Alternative models ofprimary care 83

2 Department of Health. The Patient's Charter. HMSO:London, 1991.

3 Leydon GM, Lawrenson R, Meakin R, Roberts JA. The costof alternative models of accident and emergency care: a system-atic review. A Report to North Thames Regional HealthAuthority. London: Charing Cross and Westminster Medi-cal School, Department of Public Health and PrimaryCare, 1996.

4 Dale J, Green J, Reid F, Glucksman E. Primary care in theaccident and emergency department: I. Prospective identi-fication of patients. BMJ 1995;311:423-6.

5 Meislin HW, Coates SA, Cyr J, Valenzuela T. Fast track:urgent care within a teaching hospital emergencydepartment: can it work? Ann Emerg Med 1988;17:453-6.

6 Benz JR, Shank CJ. Alteration of emergency room usage ina family practice residency program. J Fam Pract 1982; 15:1135-9.

7 Derlet RW, Nishio DA, Cole LM, Silva J. Triage of patientsout of the emergency department: three year experience.Am J Emerg Med 1992; 10:195-9.

8 Community health group starts emergency room diversionproject. Health Care Strategic ManagementJanuary) 1994; 16-18.

9 Murphy AW, Bury G, Plunkett PK, Gibney D, Smith M,Mullan E, Johnson Z. Randomised controlled trial of gen-eral practitioner versus usual medical care in an urbanaccident and emergency department: process, outcome,and comparative cost. BMJ 1996;312:1 135-42.

10 Ward P, Huddy J, Hargreaves S, Touquet R, Hurley J,Fothergill J. Primary care in London: an evaluation of gen-eral practitioners working in an inner city accident andemergency department. J Accid Emerg Med 1996; 13:11-15.

11 Dale J, Lang H, Roberts JA. The cost effectiveness of treat-ing primary care patients in Accident and Emergency: acomparison between general practitioners, senior houseofficers and registrars. BMJ 1996;312:1340-4.

12 MacKoul D, Savageau J. Emergency department utilisationin a large paediatric group practice. Am J Med Quality1995;10:88-92.

13 Chan LS, Galaif MA, Kushi CL, Bernstein S, Fagelson HJ,Drozd PJ. Referrals from hospital emergency departmentsto primary care centers for non-urgent care. Journal ofAmbulatory Care Management 1985:57-69.

14 Hansagi H, Carlsson B, Olsson M, Edhag 0. Trial of amethod of reducing inappropriate demands on a hospitalemergency department. Public Health 1987; 101:99-105.

15 Kuensting LL. "Triaging out" children with minor illnessesfrom an emergency department by a triage nurse: where dothey go? J Emerg Nursing 1995;21:102-8.

16 Selby JV, Fireman BH, Swain BE. Effect of co-payment onuse of the emergency department in a health maintenanceorganisation. N Engl J Med 1996;334:635-41.

17 Middleton EL, Whitney FW. Primary care in the emergencyroom: a collaborative model. Nursing Connections 1993;6:29-40.

18 Straus J, Orr ST, Charney E. Referrals from an emergencyroom to primary care practices at an urban hospital. Am JPublic Health 1983;73:57-61.

19 Kelly KA. Cost containment in the emergency department:shifting the cost of caring for patients with non-emergencyconditions from crowded emergency departments toprimary care settings. J Emerg Nursing 1994;20:454-7.

20 O'Shea JS, Collins EW, Pezzullo JC. An attempt to influencehealth care visits of frequent hospital emergency facilityusers. Clin Pediatr 1984;23:559-62.

21 Geyman JP. How effective is patient education? J Fam Pract1980;10:973.

22 Henry GL. Refusal of care: the ethical dilemma [letter]. AnnEmerg Med 1990; 19:1197-200.

23 Garcia de Anc6s J, Dale J, Roberts J. An economicevaluation of the costs perceived by patients who decide toattend A&E for primary care. Proceedings of the AnnualScientific Meeting of the AUDGP, Aberdeen, 1993.

