Emergency medicine journal : EMJ
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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. ⋯ 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).emermed;34/12/A869-b/T1F1T1Table 1Univariate regression analysis of variables included in the MASH score in the derivation dataset which predict the requirement for 6 units of pRBCs in 4 hours or 10 units of pRBCs in 24 hoursemermed;34/12/A869-b/T2F2T2Table 2Performance of the MASH score in derivation and validation datasets showing test characteristics for three values of the MASH score with 95% confidence intervals with sensitivity analysis for a score of 3 in the validation dataset 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.
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Triage is a key principle in the effective management of a major incident. Existing triage tools have demonstrated limited performance at predicting need for life-saving intervention (LSI). Derived on a military cohort, the Modified Physiological Triage Tool (MPTT) has demonstrated improved performance. Using a civilian trauma registry, this study aimed to validate the MPTT in a civilian environment. ⋯ During the study period, 218 985 adult patients were included in the TARN database. 127 233 (58.1%) had complete data: 55.6% male, aged 61.4 (IQR 43.1-80.0) years, Injury Severity Score 9 (IQR 9-16), 96.5% suffered blunt trauma and 24 791 (19.5%) were Priority One. The MPTT (sensitivity 57.6%, specificity 71.5%) outperformed all existing triage methods with a 44.7% absolute reduction in undertriage compared with existing UK civilian methods. AUROC comparison supported the use of the MPTT over other tools (P<0.001.) CONCLUSION: Within a civilian trauma registry population, the MPTT demonstrates improved performance at predicting need for LSI, with the lowest rates of undertriage and an appropriate level of overtriage. We suggest the MPTT be considered as an alternative to existing triage tools.
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To determine whether clinical features (in the form of a clinical decision rule) or d-dimer can be used to select pregnant or postpartum women with suspected PE for diagnostic imaging. ⋯ Clinical decision rules, d-dimer and chest x-ray should not be used to select pregnant or postpartum women with suspected PE for diagnostic imaging.
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Population-level legislation has been implemented in many countries to try and address alcohol misuse and related harms, including assault. Most violent incidents in the UK are alcohol-related, with alcohol misuse accounting for a substantial proportion of Accident and Emergency Department attendances. The Licensing Act 2003 aimed to reduce alcohol-related crime and disorder by abolishing set closing times and giving local authorities control over premises licensing in England and Wales. Concerns were raised, however, that greater availability of alcohol would lead to increased consumption and violence. This review examines primary research from hospital and police settings to evaluate whether the implementation of the Act in 2005 reduced or increased violence rates in England and Wales. ⋯ This is the most complete analysis to date of the effects of the Licensing Act on violence. There is no evidence for the Act having a significant or consistent effect on community violence rates, either in emergency departments or policing. There is consistent evidence from both hospital and police settings of a proportional increase in late-night violence since the implementation of the Act.
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Observational Study
19 Accuracy of biomarkers for venous thromboembolism in pregnancy: the diagnosis of pulmonary embolism in pregnancy (DiPEP) biomarker study.
To estimate the accuracy of biomarkers for venous thromboembolism (VTE) in pregnant and postpartum women with suspected pulmonary embolism (PE). ⋯ Currently available biomarkers show little potential for aiding the diagnosis of suspected PE in pregnancy and postpartum.emermed;34/12/A874-a/F1F1F1Figure 1emermed;34/12/A874-a/F2F2F2Figure 2emermed;34/12/A874-a/F3F3F3Figure 3.