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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.

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.

Background Approximately 1.3 million people die each year globally as a direct result of motor vehicle collisions (MVCs). Following an MVC some patients will remain trapped in their vehicle; these patients have worse outcomes and may require extrication. Following new evidence, updated multidisciplinary guidance for extrication is needed. Methods This Delphi study has been developed, conducted and reported to CREDES standards. A literature review identified areas of expertise and appropriate individuals were recruited to a Steering Group. The Steering Group formulated initial statements for consideration. Stakeholder organisations were invited to identify subject matter experts (SMEs) from a rescue and clinical background (total 60). SMEs participated over three rounds via an online platform. Consensus for agreement / disagreement was set at 70%. At each stage SMEs could offer feedback on, or modification to the statements considered which was reviewed and incorporated into new statements or new supporting information for the following rounds. Stakeholders agreed a set of principles based on the consensus statements on which future guidance should be based. Results Sixty SMEs completed Round 1, 53 Round 2 (88%) and 49 Round 3 (82%). Consensus was reached on 91 statements (89 agree, 2 disagree) covering a broad range of domains related to: extrication terminology, extrication goals and approach, self-extrication, disentanglement, clinical care, immobilisation, patient-focused extrication, emergency services call and triage, and audit and research standards. Thirty-three statements did not reach consensus. Conclusion This study has demonstrated consensus across a large panel of multidisciplinary SMEs on many key areas of extrication and related practice that will provide a key foundation in the development of evidence-based guidance for this subject area.

Aims To evaluate the potential associations between presentation cardiac troponin and the clinical impact of early computed tomography coronary angiography (CTCA) in intermediate-risk patients with suspected acute coronary syndrome. Methods and results In a large multicentre randomized controlled trial of patients with intermediate-risk chest pain due to suspected acute coronary syndrome, early CTCA had no effect on the primary outcome—death or subsequent Type 1 or 4b myocardial infarction—but reduced the rate of invasive coronary angiography. In this pre-specified secondary analysis, cardiovascular testing and clinical outcomes were compared between those with or without cardiac troponin elevation at presentation. Of 1748 patients, 1004 (57%) had an elevated cardiac troponin concentration and 744 (43%) had a normal concentration. Patients with cardiac troponin elevation had a higher Global Registry of Acute Coronary Events score (132 vs. 91; P Conclusion Presentation cardiac troponin had no demonstrable associations between the effects of early CTCA on reductions in non-invasive and invasive testing, or the lack of effect on coronary revascularization or the primary outcome in intermediate-risk patients with suspected acute coronary syndrome.

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.

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.

Background Motor vehicle collisions account for 1.3 million deaths and 50 million serious injuries worldwide each year. However, the majority of people involved in such incidents are uninjured or have injuries which do not prevent them exiting the vehicle. Self-extrication is the process by which a casualty is instructed to leave their vehicle and completes this with minimal or no assistance. Self-extrication may offer a number of patient and system-wide benefits. The efficacy of routine cervical collar application for this group is unclear and previous studies have demonstrated inconsistent results. It is unknown whether scripted instructions given to casualties on how to exit the vehicle would offer any additional utility. The aim of this study was to evaluate the effect of cervical collars and instructions on spinal movements during self-extrication from a vehicle, using novel motion tracking technology. Methods Biomechanical data on extrications were collected using Inertial Measurement Units on 10 healthy volunteers. The different extrication types examined were: i) No instructions and no cervical collar, ii) No instructions, with cervical collar, iii) With instructions and no collar, and iv) With instructions and with collar. Measurements were recorded at the cervical and lumbar spine, and in the anteroposterior (AP) and lateral (LAT) planes. Total movement, mean, standard deviation and confidence intervals are reported for each extrication type. Results Data were recorded for 392 extrications. The smallest cervical spine movements were recorded when a collar was applied and no instructions were given: mean 6.9 mm AP and 4.4 mm LAT. This also produced the smallest movements at the lumbar spine with a mean of 122 mm AP and 72.5 mm LAT. The largest overall movements were seen in the cervical spine AP when no instructions and no collar were used (28.3 mm). For cervical spine lateral movements, no collar but with instructions produced the greatest movement (18.5 mm). For the lumbar spine, the greatest movement was recorded when instructions were given and no collar was used (153.5 mm AP, 101.1 mm LAT). Conclusions Across all participants, the most frequently occurring extrication method associated with the least movement was no instructions, with a cervical collar in situ.

