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Following a motor vehicle collision some patients will remain trapped. Traditional extrication methods are time consuming and focus on movement minimisation and mitigation. 'Chain cabling' is an alternative method of extrication used in some countries. The optimal extrication strategy and the effect of extrication methods on spinal movement is unknown. This study compares 'chain cabling' to the established roof removal method of extrication on spinal movement.Biomechanical data were collected using Inertial Measurement Units on a single healthy volunteer during multiple experiments. The extrication types examined were chain cabling and roof removal. Measurements were recorded at the cervical and lumbar spine, and in the anteroposterior (AP) and lateral (LR) planes. Total movement (travel), maximal movement, mean, standard deviation and confidence intervals are reported.Eight experiments were performed using each technique. The smallest mean overall movements were recorded during roof-off extrication (cervical spine 0.6 mm for AP and LR, lumbar spine 3.9 mm AP and 0.3 mm LR). The largest overall mean movements were seen with chain cabling extrication (cervical spine AP 5.3 mm. LR 6.1 mm and lumbar spine 6.8 mm AP and 6.3 mm LR).In this study of a healthy volunteer, roof-off extrication was associated with less movement than chain cabling. The movement associated with chain cabling extrication was similar to that previously collected for other extrication types.

Triage is key to effective management of major incidents, yet there is scarce evidence surrounding the optimal method of paediatric major incident triage (MIT). This study aimed to derive consensus on key components of paediatric MIT among healthcare professionals responsible for triage during paediatric major incidents.Two-round online Delphi consensus study delivered July 2021-October 2021, including participants from pre-hospital and hospital specialities responsible for triage during paediatric major incidents. A 5-point Likert scale was used to determine consensus, set a priori at 70%.111 clinicians completed both rounds; 13 of 17 statements reached consensus. Positive consensus was reached on rescue breaths in mechanisms associated with hypoxia or asphyxiation, mobility assessment as a crude discriminator and use of adult physiology for older children. Whilst positive consensus was reached on the benefits of a single MIT tool across all adult and paediatric age ranges, there was negative consensus in relation to clinical implementation.This Delphi study has established consensus among a large group of clinicians involved in the management of major incidents on several key elements of paediatric major incident triage. Further work is required to develop a triage tool that can be implemented based on emerging and ongoing research and which is acceptable to clinicians.

Background Acute coronary syndrome is a common medical emergency. The optimal strategy to investigate patients who are at intermediate risk of acute coronary syndrome has not been fully determined. Objective To investigate the role of early computed tomography coronary angiography in the investigation and treatment of adults presenting with suspected acute coronary syndrome. Design A prospective, multicentre, open, parallel-group randomised controlled trial with blinded end-point adjudication. Setting Thirty-seven hospitals in the UK. Participants Adults (aged ≥ 18 years) presenting to the emergency department, acute medicine services or cardiology department with suspected or provisionally diagnosed acute coronary syndrome and at least one of the following: (1) a prior history of coronary artery disease, (2) a cardiac troponin level > 99th centile and (3) an abnormal 12-lead electrocardiogram. Interventions Early computed tomography coronary angiography in addition to standard care was compared with standard care alone. Participants were followed up for 1 year. Main outcome measure One-year all-cause death or subsequent type 1 (spontaneous) or type 4b (stent thrombosis) myocardial infarction, measured as the time to such event adjudicated by two cardiologists blinded to the computerised tomography coronary angiography (CTCA) arm. Cost-effectiveness was estimated as the lifetime incremental cost per quality-adjusted life-year gained. Results Between 23 March 2015 and 27 June 2019, 1748 participants [mean age 62 years (standard deviation 13 years), 64% male, mean Global Registry Of Acute Coronary Events score 115 (standard deviation 35)] were randomised to receive early computed tomography coronary angiography (n = 877) or standard care alone (n = 871). The primary end point occurred in 51 (5.8%) participants randomised to receive computed tomography coronary angiography and 53 (6.1%) participants randomised to receive standard care (adjusted hazard ratio 0.91, 95% confidence interval 0.62 to 1.35; p = 0.65). Computed tomography coronary angiography was associated with a reduced use of invasive coronary angiography (adjusted hazard ratio 0.81, 95% confidence interval 0.72 to 0.92; p = 0.001) but no change in coronary revascularisation (adjusted hazard ratio 1.03, 95% confidence interval 0.87 to 1.21; p = 0.76), acute coronary syndrome therapies (adjusted odds ratio 1.06, 95% confidence interval 0.85 to 1.32; p = 0.63) or preventative therapies on discharge (adjusted odds ratio 1.07, 95% confidence interval 0.87 to 1.32; p = 0.52). Early computed tomography coronary angiography was associated with longer hospitalisations (median increase 0.21 days, 95% confidence interval 0.05 to 0.40 days) and higher mean total health-care costs over 1 year (£561 more per patient) than standard care. Limitations The principal limitation of the trial was the slower than anticipated recruitment, leading to a revised sample size, and the requirement to compromise and accept a larger relative effect size estimate for the trial intervention. Future work The potential role of computed tomography coronary angiography in selected patients with a low probability of obstructive coronary artery disease (intermediate or mildly elevated level of troponin) or who have limited access to invasive cardiac catheterisation facilities needs further prospective evaluation. Conclusions In patients with suspected or provisionally diagnosed acute coronary syndrome, computed tomography coronary angiography did not alter overall coronary therapeutic interventions or 1-year clinical outcomes, but it did increase the length of hospital stay and health-care costs. These findings do not support the routine use of early computed tomography coronary angiography in intermediate-risk patients with acute chest pain. Trial registration This trial is registered as ISRCTN19102565 and Clinical Trials NCT02284191. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 37. See the NIHR Journals Library website for further project information.

