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Recent evidence suggests that presenting GCS may be higher in older rather than younger patients for an equivalent anatomical severity of traumatic brain injury (TBI). The aim of this study was to confirm these observations using a national trauma database and to test explanatory hypotheses.The Trauma Audit Research Network database was interrogated to identify all adult cases of severe isolated TBI from 1988 to 2013. Cases were categorised by age into those under 65 years and those 65 years and older. Median presenting GCS was compared between the groups at abbreviated injury score (AIS) level (3, 4 and 5). Comparisons were repeated for subgroups defined by mechanism of injury and type of isolated intracranial injury.25 082 patients with isolated TBI met the inclusion criteria, 10 936 in the older group and 14 146 in the younger group. Median or distribution of presenting GCS differed between groups at each AIS level. AIS 3: 14 (11-15) vs 15 (13-15), AIS 4: 14 (9-15) vs 14 (13-15), AIS 5: 9 (4-14) vs 14 (5-15) all p0.001. Similar differences between the groups were observed across all mechanisms of injury and types of isolated intracranial injury. We detected no influence of gender on results.For an equivalent severity of intracranial injury, presenting GCS is higher in older patients than in the young. This observation is unlikely to be explained by differences in mechanism of injury or types of intracranial injury between the two groups.

Defining research priorities in a specialty as broad as emergency medicine is a significant challenge. In order to fund and complete the most important research projects, it is imperative that we identify topics that are important to all clinicians, society and to our patients. We have undertaken a priority setting partnership to establish the most important questions facing emergency medicine. The top 10 questions reached through a consensus process are discussed.

Aims/Objectives/BackgroundPatient Reported Experience & Outcome Measures (PREMs/PROMs) are not yet well established in emergency care. This study aimed to determine priorities for older adults attending the ED, to inform item inclusion for a new PREM/PROM.Methods/DesignOne hundred thirty-five priority statements, linked to suggested PREM/PROM items, were derived from the literature, patient interviews (n=24) and staff focus groups (n=7)(October 2018- April 2019). All statements had a Flesch-Kincaid Reading Ease score >70. A one-day consensus meeting was held, December 2019.Invitations were issued via social media, patient/public involvement groups and charities. Following focus groups to assess interpretability, nominal group technique was used to prioritise statements. Individuals scored statements from 1(least important) to 9(most important). Statements with a median score of >6.5 were ‘critically important’, 3.5 to 6 ‘important, not critical’, and <3 ‘less important’. Inter-rater agreement was assessed using mean absolute deviation from the median (MADM). ‘Critically important’ or ‘less important’ statements with MADM 50% underwent further voting.Remaining statements underwent dichotomous voting. A >70% favourable majority was required for inclusion.Results/ConclusionsTwenty-nine participants attended. Average age was 65.6 years (R32—78). Experiences of emergency care were as a patient (n=16(55.2%)), accompanying person (n=11(37.9%)), third-sector representative (n=14(48.2%)) and/or clinician (n=7(27.6%)).Initial prioritisation yielded 71 statements for inclusion. Further voting led to the inclusion of another 31 statements (102 total).Statements relating to care delivery, communication and emotional needs ranked as more important overall. Statements related to waiting were considered less important (seesupplementary file).Participants reported having ‘adequate say’ during the meeting (76.9% Strongly Agree).ConclusionThis meeting established priorities for older adults attending the ED. The low priority assigned to waiting confounds some previous findings. Further item reduction is planned to create a final PREM/PROM for older adults.

IntroductionMajor trauma is the third leading cause of avoidable mortality in the UK. Defining which patients require care in a major trauma centre is a critical component of developing, evaluating and enhancing regional major trauma systems. Traditionally, trauma patients have been classified using the Injury Severity Score (ISS), but resource-based criteria have been proposed as an alternative. The aim of this study was to investigate the relationship between ISS and the use of life-saving interventions (LSI).MethodsRetrospective cohort study using the Trauma Audit Research Network database for all adult patients (aged ≥18 years) between 2006 and 2014. Patients were categorised as needing an LSI if they received one or more interventions from a previously defined list determined by expert consensus.Results193 290 patients met study inclusion criteria: 56.9% male, median age 60.0 years (IQR 41.2–78.8) and median ISS 9 (IQR 9–16). The most common mechanism of injury was falls ConclusionsA clinically significant number of adult trauma patients requiring LSIs have an ISS below the traditional definition of major trauma. The traditional definition should be reconsidered and either lowered, or an alternative metric should be used.