Background One third of UK medical students undertake an intercalated degree, typically in traditional academic disciplines. It is less usual for students to undertake intercalated degrees that are directly aligned to a clinical speciality with longitudinal placements. This cross sectional survey aims to explore the self-reported experiences of students, alumni and supervisors associated with a clinically oriented intercalated degree in emergency care featuring a longitudinal placement in a hospital emergency department over a 9-month academic year. Themes for exploration include student clinical and academic development, effect on career choice, supervisor experience and the effect on host institutions. Methods Current students, previous alumni, and clinical placement supervisors associated with a single intercalated degree programme in urgent and emergency care since 2005 were identified from records and using social media. Separate online surveys were then developed and distributed to current students/ previous alumni and consultant physician supervisors, between May and August 2016. Results are presented using basic descriptive statistics and selected free text comments. Results Responses were obtained from 37 out of 46 contactable students, and 14 out of 24 supervisors (80 and 63%, respectively). Students self-reported increased confidence in across a range of clinical and procedural competencies. Supervisors rated student competence in clinical, inter-professional and academic writing skills to be commensurate with, or in many cases exceeding, the level expected of a final year medical student. Supervisors reported a range of benefits to their own professional and personal development from supervising students, which included improved teaching and mentoring skills, providing intellectual challenge, and helping with the completion of audits and service improvement projects. Conclusions Students report the acquisition of a range of clinical, academic, and inter-professional skills following their intercalated BSc year. A positive experience was reported by supervisors, extending to host institutions. Students reported feeling more enthusiastic about emergency medicine careers on completion. However, as students embarking on this degree naturally bring pre-existing interest in the area, it is not possible to attribute causation to these associations. Further investigation is also required to determine the longer term effect of clinically oriented intercalated degrees on career choice. Electronic supplementary material The online version of this article (10.1186/s12909-019-1579-x) contains supplementary material, which is available to authorized users.

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

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

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.

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.

IntroductionThe Modified Physiological Triage Tool (MPTT) is a recently developed primary triage tool and in comparison with existing tools demonstrates the greatest sensitivity at predicting need for life-saving intervention (LSI) within both military and civilian populations. To improve its applicability, we proposed to increase the upper respiratory rate (RR) threshold to 24 breaths per minute (bpm) to produce the MPTT-24. Our aim was to conduct a feasibility analysis of the proposed MPTT-24, comparing its performance with the existing UK Military Sieve.MethodA retrospective review of the Joint Theatre Trauma Registry (JTTR) and Trauma Audit Research Network (TARN) databases was performed for all adult (>18 years) patients presenting between 2006–2013 (JTTR) and 2014 (TARN). Patients were defined as priority one (P1) if they received one or more LSIs. Using first recorded hospital RR in isolation, sensitivity and specificity of the ≥24 bpm threshold was compared with the existing threshold (≥22 bpm) at predicting P1 status. Patients were then categorised as P1 or not-P1 by the MPTT, MPTT-24 and the UK Military Sieve.ResultsThe MPTT and MPTT-24 outperformed existing UK methods of triage with a statistically significant (pConclusionsWhen compared with the existing MPTT, the MPTT-24 allows for a more rapid triage assessment. Both continue to outperform existing methods of primary major incident triage and within the military setting, the slight increase in undertriage is offset by a reduction in overtriage. We recommend that the MPTT-24 be considered as a replacement to the existing UK Military Sieve.

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.

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.