24 Williams RM. The costs of visits to emergency departments.N Engl J Med 1996;334:642-6.

25 Dale J, Rennie D, Roberts J, Tyson L. Minor injury services:a major public concern: an option appraisal for BromleyHealth. London: King's College School of Medicine andDentistry, Department of General Practice and PrimaryCare, October 1994.

26 Gyldmark M. A review of cost studies of intensive careunits: problems with the cost concept. Crit Care Med1995;23:964-72.

27 NHS guide to evaluating clinical trials. London: Departmentof Health, 1994.

To all refereesThe Journal ofAccident and Emergency Medicine gratefully acknowledges the contribution ofall reviewers:

Thomas Beattie Geoffrey Hughes Francis MorrisKenneth Boffard Robin Illingworth Patrick NeeAnthony Brown Michael Lambert Barbara PhillipsRob Cocks Roderick Little Laurence RockeMike Clancy Christopher Luke David SkinnerChristine Dearden Kevin Mackway-Jones Robin TouquetRoger Evans Mike McCabe David YatesJerris Hedges Alastair McGowan

98 Gavalas, Sadana, Metcalf

GENERAL RESUSCITATIONThe ABCs of resuscitation are rigidly adheredto in severe or life threatening anaphylaxis,with emphasis on prophylactic intubation ifimpending laryngeal obstruction is suspected.An endotracheal tube one or more sizessmaller than usual is recommended.'5 Ifendotracheal intubation cannot be achieved asurgical airway maybe a life saving procedure.

Adrenaline and infusion of intravenous fluidshave a synergistic effect in the treatment ofanaphylaxis.5 7 10 Significant hypotension (fall insystolic blood pressure of more than 20 mmHg) and tachycardia are features of moderate(grade II) anaphylaxis and should be treatedwith 10 ml/kg colloid intravenous fluid. Highervolumes (20 ml/kg) should be infused in severecardiovascular collapse (grades III-IV).As soon as airway problems appear likely, or

for adrenaline resistant anaphylaxis, the in-volvement of an intensive care specialist iscritical. Adrenaline infusion,5 711 measuringfilling pressures, and using other sympathomi-metic drugs5 (for example, a noradrenalineinfusion) may be beneficial. If the patient is ona 13 blocker, intravenous salbutamol or gluca-gon, or both, should be used. Glucagon is wellestablished and should be considered inprotracted anaphylaxis"6: 1 mg boluses up to 3mg (half doses in children) should be followedby an infusion of 1-5 mg/hour. Consolidatingtreatment with antihistamines and steroidsshould follow.

ConclusionsKey points which need re-emphasising are thatfor severe or life threatening anaphylaxis withcardiovascular collapse, immediate but careful

administration of high dilution (1:10 000 or1:100 000) intravenous adrenaline in a con-trolled titrated manner is required, with earlyinvolvement of senior doctors, and thereshould be a systematic approach to allergicemergencies with attention to prevention offuture episodes.

1 Giansiracusa DF, Upchurch KS. Anaphylactic and anaphy-lactoid reactions. In: Rippe JM et al, eds. Intensive caremedicine. Boston: Little, Brown & Co, 1985:1102-12.

2 Gupta S, O'Donnell J, Kupa A, et al. Management of beesting anaphylaxis. Med J Aust 1988; 14:602-4.

3 Schwartz LB, Metcalfe DD, Miller JS, et al. Tryptase levelsas an indicator of mast-cell activation in systemicanaphylaxis and mastocystosis. N Engl J Med 1987;316:1622-6.

4 Stark BJ, Sullivan TJ. Biphasic and protracted anaphylaxis. JAllergy Clin Immunol 1986;78:76-83

5 Fisher MM. Treating anaphylaxis with sympathomimeticdrugs. BMJ 1992;305:1107-8.

6 Helipern KL, The treacherous clinical spectrum of allergicemergencies: diagnosis, treatment and prevention. EmergMed Rep 1994;15:211-22.

7 Nimmo WF, Aitkenhead AR, Clarke RSJ, et al. Anaphy-lactic reactions associated with anaesthesia. London:Association of Anaesthetists of Great Britain and Ireland,1990.

