ORCID Profile
0000-0002-0508-2450
Current Organisations
Alfred Health
,
Monash University
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Publisher: SAGE Publications
Date: 18-07-2023
DOI: 10.1177/14604086231177124
Abstract: Blunt cerebrovascular injuries (BCVIs) are uncommon but associated with ischemic stroke and disability, particularly in younger adults. There is a paucity of literature on the incidence and risk factors for BCVI. The aim of this study was to report the incidence and clinical characteristics of patients diagnosed with BCVI at an adult level 1 trauma centre. This was a registry-based cohort study. The accessible s le was all patients in the Alfred Hospital Trauma Registry (AHTR) who presented from January 2014 to June 2021 and were recorded to have BCVI. The diagnosis of BCVI was confirmed by independent, blinded neuroradiologists prior to study inclusion. Demographics, injury mechanism and associated injuries of patients were extracted from the AHTR and patient medical records. There were 20,954 blunt trauma patients in the AHTR during the study period, of which 300 patients were confirmed to have 428 BCVIs. The incidence of BCVI was 1.4% (95%CI: 1.3–1.6). The mortality rate was 14% with a median survival time of 86 h from the time of injury. More men (65%) were diagnosed with BCVI than women and motor vehicle crashes (n = 180 60%) were the most common mechanism of injury. Younger age, high transfer mechanisms, high injury severity, brain and chest trauma were associated with carotid artery injuries, while vertebral artery injuries were associated with older age, higher presenting GCS and cervical spinal injuries. The incidence of BCVI was low. The risk profile for patients with CAIs and VAIs were different. Consistent with the modified Denver criteria, high energy transfer mechanisms and cervical spinal injuries were identified to be high-risk features, but they impacted carotid and vertebral arteries differently. Any trauma involving these mechanisms should trigger investigation for the detection of BCVIs.
Publisher: SAGE Publications
Date: 23-09-2019
Abstract: Procedural complication rates associated with tube thoracostomy for pleural decompression is estimated to be between 2 and 25%, with incorrect insertion site being a common problem. We hypothesised that the inferior-most hair follicle in the axillary region would provide an accurate biometric marker to identify the fourth to sixth intercostal space. A prospective cohort of patients requiring computed tomography scan of the chest was recruited from February 2015 to March 2016 at The Alfred Hospital. The inferior-most hair follicle on the patient’s axillary region was tagged with a paperclip, and a radiologist reported this location with reference to the corresponding intercostal spaces. Of the 254 enrolled patients, a total of 310 paperclip positions over intercostal spaces were analysed. There were 101 (32.5%) paperclips positioned in the fourth and fifth intercostal spaces with the remainder at the second or third intercostal spaces, and no paperclips placed at the sixth intercostal space or lower. This study demonstrated that the inferior-most hair follicle in the axilla corresponded to an area between the second and fifth intercostal spaces. Recognition of this surface anatomy has the potential to eliminate iatrogenic injuries to the diaphragm and sub-diaphragmatic organs, but should not be used as the sole marker due to potential risks from high placement of pleural drains.
Publisher: Wiley
Date: 20-04-2022
Abstract: To assess the feasibility of an ED presenting complaint (PC) tool that categorised all ED PCs into 10 categories. A retrospective analysis of 1445 consecutive patient encounters was conducted. The primary outcome was the frequency of use of the 10 PC categories. Of the 1203 patient encounters meeting inclusion criteria, the PC tool was completed by clinicians in 574 (47.7%). When completed, the tool's 10 options were selected for most presentations (72.3%). The PC tool captured the majority of presenting complaints in 10 categories. External validation is recommended.
Publisher: Wiley
Date: 12-09-2020
Publisher: Wiley
Date: 08-2017
DOI: 10.1111/JEBM.12256
Abstract: This systematic review aimed to determine the effect of prehospital notification systems for major trauma patients on overall (<30 days) and early (<24 hours) mortality, hospital reception, and trauma team presence (or equivalent) on arrival, time to critical interventions, and length of hospital stay. Experimental and observational studies of prehospital notification compared with no notification or another type of notification in major trauma patients requiring emergency transport were included. Risk of bias was assessed using the Cochrane ACROBAT-NRSI tool. A narrative synthesis was conducted and evidence quality rated using the GRADE criteria. Three observational studies of 72,423 major trauma patients were included. All were conducted in high-income countries in hospitals with established trauma services, with two studies undertaking retrospective analysis of registry data. Two studies reported overall mortality, one demonstrating a reduction in mortality (adjusted odds ratio (OR) 0.61, 95% confidence interval (CI) 0.39 to 0.94, 72,073 participants) and the other demonstrating a nonsignificant change (OR 0.61, 95% CI 0.23 to 1.64, 81 participants). The quality of this evidence was rated as very low. Limited research on the topic constrains conclusive evidence on the effect of prehospital notification on patient-centered outcomes after severe trauma. Composite interventions that combine prehospital notification with effective actions on arrival to hospital such as trauma bay availability, trauma team presence, and early access to definitive management may provide more robust evidence towards benefits of early interventions during trauma reception and resuscitation.
Publisher: Wiley
Date: 04-2021
DOI: 10.1111/ANS.16337
Publisher: Informa UK Limited
Date: 28-05-2021
Publisher: Elsevier BV
Date: 05-2008
DOI: 10.1016/J.INJURY.2007.10.021
Abstract: To characterise patients who were admitted to the ward following Emergency Department (ED) management for thoracic injury yet went on to require Intensive Care Unit (ICU) admission. To identify risk factors for failed ward management. All patients admitted to the ward following chest trauma from 2002 to 2006 were identified from the Alfred Hospital trauma database. Patients who went on to require ICU admission were compared to those admitted to and discharged from the ward without requiring ICU. Possible predictors of ICU admission were analysed. There were 764 patients during the study period who were admitted to the ward following chest trauma. Of these, 70 patients went on to require Intensive Care admission. Patients requiring ICU admission spent a significantly longer time in hospital and required significantly more rehabilitation. Multivariate analysis using stepwise logistic regression confirmed intercostal catheter (ICC) insertion and higher injury severity scores as significant independent variables associated with ICU admission. Associated abdominal injury, along with multiple rib fractures and flail were also predictive of failed ward management. This study demonstrated that intercostal catheter insertion (tube thoracostomy) was an independent risk factor for deterioration following admission along with multiple rib fractures and certain associated injuries. This should be considered when admitting patients to the ward.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-10-2023
Publisher: Elsevier BV
Date: 2023
DOI: 10.1016/J.INJURY.2022.07.048
Abstract: Concussion may be sustained in the setting of injuries to multiple body regions and persistent effects of concussion may impact recovery. This project aimed to evaluate the association between concussion and 6-month and 12-month functional outcomes in survivors after major trauma. This was a registry-based cohort study that included adult patients with major trauma who presented to hospital between 01 Jan 2008 and 31 Dec 2017 and survived to hospital discharge. We excluded patients presenting with a Glasgow Coma Scale score <13 and those diagnosed with other intracranial injuries. Additionally, from the non-concussed group, patients with fractured skull and/or face were excluded, with the assumption that such patients may have had undiagnosed concussion. A good recovery was considered for Glasgow Outcome Scale-Extended (GOS-E) scores of 7 or 8. In addition, we assessed for patient reported anxiety and/or depression measured using the 3-level EuroQol 5 dimensions questionnaire. A modified mixed effects Poisson models with random intercepts for participant was used to assess the association between concussion and outcome. There were 28,161 eligible patients and 12,822 met inclusion criteria. Concussion was diagnosed in 1860 patients (14.5% 95%CI: 13.9-15.1). There was no association between concussion and good recovery at 12 months (aRR 1.05 (95%CI: 0.99-1.11). There was no association between concussion and anxiety and/or depression at 12 months (aRR 1.03 95%CI: 0.99-1.07). Concussion was sustained among 14.5% of included patients in the setting of major trauma but not associated with longer-term adverse outcomes using GOS-E. Concussed patients did not report differential rates of anxiety and/or depression.
Publisher: Springer Science and Business Media LLC
Date: 10-01-2017
Publisher: MDPI AG
Date: 02-09-2019
Abstract: Background and Objectives: The CRASH-2 trial is the largest randomised control trial examining tranexamic acid (TXA) for injured patients. Since its publication, debate has arisen around whether results could be applied to mature trauma systems in developed nations, with global opinion ided. The aim of this study was to determine if, among trauma patients in or at significant risk of major haemorrhages, there is an association of geographic region with the proportion of patients that received tranexamic acid. Materials and Methods: We conducted a systematic review of the literature. Potentially eligible papers were first screened via title and abstract screening. A full copy of the remaining papers was then obtained and screened for final inclusion. The Newcastle–Ottawa Scale for non-randomised control trials was used for quality assessment of the final studies included. A meta-analysis was conducted using a random-effects model, reporting variation in use sub-grouped by geographical location. Results: There were 727 papers identified through database searching and 23 manuscripts met the criteria for final inclusion in this review. There was a statistically significant variation in the use of TXA for included patients. Europe and Oceania had higher usage rates of TXA compared to other continents. Use of TXA in Asia and Africa was significantly less than other continents and varied use was observed in North America. Conclusions: A large geographical variance in the use of TXA for trauma patients in or at significant risk of major haemorrhage currently exists. The populations in Asia and Africa, where the results of CRASH-2 could be most readily generalised to, reported low rates of use. The reason why remains unclear and further research is required to standardise the use of TXA for trauma resuscitation.
Publisher: Wiley
Date: 19-11-2018
Publisher: Oxford University Press (OUP)
Date: 06-2018
DOI: 10.2146/AJHP170321
Abstract: Results of a systematic literature review to identify roles for emergency medicine (EM) pharmacists beyond traditionally reported activities and to quantify the benefits of these roles in terms of patient outcomes are reported. Emergency department (ED)-based clinical pharmacy is a rapidly growing practice area that has gained support in a number of countries globally, particularly over the last 5-10 years. A systematic literature search covering the period 1995-2016 was conducted to characterize emerging EM pharmacist roles and the impact on patient outcomes. Six databases were searched for research publications on pharmacist participation in patient care in a general ED or trauma center that documented interventions by ED-based pharmacists 15 results satisfied the inclusion criteria. Six reported studies evaluated EM pharmacist involvement in the care of critically ill patients, 5 studies evaluated antimicrobial stewardship (AMS) activities via pharmacist review of positive cultures, 2 studies assessed pharmacist involvement in generating orders for nurse-administered home medications and 2 reviewed publications focused on EM pharmacist involvement in management of healthcare-associated pneumonia and dosing of phenytoin. A erse range of positive patient outcomes was identified. The included studies were assessed to be of low quality. A systematic review of the literature revealed 3 key emerging areas of practice for the EM pharmacist that are associated with positive patient outcomes. These included involvement in management of critically ill patients, AMS roles, and ordering of home medications in the ED.
Publisher: Wiley
Date: 05-01-2023
Abstract: Supported by the state government, three health networks partnered to initiate a virtual ED (VED), as part of a broader roll‐out of emergency telehealth services in Victoria. The aim of the present study (Southeast Region Virtual Emergency Department‐1 [SERVED‐1]) was to report the initial 5‐month experience and included all patients assessed through the service over the first 5 months (1 February 2022 to 30 June 2022). VED consults occurred after referral from paramedics in the pre‐hospital setting. Electronic medical records were retrospectively reviewed for demographic, presenting complaint and outcome data. The primary outcome was the count of VED consultations. The secondary outcome was the proportion of patients where physical ED attendance was avoided within 72 h. The proportion of physical ED attendances avoided sub‐grouped by primary presenting complaints were reported. There were 1748 patients who had a VED consultation, of which 1261 (72.1% 95% confidence interval [CI] 70.0–74.2) patients had physical presentation to an ED avoided in the 72 h following the consult. There was a significant increase in consultations over the 5‐month period (incidence rate ratio 1.27 95% CI 1.23–1.31, P 0.001) that was consistent in the three health services. The most common presenting complaints were COVID‐19 and shortness of breath, and physical presentation was avoided most often among younger patients and those with COVID‐19. Initial experience demonstrated a significant increase in adoption of the service and an overall avoidance of physical ED attendance by a majority of patients. These results support ongoing VED consultations, complemented by follow up and health economic evaluations.
Publisher: Wiley
Date: 15-09-2021
Abstract: Moderate to severe traumatic brain injury (TBI) contributes to a significant burden across Australia. However, the data required to inform targeted equitable system‐level improvements in emergency TBI care do not exist. The incidence and determinants of outcomes following moderate to severe TBI in Australia remain unknown. The variation in the impact of moderate to severe TBI, according to patient demographics and injury mechanism, is poorly defined. The Australian Traumatic Brain Injury National Data Project will lead to a clear understanding, across Australia and pre‐specified subgroups (including Aboriginal and Torres Strait Islander peoples), of the incidence, determinants and impact of priority outcomes following moderate to severe TBI, including survival to discharge home. Furthermore, this project will establish a set of national clinical quality indicators for patients experiencing a moderate to severe TBI. The Australian Traumatic Brain Injury National Data Project will inform where to target emergency care system‐wide improvements. Without baseline data, efforts are wasted.
Publisher: CSIRO Publishing
Date: 2016
DOI: 10.1071/AH15079
Abstract: Background There are currently limited avenues for routine feedback from hospitals to pre-hospital clinicians aimed at improvements in clinical practice. Objective The aim of this study was to pilot a method for selectively identifying cases where there was a clinically significant difference between the pre-hospital and in-hospital diagnoses that could have led to a difference in pre-hospital patient care. Methods This was a single-centre retrospective study involving cases randomly selected through informatics extraction of final diagnoses at hospital discharge. Additional data on demographics, triage and diagnoses were extracted by explicit chart review. Blinded groups of pre-hospital and in-hospital clinicians assessed data to detect clinically significant differences between pre-hospital and in-hospital diagnoses. Results Most (96.9%) patients were of Australasian Triage Scale category 1–3 and in-hospital mortality rate was 32.9%. Of 353 cases, 32 (9.1% 95% CI: 6.1–12.1) were determined by both groups of clinical assessors to have a clinically significant difference between the pre-hospital and final in-hospital diagnoses, with moderate inter-rater reliability (kappa score 0.6, 95% CI: 0.5–0.7). Conclusion A modest proportion of cases demonstrated discordance between the pre-hospital and in-hospital diagnoses. Selective case identification and feedback to pre-hospital services using a combination of informatics extraction and clinician consensus approach can be used to promote ongoing improvements to pre-hospital patient care. What is known about the topic? Highly trained pre-hospital clinicians perform patient assessments and early interventions while transporting patients to healthcare facilities for ongoing management. Feedback is necessary to allow for continual improvements however, the provision of formal selective feedback regarding diagnostic accuracy from hospitals to pre-hospital clinicians is currently not routine. What does this paper add? For a significant proportion of patients, there is a clinically important difference in the diagnosis recorded by their pre-hospital clinician compared with their final in-hospital diagnosis. These clinically significant differences in diagnoses between pre-hospital and in-hospital clinicians were most notable among acute myocardial infarction and trauma subgroups of patients in this study. What are the implications for practitioners? Identification of patients who have a significant discrepancy between their pre-hospital and in-hospital diagnoses could lead to the development of feedback mechanisms to pre-hospital clinicians. Providing pre-hospital clinicians with this selective feedback would be intended to promote ongoing improvements in pre-hospital assessments and thereby to improve service delivery.
Publisher: Elsevier BV
Date: 07-2020
Publisher: Springer Science and Business Media LLC
Date: 25-11-2020
Publisher: Elsevier BV
Date: 12-2019
DOI: 10.1016/J.AUEC.2019.08.004
Abstract: Patients currently receive discharge summaries including investigation results, medical assessment and follow up requirements with health professionals on discharge from the emergency department (ED). This study aimed to evaluate if a simplified discharge information card in addition to current care improved patients' awareness of their discharge diagnosis and requirements for follow-up appointment. A prospective pre-post design interventional study was conducted. The pre-intervention phase collected data from patients who did not receive the discharge card. The post-intervention phase occurred after implementing the discharge card. Participants underwent brief interviews to assess awareness of diagnosis and follow-up appointment requirements after discharge. Responses were compared to the plan in the medical notes and concordance determined. There were 112 patients in the pre-intervention group and 117 in the post-intervention group. Awareness of discharge diagnosis improved from 73.2% (95% CI: 64.3-80.5) of pre-interventions participants to 89.7% (95% CI: 82.9-94.0) for participants receiving the discharge card (p<0.001 NNT 6.1 patients). Statistically significant improvements were observed regarding knowledge of follow-up destination and timing. A short discharge information card improved awareness of discharge diagnoses and follow-up requirements. Such interventions that empower patients with knowledge about their health, should be considered prior to discharge from EDs.