© 2018 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists. The effect of patient-controlled analgesia during the emergency phase of care on the prevalence of persistent pain is unkown. We studied individuals with traumatic injuries or abdominal pain 6 months after hospital admission via the emergency department using an opportunistic observational study design. This was conducted using postal questionnaires that were sent to participants recruited to the multi-centre pain solutions in the emergency setting study. Patients with prior chronic pain states or opioid use were not studied. Questionnaires included the EQ5D, the Brief Pain Inventory and the Hospital Anxiety and Depression scale. Overall, 141 out of 286 (49% 95%CI 44–56%) patients were included in this follow-up study. Participants presenting with trauma were more likely to develop persistent pain than those presenting with abdominal pain, 45 out of 64 (70%) vs. 24 out of 77 (31%); 95%CI 24–54%, p < 0.001. There were no statistically significant associations between persistent pain and analgesic modality during hospital admission, age or sex. Across both abdominal pain and traumatic injury groups, participants with persistent pain had lower EQ5D mobility scores, worse overall health and higher anxiety and depression scores (p < 0.05). In the abdominal pain group, 13 out of 50 (26%) patients using patient-controlled analgesia developed persistent pain vs. 11 out of 27 (41%) of those with usual treatment; 95%CI for difference (control – patient-controlled analgesia) −8 to 39%, p = 0.183. Acute pain scores at the time of hospital admission were higher in participants who developed persistent pain; 95%CI 0.7–23.6, p = 0.039. For traumatic pain, 25 out of 35 (71%) patients given patient-controlled analgesia developed persistent pain vs. 20 out of 29 (69%) patients with usual treatment; 95%CI −30 to 24%, p = 0.830. Persistent pain is common 6 months after hospital admission, particularly following trauma. The study findings suggest that it may be possible to reduce persistent pain (at least in patients with abdominal pain) by delivering better acute pain management. Further research is needed to confirm this hypothesis.

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.

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.

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.

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.

IntroductionObservational data suggest a single high-sensitivity troponin blood test taken at emergency department (ED) presentation could be used to rule out major adverse cardiac events (MACE) in 10%–60% of ED patients with chest pain. This is done using an ‘undetectable’ cut-off (the Limit of Detection: LoD). We combined the LoD cut-off with ECG findings to create the LoDED strategy. We aim to establish whether the LoDED strategy works under real-life conditions, when compared with existing strategies, in a way that is cost-effective and acceptable to patients.Methods and analysisThis is a parallel-group pragmatic randomised controlled trial across UK EDs. Adults presenting to ED with suspected cardiac chest pain will be randomised 1:1. Existing rule-out strategies in current use across study centres, using serial high-sensitivity troponin testing, will be compared with the LoDED strategy. The primary outcome is successful early discharge (discharge from hospital within 4 hours of arrival) without MACE occurring within 30 days. Secondary outcomes include initial length of hospital stay; comparative costs; patient satisfaction and acceptability to patients. To detect a 9% difference between the early discharge rates (assuming an 8% rate in the standard care group) with 90% power, 594 patients need to be recruited, assuming a 95% follow-up rate.Ethics and disseminationThe study has been approved by the Frenchay Research Ethics Committee (reference 18/SW/0038). Results will be published in an international peer-reviewed journal. Lay summaries will be made available to patients.Trial registration numberISRCTN86184521; Pre-results.

BackgroundPatient experience is positively associated with both clinical effectiveness and patient safety and should be a priority for emergency care providers. While both quantitative and qualitative approaches can be used to evaluate patient experience in the emergency department (ED), the latter is well aligned to develop a detailed understanding of features influencing the lived experience of ED patients. This study aimed to systematically review the literature of qualitative studies to identify determinants of adult patient experience in the ED.MethodsA Preferred Reporting Items for Systematic review and Meta-Analysis compliant systematic review was conducted using PubMed, CINAHL, EMBASE, BNI and bibliography searches to identify qualitative studies exploring patient experiences in ED published in English between 1997 and 2018. Quality assessment was conducted using the Critical Appraisal Skills Programme checklist. Descriptive text and quotations relating to patient experience were extracted from included studies and a meta-synthesis conducted using thematic analysis.ResultsA total of 625 records were screened from which 40 studies underwent full review and 22 were included. Results were coded by two researchers (BG and JML). Meta-synthesis identified 198 discrete units of analysis which were clustered around five analytical themes. These were based on the perceived ‘needs’ of patients visiting the ED and were defined as communication, emotional, competent care, physical/environmental and waiting needs. Findings were translated into a conceptual model for optimising patient experience in the ED.ConclusionThis meta-synthesis provides a framework for understanding the determinants of patient experience in the ED. The resulting conceptual model and recommendations may have the potential to directly inform practice and improve the patient experience.