8 Hedner T, Samuelsson 0, Lunde H. Adrenaline in allergicemergencies [letter]. BMJ 1992;304:1443.

9 Tintinalli JE, Krome RL, Ruiz E, eds. Emergency medicine, acomprehensive study guide, 3rd ed. New York: McGraw-Hill,1992:901-3.

10 Handley AJ, Swain A. Advanced life support manual, 2nd ed.London: Resuscitation Council (UK), 1994.

11 Barach EM, Nowak RM, Lee TG, et al. Epinephrine fortreatment of anaphylactic shock. JAMA 1984;251:2118-22.

12 Smith GB, Taylor BL. Adrenaline in allergic emergencies[letter]. BMJ 1992;304:1635.

13 Bochner BS, Lichtenstein LM. Anaphylaxis. N Engl J Med199 1;324: 1785-90.

14 Advanced Life Support Group. Advanced paediatric life sup-port. London: BMJ Publishing Group, 1993.

15 Corren J, Schocket A. Anaphylaxis, a preventable emer-gency. Postgrad Med 1990;87:167-78.

16 Pollack CV. Utility of glucagon in the emergency depart-ment. J Emerg Med 1993;1 1: 195-205.

Emergency Medicine and Pre-hospital Care ConferenceJohannesburg, South Africa

7-9 October 1998

Presented byThe Royal College of Surgeons of Edinburgh

Faculty of Pre-hospital CareThe Australasian College for Emergency Medicine

The College of Medicine of South Africa

Organised bySBS Conferences and Ocean Media

Main topics* Trauma* Emergency medicine* Training assessment, accreditation, certification* Pre-hospital care* Emergency care and EMS systems

Deadline for abstracts 31 March 1998

Further details fromThe Registrar, Emergency Medicine and Pre-hospital Care Conference, Strategic BusinessServices (Pty) Ltd, PO Box 1059, Oakdale 7534, South Africa; fax +2721 (0)21 914 2890;

email registrar(sbs.co.za

Prehospital intravenous nalbuphine hydrochloride 101

69:433 in 1991 to 87:917 in 1996 is statisti-cally significant (X' = 9.1397, p = 0.003). Thisalmost certainly represents an increased use ofthe ambulance service by patients with lessacute conditions over the five year period.Emergency ambulance calls in the catchmentarea have shown an average increase of 6.7%each year over the same period (WestcountryAmbulance Trust Service statistics).

If the administration of parenteral analgesiaby doctors in the A&E department is taken asdefining those patients who need analgesia,there has been an increase in the proportiongiven analgesia prehospital from five of 69(7.25%) in 1991 to 36 of 87 (41%) in the cur-rent study. Table 3 shows that there may bescope for further improvement if the indica-tions for nalbuphine were extended (13 felloutside the protocol) and all paramedic crewswere fully trained to give nalbuphine (threewere not qualified to give nalbuphine).

Sixty seven per cent of patients givenprehospital analgesia required furtherparenteral analgesia in the A&E department.This was not entirely unexpected, as repeatdoses of analgesia would often be given formany of the conditions encountered. Fourteenpatients who received the maximum dose of 20mg required further analgesia in the A&Edepartment. These figures suggest that morepatients might benefit from nalbuphine and amaximum dose of 30 mg rather than 20 mgmight be more appropriate. Since completionof this study, doses of 30 mg have been given

on several occasions by paramedics withoutany complications, following telephone consul-tation with a senior A&E doctor. Paramedicshave been fully trained in the use of naloxonefor reversal of respiratory depression caused bynalbuphine. Any increased use of nalbuphinemust also be balanced against the increasedon-scene time, with other implications onpatient care.4The questionnaire highlighted various

points. Not all ambulance staff are currentlyqualified to give nalbuphine. Patients may notinitially complain of pain to the ambulancepersonnel or may refuse opioids and opt forentonox, which may provide sufficient analge-sia. Nalbuphine is currently given for arelatively narrow spectrum of conditions, andcontraindications for its use featured promi-nently in the reasons for not giving it. Theremay be scope for extending its use fornon-traumatic conditions such as back pain,renal colic, and abdominal pain after telephoneadvice from an experienced A&E doctor, andalso in a few stable patients with more than oneinjury.

