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Background Trauma patients requiring abdominal operation have considerable morbidity and mortality, yet no specific quality indicators are measured in the trauma systems of the UK. The aims of this study were to describe the characteristics and outcomes of patients undergoing emergency abdominal operation and key processes of care. Study Design A prospective multicenter service evaluation was conducted within all of the major trauma centers in the UK. The study was conducted during 6 months beginning in January 2019. Patients of any age undergoing laparotomy or laparoscopy within 24 hours of injury were included. Existing standards for related emergent conditions were used. Results The study included 363 patients from 34 hospitals. The majority were young men with no comorbidities who required operation to control bleeding (51%). More than 90% received attending-delivered care in the emergency department (318 of 363) and operating room (321 of 363). The overall mortality rate was 9%. Patients with blunt trauma had a greater risk of death compared with patients with penetrating injuries (16.6% vs 3.8%; risk ratio 4.3; 95% CI, 2.0 to 9.4). Patients in which the Major Hemorrhage Protocol (MHP) was activated and who received a blood transfusion (n = 154) constituted a high-risk subgroup, accounting for 45% of the study cohort but 97% of deaths and 96% of blood components transfused. The MHP subgroup had expedited timelines from emergency department arrival to knife to skin (MHP: median 119 minutes [interquartile range 64 to 218 minutes] vs no MHP: median 211 minutes [interquartile range 135 to 425 minutes]; p Conclusions The majority of trauma patients requiring emergency abdominal operation received a high standard of expedited care in a maturing national trauma system. Despite this, mortality and resource use among high-risk patients remains considerable.

Background Resuscitative thoracotomy (RT) in traumatic cardiac arrest, in particular for penetrating trauma features within several national guidelines. However, evidence surrounding its practice is poor, consisting of predominantly small-scale observational studies. Survival is generally poor, estimated at 3–13%, with better outcomes in penetrating trauma. There is no national RT database and the Trauma Audit Research Network data misses those who have died pre-hospital. It is important that a more in-depth and accurate national picture of thoracotomy practice is developed nationally to guide future practice. Traumatic emergency thoracotomy for resuscitation in shock (TETRiS) is a multi-centre, prospective and observational evaluation of current RT practice in the UK. Aims and objectives The aim of TETRiS is to evaluate the pathway of care for RT patients within the UK. This will be undertaken over a period of 12 months. This project will evaluate thoracotomies undertaken both pre-hospital and in emergency departments, examining various parameters including frequency, who performs the procedure, clinical indications, time from injury to initiation, mechanism of injury, injuries identified, interventions performed and patient outcomes. Methods This project is being conducted as a collaboration between the National Trauma Research and Innovation Collaborative, the Pre-Hospital Trainee Operated Research Network, the Trainee Emergency Research Network and the National HEMS Research and Audit Forum (NHRAF). All UK HEMS, helicopter emergency medicine services and major trauma centre (MTCs) nationally have been recruited, with site investigators identified within each participating unit. Inclusion criteria: All patients undergoing RT, pre-hospital or in an MTC emergency department will be included.

Purpose The burden of major trauma within the UK is ever increasing. There is a need to establish research priorities within the field. Delphi methodology can be used to develop consensus opinion amongst a group of stakeholders. This can be used to prioritise clinically relevant, patient-centred research questions to guide future funding allocations. The aim of our study was to identify key future research priorities pertaining to the management of major trauma in the UK. Methods A three-phased modified Delphi process was undertaken. Phase 1 involved the submission of research questions by members of the trauma community using an online survey (Phase 1). Phases 2 and 3 involved two consecutive rounds of prioritisation after questions were subdivided into 6 subcategories: Brain Injury, Rehabilitation, Trauma in Older People, Pre-hospital, Interventional, and Miscellaneous (Phases 2 and 3). Cut-off points were agreed by consensus amongst the steering subcommittees. This established a final prioritised list of research questions. Results In phase 1, 201 questions were submitted by 65 stakeholders. After analysis and with consensus achieved, 186 questions were taken forward for prioritisation in phase 2 with 114 included in phase 3. 56 prioritised major trauma research questions across the 6 categories were identified with a clear focus on long-term patient outcomes. Research priorities across the patient pathway from roadside to rehabilitation were deemed of importance. Conclusions Consensus within the major trauma community has identified 56 key research questions across 6 categories. Dissemination of these questions to funding bodies to allow for the development of high-quality research is now required. There is a clear indication for targeted multi-centre multi-disciplinary research in major trauma.