Acute coronary syndrome is a common medical emergency. The optimal strategy to investigate patients who are at intermediate risk of acute coronary syndrome has not been fully determined.To investigate the role of early computed tomography coronary angiography in the investigation and treatment of adults presenting with suspected acute coronary syndrome.A prospective, multicentre, open, parallel-group randomised controlled trial with blinded end-point adjudication.Thirty-seven hospitals in the UK.Adults (aged ≥ 18 years) presenting to the emergency department, acute medicine services or cardiology department with suspected or provisionally diagnosed acute coronary syndrome and at least one of the following: (1) a prior history of coronary artery disease, (2) a cardiac troponin level 99th centile and (3) an abnormal 12-lead electrocardiogram.Early computed tomography coronary angiography in addition to standard care was compared with standard care alone. Participants were followed up for 1 year.One-year all-cause death or subsequent type 1 (spontaneous) or type 4b (stent thrombosis) myocardial infarction, measured as the time to such event adjudicated by two cardiologists blinded to the computerised tomography coronary angiography ( CTCA ) arm. Cost-effectiveness was estimated as the lifetime incremental cost per quality-adjusted life-year gained.Between 23 March 2015 and 27 June 2019, 1748 participants [mean age 62 years (standard deviation 13 years), 64% male, mean Global Registry Of Acute Coronary Events score 115 (standard deviation 35)] were randomised to receive early computed tomography coronary angiography (The principal limitation of the trial was the slower than anticipated recruitment, leading to a revised sample size, and the requirement to compromise and accept a larger relative effect size estimate for the trial intervention.The potential role of computed tomography coronary angiography in selected patients with a low probability of obstructive coronary artery disease (intermediate or mildly elevated level of troponin) or who have limited access to invasive cardiac catheterisation facilities needs further prospective evaluation.In patients with suspected or provisionally diagnosed acute coronary syndrome, computed tomography coronary angiography did not alter overall coronary therapeutic interventions or 1-year clinical outcomes, but it did increase the length of hospital stay and health-care costs. These findings do not support the routine use of early computed tomography coronary angiography in intermediate-risk patients with acute chest pain.This trial is registered as ISRCTN19102565 and Clinical Trials NCT02284191.This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full inChest pain is a common medical emergency. It is important to decide if the cause is a heart attack. The two tests that are often used are a heart recording (electrocardiogram) and a blood test (troponin levels). If both are normal, the cause of chest pain is unlikely to be a heart attack and the patient is often discharged home. If either test is positive or if the patient has had previous heart problems, then the patient may require further investigation. We wanted to test whether or not adding a heart scan called a computerised tomography coronary angiogram improved patients’ care.We carried out a randomised trial in which half of the patients attending hospital with chest pain had a computerised tomography coronary angiography scan as part of their assessment and half of the patients did not. In total, 1749 patients were recruited and followed up for 1 year.The use of an additional early computerised tomography coronary angiography scan for chest pain patients of medium risk produced only small improvements in patient care.

BackgroundTraumatic injury is a leading cause of death worldwide. There is a crucial need to develop therapies that improve critically injured patient outcomes. Current trauma research models are ethically and financially challenging, with poor translation. However, traumatic injury and haemorrhagic shock can be modelled using ex-vivo normothermic perfusion (EVNP), a methodology adapted from transplantation. The aim of this study was to develop a 24hr EVNP duel porcine limb and kidney model.MethodEight porcine forelimbs, bilateral kidneys and blood were retrieved via standard protocols. Following ResultsPerfusion was maintained for 24hrs in all limbs, with blood flows of 345.03mls/min (±54.78 SD) and MAP of 77.57mmHg (±3.82 SD). Three kidneys achieved 24hr perfusion, with flows of 214.53mls/min (±41.6 SD) and MAP of 80.58mmHg (±0.51 SD). Biochemical analysis showed a statistically significant potassium elevation at 24hrs compared to baseline, p=0.0078. A further three kidneys were disconnected from the circuit at 7, 11 and 12hrs, and two kidneys showed decline in flow >15 hrs due to declining haemodynamics. Compared to baseline, evidence of cell death was observed in 24hr muscle samples. In the end-point kidney samples, tubular degeneration, protein loss and necrosis extended along the nephron.ConclusionsLimb EVNP can be successfully achieved for 24hrs, but further protocol improvements are required to sustain renal perfusion for 24hrs alongside adjustments to reduce the ischaemic insult and cell death.

ObjectiveThe 21st century has seen an unexpected rise in numbers of patients with severe injuries caused by low energy transfer mechanisms such as low falls. Our objective was to determine whether this increasing “low energy transfer major trauma” disease burden is more strongly associated with population ageing, better detection or registry reporting between 2000 and 2019.DesignLongitudinal series of annual cross-sectional studies from the Trauma Audit Research Network (TARN).SettingEngland and Wales.ParticipantsPatients with an Injury Severity score (ISS) >15, admitted to English or Welsh hospitals from January 2000 until December 2019.Main outcome measuresThe primary outcome was the strength of association of changes in annual rates of; major trauma patients receiving three-dimensional imaging (CT/MRI scans), registry reporting, and proportion of the population aged over seventy-five with changes in the annual proportion of patients injured via low energy transfer mechanisms.ResultsThe annual proportion of major trauma patients injured by low energy transfer mechanisms rose more than four-fold from 12.5% in 2000 to 52.6% in 2019 (+40.1%, 95% CI 38.8 to 41.4, pConclusionBetween 2000 and 2019 changes in major trauma imaging and reporting have revealed the previously hidden burden of injury resulting from low energy transfer mechanisms, potentially explaining significant increases in major trauma patient numbers. Future research should recognise low energy and high energy major trauma patients are distinct groups and require different interventions to improve patient outcomes.Section 1: What is already known on this topicFalls from standing height or less than two metres are causing an increasing major injury disease burden across Europe.Internationally trauma systems have focussed on patients with injuries caused by high energy transfer mechanisms, such as road traffic collisions.Section 2: What this study addsBetter detection and reporting of low energy transfer major trauma - rather than population ageing - appear to be are driving the increase in lower energy major trauma.Low energy transfer major trauma - characterised by older age, less abnormal physiology, but a high prevalence of traumatic brain and thoracic injuries - is now the dominant major trauma (ISS>15) presentation in England and Wales.Low energy transfer major trauma patients wait longer for CT scan, are less likely to receive the care in the highest-level trauma centre, to undergo surgery or be admitted to critical care.Section 3: How this study might affect research, policy and practiceFuture research should recognise high energy and low energy trauma patients are distinct groups, which require different interventions to improve care processes and outcomes.