Aim Major trauma (MT) has traditionally been viewed as a disease of young men caused by high-energy transfer mechanisms of injury, which has been reflected in the configuration of MT services. With ageing populations in Western societies, it is anticipated that the elderly will comprise an increasing proportion of the MT workload. The aim of this study was to describe changes in the demographics of MT in a developed Western health system over the last 20 years.\ud \ud Methods The Trauma Audit Research Network (TARN) database was interrogated to identify all cases of MT (injury severity score >15) between 1990 and the end of 2013. Age at presentation, gender, mechanism of injury and use of CT were recorded. For convenience, cases were categorised by age groups of 25 years and by common mechanisms of injury. Longitudinal changes each year were recorded.\ud \ud Results Profound changes in the demographics of recorded MT were observed. In 1990, the mean age of MT patients within the TARN database was 36.1, the largest age group suffering MT was 0–24 years (39.3%), the most common causative mechanism was road traffic collision (59.1%), 72.7% were male and 33.6% underwent CT. By 2013, mean age had increased to 53.8 years, the single largest age group was 25–50 years (27.1%), closely followed by those >75 years (26.9%), the most common mechanism was low falls (39.1%), 68.3% were male and 86.8% underwent CT.\ud \ud Conclusions This study suggests that the MT population identified in the UK is becoming more elderly, and the predominant mechanism that precipitates MT is a fall from

Objectives and background Appropriate activation of multidisciplinary trauma teams improves outcome for severely injured patients but can disrupt normal service in the rest of the hospital. Derriford Hospital uses a two-tiered trauma team activation system. The emergency department trauma team (EDTT) is activated in response to a significant traumatic mechanism; the hospital trauma team (HTT) is activated when this mechanism coexists with physiological abnormality or specific anatomical injury. The aim of this study was to compare characteristics, process measures and outcomes between patients treated by EDTTs or HTTs to evaluate the approach in a UK setting. Methods A retrospective database review was performed using Trauma Audit Research Network (TARN) and the local source trauma database. Patients who activated a trauma team between 1 April and 30 September 2012 were included. Patients were categorised according to the type of trauma team activated. Data included time to X-rays, time to CT, time to intubation, numbers discharged from ED, intensive care unit admission, injury severity score and mortality. Results During the study period, 456 patients activated a trauma team with 358 EDTT and 98 HTT activations. Patients seen by the ED team were significantly less likely to have severe injury or require hospital admission, intubation, emergency operation or blood transfusion. Differences in time taken to key investigations were statistically but not clinically significant. Conclusions A two-tiered trauma team activation system is an efficient and cost-effective way of dealing with trauma patients presenting to a major trauma centre in the UK.

Objective The authors set out to investigate perceived and actual availability of antidotes recommended for stocking in emergency departments (EDs) by the College of Emergency Medicine in EDs in the South West of England. Methods Data collectors were asked to physically locate each relevant antidote in the ED, and check whether the recommended quantity was available. If the antidote was not available in the department, the data collector located where in the hospital stocks were available. Senior medical and nursing staff were asked to specify where they believed the antidotes were stored or who they would ask if they did not know. It was then ascertained whether their source of advice would have known the location. Results 5 out of 6 departments returned data with an overall response rate from senior medical and nursing staff of 80%. Knowledge of common antidote locations was variable, and stocking of antidotes did not universally meet the College of Emergency Medicine recommendations. Conclusion Stocking of important antidotes should be rationalised and simplified using central locations, preferably close to the ED. Clinically important antidotes may not be available for patients when they need them. Clear guidance should be available for staff detailing the location of antidotes. There is a need for clarification around the treatment of cyanide poisoning to facilitate rational antidote stocking for this potentially lethal condition.

Objectives and background Elderly patients comprise an ever-increasing proportion of major trauma patients. The presenting GCS in elderly patients with traumatic brain injury (TBI) may not reflect the severity of injury as accurately as it does in the younger patient population. However, GCS is often used as part of the decision tool to define the population transferred directly to a major trauma centre. The aim of this study was to explore the relationship between age and presenting GCS in patients with isolated TBI. Methods A retrospective database review was undertaken using the Trauma Audit and Research Network database. All patients presenting to Derriford Hospital, Plymouth, between 1 January 2009 and 31 May 2014 with isolated TBI were included. Demographic, mechanistic, physiological, resource use and outcome data were collected. Abbreviated injury scale (AIS) was recorded for all patients. Patients were categorised into those older and younger than 65 years on presentation. Distribution of GCS, categorised into severe (GCS 3–8), moderate (GCS 9–12) and mild TBI (13–15), was compared between the age groups. Median GCS at each AIS level was also compared. Results The distribution of GCS differed between young and old patients with TBI (22.1% vs 9.8% had a GCS 3–8, respectively) despite a higher burden of anatomical injury in the elderly group. Presenting GCS was higher in the elderly at each level of AIS. The difference was more apparent in the presence of more severe injury (AIS 5). Conclusions Elderly patients who have sustained isolated severe TBI may present with a higher GCS than younger patients. Triage tools using GCS may need to be modified and validated for use in elderly patients with TBI.