Background Blood transfusion is rarely required in laparoscopic appendicectomies. The incidence of major vessel injury is 0.04%, yet many trusts require two valid G+S samples prior to the operation. A retrospective review was conducted to assess the incidence of peri-operative blood transfusion in laparoscopic appendicectomies in a large tertiary centre, to challenge the requirement for these G+S samples in the hope to reduce clinical and financial burden. Methods A retrospective case note review of patients undergoing emergency laparoscopic appendicectomies in the Royal London Hospital was conducted from 01/06/21 – 01/12/21. Patients under 18 years and those who received an appendicectomy as a concurrent procedure during other operations were excluded. The monetary value of each G+S sample was investigated through discussion with laboratory staff, and a total saving was calculated. Results 95 patients were included. 93 patients had two valid G+S samples prior to their appendicectomy. No patients required perioperative blood transfusion (within two days pre and post op). One patient required a blood transfusion in the 5th postoperative day. An estimated total of £10,500 could be saved per year in this hospital alone, should G+S samples not be required for laparoscopic appendicectomies based on this data. Conclusions We concluded that two G+S samples are not necessary for every patient undergoing a laparoscopic appendicectomy. The incidence of transfusion is scarce throughout literature, and it appears that the financial and clinical burden of these blood samples far outweighs the population transfusion requirement in this particular surgery

Purpose The COVID-19 pandemic has reformed global healthcare delivery. On 25 March 2020, Intercollegiate guidelines were published in the UK to promote safe surgical provision during the COVID-19 outbreak advocating non-operative management or avoidance of laparoscopy when surgery is essential. The effects of this on the investigation and management of appendicitis remain unknown. Methods We performed a multicentre, prospective, observational study from the start of the new guidelines to the 6th of May 2020. We included all patients referred to surgical teams with suspected appendicitis. A recent historical cohort was identified for comparison. The primary outcome was the impact of the COVID-19 pandemic on the use of non-operative management in appendicitis. Secondary outcomes included imaging, negative appendicectomy rate (NAR), length of stay (LOS) and 30-day complications. Results A total of 63/164 (38%) patients compared to 79/191 (41%) were diagnosed with appendicitis before and after the guidelines were introduced (p = 0.589). CT scanning increased (71/164 vs 105/191; p = 0.033) while ultrasound scanning decreased (71/164 vs 62/191; p = 0.037). Appendicitis was more likely to be managed non-operatively (11/63 vs 51/79; p

Introduction The temporal patterns and unit-based distributions of trauma patients requiring surgical intervention are poorly described in the UK. We describe the distribution of trauma patients in the UK and assess whether changes in working patterns could provide greater exposure for operative trauma training. Methods We searched the Trauma Audit and Research Network database to identify all patients between 1 January 2014 to 31 December 2016. Operative cases were defined as all patients who underwent laparotomy, thoracotomy or open vascular intervention. We assessed time of arrival, correlations between mechanism of injury and surgery, and the effect of changing shift patterns on exposure to trauma patients by reference to a standard 10-hour shift assuming a dedicated trauma rotation or fellowship. Results There were 159,719 patients from 194 hospitals submitted to the Network between 2014 and 2016. The busiest 20 centres accounted for 57,568 (36.0%) of cases in total. Of these 2147/57,568 patients (3.7%) required a general surgical operation; 43% of penetrating admissions (925 cases) and 2.2% of blunt admissions (1222 cases). The number of operations correlated more closely with the number of penetrating rather than blunt admissions (r = 0.89 vs r = 0.51). A diurnal pattern in trauma admissions enabled significant increases in trauma exposure with later start times. Conclusions Centres with high volume and high penetrating rates are likely to require more general surgical input and should be identified as locations for operative trauma training. It is possible to improve the number of trauma patients seen in a shift by optimising shift start time.

