department (ED) patient, including diagnostic testing, treatment, and disposition. This article set out to determine how well oral and tympanic membrane (TM) temperatures compared with rectal measurements. Overall it was shown that the oral and tympanic temperature readings are not equivalent to rectal thermometry readings. Oral thermometry frequently underestimates the temperature relative to rectal readings, and TM values can either under- or overestimate the rectal temperature. The clinician needs to be aware of the varying relationship between oral, TM, and rectal temperatures when interpreting readings

The Low Rate of Bacterial Meningitis in Children, Ages 6 to 18 Months, With Simple Febrile Seizures
This evidence-based review examines the risk of bacterial meningitis as diagnosed by lumbar puncture (LP) in children presenting to the emergency department (ED) with a simple febrile seizure. The study population consists of fully immunized children between ages 6 and 18 months of age with an unremarkable history and normal physical examination. Overall it was found that the sample size of the studies included in this review is too small to draw any definitive conclusion. However, their findings suggest that that the risk of bacterial meningitis in children presenting with simple febrile seizure is very low.

Levamisole Exposure and Hematologic Indices in Cocaine Users
 Levamisole is an antihelminthic agent found in nearly 70% of seized U.S. cocaine. Sporadic case literature describes a life-threatening agranulocytosis associated with levamisole exposure secondary to cocaine use. The authors of this article compared the distribution of hematologic indices in a population of cocaine users with and without a confirmed exposure to levamisole. It was found that the overall incidence of neutropenia was 4.2% in all cocaine users and 2.1% in the levamisole-positive group. A striking number of the reported patients with levamisole-associated neutropenia have presented to care with oropharyngeal complaints, vasculitis, or fever. A clinical algorithm for identifying levamisole toxicity in the emergency department setting is provided. Further research is necessary to determine the circumstances required for levamisole-associated neutropenia.

Docs Get Animated About Underused Trauma Tx
Frustrated with the apparently slow adoption of a drug, tranexamic acid, proven to save trauma victims' lives, British researchers have turned to cartoon animation and YouTube to raise clinicians' awareness of the treatment's effectiveness. Based at the London School of Hygiene and Tropical Medicine, the researchers responsible for the 2010 CRASH-2 trial -- a randomized study showing that tranexamic acid cut the risk of fatal bleeding events in trauma patients by 15% -- has posted a video on YouTube that dramatizes the drug's benefit.

Texas Teens Had Heart Attacks After Smoking K2
 Three 16-year-olds had heart attacks after smoking K2, a blend of herbs and spices laced with synthetic cannabis-like chemicals, Texas doctors reported Monday. While there is no proof that the drug is to blame, the doctors worry it might have been the cause. "Lots of teenagers get chest pain, but very few teenagers get that from a heart attack," said Dr. Colin Kane, a pediatric cardiologist at UT Southwestern & Children's Medical Center in Dallas. "I am certainly suspicious that there was something in the K2 that would have caused these heart attacks." A few earlier reports have linked marijuana use to heart disease, but this appears to be the first time K2 has surfaced in that context, Dr. Kane told Reuters Health.

The Denver Seizure Score: anion gap metabolic acidosis predicts generalized seizure
Anion gap (AG) and serum bicarbonate concentration (BICARB) may help confirm a diagnosis of seizure in an unwitnessed collapse; however, little data exist to support this practice. This article sought to assess the association between AG metabolic acidosis and generalized seizure and to derive a simple score to predict seizure. The authors found that an anion gap metabolic acidosis is associated with generalized seizure and a Denver Seizure Score greater than 20 predicts generalized seizure in the emergency department and may be useful for differentiating patients with unwitnessed loss of consciousness.