Publisher: Elsevier BV
Date: 04-2017
DOI: 10.1016/J.JOCN.2016.12.009
Abstract: Prediction of post-concussive syndrome after apparent mild traumatic brain injury (TBI) and subsequent cognitive recovery remains challenging, with substantial limitations of current methods of cognitive testing. This pilot study aimed to determine if levels of micro ribonucleic acids (RNAs) circulating in plasma are altered following TBI, and if changes to levels of such biomarkers over time could assist in determination of prognosis after TBI. Patients were enrolled after TBI on presentation to the Emergency Department and allocated to three groups: A - TBI (physical trauma to the head), witnessed loss of consciousness, amnesia, GCS=15, a normal CT Brain and a recorded first pass after post-traumatic amnesia (PTA) scale B TBI, witnessed LOC, amnesia, GCS=15, a normal CT brain and a PTA scale test fail and: C - TBI and initial GCS <13 on arrival to the ED. Venous blood was collected at three time points (arrival, day 5 and day 30). Isolation of cell-free total RNA was then assayed using a custom miRNA PCR array. Two micro-RNAs, mir142-3p and mir423-3p demonstrated potential clinical utility differentiating patients after mild head injury into those at greater risk of developing amnesia and therefore, post-concussive syndromes. In addition, these miRNA demonstrated a decrease in expression over time, possibly indicative of brain healing after the injury. Further evaluation of these identified miRNA markers with larger patient cohorts, correlation with clinical symptoms and analysis over longer time periods are essential next steps in developing objective markers of severity of TBI.
Publisher: Wiley
Date: 13-05-2019
DOI: 10.1111/ANS.15253
Abstract: In patients who are awake with normal mental and neurologic status, it has been suggested that the thoracolumbar (TL) spine may be cleared by clinical examination, irrespective of the mechanism of injury. The aim of this pilot study was to test the feasibility and accuracy of a clinical decision tool focused towards clearance of the TL spine during assessment of patients in the emergency department after trauma. A prospective interventional study was conducted at two major trauma centres. The intervention of a clinical decision tool for assessment of the TL spine was applied prospectively to all patients with subsequent imaging results acting as the comparator. The primary outcome variable was fracture of the thoracic or lumbar vertebra(e). The clinical decision tool was assessed using sensitivity and specificity for detecting a TL fracture and reported with 95% confidence intervals (CIs). There were 188 cases included for analysis that all underwent imaging of the thoracic and/or lumbar vertebrae. There were 34 (18%) patients diagnosed with fractures of the thoracic and/or lumbar vertebrae. In this pilot study, sensitivity of the clinical decision tool was 100% (95% CI 87.3-100%) and specificity was 37.0% (95% CI 29.5-45.2%) for the detection of a thoracic or lumbar vertebral fracture. Feasibility of clinical clearance of the TL spine in two major trauma centres was demonstrated in a clinical study setting. Evaluation of this clinical decision tool in patients following blunt trauma, particularly in reducing imaging rates, is indicated using a larger prospective study.
Publisher: World Journal of Emergency Medicine
Date: 2020
Publisher: Elsevier BV
Date: 2010
DOI: 10.1016/J.INJURY.2009.09.029
Abstract: Recent retrospective studies have found high fresh frozen plasma (FFP) to packed red blood cell (PRBC) ratios during trauma resuscitation to be associated with improved mortality. Whilst this association may be related to a mortality bias present in these studies, there has been an overall tendency towards a 1:1 FFP:PRBC ratio in massive transfusion guidelines worldwide. The aim of this study was to retrospectively review the administration of FFP in patients undergoing massive transfusion during trauma resuscitation, to add to the evidence base for massive transfusion guidelines. Multi-trauma patients who were administered blood transfusions of 5units or more of packed red blood cells (PRBCs) in the first 4h were included in this study. Mortality was the primary endpoint with length of hospital stay, ICU hours and mechanically ventilated hours secondary endpoints. There were 331 patients included in this study with a median Injury Severity Score (ISS) of 36 (25-50) and a mortality of 29.9%. There was little change in the ratio of FFP:PRBC transfused per patient from 2005 to 2008. A low FFP:PRBC ratio in the first 4h of resuscitation, older age, low initial GCS and coagulopathy on presentation were significant independent factors associated with mortality. When deaths in the first 24h were excluded, the FFP:PRBC ratio had no association with mortality. This study has shown increased initial survival in association with higher FFP:PRBC ratios during massive transfusion in a population with a high proportion of blunt injuries. The association is difficult to interpret because of an inherent survival bias. The optimal ratio of FFP:PRBC during massive transfusion may be different to 1:1 and further prospective research is required. There is now an increasing need for well designed randomised controlled trials to determine the best FFP:PRBC ratio for the resuscitation of blunt multi-trauma patients.
Publisher: Elsevier BV
Date: 07-2012
Publisher: Wiley
Date: 21-04-2020
Publisher: Elsevier BV
Date: 05-2019
DOI: 10.1016/J.INJURY.2019.03.003
Abstract: Reviewing prehospital trauma deaths provides an opportunity to identify system improvements that may reduce trauma mortality. The objective of this study was to identify the number and rate of potentially preventable trauma deaths through expert panel reviews of prehospital and early in-hospital trauma deaths. We conducted a retrospective review of prehospital and early in-hospital (<24 h) trauma deaths following a traumatic out-of-hospital cardiac arrest that were attended by Ambulance Victoria (AV) in the state of Victoria, Australia, between 2008 and 2014. Expert panels were used to review cases that had resuscitation attempted by paramedics and underwent a full autopsy. Patients with a mechanism of hanging, drowning or those with anatomical injuries deemed to be unsurvivable were excluded. Of the 1183 cases that underwent full autopsies, resuscitation was attempted by paramedics in 336 (28%) cases. Of these, 113 cases (34%) were deemed to have potentially survivable injuries and underwent expert panel review. There were 90 (80%) deaths that were not preventable, 19 (17%) potentially preventable deaths and 4 (3%) preventable deaths. Potentially preventable or preventable deaths represented 20% of those cases that underwent review and 7% of cases that had attempted resuscitation. The number of potentially preventable or preventable trauma deaths in the pre-hospital and early in-hospital resuscitation phase was low. Specific circumstances were identified in which the trauma system could be further improved.
Publisher: MDPI AG
Date: 30-08-2019
Abstract: Background and Objectives: Major trauma centres manage severely injured patients using multi-disciplinary teams but the evidence-base that targeted Trauma Team Training (TTT) improves patients’ outcomes is unclear. This systematic review aimed to identify the association between the implementation of TTT programs and patient outcomes. Materials and Methods: We searched OVID Medline, PubMed and The Cochrane Library (CENTRAL) from the date of the database commencement until 10 of April 2019 for a combination of Medical Subject Headings (MeSH) terms and keywords relating to TTT and clinical outcomes. Reference lists of appraised studies were also screened for relevant articles. We extracted data on the study setting, type and details about the learners, as well as clinical outcomes of mortality and/or time to critical interventions. A meta-analysis of the association between TTT and mortality was conducted using a random effects model. Results: The search yielded 1136 unique records and abstracts, of which 18 full texts were reviewed. Nine studies met final inclusion, of which seven were included in a meta-analysis of the primary outcome. There were no randomised controlled trials. TTT was not associated with mortality (Pooled overall odds ratio (OR) 0.83 95% Confidence Interval 0.64–1.09). TTT was associated with improvements in time to operating theatre and time to first computerized tomography (CT) scanning. Conclusions: Despite few publications related to TTT, its introduction was associated with improvements in time to critical interventions. Whether such improvements can translate to improvements in patient outcomes remains unknown. Further research focusing on the translation of standardised trauma team reception “actions” into TTT is required to assess the association between TTT and patient outcome.
Publisher: Elsevier BV
Date: 05-2018
DOI: 10.1016/J.JSAMS.2017.09.591
Abstract: To investigate changes from baseline on SCAT3 as a result of football game exposure, and association with X2 Patch measured head acceleration events in amateur Australian footballers. Prospective cohort. Peak linear acceleration (PLA) of the head (>10 g) was measured by wearable head acceleration sensor X2 Biosystems X-Patch in male (n=34) and female (n=19) Australian footballers. SCAT3 was administered at baseline (B) and post-game (PG). 1394 head acceleration events (HEA) >10 g were measured. Mean and median HEA PLA were recorded as 15.2 g (SD=9.2, range=10.0-115.8) and 12.4 g (IQR=11.0-15.6) respectively. No significant difference in median HEA PLA (g) was detected across gender (p=0.55), however, more HEAs were recorded in males (p=0.03). A greater number (p=0.004) and severity (p 0.05 for all), was identified for either gender. Increase in symptom severity post game was not associated with X2 measured HEA. Males sustained more HEA, however HEA PLA magnitude did not differ across gender. Further work on the validation of head acceleration sensors is required and their role in sports concussion research and medical management.
Publisher: Elsevier BV
Date: 06-2019
DOI: 10.1016/J.RESUSCITATION.2019.04.028
Abstract: To determine the initial defibrillation energy dose that is associated with sustained return of spontaneous circulation (ROSC) during paediatric cardiac arrest with ventricular fibrillation or pulseless ventricular tachycardia. A systematic review was performed using four databases (PROSPERO: CRD42016036734). Human studies and animal model studies of pediatric cardiac arrest involving assessment of external defibrillation energy dosing were considered. The primary outcome was sustained ROSC. Survival and defibrillation-induced complications were also evaluated. The search strategy identified 14,471 citations of which 232 manuscripts were reviewed. Ten human and 10 animal model studies met the inclusion criteria. Human studies were prospective (n = 6) or retrospective (n = 4) cohort studies and included between 11 and 266 patients (median = 46 patients). Sustained ROSC rates ranged from 0 to 61% (n = 7). No studies reported a statistically significant association between the initial defibrillation energy dose and the rate of sustained ROSC (n = 7) or survival (n = 6). Meta-analysis was not considered appropriate due to clinical heterogeneity. Risk of bias was moderate. All animal studies were randomized controlled trials with 8 and 52 (median = 27) piglets. ROSC was frequently achieved (≥85%) with energy dose ranging from 2 to 7 J/kg (n = 7). The defibrillation threshold varied according to the body weight and appears to be higher in infant. Defibrillation energy doses and thresholds varied according to the body weight and trended higher for infants. No definitive association between initial defibrillation doses and the sustained ROSC or survival could be demonstrated. Clinicians should follow local consensus-based guidelines.
Publisher: Wiley
Date: 13-09-2021
Abstract: Australia is rapidly moving towards ‘living with COVID‐19’, with relaxation of some public health measures. The number of severe cases of COVID‐19 may be mitigated by vaccination, but ‘living with COVID‐19’ will be associated with higher number of patients seeking emergency care. This impending impact on the emergency care system requires recognition, monitoring and co‐ordinated management. Current challenges include a lack of emergency care monitoring systems, staff shortages and patient flow processes that are quickly overwhelmed by large numbers, particularly in a system already operating at capacity. Effective monitoring systems are required for health systems to proactively detect and respond to stresses. Additional solutions include public health messaging and clinical innovation to facilitate care of the right patient in the right place at the right time. Optimising staff numbers and morale, and efficient patient flow, are integral steps to increasing capacity within the emergency care system.
Publisher: SAGE Publications
Date: 08-04-2020
Abstract: Early identification of trauma patients at risk of developing acute traumatic coagulopathy is important in initiating appropriate, coagulopathy-focused treatment. A clinical acute traumatic coagulopathy prediction tool is a quick, simple method to evaluate risk. The COAST score was developed in Australia and we hypothesised that it could predict coagulopathy and bleeding-related adverse outcomes in other advanced trauma systems. We validated COAST on a single-centre cohort of trauma patients from a trauma centre in Belgium. The COAST score was modified to suit available data we used entrapment, blood pressure, temperature, major chest injury and abdominal injury to calculate the score. Acute traumatic coagulopathy was defined as international normalised ratio .5 or activated partial thromboplastin time s upon arrival of the patient to the hospital. Data were extracted from the local trauma registry on patients that presented between 1 January and 31 December 2015. In all, 133 patients met the inclusion criteria ( years old, available COAST and outcome data) for analysis. The COAST score had an area under the receiver operating characteristics curve of 0.941 (95% CI: 0.884–0.999) and at COAST ≥3, it had 80% sensitivity and 96% specificity. The score also identified patients with higher rates of mortality, blood transfusion and emergent surgery. This retrospective cohort study demonstrated the utility of the COAST score in identifying trauma patients who are likely to have bleeding-related poor outcomes. The early identification of these patients will facilitate timely, appropriate treatment for acute traumatic coagulopathy and minimise the risk of over-treatment. It can also be used to select patients with acute traumatic coagulopathy for trials involving therapeutic agents targeted at acute traumatic coagulopathy.
Publisher: Wiley
Date: 12-01-2023
Abstract: To determine effects of implementing a sepsis alert response system in the ED that included early intervention by emergency medicine (EM) pharmacists. A prospective cohort (8 February 2016 to 28 February 2018) of patients after implementation of a sepsis alert response system in an Australian ED was compared to a retrospective cohort (3 January 2015 to 7 February 2016) of patients with sepsis who presented during EM pharmacist working hours and were admitted to the ICU. There were 184 patients, including 80 patients pre‐ and 104 patients post‐implementation. The post‐intervention cohort was triaged at a higher acuity, had higher quick Sepsis‐related Organ Failure Assessment (qSOFA) scores and higher initial lactate measurements. After the intervention, antimicrobial agents were administered to patients within 60 min of presentation more often (21 [26.3%] to 85 [81.7%], P 0.001). After adjusting for presenting triage category, admission lactate and presenting qSOFA scores, this association remained significant (adjusted odds ratio 9.99 95% confidence interval 4.7–21.3). Significant improvements were observed for proportion of patients who had intravenous fluids initiated within 60 min (47.5% vs 72.1%) proportion of patients who had serum lactate measured within 60 min (50.0% vs 77.9%) and proportion of patients who had blood cultures performed within 60 min (52.5% vs 85.6%). Implementation of a sepsis alert response that included early involvement of the EM pharmacist was associated with improvement in time to antimicrobials and other components of the sepsis bundle. An upfront, multidisciplinary approach to patients presenting to the ED with suspected sepsis should be considered more broadly.
Publisher: Informa UK Limited
Date: 31-01-2021
Publisher: Elsevier BV
Date: 2013
DOI: 10.1016/J.INJURY.2012.05.010
Abstract: The pathophysiology and time-course of coagulopathy post major burns are inadequately understood. The aims of this study were to review the incidence of acute coagulopathy post major burns, potential contributing factors associated with this coagulopathy and outcome of patients who developed early coagulopathy. A retrospective review of all patients with major burns (≥20% total body surface area (TBSA)) presenting to a tertiary burns referral centre was conducted. Data on demographic, injury characteristics and fluid resuscitation practices were recorded and tested for association with coagulopathy (INR>1.5 or aPTT>60 s) at hospital presentation and within 24 h of burns injury. Mortality, intensive care unit (ICU) admission, mechanical ventilation and blood and blood product usage were primary endpoints. There were 99 patients who met the inclusion criteria with 36 (16) %TBSA burns. Coagulopathy was present in only three patients on presentation, but 37 (37%) patients developed early onset (within 24 h of injury) coagulopathy. Early onset coagulopathy was independently associated with %TBSA burnt (p<0.001) and volume of fluid administered (p=0.005). Early onset coagulopathy was associated with higher volumes of blood and blood product administration, ICU admission and prolonged mechanical ventilation. Post major burns, a very low proportion of patients presented with coagulopathy, but a substantial proportion of patients developed coagulopathy within 24 h. This and the association of coagulopathy with the volume of fluid resuscitation suggest dilution as a major cause of the early coagulopathy of major burns.
Publisher: Wiley
Date: 17-10-2020
Publisher: Elsevier BV
Date: 08-2014
DOI: 10.1093/BJA/AEU231
Abstract: Trauma systems have been successful in saving lives and preventing disability. Making sure that the right patient gets the right treatment in the shortest possible time is integral to this success. Most trauma systems have not fully developed trauma triage to optimize outcomes. For trauma triage to be effective, there must be a well-developed pre-hospital system with an efficient dispatch system and adequately resourced ambulance system. Hospitals must have clear designations of the level of service provided and agreed protocols for reception of patients. The response within the hospital must be targeted to ensure the sickest patients get an immediate response. To enable the most appropriate response to trauma patients across the system, a well-developed monitoring programme must be in place to ensure constant refinement of the clinical response. This article gives a brief overview of the current approach to triaging trauma from time of dispatch to definitive treatment.
