Emergency telephone calls for an ambulance (999 calls) are usually dealt with first-come first-served. We have devised and assessed criteria that ambulance dispatch might use to prioritize responses. Data were collected retrospectively on consecutive patients presenting to an accident and emergency (A&E) department after a 999 call. An unblinded researcher abstracted data including age, date, time, caller, location, reason for call and A&E diagnosis and each case was examined for ten predetermined criteria necessitating an immediate ambulance response--namely, cardiac arrest; chest pain; shortness of breath; altered mental status/seizure; abdominal/loin pain >65 years old; fresh haematemesis; fall >2m; stabbing; major burns. 471 patients were recruited, 55% male, median age 50 years. 406 calls came from bystanders or the patients themselves, 36 from general practitioners, 8 from other hospitals and 21 from the police. 52% of patients were admitted. 44% met at least one of the above criteria. Most patients did not meet the criteria for an immediate ambulance response but might nonetheless be suitable for an urgent response. The criteria used in this study have the advantage of being based on the history provided by the caller. The introduction of a priority-based dispatch system could reduce response times to those who are seriously ill, and also improve road safety.

The differential diagnosis of the hyperpyrexic patient in the emergency department is extensive. It includes sepsis, heat illness including heat stroke, neuroleptic malignant syndrome, malignant hyperthermia, serotonin syndrome and thyroid storm. Each of these possible diagnoses has distinguishing features that may help to differentiate one from another. However, establishing the correct diagnosis is a challenge in the setting of the obtunded emergency patient who gives no history and where there may be limited access to any past medical or drug history. This paper presents such a case and reviews the features of the differential diagnoses and management of the hyperpyrexic patient.

In summary, SUDEP accounts for death in approximately 8% of the young epileptic population. It is commoner in young male epileptics with a long history of generalised seizures, who have a history of head trauma and alcohol excess, and who are taking more than one antiepileptic drug. Most deaths are unwitnessed and occur at home, usually in bed and presumably overnight. Subtherapeutic AED levels do not necessarily imply non compliance, and may simply reflect drug degradation in the plasma after death. Many victims have pulmonary oedema on postmortem examination, and some show ischaemic damage of the heart despite normal coronary arteries. This possibly arises as a result of repeated episodes of vasoconstriction from seizure related catecholamine bursts. Animal studies have demonstrated the occurrence of central apnoea and also support the theory of acute fatal cardiac failure. Possible association with the daily level of geomagnetic activity is reported. The precise reason for a particular seizure being fatal in an otherwise healthy individual is as yet undetermined.

Emergency telephone calls for an ambulance (999 calls) are usually dealt with first-come first-served. We have devised and assessed criteria that ambulance dispatch might use to prioritize responses. Data were collected retrospectively on consecutive patients presenting to an accident and emergency (A&E) department after a 999 call. An unblinded researcher abstracted data including age, date, time, caller, location, reason for call and A&E diagnosis and each case was examined for ten predetermined criteria necessitating an immediate ambulance response--namely, cardiac arrest; chest pain; shortness of breath; altered mental status/seizure; abdominal/loin pain >65 years old; fresh haematemesis; fall >2m; stabbing; major burns. 471 patients were recruited, 55% male, median age 50 years. 406 calls came from bystanders or the patients themselves, 36 from general practitioners, 8 from other hospitals and 21 from the police. 52% of patients were admitted. 44% met at least one of the above criteria. Most patients did not meet the criteria for an immediate ambulance response but might nonetheless be suitable for an urgent response. The criteria used in this study have the advantage of being based on the history provided by the caller. The introduction of a priority-based dispatch system could reduce response times to those who are seriously ill, and also improve road safety.

Hypothermic cardiac arrest is associated with a high mortality despite advances in pre-hospital rescue, rewarming techniques and intensive care management. Prolonged resuscitation is justified and full neurological recovery has been described using various methods of extracorporeal rewarming (Vretenar DF, Urschel JD, Parrott JCW et al. Ann Thorac Surg 1994; 58: 895-898; Hughes A, Riou P, Day C. Emerg Med J 2007; 24: 511-512). Extracorporeal rewarming is usually required at temperatures below 32 degrees C or in the presence of cardiovascular instability or neurological dysfunction (Wilkey SA. Am J Clin Med 2004; 1: 4-11). Resuscitation guidelines suggest cardiopulmonary bypass (CPB) as the method of choice in cardiac arrest, but in practice availability is restricted (Soar J, Deakin CD, Nolan JP et al. Resuscitation 2005; 67: S135-S170). Continuous veno-venous haemofiltration (CVVH) is an alternative, but underutilized approach which warrants further consideration given its ease and wider availability.