1 Stene JK, Stofberg L, MacDonald G, Myers RA, Ramsy A,Burns B. Nalbuphine analgesia in the prehospital setting.Am J Emerg Med 1988;6:634-9.

2 Chambers JA, Guly HR. Prehospital intravenous nalbu-phine administered by paramedics. Resuscitation 1994;27:153-8.

3 Chambers JA, Guly HR. The need for better pre-hospitalanalgesia. Arch Emerg Med 1993; 1O: 187-92

4 Johnson GS, Guly HR. The effect of pre-hospital adminis-tration of intravenous nalbuphine on on-scene times. JAccid Emerg Med 1995;12:20-2.

Faculty ofAccident and Emergency Medicine

Exit examinations

The next Diet of the Faculty's Exit Examination will be on 6/7 May 1998 at the Universityof Edinburgh.Inquiries to the Faculty of Accident and Emergency Medicine, 35-43 Lincoln's Inn Fields,London WC2A 3PN; tel +44 (0)171 405 7071.

12 Accid Emerg Med 1998;15:126-128

JOURNAL SCAN

Edited by James Wardrope, associate editorThis scan coordinated by A Simpson

Prescribing analgesics: the effectof patient age and physicianspecialtyM Hauswald, C AnisonPediatric Emergency Care1997;13:262-3Overview-This is a survey of the anal-gesic prescribing habits of paediatri-cians, emergency physicians, and fam-ily practitioners when presented with ahistory of a patient with severe otitismedia that has caused two sleeplessnights. Some doctors were given thepatient's age as two years and others as22 years.Results 137 of the 165 surveys of thesurveys were returned in a usableform. Overall 80% of the doctorswould have prescribed oral analgesia,28% would have given opioid analge-sia. Children and adults would havebeen equally likely to receive analgesia.However, the adults received signifi-cantly more prescriptions for narcoticanalgesics (Fisher's exact test, p =0.03). When comparing the three spe-cialties the investigators found thatthere was no significant difference inthe prescribing habits of paediatriciansand family practitioners overall (83%and 81% respectively received analge-sia) or for narcotics (20% and 23%respectively). Emergency physiciansused analgesics in all patients; 50% ofthe time these contained opioids. Thiswas significantly different from thepaediatrician and family practitionergroups. Only seven patients (one child)received stronger opioid analgesia thancodeine.Conclusions (1) Narcotic analgesicsare often not prescribed for otitismedia; (2) children are less likely toreceive analgesics than adults, espe-cially opioids; (3) emergency physi-cians are more likely to prescribestronger analgesics than paediatriciansor family practitioners.CritiqueWas the study original? The questionsbeing asked in this study are not new,and several similar studies have beencarried out previously (these are cited).Investigations carried out more than10 years ago arrived at similar conclu-sions. It therefore becomes anotherstudy in a long list.Was the study design sensible? There aretwo different questions to be answered:how did practice vary with respect tothe age of the patient, and how did it

vary with respect to the specialty of thedoctor? If the emergency physiciansand family practitioners were the onlygroups taking part this would be valid;however, the paediatricians were givendata relating only to the two year oldsbut were included in the totals whenthe comparisons were made.Were the statistics appropriate? Fisher'sexact test was used to analyse the data;this seems appropriate given its non-parametric nature. The sample size wassmall (137 replies), especially whendivided into specialties: 32 emergencyphysicians, 65 family practitioners, and40 paediatricians. The emergency andfamily doctors were also then subdi-vided into those treating the two yearold and those treating the 22 year old.Are the conclusions valid? The compari-son between specialties is difficult, forexample the emergency physicians'prescription of narcotics to all patientsis compared with the paediatricians'prescription to two year olds that is,50% compared to 20%, respectively;however, if only two year olds wereconsidered the relevant comparisonbecomes 38% v 20%. Would this nowbe statistically significant?Extrapolation-Overall the investiga-tors indicate that we still have signifi-cant problems with regard to prescrib-ing adequate analgesia, especially forchildren. This is probably true.