Aims Trauma patients requiring abdominal surgery have significant morbidity and mortality, but are not included in existing national audits of emergency laparotomy. The aim of this study was to examine processes of care and outcomes among trauma patients undergoing emergency abdominal surgery in the UK and Ireland. Methods A prospective trainee-led multicentre audit was conducted over six months from January 2019 across the national trauma system. Patients undergoing laparotomy or laparoscopy within 24 hours of injury were included. Subgroup analysis was conducted in those requiring major haemorrhage protocol (MHP) activation. Results The study included 363 patients from 34 hospitals (22 major trauma centres). The majority were young males with no co-morbidities who required surgery for control of bleeding (51%) or exploration of penetrating injuries (46%). Over 85% received consultant-led care in the emergency department (318/363) and operating theatre (321/363). The MHP subgroup made up 45% of the cohort but accounted for 97% of deaths and 79% of ICU days, with a mortality rate of 19% and a massive transfusion rate of 32%. Compared to non-MHP patients they had shorter times to theatre (122 vs 218 minutes, p Conclusion The majority of trauma patients requiring emergency abdominal surgery receive consultant-delivered perioperative care which is appropriately tailored to patient risk profile. Despite this, mortality and resource utilization among high-risk patients remains substantial, justifying ongoing performance improvement initiatives and research into novel therapeutics.

BackgroundThe potential of AI systems to support pre-hospital clinical decision-making in both military and civilian settings is significant. However, whilst such algorithms are increasingly available, far less attention has been paid to understanding the impact of such systems on clinical performance. This study had two aims; first, to compare the performance of expert clinicians against an AI system in a real-world clinical setting and second, to assess the impact of augmenting expert clinical prediction with an AI system.MethodsTwo civilian UK Air Ambulances were selected as surrogate settings relevant to military practice. We performed a prospective study over a six-month period where expert pre-hospital clinicians’ judgement of the risk of Trauma Induced Coagulopathy (TIC) in injured patients was assessed and compared to the performance of an AI system. Two TIC risk predictions were generated for every patient: an AI prediction and a human prediction. Measures of predictive performance included discrimination, calibration, and overall accuracy.ResultsOverall, 51 expert clinicians were enrolled in the study providing 184 patient interactions for analysis. The studied patients had a median age of 31 (range 16, 89), median injury severity score of 17 (IQR 9, 34), 75% were male, and 19% developed TIC.Aim 1: The AI system performed better than clinicians; higher discrimination [AUROC 0.87 (0.79, 0.95) versus 0.83 (0.74, 0.92)] better calibration [0.37 (-0.14, 0.89) versus -1.19 (-1.73, -0.65)] and more accurate [Brier Skill Score 0.34 (0.19, 0.48) versus 0.00 (-0.41, 0.30)].Aim 2: Risk prediction was better in all performance metrics when clinicians were assisted with the AI system [AUROC 0.88 (0.80, 0.95) versus 0.83 (0.74, 0.92)]ConclusionsAI systems can improve human risk prediction in the pre-hospital setting. In the military environment, where austerity and lack of senior clinical expertise may affect outcomes, the benefit of implementing predictive AI should be substantial.(*awarded First Place)

To report the initial experience and outcomes of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as an adjunct to pre-hospital resuscitation of patients with exsanguinating pelvic haemorrhage.Descriptive case series of consecutive adult patients, treated with pre-hospital Zone III REBOA by a physician-led pre-hospital trauma service, between January 2014 and July 2018.REBOA was attempted in 19 trauma patients (13 successful, six failed attempts) and two non-trauma patients (both successful) with exsanguinating pelvic haemorrhage. Trauma patients were severely injured (median ISS 34, IQR: 27-43) and profoundly hypotensive (median systolic blood pressure [SBP] 57, IQR: 40-68 mmHg). REBOA significantly improved blood pressure (Pre-REBOA median SBP 57, IQR: 35-67 mmHg versus Post- REBOA SBP 114, IQR: 86-132 mmHg; Median of differences 66, 95% CI: 25-74 mmHg; P 0.001). REBOA was associated with significantly lower risk of pre-hospital cardiac arrest (REBOA 0/13 [0%] versus no REBOA 3/6 [50%], P = 0.021) and death from exsanguination (REBOA 0/13 [0%] versus no REBOA 4/6 [67%], P = 0.004), when compared to patients with a failed attempt. Successful REBOA was associated with improved survival (REBOA 8/13 [62%] versus no REBOA 2/6 [33%]; P = 0.350). Distal arterial thrombus requiring thrombectomy was common in the REBOA group (10/13, 77%).REBOA is a feasible pre-hospital resuscitation strategy for patients with exsanguinating pelvic haemorrhage. REBOA significantly improves blood pressure and may reduce the risk of pre-hospital hypovolaemic cardiac arrest and early death due to exsanguination. Distal arterial thrombus formation is common, and should be actively managed.

