Emergency medicine journal : EMJ
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A 'whole body' or 'pan-scan' computed tomography (CT) imaging approach is now becoming the standard of care during the early management of adult patients with suspected severe blunt multitrauma. A number of studies have variously reported a mortality benefit or no benefit from a pan-scan approach compared to that of carrying out body region-focused CT and/or plain radiographs or a mixture of imaging modalities. However, unanswered questions still remain due to the significant heterogeneity in practice between institutions, and the limitations of published studies. The potential risk for harm from ionising radiation or intravenous contrast-induced nephropathy is still a concern, especially where mortality benefit from an unselective pan-scan approach is yet to be definitively proven.We present the results of our latest analysis of the Trauma Audit and Research Network (TARN) database; updated to take into account the establishment of the regional trauma network system and focusing on the Major Trauma Centre's (MTC's). ⋯ The results of our investigation demonstrate that there is no risk adjusted mortality benefit observed from current practice in MTCs in England and Wales. Key issues remain to be addressed such as pan-scan selection criteria and the significant heterogeneity observed in practice across institutions.
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Multicenter Study
Risk factors and outcomes associated with post-traumatic headache after mild traumatic brain injury.
To determine the prevalence and potential risk factors of acute and chronic post-traumatic headache (PTH) in patients with mild to moderate traumatic brain injury (TBI) in a prospective longitudinal observational multicentre study. Acute PTH (aPTH) is defined by new or worsening of pre-existing headache occurring within 7 days after trauma, whereas chronic PTH (cPTH) is defined as persisting aPTH >3 months after trauma. An additional goal was to study the impact of aPTH and cPTH in terms of return to work (RTW), anxiety and depression. ⋯ PTH is an important health problem with a significant impact on long-term outcome of TBI patients. Several risk factors were identified, which can aid in early identification of subjects at risk for PTH.
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The over 75 s make up 20% of our ED attendances. The greatest increase has been in the over 85 s. This very elderly cohort are more likely to be frail and are 10X more likely to require admission than 20-40 year olds and once in hospital have longer stays. There is evidence that multidisciplinary care and early Comprehensive Geriatric Assessment (CGA) improves outcomes for older patients, reducing readmissions, long term care, greater satisfaction and lower costs. The aim of this project was to improve the acute care provided to our older patients at the Front Door of the hospital. ⋯ 3 month pilot project underpinned by Big Room Quality Improvement methodology. The Frailty Big Room meets weekly and includes input from clinicians, QI experts and a data analyst. This project was driven by the following aims:Frailty Flying Squad to see as many older±frail patients referred for admission as close to the front door as possible.CGA at the front door with discharge planning from first reviewMDT approachExpedited discharge or transfer to other services from ED.Review following day to make sure management plans being followed through or discharge without ward teams having to become involved.Frailty Flying Squad Team:2 Medical Nurse PractitionersPhysiotherapistConsultant geriatricianKey Performance Indicators: Length of StayReadmission within 30 days of initial review RESULTS: 355 patients were seen. 168 (47%) of patients were over 85 and the median Rockwood frailty score for the whole cohort was 6. 209 patients were ED referrals and 85 were GP referrals for admission. 237 (67%) patients were seen in ED, 49 in MAU and 7 in ED obs. During the pilot period, 97 patients who had been referred for admission were discharged direct from ED. 56 (16%) of patients had zero length of stay. A low number (9.4%) of patients were readmitted within 30 days.emermed;34/12/A885-a/F1F1F1Figure 1LOSemermed;34/12/A885-a/F2F2F2Figure 2Length of stay for the > 85s 2016 and 2017 compared CONCLUSION: A multidisciplinary Acute Care of the Elderly Team predominantly based in the Emergency department can provide effective early Comprehensive Geriatric Assessment; facilitating discharge home from the Emergency Department, reducing length of stay for those admitted and reducing readmission rates within 30 days.
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Using diagnostic imaging for suspected pulmonary embolism (PE) in pregnancy involves weighing the benefits, harms and costs of different approaches to selecting women for imaging. ⋯ Decision analysis showed that a nonselective strategy of scanning all women with suspected PE accrued more QALYs and incurred fewer costs than any selective strategy based on a clinical decision rule and was therefore the dominant strategy. This finding was robust in sensitivity analysis and scenario analysis exploring assumptions in the model. Threshold analysis showed that a clinical decision rule to select women for imaging would need to have sensitivity exceeding 97.5% to be cost-effective compared to nonselective use of scanning.emermed;34/12/A867-a/F1F1F1Figure 1 CONCLUSION: There is little potential for selective imaging based on a clinical decision rule to be cost-effective compared to a strategy of nonselective imaging for all women with suspected PE in pregnancy and postpartum.
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: Emergency medicine is widely recognised as an intense specialty. Interruptions are known to derail thoughts, increasing cognitive load and result in longer periods before deep thought is re-established. Although approachability and warmth are regarded as important factors in clinicians we wondered what impact these characteristics had on the number of interruptions.