Use of fax facility improvesdecision making regardingthrombolysis in acute myocardialinfarctionV S Srikathanan, A C H Pell,N Prasad, GW Tait, A P Rae,K J Hogg, F G DunnHeart 1997;78:198-200This is a prospective audit comparingthe senior house officers' decisionmaking accuracy with that of theconsultant, using information faxed totheir home. Consultant interventionallowed four patients to benefit fromthrombolysis who would not otherwisehave received it, and stopped eightpatients receiving thrombolysis inap-propriately.

Further analysis of their results ledthe researchers to conclude that therewas good agreement between the SHOand consultant in identifying inferiormyocardial infarcts and left bundlebranch block; however, SHOs tendedto misinterpret the findings in patients

with anterior infarcts, despite guide-lines being available.

Comparison of silversulphadiazine and paraffin gauzedressings in the treatment offingertip amputationsM S Riyat, F G O'Dwyer,D N Quinton7ournal ofHand Surgery1997;22B:530-2Forty patients aged between 16 and 70with grade 1 or grade 2 finger tip inju-ries were included in this randomisedtrial. At review 24 to 36 hours after ini-tial treatment they were randomisedinto two groups: one group receivedparaffin gauze dressings appliedweekly; the other group received silversulphadiazine applied to the stumpand covered with the finger of a plasticglove. An absorbent dressing was thenapplied; this was changed twice weeklyby the patient until healing was com-plete.

Dressing changes during the first twoweeks of the study were more comfort-able with silver sulphadiazine (p =

0.059 and p = 0.072), but by week 3 thesilver sulphadiazine treated fingers weremore sensitive to touch (p = 0.058).The number of days to discharge wasless in the paraffin gauze group (p =0.0066). Finger length appeared betterpreserved using silver sulphadiazine (p= 0.0637 at three months and p =

0.0282 at six months). Of the 40patients originally recruited, 24 com-pleted the study; however data for only17 appeared to be available for assess-ment of finger length at six months.

Emergency planning in theNational Health Service: doescentral guidance reach those whoneed it?R CocksHealth Trends 1997;29:19-20This survey looks at the receipt ofinformation sent from the Departmentof Health to regional health authoritiesby accident and emergency depart-ment lead consultants. Two hundredand fifteen accident and emergencydepartment heads were sent question-naires; 174 responded during the studyperiod (three months from May 1995).The documents examined were HC(90) 25, regarding hospital major inci-dent planning; HSG (93) 24, regard-ing contracting and the funding of

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major incident exercises; HSG (93) 38dealing with chemical incidents; andHSG (94) 52, regarding protectiveclothing. It was found that only 24% ofthe unit heads had seen all four, 16%three, 11% two, 14% one, and 35%none; 51 % had received the mainplanning document HC (90) 25.The author suggests that instead of

the information being sent to ananonymous body it should be sent tonamed post holders and that healthemergency planning advisers have animportant role to play in monitoringthe implementation of central guid-ance. Have you seen all these docu-ments?

Prophylaxis after occupationalexposure to HIVP Easterbrook, G IppolitoBritish Medical Journal1997;315:557-8This editorial reviews the changingpractice of giving antiviral drugs topatients after needlestick injuries andother exposure to infected blood andbody fluids. Recent Department ofHealth guidelines' advocate that A&Edepartments should stock "starterpacks" of antiviral drugs and dispensethese after possible recipients havebeen "fully informed of the risks, andthe rationale for treatment." To beeffective the treatment should bestarted within one to two hours ofexposure.A minor injury, such as a needle-

stick, might wait two to three hoursbefore being seen and then the patientmight find the average A&E doctoruntrained in counselling on the risk/benefit of antiviral prophylaxis. Giventhe need for early treatment, this doesseem to be an emergency, but ifA&E isto be responsible for starting treatmentthere are obviously procedural, train-ing, and guideline implications forYOUR department.

1 Department of Health. Guidelines on the postexposure prophylaxis for health care workersoccupationally exposed to HIV. London: DOH,1997.