IntroductionPatients aged 60 or over account for over half of the severely injured trauma patients and a traumatic brain injury is the most common injury sustained. Many of these patients are taking antiplatelet medications but there is clinical equipoise about the role of platelet transfusion in patients with traumatic intracranial haemorrhage (ICH) taking prior antiplatelet medications.MethodA prepiloted survey was designed to explore a range of clinical issues in managing patients taking antiplatelet medications admitted with a traumatic brain injury. This was sent via email to consultants and specialty registrar members of a variety of relevant UK societies and working groups in the fields of emergency medicine, critical care, neurosurgery and haematology.Results193 responses were received, mostly from colleagues in emergency medicine, neurosurgery, anaesthesia and haematology. Respondents indicated that there is a lack of evidence to support the use of platelet transfusion in this patient population but also lack of evidence of harm. Results also demonstrate uncertainties as to whether platelets should be given to all or some patients and doubt regarding the value of viscoelastic testing.DiscussionOur survey demonstrates equipoise in current practice with regards to platelet transfusion in patients with a traumatic ICH who are taking antiplatelet medication. There is support for additional trials to investigate the effect of platelet transfusion in this rising population of older, high-risk patients, in order to provide a better evidence-base for guideline development.

This review focuses on the recent evolution of the initial resuscitation of combat-injured personnel. It summarizes the recommendations of TCCC and makes recommendations based on literature review and author experience. Over nearly 20 years, the experience in caring for combat casualties in the global war on terror has led to significant changes within military trauma care. Evolution of pre-hospital care, utilization of tourniquets and TXA for hemorrhage control, and use of whole blood as the preferred resuscitative fluid have significantly reduced mortality. Additionally, the collective wisdom of experienced trauma surgeons serves as an invaluable guide for managing setup and flow within the various levels of the military trauma system. This review article highlights recommended practices for the initial resuscitation of personnel injured in combat along with providing proven methods for trauma team preparation and management that can and should be used by any surgeon preparing to deploy.

UK Defence Medical Services personnel deployed in support of the United Nations Mission in South Sudan as part of Operation TRENTON in 2017–2018. One key contribution was the development of a multiagency major incident plan in collaboration with key stakeholders within the region, including our UN partners, other troop-contributing countries and non-governmental organisations. This paper describes the process and contribution made, with some transferable lessons for future similar operations, such as adaptation of our courses. Major incident management is one of several technical areas ripe for a proactive Defence Healthcare Engagement strategy, seeking to offer capacity building in areas where Defence is rich in expertise that is highly sought after by other sectors.

Background Motor vehicle collisions remain a common cause of spinal cord injury. Biomechanical studies of spinal movement often lack “real world” context and applicability. Additional data may enhance our understanding of the potential for secondary spinal cord injury. We propose the metric ‘travel’ (total movement) and suggest that our understanding of movement related risk of injury could be improved if travel was routinely reported. We report maximal movement and travel for collar application in vehicle and subsequent self-extrication. Methods Biomechanical data on application of cervical collar with the volunteer sat in a vehicle were collected using Inertial Measurement Units on 6 healthy volunteers. Maximal movement and travel are reported. These data and a re-analysis of previously published work is used to demonstrate the utility of travel and maximal movement in the context of self-extrication. Results Data from a total of 60 in-vehicle collar applications across three female and three male volunteers was successfully collected for analysis. The mean age across participants was 50.3 years (range 28–68) and the BMI was 27.7 (range 21.5–34.6). The mean maximal anterior–posterior movement associated with collar application was 2.3 mm with a total AP travel of 4.9 mm. Travel (total movement) for in-car application of collar and self-extrication was 9.5 mm compared to 9.4 mm travel for self-extrication without a collar. Conclusion We have demonstrated the application of ‘travel’ in the context of self-extrication. Total travel is similar across self-extricating healthy volunteers with and without a collar. We suggest that where possible ‘travel’ is collected and reported in future biomechanical studies in this and related areas of research. It remains appropriate to apply a cervical collar to self-extricating casualties when the clinical target is that of movement minimisation.

Tony Smith : D’abord, felicitations pour Smart Machines and Service Work. C’est l’un des meilleurs livres que j’ai lus sur les consequences sociales du changement technologique. Il est beaucoup plus penetrant que les nombreux livres sur le sujet qui drainent l’attention de la grande presse. Beaucoup d’entre eux defendent un techno-utopisme, affirmant que si nous patientons un peu, et elaborons des politiques justes, les technologies avancees declencheront une nouvelle ere de croissance et de ...

Closed chest compressions (CCC) are recommended for medical cardiac arrest, but there is little evidence to support their inclusion for traumatic cardiac arrest (TCA). This laboratory study evaluated CCC following haemorrhage-induced TCA and whether resuscitation with blood improved survival compared to saline. The study was conducted with the authority of UK Animals (Scientific Procedures) Act 1986 (received institutional ethical approval and a Home Office Licence) using 39 terminally anesthetised, instrumented, juvenile Large White pigs. Following baseline measurements, animals underwent captive bolt injury to the right thigh and controlled haemorrhage (30% blood volume). Sixty minutes later there was a further haemorrhage to a MAP of 20 mmHg. The randomised resuscitation protocol was initiated within 5 min: CCC (Group 1); IV whole blood (Group 2); IV 0.9% saline (Group 3); IV whole blood + CCC (Group 4); and IV saline + CCC (Group 5). Fluid was administered as 3 × 10 ml/kg boluses using the Belmont® Rapid Infuser. The LUCAS™ II Chest Compression System delivered CCC. Primary Outcome was attainment of return of spontaneous circulation (ROSC MAP ≥ 50 mmHg) at Study End (fifteen minutes post-resuscitation) and secondary outcomes included haemodynamics. Mortality (MAP≤10 mmHg) was significantly higher in Group 1 compared to Groups 2 and 3 (P 0.0001). Resuscitation with whole blood was significantly better than saline (P = 0.0069), no animals in Group 3 attained ROSC. The addition of chest compressions to fluid resuscitation resulted in a significantly worse outcome with saline resuscitation (P = 0.0023) but not with whole blood (P = 0.4411). Cardiovascular variables at the end of the Resuscitation Phase and Study End were significantly worse for Group 5 compared to Group 3. Some significant differences were present at the end of the Resuscitation Phase for Group 4 versus Group 2 but these differences were no longer present by Study End. CCC were associated with increased mortality and compromised haemodynamics compared to intravenous fluid resuscitation. Whole blood resuscitation was better than saline.