Introduction Paediatric traumatic cardiac arrest (TCA) is a high acuity, low frequency event. Traditionally, survival from TCA has been reported as low, with some believing resuscitation is futile. Within the adult population, there is growing evidence to suggest that with early and aggressive correction of reversible causes, survival from TCA may be comparable with that seen from medical out-of-hospital cardiac arrests. Key to this survival has been the adoption of a standardised approach to resuscitation. The aim of this study was, by a process of consensus, to develop an algorithm for the management of paediatric TCA for adoption in the UK. Methods A modified consensus development meeting of UK experts involved in the management of paediatric TCA was held. Statements discussed at the meeting were drawn from those that did not reach consensus (positive/negative) from a linked three-round online Delphi study. 19 statements relating to the diagnosis, management and futility of paediatric TCA were initially discussed in small groups before each participant anonymously recorded their agreement with the statement using ‘yes’, ‘no’ or ‘don’t know’. In keeping with our Delphi study, consensus was set a priori at 70%. Statements reaching consensus were included in the proposed algorithm. Results 41 participants attended the meeting. Of the 19 statements discussed, 13 reached positive consensus and were included in the algorithm. A single statement regarding initial rescue breaths reached negative consensus and was excluded. Consensus was not reached for five statements, including the use of vasopressors and thoracotomy for haemorrhage control in blunt trauma. Conclusion In attempt to standardise our approach to the management of paediatric TCA and to improve outcomes, we present the first consensus-based algorithm specific to the paediatric population. While this algorithm was developed for adoption in the UK, it may be applicable to similar healthcare systems internationally.

Body packing, pushing and stuffing are methods by which illicit drugs may be carried within the human body. Patients involved in these practices may present UK emergency departments with complex medical, legal and ethical considerations. This review article examines not only the evidence behind the clinical management of these patients, but also the legal powers afforded to the authorities to authorise the use of intimate searches and diagnostic imaging for forensic purposes. Serious complications from concealed drug packets are now rare, and most asymptomatic patients may be safely discharged from hospital after assessment. Emergency surgery is indicated for body packers with cocaine poisoning and for some cases of heroin poisoning. Urgent surgery is indicated for obstruction, perforation, the passage of packet fragments and failure of conservative treatment. Guidance is given for doctors who are faced with requests from the authorities to perform intimate searches and diagnostic imaging for forensic purposes.

Objectives & Background Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) aims to improve trauma survival by controlling torso haemorrhage. Selective Aortic Arch Perfusion (SAAP) is an experimental resuscitative technique that, in addition to controlling torso haemorrhage, allows infusion of oxygenated blood into the proximal aorta - theoretically providing coronary perfusion pressures adequate for return of spontaneous circulation (ROSC) in cardiac arrest (figure 1). Prolonged cardiac support can subsequently be achieved by converting the SAAP blood supply from exogenous to autologous via a central venous catheter–an extra-corporeal life support circuit (SAAP-ECLS). Hypotheses–1. Swine in haemorrhage-induced traumatic cardiac arrest that do not achieve a ROSC with initial therapy (REBOA), will have ROSC with more advanced therapy (SAAP). 2. Animals that do not achieve ROSC with REBOA and subsequent SAAP will achieve ROSC with SAAP-ECLS. Methods 70–90 kg swine underwent a combination of non-compressible torso and arterial haemorrhage. Arrest was defined as a systolic blood pressure (SBP) 50 mm Hg) subsequently received SAAP (800 ml/minute of intra-aortic oxygenated blood, up to 4000 ml). Animals that did not have a ROSC after SAAP received continuous SAAP-ECLS (at 800 ml/minute). The protocol end-point was 60 minutes from the start of the REBOA intervention. Data are descriptive, and presented as mean (+/−standard deviation) and number (percent). Results Eight animals were included; weight 75.0 kg (+/−3.6); time from the start of the injury to onset of arrest was 9.9 minutes (+/−1.4). Two (25.0%) animals had a ROSC with REBOA, and out of the remaining six a further two (25.0%) had a ROSC with SAAP. The four remaining animals, that had not achieved ROSC with REBOA and subsequent SAAP, all had a ROSC with SAAP-ECLS (figure 2). Conclusion A step-wise approach of more complex endovascular intervention in haemorrhage-induced traumatic cardiac arrest may be an effective clinical paradigm – in this swine model all animals had short-term survival following escalating intervention: REBOA, followed by SAAP, followed SAAP-ECLS as required.