Publisher: BMJ
Date: 07-2017
Publisher: BMJ
Date: 09-02-2018
DOI: 10.1136/EMERMED-2017-206688
Abstract: Blunt thoracic aortic injury (BTAI) is an uncommon diagnosis, usually developing as a consequence of high-impact acceleration–deceleration mechanisms. Timely diagnosis may enable early resuscitation and reduction of shear forces, essential to prevent worsening of the injury prior to definitive management. Death is commonly due to haemorrhagic shock, but clinical features may be absent until sudden and massive haemorrhage. The aim of this systematic review was to determine the proportion of patients with BTAI who present with unstable vital signs. Manuscripts were identified through a search of MEDLINE, EMBASE and the Cochrane Library databases, focusing on subject headings and keywords related to the aorta and trauma. Mechanisms of injury, haemodynamic status and mortality from the included manuscripts were reviewed. Meta-analysis of presenting haemodynamic status among a select group of similar papers was conducted. Nineteen studies were included, with five selected for meta-analysis. Most reported cases of BTAI (80.0%–100%) were caused by road traffic incidents, with mortality consistently higher among initially unstable patients. There was statistically significant heterogeneity among the included studies (P .01). The pooled proportion of patients with haemodynamic instability in the setting of BTAI was 48.8% (95% CI 8.3 to 89.4). Normal vital signs do not rule out aortic injury. A high degree of clinical suspicion and liberal use of imaging is necessary to prevent missed or delayed diagnoses.
Publisher: Hamad bin Khalifa University Press (HBKU Press)
Date: 11-02-2015
Abstract: Background: Indications for blood transfusion during trauma resuscitation remain poorly understood. This study aimed to objectively determine the range of factors that lead to initiation of blood transfusion during trauma resuscitation. Design and method: This was a prospective, observational pilot study. A questionnaire was distributed to all clinicians following any transfusion of packed red blood cells during trauma resuscitation. The questionnaire focused on the clinicians’ opinion regarding the indication for red cell transfusion. Results: Complete data on 37 in idual episodes of transfusion initiation in the Emergency Department were collected. The most commonly used pre-hospital factors that influenced initiation of transfusion was a pre-hospital systolic blood pressure (SBP) of 100 mm Hg (65%), pre-hospital tachycardia (38%) or estimated blood loss of L (30%) by paramedics. On arrival to hospital, the activation of a massive transfusion protocol was the commonest indication for transfusion, followed by a positive FAST examination (43%), low systolic blood pressure (35%), tachycardia (32%) or pallor (35%). Blood tests to guide initiation of transfusion were less commonly used with 9 (24%) patients transfused for a low haemoglobin level and 6 (16%) patients transfused for coagulopathy. Conclusions: A combination of objective pre- and in-hospital vital signs, together with subjective indicators such as pallor and estimation of blood loss guided initiation of transfusion following injury.
Publisher: Elsevier BV
Date: 2017
DOI: 10.1016/J.IENJ.2016.06.005
Abstract: To evaluate the health service requirements of obese patients admitted to an Emergency Short Stay Unit (ESSU) and specifically compare length of stay (LOS), failure of ESSU management, and rates of investigations and allied health interventions among obese and non-obese patients. A prospective cohort study, using convenience s ling was conducted. The body mass index (BMI) of participants was calculated and those with a BMI of ⩾30 were allocated to the obese group, and those that had a BMI of <30 to the non-obese group. Data collected included demographics, admission diagnosis, time and date of ESSU admission and discharge, discharge disposition, radiological investigations, and referrals made to allied health personnel during ESSU admission. There were 262 patients that were recruited sub-grouped into 127 (48.5%) obese participants and 135 (51.5%) non-obese participants with similar sex and diagnostic category distributions. The mean LOS in ESSU was similar - 11.5h (95% CI: 9.9-13.1) for obese patients and, 10.2h (95% CI: 8.8-11.6) for non-obese patients (p=0.21). Failure rates of ESSU management, defined as inpatient admission to hospital, were also similar with 29 (22.8%) obese patients admitted to hospital compared to 25 (18.5%) non-obese patients (p=0.39). Plain X-ray requests were significantly higher among obese patients (71.6 vs 53.3% p=0.002), as was the rate of allied health interventions (p=0.001). There was no significant difference in inpatient admission rates or LOS between obese and non-obese patients managed in the ESSU. Provisions for increased rate of investigations and allied health interventions for obese patients may facilitate timely assessment and disposition from ESSU.
Publisher: Wiley
Date: 09-09-2020
Publisher: BMJ
Date: 10-08-2023
DOI: 10.1136/EMERMED-2023-213186
Abstract: In-hospital alcohol testing provides an opportunity to implement prevention strategies for patients with high risk of experiencing repeated alcohol-related injuries. However, barriers to alcohol testing in emergency settings can prevent patients from being tested. In this study, we aimed to understand potential biases in current data on the completion of blood alcohol tests for major trauma patients at hospitals in Victoria, Australia. Victorian State Trauma Registry data on all adult major trauma patients from 1 January 2018 to 31 December 2021 were used. Characteristics associated with having a blood alcohol test recorded in the registry were assessed using logistic regression models. This study included 14 221 major trauma patients, of which 4563 (32.1%) had a blood alcohol test recorded. Having a blood alcohol test completed was significantly associated with age, socioeconomic disadvantage level, preferred language, having pre-existing mental health or substance use conditions, smoking status, presenting during times associated with heavy community alcohol consumption, injury cause and intent, and Glasgow Coma Scale scores (p .05). Restricting analyses to patients from a trauma centre where blood alcohol testing was part of routine clinical care mitigated most biases. However, relative to patients injured while driving a motor vehicle/motorcycle, lower odds of testing were still observed for patients with injuries from flames/scalds/contact burns (adjusted OR (aOR)=0.33, 95% CI 0.18 to 0.61) and low falls (aOR=0.17, 95% CI 0.12 to 0.25). Higher odds of testing were associated with pre-existing mental health (aOR=1.39, 95% CI 1.02 to 1.89) or substance use conditions (aOR=2.33, 95% CI to 1.47–3.70), and living in a more disadvantaged area (most disadvantaged quintile relative to least disadvantaged quintile: aOR=2.30, 95% CI 1.52 to 3.48). Biases in the collection of blood alcohol data likely impact the surveillance of alcohol-related injuries. Routine alcohol testing after major trauma is needed to accurately inform epidemiology and the subsequent implementation of strategies for reducing alcohol-related injuries.
Publisher: Wiley
Date: 17-12-2016
Abstract: ED overcrowding has been associated with increased mortality, morbidity and delays to essential treatment. It was hypothesised that hospital-wide reforms designed to improve patient access and flow, in addition to improving ED overcrowding, would impact on clinically important processes within the ED, such as timely delivery of antibiotics. A single pre-implementation and post-implementation prospective cohort study was conducted prior to and after a hospital-wide reform (Timely Quality Care (TQC)). Among patients who had intravenous antibiotics prescribed in the ED, data were prospectively collected on times of presentation, prescription and administration of antibiotics. Demographics and discharge diagnoses were retrospectively extracted. There were 380 cases included with 179 cases prior to introduction of the TQC model and 201 cases after its introduction. Time from presentation to administration of antibiotics improved significantly from 192 (99-320) min to 142 (81-209) min (P < 0.01). The time from presentation to prescription pre-TQC and post-TQC was 120 (51-230) min and 92 (49-153) min, respectively (P < 0.01). The times from prescription to administration pre-TQC and post-TQC were 43 (20-83) min and 34 (15-66) min, respectively (P = 0.03). Following implementation of hospital-wide reform directed at mitigating ED overcrowding through improved access and flow, times to administration of antibiotics were significantly reduced. These findings suggest that improved quality of care in this area may be achieved with processes aimed at improved hospital access and flow. Ongoing evaluation and vigilance is necessary to ensure sustainability and drive further improvements.
Publisher: Wiley
Date: 21-01-2018
Abstract: The Prevent Alcohol and Risk-Related Trauma in Youth (P.A.R.T.Y.) Program at The Alfred uses vivid clinical reality to build resilience and prevent injury by following a trauma patient's journey through hospital. The present study aims to analyse the effect of P.A.R.T.Y. on safety perceptions of driving after alcohol, seat belt use and risk-taking activities. Pre-programme, immediately post-programme and 3-5 months post-programme surveys with questions focused on the programme aims were distributed to all consented participants. There were 2502 participants during the study period and 1315 (53%) responses were received. The mean age was 16.2 (SD 0.8) years, 724 (56%) were women and 892 (68%) possessed a learner's permit for driving. Pre-programme, 1130 (86%) participants reported 'definitely not' likely to drive after drinking alcohol, that improved to 1231 (94%) immediately post-programme and 1215 (93%) at 3-5 months post-programme (P < 0.01). Designating a safe driver after drinking was reported by 1275 (97%) pre-programme, 1295 (98%) immediately post-programme and 1286 (98.2%) 3-5 months post-programme (P = 0.02). The perception of sustaining 'definite' injury after a motor vehicle crash without a seat belt increased from 780 (60%) pre-programme to 1051 (80%) immediately post-programme and 886 (69%) 3-5 months post-programme (P < 0.01). The possibility of sustaining 'definite' injury after risk-taking activities was reported by 158 (12%) pre-programme, 467 (36%) post-programme and 306 (23%) 3-5 months post-programme (P < 0.01). The P.A.R.T.Y. Program at The Alfred engaged substantial numbers of youths and achieved significant improvements among key outcome measures. Objectives were sustained at 3-5 months post-programme, but demonstrated decay, highlighting the importance of continual reinforcement.
Publisher: Wiley
Date: 25-02-2017
Abstract: Multiply injured patients represent a particularly demanding subgroup of trauma patients as they require urgent simultaneous clinical assessments using physical examination, ultrasound and invasive monitoring together with critical management, including tracheal intubation, thoracostomies and central venous access. Concurrent access to multiple body regions is essential to facilitate the concept of 'horizontal' resuscitation. The current positioning of trauma patient, with arms adducted, restricts this approach. Instead, the therapeutic cruciform positioning, with arms abducted at 90°, allows planning and performing of multiple life-saving interventions simultaneously. This positioning also provides a practical surgical field with improved sterility and procedural access.
Publisher: Wiley
Date: 26-05-2022
Abstract: The present study aimed to determine the difference in force required to puncture simulated pleura comparing Kelly cl s to fine artery forceps. The treatment of symptomatic traumatic pneumothorax and haemothorax involves puncture of the parietal pleura to allow decompression. This is usually performed using Kelly cl s or fine artery forceps. Over‐puncture pulmonary injury risk increases with the force used. An experienced single operator performed puncturing of simulated parietal pleura on a thoracic mannequin while wearing a force sensor under gloves. The force imparted at the device tip onto the parietal pleura was estimated by subtracting the force required to hold the device from the total force. Outcome variables were the total maximum force and force imparted by the device. There were 11 simulated procedures completed, seven using Kelly cl s and four using fine artery forceps. After subtracting the force required to hold the chosen forceps, the median value of pleural puncture force using Kelly cl s was 52.91 N (IQR 36.68–63.56) and 10.70 N (IQR 7.64–26.56) using fine artery forceps ( P = 0.006). A significantly increased force was required to puncture simulated parietal pleura using Kelly cl s compared to fine artery forceps. This higher puncture force will be associated with increased instrument acceleration at the time of pleural puncture, which may result in an increased risk of injury to the underlying lung. Based on these data, clinicians may reduce the risk of pulmonary injury by using fine artery forceps rather than Kelly cl s when performing pleural decompression.
Publisher: Wiley
Date: 27-08-2020
Abstract: Occupational violence and aggression (OVA) in the ED is an issue of global concern and increasing incidence. The empirical evidence for the relationship between the lunar cycle and ‘lunatics’ remains equivocal. The present study aims to examine the association between OVA in ED and the full moon (FM). Data on all presentations were extracted from The Alfred Hospital ED records for consecutive patients over a 3‐year period (January 2013–December 2015). The primary outcome of the present study is OVA among patients in the ED. Univariable and multivariable logistic regression were used to determine the association between aspects of the lunar cycle and OVA. There were 184 059 ED presentations during the 3 years, 6234 (3.4%) of which occurred on a FM. There were 1853 episodes of OVA, 57 (3.1%) of which occurred on a FM. OVA among patients presenting to ED was not associated with the FM (adjusted odds ratio [OR] 0.92 [95% confidence interval 0.70–1.20] P = 0.53). However, the first quarter (FQ) (adjusted OR 1.38 [1.11–1.72] P 0.01) and third quarter (TQ) (adjusted OR 1.29 [95% confidence interval 1.03–1.62] P = 0.03) moons of the lunar cycle were independently associated with OVA. Contrary to traditional beliefs, the FQ and TQ of the lunar cycle but not the FM were associated with OVA. This highlights a relatively unexplored relationship that has previously been overshadowed by the FM in the literature. Prediction models of violence in the ED could consider incorporating the FQ and TQ of the lunar cycle in their models.
Publisher: Wiley
Date: 29-01-2021
Abstract: Rib fractures are not only painful but are associated with morbidity and mortality, especially in older patients. The serratus anterior plane block (SAPB) is a plane block distant from major neurovascular bundles and may provide anaesthesia to a substantial area of the hemithorax. This pilot study was designed to assess if the SAPB can be safely and efficiently incorporated to the trauma reception workflow of an adult, level 1 trauma centre. A convenience s le of 20 adult patients with at least two or more unilateral rib fractures received a SAPB performed by an emergency physician in addition to their standard analgesic regime. Time to perform the procedure, the number of attempts and complications were recorded as feasibility measures. Secondary outcome was the safety of the block. Numerical pain scores at pre‐determined time points over 4 h, the diagnosis of hospital‐acquired pneumonia, hospital length of stay and mortality at hospital discharge were collected to provide pilot data on effectiveness. The median time to perform the procedure was 5.5 (interquartile range 4.6–10) mins with a range of 2–10.5 min. Most (16 80%) SAPBs were completed in a single attempt. There were no documented complications. Median pain scores reduced from 6.5 (6–8) and were maintained at 3 (2–5) at 4 h after the SAPB. The present study demonstrated the feasibility of ultrasound‐guided SAPB among patients with multiple rib fractures in the ED. No complications were observed. Further prospective evaluation of analgesic effects in a larger cohort is indicated.
Publisher: Elsevier BV
Date: 08-2016
DOI: 10.1016/J.AENJ.2015.12.003
Abstract: Growing research suggests that a large number of peripheral intravenous catheters (PIVCs) inserted in the Emergency Department (ED) are unused. The aim of this study was to assess the proportion of unused ED inserted PIVCs in a before-and-after interventional study. Additional aims were to ascertain indications for PIVC insertion in the ED and to increase the appropriateness of PIVC insertion. A prospective interventional study was conducted. Data were collected on 150 cases in the pre- and a further 150 cases in the post-intervention phase. During the intervention phase strategies were implemented to increase appropriate PIVC insertion in the ED. Interventions included introduction of insertion and removal stickers, new venepuncture devices, changing the intravenous (IV) trolley layout, and an educational c aign. Results from this study demonstrate that the number of PIVCs used (50 vs. 28) remained unchanged, however the number of PIVC insertions initiated by nursing staff reduced significantly (p=0.049). With regard to the indication for PIVC insertion, the implementation of the interventions was associated with significantly fewer PIVCs being inserted for routine blood collection (p=0.006) and for PIVCs inserted for a potential need of medication and intravenous fluid administration (p=0.03). There was a significant reduction in the number of PIVCs inserted following the intervention (74 vs. 50: p=0.005). This study demonstrated a high proportion of unused PIVCs in the ED. A composite intervention strategy was developed and significantly reduced the "just-in-case" PIVCs inserted.
