The CRASH3 study: prehospital TXA for every injured patient?

The CRASH3 results are out, but do we know what to do? The study enrolled 9202 head injured patients within 3 hours of injury with a Glasgow Coma Scale (GCS) of 12 or less, or any intracranial bleeding on CT scan and randomised them to Tranexamic Acid (TXA) or placebo. The relative risk (RR) of all-cause mortality (RR 0.96, 95% CI 0.89-1.04) and head injury death (RR 0.94, 95% CI 086-1.02) among those receiving TXA were not significant. However there were significant differences in subgroups who were less severely injured (RR 0.89 95%CI 0.80-1.00 if those with GCS=3 or bilateral fixed pupils were excluded, and RR 0.78, 95% CI 0.64 to 0.95, in the GCS 9 to 15 subgroup) or treated earlier (p=0.005 for time effect)[1].The results need to be considered in the context of earlier CRASH2[2] results, which showed a reduction in all-cause mortality (RR 0.91, 0.85 to 0.97) and death due to bleeding (RR 0.85, 0.76-0.96) if trauma patients who were bleeding or at risk of bleeding were given TXA. In both CRASH2 and CRASH3 the TXA was given in the emergency department.</div

Validation of the BATT score for prehospital risk stratification of traumatic haemorrhagic death: usefulness for tranexamic acid treatment criteria.

Tranexamic acid reduces surgical blood loss and reduces deaths from bleeding in trauma patients. Tranexamic acid must be given urgently, preferably by paramedics at the scene of the injury or in the ambulance. We developed a simple score (Bleeding Audit Triage Trauma score) to predict death from bleeding. We conducted an external validation of the BATT score using data from the UK Trauma Audit Research Network (TARN) from 1st January 2017 to 31st December 2018. We evaluated the impact of tranexamic acid treatment thresholds in trauma patients. We included 104,862 trauma patients with an injury severity score of 9 or above. Tranexamic acid was administered to 9915 (9%) patients. Of these 5185 (52%) received prehospital tranexamic acid. The BATT score had good accuracy (Brier score = 6%) and good discrimination (C-statistic 0.90; 95% CI 0.89-0.91). Calibration in the large showed no substantial difference between predicted and observed death due to bleeding (1.15% versus 1.16%, P = 0.81). Pre-hospital tranexamic acid treatment of trauma patients with a BATT score of 2 or more would avoid 210 bleeding deaths by treating 61,598 patients instead of avoiding 55 deaths by treating 9915 as currently. The BATT score identifies trauma patient at risk of significant haemorrhage. A score of 2 or more would be an appropriate threshold for pre-hospital tranexamic acid treatment

Major trauma from suspected child abuse: A profile of the patient pathway

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. Background Networked organised systems of care for patients with major trauma now exist in many countries, designed around the needs of the majority of patients (90% adults). Non-accidental injury is a significant cause of paediatric major trauma and has a different injury and age profile from accidental injury (AI). This paper compares the prehospital and inhospital phases of the patient pathway for children with suspected abuse, with those accidentally injured. Methods The paediatric database of the national trauma registry of England and Wales, Trauma Audit and Research Network, was interrogated from April 2012 (the launch of the major trauma networks) to June 2015, comparing the patient pathway for cases of suspected child abuse (SCA) with AI. Results In the study population of 7825 children, 7344 (94%) were classified as AI and 481 (6%) as SCA. SCA cases were younger (median 0.4 years vs 7 years for AI), had a higher Injury Severity Score (median 16vs9 for AI), and had nearly three times higher mortality (5.7%vs2.2% for AI). Other differences included presentation to hospital evenly throughout the day and year, arrival by non-ambulance means to hospital (74%) and delayed presentation to hospital from the time of injury (median 8 hours vs 1.8 hours for AI). Despite more severe injuries, these infants were less likely to receive key interventions in a timely manner. Only 20% arrived to a designated paediatric-capable major trauma centre. Secondary transfer to specialist care, if needed, took a median of 21.6 hours from injury(vs 13.8 hours for AI). Conclusion These data show that children with major trauma that is inflicted rather than accidental follow a different pathway through the trauma system. The current model of major trauma care is not a good fit for the way in which child victims of suspected abuse present to healthcare. To achieve better care, awareness of this patient profile needs to increase, and trauma networks should adjust their conventional responses

