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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.

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.

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.

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.

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.

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.

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.

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

Over the past century trauma care within the Royal Navy (RN) has evolved; wartime experiences and military medical research have combined to allow signifi cant improvement in the care of casualties. This article describes the key maritime and amphibious operations that have seen the Royal Navy Medical Service (RNMS) deliver high levels of support to wherever the Naval Service has deployed in the last 100 years. Key advancements in which progress has led to improved outcomes for injured personnel are highlighted – the control and treatment of blood loss, wound care, and the prevention and management of organ failure with optimal resuscitation.Historians often point out how slowly military medicine progressed for the fi rst few thousand years of its recorded history, and how quickly it has progressed in the last century. This refl ective article will show how the RNMS has been an integral part of that story, and how the lessons learnt by our predecessors have shaped our modern day doctrine surrounding trauma care.

Introduction Secondary triage at a major incident allows for a more detailed assessment of the patient. In the UK, the Triage Sort (TSO) is the preferred method, combining GCS, systolic BP (SBP) and RR to categorise Priority 1 casualties. The Shock Index (SI) is calculated by dividing HR by SBP (HR/SBP). This study examines whether SI is better at predicting need for life-saving intervention (LSI) following trauma than TSO. Methods A prospective observational study was undertaken. Physiological data and interventions performed in the Emergency Department and operating theatre were prospectively collected for 482 consecutive adult trauma patients presenting to Camp Bastion, Afghanistan, over a 6-month period. A patient was deemed to have required LSI if they received any intervention from a set described previously. Results Complete data were available for 345 patients (71.6%). Of these, 203 (58.8%) were gold standard P1, and 142 (41.2%) were non-P1. The TSO predicted need for LSI with a sensitivity of 58.6% (95% CI 51.8% to 65.4%) and specificity of 88.7% (95% CI 83.5% to 93.9%). Using an SI cut-off >0.75 provided greater sensitivity of 70.0% (95% CI 63.6% to 76.3%) while maintaining an acceptably high (although lower than TSO) specificity of 74.7% (95% CI 67.5% to 81.8%). At this SI cut-off, there was evidence of a difference between TSO and SI in terms of the way in which patients were triaged (p Discussion Our study showed that a SI >0.75 more accurately predicted the need for LSI, while maintaining acceptable specificity. SI may be more useful than TSO for secondary triage in a mass-casualty situation; this relationship in civilian trauma should be examined to clarify whether these results can be more widely translated into civilian practice. Project registration number RCDM/Res/Audit/1036/12/0050.

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.

The 2014 Tri-Service Emergency Medicine Conference was held at the Royal Air Force, Linton on Ouse, from 14 October to 16 October 2014. Abstracts were invited from military trainees in emergency medicine, and subjected to standardised assessment and scoring. The authors of the eight highest scoring abstracts were invited to present their abstracts in the final conference session. The top eight scoring abstracts that were presented in the session are included below. The prize for the best abstract was awarded to Captain Pip Lewis, Royal Army Medical Corps, for her work on intraosseous access.

The identification of major trauma patients before arrival in hospital allows the activation of an appropriate trauma response. The Wessex triage tool (WTT) uses a combination of anatomical injury assessment and physiological criteria to identify patients with major trauma suitable for triage direct to a major trauma centre (MTC), and has been adopted by the South-West Peninsula Trauma Network (PTN). A retrospective database review, using the Trauma Audit Research Network (TARN) database, was undertaken to identify a population of patients presenting to Derriford Hospital with an injury severity score (ISS) > 15. The WTT was then applied to this population to identify the sensitivity of the tool. The sensitivity of the WTT at identifying patients with an ISS>15 was 53%. One of the reasons for this finding was that elderly patients who are defined as having major trauma due to the nature of their injuries, but who did not have a mechanism to suggest they had sustained major trauma (such as a fall from standing height), were not identified by these triage tools. The implications of this are discussed.

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.

The 2016 Tri-Service Emergency Medicine Conference was held at RAF St Mawgan from 4-5 October 2016. 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 give an oral

Blast lung injury is an increasing problem for UK forces in Afghanistan, but is not a new phenomenon, with evidence that it has been increasing in incidence over the last century. Management is conservative, but there are newer therapies that may play a role in the future management of this 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.

Sir, We would like to thank Colonel Nigel Tai L/RAMC and colleagues for their interest in our paper.[1][1] The authors correctly report that we derived and validated the Modified Physiological Triage Tool-24 (MPTT-24) against the need for life-saving intervention, but this is not a novel outcome

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.