Publisher: Elsevier BV
Date: 09-2023
Publisher: Wiley
Date: 29-08-2020
Publisher: Wiley
Date: 10-11-2022
Abstract: Inter‐hospital transfers are increasingly common due to the regionalisation of healthcare, but are associated with patient discomfort, high costs and adverse events. The aim of the present study was to evaluate the effectiveness of a trauma outreach service for preventing inter‐hospital transfers to a major trauma centre. This was an observational pre‐ and post‐intervention study over a 12‐month period from 1 October 2020 to 30 September 2021. Eligible patients sustained a fall at Caulfield Hospital, a subacute care hospital specialising in community services, rehabilitation, geriatric medicine and aged mental health. The intervention was delivery of site‐specific education at Caulfield Hospital and a trauma outreach service by specialist trauma clinicians at The Alfred Hospital who provided remote assessment, assisted with clinical management decisions and advised on appropriateness of transfer. The present study included 160 patients in the pre‐intervention phase and 203 after the intervention. The primary outcome of transfer occurred in 19 (11.9%) patients in the pre‐intervention phase and 4 (2.0%) in the post‐intervention phase ( P 0.001). In the subgroup of patients without pelvis or long bone fractures, pre‐intervention transfer occurred for 17 (10.9%) patients and post‐intervention transfer occurred for 4 (2.0%) patients ( P 0.001). CT imaging was performed for 54 (33.8%) patients in the pre‐intervention and 45 (22.2%) patients in the post‐intervention group ( P = 0.014). Telehealth consultation with a trauma specialist was associated with significant reduction of inter‐hospital transfers, and significant reduction of CT imaging. This supports continuation of the service with scope for expansion and evaluation of patient‐centred outcomes.
Publisher: Wiley
Date: 06-2023
Abstract: Excessive pathology testing is associated with ED congestion, increased healthcare costs and adverse patient health outcomes. This study aimed to determine the frequency, yield and influence of pathology tests among patients presenting to the ED with atraumatic recurrent seizures. This was a retrospective cohort study conducted at a level 4 adult ED in Australia and included atraumatic patients presenting to ED with recurrent seizures over a 4‐year period (2017–2020). The primary outcome was the frequency of pathology tests. Additionally, the proportion of abnormal pathology test results and the association between pathology tests and change in management were assessed. Of the 398 eligible presentations, 346 (86.9%, 95% confidence interval [CI] 83.3–89.9%) underwent at least one pathology test. In total 18.3% ( n = 517) of pathology tests had an abnormal result which led to 15 changes in ED management among 12 presentations. Patients who had an abnormal pathology test result were more likely to undergo a change in antiepileptic drug management (odds ratio 2.08, 95% CI 1.23–3.65 P = 0.008). Most patients presenting to the ED with atraumatic recurrent seizures underwent pathology tests. Abnormalities were frequently detected but were uncommonly associated with change in management. Abnormal pathology test results were associated with changes in antiepileptic drug management although rarely led to acute changes in patient management. This study suggests that pathology tests may be excessively requested in this population.
Publisher: Wiley
Date: 24-06-2022
Abstract: The aim of the present study was to describe the burden of patients presenting to the ED with symptoms occurring after receiving a COVID‐19 vaccination. This was a retrospective cohort study performed over a 4‐month period across two EDs. Participants were eligible for inclusion if it was documented in the ED triage record that their ED attendance was associated with the receipt of a COVID‐19 vaccination. Data regarding the type of vaccine (Comirnaty or ChAdOx1) were subsequently extracted from their electronic medical record. Primary outcome was ED length of stay (LOS) and secondary outcomes included requests for imaging and ED disposition destination. During the study period of 22 February 2021 to 21 June 2021, 632 patients were identified for inclusion in the present study, of which 543 (85.9%) had received the ChAdOx1 vaccination. The highest proportion of COVID‐19 vaccine‐related attendances occurred in June 2021 and accounted for 21 (8%) of 262 total daily ED attendances. Patients who had an ED presentation related to ChAdOx1 had a longer median ED LOS (253 vs 180 min, P 0.001) compared to Comirnaty and a higher proportion had haematology tests and imaging requested in the ED. Most patients ( n = 588, 88.8%) were discharged home from the ED. There was a notable proportion of ED attendances related to recent COVID‐19 vaccination administration, many of which were associated with lengthy ED stays and had multiple investigations. In the majority of cases, the patients were able to be discharged home from the ED.
Publisher: Springer Science and Business Media LLC
Date: 20-06-2019
DOI: 10.1007/S00268-019-05039-2
Abstract: The completeness of a trauma registry's data is essential for its valid use. This study aimed to evaluate the extent of missing data in a new multicentre trauma registry in India and to assess the association between data completeness and potential predictors of missing data, particularly mortality. The proportion of missing data for variables among all adults was determined from data collected from 19 April 2016 to 30 April 2017. In-hospital physiological data were defined as missing if any of initial systolic blood pressure, heart rate, respiratory rate, or Glasgow Coma Scale were missing. Univariable logistic regression and multivariable logistic regression, using manual stepwise selection, were used to investigate the association between mortality (and other potential predictors) and missing physiological data. Data on the 4466 trauma patients in the registry were analysed. Out of 59 variables, most (n = 51 86.4%) were missing less than 20% of observations. There were 808 (18.1%) patients missing at least one of the first in-hospital physiological observations. Hospital death was associated with missing in-hospital physiological data (adjusted OR 1.4 95% CI 1.02-2.01 p = 0.04). Other significant associations with missing data were: patient arrival time out of hours, hospital of care, 'other' place of injury, and specific injury mechanisms. Assault/homicide injury intent and occurrence of chest X-ray were associated with not missing any of first in-hospital physiological variables. Most variables were well collected. Hospital death, a proxy for more severe injury, was associated with missing first in-hospital physiological observations. This remains an important limitation for trauma registries.
Publisher: Wiley
Date: 16-06-2023
Abstract: The Victorian State Trauma System recommends that all major trauma patients receive definitive care at a major trauma service (MTS). The aim of the present study was to assess the outcomes of patients with major trauma after near‐hangings who received definitive management at an MTS compared to a non‐MTS. This was a registry‐based cohort study of all adult (age ≥16 years) patients with near‐hanging included in the Victorian State Trauma Registry from 1 July 2010 to 30 June 2019. Outcomes of interest were death at hospital discharge, time to death and extended Glasgow Outcome Scale (GOSE) score of 5–8 (favourable) at 6 months. There were 243 patients included and 134 (55.1%) in‐hospital deaths. Among patients presenting to a non‐MTS, 24 (16.8%) were transferred to an MTS. There were 59 (47.6%) deaths at an MTS and 75 (63.0%) at a non‐MTS (odds ratio [OR] 0.53 95% confidence interval [CI] 0.32–0.89). However, more patients were managed at a non‐MTS after out‐of‐hospital cardiac arrest (58.8% vs 50.8%) and less patients had serious neck injury (0.8% vs 11.3%). After adjustment for out‐of‐hospital cardiac arrests and serious neck injury, management at an MTS was not associated with mortality (adjusted OR [aOR] 0.61 95% CI 0.23–1.65) or favourable GOSE at 6 months (aOR 1.09 95% CI 0.40–3.03). After major trauma sustained from near‐hanging, definitive management at an MTS did not offer a mortality benefit or better functional outcomes. Consistent with current practice, these findings suggest that most near‐hanging related major trauma patients could be managed safely at a non‐MTS.
Publisher: Wiley
Date: 08-11-2017
Abstract: Workplace violence (WPV) is an increasingly concerning occupational hazard within the ED. The aim of the present study was to evaluate the incidence and characteristics of WPV in an adult ED. A retrospective cohort study was conducted to identify the incidence of ED WPV in an adult metropolitan ED. Data were obtained from the activity records of security staff from 1 January 2013 to 31 December 2015 for all incidents of patient-perpetrated violence. Data on patients identified from these records as requiring security staff intervention for violence in the ED were collected through an explicit chart review. Data on patient illicit drug or alcohol exposure and acute psychiatric diagnoses were also collected. There were 1853 episodes of patient-perpetrated WPV identified over the study period. The incidence of WPV over the 3 years was 103 (95% CI: 98-108) per 10 000 of the presenting population, with a significant increase from 2013 to 2015 (IRR 1.07 95% CI: 1.04-1.10 P < 0.01). Drug and/or alcohol exposure was observed in 1145 (61.8%) patients. Among the drug- and/or alcohol-affected violent population, three quarters (840/1145 = 73.4%) did not have a concurrent psychiatric diagnosis that required assessment during the violent presentation. The rate of WPV was increasing within this Australian ED during the study period. The majority of violent patients were affected by drugs and/or alcohol in the absence of a psychiatric diagnosis. Interventions to reduce access to and misuse of alcohol and illicit drugs could have a substantial impact on the concerning increase of violence in the ED.
Publisher: Elsevier BV
Date: 2019
DOI: 10.1016/J.INJURY.2018.08.007
Abstract: Complications related to incorrect positioning of tube thoracostomy (TT) have been reported to be as high as 30%. The aim of this study was to assess the feasibility of flexible videoscope guided placement of a pre-loaded chest tube, permitting direct intrapleural visualization and placement (Video-Tube Thoracostomy [V-TT]). A prospective, single centre, phase 1 pilot study with a parallel control group was undertaken. The population studied were adult thoracic trauma patients requiring emergency TT who were haemodynamically stable. The intervention performed was VTT. Patients in the control group underwent conventional TT. The primary outcome was tube position as defined by a consultant radiologist's interpretation of chest x-ray (CXR) or CT. The trial was registered with ANZCTR.org.au (ACTRN: 12,615,000,870,550). There were 37 patients enrolled in the study - 12 patients allocated to the VTT intervention group and 25 patients allocated to conventional TT. Mean age of participants was 48 years (SD 15) in intervention group and 46 years (SD 15) years in the control group. In the VTT group all patients were male the indications were pneumothorax (83%), haemothorax (8%) and haemopneumothorax (8%). The median injury severity score was 23 (16-28). There were 1 positional and 1 insertional complications. In the control group 72% of patients were male, the indications were pneumothorax (56%), haemothorax (4%) and haemopneumothorax (40%). The median injury severity score was 24 (14-36). There were 8 (32%) positional complications and no insertional complications. V-TT was demonstrated to be a feasible alternative to conventional thoracostomy and merits further investigation.
Publisher: Elsevier BV
Date: 09-2011
DOI: 10.1016/J.INJURY.2010.08.007
Abstract: During trauma resuscitation, blind catheterization of an injured urethra may aggravate the injury by disrupting a partially torn urethra. In busy trauma centers, retrograde urethrograms (RUG) prior to catheterisation for all patients with unstable pelvic fractures presents a challenge during trauma resuscitation, and the procedure is not commonly practiced despite Advanced Trauma Life Support (ATLS) and World Health Organisation recommendations. The aim of this study was to determine the presenting clinical features of patients with urethral injuries and to predict major trauma patients needing further investigation to exclude this injury. A retrospective review of adult major trauma patients diagnosed with urethral injuries during an 8-year period at a major trauma centre, was conducted. There were 998 major trauma patients with fractures of the pelvis over the study period, of whom 223 had pubic symphysis disruption. There were 29 patients with urethral injuries. The sensitivity of any one of the traditional signs of urethral trauma was 66.7% (95% CI: 46.0-82.8). After exclusion of patients with penetrating trauma and iatrogenic injuries, pubic symphysis disruption on initial pelvis AP X-ray and/or the clinical signs of urethral injury had a sensitivity of 100% (95% CI: 84.4-100.0) for urethral trauma. Reliance on clinical features alone to predict urethral injury results in a substantial proportion of missed injuries in major trauma patients. RUGs did not appear to be needed in patients with no disruption of the pubic symphysis on initial pelvis X-ray or where no signs of urethral injury are present. In the absence of clinical signs and pubic symphysis disruption, blind urethral catheterisation may be attempted.
Publisher: Wiley
Date: 14-09-2020
Abstract: The role of paramedics in hospital triage or streaming models has not been adequately explored and is potentially a missed opportunity for enhanced patient flow. The aim of the present study was to assess the concordance between a streaming decision by paramedics with the decision by nurses after arrival to the ED. A prospective observational study was conducted. Paramedics were met at the entrance to the hospital and asked which destination they thought was appropriate (the index test). The ED nurse streaming decision was the reference standard. Cases of discordance were reviewed and assessed for clinical risk by an independent expert panel that was blinded. We collected data from 500 cases that were transported by ambulance consisting of 55% males with a median age of 57 years (interquartile range 38–75). The overall concordance between paramedics' and streaming decision was 86.4% (95% confidence interval 83.1–89.1). The concordance was highest among patients streamed to resuscitation and general cubicles. Among discordant cases ( n = 68), 39 were streamed to a more acute destination than the paramedic suggested. Of the 68 discordant cases, 56 were deemed to be of no clinical risk. Despite limited knowledge of patient load within the ED, paramedics can allocate a streaming destination with high accuracy and this appears to be associated with low clinical risks. Early pre‐hospital notification of streaming destination with proactive allocation of ED destination presents a real opportunity to minimise off‐load times and improve patient flow.
Publisher: Elsevier BV
Date: 09-2011
DOI: 10.1016/J.RESUSCITATION.2011.04.007
Abstract: The inability to accurately predict acute traumatic coagulopathy (ATC) has been a key factor in the low level of evidence guiding its management. The aim of this study was to develop a tool to accurately identify patients with ATC using pre-hospital variables without the use of pathology or radiological testing. Retrospective data from the trauma registry on major trauma patients were used to identify variables independently associated with coagulopathy. These variables were clinically evaluated to develop a scoring system to predict ATC, which was prospectively validated in the same setting. There were 1680 major trauma patients in the derivation dataset, with 151 patients being coagulopathic. Pre-hospital variables independently associated with ATC were entrapment (OR 1.85 95% CI: 1.12-3.06), temperature (OR 0.60 95% CI: 0.60-0.72), systolic blood pressure (OR 0.99 95% CI: 0.98-0.99), abdominal or pelvic content injury (OR 2.0 95% CI: 1.27-3.12) and pre-hospital chest decompression (OR 4.99 2.77-8.99). The COAST score was developed, scoring points for entrapment, temperature <35°C, systolic blood pressure < 100 mm Hg, abdominal or pelvic content injury and chest decompression. Prospectively validated using 1225 major trauma patients, a COAST score of ≥ 3 had a specificity of 96.4% with a sensitivity of 60.0%, with an area under the receiver operating characteristic curve of 0.83 (0.78-0.88). The COAST score accurately identified a group of patients with ATC using pre-hospital observations. This predictive tool can be used to select patients for inclusion into prospective studies examining management options for ATC. Mortality in these patients is high, potentially improving feasibility of outcome studies.
Publisher: Elsevier BV
Date: 05-2016
Publisher: Informa UK Limited
Date: 09-11-2022
Publisher: Elsevier BV
Date: 05-2014
DOI: 10.1016/J.INJURY.2014.01.011
Abstract: Acute traumatic coagulopathy (ATC) has been reported in the setting of isolated traumatic brain injury (iTBI) and associated with high mortality and poor outcomes. The aim of this systematic review was to examine the incidence and outcome of patients with ATC in the setting of iTBI. We conducted a search of the MEDLINE database and Cochrane library, focused on subject headings and keywords involving coagulopathy and TBI. Design and results of each study were described. Studies were assessed for heterogeneity and the pooled incidence of ATC in the setting of iTBI determined. Reported outcomes were described. There were 22 studies selected for analysis. A statistically significant heterogeneity among the studies was observed (p<0.01). Using the random effects model the pooled proportion of patients with ATC in the setting of iTBI was 35.2% (95% CI: 29.0-41.4). Mortality of patients with ATC and iTBI ranged between 17% and 86%. Higher blood transfusion rates, longer hospital stays, longer ICU stays, decreased ventilator free days, higher rates of single and multiple organ failure and higher incidence of delayed injury and disability at discharge were reported among patients with ATC. ATC is commonly associated with iTBI and almost uniformly associated with worse outcomes. Any disorder of coagulation above the normal range appears to be associated with worse outcomes and therefore a clinically important target for management. Earlier identification of patients with ATC and iTBI, for recruitment into prospective trials, presents avenues for further research.