Paediatric arrhythmias in the emergency department
Emergency department (ED) staff need to rapidly establish accurate diagnosis and management for children with arrhythmias. Limited data are available on the presenting features, epidemiology and management of arrhythmias encountered in the ED. The aim of this study was to characterise the incidence, presenting features, management and outcomes of arrhythmias at a large tertiary children's hospital ED.  There were a total of 444 non-arrest arrhythmias with an incidence of 11.5:10 000 presentations. Median age of patients at presentation was 10.4 years; 45% were male. Supraventricular arrhythmias (SVTs) represented the largest subgroup (n=250, 56%). Conduction disorders (n=18), ventricular tachycardia (n=17) and atrial flutter/fibrillation (n=7) were rare. There were 19 cardiac arrests. Fifty-seven (13%) patients had underlying congenital heart disease. For ongoing SVT (n=135), vagal manoeuvres were used in 74%, and antiarrhythmic drugs in 64%. In five patients with SVT, drugs other than adenosine were used. Defibrillators were used only on 2 occasions for arrthymias and 6 times for cardiac arrests. 18 of 19 children in cardiac arrest died.

Eli Lilly withdraws sepsis treatment Xigris
Drugmaker Eli Lilly and Co. is withdrawing the severe sepsis treatment Xigris from all markets because a recently concluded study showed that it is no longer effective. Severe sepsis is blood poisoning caused by an aggressive bacterial infection that can cause major organ failure. It can develop as a complication from pneumonia or bacterial infections. The Indianapolis company said Tuesday there is no safety issue with the drug, but a study started in 2008 found it failed to reduce mortality in patients with septic shock. Lilly said patients should stop taking Xigris, which U.S. regulators approved in 2001.

Selective Use of Computed Tomography Compared With Routine Whole Body Imaging in Patients With Blunt Trauma
Routine pan–computed tomography (CT, including of the head, neck, chest, abdomen/pelvis) has been advocated for evaluation of patients with blunt trauma based on the belief that early detection of clinically occult injuries will improve outcomes. We sought to determine whether selective imaging could decrease scan use without missing clinically important injuries. Pan-CT was performed in 600 of the patients; the remaining 101 underwent limited scanning. One or both physicians indicated a willingness to omit 35% of the individual scans. An abnormality was present in 18% of scans, including 22% of desired scans and 10% of undesired scans. Among the 95 patients who had one of the 102 undesired scans with abnormal results, 3 underwent a predefined critical action. There is disagreement among the authors about the clinical significance of the abnormalities found on the 99 undesired scans that did not lead to a critical action.

Diabetes Is Not Associated With Increased Mortality in Emergency Department Patients With Sepsis
Despite its high prevalence, the influence of diabetes on outcomes of emergency department (ED) patients with sepsis remains undefined. Our aim is to investigate the association of diabetes and initial glucose level with mortality in patients with suspected infection from the ED. Three independent, observational, prospective cohorts from 2 large US tertiary care centers were studied. We included patients admitted to the hospital from the ED with suspected infection. A total of 7,754 patients were included. The mortality rate was 4.3% and similar in diabetic and nondiabetic patients (4.1% versus 4.4%). There was no significant association between diabetes and mortality in adjusted analysis. Diabetes significantly modified the effect of hyperglycemia and hypoglycemia with mortality; initial glucose levels greater than 200 mg/dL were associated with higher mortality in nondiabetic patients but not in diabetic patients, whereas glucose levels less than 100 mg/dL were associated with higher mortality mainly in the diabetic population and to a lesser extent in nondiabetic patients.

Droperidol Analgesia for Opioid-Tolerant Patients
Patients with acute and chronic pain syndromes such as migraine headache, fibromyalgia, and sickle cell disease represent a significant portion of emergency department (ED) visits. Certain patients may have tolerance to opioid analgesics and often require large doses and prolonged time in the ED to achieve satisfactory pain mitigation. Droperidol is a unique drug that has been successfully used not only as an analgesic adjuvant for the past 30 years, but also for treatment of nausea/vomiting, psychosis, agitation, sedation, and vertigo. In this review the authors examined the evidence supporting the use of droperidol for analgesia, adverse side effects, and controversial United States (US) Food and Drug Administration (FDA) black box warning and conclude that Droperidol is an important adjuvant for patients who are tolerant to opioid analgesics. The FDA black box warning does not apply to doses below 2.5mg.

