As far as your question about delirium screening goes the 2007 urgent care working group recommended the Abbreviated Mental test (AMT4) which as the name suggests has only four criteria inherent in it and can be used for delirium screening as a new or existing co-morbid for instance in patients with # NOF
http://www.akaz.ba/Klinicki_put/Dokumenti/DH_080136.pdf
you might want to take a look at page 29 of 'the silver book' which also has links to best practice in this area of assessment
http://www.bgs.org.uk/campaigns/silverb/silver_book_complete.pdf
Jim Bethel
________________________________________
From: Accident and Emergency Academic List [[log in to unmask]] on behalf of ACAD-AE-MED automatic digest system [[log in to unmask]]
Sent: 26 January 2013 00:01
To: [log in to unmask]
Subject: ACAD-AE-MED Digest - 24 Jan 2013 to 25 Jan 2013 (#2013-4)
There are 4 messages totaling 1511 lines in this issue.
Topics of the day:
1. <No subject given> (4)
----------------------------------------------------------------------
Date: Fri, 25 Jan 2013 09:42:21 +0000
From: Coats Tim - Professor of Emergency Medicine <[log in to unmask]>
Subject: <No subject given>
There is a current trial on the NHS Research Portfolio under the 'Injuries and Emergencies' section http://public.ukcrn.org.uk/search/Portfolio.aspx?Level1=20&Level2=112&Level3=122&Status=34
16152419
FIB trial<http://public.ukcrn.org.uk/search/StudyDetail.aspx?StudyID=7820> - Randomised trial of the fascia-iliaca block versus the 'three-in-one' block for femoral neck fractures in the emergency department
Open
Interventional
No
Trial outline is at http://public.ukcrn.org.uk/search/StudyDetail.aspx?StudyID=7820
I think that I remember that it is CEM funded,
Tim
Prof T Coats
Professor of Emergency Medicine,
University of Leicester, UK.
________________________________
From: Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of John Cronin
Sent: 23 January 2013 22:07
To: [log in to unmask]
Subject:
Interesting what you say William about the lack of studies in the ED setting. I was part of a recent systematic review looking for acute pain studies in a different patient cohort & condition. The search strategy was broad and found hundreds (almost thousands) of studies/RCTs in the post-op and chronic pain settings. However, RCTs for pain in the emergency setting you could count on one hand! Obviously there are challenges for doing these studies in the ED/pre-hospital but it would be great to see more being performed going forward.
With regard to the NOF pain protocol, I think they may have one at the MidWestern Regional, Limerick so you could ask someone there
Good luck
John
On 23 January 2013 21:20, Ash Basu <[log in to unmask]<mailto:[log in to unmask]>> wrote:
Some of us in our ED, perform US guided 3-in-1 blocks, and there is a movement in Wales to make the landmark fasca iliaca block standard practice, to limit opiate use.
In some S. Wales hospitals, fascia iliaca blocks are routinely placed by orthopaedic nurse practitioners, and in the N. Wales hospitals there is a move to also make this standard practice, but the issue with that is to have an ever-present constant workforce appropriately trained (& available) to deliver the block.
The obvious advantage of the fascia iliaca block being that it is a much safer block landmark-wise, and therefore has an easier learning curve. Currently some of the orthopaedic medical & nursing staff are learning these, but we are still a way off having someone trained and always available & free to undertake them for every patient.
Also my FCEM CTR was about US guided femoral & 3-in-1 blocks, but most of the evidence is US vs. Nerve stim & always tend to be in elective pre-ops rather than traumatic injuries, so there is the issue about generalisability.
Ash Basu,
Consultant Emergency Physician,
Wrexham Maelor Hospital
From: william niven<mailto:[log in to unmask]>
Sent: Wednesday, January 23, 2013 10:32 AM
To: [log in to unmask]<mailto:[log in to unmask]>
Dear all
We are currently putting together a national guideline for the ED management of fractured NOF in Ireland. Not wishing to re-invent the wheel, we have been borrowing extensively from both the NICE and SIGN guidelines. Some pain management issues nevertheless require some clarification which I would be grateful for your thoughts and reflections on!
