The development of evidence-based guidelines to inform the extrication of casualties trapped in motor vehicles following a collision

Background Motor vehicle collisions (MVCs) are a common cause of injury and death throughout the world. Following an MVC some patients will remain in their vehicles due to injury, the potential for injury or physical obstruction. Extrication is the process of removing injured or potentially injured patients from vehicles following a motor-vehicle collision. Current extrication practices are based on the principles of 'movement minimisation' with the purpose of minimising the incidence of avoidable secondary spinal injury. Movement minimisation adds time to the process of extrication and may result in an excess morbidity and mortality for patients with time dependent injuries. The current extrication approach has evolved without the application of evidence-based medicine (EBM) principles. The principles of EBM; consideration of the relevant scientific evidence, patient values and preferences and expert clinical judgement are used as a framework for this thesis. Aims and Objectives To develop evidence-based guidance for the extrication of patients trapped in motor vehicles by applying EBM principles to this area of practice. This will be achieved through: - Describing the injury patterns, morbidity and mortality of patients involved in MVCs (trapped and not trapped). - To analyse the movement associated with and the time taken to deliver across a variety of extrication methods. - Determining the perceptions of patients who have undergone vehicle extrication and describe their experiences of extrication. - Developing consensus-based guidelines for extrication

49 Paediatric traumatic cardiac arrest - the development of a treatment algorithm

© 2017, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions. INTRODUCTION: Paediatric Traumatic Cardiac Arrest (TCA) is a high acuity, low frequency event with fewer than 15 cases reported per year to the Trauma Audit Research Network (TARN). Traditionally survival from TCA has been reported as low, with some believing resuscitation is futile. Within the adult population there is growing evidence to suggest that with early and aggressive correction of reversible causes, survival from TCA may be comparable to that seen from medical out-of-hospital cardiac arrests. Key to this survival has been the adoption of a standardised approach to resuscitation.The aim of this study was, by a process of consensus, to develop a national, standardised algorithm for the management of paediatric TCA.METHODS: A modified consensus development meeting was held. Statements discussed in the meeting were drawn from those that did not reach consensus (positive/negative) from a linked three round online Delphi study. Those participants completing the first round of the Delphi study were invited to attend.19 statements relating to the diagnosis, management and futility of paediatric TCA were discussed in small groups. After five minutes the key points from the small groups were presented to the whole audience. Subsequently, using electronic voting devices, each participant anonymously recorded their agreement with the statement using 'yes', 'no' or 'don't know'. In keeping with our Delphi study, consensus was set a priori at 70%. Statements reaching consensus were included in the proposed algorithm.RESULTS: 41 participants attended the consensus development meeting. Of the 19 statements discussed, 13 reached positive consensus and were included in the algorithm. A single statement regarding initial rescue breaths reached negative consensus and was excluded. Consensus was not reached for five statements, including the use of vasopressors and thoracotomy for haemorrhage control in blunt trauma. The proposed algorithm for the management of paediatric TCA is shown as Figures 1 and 2 for blunt and penetrating trauma respectively.emermed;34/12/A892-b/F1F1F1Figure 1emermed;34/12/A892-b/F2F2F2Figure 2 CONCLUSION: In attempt to standardise our approach to the management of paediatric TCA and to improve outcomes, we present the first algorithm specific to the paediatric population

Maximum movement and cumulative movement (travel) to inform our understanding of secondary spinal cord injury and its application to collar use in self-extrication