Gold in the Dalradian terrane : a review of previous work

The Dalradian Supergroup comprises a Late Precambrian sequence of marine clastic sedimentary rocks and minor basic volcanic rocks which was folded and metamorphosed during the early Palaeozoic Caledonian Orogeny. Intrusive igneous rocks are widespread throughout the Dalradian terrane. The most important in terms of gold metallogenesis are the post-tectonic granites which comprise a diverse suite of calc-alkaline intrusions emplaced between 420 and 395 Ma. Numerous occurrences of gold in bedrock and alluvium are documented in the Dalradian terrane of Scotland. Mesothermal vein occurrences are the most important and include the Cononish deposit, near Tyndrum in Perthshire, where planning permission for mining has been granted. Gold mineralisation of several other styles, including intrusion-related, epithermal, stratiform and occurrences associated with mafic-ultramafic intrusions, is also present. This report has been compiled for the BGS Core Programme project ‘Sedimentary Basin Resources: Gold in orogenic extensional basins – the Dalradian’. This project, carried out between 1997–2000, was designed to investigate the factors controlling the distribution of gold in the Dalradian and to develop a predictive metallogenic model for gold mineralisation in this terrane. This report provides a` review of known gold occurrences and the results of past mineral exploration activity in the Dalradian terrane. The latter has been compiled from records held in BGS archives and the available data are summarised in a series of appendices. Exploration for metalliferous mineralisation has been carried out widely in the Dalradian terrane by commercial mining companies and by BGS. In the 1970s most work focused on Cu, Pb, Zn, Ni and Mo, while more recently, from 1981 onwards, precious metals (Au and PGE) were the prime target. Between 1972 and 1984 the DTI sought to encourage private-sector mineral exploration by the provision of grants under the Mineral Exploration and Investment Grants Act (MEIGA). About 150 reports derived from these projects are available on open-file at BGS. Exploration by BGS was carried out mainly through the DTI-funded Mineral Reconnaissance Programme (MRP), which ran between 1972 and 1997. Nearly 150 reports and associated data releases were produced by the MRP. Together the MEIGA and MRP reports have been the major sources of information used in this report. The combination of improved genetic models for gold deposits, the increased availability of multidisciplinary digital geoscience data and the information on previous exploration summarised in this report provides a sound basis for research on gold mineralisation in the Dalradian terrane. Potential exists in a range of settings that may host economic gold deposits

A consensus building exercise to determine research priorities for silver trauma

Background Emergency care research into ‘Silver Trauma’, which is simply defined as major trauma consequent upon relatively minor injury mechanisms, is facing many challenges including that at present, there is no clear prioritisation of the issues. This study aimed to determine the top research priorities to guide future research. Methods This consensus-based prioritization exercise used a three-stage modified Delphi technique. The study consisted of an idea generating (divergent) first round, a ranking evaluation in the second round, and a (convergent) consensus meeting in the third round. Results A total of 20 research questions advanced to the final round of this study. After discussing the importance and clinical significance of each research question, five research questions were prioritised by the experts; the top three research priorities were: (1). What are older people’s preferred goals of trauma care? (2). Beyond the Emergency Department (ED), what is the appropriate combined geriatric and trauma care? (3). Do older adults benefit from access to trauma centres? If so, do older trauma patients have equitable access to trauma centre compared to younger adults? Conclusion The results of this study will assist clinicians, researchers, and organisations that are interested in silver trauma in guiding their future efforts and funding toward addressing the identified research priorities

The effect of relative hypotension on 30-day mortality in older people receiving emergency care