Emergency Department Control of Blood Pressure in Intracerebral Hemorrhage
Early treatment of elevated blood pressure (BP) in patients presenting with spontaneous intracerebral hemorrhage (ICH) may decrease hematoma enlargement and lead to better neurologic outcome. Study Objective: To determine whether early BP control in patients with spontaneous ICH is both feasible and tolerated when initiated in the Emergency Department (ED).This was a single-center, prospective observational study in patients with spontaneous ICH was performed to evaluate a protocol to lower, and maintain for 24 h, the mean arterial pressure (MAP) to a range of 100–110 mm Hg within 120 min of arrival to the ED. An additional goal of placing a functional arterial line within 90 min was specified in our protocol. Hematoma volume, neurologic disability, adverse events, and in-hospital mortality were recorded. A total of 22 patients were enrolled over a 1-year study period. The in-hospital mortality rate in this group of patients was 41% and show that adopting a protocol to reduce and maintain the MAP to a target of 100–110 mm Hg within 120 min of ED arrival was safe and well tolerated in patients presenting with spontaneous ICH. If future trials demonstrate a clinical benefit of early BP control in spontaneous ICH, EDs should implement similar protocols.

How Well Does Serum Bicarbonate Concentration Predict the Venous pH in Children Being Evaluated for Diabetic Ketoacidosis?
: The objective of the study was to determine whether serum bicarbonate (HCO3) concentration can accurately predict venous pH in the evaluation of diabetic ketoacidosis (DKA). This was a retrospective review of patients who presented to a children's hospital emergency department and received an International Classification of Diseases, Ninth Revision code related to DKA or diabetes mellitus was performed.The results demonstrated that a HCO3 18.5 or less predicts pH less than 7.3 (area under the curve = 0.97; CI, 0.94-0.99; sensitivity, 93%; specificity, 91%), and a HCO3 10.5 or less predicts pH less than 7.1. The authors conclude that a serum bicarbonate accurately predicts abnormal venous pH in children with DKA. Venous pH determination may not be necessary for all patients being evaluated for DKA.

Anterior Versus Lateral Needle Decompression of Tension Pneumothorax: Comparison by Computed Tomography Chest Wall Measurement 
With commonly available angiocatheters, the lateral approach is less likely to be successful than the anterior approach. The anterior approach may fail in many patients as well. Longer angiocatheters may increase the chances of decompression, but would also carry a higher risk of damage to surrounding vital structures. This was a retrospective study was conducted of emergency department (ED) patients who underwent computed tomography (CT) of the chest as part of their evaluation for blunt trauma. Six measurements from the skin surface to the pleural surface were made for each patient: anterior second intercostal space, lateral fourth intercostal space, and lateral fifth intercostal space on the left and right sides.  The distance from skin to pleura at the anterior second intercostal space averaged 46.3 mm on the right and 45.2 mm on the left. The distance at the midaxillary line in the fourth intercostal space was 63.7 mm on the right and 62.1 mm on the left. In the fifth intercostal space the distance was 53.8 mm on the right and 52.9 mm on the left. The distance of the anterior approach was statistically less when compared to both intercostal spaces. Overall this article showed that the lateral approach is less likely to be successful than the anterior approach. The anterior approach may fail in many patients as well. Longer angiocatheters may increase the chances of decompression, but would also carry a higher risk of damage to surrounding vital structures.

Rapid Rehydration in the ED Effective for Children
A 4-hour rehydration technique for children with gastroenteritis worked just as well as a 24-hour inpatient approach, according to a study published online September 26 inPediatrics.

What's New with Flu? For Doctors, Vaccination by Example
Flu vaccination rates in the United States are up, and more health care professionals are leading by example, Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention, said at a press conference on Sept. 21. The annual flu vaccine is never perfect, but "we can say with certainty that the best way to protect yourself, your family, and your community is to get a flu shot," Dr. Frieden said. Approximately 90 million doses of vaccine are currently available, and 170 million doses are expected this year, Dr. Frieden said. Availability of the flu vaccine should not be a concern this year, and now is a great time for health care professionals and the public to get their flu vaccines.