OBJECTIVES Triage is a key principle in the effective management of a major incident. Its effectiveness is a balance between identifying those in need of life-saving intervention, and those triaged incorrectly as either needing/not needing a life-saving intervention. The primary aim of this study was to report mortality in those under-triaged by existing major incident triage tools. Secondary aims were to report the ability of triage tools at identifying serious injury by body region (defined as an Abbreviated Injury Scale severity score≥3). PATIENTS AND METHODS Retrospective database analysis of the UK Trauma Audit Research Network for all adult patients (≥18 years) between 2006 and 2014. Patients were defined as priority one using a previously published list. Using the first recorded hospital physiology, patients were categorized by the Modified Physiological Triage Tool (MPTT), National Ambulance Resilience Unit (NARU) Sieve and the Major Incident Medical Management and Support (MIMMS) Triage Sieve. Categorical and continuous data were analyzed using a χ-test and Mann-Whitney U-test respectively. RESULTS During the study period, 218 985 adult patients met the Trauma Audit Research Network inclusion criteria, with 24 791 (19.5%) priority one patients, of which 70% were male with a median age of 51 (33-71) years and injury severity score of 16 (9-25). The MPTT showed the lowest rate of under-triage (42.4%, P

When studies measure the effect of a treatment longitudinally over time, multiple data points are generated, but are sometimes incomplete. This may affect studies in a range of different settings, including studies on military patients. When analysing the data from such a study, one of the challenges is how to deal with missing data points in the final analysis. This article describes the possible different ways of dealing with missing data points in such a context, and outlines some pragmatic methods used for handling missing pain scores in the recent PAin SoluTions In the Emergency Setting (PASTIES) trials.

IntroductionSupplemental oxygen is a key element of emergency treatment algorithms. However, in the operational environment, oxygen supply poses a challenge. The lack of high-quality evidence alongside emerging technologies provides the opportunity to challenge current guidelines. The aim of this review was to appraise the evidence for the administration of oxygen in emergency patients and give recommendations for its use in clinical practice.MethodsA critical review of the literature was undertaken to determine the evidence for emergency supplemental oxygen use.ResultsBased on interpretation of the limited available evidence, five key recommendations are made: pulse oximetry should be continuous and initiated as early as possible; oxygen should be available to all trauma and medical patients in the forward operating environment; if peripheral oxygen saturations (SpO2) are greater than or equal to 92%, supplemental oxygen is not routinely required; if SpO2 is less than 92%, supplemental oxygen should be titrated to achieve an SpO2 of greater than 92%; and if flow rates of greater than 5 L/min are required, then urgent evacuation and critical care support should be requested.ConclusionOxygen is not universally required for all patients. Current guidelines aim to prevent hypoxia but with potentially conservative limits. Oxygen should be administered to maintain SpO2 at 92% or above. New areas for research, highlighted in this review, may provide a future approach for oxygen use from point of injury to definitive care.

A recent report from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) highlights some key points relating to the treatment and outcome of patients who suffer out-of-hospital cardiac arrest (OOHCA) in the UK.1 Its aim was ‘to identify opportunities to improve the organisation of services and the clinical care of patients following an OOHCA, to enhance the overall quality of care they receive’. In the 12 months of 2018, the Out-of-Hospital Cardiac Arrest Outcomes Registry at the University of Warwick recorded 30 829 patients who had an OOHCA for whom the emergency services were called and resuscitation was attempted. Adult patients with medical arrest who were transported to the hospital and who had a sustained return of spontaneous circulation (ROSC) were included, with a sample taken from each hospital resulting in the analysis of 699 questionnaires and 416 case note reviews. Overall, there was a 9.7% survival to hospital discharge, consistent with previous UK data, and a recent meta-analysis of global survival rates.2 However, the international picture is one of improving survival in the best systems with some reporting survival rates of up to 28%,3 so in reality, this may mean that the UK is lagging behind, despite laudable initiatives to improve outcomes.4 The report highlights that the key elements of successful resuscitation are the basics: witnessed arrest with early and effective bystander cardiopulmonary resuscitation (CPR) and access to early defibrillation. Many elderly patients come to the end of their lives and do not have a reversible cause for their cardiac arrest. However, the mean age in this report …

This paper examines the development and evolution of the deployed medical director (DMD) role and argues for the re-establishment of a formal selection process and training pathway. Recent deployments into new areas of operations, deployment of smaller medical treatment facilities (MTFs), the reduced numbers of deployments for clinicians, working with various multinational partners and both military and civilian organisations all pose specific problems for DMDs. The initial and then continued deployment of a secondary care role 2 MTF as part of the United Nations Mission in South Sudan illustrated some of these challenges. Although a novel operation, the broad categories of these new challenges were similar to the historical challenges facing the first DMDs in Afghanistan. Corporate memory loss may be unavoidable to some degree due to rapid turnover in appointments, particularly in single service and joint headquarters. However, individual memory and experience remains extant within the military medical deployable workforce. After the cessation of UK military deployed hospital care involvement in Afghanistan, the UK DMD formal training pathway ended. This paper argues for the re-establishment of a more formal DMD selection process and training pathway to ensure that organisational learning is optimised.