Meta-analysis: potentials andpromiseM Egger, G D SmithBritish Medical Journal1997;315: 1371-4

Discrepancies betweenmeta-analyses and subsequentlarge randomised controlled trialsJ LeLorier, G Gregoire,A Benhaddad, J Lapierre, F DerderianNew England J7ournal of Medicine1997;337:536-41

Meta-analysis and themeta-epidemiology of clinicalresearchC D NaylorBritish MedicalJournal1997;315:617-19Meta-analyses are being used increas-ingly as a research tool and to review theevidence for treatments. Some can bevery useful and the techniques are wellexplained in the article by Egger andSmith in the BM7. There are pitfallsand drawbacks in any methods, and thepapers by LeLorier et al and Naylorexamine the accuracy of meta-analysisand reveal some disturbing results.The LeLorier study compared the

results of meta-analyses with subse-quent large randomised controlled tri-als that were published in one of thefollowing journals: New England Jour-nal of Medicine, Lancet, Annals of Inter-nal Medicine, and the J7ournal of theAmerican Medical Association. Twelvelarge randomised controlled trials wereidentified, and all the trials includedhad to have adequate statistical power.Nineteen meta-analyses answering thesame questions were then found. Theynext analysed the outcomes of thetrials and meta-analyses and foundthat for a total of 40 primary andsecondary outcomes agreement wasonly fair. The BMJ editorial andarticles in the same issue highlightsome surprising information revealedby meta-analyses, such that a singletrial was published on seven occasions.Understanding meta-analysis is becom-ing a requirement of reading researchjournals and these articles attempt togive guidance on appraisal of the qualityof papers that use this technique.

Radiographic detection of gravelin soft tissueC D Chisholm, C 0 Wood, G Chua,W H Cordell, D R NelsonAnnals ofEmergency Medicine1997;29:725-30In this randomised blinded study theauthors used a standard sized woundin 160 chicken legs to implant pieces ofgravel of four different types, rangingin size from 0.25 mm to 2 mm. Fromone to four pieces were placed in eachleg wound; controls had leg woundswith no gravel. The chicken legs werethen x rayed. Three radiologists inter-preted the films and three emergencyresidents followed the same procedure.The investigators found that 1 mm and2 mm particles were accurately identi-fied in 97.7% of cases, but 0.25 mmand 0.5 mm particles were only identi-fied in 75% of cases. The radiologistswere more specific but the emergencyresidents were more sensitive.

Using the hand to estimate thesurface area of a burn in a childT R Nagel, J E SchunkPediatric Emergency Care1997;13:254-6The investigators asked the question"is the palm or the whole of the palmarsurface of the hand the best guide forestimating the percentage burn in achild." They used standard nomo-grams to calculate the surface area of91 children. They then photocopiedthe child's palm and worked out thesurface area. They found that theentire palmar surface represented0.94% (95% confidence interval0.93% to 0.95%) of the total body sur-face area, and the mean percentage bythe palm alone was 0.52% (0.51% to0.53%). They concluded that theentire palmar surface of the handincluding the fingers more closelyapproximates 1% of body surface thanthe surface of the palm alone. My 1993edition of the ATLS manual states"remember the palm (not includingthe fingers) represents approximately1% of the patient's body surface." Thisarticle therefore makes a very impor-tant point. However, exactly the samemethodology and findings were pub-lished in the BMJ in May 1996.'

1 Perry RJ, Moore CA, Morgan BD, Plummer DL.Determining the approximate surface area of aburn: an inconsistency investigated and re-evaluated. BMJ 1996;312:1338.

