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CHEMICAL INCAPACITANTS The chemical incapacitants are a group of chemicals including 2-chlorobenzylidene malononitrile (CS) (Fig. 1), 1-chloroacetophenone (CN; the main constituent of Mace), and dibenzoxazepine (CR). All of these are irritant to the eyes, skin, and respiratory tract, and can therefore be used to temporarily incapacitate (Table 1). CN was first marketed as a personal defense spray in 1965 under the brand name Mace and this term is now (incorrectly) used in some circles as a generic term for all personal defense sprays. Each of these compounds has a different toxicity profile; for example, CS is a much more potent lacrimatory agent than CN. It is generally accepted that CN is the most injurious, CS being reputedly the safest. Several cases of death in adults have been attributed to the use of CN. As a consequence of its toxicity, CN is now used less frequently than either CS or OC. CS spray has been used as a chemical incapacitant since the 1950s, and it is legally available in most states of the United States for use by the general public, although possession and discharge by members of the general public in the United Kingdom still constitutes a legal offense under Section 5 of the Firearms Act (1968). It has been used by police forces in the United Kingdom since 1996, after strict guidelines for its use were developed. However, the question of safety of CS use has been raised in several arenas over the years, and a recent editorial in The Lancet called for a moratorium on its use. The incidence of complaints about its use by the police has increased steadily since its introduction. Pepper (oleoresin capsicum [OC]) sprays are available commercially in the United States, and are advertised as “legal, non-lethal self-protection devices,” but similar concerns about their usage exist. Pepper spray has been suggested as a possible alternative chemical incapacitant for use by police forces in the United Kingdom and Europe.

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

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

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

The Defence Medical Services, of which the Defence Secondary Care Agency (DSCA) is a part, has a total of 140 specialist registrars in training across all hospital specialties, of whom several are training in hospitals with no formal military connection. Most of these posts are funded by the DSCA and therefore the civilian department has, effectively, a free registrar. However, little is known outside of the Defence Medical Services about who these doctors are, where they have come from, and what can be expected of them. Indeed, is the presence of one of these registrars a blessing or an encumbrance?

Tuberculosis (TB) remains the leading cause of death in the world from a single infectious disease, and the threat is becoming more critical with the spread of multi-drug resistant Tuberculosis (MDR-TB). TB detection, and susceptibility testing for drug resistant strain identification, is advancing with the development of Luciferase Reporter Mycobacteriophages (LRM). LRM will emit visible light at very low intensity when in the presence of live mycobacteria cells such as Tuberculosis strains. InterScience, Inc., together with its collaboration, is developing a highly sensitive, real-time digital detection system for the analysis of luminescent assays. Recent advances in system sensitivity, design, and implementation, as well as preliminary results of the development of individual test cartridges, will be presented. The ultimate goal of this work is to provide a versatile luminescence detection tool for widespread research and clinical applications.

3. A 23 year old soldier attends your surgery with a colleague. That morning he had been watching television when he had suffered an episode of collapse with loss of consciousness and he is unable to recall anything else until he remembers coming around lying on the floor. His colleague, who witnessed the episode, describes what sounds like a generalised tonic-clonic convulsion. There was no preceding aura, and no associated injuries, although he had been incontinent of urine. Afterwards, he was confused and dazed for about an hour, but by the time you see him he says he feels back to normal.

Colonoscopy is a generally safe test whose use is rapidly increasing; complications are unusual and the accepted rate of perforation after diagnostic colonoscopy is between 1 in 800-1500 cases. Colonoscopic perforation may not be recognised at the time and the patient may present to a variety of medical practitioners after discharge from hospital. The presentation is usually with abdominal pain. We report an unusual presentation of colonoscopic perforation in which the patient attended the Emergency Department complaining of a painful neck.

Botulinum neurotoxin (BoNT) is one of the most toxic substances known to produce severe neuromuscular paralysis. The currently used vaccine is prepared mainly from biohazardous toxins. Thus, we studied an alternative method and demonstrated that DNA immunization provided sufficient protection against botulism in a murine model. A plasmid of pBoNT/A-Hc, which encodes the fragment C gene of type A botulinum neurotoxin, was constructed and fused with an Igkappa leader sequence under the control of a human cytomegalovirus promoter. After 10 cycles of DNA inoculation with this plasmid, mice survived lethal doses of type A botulinum neurotoxin challenges. Immunized mice also elicited cross-protection to the challenges of type E botulinum neurotoxin. This is the first study demonstrating the potential use of DNA vaccination for botulinum neurotoxins.

