Search

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

This Chapter argues that one of the key concepts in Agamben’s account of the ‘coming politics’ – form-of-life – was initially developed through a critical engagement with three concepts central to the post-workerist strain of Italian Marxism: general intellect, multitude, and antagonism. Smith makes the argument through a close reading of the essay ‘Form-of-Life’, which appeared two years prior to the Italian publication of Homo Sacer: Sovereign Power and Bare Life. The chapter suggests that Agamben’s account of ‘form-of-life,’ which is a power irreducibly antagonistic to sovereignty and the social, is a contribution to the revolutionary communist tradition. However, Smith raises concerns that Agamben’s account of antagonism does not adequately account for the fact that certain forms of social identity – namely the categories of worker and woman – are themselves constituted through forms of antagonism that traverse the social.

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

Introduction Identifying weaknesses in emergency department (ED) communication may highlight areas where quality improvement may be beneficial. This study explores whether the Communication Assessment Tool-Team (CAT-T) survey can identify communication strengths and weaknesses in a UK setting. Objectives This study aimed to determine the frequency of patient responses for each item on the CAT-T survey and to compare the proportion of responses according to patient and operational characteristics. Methods Adults presenting to the minors area of a semi-urban ED between April and May 2015 were included. Those lacking capacity or in custody were excluded. Multivariate analysis identified associations between responses and demographic/operational characteristics. Results A total of 407/526 eligible patients responded (77.3%). Respondents were mostly White British (93.9%), with a median age of 45 years. Most responses were obtained during daytime hours (84.2% between 08 : 00 and 18 : 00). The median reported times to triage, assessment and disposition were 15, 35 and 90 min, respectively. Items most frequently rated as 'very good'/'excellent' (strengths) were 'ambulance staff treated me with respect' (86.7%), ED staff 'let me talk without interruptions' (85%) and 'paid attention to me' (83.7%). Items most frequently rated as 'poor'/'fair' (weaknesses) were 'encouraged me to ask questions', 'reception treated me with respect' (10.4%) and 'staff showed an interest in my health' (6.8%). Arrival time, analgesia at triage and time to assessment were associated with significantly increased odds of positive perception of team communication for a range of items. Conclusion The CAT-T survey may be used within a UK setting to identify discrete strengths and weaknesses in ED team communication.

Background The insertion of a surgical airway in the presence of severe airway compromise is an uncommon occurrence in everyday civilian practice. In conflict, the requirement for insertion of a surgical airway is more common. Recent military operations in Afghanistan resulted in large numbers of severely injured patients, and a significant proportion required definitive airway management through the insertion of a surgical airway. Objective To examine the procedural success and survival rate to discharge from a military hospital over an 8-year period. Methods A retrospective database and chart review was conducted, using the UK Joint Theatre Trauma Registry and the Central Health Records Library. Patients who underwent surgical airway insertion by UK medical personnel from 2006 to 2014 were included. Procedural success, demographics, Injury Severity Score, practitioner experience and patient survival data were collected. Descriptive statistics were used for data comparison, and statistical significance was defined as p Results 86 patients met the inclusion criterion and were included in the final analysis. The mean patient age was 25 years, (SD 5), with a median ISS of 62.5 (IQR 42). 79 (92%) of all surgical airways were successfully inserted. 7 (8%) were either inserted incorrectly or failed to perform adequately. 80 (93%) of these procedures were performed either by combat medical technicians or General Duties Medical Officers (GDMOs) at the point of wounding or Role 1. 6 (7%) were performed by the Medical Emergency Response Team. 21 (24%) patients survived to hospital discharge. Discussion Surgical airways can be successfully performed in the most hostile of environments with high success rates by combat medical technicians and GDMOs. These results compare favourably with US military data published from the same conflict.