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Caremaps lack a systematic, easy-to-use graphical representation method for care decision points (DPs), which are often missing. This paper addresses this gap by presenting a consistent model and representational notation for clinical decisions. This paper presents: (1) an analysis of clinical decisions that directly impact the path of patient care in the contemporary caremap; (2) an extension of the activity diagram for caremaps; and (3) the extended TaSC (e-TaSC) model and notation for caremaps modelling. Evaluation is done in two case studies: gestational diabetes mellitus and trauma caremaps. In both case studies, e-TaSC enabled systematic consideration and inclusion of clinical DPs leading to clearer, easier-to-follow and more comprehensive caremaps than found in the literature.

Developments in military personal armour have aimed to achieve a balance between anatomical coverage, protection and mobility. When death is likely to occur within 60 min of injury to anatomical structures without damage control surgery, then these anatomical structures are defined as ‘essential’. However, the medical terminology used to describe coverage is challenging to convey in a Systems Requirements Document (SRD) for acquisition of new armour and to ultimately translate to the correct sizing and fitting of personal armour. Many of those with Ministry of Defence responsible for the procurement of personal armour and thereby using SRDs will likely have limited medical knowledge; therefore, the potentially complex medical terminology used to describe the anatomical boundaries must be translated into easily recognisable and measurable external landmarks. We now propose a complementary classification for ballistic protection coverage, termed threshold and objective, based on the feasibility of haemorrhage control within the prehospital environment.

IntroductionThe majority of combat deaths occur before arrival at a medical treatment facility but no previous studies have comprehensively examined this phase of care.MethodsThe UK Joint Theatre Trauma Registry was used to identify all UK military personnel who died in Afghanistan (2004–2014). These data were linked to non-medical tactical and operational records to provide an accurate timeline of events. Cause of death was determined from records taken at postmortem review. The primary objective was to report time between injury and death in those killed in action (KIA); secondary objectives included: reporting mortality at key North Atlantic Treaty Organisation timelines (0, 10, 60, 120 min), comparison of temporal lethality for different anatomical injuries and analysing trends in the case fatality rate (CFR).Results2413 UK personnel were injured in Afghanistan from 2004 to 2014; 448 died, with a CFR of 18.6%. 390 (87.1%) of these died prehospital (n=348 KIA, n=42 killed non-enemy action). Complete data were available for n=303 (87.1%) KIA: median Injury Severity Score 75.0 (IQR 55.5–75.0). The predominant mechanisms were improvised explosive device (n=166, 54.8%) and gunshot wound (n=96, 31.7%).In the KIA cohort, the median time to death was 0.0 (IQR 0.0–21.8) min; 173 (57.1%) died immediately (0 min). At 10, 60 and 120 min post injury, 205 (67.7%), 277 (91.4%) and 300 (99.0%) casualties were dead, respectively. Whole body primary injury had the fastest mortality. Overall prehospital CFR improved throughout the period while in-hospital CFR remained constant.ConclusionOver two-thirds of KIA deaths occurred within 10 min of injury. Improvement in the CFR in Afghanistan was predominantly in the prehospital phase.

OBJECTIVE The aim of this study was to develop and validate a risk prediction tool for trauma-induced coagulopathy (TIC), to support early therapeutic decision-making. BACKGROUND TIC exacerbates hemorrhage and is associated with higher morbidity and mortality. Early and aggressive treatment of TIC improves outcome. However, injured patients that develop TIC can be difficult to identify, which may compromise effective treatment. METHODS A Bayesian Network (BN) prediction model was developed using domain knowledge of the causal mechanisms of TIC, and trained using data from 600 patients recruited into the Activation of Coagulation and Inflammation in Trauma (ACIT) study. Performance (discrimination, calibration, and accuracy) was tested using 10-fold cross-validation and externally validated on data from new patients recruited at 3 trauma centers. RESULTS Rates of TIC in the derivation and validation cohorts were 11.8% and 11.0%, respectively. Patients who developed TIC were significantly more likely to die (54.0% vs 5.5%, P < 0.0001), require a massive blood transfusion (43.5% vs 1.1%, P < 0.0001), or require damage control surgery (55.8% vs 3.4%, P < 0.0001), than those with normal coagulation. In the development dataset, the 14-predictor BN accurately predicted this high-risk patient group: area under the receiver operating characteristic curve (AUROC) 0.93, calibration slope (CS) 0.96, brier score (BS) 0.06, and brier skill score (BSS) 0.40. The model maintained excellent performance in the validation population: AUROC 0.95, CS 1.22, BS 0.05, and BSS 0.46. CONCLUSIONS A BN (http://www.traumamodels.com) can accurately predict the risk of TIC in an individual patient from standard admission clinical variables. This information may support early, accurate, and efficient activation of hemostatic resuscitation protocols.