Background The predominant cause of preventable death from trauma is bleeding. Many patients need resuscitation with massive blood transfusion (MBT). In some theatres of military operation there is limited blood product availability and walking donor panels can be required. This study aimed to produce a tool to predict the need for MBT using information available on patient arrival at the ED for patients sustaining battlefield trauma. Methods A retrospective database analysis was undertaken using the UK Joint Theatre Trauma Registry (JTTR) to provide derivation and validation datasets. Regression analysis of potential predictive factors was performed. MBT was defined either as receiving 6 or more units of red blood cells (RBCs) in 4 hours or 10 units of RBCs in 24 hours. Predictive factors were analysed through multi-logistic regression analysis to build predictive models; sensitivity and specificity of these models was assessed, and the best fit models were analysed in the validation dataset. Results The derivation dataset was made up of 1298 casualties with a massive blood transfusion rate of 21.2% (n=275). The validation dataset contained 1186; MBT rate 6.7% (n=79). The majority of patients were young, male and with penetrating injury. Univariate regression analyses showing the predictive value of the variables within the MASH score are shown in table 1. A decision rule was produced using a combination of injury pattern, clinical observations and pre-hospital interventions. The test characteristics for three cut off thresholds for the rule are shown in Table 2 alongside the sensitivity analysis. The proposed rule, using a score of 3 or greater, demonstrated a sensitivity of 82.7% and a specificity of 88.8% for prediction of MBT, with an AUROC of 0.93 (95% CI:0.91 to 0.95). Conclusions This study has produced the first military scoring system that uses clinical observations, injuries sustained and pre-hospital interventions to predict the need for MBT and therefore the requirement for an emergency donor panel in resource-limited environments. The MASH score has higher sensitivity and specificity than previous military prediction tools, and has the advantage of only using information which is rapidly available in the resuscitation bay. This is of importance to civilian practitioners with increasing possibility of major terrorist attacks.

Introduction Paediatric Traumatic Cardiac Arrest (TCA) is a high acuity, low frequency event with fewer than 15 cases reported per year to the Trauma Audit Research Network (TARN). Traditionally survival from TCA has been reported as low, with some believing resuscitation is futile. Within the adult population there is growing evidence to suggest that with early and aggressive correction of reversible causes, survival from TCA may be comparable to that seen from medical out-of-hospital cardiac arrests. Key to this survival has been the adoption of a standardised approach to resuscitation. The aim of this study was, by a process of consensus, to develop a national, standardised algorithm for the management of paediatric TCA. Methods A modified consensus development meeting was held. Statements discussed in the meeting were drawn from those that did not reach consensus (positive/negative) from a linked three round online Delphi study. Those participants completing the first round of the Delphi study were invited to attend. 19 statements relating to the diagnosis, management and futility of paediatric TCA were discussed in small groups. After five minutes the key points from the small groups were presented to the whole audience. Subsequently, using electronic voting devices, each participant anonymously recorded their agreement with the statement using ‘yes’, ‘no’ or ‘don’t know’. In keeping with our Delphi study, consensus was set a priori at 70%. Statements reaching consensus were included in the proposed algorithm. Results 41 participants attended the consensus development meeting. Of the 19 statements discussed, 13 reached positive consensus and were included in the algorithm. A single statement regarding initial rescue breaths reached negative consensus and was excluded. Consensus was not reached for five statements, including the use of vasopressors and thoracotomy for haemorrhage control in blunt trauma. The proposed algorithm for the management of paediatric TCA is shown as Figures 1 and 2 for blunt and penetrating trauma respectively. Conclusion In attempt to standardise our approach to the management of paediatric TCA and to improve outcomes, we present the first algorithm specific to the paediatric population.

Time is a precious commodity and with more junior doctors coming through our departments for shorter periods of time it has been useful to lay down some ground rules to facilitate their induction. These are presented in the form of the twelve commandments of emergency medicine.