Atrial fibrillationS M Narayan, M E Cain, JM SmithLancet 1997;350:943-50The authors provide us with a compre-hensive algorithm to simplify treat-ment of this relatively common condi-tion. In most cases accident andemergency medical staff would beunlikely to treat once the condition isidentified, or to provide any furthermanagement other than appropriatereferral. If the patient is haemodynami-cally unstable, synchronised dc cardio-version should be the initial treatment:100 J is successful in 50% of cases and200 J in 85%. Pharmacological cardio-version may also be tried in acute atrialfibrillation. Flecanide, propafenone,and amiodarone are the most success-ful drugs at doing this. Cardioversionby any method results in a stroke riskof 3%. Therefore in emergency cardio-version the authors suggest it may beprudent to heparinise the patient, andthen give warfarin for at least fourweeks. Warfarin has been shown toreduce the annual incidence of strokefrom 4.5% to 1.4%, the mortality rateby 33%, and the combined outcomesof stroke, systemic embolism, or deathby 48%, with a 1.3% risk of haemor-rhage. However this potential forhaemorrhage must not be forgotten in

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1ournal scan

the accident and emergency depart-ment when these patients are seen withseemingly innocuous head injuries.

EMERGENCY CASEBOOKDevelopment of tension pneumothorax after chest drain insertion

A 50 year old man presented by ambulance to the accident and emergency department fol-lowing a road traffic accident. He had been driving a car which collided with a tree. Theimpact had been on the driver's side of the car. He had been wearing a seat belt and was notentrapped. There was no head injury or any loss of consciousness. On arrival he was con-fused and complaining of severe right sided chest pain.Management was according to ATLS principles and revealed a right sided flail chest

associated with multiple rib fractures, pulmonary contusion, and marked hypoxia (Po, 5.7kPa and Spo2 78% on 15 1 of oxygen by trauma mask). In view of these findings the patientunderwent a rapid sequence induction of anaesthesia, endotracheal intubation, ventilation,and insertion of a 32G intercostal drain on the right side. This improved his Spo, to 96%.The drain discharged 200 ml of blood and was noted to be swinging with respiration. Acheck chest x ray confirmed satisfactory placement of the drain, but also a widened medi-astinum which had not been apparent on the initial chest x ray. His condition was stable sothoracic computed tomography was arranged to exclude aortic arch injury. While this wasbeing done his clinical condition suddenly deteriorated. He became hypotensive (BP 70/40)and tachycardic (HR 1 30/min) with no improvement after a rapid infusion of colloid. Onexamination of the scan (fig 1) it became apparent that he had developed a right sided ten-sion pneumothorax. Following decompression and insertion of a second intercostal drainhis clinical indices returned to normal.

This patient developed a life threatening tension pneumothorax despite the insertion of alarge intercostal drain. It is postulated that the drain either kinked during transfer orbecame occluded with blood clot. The presence of the drain led to a delay in diagnosis as itwas assumed that this particular potential complication had already been dealt with. AsATLS and common sense suggests, whenever a trauma patient deteriorates the primarysurvey must be repeated. An assumption that any tube previously inserted has becomeblocked or displaced will prevent serious complications being overlooked.

R C BAILEY_, D ESBERGER Department ofA&E, Queens Medical Centre, Nottingham NG7 2UH,UK. Correspondence to: Mr Richard C Bailey.

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140 J Accid Emerg Med 1998; 15:140

LETTER

Measurement ofpain in children in theemergency department

EDITOR,-Despite increased awareness of "oli-goanalgesia" in the paediatric population,children in acute pain are often undertreated.'Effective pain management requires accurateassessment, appropriate analgesia, and moni-toring response to treatment.

Various tools have been developed to aid theassessment of pain in children. However, atpresent there is no accepted measure ofpain orits response to analgesia in the acute accidentand emergency setting. We carried out a studyinvestigating the use of two self report tools-avisual analogue scale (VAS) and a five facesscale'-in our A&E department.We found that the five faces scale was a reli-

able measure in children aged four years andover. Although the faces scale could be used insome children aged three years, the failure ratewas 50%. The VAS was only useful in childrenaged six years and over. These findings areconsistent with studies in other settings.'

Self report pain measurement tools areuseful in assessing intensity of pain in childrenand in measuring the effectiveness of analgesiagiven in the A&E departnent. Although boththe VAS and the faces scale were successfullyapplied, the faces scale is preferred because itmay be applied to a wider age group, is simplerto administer, and is easier to use in a busydepartment.