Objectives Wrist injuries are a common presentation to emergency departments. A clinical pathway has recently been introduced in our institution for patients with clinical suspicion of a scaphoid injury, using computed tomography (CT) at 2 weeks postinjury to rule out scaphoid fracture. However, it is not known what happens to patients who have a normal CT after such an injury. The aim of this pilot study was to assess disability after CT-negative wrist injuries. Methods A prospective questionnaire study was undertaken to assess disability in patients who had a normal CT after clinical suspicion of a scaphoid fracture, using the Patient Rated Wrist Evaluation questionnaire. Adult patients were recruited at their first emergency department clinic review, where a baseline questionnaire was completed. Follow-up questionnaires were sent 3, 6 and 12 months later. Pain and function were assessed on a 0–10 scale, giving a total score out of 100. Results Ninety-nine patients were initially recruited, of whom 72 had negative CT; 40 patients completed follow-up. There was a statistically significant reduction in pain, functional deficit and combined disability between baseline scores and 12-month follow-up. Overall, three (8%) patients had severe disability (pain and function combined), and six (15%) had moderate disability at 12 months. Conclusion The majority of these patients recover from their injury, but a small proportion with normal CT scans have considerable disability 12 months after injury. Appropriate advice should be given to these patients to enable them to access further investigation and treatment.

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

Sternoclavicular joint (SCJ) injuries are uncommon, but delay in diagnosis and treatment can result in significant morbidity. This review outlines the relevant clinical anatomy and biomechanics of the joint, and examines the evidence supporting specific investigation and management of such injuries.

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.

Background With the end of UK military operations in Iraq and Afghanistan, it is essential that peacetime training of Defence Medical Services (DMS) trauma teams ensures appropriate future preparedness. A new model of pre-deployment training involves placement of formed military trauma teams into civilian trauma centres. This study evaluates the benefit of ‘live training during an exercise period’ (LIVEX) for DMS trauma teams. Methods A cross-sectional questionnaire-based survey of participants was conducted. Quantitative data were collected prior to the start and on the final day. Written reports were collected from the coordinators. Thematic analysis was used to identify emergent themes in a supplementary, qualitative analysis. Results Each team comprised 13 personnel and results should be interpreted with knowledge of this small sample size. The response rate for both the pre-LIVEX and post-LIVEX questionnaire was 100%. By the end of the week, 89% of participants (n=23) stated LIVEX was an ‘appropriate or very appropriate’ way of preparing for an operational role compared with 40% (n=9) before the exercise (p Conclusions Completing LIVEX made no statistically significant difference to participants' personal perception of their own operational preparedness, but the perception of LIVEX as an appropriate training platform improved significantly after conducting the training exercise.

Objective To determine whether patient controlled analgesia (PCA) is better than routine care in providing effective analgesia for patients presenting to emergency departments with moderate to severe non-traumatic abdominal pain. Design Pragmatic, multicentre, parallel group, randomised controlled trial Setting Five English hospitals. Participants 200 adults (66% (n=130) female), aged 18 to 75 years, who presented to the emergency department requiring intravenous opioid analgesia for the treatment of moderate to severe non-traumatic abdominal pain and were expected to be admitted to hospital for at least 12 hours. Interventions Patient controlled analgesia or nurse titrated analgesia (treatment as usual). Main outcome measures The primary outcome was total pain experienced over the 12 hour study period, derived by standardised area under the curve (scaled from 0 to 100) of each participant’s hourly pain scores, captured using a visual analogue scale. Pre-specified secondary outcomes included total morphine use, percentage of study period in moderate or severe pain, percentage of study period asleep, length of hospital stay, and satisfaction with pain management. Results 196 participants were included in the primary analyses (99 allocated to PCA and 97 to treatment as usual). Mean total pain experienced was 35.3 (SD 25.8) in the PCA group compared with 47.3 (24.7) in the treatment as usual group. The adjusted between group difference was 6.3 (95% confidence interval 0.7 to 11.9). Participants in the PCA group received significantly more morphine (mean 36.1 (SD 22.4) v 23.6 (13.1) mg; mean difference 12.3 (95% confidence interval 7.2 to 17.4) mg), spent less of the study period in moderate or severe pain (32.6% v 46.9%; mean difference 14.5% (5.6% to 23.5%)), and were more likely to be perfectly or very satisfied with the management of their pain (83% (73/88) v 66% (57/87); adjusted odds ratio 2.56 (1.25 to 5.23)) in comparison with participants in the treatment as usual group. Conclusions Significant reductions in pain can be achieved by PCA compared with treatment as usual in patients presenting to the emergency department with non-traumatic abdominal pain. Trial registration European Clinical Trials Database EudraCT2011-000194-31; Current Controlled Trials ISRCTN25343280.