Introduction The misdiagnosis of appendicitis and consequent removal of a normal appendix occurs in one in five patients in the UK. On the contrary, in healthcare systems with routine cross-sectional imaging of suspected appendicitis, the negative appendicectomy rate is around 5%. If we could reduce the rate in the UK to similar numbers, would this be cost effective? This study aimed to calculate the financial impact of negative appendicectomy at the Queen Alexandra Hospital and to explore whether a policy of routine imaging of such patients could reduce hospital costs. Materials and methods We performed a retrospective analysis of all appendicectomies over a 1-year period at our institution. Data were extracted on outcomes including appendix histology, operative time and length of stay to calculate the negative appendicectomy rate and to analyse costs. Results A total of 531 patients over 5 years of age had an appendicectomy. The negative appendicectomy rate was 22% (115/531). The additional financial costs of negative appendicectomy to the hospital during this period were £270,861. Universal imaging of all patients with right iliac fossa pain that could result in a 5% negative appendicectomy rate would cost between £67,200 and £165,600 per year but could save £33,896 (magnetic resonance imaging), £105,896 (computed tomography) or £132,296 (ultrasound) depending on imaging modality used. Conclusions Negative appendicectomy is still too frequent and results in additional financial burden to the health service. Routine imaging of patients with suspected appendicitis would not only reduce the negative appendicectomy rate but could lead to cost savings and a better service for our patients.

Established in 2018, the Defence Endovascular Resuscitation (DefER) group recognised that resuscitative endovascular balloon occlusion of the aorta (REBOA) offered an option to improve survival in battle casualties dying from haemorrhage, particularly in remote and austere surgical settings. Following a successful jHub opportunity assessment, DefER purchased training and operational kit at pace. By 1 April 2019, the first forward surgical group undertook a bespoke endovascular training and assessment package. Results of the pilot were presented back to a jHub 4* Innovation Board, which initially awarded £500 000 to fund the project to full implementation. Med Op Cap provided a solution to establish REBOA as a core capability on to the 370 modules. REBOA catheters and arterial access kit are now available to deployed Role 2 facilities across defence as an adjunct to damage control resuscitation in specific circumstances. REBOA has, from a standing start, gained pan-Defence Medical Services (DMS) endorsement and has been integrated into deployed damage control resuscitation. To establish a new resuscitation capability across all Role 2 platforms within 15 months of inception represents implementation at pace. This agility was unlocked by empowering clinicians to develop the platform in conjunction with commercial procurement. This article describes how this innovative pathway facilitated the rapid introduction of a lifesaving haemorrhage control technique to equip DMS clinicians.

A mixed methods investigation of the training of F1 doctors in general surgery.

This is the accepted version of the pee-reviewed article as published in Annals of Surgery. The final version of record may be found at: Naumann, David N. PhD∗; Marsden, Max E. R. MRCS†; Brandt, Mary L. MD‡; Bowley, Douglas M. FRCS§ The Bouffant Hat Debate and the Illusion of Quality Improvement, Annals of Surgery: April 2020 - Volume 271 - Issue 4 - p 635-636 doi: 10.1097/SLA.0000000000003623

Aims/Objectives/BackgroundMost fatalities from trauma, in civilian and military settings, die before reaching a hospital. However, no previous studies have comprehensively examined this phase of care. The aim of this study was to define the time interval between injury and death in UK military personnel who died pre-hospital from enemy action (Killed in Action, KIA).Methods/DesignThe UK Joint Trauma Theatre Registry (JTTR) was used to identify all UK military personnel who died in Afghanistan (2004–2014). Through novel linkage of medical and tactical databases, an accurate timeline of events was obtained. Cause of death was determined from post mortem review. The primary objective was to report time between injury and death. Secondary objectives: mortality at key timepoints, the temporal lethality of different anatomical injuries, and trends in the case fatality rate (CFR, defined as deaths/injuries x100). Data are reported as n(%), and median [inter-quartile range]. Proportions compared with a Fisher’s exact test, and survival was with a Gehan-Breslow-Wilcoxon test; level of significance was corrected by Bonferroni.Results/Conclusions2413 UK personnel were injured in Afghanistan from 2004–2014; 448 died, a CFR of 18.6%. 390 (87.1%) of total deaths (KIA + Killed Non-Enemy Action) were prehospital. Complete timeline data were available for n=303 (87.1%) KIA – this cohort had a median injury severity score of 75.0 [55.5–75.0]. The median time between injury and death in KIA was 0.0 [0.0–21.8] minutes; 173 (57.1%) died immediately, and by 10 min more than two-thirds had died. Primary injury to the head had a significantly shorter time to death compared to the abdomen and lower extremity (both pOver two-thirds of KIA deaths occurred within 10 min of injury. Improvement in the CFR in Afghanistan was predominantly in the prehospital phase.