The majority of patients injured in the recent conflicts in Iraq and Afghanistan were as a result of explosion, and terrorist incidents have brought blast injuries to the front door of many civilian hospitals that had not previously encountered such devastation. This article reviews the physics and pathophysiology of blast injury with particular relevance to the presentation and management of primary blast injury, which is the mechanism least familiar to most clinicians and which may cause devastating injury without externals signs.

Having used the medical audit form (MAF) on Op TRENTON 4 in South Sudan,[1][1] we would like to raise awareness of this project among your readership and to commend its usefulness. The MAF was developed in preparation for Op GRITROCK with the aim for future clinicians to be able to access details

ObjectiveTo describe the epidemiology and aetiology of paediatric traumatic cardiac arrest (TCA) in England and Wales.DesignPopulation-based analysis of the UK Trauma Audit and Research Network (TARN) database.Patients and settingAll paediatric and adolescent patients with TCA recorded on the TARN database for a 10-year period (2006–2015).MeasuresPatient demographics, Injury Severity Score (ISS), location of TCA (‘prehospital only’, ‘in-hospital only’ or ‘both’), interventions performed and outcome.Results21 710 paediatric patients were included in the database; 129 (0.6%) sustained TCA meeting study inclusion criteria. The majority, 103 (79.8%), had a prehospital TCA. 62.8% were male, with a median age of 11.7 (3.4–16.6) years, and a median ISS of 34 (25–45). 110 (85.3%) had blunt injuries, with road-traffic collision the most common mechanism (n=73, 56.6%). 123 (95.3%) had severe haemorrhage and/or traumatic brain injury. Overall 30-day survival was 5.4% ((95% CI 2.6 to 10.8), n=7). ‘Pre-hospital only’ TCA was associated with significantly higher survival (n=6) than those with TCA in both ‘pre-hospital and in-hospital’ (n=1)—13.0% (95% CI 6.1% to 25.7%) and 1.2% (95% CI 0.1% to 6.4%), respectively, pConclusionsSurvival is possible from the resuscitation of children in TCA, with overall survival comparable to that reported in adults. The highest survival was observed in those with a pre-hospital only TCA, and those who were transported to an MTC. Early identification and aggressive management of paediatric TCA is advocated.

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

Traumatic cardiac arrest is known to have a poor outcome, and some authors have stated that attempted resuscitation from traumatic cardiac arrest is futile. However, advances in damage control resuscitation and understanding of the differences in pathophysiology of traumatic cardiac arrest compared to medical cardiac arrest have led to unexpected survivors. Recently published data have suggested that outcome from traumatic cardiac arrest is no worse than that for medical causes of cardiac arrest, and in some groups may be better. This review highlights key areas of difference between traumatic cardiac arrest and medical cardiac arrest, and outlines a strategy for the management of patients in traumatic cardiac arrest. Standard Advanced Life Support algorithms should not be used for patients in traumatic cardiac arrest.

AimsPaediatric traumatic cardiac arrest (TCA) is associated with low survival and poor outcomes. The mechanisms that underlie TCA are different from medical cardiac arrest; the approach to treatment of TCA may therefore also need to differ to optimise outcomes. The aim of this study was to explore the opinion of subject matter experts regarding the diagnosis and treatment of paediatric TCA, and to reach consensus on how best to manage this group of patients.MethodsAn online Delphi study was conducted over three rounds, with the aim of achieving consensus (defined as 70% agreement) on statements related to the diagnosis and management of paediatric TCA. Participants were invited from paediatric and adult emergency medicine, paediatric anaesthetics, paediatric ICU and paediatric surgery, as well as Paediatric Major Trauma Centre leads and representatives from the Resuscitation Council UK. Statements were informed by literature reviews and were based on elements of APLS resuscitation algorithms as well as some concepts used in the management of adult TCA; they ranged from confirmation of cardiac arrest to the indications for thoracotomy.Results73 experts completed all three rounds between June and November 2016. Consensus was reached on 14 statements regarding the diagnosis and management of paediatric TCA; oxygenation and ventilatory support, along with rapid volume replacement with warmed blood, improve survival. The duration of cardiac arrest and the lack of a response to intervention, along with cardiac standstill on ultrasound, help to guide the decision to terminate resuscitation.ConclusionThis study has given a consensus-based framework to guide protocol development in the management of paediatric TCA, though further work is required in other key areas including its acceptability to clinicians.