Background Motor vehicle collisions (MVCs) are a common cause of major trauma and death. Following an MVC, up to 40% of patients will be trapped in their vehicle. Extrication methods are focused on the prevention of secondary spinal injury through movement minimisation and mitigation. This approach is time consuming and patients may have time-critical injuries. The purpose of this study is to describe the outcomes and injuries of those trapped following an MVC: this will help guide meaningful patient-focused interventions and future extrication strategies. Methods We undertook a retrospective database study using the Trauma Audit and Research Network database. Patients were included if they were admitted to an English hospital following an MVC from 2012 to 2018. Patients were excluded when their outcomes were not known or if they were secondary transfers. Results This analysis identified 426,135 cases of which 63,625 patients were included: 6983 trapped and 56,642 not trapped. Trapped patients had a higher mortality (8.9% vs 5.0%, p p Injury Severity Score (ISS) was higher in the trapped group 18 (IQR 10–29) vs 13 (IQR 9–22). Trapped patients had more deranged physiology with lower blood pressures, lower oxygen saturations and lower Glasgow Coma Scale, GCS (all p p Conclusion Trapped patients are more likely to die than those who are not trapped. The frequency of spinal cord injuries is low, accounting for

Background: Rapid identification of coronary heart disease may improve clinical outcomes in patients presenting with acute chest pain. We aimed to establish whether early CT coronary angiography in intermediate-risk patients presenting to the Emergency Department with acute chest pain could improve one-year clinical outcomes. Methods: In a prospective randomised open blinded-endpoint parallel-group clinical trial, adults with suspected acute coronary syndrome and prior coronary heart disease, elevated cardiac troponin or ischaemic electrocardiogram, were randomised 1:1 to early CT coronary angiography plus standard of care or standard of care alone in 37 UK hospitals. The primary endpoint was one-year all-cause death or subsequent type 1 or 4b myocardial infarction. Findings: Between 23rd March 2015 and 27th June 2019, 1748 participants (mean age 62 (SD 13) years, 64% male, mean GRACE score 115 (SD 35)) were randomised to early CT coronary angiography (n=877) or to standard of care alone (n=871). The primary endpoint occurred in 51 (5·8%) participants randomised to CT coronary angiography and 53 (6·1%) participants with standard of care (adjusted hazard ratio 0·91 (95% confidence interval, 0·62 to 1·35), P=0·65). CT coronary angiography was associated with reduced invasive coronary angiography (adjusted hazard ratio 0·81 (95% confidence interval, 0·72 to 0·92), P=0·001) but no change in coronary revascularisation or preventative therapies. Early CT coronary angiography was associated with longer hospitalisations (median increase 0·21 (95% confidence interval 0·05 to 0·40) days) and higher costs (£561 more per patient). Interpretation: In patients with suspected acute coronary syndrome, CT coronary angiography did not alter overall coronary therapeutic interventions or one-year clinical outcomes but increased length of hospital stay and healthcare costs. These findings do not support the routine use of early CT coronary angiography in intermediate-risk patients with acute chest pain. Trial Registration: ISRCTN19102565 and NCT02284191. Funding Statement: National Institute for Health Research HTA Programme (13/04/108). Declaration of Interests: SG was deputy director of the National Institute for Health Research Health Technology Assessment Programme and chairs the NIHR HTA commissioning committee. NC reports Unrestricted research grants from HeartFlow, Boston Scientific, Haemonetics, Beckmann Coulter Speaker fees and Consultancy from HeartFlow, Boston Scientific, Abbott, Haemonetics Travel sponsorship from Haemonetics, Boston Scientific, HeartFlow, Biosensors, Edwards, Medtronic. DEN reports grant support from Siemens. All other authors report no conflicts of interest. Ethics Approval Statement: The trial was approved by the South East Scotland Research Ethics Committee 01.

Objectives To establish if the use of early computed tomography (CT) coronary angiography improves one year clinical outcomes in patients presenting to the emergency department with acute chest pain and at intermediate risk of acute coronary syndrome and subsequent clinical events. Design Randomised controlled trial. Setting 37 hospitals in the UK. Participants Adults with suspected or a provisional diagnosis of acute coronary syndrome and one or more of previous coronary heart disease, raised levels of cardiac troponin, or abnormal electrocardiogram. Interventions Early CT coronary angiography and standard of care compared with standard of care only. Main outcome measures Primary endpoint was all cause death or subsequent type 1 or 4b myocardial infarction at one year. Results Between 23 March 2015 and 27 June 2019, 1748 participants (mean age 62 years (standard deviation 13), 64% men, mean global registry of acute coronary events (GRACE) score 115 (standard deviation 35)) were randomised to receive early CT coronary angiography (n=877) or standard of care only (n=871). Median time from randomisation to CT coronary angiography was 4.2 (interquartile range 1.6-21.6) hours. The primary endpoint occurred in 51 (5.8%) participants randomised to CT coronary angiography and 53 (6.1%) participants who received standard of care only (adjusted hazard ratio 0.91 (95% confidence interval 0.62 to 1.35), P=0.65). Invasive coronary angiography was performed in 474 (54.0%) participants randomised to CT coronary angiography and 530 (60.8%) participants who received standard of care only (adjusted hazard ratio 0.81 (0.72 to 0.92), P=0.001). There were no overall differences in coronary revascularisation, use of drug treatment for acute coronary syndrome, or subsequent preventive treatments between the two groups. Early CT coronary angiography was associated with a slightly longer time in hospital (median increase 0.21 (95% confidence interval 0.05 to 0.40) days from a median hospital stay of 2.0 to 2.2 days). Conclusions In intermediate risk patients with acute chest pain and suspected acute coronary syndrome, early CT coronary angiography did not alter overall coronary therapeutic interventions or one year clinical outcomes, but reduced rates of invasive angiography while modestly increasing length of hospital stay. These findings do not support the routine use of early CT coronary angiography in intermediate risk patients with acute chest pain and suspected acute coronary syndrome. Trial registration ISRCTN19102565 , NCT02284191 .