Publisher: Elsevier BV
Date: 09-2014
DOI: 10.1016/J.INJURY.2014.01.016
Abstract: Older age and blood transfusion have both been independently associated with higher mortality post trauma and the combination is expected to be associated with catastrophic outcomes. Among patients who received a massive transfusion post trauma, we aimed to investigate mortality at hospital discharge of patients ≥65 years old and explore variables associated with poor outcomes. A retrospective review of registry data on all major trauma patients presenting to a level I trauma centre between 2006 and 2011 was conducted. Mortality at hospital discharge among patients ≥65 years old was compared to the younger cohort. A multivariable logistic regression model was constructed to determine independent risk-factors for mortality among older patients. There were 51 (16.4%) patients of age ≥65 years who received a massive transfusion. There were 20 (39.2%) deaths, a proportion significantly higher than 55 (21.1%) deaths among younger patients (p<0.01). Pre-hospital GCS, the presence of acute traumatic coagulopathy and higher systolic blood pressure on presentation were independently associated with higher mortality. Age and volume of red cells transfused were not significantly associated with higher mortality. Survival to hospital discharge was demonstrated in elderly patients receiving massive transfusions post trauma, even in the presence of multiple risk factors for mortality. Restrictive resuscitation or transfusion on the basis of age alone cannot be supported. Early aggressive resuscitation of elderly trauma patients along specific guidelines directed at the geriatric population is justified and may further improve outcomes.
Publisher: Wiley
Date: 03-08-2022
DOI: 10.5694/MJA2.51674
Abstract: Traumatic brain injury (TBI) is the largest contributor to death and disability in people who have experienced physical trauma. There are no national data on outcomes for people with moderate to severe TBI in Australia. To determine the incidence and key determinants of outcomes for patients with moderate to severe TBI, both for Australia and for selected population subgroups, including Aboriginal and Torres Strait Islander Australians. The Australian Traumatic Brain Injury National Data (ATBIND) project will analyse Australia New Zealand Trauma Registry (ATR) data and National Coronial Information Service (NCIS) deaths data. The ATR documents the demographic characteristics, injury event description and severity, processes of care, and outcomes for people with major injury, including TBI, assessed and managed at the 27 major trauma services in Australia. We will include data for people with moderate to severe TBI (Abbreviated Injury Scale [AIS] (head) score higher than 2) who had Injury Severity Scores [ISS] higher than 12 or who died in hospital. People will also be included if they died before reaching a major trauma service and the coronial report details were consistent with moderate to severe TBI. The primary research outcome will be survival to discharge. Secondary outcomes will be hospital discharge destination, hospital length of stay, ventilator-free days, and health service cost. The Alfred Ethics Committee approved ATR data extraction (project reference number 670/21). Further ethics approval has been sought from the NCIS and multiple Aboriginal health research ethics committees. The ATBIND project will conform with Indigenous data sovereignty principles. Our findings will be disseminated by project partners with the aim of informing improvements in equitable system-level care for all people in Australia with moderate to severe TBI. Not applicable.
Publisher: Hindawi Limited
Date: 02-06-2016
DOI: 10.1111/JCPT.12405
Abstract: Patients admitted to general medical units and emergency short-stay units are often complex with multiple comorbidities, polypharmacy and at risk for drug-related problems associated with increased morbidity and mortality. The aim of this study was to evaluate the effectiveness of a partnered pharmacist charting model completed at the time of admission to prevent medication errors. We conducted an unblinded cluster randomized controlled trial comparing partnered pharmacist charting to standard medical charting among patients admitted to general medical units and emergency short-stay units with complex medication regimens or polypharmacy. This trial was conducted at an adult major referral hospital in metropolitan Melbourne, Australia, with an annual emergency department attendance of approximately 60 000 patients. The evaluation included patients' medication charts written in the period of 16 March 2015 to 27 July 2015. Patients randomized to the intervention were managed using the partnered pharmacist charting model. The primary outcome variable was a medication error identified by an independent assessor within 24 h of admission, who was not part of the patient's admission process. Of the 473 patients who received standard medical staff charting during the study period, 372 (78·7%) had at least one medication error identified compared to 15 patients (3·7%) on the partnered pharmacist charting arm (P < 0·001). The relative risk of an error with standard medical charting was 21·4 (95% CI: 13·0-35·0) with a number needed to treat (NNT) to prevent one error of 1·3 (95% CI: 1·3-1·4), and the relative risk of a high or extreme risk error with standard medical charting was 150·9 (95% CI: 21·2-1072·9) with a NNT to prevent one high or extreme error of 2·7 (95% CI 2·4-3·1). Partnering between medical staff and pharmacists to jointly chart initial medications on admission significantly reduced inpatient medication errors (including errors of high and extreme risk) among general medical and emergency short-stay patients with complex medication regimens or polypharmacy.
Publisher: Hamad bin Khalifa University Press (HBKU Press)
Date: 14-11-2016
Abstract: Purpose: Hyoid bone fractures are uncommon, reported mainly in cases of hanging. There is a paucity of reports involving other mechanisms, and only a handful of case reports are available to guide the management of these fractures, especially within the emergency department setting. This study focused on identifying optimal initial airway management and subsequent treatment of patients with hyoid fractures. Methods: Patients presenting to an adult major trauma referral centre between January 2007 and July 2014 with a diagnosis of hyoid bone fracture were identified. Patient records were reviewed retrospectively. Results: Of the 19 patients identified, 16 cases were secondary to blunt force trauma. Motor vehicle crashes accounted for eight of the 19 cases. All patients with major trauma were intubated as part of their initial airway management, while 50% of the minor trauma patients were intubated. Only one patient underwent surgical repair of the hyoid bone. Most patients experienced excellent outcomes with no hyoid fracture-related complications. Conclusion: Early intubation for suspected hyoid fractures is advised for those with a penetrating mechanism of injury, clinical features of airway compromise, and severe associated injuries. Conservative, nonsurgical management of hyoid fractures remains the mainstay of management. A minimum 24-hour period of observation for patients who are not managed with endotracheal intubation is advised.
Publisher: Elsevier BV
Date: 04-2017
DOI: 10.1016/J.RESUSCITATION.2017.01.018
Abstract: Cardiopulmonary resuscitation-induced consciousness (CPRIC) is a phenomenon that has been described in only a handful of case reports. In this study, we aimed to describe CPRIC in out-of-hospital cardiac arrest (OHCA) patients and determine its association with survival outcomes. Retrospective study of registry-based data from Victoria, Australia between January 2008 and December 2014. Adult OHCA patients treated by emergency medical services (EMS) were included. Multivariable logistic regression was used to determine the association between CPRIC and survival to hospital discharge. There were 112 (0.7%) cases of CPRIC among 16,558 EMS attempted resuscitations, increasing in frequency from 0.3% in 2008 to 0.9% in 2014 (p=0.004). Levels of consciousness consisted of spontaneous eye opening (20.5%), jaw tone (20.5%), speech (29.5%) and/or body movement (87.5%). CPRIC was independently associated with an increased odds of survival to hospital discharge in unwitnessed/bystander witnessed events (OR 2.09, 95% CI: 1.14, 3.81 p=0.02) but not in EMS witnessed events (OR 0.98, 95% CI: 0.49, 1.96 p=0.96). Forty-two (37.5%) patients with CPRIC received treatment with one or more of midazolam (35.7%), opiates (5.4%) or muscle relaxants (3.6%). When stratified by use of these medications, CPRIC in unwitnessed/bystander witnessed patients was associated with improved odds of survival to hospital discharge if medications were not given (OR 3.92, 95% CI: 1.66, 9.28 p=0.002), but did not influence survival if these medications were given (OR 0.97, 95% CI: 0.37, 2.57 p=0.97). Although CPRIC is uncommon, its occurrence is increasing and may be associated with improved outcomes. The appropriate management of CPRIC requires further evaluation.
Publisher: AMPCo
Date: 05-2012
DOI: 10.5694/MJA12.10315
Publisher: Wiley
Date: 12-04-2017
Abstract: Patient or visitor perpetrated workplace violence (WPV) has been reported to be a common occurrence within the ED. No universal definition of violence or recording of such events exists. In addition ED staff are often reluctant to report violent incidents. The true incidence of WPV is therefore unclear. This systematic review aimed to quantify WPV in EDs. The association of WPV to drug and alcohol exposure was explored. The databases MEDLINE, Embase, PsycInfo and the Cochrane Library were searched from their commencement to 10 March 2016. MeSH terms and text words for ED, violence and aggression were combined. A meta-analysis was conducted on the primary outcome variable-proportion of violent patients among total ED presentations. A secondary meta-analysis used studies reporting on proportion of drug and alcohol affected patients occurring within the violent population. The search yielded a total of 8720 records. A total of 7235 were unique and underwent abstract screening. A total of 22 studies were deemed relevant according to inclusion and exclusion criteria. Retrospective study design predominated, analysing mainly security records and incident reports. The rates of violence from in idual studies ranged from 1 incident to 172 incidents per 10 000 presentations. The pooled incidence suggests there are 36 violent patients for every 10 000 presentations to the ED (95% confidence interval 0.0030-0.0043). WPV in the ED was commonly reported. There is wide heterogeneity across the study methodology, definitions and rates. More standardised recording and reporting may inform preventive measures and highlight effective management strategies.
Publisher: Elsevier BV
Date: 04-2017
DOI: 10.1016/J.RESUSCITATION.2017.01.016
Abstract: In December 2013, our institution changed the target temperature management (TTM) for the first 24h in ventricular fibrillation out-of-hospital cardiac arrest (VF-OHCA) patients from 33°C to 36°C. This study aimed to examine the impact this change had on measured temperatures and patient outcomes. We conducted a retrospective cohort study of consecutive VF-OHCA patients admitted to a tertiary referral hospital in Melbourne (Australia) between January 2013 and August 2015. Outcomes were adjusted for age and duration of cardiac arrest. Over the 30-month period, 76 VF-OHCA cases were admitted (24 before and 52 after the TTM change). Patient demographics, cardiac arrest features and hospital interventions were similar between the two periods. After the TTM change, less patients received active cooling (100% vs. 70%, p < 0.001), patients spent less time at target temperature (87% vs. 50%, p < 0.001), and fever rates increased (0% vs. 19%, p = 0.03). During the 36°C period, there was a decrease in the proportion of patients who were discharged: alive (71% vs. 58%, p=0.31), home (58% vs. 40%, p=0.08) and, with a favourable neurological outcome (cerebral performance category score 1-2: 71% vs. 56%, p=0.22). After the change from a TTM target of 33°C to 36°C, we report low compliance with target temperature, higher rates of fever, and a trend towards clinical worsening in patient outcomes. Hospitals adopting a 36°C target temperature to need to be aware that this target may not be easy to achieve, and requires adequate sedation and muscle-relaxant to avoid fever.
Publisher: Wiley
Date: 12-12-2018
Abstract: The National Emergency X-Radiography Utilization Study (NEXUS) criteria were derived from a heterogeneous group of adult blunt trauma patients, with the outcome measure assessed most commonly using plain X-ray radiographs. Recent observations have suggested inadequacy of these criteria for excluding injury in population subgroups such as the elderly. The aim of this systematic review was to determine the sensitivity of the NEXUS criteria in excluding cervical spine injury among older patients aged ≥65 years. A systematic review of the literature published prior to 1 January 2017 that reported on the performance of the NEXUS criteria among older patients was conducted. The databases OVID Embase and OVID Medline were searched. The sensitivity of the NEXUS criteria was recalculated for each study among older patients. There were seven studies included in this review. All studies were considered to be at risk of bias and rated down for quality of evidence. Emergency physicians were assessors in all included studies. Sensitivity of the NEXUS criteria among older patients ranged from 66% to 100%. Variable sensitivity was demonstrated when the NEXUS criteria were applied to older blunt trauma patients. This questions the applicability of the NEXUS criteria in this subgroup.
Publisher: Hamad bin Khalifa University Press (HBKU Press)
Date: 20-02-2016
Abstract: Introduction: Traumatic haemorrhagic shock can be difficult to diagnose. Models for predicting critical bleeding and massive transfusion have been developed to aid clinicians. The aim of this review is to outline the various available models and report on their performance and validation. Methods: A review of the English and non-English literature in Medline, PubMed and Google Scholar was conducted from 1990 to September 2015. We combined several terms for i) haemorrhage AND ii) prediction, in the setting of iii) trauma. We included models that had at least two data points. We extracted information about the models, their developments, performance and validation. Results: There were 36 different models identified that diagnose critical bleeding, which included a total of 36 unique variables. All models were developed retrospectively. The models performed with variable predictive abilities–the most superior with an area under the receiver operating characteristics curve of 0.985, but included detailed findings on imaging and was based on a small cohort. The most commonly included variable was systolic blood pressure, featuring in all but five models. Pattern or mechanism of injury were used by 16 models. Pathology results were used by 15 models, of which nine included base deficit and eight models included haemoglobin. Imaging was utilised in eight models. Thirteen models were known to be validated, with only one being prospectively validated. Conclusions: Several models for predicting critical bleeding exist, however none were deemed accurate enough to dictate treatment. Potential areas of improvement identified include measures of variability in vital signs and point of care imaging and pathology testing.
Publisher: Wiley
Date: 16-01-2023
Publisher: Elsevier BV
Date: 02-2018
DOI: 10.1016/J.INJURY.2017.10.009
Abstract: Pelvic x-ray is frequently used as a screening tool during initial assessment of injured patients. However routine use in the awake and alert blunt trauma patient may be questioned due to low yield. We propose a clinical tool that may avoid unnecessary imaging by examining whether the ability to straight leg raise, without pain, can rule out pelvic injury. We conducted a prospective cohort study with the exposure variables of ability to straight leg raise and presence of pain on doing so, and presence of pelvic fracture on x-ray as the primary outcome variable. Of the 328 participants, 35 had pelvic fractures, and of these 32 were either unable to straight leg raise, or had pain on doing so, with a sensitivity of 91.43% (95% CI: 76.94-98.2%) and a negative predictive value of 98.57% (95% CI: 95.88-99.70%). The 3 participants with a pelvic fracture who could straight leg raise with no pain, all had a GCS of less than 15, and therefore, among the sub-group of patients with GCS15, a 100% sensitivity and 100% negative predictive value for straight leg raise with no pain to rule out pelvic fracture was demonstrated. Among awake, alert patients, painless straight leg raise can exclude pelvic fractures and be incorporated into initial examination during reception and resuscitation of injured patients.
Publisher: Elsevier BV
Date: 02-2018
DOI: 10.1016/J.INJURY.2017.12.014
Abstract: Road traffic injuries are the fifth leading cause of years of life lost, with pedestrians comprising 39% of all road deaths (Global Burden of Disease Mortality and Causes of Death Collaborators [1]). Programs that use injury surveillance data to identify high-risk targets for intervention are known to be effective for reducing injury. This study aims to identify trends in the population incidence of pedestrian traffic injury (PTI) in Victoria, Australia. A retrospective review of data from the Victorian Emergency Minimum Dataset, the Victorian Admitted Episodes Dataset, the Victorian State Trauma Registry and the National Coronial Information System was conducted of patients with a PTI who present to a public hospital emergency department, were admitted to hospital, sustained major trauma or who died of their injuries from January 1st 2009 to December 31st 2013. The primary outcome measure was population incidence of pedestrian traffic-related emergency presentations, hospital admissions, major trauma and deaths. Over the study period, 1838 cases presented to a public hospital emergency department and were discharged without admission to hospital and an additional 3241 cases were admitted to hospital. Of these, 628 cases were classified as major trauma including 90 in-hospital deaths. From January 1st 2008 to December 31st 2011, a total of 216 deaths occurred. A decrease in the population incidence of emergency presentations for PTI was observed over the study period. No significant change was observed in the population incidence of hospital admissions, major trauma cases or deaths from PTI. The demographics of PTI were observed more commonly to be young, intoxicated males and pedestrians aged over 65 years. Although the population-adjusted incidence of emergency presentations for PTI in Victoria has decreased from 2009 to 2013, no change was observed in the incidence of hospital admissions, major trauma or pedestrian fatalities. Novel programs designed to address high-risk groups should be considered to achieve further reductions in PTI and severity of injuries.
Publisher: Public Library of Science (PLoS)
Date: 04-06-2019
Publisher: No publisher found
Date: 2007
Publisher: Elsevier BV
Date: 04-2015
DOI: 10.1016/J.IENJ.2014.07.002
Abstract: To evaluate quality of care delivered to patients presenting to the emergency department (ED) with pain and managed by emergency nurse practitioners by: 1 Evaluating time to analgesia from initial presentation 2 Evaluating time from being seen to next analgesia 3 Measuring pain score documentation The delivery of quality care in the emergency department (ED) is emerging as one of the most important service indicators being measured by health services. Emergency nurse practitioner services are designed to improve timely, quality care for patients. One of the goals of quality emergency care is the timely and effective delivery of analgesia for patients. Timely analgesia is an important indicator of ED service performance. A retrospective explicit chart review of 128 consecutive patients with pain and managed by emergency nurse practitioners was conducted. Data collected included demographics, presenting complaint, pain scores, and time to first dose of analgesia. Patients were identified from the ED patient information system (Cerner log) and data were extracted from electronic medical records. Pain scores were documented in 67 (52.3% 95% CI: 43.3-61.2) patients. The median time to analgesia from presentation was 60.5 (IQR 30-87) minutes, with 34 (26.6% 95% CI: 19.1-35.1) patients receiving analgesia within 30 minutes of presentation to hospital. There were 22 (17.2% 95% CI: 11.1-24.9) patients who received analgesia prior to assessment by a nurse practitioner. Among patients who received analgesia after assessment by a nurse practitioner, the median time to analgesia after assessment was 25 (IQR 12-50) minutes, with 65 (61.3% 95% CI: 51.4-70.6) patients receiving analgesia within 30 minutes of assessment. The majority of patients assessed by nurse practitioners received analgesia within 30 minutes after assessment. However, opportunities for substantial improvement in such times along with documentation of pain scores were identified and will be targeted in future research.
