Emergency medicine journal : EMJ
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There are no widely accepted validated clinical decision rules for the use of WBCT in trauma. Given the potential risks and costs, there is a clear need for a clinical decision rule (CDR) to safely guide targeted use of WBCT. We aimed to derive a CDR to guide clinical decisions on WBCT utilisation by detecting patients at high and low risk of multi-region trauma. ⋯ 1608 patients were included in the study. The derived model combined a bespoke physiological score with mechanistic and anatomical factors. The physiological score identified the risk of multi-region injury at various cut-offs of age, systolic blood pressure, GCS, heart rate and respiratory rate. Patients were further categorised according to mechanism of injury and clinical findings, and specific physiological scores were applied to each category to determine which patients in these categories required WBCT. 'High risk' injury mechanisms included high falls and unprotected road traffic collisions. Clinical signs of injury were categorised by body region, including the head, chest, abdomen and pelvis (figure 1). The overall sensitivity of the clinical decision rule for the primary objective was 96.0% (95% CI:94.8 to 97.2) while the specificity was36.1% (95% CI:33.3 to 39.0). The negative likelihood ratio was 0.11. For the secondary objective the sensitivity was 98.5%, the negative likelihood ratio 0.04.emermed;34/12/A861-a/F1F1F1Figure 1 CONCLUSION: This study derived a two stage CDR which was highly sensitive for identifying patients at high risk of multiregion injury. A prospective external validation study is now required to further refine and improve this model. This could provide a useful screening tool in the future.
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The quality of cardiopulmonary resuscitation (CPR) has been shown to affect the survival of out-of-hospital cardiac arrest cases (OHCA). There are various individual factors that can affect the quality of chest compression. We aimed to determine if age, gender and physical attributes (height, weight and BMI) affected the quality of chest compressions administered by laypersons during training. ⋯ Overall, at least 1 parameter of chest compression quality decreased with age, and was better in males than females. A possible application of these results is to have differences in training methods for different ages and sexes, targeting parameters that they are weaker at.
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PATCH is a pilot acute community children's nurse led service delivering assessment and treatment for children at home who are moderately unwell and might otherwise be admitted to hospital or attend Paediatric Emergency Department (PED). Children are referred by PED or GP and followed up via telephone support and home visits depending on clinical need for duration of acute illness. ⋯ Activity - Appendix 1Phase 1 - Concentrated on respiratory conditions from PED.Total 188 referrals in first 7 months. Bronchiolitis 45%; viral wheeze 37.5%; asthma 7%; lower respiratory tract infections 5.4%.emermed;34/12/A895-b/F2F2F2Figure 250% of patients received home visits and telephone consultations; 50% only telephone support.Successes: Cost effective - Appendix 273 acute admissions avoided, costing c£400 per/night97 PED re-attendances prevented at £117 per attendance.Projected cost avoidance within acute care provider £3 27 640 pa.Estimated cost of service £2 84 000 pa.Positive feedback and reported health seeking behaviour change - Appendix 3 CHALLENGES: Information governance, cross organisational working, complex commissioning arrangements.emermed;34/12/A895-b/F3F3F3Figure 3 DISCUSSION: Within first 7 months PATCH has had a significant impact on avoiding admissions and re-attendances, thus improving flow and performance in PED. The projected financial impact is that it is cost effective.We are using this data to pursue a business case internally and with local CCGs. We are optimistic of succeeding and using phase 2 to build on partnerships garnered across the whole system to expand PATCH's impact further by reducing PED attendances and continuing to improve our local urgent care pathway for children.
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Triage, the process of prioritising patients on the basis of clinical acuity, is a key principle in the effective management of a major incident. The overall effectiveness of the triage process is not only a balance between identifying those who need or don't need a life-saving intervention, but also those who are under or over-triaged as either incorrectly needing/not needing intervention. The primary aim of this study was to describe the implications of under-triage using existing major incident triage tools, including the 2013 National Ambulance Resilience Unit (NARU) Sieve. The secondary aim was to describe the safety profile of the Modified Physiological Triage Tool (MPTT) in comparison to other triage tools, and to report mortality and identification of serious injury (AIS>3) in discrete AIS body regions. ⋯ During the study period, 2 18 985 adult patients were included with 24 791 (19.5%) identified as Priority One. 70% were male, aged 51 years [33-71], ISS 16 [9-25] with road traffic collision the most common mechanism (34%). The MPTT demonstrated the lowest rate of under-triage (42.4%, p<0.001). Overall 30 day mortality for the Priority One cohort was 12.4%. Compared to existing methods, the MPTT under-triage population had significantly lower mortality (5.7%, p<0.001), identical to the overall study population. Patients under-triaged by the MPTT had significantly lower requirement for intubation, thoracocentesis and massive transfusion than both the NARU Sieve and Triage Sieve (p<0.001). Serious injuries to the thorax (47.0%) and head (27.4%) predominated, with the MPTT again significantly under-triaging fewer of these patients (p<0.001).emermed;34/12/A871-a/F1F1F1Figure 1 CONCLUSION: This study has defined the effects of and compared the implications of under-triage when different triage tools are used in the context of a major trauma population. The MPTT misses fewer severely injured patients, with fewer LSIs necessary in the under-triaged population. We suggest that the MPTT should be considered as an alternative to existing major incident triage tools.emermed;34/12/A871-a/T1F2T1Table 1Frequency of interventions performed in the priority one cohort and patients under-triaged by the MPTT, UK NARU sieve and MIMMS triage sieve2Defined as administration of 4 or more units of blood/blood products 3Defined as craniotomy, burr holes or removal of intracranial haemorrhageemermed;34/12/A871-a/T2F3T2Table 2Frequency of severe injuries (AIS ≥ 3) by body region within the whole study population, the priority one cohort and in those under-triaged by the MPTT, the UK NARU sieve and the MIMMS triage sieve.
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The number of ventricular assist devices (VADs) being implanted for terminal heart failure is rising at an exponential rate. These implanted patients have a decreased mortality, but still have significant morbidities, as the prevalence of these patients increases in the community. When VAD patients are discharged to home, they will very likely require emergency medical services (EMSs) and emergency medical doctors (EDs) with their future care. ⋯ The cardiovascular treatment of VAD patients in the field can pose different challenges typically encountered including difficulties measuring a pulse and sometimes undetectable BP. Despite these unique challenges, official guidelines or even standard operating procedures regarding the emergency treatment of VAD patients are still lacking. We present a basic overview of the most commonly used left VAD systems and propose guidelines that should be followed in the event of an emergency with a VAD patient out of hospital.