Objectives In effort to improve chest compression quality among health care providers, numerous feedback devices have been developed. Few studies, however, have focused on the use of cardiopulmonary resuscitation feedback devices for infants and children. This study evaluated the quality of chest compressions with standard team-leader coaching, a metronome (MetroTimer by ONYX Apps), and visual feedback (SkillGuide Cardiopulmonary Feedback Device) during simulated infant cardiopulmonary resuscitation. Methods Seventy voluntary health care providers who had recently completed Pediatric Advanced Life Support or Basic Life Support courses were randomized to perform simulated infant cardiopulmonary resuscitation into 1 of 3 groups: team-leader coaching alone (control), coaching plus metronome, or coaching plus SkillGuide for 2 minutes continuously. Rate, depth, and frequency of complete recoil during cardiopulmonary resuscitation were recorded by the Laerdal SimPad device for each participant. American Heart Association-approved compression techniques were randomized to either 2-finger or encircling thumbs. Results The metronome was associated with more ideal compression rate than visual feedback or coaching alone (104/min vs 112/min and 113/min; P = 0.003, 0.019). Visual feedback was associated with more ideal depth than auditory (41 mm vs 38.9; P = 0.03). There were no significant differences in complete recoil between groups. Secondary outcomes of compression technique revealed a difference of 1 mm. Subgroup analysis of male versus female showed no difference in mean number of compressions (221.76 vs 219.79; P = 0.72), mean compression depth (40.47 vs 39.25; P = 0.09), or rate of complete release (70.27% vs 64.96%; P = 0.54). Conclusions In the adult literature, feedback devices often show an increase in quality of chest compressions. Although more studies are needed, this study did not demonstrate a clinically significant improvement in chest compressions with the addition of a metronome or visual feedback device, no clinically significant difference in Pediatric Advanced Life Support-approved compression technique, and no difference between compression quality between genders.

Purpose To study the relationship between serum neutrophil gelatinase-associated lipocalin (NGAL) and military blast and gunshot wound (GSW) to establish whether potential exists for NGAL as a biomarker for blast lung injury (BLI). Method Patients from the intensive care unit (ICU) of the Role 3 Medical Treatment Facility at Camp Bastion, Helmand Province, Afghanistan were studied over a five month period commencing in 2012. Age, mechanism, trauma injury severity score (TRISS) and serum NGAL were recorded on ICU admission (NGAL1). Serum NGAL (NGAL2) and PaO 2 /FiO 2 ratio (P/F ratio2) were recorded at 24 h. Results 33 patients were injured by blast and 23 by GSW. NGAL1 inversely correlated with TRISS ( p = 0.020), pH ( p = 0.002) and P/F ratio 2 ( p = 0.009) overall. When data was stratified into blast and GSW, NGAL1 also inversely correlated with P/F ratio 2 in the blast injured group ( p = 0.008) but not GSW group ( p = 0.27). Conclusion Raised NGAL correlated with increased severity of injury (worse survival probability i.e. TRISS and low pH) in both patient groups. There was an inverse correlation between admission NGAL and a marker of blast lung injury (low P/F ratio) at 24 h in blast injured group but not GSW group that warrants further investigation.