Publisher: Wiley
Date: 13-05-2019
Publisher: Wiley
Date: 21-06-2020
Publisher: Wiley
Date: 18-05-2020
Publisher: Wiley
Date: 24-07-2020
Publisher: BMJ
Date: 22-08-2013
Publisher: Hamad bin Khalifa University Press (HBKU Press)
Date: 14-11-2016
Abstract: Introduction: Migraines are one of the commonest presenting complaints to emergency departments (ED), and may result in prolonged length of stay with symptoms being severe and refractory to typical remedies, such as paracetamol, non-steroidal anti-inflammatory drugs and triptans. The objective of this study was to describe and compare patient demographics, presentation, management and outcomes to hospital discharge between first presenters and patients with a history of migraines in two metropolitan emergency departments in Melbourne, Australia. Given that the assessment and management of patients who have had a prior history of migraines is likely to be substantially different, patients were subgrouped by this exposure variable. Methods: A total of 365 patients were identified retrospectively during the study period of March 2013 – September 2014 that met the inclusion criteria of a headache with no organic cause and/or symptoms consistent with visual or abdominal migraines. Presenting pain scores, assessment, management and disposition were extracted using explicit chart review. Results: The mean age of patients included was 37.8 years and 23.3% were males. Significantly more first presenters were investigated with a CT scan of the brain (34.4% as compared to 22.9% of patients with a prior history of migraine). Initial management included administration of paracetamol in 178 (48.8%) cases, NSAIDs (mostly ibuprofen and aspirin) in 187 (51.2%) and parenteral dopamine antagonists (e.g. metoclopramide, prochlorperazine and chlorpromazine) in 191 (52.3%) cases. Migraine-specific agents such as triptans were prescribed in 46 (12.6%) and ergots in two (0.5%) cases. Opioids such as morphine or oxycodone were administered in 94 (25.8%) cases. There was no statistical difference in the management of patients with a history of migraines as compared to first presenters, with the exception of the use of intravenous fluids and parenteral dopamine antagonists. The median length of stay in the ED was 4 (inter-quartile range 2–7) hours, with 163 (44.7%) patients admitted to the short-stay unit. A pain score of ≥ 5 was recorded at discharge in 31 (8.5%) patients. Disposition was similar across both groups of patients. Conclusions: Although first presenters seem to be more thoroughly investigated, the acute management of migraine did not differ largely between patients who had a history of migraine compared with first presenters. The management of acute migraine in the ED setting has varied efficacy, suggesting that further research into newer therapeutic options is needed.
Publisher: No publisher found
Date: 2007
Publisher: Wiley
Date: 08-2013
Publisher: Springer Science and Business Media LLC
Date: 07-06-2019
DOI: 10.1007/S40279-019-01135-4
Abstract: Sensor devices have enabled estimations of head impact kinematics across contact sports. To quantitatively report the magnitude (linear and rotational acceleration) and frequency of game-related head impacts recorded in male contact sports athletes. A systematic review was conducted in June 2017. Inclusion criteria were English-language in vivo studies published after 1990 with a study population of male athletes aged ≥ 16 years, in any sport, where athletes were instrumented with an accelerometer device for measuring head impacts. Study populations were not limited to players with a clinical diagnosis of concussion. Twenty-one studies met the inclusion criteria with 12 conducted on American Football athletes. Six of these studies were included for meta-analysis. At a threshold of 10g, amateur rugby players sustained the most impacts per player per game (mean = 77, SD = 42), followed by amateur Australian Football (mean = 29, SD = 37) and collegiate lacrosse athletes (mean = 11.5, SD = 3.6). At thresholds of greater than 14.4g, high school American Football athletes sustained between 19 (SD = 19.1) and 24.4 (SD = 22.4) impacts per player per game. Statistically significant heterogeneity was observed among the included studies, and meta-analysis of impact magnitude was limited. The frequency of "head acceleration events" was quantified and demonstrated substantial variation in methodology and reporting of results. Future research with standardised reporting of head impacts and inclusion of non-helmeted sports is warranted to enable more robust comparisons across sports. CRD42017070065.
Publisher: Wiley
Date: 27-06-2020
Publisher: Oxford University Press (OUP)
Date: 27-05-2014
Abstract: The Alfred Emergency Short Stay Unit initiated a chest pain protocol for patients presenting with chest pain to risk stratify for acute coronary syndrome (ACS). A 30-day follow-up of patients discharged with low-or-intermediate risk of ACS demonstrated no deaths or ACS. The purpose of this study was to evaluate the long-term safety of the chest pain protocol, a one year follow-up was undertaken. A questionnaire was designed for the one-year follow-up and it was administered via a telephone interview by emergency nurses to document adverse cardiac events and health care utilisation. From 297 patients, 224 (75%) were contacted 12 months following discharge. There was one death from stroke (0.4% 95% confidence interval (CI): 0.01-2.5%) and another from an unknown cause. Five patients had been diagnosed with atrial fibrillation (2.2% 95% CI: 0.7-5.1%), two patients had an acute myocardial infarction (0.9% 95% CI: 0.03-2.1%) and four were diagnosed with angina (1.8% 95% CI: 0.9-3.2%). Nearly half (n=103, 46% 95% CI: 39.5-52.5%) had returned to the emergency department (ED) for various conditions including 42 patients with further chest pain. Ninety-six patients (43% 95% CI: 39.3-52.7%) had specialist referrals and 124 investigations were performed. Thirty-four patients had cardiology referrals (15% 95% CI: 10.7-20.5%) and 25 patients had gastroenterology referrals (11% 95% CI: 7.3-16.0%). Diagnostic cardiac tests were performed on 38 patients: coronary angiography (n=10), 24-hour Holter monitoring (n=17), 24-hour blood pressure (BP) monitoring (n=4), thallium scans (n=5), exercise stress test (n=1) and CT scan (n=1). Patients had a low risk of adverse events 12 months after discharge but substantial continuing health care utilization was observed. Complete assessment by health care professionals prior to discharge may help mitigate representations.
Publisher: BMJ
Date: 09-2017
DOI: 10.1136/BMJOPEN-2017-017848
Abstract: Mild traumatic brain injury (mTBI) has been insufficiently researched, and its definition remains elusive. Investigators are confronted by heterogeneity in patients, mechanism of injury and outcomes. Findings are thus often limited in generalisability and clinical application. Serum protein biomarkers are increasingly assessed to enhance prognostication of outcomes, but their translation into clinical practice has yet to be achieved. A systematic review was performed to describe the adult populations included and enrolled in studies that evaluated the prognostic value of protein biomarkers to predict postconcussion symptoms following an mTBI. Searches of MEDLINE, Embase, CENTRAL, CINAHL, Web of Science, PsycBITE and PsycINFO up to October 2016. Two reviewers independently screened for potentially eligible studies, extracted data and assessed the overall quality of evidence by outcome using the Grading of Recommendations Assessment, Development and Evaluation approach. A total of 23 298 citations were obtained from which 166 manuscripts were reviewed. Thirty-six cohort studies (2812 patients) having enrolled between 7 and 311 patients (median 89) fulfilled our inclusion criteria. Most studies excluded patients based on advanced age (n=10 (28%)), neurological disorders (n=20 (56%)), psychiatric disorders (n=17 (47%)), substance abuse disorders (n=13 (36%)) or previous traumatic brain injury (n=10 (28%)). Twenty-one studies (58%) used at least two of these exclusion criteria. The pooled mean age of included patients was 39.3 (SD 4.6) years old (34 studies). The criteria used to define a mTBI were inconsistent. The most frequently reported outcome was postconcussion syndrome using the Rivermead Post-Concussion Symptoms Questionnaire (n=18 (50%)) with follow-ups ranging from 7 days to 5 years after the mTBI. Most studies have recruited s les that are not representative and generalisable to the mTBI population. These exclusion criteria limit the potential use and translation of promising serum protein biomarkers to predict postconcussion symptoms.
Publisher: Wiley
Date: 02-2010
DOI: 10.1111/J.1742-6723.2010.01260.X
Abstract: There have been few cases of cold burn related to the exposure of liquid petroleum gas (LPG). We present the case of a young woman exposed to LPG while refueling her car who sustained partial thickness burns to the dorsum of her hand. Contact with LPG leaking from a pressurized system causes tissue damage because of cold injury. Immediate management of LPG is extrapolated from the management of frostbite. The increasing use of LPG mandates an awareness of prevention strategies and management principles in the setting of adverse events.
Publisher: Wiley
Date: 11-2012
Publisher: Oxford University Press (OUP)
Date: 08-2018
DOI: 10.1136/POSTGRADMEDJ-2018-135828
Abstract: A surgical approach to airway management may be essential in situations of difficult or failed airway, where immediate airway access is needed to provide oxygenation. However, the procedure is uncommonly performed and expertise among emergency clinicians may be limited. The aim of this study was to assess the accuracy of cricothyroid membrane (CTM) identification by junior and senior emergency trainees by identification of surface anatomy landmarks. A secondary aim was to determine patient variables associated with accurate identification of CTM. A prospective observational study was conducted in a tertiary emergency department in the Kingdom of Saudi Arabia. Saudi Emergency Medicine board trainees participated in the study. Data were also obtained on gender and body habitus of patients. Junior trainees attempted to locate the membrane by palpation and marked it with an ultraviolet mark (blinded) pen followed by senior trainees. A certified ultrasound physician, also blinded to the trainee attempts, marked the membrane within a 5 mm circumference using a different coloured ultraviolet pen and was used as the reference gold standard. There were 80 patients enrolled with junior and senior doctors assessing location for emergency cricothyrotomy. Proportion of correct localisation was 30% (95% CI 20% to 41%) among junior trainees and 33% (95% CI 22% to 44%) among seniors (P=0.73). Level of training, sex, height and weight of patients were not associated with success. Clinical localisation of CTM by emergency medicine trainees was poor even in non-stressful settings, and warrants further dedicated education and/or use of adjunct techniques.
Publisher: Elsevier BV
Date: 09-2007
DOI: 10.1016/J.INJURY.2007.03.021
Abstract: To review the massive transfusion practice at a Level I adult Trauma Centre during initial trauma reception and resuscitation. All trauma patients presenting to The Alfred Emergency & Trauma Centre and receiving a transfusion of five units or more of packed red blood cells within 4h of presentation over a 26-month period were included in this study. Patient demographics, clinical characteristics, injuries, surgical management and volume of blood transfused were analysed with mortality as the primary endpoint. Initial clinical features and injuries predictive of massive transfusion were also analysed. There were 119 patients who received a transfusion of five units or more of packed red blood cells (PRBCs) within 4h of presentation. The median Injury Severity Score of this group of patients was 34.0 (IQR 26-48) and mortality was 27.7%. The median number of packed red blood cell transfused was 8.0 (IQR 6-14) in the 1st 4h. Initial clinical features and injuries independently associated with a larger volume of blood transfused were initial hypotension, fractures of the pelvis, kidney injuries, initial acidaemia, and thrombocytopaenia. The Injury Severity Score, initial coagulopathy measured by APTT and the presence of head injuries were the independent predictors of mortality. The volume of blood transfused during trauma resuscitation was not found to be an independent predictor of mortality. Prospective studies into transfusion practice and clinical features of patients during the trauma resuscitation phase requiring massive transfusion are needed to establish evidence-based guidelines for massive transfusion.
Publisher: Wiley
Date: 20-09-2022
Abstract: There has been great interest regarding tele-emergency care (TEC) and its utility following the COVID-19 pandemic. We have seen a roll out of multiple TEC services across Australia, operating in isolation, without coordination and under differing models of care, creating the potential for an uncoordinated, inefficient healthcare system. We outline a potential framework under which TEC services might function as part of the current system, defining potential strategies that may be used to appropriately coordinate the acute care of select patients outside of the ED as well as improve the efficiency of the physical ED itself.
Publisher: SAGE Publications
Date: 15-10-2023
DOI: 10.1177/14604086211050191
Abstract: The neutrophil-to-lymphocyte ratio (NLR) has been proposed as a marker of systemic inflammation in major trauma patients that is associated with in-hospital mortality. We aimed to determine the discriminative ability of initial NLR as a predictor of outcomes following major trauma. This was a registry-based cohort study involving all major trauma patients meeting criteria for inclusion into the Alfred Health Trauma Registry who presented directly from the scene of injury over a 24-month period (January 2018 to December 2019). The initial NLR was calculated for each patient and was compared against the Shock Index (SI), lactate and Revised Trauma Score (RTS). Outcomes observed were mortality at hospital discharge and intensive care unit (ICU) admission. We assessed the predictive capacity of each test using the receiver operating characteristic (ROC) curve and performed area under the ROC curve (AUROC) analysis to compare their performance. Data were extracted for 1687 major trauma patients, of which 72% were male, the median age was 49 years (IQR 31–68) and most (90%) of patients presented after a blunt mechanism of injury. In-hospital mortality occurred in 165 (9.77%) patients, and 725 (42.92%) patients required ICU admission. The median NLR was 6.84 (IQR 3.89–11.52). Initial NLR performed poorly with an AUROC of 0.46 (95% confidence interval (CI): 0.40–0.52) for prediction of mortality and AUROC of 0.53 (95% CI: 0.50–0.56) for prediction of ICU admission. The AUROCs of initial NLR for both mortality at hospital discharge and ICU admission were significantly lower than SI, lactate and RTS. Initial NLR was not predictive of outcomes in major trauma. NLR at other time-points may provide better predictive capacity for outcomes.
Publisher: BMJ
Date: 05-2017
Publisher: Elsevier BV
Date: 02-2014
DOI: 10.1016/J.AENJ.2013.12.002
Abstract: Community-acquired pneumonia (CAP) is a growing public health concern in many developed countries including Australia. CAP account for an estimated two percent of all overnight hospital admissions in Australia. Despite the significant burden on the Australian healthcare system and the high level of morbidity and mortality associated with CAP, there has been a paucity of research on the incidence of disease in this country, particularly in relation to seasonal variation of emergency department presentations and subsequent admission. The following search terms were used: community-acquired AND pneumonia AND/OR seasonal AND season AND/OR variation OR differences. The limits used for the search terms included: "All Adult" the years 1948 to current or 1948 to week 1 May 2012, (depending on the database) English language and with full text. The databases searched included MEDLINE, Embase and CINAHL. Distinct seasonal patterns in the occurrence of CAP were observed: 34% of CAP admissions occurred in spring 18% in autumn 26% in winter and 22% in summer (p=0.036). Hospital admissions for CAP were significantly higher in the winter and spring (p=<0.001) and highest in December (20.5%) and January (25.1%). Peak hospitalisations from January through to April were observed. The included studies were conducted in the northern hemisphere where the months December to February relate to winter. International studies have shown an association between seasonal variation and the occurrence of CAP in temperate and subtropical climates. Selected studies had methodological limitations that limit conclusions and applicability to clinical practice. There are no studies in the Australian context. Further epidemiological studies are required to elucidate this important aspect of the epidemiology of CAP.