1. NICE does not clarify initial dosages for the admin of opioids. Reading the following articles from anaesthesiology had some interesting insights but was nevertheless in a post-op, PACU setting with close monitoring and small nurse to pt ratios. Unsure of its generalizability...
http://journals.lww.com/anesthesiology/Fulltext/2002/01000/Postoperative_Titration_of_Intravenous_Morphine_in.9.aspx
http://journals.lww.com/anesthesiology/Fulltext/2002/01000/Anesthesiology_and_Geriatric_Medicine__Mutual.6.aspx
Does anyone have any specific policy with respect to IV opiates in the elderly, or has there been any reliable research done on this in the ED setting?
2. The use of 3 in 1 / fascia iliaca blocks is gaining popularity. The evidence seems to suggest that we should be doing these under US guidance.
a) Are any departments doing these as a standard of care?
b) Is it ED or anaesthetics personnel that are doing them?
c) Have any departments been pushing this under US guidance?
A good best-bet was done on this topic http://bestbets.org/bets/bet.php?id=1024 but the real crux of the issue seems to be related to implementation and capacity building in departments with junior docs and poor staffing.
3) Does anyone do any form of initial delerium screening on their NOF patients in the ED? If not, should we, or should this be the remit of ortho-geriatrics / anaesthetics/ICU?
Lots of questions, looking forward to your responses!
Regards
Will Niven
--
Dr John Cronin
SpR in Emergency Medicine
________________________________
This e-mail, including any attached files, may contain confidential and / or privileged information and is intended for the exclusive use of the addressee(s) printed above. If you are not the addressee(s), any unauthorised review, disclosure, reproduction, other dissemination or use of this e-mail, or taking of any action in reliance upon the information contained herein, is strictly prohibited. If this e-mail has been sent to you in error, please return to the sender. No guarantee can be given that the contents of this email are virus free - The University Hospitals of Leicester NHS Trust cannot be held responsible for any failure by the recipient(s) to test for viruses before opening any attachments. The information contained in this e-mail may be the subject of public disclosure under the Freedom of Information Act 2000 - unless legally exempt from disclosure, the confidentiality of this e-mail and your reply cannot be guaranteed. Copyright in this email and any attachments created by us remains vested in the University Hospitals of Leicester NHS Trust.
------------------------------
Date: Fri, 25 Jan 2013 04:43:23 -0800
From: Taj Hassan <[log in to unmask]>
Subject: <No subject given>
http://rehabilitasyonmerkezim.com/yahoo.php?curve816.img
Warm regards
Taj Hassan
------------------------------
Date: Fri, 25 Jan 2013 17:10:24 -0000
From: Rowley <[log in to unmask]>
Subject: <No subject given>
I think Taj's account has been compromised. I'm not sure what the email he
sent is all about, but it looks a lot like spam to me, suggesting that yet
another Yahoo account may have been compromised. Taj, you need to run a
virus check and change your password for your account immediately.
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Taj Hassan
Sent: 25 January 2013 12:43
To: [log in to unmask]
Subject:
http://rehabilitasyonmerkezim.com/yahoo.php?curve816.img
Warm regards
Taj Hassan
1/25/2013 1:43:18 PM
------------------------------
Date: Fri, 25 Jan 2013 21:35:13 -0000
From: Jonathan Benger <[log in to unmask]>
Subject: <No subject given>
Thanks Tim,
We have just completed recruitment to this trial (which is indeed CEM
funded), and are now commencing data analysis: results to follow.
Regards to all,
Jonathan Benger.
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Coats Tim - Professor of
Emergency Medicine
Sent: 25 January 2013 09:42
To: [log in to unmask]
Subject:
There is a current trial on the NHS Research Portfolio under the 'Injuries
and Emergencies' section
http://public.ukcrn.org.uk/search/Portfolio.aspx?Level1=20
<http://public.ukcrn.org.uk/search/Portfolio.aspx?Level1=20&Level2=112&Level
3=122&Status=34> &Level2=112&Level3=122&Status=34
16152419
FIB trial <http://public.ukcrn.org.uk/search/StudyDetail.aspx?StudyID=7820>
- Randomised trial of the fascia-iliaca block versus the 'three-in-one'
block for femoral neck fractures in the emergency department
Open
Interventional
No
Trial outline is at
http://public.ukcrn.org.uk/search/StudyDetail.aspx?StudyID=7820
I think that I remember that it is CEM funded,
Tim
Prof T Coats
Professor of Emergency Medicine,
University of Leicester, UK.