BackgroundThe UK military was continuously engaged in armed conflict in Iraq and Afghanistan between 2003 and 2014, resulting in 629 UK fatalities. Traumatic cardiac arrest (TCA) is a precursor to traumatic death, but data on military outcomes are limited. In order to better inform military treatment protocols, the aim of this study was to define the epidemiology of TCA in the military population with a particular focus on survival rates and injury patterns.MethodsA retrospective database analysis of the UK Joint Theatre Trauma Registry was undertaken. Patients who were transported to a UK deployed hospital between 2003 and 2014 and suffered TCA were included. Those patients injured by asphyxiation, electrocution, burns without other significant trauma and drowning were excluded. Data included mechanism of injury, Injury Severity Score (ISS), Abbreviated Injury Scale (AIS) for each body region and survival to deployed (Role 3) field hospital discharge.Results424 TCA patients were identified during the study period; median age was 23 years, with a median ISS of 45. The most common mechanism of injury was explosive (55.7%), followed by gunshot wound (38.9%), road traffic collision (3.5%), crush (1.7%) and fall (0.2%). 45 patients (10.6% (95% CI 8.0% to 13.9%)) survived to deployed (Role 3) hospital discharge. The most prevalent body region with a severe to maximum AIS injury was the head, followed by the lower limbs, thorax and abdomen. Haemorrhage secondary to abdominal and lower limb injury was associated with survival; traumatic brain injury was associated with death.ConclusionsThis study has shown that short-term survival from TCA in a military population is 10.6%. With appropriate and aggressive early management, although unlikely, survival is still potentially possible in military patients who suffer traumatic cardiac arrest.

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.

Trauma is a leading cause of death and disability worldwide, in civilian environments and on the battlefield. Trauma-induced haemorrhage is the principal cause of potentially preventable death, which is generally attributable to a combination of vascular injury and coagulopathy. Survival rates following severe traumatic injury have increased due to advanced trauma management initiatives and treatment protocols, influenced by lessons learned from recent conflicts in Iraq and Afghanistan. The use of tourniquets and intraosseous needles, early blood and blood product transfusion, administration of tranexamic acid in pre-hospital settings, and consultant-led damage control resuscitation incorporating damage control surgery have all played their part. All are quantified by trauma governance processes, including a robust trauma registry. Some of the lessons learned in combat are equally applicable to civilian environments, and this article describes several of the most important of these. It also gives an overview of advancements in UK military trauma management of severely injured combat casualties, honed over a decade of conflict.

BACKGROUND The 4-h standard performance is a controversial quality indicator. Crowding in emergency departments (EDs) causes increased patient morbidity and mortality. The aim of this study was to investigate the relationship between 4-h standard performance and ED crowding as measured by occupancy. METHODS A retrospective observational study was carried out using the computerized Emergency Department Information System. Daily occupancy was considered in three ways: as minutes per day spent at occupancy thresholds of 70, 80, 90 and 100%; as the peak occupancy of resuscitation and majors beds at any point in the day; and as a percentage of the total potential ED bed minutes used during the day. RESULTS An inverse relationship was observed between occupancy and 4-h standard performance using each method. Performance could be sustained at 70% occupancy, but deteriorated in a linear manner at a progressively increasing rate at 80, 90 and 100% occupancy (all P

Emergency department attendances with chest pain requiring assessment for acute coronary syndrome (ACS) are a major global health issue. Standard assessment includes history, examination, electrocardiogram (ECG) and serial troponin testing. Computerised tomography coronary angiography (CTCA) enables additional anatomical assessment of patients for coronary artery disease (CAD) but has only been studied in very low-risk patients. This trial aims to investigate the effect of early CTCA upon interventions, event rates and health care costs in patients with suspected/confirmed ACS who are at intermediate risk. Participants will be recruited in about 35 tertiary and district general hospitals in the UK. Patients ≥18 years old with symptoms with suspected/confirmed ACS with at least one of the following will be included: (1) ECG abnormalities, e.g. ST-segment depression >0.5 mm; (2) history of ischaemic heart disease; (3) troponin elevation above the 99th centile of the normal reference range or increase in high-sensitivity troponin meeting European Society of Cardiology criteria for ‘rule-in’ of myocardial infarction (MI). The early use of ≥64-slice CTCA as part of routine assessment will be compared to standard care. The primary endpoint will be 1-year all-cause death or recurrent type 1 or type 4b MI at 1 year, measured as the time to such event. A number of secondary clinical, process and safety endpoints will be collected and analysed. Cost effectiveness will be estimated in terms of the lifetime incremental cost per quality-adjusted life year gained. We plan to recruit 2424 (2500 with ~3% drop-out) evaluable patients (1212 per arm) to have 90% power to detect a 20% versus 15% difference in 1-year death or recurrent type 1 MI or type 4b MI, two-sided p