Objectives & Background Triage, the process of categorising patients based on clinical acuity, is a key principle in the effective management of a major incident (MI). Existing triage systems have so far demonstrated limited performance. The Modified Physiological Triage Tool (MPTT) was derived using a military cohort and significantly demonstrated improved performance. Within the adult civilian population, with a predominance to an older population and a blunt mechanism, no such work has been undertaken. The purpose of this study was to perform a comparative analysis and validation of the MPTT within a civilian environment. Methods The Trauma Audit Research Network (TARN) database was interrogated to identify all adult patients (≥18 years) treated at a single hospital between 2006 and 2014. Patients were defined as Priority One (P1) if they received a life-saving intervention from a previously defined list. Only patients with complete physiological data were included in the analysis. Using first recorded physiological data (HR/RR/GCS/SBP), patients were categorised as P1 or Not-P1 by the MPTT (12 >RR≤ 22, HR≥100, GCS Results During 2006–2014, 218,453 adult trauma patients were identified. 129,647 (59.3%) had complete data and were included: 55% male, median age 61 years and median Injury Severity Score 9. Blunt trauma predominated (96.5%), with falls 2 =83.91, p Conclusion This study has demonstrated the performance of the MPTT (a tool derived using a military cohort) in a civilian environment, where it has been shown to outperform all existing MI triage systems in its ability to predict need for life-saving intervention. As a result of this validation, its use within a civilian major incident context is recommended.

Objectives & Background The clinical effectiveness of patient controlled analgesia (PCA) has been demonstrated in a variety of settings. However, PCA is rarely utilized in the emergency department (ED). The aim of this study was to compare the cost effectiveness of PCA versus treatment as usual (TAU) in patients admitted to the ward from the ED with pain due to traumatic injury or non-traumatic abdominal pain. This is the cost-effectiveness analysis of the previously reported PAin SoluTions In the Emergency Setting (PASTIES) study. Methods Pain scores were measured hourly for 12 hours using a visual analogue scale from 0–100 mm. Scores of 45 mm or above reflected moderate or severe pain. Cost-effectiveness is reported as the additional cost per hour in moderate to severe pain avoided by using PCA rather than TAU, the incremental cost-effectiveness ratio (ICER). Sampling variation was estimated using bootstrap methods and the effects of parameter uncertainty explored in a sensitivity analysis. Results For patients suffering pain from traumatic injuries, the cost per hour in moderate or severe pain averted (ICER) was estimated as £24.77 (bootstrap estimate 95% CI=£8.72 to £89.17). The ICER for patients with abdominal pain was estimated as £15.17 (bootstrap estimate 95% CI=£9.03 to £46.00). Overall costs were higher with PCA than TAU in both groups: for pain from traumatic injuries an additional £18.58 (95% CI 15.81 to 21.35) per 12 hours; for abdominal pain £20.18 (95% CI 19.45 to 20.84). Conclusion The cost of PCA use in ED varies with the clinical scenario, but is in the region of £15–£25 per hour of moderate or severe pain averted. Overall additional costs are around £20 per 12-hour patient episode.

Objectives & Background Haemorrhage is the leading cause of potentially survivable trauma death. Selective Aortic Arch Perfusion (SAAP) is an experimental resuscitative intervention that has the potential to improve trauma survival: a trans-femoral intra-aortic balloon controls torso haemorrhage, while the catheter9s large central lumen allows oxygenated blood to be delivered to the proximal aorta–theoretically providing coronary perfusion pressures adequate for return of spontaneous circulation in cardiac arrest (figure 1). Hypothesis–In haemorrhage-induced traumatic cardiac arrest, SAAP with oxygenated blood will infer a short-term survival advantage over both closed chest compressions (CPR) with intravenous blood, and Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) with intravenous blood. Methods 70–90 kg swine underwent a non-compressible torso haemorrhage (NCTH) and controlled arterial haemorrhage. Arrest was defined as a systolic blood pressure (SBP) Results There were ten animals per group, a total of 30 swine. Mean weight of 79.9 kg (+/−5.5) p=0.3. Mean time from the start of the injury to onset of arrest was 11.2 minutes (+/−1.9) p=0.2. Prior to intervention the mean SBP was 2.9 mm Hg (+/−3.2) p=0.7, and the mean heart rate was 41 bpm (+/−32) p=0.5. Primary outcome – FWB-SAAP demonstrated an 80% 60-minute ‘pre-hospital’ survival, compared to 10% with CPR, and 0% with REBOA, p Conclusion In this swine model of haemorrhage-induced traumatic cardiac arrest with NCTH, SAAP infers a short-term survival advantage over both conventional therapy (CPR), and over evolving therapy (REBOA). Of note, SAAP induced return of spontaneous circulation from cardiac electrical asystole.