IntroductionTranexamic acid (TXA) reduces bleeding and mortality. Recent trials have demonstrated improved survival with shorter intervals to TXA administration. The aims of this service evaluation were to assess the interval from injury to TXA administration and describe the characteristics of patients who received TXA pre-hospital and in-hospital.MethodsWe reviewed Trauma and Audit Research Network records and local trauma registries to identify patients of any age that received TXA at all London Major Trauma Centres and Queen’s Medical Centre, Nottingham, during 2017. We used the 2016 NICE Guidelines (NG39) which state that TXA should be given within 3 hours of injury.ResultsWe identified 1018 patients who received TXA, of whom 661 (65%) had sufficient data to assess the time from injury to TXA administration. The median interval was 74 min (IQR: 47–116). 92% of patients received TXA within 3 hours from injury, and 59% within 1 hour. Half of the patients (54%) received prehospital TXA. The median time to TXA administration when given prehospital was 51 min (IQR: 39–72), and 112 min (IQR: 84–160) if given in-hospital (pConclusionPrehospital administration of TXA is associated with a shorter interval from injury to drug delivery. Identifying a proportion of patients at risk of haemorrhage remains a challenge. However, further reinforcement is needed to empower pre-hospital clinicians to administer TXA to trauma patients without overt signs of shock.

The management of trauma patients has changed radically in the last decade, and studies have shown overall improvements in survival. However, reduction in mortality for the many may obscure a lack of progress in some high-risk patients. We sought to examine the outcomes for hypotensive patients requiring laparotomy in UK military and civilian cohorts.We undertook a review of two prospectively maintained trauma databases: the UK Joint Theatre Trauma Registry for the military cohort (February 4, 2003, to September 21, 2014) and the trauma registry of the Royal London Hospital major trauma center (January 1, 2012, to January 1, 2017) for civilian patients. Adults undergoing trauma laparotomy within 90 minutes of arrival at the emergency department (ED) were included.Hypotension was present on arrival at the ED in 155 (20.4%) of 761 military patients. Mortality was higher in hypotensive casualties (25.8% vs. 9.7% in normotensive casualties; p0.001). Hypotension was present on arrival at the ED in 63 (35.7%) of 176 civilian patients. Mortality was higher in hypotensive patients (47.6% vs. 12.4% in normotensive patients; p0.001). In both cohorts of hypotensive patients, neither the average injury severity, the prehospital time, the ED arrival systolic blood pressure, nor mortality rate changed significantly during the study period.Despite improvements in survival after trauma for patients overall, the mortality for patients undergoing laparotomy who arrive at the ED with hypotension has not changed and appears stubbornly resistant to all efforts. Specific enquiry and research should continue to be directed at this high-risk group of patients.Prognostic/Epidemiologic, level IV.

Key performance indicators (KPIs) are metrics that compare actual care against an ideal structure, process or outcome standard. KPIs designed to assess performance in deployed military surgical facilities have previously been published. This study aimed to review the overall performance of surgical trauma care for casualties treated at Role 3 Camp Bastion, Medical Treatment Facility, Afghanistan, in light of the existing Defence Medical Services (DMS) KPIs. The secondary aims were to assess the utility of the surgical KPIs and make recommendations for future surgical trauma care review.Data on 22 surgical parameters were prospectively collected for 150 injured patients who had primary surgery at Camp Bastion between 1 May 2013 and 20 August 2013. Additional information for these patients was obtained using the Joint Theatre Trauma Register. The authors assessed data recording, applicability and compliance with the KPIs.Median data recording was 100% (IQR 98%-100%), median applicability was 56% (IQR 10%-99%) and median compliance was 78% (IQR 58%-93%). One KPI was not applicable to any patient in our population. Eleven KPIs achieved80% compliance, five KPIs had 80%-60% compliance and five KPIs had60% compliance. Recommendations are made for minor modifications to the current KPIs.78% compliance with the DMS KPIs provides a snapshot of the performance of the surgical aspect of military trauma care in 2013. The KPIs highlight areas for improvement in service delivery. Individual KPI development should be driven by evidence and reflect advances in practice and knowledge. A method of stakeholder consultation, and sequential refinement following evidence review, may be the right process to develop the future set of DMS KPIs.