Attempts to resuscitate patients in traumatic cardiac arrest (TCA) have, in the past, been viewed as futile. However, reported outcomes from TCA in the past five years, particularly from military series, are improving. The pathophysiology of TCA is different to medical causes of cardiac arrest, and therefore, treatment priorities may also need to be different. This article reviews recent literature describing the pathophysiology of TCA and describes how the military has challenged the assumption that outcome is universally poor in these patients.

Seatbelts save lives. However, they may cause injury to adjacent structures and when they malfunction can cause injury to the abdominal viscera, bony skeleton and vascular structures. The motor industry has attempted to reduce these injuries by modification of vehicle design and safety equipment. This paper discusses the patterns of injury caused by seatbelts and the methods by which the motor industry attempts to reduce their incidence.

Summary Study objectives: To prospectively evaluate compliance with current interhospital trauma transfer guidelines in South West Sydney, before and after an implementation programme was instituted. Methods: A scoring system was developed to assess compliance with the 11 main components of the guideline. Baseline compliance was measured during an initial 3-month period (pre), followed by an implementation programme to alert staff at referring hospitals to the presence of the guidelines. Following this, compliance was again measured over 3 months (post). Results: Twenty-two patients were transferred during the pre-implementation phase and 35 patients during the post-phase. Overall compliance with the guidelines increased from 62 to 67%. Mean pre-hospital compliance rose from 75 to 95%, and referring hospital compliance rose from 59 to 63%. While there was an improvement in compliance with the use of the dedicated trauma hotline (86–97%), the use of a transfer checklist (41–53%), and appropriateness of transfer (95–100%), none of these reached statistical significance. Conclusion: Practice guidelines have been developed to optimise the process of interhospital trauma transfers. An implementation programme met with limited success in improving compliance with the guidelines. Further work is needed to ensure awareness of these guidelines, with ongoing monitoring to ensure best practice and optimal patient outcome.

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.

Background The management of male urethral trauma in the multiply injured battle casualty has proved challenging to the deployed military trauma surgeon. Foreign nationals will need culturally sensitive outcomes with adequate urinary function when further surgical management is unlikely to be available in a developing country. For those likely to undergo reconstructive surgery, the early restoration of anatomy is important as it may improve the long-term reconstructive outcome. Method We illustrate our technique with a case report and discuss salient points of other patients treated in the same manner, all of whom presented to a role 2 (enhanced) field hospital in Afghanistan with urethral injuries. Results A transpelvic high velocity gunshot wounds (HVGSW) was sustained and the patient underwent immediate anatomical re-alignment of the urethra with suture of the bladder neck to the pelvic floor. This case is discussed in detail. Conclusions Complete disruption of the male urethra can be successfully managed in the field hospital by urethral catheterization at the time of initial surgery. In patients where further reconstruction may not be possible, urethral catheterization provides a culturally permissible solution for patients. In those who may undergo further reconstructive surgery, approximation of the bladder to the pelvic floor may reduce stricture rate in comparison with the suprapubic catheterization alone.

A case is described where recombinant activated factor VII was used to control pulmonary hemorrhage in a patient who had sustained a high-velocity gunshot wound to the chest, in the deployed medical setting, allowing onward transfer of the patient to the United Kingdom for further management.

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. It reports the findings of a consensus meeting on crush injury and crush syndrome held in Birmingham on 31 May 2001, and coordinated by the Faculty of Pre-Hospital Care of the Royal College of Surgeons of Edinburgh.