BACKGROUND: Motor vehicle collisions remain a common cause of spinal cord injury. Biomechanical studies of spinal movement often lack “real world” context and applicability. Additional data may enhance our understanding of the potential for secondary spinal cord injury. We propose the metric ‘travel’ (total movement) and suggest that our understanding of movement related risk of injury could be improved if travel was routinely reported. We report maximal movement and travel for collar application in vehicle and subsequent self-extrication. METHODS: Biomechanical data on application of cervical collar with the volunteer sat in a vehicle were collected using Inertial Measurement Units on 6 healthy volunteers. Maximal movement and travel are reported. These data and a re-analysis of previously published work is used to demonstrate the utility of travel and maximal movement in the context of self-extrication. RESULTS: Data from a total of 60 in-vehicle collar applications across three female and three male volunteers was successfully collected for analysis. The mean age across participants was 50.3 years (range 28–68) and the BMI was 27.7 (range 21.5–34.6). The mean maximal anterior–posterior movement associated with collar application was 2.3 mm with a total AP travel of 4.9 mm. Travel (total movement) for in-car application of collar and self-extrication was 9.5 mm compared to 9.4 mm travel for self-extrication without a collar. CONCLUSION: We have demonstrated the application of ‘travel’ in the context of self-extrication. Total travel is similar across self-extricating healthy volunteers with and without a collar. We suggest that where possible ‘travel’ is collected and reported in future biomechanical studies in this and related areas of research. It remains appropriate to apply a cervical collar to self-extricating casualties when the clinical target is that of movement minimisation

Assessing spinal movement during four extrication methods:a biomechanical study using healthy volunteers

BACKGROUND Motor vehicle collisions are a common cause of death and serious injury. Many casualties will remain in their vehicle following a collision. Trapped patients have more injuries and are more likely to die than their untrapped counterparts. Current extrication methods are time consuming and have a focus on movement minimisation and mitigation. The optimal extrication strategy and the effect this extrication method has on spinal movement is unknown. The aim of this study was to evaluate the movement at the cervical and lumbar spine for four commonly utilised extrication techniques. METHODS Biomechanical data was collected using inertial Measurement Units on 6 healthy volunteers. The extrication types examined were: roof removal, b-post rip, rapid removal and self-extrication. Measurements were recorded at the cervical and lumbar spine, and in the anteroposterior (AP) and lateral (LAT) planes. Total movement (travel), maximal movement, mean, standard deviation and confidence intervals are reported for each extrication type. RESULTS Data from a total of 230 extrications were collected for analysis. The smallest maximal and total movement (travel) were seen when the volunteer self-extricated (AP max = 2.6 mm, travel 4.9 mm). The largest maximal movement and travel were seen in rapid extrication extricated (AP max = 6.21 mm, travel 20.51 mm). The differences between self-extrication and all other methods were significant (p < 0.001), small non-significant differences existed between roof removal, b-post rip and rapid removal. Self-extrication was significantly quicker than the other extrication methods (mean 6.4 s). CONCLUSIONS In healthy volunteers, self-extrication is associated with the smallest spinal movement and the fastest time to complete extrication. Rapid, B-post rip and roof off extrication types are all associated with similar movements and time to extrication in prepared vehicles

Paediatric traumatic cardiac arrest: A Delphi study to establish consensus on definition and management

Aims Paediatric traumatic cardiac arrest (TCA) is associated with low survival and poor outcomes. The mechanisms that underlie TCA are different from medical cardiac arrest; the approach to treatment of TCA may therefore also need to differ to optimise outcomes. The aim of this study was to explore the opinion of subject matter experts regarding the diagnosis and treatment of paediatric TCA, and to reach consensus on how best to manage this group of patients.Methods An online Delphi study was conducted over three rounds, with the aim of achieving consensus (defined as 70% agreement) on statements related to the diagnosis and management of paediatric TCA. Participants were invited from paediatric and adult emergency medicine, paediatric anaesthetics, paediatric ICU and paediatric surgery, as well as Paediatric Major Trauma Centre leads and representatives from the Resuscitation Council UK. Statements were informed by literature reviews and were based on elements of APLS resuscitation algorithms as well as some concepts used in the management of adult TCA; they ranged from confirmation of cardiac arrest to the indications for thoracotomy.Results 73 experts completed all three rounds between June and November 2016. Consensus was reached on 14 statements regarding the diagnosis and management of paediatric TCA; oxygenation and ventilatory support, along with rapid volume replacement with warmed blood, improve survival. The duration of cardiac arrestand the lack of a response to intervention, along with cardiac standstill on ultrasound, help to guide the decision to terminate resuscitation.Conclusion This study has given a consensus-based framework to guide protocol development in the management of paediatric TCA, though further work is required in other key areas including its acceptability to clinicians