The 2017 Tri-Service Emergency Medicine Conference was held at RAF Cosford from 4–6 October 2017. 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 give an oral

Postpartum haemorrhage (PPH) remains a major cause of maternal morbidity worldwide, particularly in developing countries. PPH is thought to be preventable in most cases. Previous PPH poses a risk for recurrent PPH in subsequent delivery and an increased risk for caesarean section. PPH remains one of

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.

Objective: To review the different methods of reducing body core temperature in patients with exertional heatstroke. Methods: The search strategy included articles from 1966 to July 2003 using the databases Medline and Premedline, Embase, Evidence Based Medicine (EBM) reviews, SPORTDiscus, and cross referencing the bibliographies of relevant papers. Studies were included if they contained original data on cooling times or cooling rates in patients with heat illness or normal subjects who were subjected to heat stress. Results: In total, 17 papers were included in the analysis. From the evidence currently available, the most effective method of reducing body core temperature appears to be immersion in iced water, although the practicalities of this treatment may limit its use. Other methods include both evaporative and invasive techniques, and the use of chemical agents such as dantrolene. Conclusions: The main predictor of outcome in exertional heatstroke is the duration and degree of hyperthermia. Where possible, patients should be cooled using iced water immersion, but, if this is not possible, a combination of other techniques may be used to facilitate rapid cooling. There is no evidence to support the use of dantrolene in these patients. Further work should include a randomised trial comparing immersion and evaporative therapy in heatstroke patients.

Exertional heat illness remains a major cause of morbidity and occasional mortality within the Armed Forces. This review explores the normal responses to heat, known causes of exertional heatstroke, and suggests possible answers to the question of why one member of a military unit collapses with heat stroke, while matched controls at his side remain unaffected.

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.

Crush Syndrome remains rare in European practice. It is however common in areas of civil disorder and where the normal structures of society have given way to civil war or natural disaster. Western Doctors are becoming increasingly involved in such situations and there is no reason to believe that instances due to more conventional causes, such as collapse in the elderly or road traffic accidents will cease. For all these reasons it is important that clinicians who deal infrequently with crush syndrome have access to appropriate guidelines. This consensus report seeks to provide such advice.

Current pre-hospital trauma triage systems are based mainly on physiological parameters, but in compensated shock injury severity may not be immediately obvious, as the physiological parameters remain normal for some time. Serum lactate, measured in hospital, is known to be a predictor of injury severity and outcome. The technology for easy field lactate measurement has recently become available. We found that capillary lactate is elevated in trauma patients in the early phase of the response to injury. There is a moderate correlation (R2 = 0.44) between early lactate levels and injury severity, in patients who might otherwise be difficult to triage. Our aims were: (a) To determine if lactate levels are elevated in the pre-hospital phase of trauma, and to establish whether there is a correlation between pre-hospital lactate and injury severity. (b) To determine if there is a relationship between pre-hospital lactate and injury severity in patients with normal blood pressure and Glasgow Coma Score of greater than 12 (“difficult to triage” group). Methods Prospective analysis of pre-hospital capillary lactate levels and Injury Severity Score (ISS) in 23 trauma patients attended by the London Helicopter Emergency Medical Service. Results Capillary lactate is elevated in trauma patients in the early phase of the response to injury. There is a moderate correlation (R2 = 0.44) between early lactate levels and injury severity, in patients who might otherwise be difficult to triage. Conclusions Lactate is elevated in the earliest prehospital phase of injury following trauma. The potential contribution of this biochemical para-meter to field triage requires further evaluation.

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:To investigate the effects of strenuous exercise on commonly used biochemical and haematological variables in subjects running the 2002 London marathon.Methods:34 healthy volunteers (7 female, 27 male) were recruited for the study. Blood was taken before the start (at registration) and immediately after completion of the marathon. Samples were analysed for urea and electrolytes, liver function tests, creatine kinase (CK), CK-MB isoenzyme, myoglobin, troponin I, full blood count, a clotting screen, and D-dimers. The results before and after exercise were compared. Pearson’s correlation coefficients were calculated for all variables.Results:Significant increases were found in CK, CK-MB, aspartate aminotransferase (AST), lactate dehydrogenase (LDH), and myoglobin following the marathon. However, there was no significant change in the level of troponin I. There was also evidence of activation of the coagulation and fibrinolytic cascades following the marathon, with a reduction in activated partial thromboplastin time, a reduction in fibrinogen, and an increase in D-dimers.Conclusions:The results confirm previous individual studies on marathon running and the biochemical and haematological tests routinely carried out in hospital. These are affected by prolonged exercise, and “abnormal” results in these tests may be normal after prolonged exercise and therefore not diagnostic of a disease process. The results of investigations in patients who have been exercising should be interpreted with caution.

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.