Publisher: Elsevier BV
Date: 07-2016
DOI: 10.1016/J.IENJ.2015.10.007
Abstract: Emergency department presentations after mammalian bites may be associated with injection of bacteria into broken skin and may require prophylactic antibiotics to prevent subsequent infection. We aim to describe the epidemiology of patients presenting with a mammalian bite injury and antibiotic choice to an Australian adult tertiary centre. A retrospective cohort study was performed capturing all presentations after mammalian bite wounds between 01 Jan 2014 and 31 Dec 2014. An explicit chart review was conducted to determine management of each case. Cases were subgrouped into high- and low-risk groups as defined by the Australian Therapeutic Guidelines for animal bites. There were 160 cases of mammalian bite wounds included, with 143 (89.4%) patients grouped as high-risk and 17 (10.6%) patients identified as low-risk. High-risk features were delayed presentation > 8 hours (57 patients, 35.6%), bites to the head, hand or face (113 patients, 70.6%), and puncture wounds unable to be adequately debrided (74 patients, 46.3%). There was a significant association with delayed presentation of more than eight hours and clinically established infection [OR 36.2 95% CI: 12.6-103.6 P < 0.001]. Prescriptions for antibiotics that adhered to current guidelines occurred in 99 (61.9%) cases. This study highlights variability in antibiotic prescription practice among clinicians and the need for ongoing education on antibiotic stewardship. Intervention strategies, including ongoing education, are indicated to improve adherence to antibiotic guidelines.
Publisher: Wiley
Date: 31-07-2023
DOI: 10.5694/MJA2.52055
Abstract: To describe the frequency of hospitalisation and in‐hospital death following moderate to severe traumatic brain injury (TBI) in Australia, both overall and by patient demographic characteristics and the nature and severity of the injury. Cross‐sectional study analysis of Australia New Zealand Trauma Registry data. People with moderate to severe TBI (Abbreviated Injury Score [head] greater than 2) who were admitted to or died in one of the twenty‐three major Australian trauma services that contributed data to the ATR throughout the study period, 1 July 2015 – 30 June 2020. Primary outcome: number of hospitalisations with moderate to severe TBI secondary outcome: number of deaths in hospital following moderate to severe TBI. During 2015–20, 16 350 people were hospitalised with moderate to severe TBI (mean, 3270 per year), of whom 2437 died in hospital (14.9% mean, 487 per year). The mean age at admission was 50.5 years (standard deviation [SD], 26.1 years), and 11 644 patients were male (71.2%) the mean age of people who died in hospital was 60.4 years (SD, 25.2 years), and 1686 deaths were of male patients (69.2%). The overall number of hospitalisations did not change during 2015–20 (per year: incidence rate ratio [IRR], 1.00 95% confidence interval [CI], 0.99–1.02) and death (IRR, 1.00 95% CI, 0.97–1.03). Injury prevention and trauma care interventions for people with moderate to severe TBI in Australia reduced neither the incidence of the condition nor the associated in‐hospital mortality during 2015–20. More effective care strategies are required to reduce the burden of TBI, particularly among younger men.
Publisher: SAGE Publications
Date: 26-07-2022
DOI: 10.1177/14604086211034008
Abstract: Early identification of trauma injury severity is important for prognostication. The neutrophil–lymphocyte ratio (NLR) has been proposed as a marker of systemic inflammation in major trauma patients that is associated with in-hospital mortality. The aim of this systematic review is to compile all the best evidence available to determine the prognostic capabilities of the NLR in trauma and to assess the NLR as a predictor of mortality in adult major trauma patients. Additionally, comparing NLR and hospital length of stay (LOS), ICU LOS, mechanical ventilation and transfusion requirements. We conducted a search of online information sources to identify manuscripts observing the NLR in adult major trauma patients. Outcomes of interest include mortality as defined by the author, hospital LOS, ICU LOS, mechanical ventilation and transfusion requirements. Quality was assessed using the Newcastle–Ottawa Scale. We aimed to conduct a meta-analysis if there were sufficient manuscripts included. Eight studies fulfilled our inclusion criteria. Trials were of good methodological quality. Substantial heterogeneity present between the studies prevented a meta-analysis from being conducted. Overall, five studies demonstrated the NLR as a significantly predictive marker of mortality. NLR was observed to be significantly associated with increased ICU LOS and longer duration of mechanical ventilation. Mixed results were observed between NLR and hospital LOS and transfusion requirements. A potential association between NLR and mortality, ICU LOS and duration of mechanical ventilation has been reported. However, clinical utility of this measure during trauma resuscitation remains unknown.
Publisher: Informa UK Limited
Date: 25-08-2015
DOI: 10.3109/02688697.2014.950632
Abstract: Acute traumatic coagulopathy (ATC) has been reported in the setting of isolated traumatic brain injury (iTBI) and associated with poor outcomes. Among patients with iTBI, we aimed to select an appropriate definition of ATC, outline the incidence of ATC and examine clinical variables associated with ATC. A retrospective review of The Alfred Trauma Registry was conducted and patients with iTBI (head AIS [Abbreviated Injury Score] ≥ 3 and all other body regions AIS < 3) were selected for analysis. The association of the international normalised ratio (INR) on arrival at hospital with the mortality on hospital discharge was explored, to select an appropriate clinical horizon to define ATC. The incidence of ATC was calculated using this definition. Injury and clinical variables measurable pre-hospital and immediately on arrival at the hospital were analysed to determine independent associations with ATC. There were 1718 patients with iTBI included in the study. The overall mortality was 12%, but significantly greater when initial INR was measured at ≥ 1.3 (45.1% p 50 yrs, SI ≥ 1, or abnormal pupils, was 97.54% (95% CI: 96.6-98.2) specific for ATC. An abnormal initial INR in the setting of iTBI was associated with poor outcomes, regardless of magnitude. The incidence of ATC appears too low to recommend empiric pro-coagulant management for all patients with iTBI. The subgroup of patients older than 50 yrs., with shock or abnormal size of pupils, may be considered for interventional trials of early treatment against ATC.
Publisher: Elsevier BV
Date: 09-2018
DOI: 10.1016/J.INJURY.2018.03.035
Abstract: Trauma registries play an integral role in trauma systems but their valid use hinges on data quality. The aim of this study was to determine, among contemporary publications using trauma registry data, the level of reporting of data completeness and the methods used to deal with missing data. A systematic review was conducted of all trauma registry-based manuscripts published from 01 January 2015 to current date (17 March 2017). Studies were identified by searching MEDLINE, EMBASE, and CINAHL using relevant subject headings and keywords. Included manuscripts were evaluated based on previously published recommendations regarding the reporting and discussion of missing data. Manuscripts were graded on their degree of characterization of such observations. In addition, the methods used to manage missing data were examined. There were 539 manuscripts that met inclusion criteria. Among these, 208 (38.6%) manuscripts did not mention data completeness and 88 (16.3%) mentioned missing data but did not quantify the extent. Only a handful (n = 26 4.8%) quantified the 'missingness' of all variables. Most articles (n = 477 88.5%) contained no details such as a comparison between patient characteristics in cohorts with and without missing data. Of the 331 articles which made at least some mention of data completeness, the method of managing missing data was unknown in 34 (10.3%). When method(s) to handle missing data were identified, 234 (78.8%) manuscripts used complete case analysis only, 18 (6.1%) used multiple imputation only and 34 (11.4%) used a combination of these. Most manuscripts using trauma registry data did not quantify the extent of missing data for any variables and contained minimal discussion regarding missingness. Out of the studies which identified a method of managing missing data, most used complete case analysis, a method that may bias results. The lack of standardization in the reporting and management of missing data questions the validity of conclusions from research based on trauma registry data.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2011
Publisher: AMPCo
Date: 2017
DOI: 10.5694/MJA16.00628
Abstract: To evaluate whether pharmacists completing the medication management plan in the medical discharge summary reduced the rate of medication errors in these summaries. Unblinded, cluster randomised, controlled investigation of medication management plans for patients discharged after an inpatient stay in a general medical unit. The Alfred Hospital, an adult major referral hospital in metropolitan Melbourne, with an annual emergency department attendance of about 60000 patients. The evaluation included patients' discharge summaries for the period 16 March 2015 - 27 July 2015. Patients randomised to the intervention arm received medication management plans completed by a pharmacist (intervention) those in the control arm received standard medical discharge summaries (control). The primary outcome variable was a discharge summary including a medication error identified by an independent assessor. At least one medication error was identified in the summaries of 265 of 431 patients (61.5%) in the control arm, compared with 60 of 401 patients (15%) in the intervention arm (P<0.01). The absolute risk reduction was 46.5% (95% CI, 40.7-52.3%) the number needed to treat (NNT) to avoid one error was 2.2 (95% CI, 1.9-2.5). The absolute risk reduction for a high or extreme risk error was 9.6% (95% CI, 6.4-12.8%), with an NNT of 10.4 (95% CI, 7.8-15.5). Pharmacists completing medication management plans in the discharge summary significantly reduced the rate of medication errors (including errors of high and extreme risk) in medication summaries for general medical patients.Australia New Zealand Clinical Trials Registry number: ACTRN12616001034426.
Publisher: BMJ
Date: 20-10-2012
Publisher: Wiley
Date: 08-11-2019
Abstract: The Victorian Emergency Minimum Dataset (VEMD) collects administrative and clinical data for all presentations to Victorian public ED. The present study aimed to examine the level of agreement between the VEMD data and the medical record for a s le of patients coded as having acute cardiovascular conditions (acute coronary syndrome, stroke and transient ischaemic attack [TIA]) and unspecified chest pain in the VEMD. Six months of data provided to the VEMD from a large metropolitan hospital was obtained, and a random s le of 10% of cases (n = 310) were selected for review. Data for eight VEMD items were compared for concordance to data recorded in the ED medical record. Complete concordance between the VEMD and medical records for all eight items was observed only for 101 (33%) presentations. Overall, the least concordant variables were those with a high number of coding options: usual type of accommodation (76%), referral pattern (84%) and primary diagnosis (85%). The concordance of the VEMD primary diagnosis varied when examined as in idual codes (range 75%-100%) and when combined (acute coronary syndrome = 94%, stroke or TIA = 85% and chest pain unspecified = 75%). The level of agreement for some items improved when VEMD codings were combined. When compared to the medical record, our data suggest there is likely variation in the accuracy of some VEMD items, and suggests a larger prospective validation of the VEMD is warranted. For researchers using existing VEMD data, combining of some codes may be necessary.
Publisher: Elsevier BV
Date: 09-2019
DOI: 10.1016/J.WNEU.2019.05.187
Abstract: Cervical spine immobilization, including cervical collars, has been recommended in most trauma guidelines. However, cervical spine immobilization can be associated with harm, and an increasing body of evidence has demonstrated associated complications. We hypothesized that older trauma patients placed in cervical collars for >24 hours were at greater risk of developing collar-related complications compared with those placed in cervical collars for ≤24 hours. We conducted a retrospective cohort study of injured patients without a fracture of the cervical vertebrae, aged ≥65 years, who had been placed in a cervical collar during the period from January 1, 2015 to December 31, 2015. The primary outcome was the composite of the in-hospital development of nosocomial pneumonia and collar-related pressure ulcers. A total of 1154 patients had been treated with cervical collars during the study period, and 61 (5.1%) had developed collar-related complications. Male sex, a lower initial Glasgow Coma Scale score, a history of congestive heart failure, a history of chronic obstructive pulmonary disease or asthma, operative management, and longer hospital and intensive care unit lengths of stay demonstrated a univariable association with collar-related complications (P 24 hours. An independent association was found between collar duration >24 hours and the outcome of interest (adjusted odds ratio, 2.50 95% confidence interval, 1.16-5.39 P = 0.02). Among older patients without a cervical vertebral fracture, duration of cervical collar use for >24 hours was associated with the development of collar-related complications. We recommend attention to early collar clearance for older trauma patients.
Publisher: AMPCo
Date: 2007
DOI: 10.5694/J.1326-5377.2007.TB00785.X
Abstract: To describe the epidemiology of falls from ladders in a state-wide population. Retrospective review of data from the the Victorian State Trauma Registry and the Victorian Emergency Minimum Dataset on patients presenting to public hospital emergency departments (EDs) with injuries due to a fall while climbing a ladder, from 1 July 2001 to 30 June 2005. Overall trends in the incidence of ladder-related ED presentations, and in cases of major trauma, trends according to age, and trends according to activity at the time of the fall. 4553 patients presented to EDs after falls from ladders in Victoria during the study period 160 patients had injuries classified as major trauma. There has been a significant rise in the number of presentations to EDs following falls from ladders in Victoria, with a marked increase in the number of cases involving patients aged over 50 years and those climbing ladders outside of paid working conditions. Deaths occurred predominantly in the elderly after falls from heights above 1 metre. Despite knowledge of the dangers of falls from ladders, there has been a significant increase in the number of patients presenting to hospitals after ladder falls. Middle-aged to elderly patients undertaking unpaid work account for this increase. A targeted public health initiative is required to curb this trend.
Publisher: Elsevier BV
Date: 10-2019
DOI: 10.1016/J.INJURY.2019.04.003
Abstract: Each year approximately five million people die from injuries. In countries where systems of trauma care have been introduced, death and disability have decreased. A major component of developed trauma systems is a trauma quality improvement (TQI) program and trauma quality improvement meeting (TQIM). Effective TQIMs improve trauma care by identifying and fixing problems. But globally, TQIMs are absent or unstructured in most hospitals providing trauma care. The aim of this study was to implement and evaluate a checklist for a structured TQIM. This project was conducted as a prospective before-and-after study in four major trauma centres in India. The intervention was the introduction of a structured TQIM using a checklist, introduced with a workshop. This workshop was based on the World Health Organization (WHO) TQI Programs short course and resources, plus the developed TQIM checklist. Pre- and post-intervention data collection occurred at all meetings in which cases of trauma death were discussed. The primary outcome was TQIM Checklist compliance, defined by the discussion of, and agreement upon each of the following: preventability of death, identification of opportunities to improve care and corrective actions and a plan for closing the loop. There were 34 meetings in each phase, with 99 cases brought to the pre-intervention phase and 125 cases brought to the post-intervention phase. There was an increase in the proportion of cases brought to the meeting for which preventability of death was discussed (from 94% to 100%, p = 0.007) and agreed (from 7 to 19%, OR 3.7 95% CI:1.4-9.4, p = 0.004) and for which a plan for closing the loop was discussed (from 2% to 18%, OR 10.9 95% CI:2.5-47.6, p < 0.001) and agreed (from 2% to 18%, OR 10.9 95% CI:2.5-47.6, p < 0.001). This study developed, implemented and evaluated a TQIM Checklist for improving TQIM processes. The introduction of a TQIM Checklist, with training, into four Indian trauma centres, led to more structured TQIMs, including increased discussion and agreement on preventability of death and plans for loop closure. A TQIM Checklist should be considered for all centres managing trauma patients.
Publisher: Wiley
Date: 02-04-2014
DOI: 10.1111/VOX.12121
Abstract: The type and clinical characteristics of patients identified with commonly used definitions of massive transfusion (MT) are largely unknown. The objective of this study was to define the clinical characteristics of patients meeting different definitions of MT for the purpose of patient recruitment in observational studies. Data were extracted on all patients who received red blood cell (RBC) transfusions in 2010 at three tertiary Australian hospitals. MT patients were identified according to three definitions: ≥10 units RBC in 24 h (10/24 h), ≥6 units RBC in 6 h (6/6 h) and ≥5 units RBC in 4 h (5/4 h). Clinical coding data were used to assign bleeding context. Data on in-hospital mortality were also extracted. Five hundred and forty-two patients met at least one MT definition, with 236 (44%) included by all definitions. The most inclusive definition was 5/4 h (508 patients, 94%) followed by 6/6 h (455 patients, 84%) and 10/24 h (251 patients, 46%). Importantly, 40-55% of most types of critical bleeding events and 82% of all obstetric haemorrhage cases were excluded by the 10/24 h definition. Patients who met both the 5/4 h and 10/24 h definitions were transfused more RBCs (19 vs. 8 median total RBC units P < 0·001), had longer ventilation time (120 vs. 55 h P < 0·001), median ICU (149 vs. 99 h P < 0·001) and hospital length of stay (23 vs. 18 h P = 0·006) and had a higher in-hospital mortality rate (23·3% vs. 16·4% P = 0·050). The 5/4 h MT definition was the most inclusive, but combination with the 10/24 h definition appeared to identify a clinically important patient cohort.
Publisher: Wiley
Date: 09-01-2023
Abstract: To report the frequency of electric scooter‐related trauma and association with alcohol and other drug (AOD) use. A retrospective cohort study was conducted, including presentations from 1 January 2017 to 31 May 2022 to a metropolitan health service. There were 272 cases included, with increasing frequency, of which 65 (24%) had AOD exposure. Most AOD‐related trauma occurred at night, among males, without helmet use, had higher injury severity, requirement for surgical intervention and longer hospital length of stay. Urgent preventive measures with a focus on reducing AOD exposure and promoting of helmet use is indicated.