Jennifer Ferguson2, Guy Stevens1, Robert Hills2, Kate Gower Thomas1 1Breast Test Wales, Cardiff, UK; 2Cardiff University School of Medicine, Cardiff, UK Correspondence: Jennifer Ferguson Introduction To determine the rate and classification of interval breast cancer (IC) in the two years preceeding and following the introduction of digital mammography in 2011 in a national screening programme. Methods Two 2-year bands were used to ensure completed data for pre and post digital groups. Retrospective analysis of a prospectively collected database of IC was undertaken, identifying women who had undergone screening in the two years prior to and after the introduction of digital screening mammography (1.1.10 until 31.12.11 and 1.1.12 until 31.12.13). Chi squared analysis was used to compare the rate between the two groups and the rate of false negative (FN) and minimal signs (MS) categories considered together. Results Of 87,868 screened before digital between 1.1.10 and 31.12.11, 103 developed IC (0.12%) and of 100,672 screened with digital between 1.1.12 and 31.12.13, 145 developed IC (0.14%) (p = 0.12). Those women with FN and MS interval cancer numbered 17 (16.5%) predigital and 41 (28.3%) with digital; (p = 0.04). The number of true IC was similar in the pre (49.5%) and post (46.9%) groups. Conclusion The rate if IC is similar to the NHSBSP standard (1.2 per 1000 women screened). Despite earlier groups indicating that digital technology will lessen the number of IC, especially those ‘missed’ (FN and MS groups) which are often asymmetric densities and poorly defined masses, this has not been found in our study. The reasons for this will be discussed and examples will be shown.

We read with interest Vassallo et al ’s article[1][1] in which the authors describe the development of the MPTT-24, a major incident triage tool. We fully support the authors’ aims in developing a triage tool with such potential for improving the care of injured service personnel, but suggest

The United Kingdom National Health Service treats both elective and emergency patients and seeks to provide high quality care, free at the point of delivery. Equal numbers of emergency and elective general surgical procedures are performed, yet surgical training prioritisation and organisation of NHS institutions is predicated upon elective care. The increasing ratio of emergency general surgery consultant posts compared to traditional sub-specialities has yet to be addressed. How should the capability gap be bridged to equip motivated, skilled surgeons of the future to deliver a high standard of emergency surgical care? The aim was to address both training requirements for the acquisition of necessary emergency general surgery skills, and the formation of job plans for trainee and consultant posts to meet the current and future requirements of the NHS. Twenty nine trainees and a consultant emergency general surgeon convened as a Working Group at The Association of Surgeons in Training Conference, 2015, to generate a united consensus statement to the training requirement and delivery of emergency general surgery provision by future general surgeons. Unscheduled general surgical care provision, emergency general surgery, trauma competence, training to meet NHS requirements, consultant job planning and future training challenges arose as key themes. Recommendations have been made from these themes in light of published evidence. Careful workforce planning, education, training and fellowship opportunities will provide well-trained enthusiastic individuals to meet public and societal need.

To determine utilization and accuracy of focused assessment with sonography for trauma (FAST) and computed tomography (CT) in a mature military trauma system to inform service provision for future conflicts.FAST and CT scans undertaken by attending radiologists contribute to surgical decision making for battlefield casualties at the Joint Force, Role 3 Medical Treatment Facility at Camp Bastion (R3), Afghanistan.Registry data for abdominally injured casualties treated at R3 from July to November 2012 were matched to radiological and surgical records to determine diagnostic accuracy for FAST and CT and their influence on casualty management.A total of 468 casualties met inclusion criteria, of whom 85.0% underwent FAST and 86.1% abdominal CT; 159 (34.0%) had abdominal injuries. For detection of intra-abdominal injury, FAST sensitivity (Sn) was 0.56, specificity (Sp) 0.98, positive predictive value (PPV) 0.87, negative predictive value (NPV) 0.90, and accuracy (Acc) 0.89. For CT, Sn was 0.99, Sp 0.99, PPV 0.96, NPV 1.00, and Acc 0.99. Forty-six solid organ injuries were identified in 38 patients by CT; 17 were managed nonoperatively. A further 61 patients avoided laparotomy after CT confirmed extra-abdominal wounds only. The negative laparotomy rate was 3.9%.FAST and CT contribute to triage, guide surgical management, and reduce nontherapeutic laparotomy. When imaging is available, these data challenge current doctrine about inadvisability of nonoperative management of abdominal injury after combat trauma.