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.

This review describes a simple approach to perimortem caesarean section (PMCS) that can be used by a doctor in the resuscitation room or prehospital environment when faced with a mother of more than 20 weeks gestation in cardiac arrest. It explores the indications for and contraindications to the procedure, the physiological rationale behind it, equipment needed, technical aspects of the procedure and reviews recent literature on maternal and fetal outcomes. Like other uncommon procedures such as emergency department thoracotomy, rehearsal and preparation for a PMCS is essential to give both mother and baby the best chance of survival.

To determine the effect of blood sampling through an intravenous catheter compared with a needle in Emergency Department blood sampling.We undertook a prospective, cross-sectional study in a UK university teaching hospital Emergency Department. A convenience sample of 985 patients who required blood sampling via venepuncture was collected. A total of 844 complete sets of data were analysed. The median age was 63 years, and 57% of patients were male. The primary outcome measure was the incidence of haemolysis in blood samples obtained via a needle compared with samples obtained via an intravenous catheter. Secondary outcome measures defined the effect on sample haemolysis of the side of the patient the sample was obtained from, the anatomical location of sampling, the perceived difficulty in obtaining the sample, the order of sample tubes collected, estimated tourniquet time and bench time. Data were analysed with logistic regression, and expressed as odds ratios (95% confidence intervals; P-values).Blood samples obtained through an intravenous catheter were more likely to be haemolysed than those obtained via a needle, odds ratio 5.63 (95% confidence interval 2.49-12.73; P0.001).Blood sampling via an intravenous catheter was significantly associated with an increase in the likelihood of sample haemolysis compared with sampling with a needle. Wherever practicable, blood samples should be obtained via a needle in preference to an intravenous catheter. Future research should include both an economic evaluation, and staff and patient satisfaction of separating blood sampling and intravenous catheter placement.

This article examines an often-mentioned but largely undeveloped concept in the work of Giorgio Agamben and in particular his Homo Sacer project: form-of-life. What is at stake in this concept is, I attempt to show, a way of thinking “politics” outside of the space of sovereignty. By examining a short text on this notion published just before the opening installment of the Homo Sacer sequence, this article demonstrates the way this early formulation of the concept is indebted to certain strains of Italian workerist and post-workerist thought. The fundamental question this analysis poses, however, is whether the concept of form-of-life, being to some extent “beyond” the classical space of politics, should in fact be understood as fundamentally aesthetic in nature.

Background Intraosseous (IO) drug infusion has been reported to have similar pharmacokinetics to intravenous (IV) infusion. In military and civilian trauma, the IO route is often used to obtain rapid and reliable parenteral access for drug administration. Only a few case reports have described the use of IO infusion to administer drugs for rapid sequence induction of anaesthesia (RSI). Objective We aimed to assess the feasibility of the administration of RSI drugs via an IO catheter in a prospective observational study. Methods A prospective observational study was undertaken at a combat hospital in Afghanistan. A validated data form was used to record the use of IO drugs for RSI by the prehospital, physician-led Medical Emergency Response Team (MERT), and by inhospital physicians. Data were captured between January and May 2012 by interview with MERT physicians and inhospital physicians directly after RSI. The primary outcome measure was the success rate of first-pass intubation with direct laryngoscopy. Results 34 trauma patients (29 MERT and 5 inhospital) underwent RSI with IO drug administration. The median age was 24 years and median injury severity score 25; all were male. The predominant mechanism of injury was blast (n=24), followed by penetrating (n=6), blunt (n=3) and burn (n=1). First-pass intubation success rate was 97% (95% CI 91% to 100%). A Cormack-Lehane grade 1 view, by direct laryngoscopy, was obtained at first look in 91% (95% CI 81% to 100%) of patients. Conclusions In this prospective, observational study, IO drug administration was successfully used for trauma RSI, with a comparable first pass intubation success than published studies describing the IV route. Trial registration number RCDM/Res/Audit/1036/12/0162.