ObjectivesCatastrophic haemorrhage is a leading cause of morbidity and mortality in trauma, in both military and civilian settings. There are numerous studies looking at the effectiveness of different haemostatic agents in the laboratory but few in a clinical setting. This study analyses the use of haemostatic dressings used in patients injured on the battlefield and their association with survival.MethodA retrospective database review was undertaken using the UK Joint Theatre Trauma Registry from 2003 to 2014, during combat operations in Iraq and Afghanistan. Data included patient demographics, the use of haemostatic dressings, New Injury Severity Score (NISS) and patient outcome.ResultsOf 3792 cases, a haemostatic dressing was applied in 317 (either Celox, Hemcon or Quickclot). When comparing patients who had a haemostatic dressing applied versus no haemostatic agent, there was a 7% improvement in survival. Celox was the only individual haemostatic dressing that was associated with a statistically significant improvement in survival, which was most apparent in the more severely injured (NISS 36–75).ConclusionWe have shown an association between use of haemostatic agents and improved survival, mostly in those with more severe injuries, which is particularly evident in those administered Celox. This supports the continued use of haemostatic agents as part of initial haemorrhage control for patients injured in conflict and suggests that civilian organisations that may need to deal with patients with similar injury patterns should consider their use and implementation.

“A Questionnaire on Monuments” features 49 responses to questions formulated by Leah Dickerman, Hal Foster, David Joselit, and Carrie Lambert-Beatty: “From Charlottesville to Cape Town, there have been struggles over monuments and other markers involving histories of racial conflict. How do these charged situations shed light on the ethics of images in civil society today? Speaking generally or with specific examples in mind, please consider any of the following questions: What histories do these public symbols represent, what histories do they obscure, and what models of memory do they imply? How do they do this work, and how might they do it differently? What social and political forces are in play in their erection or dismantling? Should artists, writers, and art historians seek a new intersection of theory and praxis in the social struggles around such monuments and markers? How might these debates relate to the question of who is authorized to work with particular images and archives?”

Six-year-old 'Shiraz' vines were grown under field-like conditions in 780-L soil filled plastic bins. One year after transplanting, root growth was monitored non-destructively using minirhizotron tubes. Images of the roots were collected at sunrise, midday, sunset and midnight over six consecutive days during flowering. It was found that the vines displayed a diurnal dynamic in root growth with a maximum in the afternoon and evening, and a minimum in the morning. While it was not possible to separate the effects of time of day and soil temperature a positive relationship between soil temperature and root elongation was observed. The diurnal dynamics of root growth was consistent with earlier observations in young potted vines and is the first indication that mature vines also exhibit a pronounced diurnal dynamic of fine root growth. The possible influence of carbon supply and the role of the circadian clock in these diurnal growth dynamics are discussed.

The Trauma Hemostasis and Oxygenation Research (THOR) Network has developed a consensus statement on the role of permissive hypotension in remote damage control resuscitation (RDCR). A summary of the evidence on permissive hypotension follows the THOR Network position on the topic. In RDCR, the burden of time in the care of the patients suffering from noncompressible hemorrhage affects outcomes. Despite the lack of published evidence, and based on clinical experience and expertise, it is the THOR Network’s opinion that the increase in prehospital time leads to an increased burden of shock, which poses a greater risk to the patient than the risk of rebleeding due to slightly increased blood pressure, especially when blood products are available as part of prehospital resuscitation. The THOR Network’s consensus statement is, “In a casualty with life-threatening hemorrhage, shock should be reversed as soon as possible using a blood-based HR fluid. Whole blood is preferred to blood components. As a part of this HR, the initial systolic blood pressure target should be 100 mm Hg. In RDCR, it is vital for higher echelon care providers to receive a casualty with sufficient physiologic reserve to survive definitive surgical hemostasis and aggressive resuscitation. The combined use of blood-based resuscitation and limiting systolic blood pressure is believed to be effective in promoting hemostasis and reversing shock” Postprint

Background The predominant cause of preventable trauma death is bleeding, and many of these patients need resuscitation with massive blood transfusion. In resource-constrained environments, early recognition of such patients can improve planning and reduce wastage of blood products. No existing decision rule is sufficiently reliable to predict those patients requiring massive blood transfusion. This study aims to produce a decision rule for use on arrival at hospital for patients sustaining battlefield trauma. Methods A retrospective database analysis was undertaken using the UK Joint Theatre Trauma Registry to provide a derivation and validation dataset. Regression analysis of potential predictive factors was performed. 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 A decision rule was produced using a combination of injury pattern, clinical observations and pre-hospital data. 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 massive blood transfusion, with an AUROC of 0.93 (95% CI 0.91–0.95). Conclusions We have produced a decision tool with improved accuracy compared to any previously described tools that can be used to predict blood transfusion requirements in the military deployed hospital environment.

Major incidents occur on a regular basis. So far in 2017, England has witnessed five terrorism-related major incidents, resulting in approximately 40 fatalities and 400 injured. Triage is a key principle in the effective management of a major incident and involves prioritising patients on the basis of their clinical acuity. This paper describes the limitations associated with existing methods of primary major incident triage and the process of developing a new and improved triage tool—the Modified Physiological Triage Tool-24 (MPTT-24). Whilst the MPTT-24 is likely to be the optimum physiological method for primary major incident triage, it needs to be accompanied by an appropriate secondary triage process. The existing UK military and civilian secondary triage tool, the Triage Sort, is described, which offers little advantage over primary methods for identifying patients who require life-saving intervention. Further research is required to identify the optimum method of secondary triage.

