Mike Wells

Aim The goal of this study was to compare the relative effectiveness of three adjunctive maneuvers - head elevation (HE), forward laryngoscope traction (FT), and external laryngeal manipulation (ELM) - on laryngoscopic view, intubation time, and intubation success performed by a sample of novice intubators using a simulated airway. Twenty-two second year university paramedic students were required to perform laryngoscopy and intubation on a simulator four times on two separate days. The first day involved intubation using no adjunctive maneuvers (control) plus HE, FT, and ELM in random order in a normal simulated airway. A similar approach was used on the second day, but the simulator was configured to have a difficult airway. Percentage of glottic opening (POGO) scores, intubation time, and intubation success were measured for all intubation attempts. Head elevation was found to be the most effective adjunctive maneuver in the normal airway, increasing the mean POGO score from cont...

A rapid, accurate weight-estimation method is essential in paediatric emergency care, when it may not be possible to weigh a child, as drug dose calculations cannot be completed without weight. To determine and compare the performance of the Broselow tape, PAWPER (Paediatric Advanced Weight Prediction in the Emergency Room) tape, Mercy method, Wozniak method and three age-based formulae in estimating the weight of children. A secondary objective was to assess whether the addition of a figural rating scale to assess body habitus improved the performance of the PAWPER tape. We estimated the weights of children between the ages of 1 month and 12 years using the Broselow tape, PAWPER tape, Mercy method and Wozniak method. The performance of the four methods was evaluated, and they were compared with one another and with three aged-based formulae. Three hundred children were enrolled in the study. The PAWPER tape and Mercy method performed the best, estimating weight within 10% of actual...

This ultrasound-based cross-sectional study aimed to visualize, locate and compare the position of the mental foramen with regard to its relationship to various soft tissue landmarks. 100 Black and Caucasian subjects were included. An ultrasound transducer was used to locate the mental foramina. Distances to various landmarks were measured and compared. All mental foramina were visualized. The mean soft tissue distance of the entire group from the mental foramen on the right and left sides, respectively, were as follows: (a) 3.4 mm [standard deviation (SD) 1.7 mm] and 3.4 mm (SD 1.5 mm) lateral to a vertical line passing through the chelion; (b) 20.1 mm (SD 2.6 mm) and 20.1 mm (SD 2.6 mm) distal to a horizontal line bisecting the chelions; (c) 15.1 mm (SD 2.4 mm) and 15.0 mm (SD 2.4 mm) proximal to the inferior border of the mandible. We found no statistically significant differences between race groups, between gender group and between age categories with regard to the horizontal soft tissue distance from a vertical line passing through the chelion to the mental foramen on the right or left sides. There were statistically significant (but not clinically significant) differences between race groups and between gender groups but not between age groups with regard to the vertical soft tissue distance from a horizontal line bisecting the chelions to the mental foramen as well as from the inferior border of the mandible to the mental foramen on both the right and left sides. This study suggests that ultrasound is a feasible imaging modality that can be utilized to locate the mental foramen. Differences in the position of the mental foramen with regard to various soft tissue landmarks are minor and clinically insignificant.

The mental foramen and mental nerve are clinically important landmarks for clinicians across various disciplines including dentists, oral maxillofacial surgeons, emergency physicians and plastic and reconstructive surgeons. To minimize complications related to procedures in the vicinity of the mental foramen and nerve, knowledge of its anatomy and anatomical variations is cardinal to concerned clinicians. In this review, basic anatomy, procedural complications, hard and soft tissue relations, variations between population groups, asymmetry, accessory mental foramina and the use of various radiological modalities to determine the position of the mental foramen are reviewed to provide a more thorough understanding of this important landmark.

Conclusion Pre-hospital RSI may not be implementable in all emergency medical services in South Africa because of lack of resources. Apart from personnel requirements, services wishing to implement pre-hospital RSI must be properly prepared, including providing ...

This is a prospective study of 212 black South African patients operated on with a pre-operative diagnosis of acute appendicitis. There were 143 male and 69 female patients. Forty-four patients had normal appendices and 122 non-perforated and 46 perforated acute appendices. The appendix was normal in 12 male and 32 female patients. Most presenting signs had a high positive predictive value but few had a high negative predictive value. There was no significant difference in the systemic response between perforated and non-perforated groups. Delay in presentation accounted for the majority of perforated appendices, while there was no causal relationship between in-hospital observation and perforation. The complication rate was higher and hospital stay longer in the perforated group. We concluded that the presentation and clinical course of acute appendicitis in the population of black South Africans catered to by our hospital is not very different from that in the white population elsewhere in the world.

The ideal management for penetrating ureteral trauma is primary repair, but the effect of other abdominal injuries might preclude this. We attempted to determine what factors could be used to predict a poor outcome of a ureteral anastomosis, so that the initial management can be modified appropriately. The case notes of 41 patients treated for penetrating ureteral trauma were studied retrospectively. Any factors that could influence postoperative complications and outcome were statistically analyzed in order to determine which could be used pre- or intraoperatively to indicate a poor prognosis for the ureteral anastomosis. The presence of shock on admission (P = 0.013), intraoperative bleeding (P = 0.006), colonic injury and specifically injury requiring colectomy (P = 0.006) were associated with a high complication and mortality rate. Patients presenting with penetrating ureteral trauma who are severely shocked and have complicated intraoperative hemostasis and patients who require colectomy should not have a primary ureteral anastomosis, but rather initial ureteral exteriorization or even nephrectomy.

Most traumatic colon injuries can be repaired primarily, but a colostomy may still be required for severe colonic or rectal injury. The current trend is to reverse the colostomy early, rather than to wait the traditional 3 months before closure. Forty-nine patients with colostomies after abdominal trauma were entered into the study. All patients had undergone a contrast enema in the second postoperative week to assess distal colon healing. Patients were excluded from early closure for nonhealing of the bowel injury, unresolving wound sepsis, or an unstable condition. We then compared the outcome of the remaining 38 (77.6%) patients allocated to either an early or a late colostomy group in a controlled, prospective, randomized trial. We found no significant difference in morbidity between the two groups, with an overall complication rate of 26.3%. Technically the early closure of colostomies was far easier than late closure and required significantly less operating time (p = 0.036) and with less intraoperative blood loss (p = 0.020). The closure of end colostomies was more time consuming, both early (p < 0.001) and late (p < 0.001) and caused more bleeding (p < 0.001 and p < 0.001, respectively). Total hospitalization was marginally shorter overall for early closure, but late closure of end colostomies resulted in prolonged hospitalization (p = 0.023). The early closure of colostomies and the use of loop colostomies whenever possible are recommended as both safe and beneficial for patients with colonic injury after trauma. Contraindications for early closure include nonhealing distal bowel, persistent wound sepsis, or persistent postoperative instability.

Healthcare professionals working in emergency medicine are often exposed to noisy environments. We determined if there is any difference in cognitive task performance required for clinical decision-making of healthcare professionals in a quiet compared with noisy environment and to assess the subjective experience of participants with regard to performance in a noisy environment. This was a prospective cross-over study conducted at three academic hospitals in Johannesburg, South Africa. 41 doctors involved in the emergency management of patients were administered six matched and prevalidated medical questions over a 30-min period. Each doctor completed half of the questions with exposure to ambient noise (range 40-52 dB(A)) and the other half with exposure to pre-recorded background emergency department noise at 80-85 dB(A). The questions were completed in alternating quiet and noise: half of the physicians answered the odd questions in noise and half answered even numbered question...