Simvastatin in traumatic brain injury
Traumatic brain injury causes deleterious brain edema, leading to high mortality and morbidity. Brain edema exacerbates neurologic deficits and may be attributable to the breakdown of endothelial cell junction protein, leukocyte infiltration, and matrix metalloproteinase activation. These all contribute to loss of blood–brain barrier integrity. The pleiotropic effects of statins, hydroxymethylglutaryl-coenzyme A reductase inhibitors, may inhibit posttraumatic brain edema. We therefore investigated the effect of acute simvastatin on neurologic deficits, cerebral edema, and its origins. This Randomized laboratory animal study found that  Simvastatin could be a new therapy for reducing posttraumatic edema by preventing damage to tight junctions and neutrophil infiltration into the parenchyma, thus preserving blood–brain barrier integrity.

Ethanol Intoxication Is Associated with a Lower Incidence of Admission Coagulopathy in Severe Traumatic Brain Injury Patients
The aim of this study was to determine the impact of ethanol (ETOH) on the incidence of severe traumatic brain injury (sTBI)-associated coagulopathy and to examine the effect of ETOH on in-hospital outcomes in patients sustaining sTBI. Coagulopathy was significantly less frequent in the ETOH (+) patients compared to their ETOH (−) counterparts (5.4% versus 15.3%). In the forward logistic regression analysis, a positive ETOH level proved to be an independent protective factor for admission coagulopathy and patients had a significantly lower in-hospital mortality rate than ETOH (−) patients (9.8% versus 16.6%).  For brain-injured patients arriving alive to the hospital, ETOH intoxication is associated with a significantly lower incidence of early coagulopathy and in-hospital mortality. Further research to establish the pathophysiologic mechanisms underlying any potential beneficial effect of ETOH on the coagulation system following sTBI is warranted.

Is Succinylcholine Really Superior for RSI?
Intubation is arguably the most important procedure performed by Emergency Physicians (EPs). Ideally, it would be performed successfully on the first attempt each and every time, but this of course cannot always be the case. Rapid Sequence Intubation (RSI) has become the preferred method for emergency intubations, as it improves visualization of the vocal cords, and decreases complications such as aspiration and increased intracranial pressure. This study was performed as a retrospective analysis of prospectively collected data at an academic Level 1 Trauma, tertiary care center with an emergency medicine residency program. Data from consecutive ED patients requiring intubation were collected prospectively over 15 months.  The groups were demographically similar, and had similar intubation parameters. None of the patients required surgical airways. Rates of successful first intubation were similar with 72.6% in the succinylcholine group and 72.9% in the rocuronium group. Bottom line – it seems reasonable to reach for the roc in patients with potential contraindications to succ – but think carefully about its long ½ life.

Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins
Current European Resuscitation Council (ERC) guidelines recommend intraosseous (IO) vascular access, if intravenous (IV) access is not readily available. Because central venous catheterisation (CVC) is an established alternative for in-hospital resuscitation, we compared IO access versus landmark-based CVC in adults with difficult peripheral veins. Forty consecutive adults patients under resuscitation were analysed, each receiving IO access and CVC simultaneously. Success rates on first attempt were significantly higher for IO cannulation than CVC (85% versus 60%, p=0.024) and procedure times were significantly lower for IO access compared to CVC (2.0 versus 8.0min, p<0.001). As for complications, failure of IO access was observed in 6 patients, while 2 or more attempts of CVC were necessary in 16 patients. 

Stable Patients With Pulmonary Embolism Can Be Treated as Outpatients
Typically, diagnosis of pulmonary embolism (PE) means certain admission. Researchers performed an open-label, randomized, noninferiority study to compare outcomes of outpatient and inpatient treatment in consecutive adult patients who presented to 19 emergency departments in Europe and the U.S. with symptomatic PE and risk for death less than 4%. Overall, the study included 171 outpatients (mean age, 47) and 168 inpatients (mean age, 49). Cancer prevalence was 1% and 2%, respectively. Within 90 days, one patient in each group died, neither from PE. Recurrent venous thromboembolism occurred in only one patient (outpatient group).