s / International Journal of Surgery 12 (2014) S13eS117 S57 55yrs. Patients treated between April 2008 January 2013. A single incision approach was used and repaired with anchor sutures. Results: Time to surgery, mean of 13.6 days, follow up mean 13.5 weeks, range 9 26 weeks. 2 patients lost to follow up at 9 weeks. Full range of movement in 15/17 patients. Pre-injury strength regained in 12/17 patients. 2 patients had reasonable power at 12 weeks. Slow improvement in 2 patients at week 12. 2 patients had complications, 1 had injury to lateral cutaneous nerve of the forearm, and 1 had a superficial blister proximal to the wound. Conclusions: Single incision approach has a low complication rate and a high satisfaction outcome. It provides acceptable functional recovery of elbow and forearm mechanics and we believe it a safe repair for distal biceps tendon injuries. 0298: TOTAL HIP ARTHROPLASTY TO TREAT FRACTURE NECK OF FEMURS e ARE NICE GUIDELINES BEING IMPLEMENTED? Piyush Mahapatra , Edmund Leong, Chris Huber. West Middlesex University Hospital, London, UK. Introduction: In 2011 NICE suggested that a specific subset of patients with a displaced intracapsular neck of femur fracture (#NOF) should be offered a total hip arthroplasty (THA); a significant paradigm shift from the traditional treatment of hemiarthroplasty (HA). This audit aims to ascertain whether the guidelines have changed local practice in a busy urban district general hospital. Methods: A retrospective analysis was performed of the local #NOF registry data for all patients who were admitted to our institution with a #NOF in 2012. Results: 230 patients were admitted. In total, 119 patients had intracapsular fractures, of which 108 were displaced fractures. 82 patients were treated with an arthroplasty; 79 HAs and 3 THAs. Of those patients treated with HA,15 met the new NICE guidelines for THA but had a HA instead of a THA. There was no statistical difference in length of stay of patients undergoing THA or HA (median 10 vs 11, p1⁄40.164; Mann-Whitney U). Conclusions: NICE ‘moved the goalposts' with the release of their guidelines and this study shows that institutions are struggling to find the new target. We feel that systemic changes have to occur in order to allow these guidelines to be effectively implemented. 0301: THE USE OF TRANEXAMIC ACID RESULTS IN DECREASED BLOOD LOSS IN PATIENTS UNDERGOING PRIMARY LOWER LIMB ARTHROPLASTY Max Marsden , Hiro Ishii, James Logan, Philip Pettit. Salisbury District General Hospital, Salisbury, UK. Introduction: To assess the effect of tranexamic acid (TXA) on blood loss, transfusion rate and length of stay following lower limb arthroplasty. Methods: The study group included 81 patients who underwent lower limb arthroplasty with 1g of TXA given at induction of anaesthesia for total hip replacement (THR) and at deflation of the tourniquet for total knee replacement (TKR). Post-operative haemoglobin, length of stay and blood transfusion episodes were recorded. These figures were compared with a historical cohort of 88 patients. Results: At 24 hours post operation the mean (± SD) drop in haemoglobin decreased from 3.5 ± 1.5 g /dL to 2.5 ± 0.9 g/dL following administration of TXA in THR p

a b s t r a c t INTRODUCTION: Colorectal cancer and inguinal hernias are both common surgical pathologies in the elderly but rarely co-exist. Where the conditions overlap, there can be difficulties in both diagnosis and treatment. PRESENTATION OF CASE: A 78 year old man with unexplained iron deficiency anaemia was investigated for gastrointestinal cancer. He was found to have enlarging bilateral inguinoscrotal hernias. CT colonoscopy revealed a herniated caecal carcinoma contained within the scrotum. An open excision was performed. DISCUSSION: Iron deficiency anaemia without obvious bleeding is associated with colorectal cancer and should be thoroughly investigated. Asymptomatic inguinal hernias are often ignored by patients. However, a change in an existing hernia may be associated with neoplasia. CONCLUSION: Dual pathology raises new difficulties in assessment, investigation and management of colorectal cancer. © 2014 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).