Use of tranexamic acid in major trauma: a sex-disaggregated analysis of the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH-2 and CRASH-3) trials and UK trauma registry (Trauma and Audit Research Network) data

Background Women are less likely than men to receive some emergency treatments. This study examines whether the effect of tranexamic acid (TXA) on mortality in trauma patients varies by sex and whether the receipt of TXA by trauma patients varies by sex. Methods First, we conducted a sex-disaggregated analysis of data from the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH)-2 and CRASH-3 trials. We used interaction tests to determine whether the treatment effect varied by sex. Second, we examined data from the Trauma and Audit Research Network (TARN) to explore sex differences in the receipt of TXA. We used logistic regression models to estimate the odds ratio for receipt of TXA in females compared with males. Results are reported as n (%), risk ratios (RR), and odds ratios (OR) with 95% confidence intervals. Results Overall, 20 211 polytrauma patients (CRASH-2) and 12 737 patients with traumatic brain injuries (CRASH-3) were included in our analysis. TXA reduced the risk of death in females (RR=0.69 [0.52–0.91]) and in males (RR=0.80 [0.71–0.90]) with no significant heterogeneity by sex (P=0.34). We examined TARN data for 216 364 patients aged ≥16 yr with an Injury Severity Score ≥9 with 98 879 (46%) females and 117 485 (54%) males. TXA was received by 7198 (7.3% [7.1–7.4%]) of the females and 19 697 (16.8% [16.6–17.0%]) of the males (OR=0.39 [0.38–0.40]). The sex difference in the receipt of TXA increased with increasing age. Conclusions Administration of TXA to patients with bleeding trauma reduces mortality to a similar extent in women and men, but women are substantially less likely to be treated with TXA

A Delphi study of rescue and clinical subject matter experts on the extrication of patients following a motor vehicle collision

Background Approximately 1.3 million people die each year globally as a direct result of motor vehicle collisions (MVCs). Following an MVC some patients will remain trapped in their vehicle; these patients have worse outcomes and may require extrication. Following new evidence, updated multidisciplinary guidance for extrication is needed. Methods This Delphi study has been developed, conducted and reported to CREDES standards. A literature review identified areas of expertise and appropriate individuals were recruited to a Steering Group. The Steering Group formulated initial statements for consideration. Stakeholder organisations were invited to identify subject matter experts (SMEs) from a rescue and clinical background (total 60). SMEs participated over three rounds via an online platform. Consensus for agreement / disagreement was set at 70%. At each stage SMEs could offer feedback on, or modification to the statements considered which was reviewed and incorporated into new statements or new supporting information for the following rounds. Stakeholders agreed a set of principles based on the consensus statements on which future guidance should be based. Results Sixty SMEs completed Round 1, 53 Round 2 (88%) and 49 Round 3 (82%). Consensus was reached on 91 statements (89 agree, 2 disagree) covering a broad range of domains related to: extrication terminology, extrication goals and approach, self-extrication, disentanglement, clinical care, immobilisation, patient-focused extrication, emergency services call and triage, and audit and research standards. Thirty-three statements did not reach consensus. Conclusion This study has demonstrated consensus across a large panel of multidisciplinary SMEs on many key areas of extrication and related practice that will provide a key foundation in the development of evidence-based guidance for this subject area

In adult patients presenting as emergencies with upper gastrointestinal bleeding, does tranexamic acid decrease mortality?

Upper gastrointestinal bleeding (UGIB) is a common Emergency Centre presentation with a high mortality (5–30%). Despite theoretical benefits, tranexamic acid is not widely used for this condition. Tranexamic acid is widely available in the developing world and is on the World Health Organisation’s essential medicines list. This review considers the following three-part question: “In adult patients with upper gastrointestinal bleeding, does tranexamic acid decrease mortality? A systematic review of the literature was performed (1900–2012). Databases searched included: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, National Research Register, NIHR CRN portfolio, and http://ClinicalTrials.gov/. Grey literature databases searched included: Open Grey, Worldcat.org and Google Scholar. The conclusion of this review is that in adult patients with upper gastrointestinal bleeding, the administration of tranexamic acid may lead to a significant decrease in mortality