Prolonged Fever is Typhoid's Hallmark
Two-thirds of all cases of typhoid fever seen in the United States result from travel to India or neighboring Pakistan or Bangladesh. Add in Mexico, the Philippines, and Guatemala, and travel to just those six countries accounts for 80% of all U.S. cases of typhoid fever, according to a Centers for Disease Control and Prevention study. Some 41% of cases in the United States during 1999-2006 occurred in patients aged 17 years or younger."This is a very important disease in children," Dr. Jay S. Keystone noted in highlighting the CDC report at a conference on pediatric infectious diseases sponsored by Children's Hospital, Colorado, Aurora. The infection has substantial morbidity, as 73% of patients were hospitalized, half for longer than a week. The mortality rate, however, was only 0.2%.

Association between timing of antibiotic administration and mortality from septic shock
This article sought to determine the association between time to initial antibiotics and mortality of patients with septic shock treated with an emergency department-based early resuscitation protocol. In this large, prospective study of emergency department patients with septic shock, we found no increase in mortality with each hour delay to administration of antibiotics after triage. However, delay in antibiotics until after shock recognition was associated with increased mortality.

One-Year Prognosis After Syncope and the Failure of the ROSE Decision Instrument to Predict One-Year Adverse Events
The authors investigated the incidence of adverse events at 1 year in the cohort of emergency department (ED) syncope patients enrolled in the original Risk Stratification of Syncope in the Emergency Department (ROSE) study, the time to adverse event, and the test performance of the ROSE decision instrument to detect events at 1 year. This article found that the proportion of patients with serious outcome and all-cause death 1 year after syncope is similar to that reported in recent international syncope studies. We have defined the proportion of patients with cardiovascular serious outcome at 1 year and have shown that most events occurred in the first month, with decreased frequency of events observed after that time especially marked for cardiovascular serious outcome. More than 50% of the outcomes observed, however, occurred after the first month. The ROSE decision instrument does not perform well at predicting 1-year outcome of ED syncope patients.

Predictors of severity in ischaemic colitis
Ischaemic colitis (IC) is an inadequate perfusion leading to potentially life-threatening colonic inflammation. The aim was to identify patient characteristics that predict severity in biopsy-confirmed IC. This article found that the majority of patients with IC can be managed conservatively. Right-sided IC, guarding, lack of bleeding per rectum and chronic constipation are associated with severe IC.

Does therapeutic hypothermia benefit adult cardiac arrest patients presenting with non-shockable initial rhythms?
The benefit of therapeutic hypothermia (TH) for comatose adult patients with return of spontaneous circulation after cardiac arrest (CA) with non-shockable initial rhythms is uncertain. The authors evaluated whether TH reduces mortality and improves neurological outcome in comatose adults resuscitated from non-shockable CA. The authors searched PubMed, EMBASE, CENTRAL, and BIOSIS through March 2010, to identify studies using TH after non-shockable CA. Overall TH is associated with reduced in-hospital mortality for adults patients resuscitated from non-shockable CA. However, most of the studies had substantial risks of bias and quality of evidence was very low. Further high quality randomized clinical trials would confirm the actual benefit of TH in this population.

Ketamine/Propofol Versus Midazolam/Fentanyl for Procedural Sedation and Analgesia in the Emergency Department: A Randomized, Prospective, Double-Blind Trial
The authors performed a prospective, double-blinded, randomized trial with emergency department (ED) patients requiring procedural sedation and analgesia (PSA) for repair of deep traumatic lacerations and reduction of bone fractures, to compare the ketamine/propofol (ketofol) combination with the midazolam/fentanyl (MF) combination. Sixty-two patients scheduled for PSA who presented between January 2009 and June 2009 were enrolled prospectively. Thirty-one were randomly assigned to the ketofol group, and 31 were assigned to the MF group. Overall the ketamine/propofol combination provides adequate sedation and analgesia for painful procedures and appears to be a safe and useful technique in the ED.

