'Stealth trauma' in the young and the old: the next challenge for major trauma networks?

[First paragraph] In the UK, reports from the Trauma Audit Research Network (TARN)1 2 have shown that the very young and the very old now outnumber higher profile trauma groups, such as road accidents and stabbings. Other countries have seen similar demographic shifts. The very young and the very old share many societal and medical traits, including late diagnosis of severe injuries that may not be apparent on initial presentation.3 This could be described as ‘stealth trauma’

Fluid therapy in the emergency department: an expert practice review.

Intravenous fluid therapy is one of the most common therapeutic interventions performed in the ED and is a long-established treatment. The potential benefits of fluid therapy were initially described by Dr W B O'Shaughnessy in 1831 and first administered to an elderly woman with cholera by Dr Thomas Latta in 1832, with a marked initial clinical response. However, it was not until the end of the 19th century that medicine had gained understanding of infection risk that practice became safer and that the practice gained acceptance. The majority of fluid research has been performed on patients with critical illness, most commonly sepsis as this accounts for around two-thirds of shocked patients treated in the ED. However, there are few data to guide clinicians on fluid therapy choices in the non-critically unwell, by far our largest patient group. In this paper, we will discuss the best evidence and controversies for fluid therapy in medically ill patients

A week of pain in the Emergency Department

Background: Pain is a common complaint in patients attending the emergency department and historically it is under-assessed and undertreated. Previous research is heterogeneous and does not well describe pain in emergency departments (EDs) over time. Our aim was to describe pain in a UK emergency department by using a sample that included every adult attendance over the course of one week. Methods: We retrospectively reviewed every adult attendance (N=1872) over 1 week to the emergency department of a large English NHS District General Hospital. We noted the initial pain score and, if the initial score was ≥5, the final recorded pain score. We categorised attendances as ‘illness’ or ‘injury’. Results: 62.1% of patients had a pain score recorded, of whom 50.7% had a pain score of zero. Median pain score was 6/10 in patients with pain. 58% had a second score recorded. More patients with illness than injury had a second score recorded. Most patients had an improvement in their pain, however around one third had no change or worse pain at the end of their ED stay. Conclusion: We have defined the incidence, severity and change in pain in an Emergency Department over one week. This information will underpin the design of future studies aimed at improving patient care in this important area of emergency medicine practice

Early, Goal-Directed Resuscitation for Septic Shock. The authors reply

Early, Goal-Directed Resuscitation for Septic Shock. The authors repl

Handling missing data in large healthcare dataset: A case study of unknown trauma outcomes

Handling of missed data is one of the main tasks in data preprocessing especially in large public service datasets. We have analysed data from the Trauma Audit and Research Network (TARN) database, the largest trauma database in Europe. For the analysis we used 165,559 trauma cases. Among them, there are 19,289 cases (11.35%) with unknown outcome. We have demonstrated that these outcomes are not missed 'completely at random' and, hence, it is impossible just to exclude these cases from analysis despite the large amount of available data. We have developed a system of non-stationary Markov models for the handling of missed outcomes and validated these models on the data of 15,437 patients which arrived into TARN hospitals later than 24h but within 30days from injury. We used these Markov models for the analysis of mortality. In particular, we corrected the observed fraction of death. Two naïve approaches give 7.20% (available case study) or 6.36% (if we assume that all unknown outcomes are 'alive'). The corrected value is 6.78%. Following the seminal paper of Trunkey (1983 [15]) the multimodality of mortality curves has become a much discussed idea. For the whole analysed TARN dataset the coefficient of mortality monotonically decreases in time but the stratified analysis of the mortality gives a different result: for lower severities the coefficient of mortality is a non-monotonic function of the time after injury and may have maxima at the second and third weeks. The approach developed here can be applied to various healthcare datasets which experience the problem of lost patients and missed outcomes

Valsalva using a syringe: pressure and variation.

BACKGROUND: The Valsalva manoeuvre is commonly used in EDs to terminate supraventricular tachycardia by the patient blowing into a syringe. AIM: To identify whether a specific syringe size can be recommended for use in the ED. RESULTS: 20% of syringes 'stuck' and required high pressures to move. In the remaining 80% of syringes, a 20 mL syringe was the most appropriate size to achieve the recommended 40 mm Hg. Once 'released' plunger position did not make a difference. CONCLUSIONS: Use of a syringe of any size cannot be recommended if a consistent pressure is required