Triage is a key principle in the effective management of major incidents. There is limited evidence to support existing triage tools, with a number of studies demonstrating poor performance at predicting the need for a life-saving intervention. The Modified Physiological Triage Tool (MPTT) is a novel triage tool derived using logistic regression, and in retrospective data sets has shown optimum performance at predicting the need for life-saving intervention.Physiological data and interventions were prospectively collected for consecutive adult patients with trauma (18 years) presenting to the emergency department at Camp Bastion, Afghanistan, between March and September 2011. Patients were considered priority 1 (P1) if they received one or more interventions from a previously defined list. Patients were triaged using existing triage tools and the MPTT. Performance was measured using sensitivity and specificity, and a McNemar test with Bonferroni calculation was applied for tools with similar performance.The study population comprised 357 patients, of whom 214 (59.9%) were classed as P1. The MPTT (sensitivity: 83.6%, 95% CI 78.0% to 88.3%; specificity: 51.0%, 95% CI 42.6% to 59.5%) outperformed all existing triage tools at predicting the need for life-saving intervention, with a 19.6% absolute reduction in undertriage compared with the existing Military Sieve. The improvement in undertriage comes at the expense of overtriage; rates of overtriage were 11.6% higher with the MPTT than the Military Sieve. Using a McNemar test, a statistically significant (p0.001) improvement in overall performance was demonstrated, supporting the use of the MPTT over the Military Sieve.The MPTT outperforms all existing triage tools at predicting the need for life-saving intervention, with the lowest rates of undertriage while maintaining acceptable levels of overtriage. Having now been validated on both military and civilian cohorts, we recommend that the major incident community consider adopting the MPTT for the purposes of primary triage.

BACKGROUND: Triage is a key principle in the effective management at a major incident. There are at least three different triage systems in use worldwide and previous attempts to validate them, have revealed limited sensitivity. Within a civilian adult population, there has been no work to develop an improved system. METHODS: A retrospective database review of the UK Joint Theatre Trauma Registry was performed for all adult patients (>18years) presenting to a deployed Military Treatment Facility between 2006 and 2013. Patients were defined as Priority One if they had received one or more life-saving interventions from a previously defined list. Using first recorded hospital physiological data (HR/RR/GCS), binary logistic regression models were used to derive optimum physiological ranges to predict need for life-saving intervention. This allowed for the derivation of the Modified Physiological Triage Tool-MPTT (GCS≥14, HR≥100, 12

Objective: To carry out a prospective evaluation of tranexamic acid (TXA) use in trauma patients. Patients and methods: TXA was introduced to all emergency ambulances and emergency departments in the South West, UK, on 1 December 2011. We carried out a prospective evaluation of TXA use in trauma patients in the South West Peninsula between December 2011 and December 2012. We collected prehospital and hospital data on TXA administration using the Trauma Audit Research Network database. Data on prehospital administration of TXA were cross-checked with the South Western Ambulance Service Trust. Data were analysed using SPSS (version 20). Results: Altogether, 82 patients were administered TXA during the study period. The median age of the patients was 49 years (IQR 30, 66), and 72% were men. One-third of the patients arrived at hospital by air ambulance. During the first 3 months, administration of TXA was limited to one patient each month receiving the drug. However, an upward trend was observed after June until October 2012, with the increment being more than 10 fold in July, September and October 2012. Conclusion: This is the first study to evaluate the use of TXA in civilian practice in the UK. Our study shows that ambulance service personnel and emergency departments can effectively administer TXA.

Background Historically, reported survival from traumatic cardiac arrest (TCA) was extremely low. More recent publications have recorded survival to discharge of up to 8%. This improvement is likely to be multi-factorial; however, there are currently no published data describing the epidemiology or aetiology of TCA in England and Wales to guide future practice improvement. Methods Population-based analysis of 2009–2015 Trauma Audit and Research Network (TARN) data. The primary aim was to describe the 30-day survival following TCA. Patients of all ages with traumatic cardiac arrest pre-hospital or in the emergency department (ED) were included. Data are described as number (%), and median [interquartile range]. Two-group analysis with Chi-squared test was performed. Results During the study period 227,944 patients were included in the TARN database. Seven hundred and five (0.3%) suffered TCA: 74.3% were male, aged 44.3 [25.2–83.2] years, ISS 29 [21–75], and 601 (85.2%) had blunt injuries. 612 (86.8%) had a severe traumatic brain injury and or severe haemorrhage. Overall 30-day survival was 7.5% (95%CI 5.6–9.5) — ‘pre-hospital only’ TCA 11.5%, ‘ED only’ TCA 3.9%, p Conclusion This study has shown that short-term survival from TCA in this large civilian registry is 7.5%. Early and aggressive management of patients with TCA, using protocols that target the reversible causes of TCA, should be initiated. Further work to establish novel ways to manage patients with reversible causes of TCA is indicated. Resuscitation in this patient group is not futile.

This paper describes a series of critically ill patients who were cared for at a UK military field hospital during Op TRENTON 4, in support of the United Nations Mission in South Sudan. These cases highlight the potential challenges in managing the critically ill patient during contingency operations that take place in an austere resource-limited environment.

The United Nations Mission in South Sudan has a mandate to protect civilians and support the delivery of humanitarian assistance. Recognising this during Operation TRENTON, UK staff of the UN level 2 hospital were able to support the people of Bentiu through initiatives to develop local health services with on-the-ground civil–military cooperation. The Bentiu State Hospital Medical Training Programme was developed to train and mentor staff associated with healthcare in Bentiu, to help improve service delivery, support local health services with on-the-ground non-governmental organisation/military coordination and to create a platform to facilitate the sharing of information to support local health services with the overall humanitarian response. It was recognised how important it was to deliver a programme that carefully understood the unique challenging limitations, circumstances and environment. Hence careful tailoring of the programme was essential to ensure that the training was valuable, implementable and durable, long beyond the operational deployment of TRENTON. Despite the logistical and practical complexities, the programme was very positively received, and the training team believed that the development and progress made would build a small part of the future infrastructure of healthcare delivery in the region. Future contingency operations are likely to take place in the resource- limited austere environment. As reflected in this deployed initiative, local health training activity providing key knowledge to build resilience for the current and immediate future is a precious and important defence engagement utility.