Objectives & Background Inadvertent intra-arterial cannulation (IIAC) occurs in some Emergency Department (ED) patients. Interpretation of point of care blood gas analysis (BGA) by a senior emergency physician (EP) may be used to screen for this. We conducted a prospective observational pilot study to investigate the rate of IIAC in the ED setting and to explore feasibility questions to inform a future larger study. Objectives: ▸ To assess the performance of medical students and foundation year one doctors in ultrasound (US) assessment of cannula location. ▸ To determine the time taken to complete US assessment of one cannula. ▸ To assess EP confidence in BGA interpretation. ▸ To explore whether or not venous BGA values varied by site of cannula. Methods Five medical students and FY1 doctors received a two-hour training session from an EP in US assessment of peripheral cannula location. Competence was confirmed by five observed US assessments. Data collectors performed US assessment of cannulas inserted in a convenience sample of ED patients over a two week period (83 patients). Their confidence and time taken to complete US assessment were recorded. Routine BGA obtained during cannula insertion were shown to an EP whose confidence in interpretation was recorded. Data collectors completed a survey to record their experience of various aspects of the study. Results 100% of data collectors found using ultrasound to determine the location of a cannula to be 9very easy9 or 9quite easy9. Adequate US views were obtained in 94% of examinations. Mean duration of US assessment was 11 minutes 25 seconds. 87% of cannulae had a routine BGA taken and EPs were 9quite confident9 or 9very confident9 in their interpretation in 97% of BGAs. There was no difference in blood gas values between different insertion sites. Conclusion Junior doctors and medical students can be trained in US assessment of cannula placement. BGA is frequently performed during cannula insertion. EPs interpret BGA confidently. Insertion site does not complicate interpretation. It is feasible to use this methodology for larger studies.

Objectives & Background Inadvertent intra-arterial cannulation (IIAC) is a recognised complication of peripheral cannulation with the potential for severe consequences including limb ischaemia and amputation. Patients presenting to EDs are often complex, frail or obese (known risk factors for difficult cannulation) meaning the overall incidence may be much higher than that suggested by existing evidence. Objectives: ▸ To report the rate of IIAC in our Emergency Department. ▸ To assess whether blood gas analysis can be used to screen for IIAC. Methods A prospective observational study was undertaken over a two week period. Every cannula inserted in the ED during hours of recruitment had blood drawn and blood gas analysis performed. The results were analysed by a senior ED clinician who assessed whether the blood gas values represented arterial or venous blood. Ultrasound assessment was performed on every cannula to confirm placement and, if there was any degree of uncertainty, transduced pressure readings were obtained. Results Two IIACs were confirmed out of the 83 cannulae analysed, a rate of 2.4%. Both of these IIACs were detected by the senior clinician interpreting the blood gas. Two further cannulae were incorrectly identified as potentially arterial on the blood gas, but were proven to be venous using ultrasound. Both patients experiencing IIACs had multiple risk factors for difficult cannulation and 44% of all subjects had at least one risk factor. Conclusion IIAC occurs more frequently than previously reported in our ED. A high proportion of ED patients have risk factors that make IIAC more likely. Point of care blood gas analysis may be a useful screening tool for detecting IIAC, particularly when used in conjunction with ultrasound +/− transduction. The results of this study justify further research to confirm and extend these observations. Implications for everyday practice within the ED include increased awareness and recognition of IIAC.

Objectives & Background Higher Speciality Trainees (HSTs) are expected to gain competence required for autonomous practice as a consultant. Whether EM HSTs have adequate exposure to achieve competence in the trauma team leader (TTL) role is unclear. Our primary aim was to investigate whether the supply of learning encounters is sufficient to generate competence in the TTL role during HST. Secondary aims were to explore HSTs9 participation in trauma calls, roles undertaken, confidence and competence within the TTL role, supervision, opinions on training and the number of TTL encounters required to attain competence. Methods HSTs in the West Midlands completed a survey exploring the study objectives including confidence in the TTL role. Consultants completed a separate survey assessing HST competence in the TTL role, reasons for lack of competence, and the desired number of supervised encounters required for HSTs to attain competence. To estimate the supply of TTL encounters available, the number of trauma calls was derived from regional and TARN data. This number was proportionally reduced to represent a 48 hour week, divided by the number of HSTs. To assess demand, the supply estimate was compared to the mean number of supervised TTL encounters specified by consultants. Results 27/27 eligible HSTs responded. HSTs reported attending 67% of activations during working hours, frequently in the TTL (67%) or Primary Survey roles (29%) but rarely in the airway role (3.2%). 39% of TTL encounters were supervised. 70% reported being confident in the TTL role. 35/37 eligible consultants responded. 42% felt that their HSTs were competent in the TTL role. Common deficiencies were lack of exposure and leadership ability. 100% of HSTs and 88.5% of consultants reported that a dedicated trauma placement would be desirable (median duration=6 months). Analysis estimates that the number of actual supervised TTL encounters during HST (n=33) is in keeping with the number desired by consultants (n=36) (figure 1). Conclusion The quantity of TTL encounters during HST broadly matches the demand for exposure specified by consultants. Despite this, there is a disparity between trainee confidence and consultant assessment of competence. Exploration of reasons underlying this difference and the desire for dedicated training may identify areas where HSTs development can be enhanced.