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

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

Introduction Pain is the commonest reason that patients present to an emergency department (ED), but it is often not treated effectively. Patient controlled analgesia (PCA) is used in other hospital settings but there is little evidence to support its use in emergency patients. We describe two randomised trials aiming to compare PCA to nurse titrated analgesia (routine care) in adult patients who present to the ED requiring intravenous opioid analgesia for the treatment of moderate to severe pain and are subsequently admitted to hospital. Methods and analysis Two prospective multi-centre open-label randomised trials of PCA versus routine care in emergency department patients who require intravenous opioid analgesia followed by admission to hospital; one trial involving patients with traumatic musculoskeletal injuries and the second involving patients with non-traumatic abdominal pain. In each trial, 200 participants will be randomised to receive either routine care or PCA, and followed for the first 12 h of their hospital stay. The primary outcome measure is hourly pain score recorded by the participant using a visual analogue scale (VAS) over the 12 h study period, with the primary statistical analyses based on the area under the curve of these pain scores. Secondary outcomes include total opioid use, side effects, time spent asleep, patient satisfaction, length of hospital stay and incremental cost effectiveness ratio. Ethics and dissemination The study is approved by the South Central—Southampton A Research Ethics Committee (REC reference 11/SC/0151). Data collection will be completed by August 2013, with statistical analyses starting after all final data queries are resolved. Dissemination plans include presentations at local, national and international scientific meetings held by relevant Colleges and societies. Publications should be ready for submission during 2014. A lay summary of the results will be available to study participants on request, and disseminated via a publically accessible website. Registration details The study is registered with the European Clinical Trials Database (EudraCT Number: 2011-000194-31) and is on the ISCRTN register (ISRCTN25343280).

In this interview taken shortly after the launch of the Italian translation of the Commonwealth, Antonio Negri, besides discussing details of his collaboration with Michael Hardt, addresses the most important topics of the book, which could remain unclear for the readers. He gives a wide range of answers for the questions on, for example, importance of revision and revitalization of seventeenth century’s categories, what does it mean to be a communist today, elaboration of the thesis of real subsumption. He also stresses the significance of the struggle over the common and processes of its institutionalization for contemporary revolutionary politics and faces criticism of the conception of immaterial and biopolitical labour.

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

A case is presented where an incidental finding on a trauma radiograph led to early diagnosis of a potentially life-threatening tumour, highlighting the need to be vigilant when interpreting X-rays.

Experience from the Role 3 Medical Treatment Facility in Afghanistan has allowed the development of a variety of processes to improve management of seriously injured patients. This review describes some of the techniques that facilitate the reception of the patient in the Emergency Department. In particular the preparation of the team and the resuscitation bay, and the way the team members work together to optimise assessment and resuscitation while minimising delay to imaging and surgery. Within this context the systems described have been refined and function effectively. Many of these lessons may be relevant to future deployments.

Introduction In an operational military environment, circulatory access can prove difficult for a variety of reasons including profound hypovolaemia, and limited first responder experience. With many injuries that cause catastrophic haemorrhage, such as traumatic limb amputations, circulatory access is needed as quickly as possible. Since 2006, the Defence Medical Services have been using the EZ-IO and FAST1 devices as a means of obtaining circulatory access. Methods A prospective observational study was conducted between March and July 2011 at the Emergency Department, Camp Bastion, Afghanistan. All patients with an intraosseous device had data recorded that included if the device successfully flushed (functionality) and if any problems were encountered. Results 117 patients presented with a total of 195 devices: 149 were EZ-IO (76%) and 46 were FAST1 (24%). Functionality was recorded for 111 (57%), with 17 failing to function, yielding an overall success rate of 84.7%. Device failure was observed to be more prevalent in the humerus; inability to flush the device was the leading cause, followed by mechanical failure. There were 2 complications, device breaking on removal being the reason for both. Conclusions The devices in the study were tested for a period of time following insertion (median 32 minutes), and still the success rates mirror those found in the literature. Observed differences between sites were not found to be significant with confidence intervals overlapping. Further work is proposed to investigate the long-term complications of intraosseous devices.