BackgroundThe Need for Recovery (NFR) Scale is an 11-item questionnaire that assesses how work affects intershift recovery. Items are summated to form a score with a maximum value of 100. Previously reported scores range from 38 in nurses to 55 in miners. This study aimed to determine the NFR Score among ED staff and to identify whether the NFR Score was associated with characteristics potentially implicated with recovery from work.MethodsStaff in a single ED in the South West of England (annual attendances of 93 000) were asked to complete an electronic questionnaire incorporating the NFR Scale plus additional items relating to demographic, work-related and well-being characteristics, in their own time during January 2018. Descriptive statistics are presented, including median NFR Scores and associations with additional characteristics. Thematic analysis of free-text comments from an open-ended question was undertaken.ResultsOne hundred and sixty-eight responses were obtained (80.3% capture). Median NFR Score across all staff groups was 81.8 out of 100.0 (95% CI 72.7 to 81.8). Shift duration exceeding 12 hours, dissatisfaction with work–life balance and self-reported perceptions of burnout were associated with significantly elevated NFR Scores. Themes resulting from the open-ended question were ‘barriers to intershift recovery’ and ‘coping with work’.ConclusionThe NFR Scores in this study exceeded scores reported elsewhere and were associated with some demographic, occupational and well-being characteristics. The NFR Scale has utility to measure the need for intershift recovery among ED staff. A larger study is warranted to identify specific determinants of recovery and to provide recommendations.

Introduction Triage is a key principle in the effective management of major incidents. The process currently relies on algorithms assigning patients to specific triage categories; there is, however, little guidance as to what these categories represent. Previously, these algorithms were validated against injury severity scores, but it is accepted now that the need for life-saving intervention is a more important outcome. However, the definition of a life-saving intervention is unclear. The aim of this study was to define what constitutes a life-saving intervention, in order to facilitate the definition of an adult priority one patient during the definitive care phase of a major incident. Methods We conducted a modified Delphi study, using a panel of subject matter experts drawn from the United Kingdom and Republic of South Africa with a background in Emergency Care or Major Incident Management. The study was conducted using an online survey tool, over three rounds between July and December 2013. A four point Likert scale was used to seek consensus for 50 possible interventions, with a consensus level set at 70%. Results 24 participants completed all three rounds of the Delphi, with 32 life-saving interventions reaching consensus. Conclusions This study provides a consensus definition of what constitutes a life-saving intervention in the context of an adult, priority one patient during the definitive care phase of a major incident. The definition will contribute to further research into major incident triage, specifically in terms of validation of an adult major incident triage tool.

Cardiopulmonary resuscitation is a potentially lifesaving intervention, although significant iatrogenic injury may occur. Unlike cardiac and thoracic injuries, the incidence of abdominal injuries as a consequence of cardiopulmonary resuscitation has not been defined. We report a case of significant abdominal injury sustained during cardiopulmonary resuscitation, which was incidentally detected using focussed ultrasound. A review of the available literature summarises the incidence of abdominal injuries sustained during cardiopulmonary resuscitation. We consider whether the standard application of focussed abdominal ultrasound is desirable as part of post-resuscitation care. Clinicians should consider the potential for iatrogenic injuries following resuscitation, especially where persistent and unexplained haemodynamic instability occurs following return of spontaneous circulation. Many emergency departments have access to point-of-care ultrasound and staff skilled in focussed assessment with sonography for trauma. Post-resuscitation detection of abdominal injuries could be facilitated by utilising this approach. This may improve outcomes for patients with potentially treatable injuries that may have otherwise been missed or diagnosed late.

Introduction Most patient–provider communication skills frameworks focus on interpersonal behaviours within the context of a single consultation. In contrast, Emergency Department (ED) patient encounters consist of many new interactions with different professionals over a short time period. Additionally, ED care often occurs in a chaotic, unpredictable, and overcrowded environment. While these factors are recognised to present a major challenge to effective patient–provider communication in the ED, there is no accepted framework to guide how professionals or teams should approach and optimise communication with patients in the ED.Objectives This review aims to identify the current literature relating to routine patient provider communication processes in the ED and synthesise a new framework to enhance understanding of routine patient-provider communication processes in the ED.Methods Searches of Scopus, Medline, EMBASE and CINAHL were conducted to identify literature written between 2000 and 2016...

Background Wrist injuries are common, and there is often diagnostic uncertainty following normal initial radiographs when there is ongoing clinical suspicion of a scaphoid fracture.The aims of this study were to define the problem in our hospital, and to identify current practice relating to the management of patients with clinically suspected scaphoid injury across hospitals in England. Methods A retrospective review was undertaken of all patients presenting to our Emergency Department with a wrist injury, over a 12-month period.A cross-sectional survey of all hospitals in NHS England was then undertaken, using a web-based questionnaire. The results of the survey were analysed in Microsoft Excel to provide descriptive data only. Results Of 2367 patients presenting to our Emergency Department with a wrist injury, 420 (17.7%) were followed up due to ongoing clinical suspicion of a scaphoid injury.From the 141 acute hospital Trusts in NHS England, survey responses were received from 116 (82% response rate).Symptomatic patients undergo repeat radiograph in 68.0% of hospitals before second line imaging. This is performed using MRI in 63.9%, computed tomography in 27.0% or isotope bone scan in 9.0%.Secondary imaging is carried out between 10 days and 4 weeks following the initial injury in 86.8% of trusts. Conclusion This is still considerable variability in the way these patients are managed in England. Further work needs to be undertaken to establish the most appropriate way to manage patients with wrist injuries with ongoing clinical suspicion of scaphoid fracture.

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.

The 2015 Tri-Service Emergency Medicine Conference was held at RAF Linton on Ouse, from 24–26 November 2015. Abstracts were invited from military trainees in emergency medicine, and subjected to standardised assessment and scoring. The authors of the highest scoring abstracts were invited to

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.