Emergency medicine is such a broad specialty, and the research underway and planned in emergency medicine such a vast undertaking, that we need to focus on the most important research questions to answer the most pressing clinical dilemmas. Funding for research is limited, and competition for money is fierce. It therefore is imperative that as a specialty we define the most important questions, to find the answers, to improve the clinical care our patients receive. The people who should be involved in defining these questions must include the clinicians working in our emergency departments, and our patients and their carers. Over the coming months, a research priority setting process will take place, to establish what the most important research questions are to clinicians working in the specialty of emergency medicine, and also to the patients we serve. The Royal College of Emergency Medicine, in partnership with the James …

Objective To investigate whether elderly patients, presenting following trauma and requiring immobilisation and imaging of the cervical spine, require increased use of CT and spend longer immobilised when compared to the younger population. Methods A retrospective chart review was undertaken of 35 adults aged 18–65 years, and 32 adults over 65 years, requiring cervical spine imaging following trauma. Results 1 of the 35 younger patients, and 16 of the 32 elderly patients, underwent CT. Elderly patients spent 1:05 h longer immobilised (p Conclusions Half of the elderly patients underwent CT, and they were immobilised for significantly longer than younger patients. Measures should be adopted to facilitate early diagnosis and mitigate complications of prolonged immobilisation in elderly patients with neck trauma.

Objectives & Background Traumatic cardiac arrest (TCA) in children is associated with poor survival ( Since 2003, over 600 seriously injured local national children have been treated at deployed UK military medical treatment facilities during the Iraq and Afghanistan conflicts. A number of these were in cardiac arrest after sustaining traumatic injuries. Trauma care has continually advanced during the recent conflicts, leading to many unexpected survivors (1). The objective of this study was to define outcomes from paediatric TCA in this cohort. Methods A retrospective database review was undertaken using the Joint Theatre Trauma Registry. This includes UK military, coalition military, civilians, and local security forces personnel who prompted trauma team activation. However, all children in this series were local nationals. All children aged less than 18 years who presented between January 2003 and April 2014, and who underwent CPR, were included. Results 32 children with TCA were included. The mechanisms of injury were IED (improvised explosive device), GSW (gunshot wound), MVC (motor vehicle collision), drowning and others (rocket propelled grenade, unexploded ordnance) – see Table 1. 4 children survived to discharge from the medical treatment facility (12.5%), though no data are available regarding the long-term neurological outcome in these patients. Further analyses, in particular with regard to injury patterns and life saving interventions, are underway. Conclusion Outcomes from this cohort show better survival rates in paediatric traumatic cardiac arrest compared to the most other studies. The reason for this is not known, although this mirrors the unexpected survivors previously reported in recent military series. Further work is necessary to define the optimal management of paediatric patients in TCA.

Objectives & Background The relationship between age and presenting Glasgow Coma Scale (GCS) in adults with traumatic brain injury (TBI) has not so far been explored in detail. We have previously reported a trend for higher GCS in elderly patients presenting to our major trauma centre with isolated TBI compared with younger adults. The aim of this study was to confirm and define this relationship using a national trauma registry and to evaluate potential contributory factors. Methods The Trauma Audit Research Network (TARN) database was interrogated to identify all adult (>16 years) cases of isolated TBI (Abbreviated Injury Score (AIS) 3 or greater for head with no AIS >3 in any other system) from 1988 to present. Cases were excluded if evidence of drug or alcohol intoxication, smoke or fume inhalation, psychiatric disturbance or traumatic asphyxia had been recorded. Demographic and detailed injury description data were recorded alongside GCS at Emergency Department presentation. Cases were categorised into adults (16–65 years) and elderly (>65 years). Presenting GCS was compared between the two groups for AIS head 3, 4 and 5. GCS data were not normally distributed therefore differences in GCS between groups were considered using two-way ANOVA performed on rank GCS. Sub-group analyses were performed comparing presenting GCS between adults and elderly in specific mechanisms of injury and for particular types of intracranial injury. Results 16,032 cases were identified whose baseline characteristics are presented in table 1. Overall, presenting GCS differed significantly between the two groups at each level of AIS severity (figure 1), a finding that was consistently replicated for each common mechanism of injury (all p Conclusion We believe that this is the first study to demonstrate that elderly patients present with a higher GCS than younger adults for a given anatomical severity of TBI. This difference is not confined to any particular mechanism of injury nor any type of intracranial injury. These findings may have profound implications for prehospital trauma triage tools, outcome prediction methodologies and neurosurgical decision-making.

