Emergency medicine journal : EMJ
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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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The presentation of multiple simultaneous trauma patients in an Emergency Department, is likely to place significant stress and strain on trauma care resources. Currently there is limited data available to understand the impact simultaneous trauma demands on patient outcomes. For the purposes of this project we define simultaneous trauma as occurring when there is more than one TARN qualifying major trauma patient within an Emergency Department at any one time. We hypothesise that with increasing numbers of simultaneous trauma patients a relative increase in mortality will be seen. ⋯ The impact of simultaneous trauma patients on patient outcomes within the UK has not been previously defined. Simultaneous trauma patients do not appear to have an impact on overall mortality rate.emermed;34/12/A888-a/T1F1T1Table 1Further work planned will understand the impact of multiple trauma patients on length of stay and time to CT/operating theatre.
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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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Overdose is a common presentation in Emergency Departments (EDs) across the UK. Salicylate poisoning is potentially fatal; however it is becoming increasingly uncommon in the UK. This may be due to restriction of pack sizes in over the counter medicines as well as the use of aspirin as an analgesic being superseded by other NSAIDs, particularly ibuprofen.In conjunction with clinical features of salicylate toxicity, measurement of plasma salicylate concentration can help guide management. Many EDs routinely test for salicylate levels in all cases of overdose, and yet this may not be necessary as recommended by the NPIS.This study aims to assess the cost implication of over testing for salicylate in overdose patients, as well as the prevalence of salicylate poisoning in three EDs in the West Midlands. ⋯ Salicylate poisoning appears to be uncommon among patients presenting with overdose.Results show that it is likely that EDs are over testing for salicylate levels.In accordance with NPIS advice, there is no need to measure salicylate levels in conscious overdose patients who have no features of toxicity and deny salicylate ingestion.This may have cost implications, allowing departments to save money by reducing the amount of routine salicylate testing overall.
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The benefit of antiplatelet medication in confirmed acute coronary syndrome (ACS) is well established. In the Emergency Department (ED) diagnostic uncertainty may lead to over-treatment, with consequent risks (e.g., bleeding), or under-treatment, compromising clinical outcomes. Clinicians must subjectively balance the anticipated risks and benefits with their perceived probability of ACS in order to decide whether to prescribe these medications. We aimed to construct a clinical model to optimise and personalise recommendations for anti-platelet prescription in this context. ⋯ Systematic review identified three relevant original studies, and three sub-studies. After extracting data, we constructed two separate models, based on clinical outcomes after 30 days and 12 months. Aspirin alone led to greater net utility at probabilities below 7.4%, whereas treatment with ticagrelor led to greater net benefit when the probability of ACS exceeded 8.3% (figures 1 and 2). Sensitivity analyses including 10,000-fold Monte Carlo simulations demonstrated that the models were robust to a wide range of assumptions (figure 3).emermed;34/12/A870-a/F1F1F1Figure 1Acute coronary syndrome risk thresholds of treatment strategy superiority. (Clopidogrel and ticagrelor treatment strategies included the use of aspirin at ACS treatment)emermed;34/12/A870-a/F2F2F2Figure 2Net expected utility of anti-platelet therapy in 12 months combined outcome modelemermed;34/12/A870-a/F3F3F3Figure 3A monte carlo simulation (n=10,000) - net expected utility of anti-platelet therapy in 12 month combined outcome model - varying risk and utility outcomes CONCLUSION: This work suggests that treatment with ticagrelor yields greater net benefit for patients when the probability of ACS exceeds 8.3%. This has potential to improve clinical outcomes when used alongside a prediction model, such as the Manchester Acute Coronary Syndromes (MACS) decision aid, which calculates each patient's individual probability of ACS. The clinical and cost effectiveness of this novel 'precision Emergency Medicine' approach should now be evaluated in clinical studies.