(Rakita et al., 1954;Maroko et al., 1971;Kjekshus et al., 1972). Though absolute infarct size may not be accurately predicted by this technique (Norris et al., 1976), it is likely that changes in praecordial ST segment elevation, at least in the early hours after infarction, do reflect acute changes in underlying myocardial ischaemic injury. A close correlation has been shown in the dog between the magnitude of praecordial and of epicardial ST segment changes (Muller et al., 1975), and further between epicardial ST segment elevation and changes in local myocardial oxygen tension (Sayen et al., 1961) and blood flow (Kjekshus et al., 1972 The method of praecordial ST segment mapping in common use (Reid et al., 1971;Maroko et al., 1972)

Background and objectives: After an acute myocardial infarction (AMI) prehospital thrombolysis (PHT) reduces mortality compared with inhospital thrombolysis. In practice, a relatively small proportion of the total population with AMI receives PHT. This study was designed to identify the current barriers to PHT. Methods: A retrospective practice review of 57 consecutive patients treated in or before arrival at a district general hospital emergency department. All patients received thrombolysis for an AMI. Results: The main barriers to delivery of PHT appear to be the inclusion and exclusion criteria laid out in the ambulance service central guidelines. Despite recent widening of the inclusion criteria, 54% of patients eligible for immediate treatment on arrival in hospital either received or were eligible for PHT. Conclusion: To increase the number of patients who are eligible for PHT these guidelines need to be revised further in line with inhospital criteria for thrombolysis. Since the 1970s, a number of landmark treatments have led to a fall in mortality from acute myocardial infarction (AMI). With the introduction of specialised coronary care units (CCU), pharmacological reperfusion therapies, and the use of catheter based interventions, clinical outcomes have markedly improved. However, the key prognostic factor for improved mortality and morbidity is the speed of intervention. It has been consistently proved that early restoration of coronary blood flow in the infarct related artery is needed to preserve functional myocardium. 1In 1996 Boersma et al demonstrated that the duration of coronary occlusion and the extent of collateral circulation are the main determinants of myocardial infarct size.2 Treatment within one hour of symptom onset resulted in a 6.5% absolute reduction in mortality. Figure 1 shows that the benefit of treatment (absolute reduction in mortality) falls with time in a non-linear fashion, clearly demonstrating that very early reperfusion of the occluded coronary artery (within 30 minutes) may lead to full recovery of ischaemic tissue and thus prevent necrosis. Therefore the primary objective in managing patients with AMI is reperfusion as early as possible. 3Both pharmacological and mechanical treatment strategies can be used to achieve reperfusion. The most widely used and established method is pharmacological fibrinolysis. Fibrinolysis, irrespective of the agent used, is usually referred to as thrombolysis. Until 15 years ago, thrombolysis was carried out almost exclusively in a coronary care unit (CCU). However, treatment is most effective when the delay to the delivery of thrombolysis, or call for help to needle time (CTN), is minimised. To improve morbidity and lower mortality, the CTN had to be reduced. In response to this observation, thrombolysis was moved from CCUs to emergency departments (EDs), usually the first point of medical contact for the patient. This was successful in significantly reducing the time from arrival at hospital to the time the thrombolytic drug was administe...

Magnesium sulphate was added to conventional medical therapy in the treatment of persistent severe hypotension and wide QRS complex tachyarrhythmia in an 18-year-old woman presenting with a 1200 mg flecainide overdose. Blood pressure was restored with associated resolution of the electrocardiogram abnormalities.

Objectives: An observational study to determine the difference between documented ambulance arrival times and the actual arrival times of patients from the ambulance into the emergency department. Methods: In a busy, purpose built, modern emergency department with easy access, we recorded the time that ambulance borne patients were wheeled over the threshold of the clinical area and compared this to the times recorded by the ambulance trusts as the official ambulance arrival times. Results: 352 ambulance arrivals were observed. Data were incomplete in 34 instances (9.5%) and were not included in the analysis. For the remaining 318 arrivals, the median time difference was 2 min 1 s (range 5 s to 21 min 45 s). In a subgroup of chest pain patients (45 patients), the median time difference was 2 min 11 s (range 23 s to 5 min 38 s). The difference between the chest pain group and the remaining patients was not significant (p = 0.528). Conclusions: There is inevitably some delay between the arrival of an ambulance and the arrival of the patient into a clinical area. This study quantifies that difference. In an era of stringent time related standards, this paper highlights the need for accurate recording of times to enable us to carry out valid audit of these standards. This study supports the redefining of an arrival time as the time when the patient arrives in the clinical area.

In March 2021, 43% of doctors and nurses surveyed reported they had screened the last patient they saw; 79% were aware of resources and; 67% had signposted someone to help in the last 3 months. From zero introductions to Connected Communities in October 2020, a staggering 95 parents have been screened and recommended to contact our support workers. Only 23 have engaged so far and they have received help with housing, finances/benefits and citizenship. Ten do not speak English but will be supported to access advice. Conclusions Tackling health inequalities takes commitment.By seeing, screening and intervening, we help reduce stigma and identify vulnerable families. Our close partnership with Connected Communities increased staff confidence and increased introductions. More work is needed to determine why only 23/95 parents take up the offer but language barrier, parental expectations or clerical factors may contribute.