High Plasma Lactate Levels Are Associated With Increased Risk of In-hospital Mortality in Patients With Pulmonary Embolism
The objective of this article was to investigate the prognostic value of plasma lactate in patients with acute pulmonary embolism (PE). This was a retrospective study at the emergency department (ED) of a third-level teaching hospital. The authors considered consecutive patients with a diagnosis of PE established by lung scan or spiral computed tomography (CT) and confirmed by pulmonary angiography if necessary. Only patients for whom plasma lactate levels had been tested within 6 hours from presentation to the ED were included. Primary outcome was in-hospital death due to any cause; secondary outcome was mortality related to PE. Overall Twenty patients died during their hospital stay (7%). Plasma lactate levels ≥ 2 mmol/L were associated with in-hospital mortality from all causes (odds ratio [OR] = 4.60, 95% confidence interval [CI] = 1.57 to 13.53) and with PE-related mortality (OR = 4.94, 95% CI = 1.38 to 17.63), independent of hypotension or RVD at presentation. 

Risk factors for sedation-related events during procedural sedation in the emergency department
This article sought to determine the nature, incidence and risk factors for sedation-related events during ED procedural sedation, with particular focus on the drugs administered.  Two thousand, six hundred and twenty-three patients were enrolled (60.3% male, mean age 39.2 years). Reductions of fracture/dislocations of shoulders, wrists and ankles were most common. Four hundred and sixty-one (17.6%) cases experienced at least one airway event that required intervention. Airway obstruction, hypoventilation and desaturation occurred in 12.7%, 6.4% and 3.7% of all patients, respectively. Two thousand, one hundred and forty-six cases had complete datasets for further analyses. Increasing age and level of sedation, pre-medication with fentanyl, and sedation with propofol, midazolam or fentanyl were risk factors for an airway event (P < 0.05). Ketamine was a protective factor. Hypotension (systolic pressure <80 mmHg) occurred in 34 (1.6%) cases with midazolam being a significant risk factor (P < 0.001). Vomiting also occurred in 34 (1.6%) cases, 12 of whom required an intervention. One patient aspirated. Vomiting occurred after administration of all drugs but was not associated with fasting status. Other events were rare. Overall it was found that sedation-related events, especially airway events, are common but very rarely have an adverse outcome. Elderly patients, deeply sedated with short-acting agents, are at particular risk. The results will help tailor sedation to individual patients.

Effect of type of alcoholic beverage in causing acute pancreatitis
The effect of different alcoholic beverages and drinking behaviour on the risk of acute pancreatitis has rarely been studied. The aim of this study was to investigate the effect of different types of alcoholic beverage in causing acute pancreatitis. A follow-up study was conducted, using the Swedish Mammography Cohort and Cohort of Swedish Men, to study the association between consumption of spirits, wine and beer and the risk of acute pancreatitis. No patient with a history of chronic pancreatitis was included and those who developed pancreatic cancer during follow-up were excluded. Overall The risk of acute pancreatitis was associated with the amount of spirits consumed on a single occasion but not with wine or beer consumption.

What is the relationship between the Glasgow coma scale and airway protective reflexes
The authors of this article was to describe the relationship of gag and cough reflexes to Glasgow coma score (GCS) in Chinese adults requiring critical care. This was a Prospective observational study of adult patients requiring treatment in the trauma or resuscitation rooms of the Emergency Department, Prince of Wales Hospital, Hong Kong. A total of 208 patients were recruited. Reduced gag and cough reflexes were found to be significantly related to reduced GCS. Of 33 patients with a GCS≤8, 12 (36.4%) had normal gag reflexes and 8 (24.2%) had normal cough reflexes. 23/62 (37.1%) patients with a GCS of 9–14 had absent gag reflexes, and 27 (43.5%) had absent cough reflexes. In patients with a normal GCS, 22.1% (25/113) had absent gag reflexes and 25.7% (29) had absent cough reflexes. This study has shown that in a Chinese population with a wide range of critical illness (but little trauma or intoxication), reduced GCS is significantly related to gag and cough reflexes. However, a considerable proportion of patients with a GCS≤8 have intact airway reflexes and may be capable of maintaining their own airway, whilst many patients with a GCS>8 have impaired airway reflexes and may be at risk of aspiration. This has important implications for airway management decisions.

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