Research has observed increased mortality among older people attending the emergency department (ED) who had systolic pressure > 7 mmHg lower than baseline primary care values. This study aimed to (1) assess feasibility of identifying this ‘relative hypotension’ using readily available ED data, (2) externally validate the 7 mmHg threshold, and (3) refine a threshold for clinically important relative hypotension. A single-centre retrospective cohort study linked year 2019 data for ED attendances by people aged over 64 to hospital discharge vital signs within the previous 18 months. Frailty and comorbidity scores were calculated. Previous discharge (‘baseline’) vital signs were subtracted from initial ED values to give individuals’ relative change. Cox regression analysis compared relative hypotension > 7 mmHg with mean time to mortality censored at 30 days. The relative hypotension threshold was refined using a fully adjusted risk tool formed of logistic regression models. Receiver operating characteristics were compared to NEWS2 models with and without incorporation of relative systolic. 5136 (16%) of 32,548 ED attendances were linkable with recent discharge vital signs. Relative hypotension > 7 mmHg was associated with increased 30-day mortality (HR 1.98; 95% CI 1.66–2.35). The adjusted risk tool (AUC: 0.69; sensitivity: 0.61; specificity: 0.68) estimated each 1 mmHg relative hypotension to increase 30-day mortality by 2% (OR 1.02; 95% CI 1.02–1.02). 30-day mortality prediction was marginally better with NEWS2 (AUC: 0.73; sensitivity: 0.59; specificity: 0.78) and NEWS2 + relative systolic (AUC: 0.74; sensitivity: 0.63; specificity: 0.75). Comparison of ED vital signs with recent discharge observations was feasible for 16% individuals. The association of relative hypotension > 7 mmHg with 30-day mortality was externally validated. Indeed, any relative hypotension appeared to increase risk, but model characteristics were poor. These findings are limited to the context of older people with recent hospital admissions

Measuring health-related quality of life of older people with frailty receiving acute care: feasibility and psychometric performance of the EuroQol EQ-5D

Background Although outcome goals for acute healthcare among older people living with frailty often include Health-Related Quality of Life (HRQoL) and other patient-reported outcome measures (PROMs), current quality metrics usually focus on waiting times and survival. Lay and patient review have identified the EuroQol EQ-5D as a candidate measure for this setting. This research appraised the EQ-5D for feasibility, psychometric performance, and respondents’ outcomes in the acute frailty setting. Methods People aged 65 + with Clinical Frailty Scale (CFS) 5–8 were recruited from eight UK hospitals’ emergency care and acute admissions settings. They completed the five-level EQ-5D and the EQ-VAS. Feasibility was assessed with completion times and completeness. For reliability, response distributions and internal consistency were analysed. Finally, EQ-Index values were compared with demographic characteristics and service outcomes for construct validity. Results The 232 participants were aged 65–102. 38% responded in emergency departments and 62% in admissions wards. Median completion time was 12 (IQR, 11) minutes. 98% responses were complete. EQ-5D had acceptable response distribution (SD 1.1–1.3) and internal consistency (Cronbach’s alpha 0.69). EQ-VAS demonstrated a midpoint response pattern. Median EQ-Index was 0.574 (IQR, 0.410) and was related positively with increasing age (p = 0.010) and negatively with CFS (p < 0.001). Participants with higher CFS had more frequent problems with mobility, self-care, and usual activities. Conclusions Administration of the EQ-5D was feasible in these emergency and acute frailty care settings. EQ-5D had acceptable properties, while EQ-VAS appeared problematic. Participants with more severe frailty had also poorer HRQoL

New horizons in understanding appropriate prehospital identification and trauma triage for older adults