_____
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of John Cronin
Sent: 23 January 2013 22:07
To: [log in to unmask]
Subject:
Interesting what you say William about the lack of studies in the ED
setting. I was part of a recent systematic review looking for acute pain
studies in a different patient cohort & condition. The search strategy was
broad and found hundreds (almost thousands) of studies/RCTs in the post-op
and chronic pain settings. However, RCTs for pain in the emergency setting
you could count on one hand! Obviously there are challenges for doing these
studies in the ED/pre-hospital but it would be great to see more being
performed going forward.
With regard to the NOF pain protocol, I think they may have one at the
MidWestern Regional, Limerick so you could ask someone there
Good luck
John
On 23 January 2013 21:20, Ash Basu <[log in to unmask]> wrote:
Some of us in our ED, perform US guided 3-in-1 blocks, and there is a
movement in Wales to make the landmark fasca iliaca block standard practice,
to limit opiate use.
In some S. Wales hospitals, fascia iliaca blocks are routinely placed by
orthopaedic nurse practitioners, and in the N. Wales hospitals there is a
move to also make this standard practice, but the issue with that is to have
an ever-present constant workforce appropriately trained (& available) to
deliver the block.
The obvious advantage of the fascia iliaca block being that it is a much
safer block landmark-wise, and therefore has an easier learning curve.
Currently some of the orthopaedic medical & nursing staff are learning
these, but we are still a way off having someone trained and always
available & free to undertake them for every patient.
Also my FCEM CTR was about US guided femoral & 3-in-1 blocks, but most of
the evidence is US vs. Nerve stim & always tend to be in elective pre-ops
rather than traumatic injuries, so there is the issue about
generalisability.
Ash Basu,
Consultant Emergency Physician,
Wrexham Maelor Hospital
From: william niven <mailto:[log in to unmask]>
Sent: Wednesday, January 23, 2013 10:32 AM
To: [log in to unmask]
Dear all
We are currently putting together a national guideline for the ED management
of fractured NOF in Ireland. Not wishing to re-invent the wheel, we have
been borrowing extensively from both the NICE and SIGN guidelines. Some
pain management issues nevertheless require some clarification which I would
be grateful for your thoughts and reflections on!
1. NICE does not clarify initial dosages for the admin of opioids. Reading
the following articles from anaesthesiology had some interesting insights
but was nevertheless in a post-op, PACU setting with close monitoring and
small nurse to pt ratios. Unsure of its generalizability...
http://journals.lww.com/anesthesiology/Fulltext/2002/01000/Postoperative_Tit
ration_of_Intravenous_Morphine_in.9.aspx
http://journals.lww.com/anesthesiology/Fulltext/2002/01000/Anesthesiology_an
d_Geriatric_Medicine__Mutual.6.aspx
Does anyone have any specific policy with respect to IV opiates in the
elderly, or has there been any reliable research done on this in the ED
setting?
2. The use of 3 in 1 / fascia iliaca blocks is gaining popularity. The
evidence seems to suggest that we should be doing these under US guidance.
a) Are any departments doing these as a standard of care?
b) Is it ED or anaesthetics personnel that are doing them?
c) Have any departments been pushing this under US guidance?
A good best-bet was done on this topic
http://bestbets.org/bets/bet.php?id=1024 but the real crux of the issue
seems to be related to implementation and capacity building in departments
with junior docs and poor staffing.
3) Does anyone do any form of initial delerium screening on their NOF
patients in the ED? If not, should we, or should this be the remit of
ortho-geriatrics / anaesthetics/ICU?
Lots of questions, looking forward to your responses!
Regards
Will Niven
--
Dr John Cronin
SpR in Emergency Medicine
_____
This e-mail, including any attached files, may contain confidential and / or
privileged information and is intended for the exclusive use of the
addressee(s) printed above. If you are not the addressee(s), any
unauthorised review, disclosure, reproduction, other dissemination or use of
this e-mail, or taking of any action in reliance upon the information
contained herein, is strictly prohibited. If this e-mail has been sent to
you in error, please return to the sender. No guarantee can be given that
the contents of this email are virus free - The University Hospitals of
Leicester NHS Trust cannot be held responsible for any failure by the
recipient(s) to test for viruses before opening any attachments. The
information contained in this e-mail may be the subject of public disclosure
under the Freedom of Information Act 2000 - unless legally exempt from
disclosure, the confidentiality of this e-mail and your reply cannot be
guaranteed. Copyright in this email and any attachments created by us
remains vested in the University Hospitals of Leicester NHS Trust.
------------------------------
End of ACAD-AE-MED Digest - 24 Jan 2013 to 25 Jan 2013 (#2013-4)
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