What older people want from emergency care: a systematic review

Objectives: To evaluate the expectations and preferred outcomes from emergency care among older people or their caregivers. Methods: A review protocol was registered. Medline, Embase, CINAHL, PsychInfo, BNI, AgeInfo and the Cochrane Database of Systematic Reviews were searched in their full date ranges to September 2018. Included articles were hand-searched for further citations. Citations were screened for (1) older people aged over 65 years, (2) ED settings and (3) reporting expectations or preferred outcomes for emergency care (as opposed to experience or satisfaction). Quality appraisal and data extraction of eligible articles were undertaken by two reviewers. Themes were synthesised through content analysis and described narratively. Results: Older people wished to have prompt waiting times, efficient care, clear communication and comfortable environments. They had additional and unique expectations for holistic care and support in decision-making. The ED provoked a sense of vulnerability among older people who were likely to have had frailty. Conclusion: The lack of dominant themes among included studies suggests that older people should be treated as individuals rather than a homogenous group. Establishing individuals' preferred outcomes could improve person-centred care. PROSPERO registration number CRD42018107050

The haemodynamic dilemma in emergency care: Is fluid responsiveness the answer? A systematic review

BACKGROUND: Fluid therapy is a common and crucial treatment in the emergency department (ED). While fluid responsiveness seems to be a promising method to titrate fluid therapy, the evidence for its value in ED is unclear. We aim to synthesise the existing literature investigating fluid responsiveness in ED. METHODS: MEDLINE, Embase and the Cochrane library were searched for relevant peer-reviewed studies published from 1946 to present. RESULTS: A total of 249 publications were retrieved of which 22 studies underwent full-text review and eight relevant studies were identified. Only 3 studies addressed clinical outcomes - including 2 randomised controlled trials and one feasibility study. Five articles evaluated the diagnostic accuracy of fluid responsiveness techniques in ED. Due to marked heterogeneity, it was not possible to combine results in a meta-analysis. CONCLUSION: High quality, adequately powered outcome studies are still lacking, so the place of fluid responsiveness in ED remains undefined. Future studies should have standardisation of patient groups, the target response and the underpinning theoretic concept of fluid responsiveness. The value of a fluid responsiveness based fluid resuscitation protocol needs to be established in a clinical trial

Thoracic electrical bioimpedance versus suprasternal Doppler in emergency care

OBJECTIVE: There are a number of cardiac output (CO) monitors that could potentially be used in the ED. Two of the most promising methods, thoracic electrical bioimpedance and suprasternal Doppler, have not been directly compared. The aim of this study was to investigate the feasibility of CO monitoring using suprasternal Doppler and bioimpedance in emergency care and compare haemodynamic data obtained from both monitors. METHODS: Haemodynamic measurements were made on the same group of patients using bioimpedance (Niccomo, Medis, Germany) and suprasternal Doppler (USCOM, Sydney, Australia). RESULTS: Usable CO data were obtained in 97% of patients by suprasternal Doppler and 87% by bioimpedance. The median CO obtained by Doppler was 3.4 L/min lower than bioimpedance. The stroke volume median was lower by 51 mL in Doppler. CONCLUSIONS: These two methods of non-invasive cardiac monitoring are not interchangeable. The results suggest that the choice of non-invasive cardiac monitor is important, but the grounds on which to make this choice are not currently clear

Changing the System - Major Trauma Patients and Their Outcomes in the NHS (England) 2008-17.

Background: Trauma care in England was re-organised in 2012 with ambulance bypass of local hospitals to newly designated Major Trauma Centres (MTCs). There is still controversy about the optimal way to organise health series for patients suffering severe injury. Methods: A longitudinal series of annual cross-sectional studies of care process and outcomes from April 2008 to March 2017. Data was collected through the national clinical audit of major trauma care. The primary analysis was carried out on the 110,863 patients admitted to 35 hospitals that were 'consistent submitters' throughout the study period. The main outcome was longitudinal analysis of risk adjusted survival. Findings: Major Trauma networks were associated with significant changes in (1) patient flow (with increased numbers treated in Major Trauma Centres), (2) treatment systems (more consultant led care and more rapid imaging), (3) patient factors (an increase in older trauma), and (4) clinical care (new massive transfusion policies and use of tranexamic acid). There were 10,247 (9.2%) deaths in the 110,863 patients with an ISS of 9 or more. There were no changes in unadjusted mortality. The analysis of trends in risk adjusted survival for study hospitals shows a 19% (95% CI 3%-36%) increase in the case mix adjusted odds of survival from severe injury over the 9-year study period. Interrupted time series analysis showed a significant positive change in the slope after the intervention time point of April 2012 (+ 0.08% excess survivors per quarter, p = 0.023), in other words an increase of 0.08 more survivors per 100 patients every quarter. Interpretation: A whole system national change was associated with significant improvements in both the care process and outcomes of patients after severe injury. Funding: This analysis was carried out independently and did not receive funding. The data collection for the national clinical audit was funded by subscriptions from participating hospitals