Caring for older people is an important part of prehospital practice, including appropriate triage and transportation decisions. However, prehospital triage criteria are designed to predominantly assess injury severity or high-energy mechanism which is not the case for older people who often have injuries compounded by multimorbidity and frailty. This has led to high rates of under-triage in this population. This narrative review aimed to assess aspects other than triage criteria to better understand and improve prehospital triage decisions for older trauma patients. This includes integrating frailty assessment in prehospital trauma triage, which was shown to predict adverse outcomes for older trauma patients. Furthermore, determining appropriate outcome measures and the benefits of Major Trauma Centers (MTCs) for older trauma patients should be considered in order to direct accurate and more beneficial prehospital trauma triage decisions. It is still not clear what are the appropriate outcome measures that should be applied when caring for older trauma patients. There is also no strong consensus about the benefits of MTC access for older trauma patients with regards to survival, in-hospital length of stay, discharge disposition, and complications. Moreover, looking into factors other than triage criteria such as distance to MTCs, patient or relative choice, training, unfamiliarity with protocols, and possible ageism, which were shown to impact prehospital triage decisions but their impact on outcomes has not been investigated yet, should be more actively assessed and investigated for this population. Therefore, this paper aimed to discuss the available evidence around frailty assessment in prehospital care, appropriate outcome measures for older trauma patients, the benefits of MTC access for older patients, and factors other than triage criteria that could adversely impact accurate prehospital triage decisions for older trauma patients. It also provided several suggestions for the future

Co-creation of a patient-reported outcome measure for older people living with frailty receiving acute care (PROM-OPAC)

Older people living with frailty emphasize autonomy and function as acute healthcare outcome goals. Existing Patient-Reported Outcome Measures (PROMs) measure function but do not comprehensively address autonomy. This initial development of a novel autonomy outcome measure used co-creation and cognitive interviews, working toward a PROM for Older People living with frailty receiving Acute Care (“PROM-OPAC”). Novel item question stems and responses considering autonomy were devised with lay research partners. Items were examined for content by lay volunteers, and then selected based on relevance, completeness, and accessibility. Retained items were cognitively tested with patient participants. Item selection considered content validity and feasibility and was undertaken collaboratively with lay research partners. The study involved 3 lay research partners and 4 further lay collaborators throughout all stages, and 14 patient participants were recruited for the cognitive interviews. Twenty-two novel items were appraised. Seven were selected for retention. This preliminary PROM-OPAC comprised 7 items to measure autonomy and was intended for administration alongside a function measure to capture meaningful acute healthcare outcomes. Development will continue with quantitative testing and validation

What matters most in acute care: an interview study with older people living with frailty

Background Healthcare outcome goals are central to person-centred acute care, however evidence among older people is scarce. Older people who are living with frailty have distinct requirements for healthcare delivery and have distinct risk for adverse outcomes from healthcare. There is insufficient evidence for whether those living with frailty also have distinct healthcare outcome goals. This study explored the nature of acute care outcome goals in people living with frailty. Methods Healthcare outcome goals were explored using semi-structured patient interviews. Participants aged over 65 with Clinical Frailty Score 5-8 (mild to very severe frailty) were recruited during their first 72 hours in a UK hospital. Purposive, maximum variation sampling was guided by lay partners from a Patient and Public Involvement Forum specialising in ageing-related research. Qualitative analysis used a blended approach based on framework and constant comparative methodologies for the identification of themes. Findings were validated through triangulation with participant, lay partner, and technical expert review. Results The 22 participants were aged 71 to 98 and had mild to very severe frailty. One quarter were living with dementia. Most participants had reflected on their situation and considered their outcome goals. Theme categories (and corresponding sub-categories) were ‘Autonomy’ (information, control, and security) and ‘Functioning’ (physical, psychosocial, and relief). A novel ‘security’ theme was identified, whereby participants sought to feel safe in their usual living place and with their health problems. Those living with milder frailty were concerned to maintain ability to support loved ones, while those living with most severe frailty were concerned about burdening others. Conclusions Outcome goals for acute care among older participants living with frailty were influenced by the insecurity of their situation and fear of deterioration. Patients may be supported to feel safe and in control through appropriate information provision and functional support