Objectives & Background Pain is the commonest reason that patients present to an Emergency Department (ED), but is often not treated effectively. Patient controlled analgesia (PCA) is used in other hospital settings but there is little evidence to support its use in emergency patients. This study (one of two parallel trials) aimed to assess the effectiveness and cost-effectiveness of PCA in emergency patients with traumatic injuries. Methods Prospective multi-centre randomised trial of PCA versus routine care (nurse-titrated analgesia) in emergency department patients presenting with traumatic injuries, who required IV opioid analgesia and admission to hospital. Participants were randomised to receive either routine care or PCA, and followed for the first 12 hours of their hospital stay. The primary outcome measure was hourly participant-recorded pain, scored using a visual analogue scale (VAS), with primary statistical analyses based on the standardised (scaled from 0–100) area-under–the-curve (AUC) of each participant9s pain scores, with adjustment for time of admission, centre and baseline pain score. Results 200 participants (71% male) were recruited from 4 centres, mean (SD) age of 43 (15.0) years. Preliminary analysis showed mean (SD) standardised pain AUCs were 47.2 (21.9) for the routine care group and 44.0 (24.0) for the PCA group. Provisional adjusted analyses indicated a slightly lower (but not statistically significant) standardised pain AUC in the PCA group than for the routine care group (mean difference (routine care -PCA): 2.7; 95% confidence interval; –2.4 to 7.8). Conclusion Provisional results indicate that there is no statistically significant reduction in pain using PCA compared to routine care for emergency department patients with traumatic injuries. Further analyses are in progress, in particular, of total morphine consumption and cost-effectiveness.

Falls causing hip injury are common among older people. In elderly patients who cannot weight bear following a hip injury but have normal initial x rays, management often involves admission to the clinical decision unit for analgesia, mobilisation and physiotherapy. A proportion of these patients require further investigation due to continuing pain or inability to weight bear. There is currently no agreed pathway for these patients, who often wait days for definitive diagnosis and management. Some centres suggest investigating such patients with magnetic resonance imaging at 24 h post-admission. This study aimed to define this patient group in terms of emergency management, number undergoing further investigation and outcome. A secondary aim was to produce a management pathway for these patients.

Objectives & Background Appropriate activation of multi-disciplinary trauma teams improves outcome for severely injured patients, but can disrupt normal service in the rest of the hospital. Derriford Hospital uses a two-tiered trauma team activation system. The emergency department (ED) trauma team is activated in response to a significant traumatic mechanism; the hospital trauma team is activated when this mechanism co-exists with physiological abnormality or specific anatomical injury. The aim of this study was to compare characteristics, process measures and outcomes between patients treated by ED or hospital trauma teams to evaluate the approach in a UK setting and to estimate any cost savings involved. Figure 1 outlines the composition and activation criteria of the teams. Methods A retrospective database review was performed, using the TARN database and the local source trauma database. All patients who activated a trauma team between 1 Apr 12 to 30 Sep 12 were included. Patients were categorised according to the type of trauma team activated to receive them. Data included time to primary survey X-rays, time to CT, time to intubation, numbers discharged from ED, ICU admission, injury severity score (ISS), and mortality. Cost savings associated with activating an ED rather than hospital response were extrapolated from previously described methodology. Results During the study period 456 patients activated a trauma team, 358 ED and 98 hospital (see Figure 2). Patients seen by the ED team were significantly less likely to have severe injury or require hospital admission, intubation, emergency operation or blood transfusion. Differences in time taken to key investigations were statistically but not clinically significant. The cost saving of avoiding hospital team activation for those patients not requiring specialist care was estimated at £180,663 per annum. Conclusion A two-tiered trauma team activation system is an efficient, safe and cost-effective way of dealing with trauma patients presenting to a Major Trauma Centre in the UK.

Report by Jason Smith, Specialist Registrar in Emergency Medicine Checked by Simon Carley, Specialist Registrar in Emergency Medicine A 60 year old man attends the emergency department with chest pain. He also gives a history of belching since the onset of the pain. His initial ECG is normal. You …