L FERGUSONT F BEATTIE

Accident and Emergency Department, Royal Hospitalfor Sick Children, Edinburgh EH9 lLF

1 Selbst SM, Clark M. Analgesic use in theemergency department. Ann Emerg Med1990; 19:1010-13.

2 Carter B. Child and infant pain: principles ofnursing care and management. London: Chap-man and Hall, 1994.

3 Tyler DC, Tu A, Douthit J, Chapman CR.Toward validation of pain measurement toolsfor children: a pilot study. Pain 1993;52:301-9.

BOOK REVIEW

Poisonous Plants in Britain and Ireland(CD-ROM). By the Royal Botanic Gardens,Kew, and the Guy's and St Thomas' PoisonsUnit. (k175.) HMSO Electronic Publishing,1997. Available from: Publications Centre,Stationery Office, 51 Nine Elms Lane,London SW8 5DR; fax +171 873 8200;email http:\\www.the-stationery-office.co.uk

This CD-ROM package from the RoyalBotanic Gardens at Kew and the Guy's and StThomas' Poisons Unit, is designed to helpstaff with no botanical knowledge to identifyplant material quickly and easily. It coversaround 2000 plants in 214 groups and givesdetails of their toxic effects. You will needsome serious computer hardware and thesoftware costs about 4C175 for a year'ssubscription, so it doesn't come cheap.

Poisonous plants in Britain and Ireland helpsto identify plants from their leaves, stems,fruit, flowers, seeds, or roots. It is interactiveand the user is asked several questions aboutthe plant material that is available. The ques-tions are not particularly technical and areillustrated by simple line drawings. There is aneasy to use glossary which explains some ofthe botanical terms and a question can beskipped if the answer is not known. The ques-tions narrow the field of possible suspectsuntil only five or fewer remain. The user can

then view the superb photographs of thesuspects and compare them to the plant mate-rial available. Where a plant is listed on thedatabase, it is usually identified easily andthere is a good description and sound adviceon toxicity. Treatment advice is usually limitedto an invitation to contact the Poisons Unit.Unfortunately, the database is not exhaustive:most toxic plants are included, but the makerspoint out that exclusion from the databasedoes not necessarily mean that the plant isnon-toxic. Some patients will still be treatedon clinical grounds, without a formal identifi-cation of the offending plant.Apart from its cost, there are a few other

limitations to Poisonous plants in Britain andIreland. Firstly, it does not cover mushroomsor toadstools, which are commonly ingestedby children. Secondly (and rather irritatingly),it does not allow the user to see a descriptionof a plant and its toxicity if only the commonname is known. The photographs, descrip-tion, and toxicity data can be reached from theLatin name but this is clearly only useful ifyouhappen to know the Latin name of the plant-not particularly likely in our department. Afew minor technical problems make theprogram a little less user friendly than it couldbe and we shall write to the makers with ourcomments on these.

In its current format, Poisonous plants inBritain and Ireland should perhaps be viewedas a helpful luxury rather than an essential toolfor every A&E department. However, it iscontinually developing and annual revisionsare planned so it should be increasingly usefulin the future.

STEVEN CRANEADRIAN KERNER

Leeds

Fourth World Conference on Injury Prevention and ControlBuilding partnerships for safety promotion and injury prevention

17-20 May 1998, RAI Congress Centre, Amsterdam

The Fourth World Conference on Injury Prevention and Control will stress the need for building an international community forinjury control management and for sharing experiences in the different countries of the world. It will encompass a rich variety ofknowledge and experience in the various sectors concerned, including:* control of road traffic injury* safety at work* home and leisure safety* prevention of sports injury* prevention of interpersonal and self inflicted violence

It will pinpoint divergences as well as similarities in different countries and regions in terms of: the need for controlprogrammes, the approach to injury control, and the techniques applied and achievements made in closing the gap betweenresearch and intervention.The conference is an initiative of the World Health Organisation and its collaborating centres for safety promotion and injurycontrol. The Consumer Safety Institute is the coordinating institute in the host country.Contact address for information:PO Box 1558, 6501 BN Nijmegen, The NetherlandsTel +31 24 323 4471; fax +31 24 360 1159email: reg.fowoco.nw@prompt.nlWebsite: http://www.consafe.nl/conference