Publisher: American Medical Association (AMA)
Date: 07-2017
Publisher: Elsevier BV
Date: 12-2015
DOI: 10.1016/J.JOCN.2015.05.034
Abstract: This study aims to investigate an association between ethanol exposure and in-hospital mortality among patients with isolated traumatic brain injury (iTBI). Ethanol exposure is associated with a substantially increased risk of sustaining an iTBI. However, once an iTBI has been sustained, it is unclear whether ethanol exposure is neuroprotective or harmful. We conducted a retrospective review of patients who presented between 2006 and 2012 and were entered into the Alfred Hospital trauma registry. The patients who presented with iTBI, as defined by a head abbreviated injury scale (AIS) score ⩾3 and all other body regions with AIS<3, and who had ethanol levels recorded on admission, were eligible for inclusion. The association between ethanol exposure as a continuous variable, and in-hospital mortality, was explored using multivariable logistic regression analysis. There were 1688 patients with iTBI who met the inclusion criteria, 577 (34.2%) of whom tested positive for ethanol. Ethanol exposure was not significantly associated with a change in the in-hospital mortality rate (adjusted odds ratio 1.01 95% confidence interval 1.00-1.02 p=0.19). A substantial proportion of patients with iTBI were exposed to ethanol, but ethanol exposure was not independently associated with a change in mortality rate following iTBI. Any neuroprotection or harm from ethanol exposure was not conclusive, requiring further prospective trials.
Publisher: Elsevier BV
Date: 07-2016
DOI: 10.1016/J.JOCN.2015.11.024
Abstract: Acute traumatic coagulopathy (ATC) has been reported in the setting of isolated traumatic brain injury (iTBI) and is associated with poor outcomes. We aimed to evaluate the effectiveness of procoagulant agents administered to patients with ATC and iTBI during resuscitation, hypothesizing that timely normalization of coagulopathy may be associated with a decrease in mortality. A retrospective review of the Alfred Hospital trauma registry, Australia, was conducted and patients with iTBI (head Abbreviated Injury Score [AIS] ⩾3 and all other body AIS <3) and coagulopathy (international normalized ratio ⩾1.3) were selected for analysis. Data on procoagulant agents used (fresh frozen plasma, platelets, cryoprecipitate, prothrombin complex concentrates, tranexamic acid, vitamin K) were extracted. Among patients who had achieved normalization of INR or survived beyond 24hours and were not taking oral anticoagulants, the association of normalization of INR and death at hospital discharge was analyzed using multivariable logistic regression analysis. There were 157 patients with ATC of whom 68 (43.3%) received procoagulant products within 24hours of presentation. The median time to delivery of first products was 182.5 (interquartile range [IQR] 115-375) minutes, and following administration of coagulants, time to normalization of INR was 605 (IQR 274-1146) minutes. Normalization of INR was independently associated with significantly lower mortality (adjusted odds ratio 0.10 95% confidence interval 0.03-0.38). Normalization of INR was associated with improved mortality in patients with ATC in the setting of iTBI. As there was a substantial time lag between delivery of products and eventual normalization of coagulation, specific management of coagulopathy should be implemented as early as possible.
Publisher: Wiley
Date: 10-07-2019
DOI: 10.1002/JPPR.1546
Publisher: Wiley
Date: 03-03-2016
Abstract: History, clinical examination and throat culture may be inadequate to rule in or out the presence of group A streptococci (GAS) infection in patients with sore throat in a remote location. We correlated the diagnostic accuracy for guiding antibiotic prescription of clinical decision and physiological scoring systems to a rapid diagnostic point of care (POC) test result in paediatric patients presenting with sore throat. Prospective diagnostic accuracy study conducted between 30 June 2014 and 27 February 2015 in a remote Australian ED using a convenience s le. Among paediatric patients presenting with sore throat, the Centor criteria and clinical decision were documented. Simultaneously, patients without sore throat or respiratory tract infection were tested to determine the number of carriers. A throat swab on all patients was tested using a POC test (Alere TestPack +Plus Strep A with on board control), considered as reference standard to detect GAS infection. A total of 101 patients with sore throat were tested with 26 (25.7%) positive for GAS. One hundred and forty-seven patients without sore throat were tested with one positive POC test result (specificity 99% 95% CI 96-100). Positive predictive value for clinician decision-making for a positive GAS swab (bacterial infection) was 29% (95% CI 17-43), negative predictive value 78% (95% CI 63-88). Area under ROC for the Centor score was 0.70 (95% CI 0.58-0.81). Clinician judgement and Centor score are inadequate tools for clinical decision-making for children presenting with sore throat. Adjunctive POC testing provides sufficient accuracy to guide antibiotic prescription on first presentation.
Publisher: Elsevier BV
Date: 2020
DOI: 10.1016/J.INJURY.2019.08.001
Abstract: Pelvic ring fractures are common following high-energy blunt trauma and can lead to substantial haemorrhage, morbidity and mortality. Pelvic circumferential compression devices (PCCDs) improve position and stability of open-book type pelvic fracture, and can improve haemodynamics in patients with hypovolaemic shock. However, PCCDs may cause adverse outcomes including worsening of lateral compression fracture patterns and routine use is associated with high costs. Controversy regarding indication of PCCDs exists with some centres recommending PCCD in the setting of hypovolaemic shock compared to placement for any suspected pelvic injury. To assess the need for PCCD application based on pre-hospital vital signs and mechanism of injury. A retrospective cohort study was conducted in a single adult major trauma centre examining a 2-year period. Patients were sub-grouped based on initial pre-hospital and emergency department observations as haemodynamically normal (heart rate <100 bpm, systolic blood pressure ≥100 mmHg and Glasgow Coma Scale ≥13) or abnormal. Diagnostic accuracy of pre-hospital haemodynamics as a predictor of pelvic fracture requiring intervention within 24 h was assessed. There were 376 patients with PCCD in-situ on hospital arrival. Pelvic fractures were diagnosed in 137 patients (36.4%). Of these, 39 (28.5%) were haemodynamically normal and 98 (71.5%) were haemodynamically abnormal. The most common mechanisms of injury were motor vehicle collision (57.7%) and motorcycle collision (13.8%). Of those with fractures, 40 patients (29.2%) required pelvic intervention within 24 h of admission of these, 8 (20%) were haemodynamically normal and 32 (80%) were haemodynamically abnormal. As a test for pelvic fracture requiring intervention within 24 h, abnormal pre-hospital haemodynamics had a sensitivity of 0.80 (95% CI 0.64-0.91), specificity of 0.32 (95% CI 0.27-0.38) and negative predictive value (NPV) of 0.93 (95% CI 0.88-0.96). Combined with absence of a major mechanism of injury, normal haemodynamics had a sensitivity 1.00, specificity 0.51 (95% CI 0.36-0.66) and NPV of 1.00 for pelvic intervention within 24 h. Normal haemodynamic status, combined with absence of major mechanism of injury can rule out requirement for urgent pelvic intervention. Ongoing surveillance is recommended to monitor for any adverse effects of this change in practice.
Publisher: Wiley
Date: 26-11-2020
Abstract: To determine current clinical practices for managing behavioural emergencies within Victorian public hospital EDs. A multi-centre retrospective study involving all patients who attended ED in 2016 at the Alfred, Ballarat, Dandenong, Geelong and Royal Melbourne Hospitals. The primary outcome was the rate of patient presentations with at least one restrictive intervention. Secondary outcomes included the rate of security calls for unarmed threats (Code Grey), legal status under the Mental Health Act at both the time of ED arrival and the restrictive intervention, and intervention details. For each site, data on 100 patients who had a restrictive intervention were randomly extracted for indication and methods of restraint. In 2016, 327 454 patients presented to the five EDs the Code Grey rate was 1.49% (95% CI 1.45-1.54). Within the Code Grey population, 942 had at least one restrictive intervention (24.3%, 95% CI 23.0-25.7). Details were extracted on 494 patients. The majority (62.8%, 95% CI 58.4-67.1) were restrained under a Duty of Care. Physical restraint was used for 165 (33.4%, 95% CI 29.3-37.8) patients, 296 were mechanically restrained (59.9%, 95% CI 55.4-64.3), median mechanical restraint time 180 min (IQR 75-360), and 388 chemically restrained (78.5%, 95% CI 74.6-82.0). Restrictive interventions in the ED largely occurred under a Duty of Care. Care of patients managed under legislation that covers assessment and treatment of mental illness has a strong clinical governance framework and focus on minimising restrictive interventions. However, this is not applied to the majority of patients who experience restraint in Victorian EDs.
Publisher: SAGE Publications
Date: 12-2006
DOI: 10.1177/0310057X0603400606
Abstract: Cultural barriers in hospital ward staff may limit the use of a Medical Emergency Team (MET) service. In December 2000 the role of the existing Code Blue team in our hospital was expanded to incorporate review of patients fulfilling commonly employed MET criteria. Between January 2001 and June 2003, the average call rate was only 9.8 calls/1000 admissions. Anecdotal feedback and a group-administered questionnaire conducted in July 2003 demonstrated a number of obstacles to initiating calls and the system was modified in October 2004. Specifically, emergency response calls were separated into Code Blue calls (for cardiorespiratory arrests) and MET calls (with physiological and worried criteria). Further, loud overhead chimes as well as anaesthetist and cardiologist attendance were used only in the case of Code Blue calls (suspected arrests). Finally, the heart rate and respiratory rate criteria for MET service activation were modified. In the 12 months before the intervention (October 2003 to September 2004) there were 817 emergency response calls and 51,963 admissions (15.7 calls/1000 admissions). In the 12 months after the intervention there were 1349 emergency response calk (Code Blue plus MET calk) and 54,593 admissions (24.7 calls/1000 admissions [OR 1.59 95% CI=1.45–1.73 P .0001]). Our findings suggest that increasing the use of an existing service to review patients fulfilling MET criteria requires repeated education and a periodic assessment of site-specific obstacles to utilization.
Publisher: Springer Science and Business Media LLC
Date: 03-01-2018
Publisher: Elsevier BV
Date: 2011
DOI: 10.1016/J.INJURY.2011.10.011
Abstract: A high ratio of fresh frozen plasma (FFP) to packed red blood cells (PRBC) is currently recognised as the standard of care in some centres during massive transfusion post trauma. The aim of this study was to test whether the presumption of benefit held true for severely injured patients who received a massive transfusion, but did not present with acute traumatic coagulopathy. Data collected in The Alfred Trauma Registry over a 6 year period were reviewed. Included patients were sub-grouped by a high FFP:PRBC ratio (≥1:2) in the first 4 h and compared to patients receiving a lower ratio. Outcomes studied were associations with mortality, hours in the intensive care unit and hours of mechanical ventilation. Of 4164 eligible patients, 374 received a massive transfusion and 179 (49.7%) patients who did not have coagulopathy were included for analysis. There were 66 patients who received a high ratio of FFP:PRBC, and were similar in demographics and presentation to 113 patients who received a lower ratio. There was no significant difference in mortality between the two groups (p=0.80), and the FFP:PRBC ratio was not significantly associated with mortality, ICU length of stay or mechanically ventilated hours. A small proportion of major trauma patients received a massive blood transfusion in the absence of acute traumatic coagulopathy. Aggressive FFP transfusion in this group of patients was not associated with significantly improved outcomes. FFP transfusion carries inherent risks with substantial costs and the population most likely to benefit from a high FFP:PRBC ratio needs to be clearly defined.
Publisher: Informa UK Limited
Date: 20-07-2023
Publisher: AMPCo
Date: 12-2013
DOI: 10.5694/MJA13.11314
Abstract: To determine the incidence of patients presenting to a major metropolitan hospital after experiencing syncope at church, and to compare their outcomes with those of patients experiencing syncope at other locations. A retrospective matched cohort study in which patients presenting with church syncope between July 2009 and June 2013 were compared with controls (patients presenting after syncope experienced elsewhere) matched by 5-year age group and San Francisco Syncope Score. Admission to hospital was the primary outcome measure. Mortality, intensive care unit or coronary care unit admission, and length of stay in hospital were secondary outcome measures. There were 31 cases of church syncope during the study period, which were matched to 62 controls. The hospital admission rate among patients who experienced syncope in church was significantly lower than among controls (22.6% v 46.8% P = 0.02). After adjusting for other variables significantly associated with admission to hospital, the church as a location for syncope was no longer significantly associated with hospital admission (odds ratio, 0.4 95% CI, 0.1-1.1 P = 0.06). The number of patients presenting to hospital after church syncope was low most had benign diagnoses and were discharged home from the emergency department. While syncope at church was associated with a lower rate of hospital admission, the church did not appear to offer any additional sanctuary when clinical risk profiles were taken into consideration.
Publisher: Wiley
Date: 09-2022
Abstract: Inconsistency in the structure and function of team‐based major trauma reception and resuscitation is common. A standardised trauma team training programme was initiated to improve quality and consistency among trauma teams across a large, mature trauma system. The aim of this manuscript is to outline the programme and report on the initial perception of participants. The Alfred Trauma Team Reception and Resuscitation Training (TTRRT) programme commenced in March 2019. Participants included critical care and surgical craft group members commonly involved in trauma teams. Training was site‐specific and included rural, urban and tertiary referral centres. The programme consisted of prescribed pre‐learning, didactic lectures, skill stations and simulated team‐based scenarios. Participant perceptions of the programme were collected before and after the programme for analysis. The TTRRT was delivered to 252 participants and 120 responses were received. Significant improvement in participant‐reported confidence was identified across all key topic areas. There was also a significant increase in both confidence and clinical exposure to trauma team leadership roles after participation in the programme (from 53 [44.2%] to 74 [61.7% P = 0.007]). This finding was independent of clinician experience. A team‐based trauma reception and resuscitation education programme, introduced in a large, mature trauma system led to positive participant‐reported outcomes in clinical confidence and real‐life team leadership participation. Wider implementation combined with longitudinal data collection will facilitate correlation with patient and staff‐centred outcomes.
Publisher: Elsevier BV
Date: 07-2019
DOI: 10.1016/J.JSAMS.2019.02.004
Abstract: To assess the utility and functionality of the X-Patch Laboratory tests and prospective observational study. Laboratory tests on X-Patch Laboratory head impacts, performed at multiple impact sites and velocities, identified significant correlations between headform-measured and device-measured kinematic parameters (p<0.05 for all). On average, the X-Patch This study reinforces evidence that use of the current X-Patch
Publisher: Wiley
Date: 13-05-2020
Publisher: Wiley
Date: 19-10-2020
Publisher: Wiley
Date: 03-10-2020
Publisher: Elsevier BV
Date: 11-2011
DOI: 10.1016/J.BURNS.2011.04.009
Abstract: The Alfred pre-hospital fluid isotonic crystalloid resuscitation formula for major burns (body weight (kg)×%TBSA burnt=mls in the first 2 h) was adopted by Ambulance Victoria in 2007 for the early and consistent correction of fluid deficit in major burns patients. The aim of this study was to evaluate the associated change in pre-hospital fluid administration. A retrospective explicit chart review of patient records was conducted of all patients with major burns presenting to The Alfred Emergency & Trauma Centre over a 10 year period. Patient demographics, fluid resuscitation and outcomes in the period before the introduction of the new formula were compared to those in the post-introduction period. There were 126 patients with major burns (≥20% total body surface area burnt) included in the study. The median fluid volume administration pre-hospital after introduction of The Alfred formula was 0.35 (0.22-0.44) mL/kg/%TBSA burnt, which was significantly higher than 0.14 (0.04-0.26) mL/kg/%TBSA administered in the prior period (p=0.013). There was no significant change in physiological endpoints associated with the increased volume. At 24 h, the volume of fluid administered in patients when The Alfred formula was used was 4.9±1.6 mL/kg/%TBSA, which was not significantly higher than the volume administered before 2007 of 4.8±2.2 mL/%TBSA/kg (p=0.802). The Alfred pre-hospital fluid formula has resulted in patients receiving significantly more fluids early, although still below volumes suggested by the Parkland formula. There were no adverse effects of this increased volume detected over the study period. The Alfred pre-hospital fluid formula appears to be safe and more effective in delivering fluid volumes predicted by the current 'gold standard'.
Publisher: Wiley
Date: 04-10-2017
Abstract: To determine the proportion of non-motorised road users involved in road traffic crashes that presents to hospital intoxicated. We undertook a retrospective cohort study using data collected from the Alfred Trauma Registry. All patients presenting to an adult major trauma centre in Victoria, Australia from July 2009 to June 2014 who were involved in a road traffic crash as a non-motorised road user - pedestrians, pedal-cyclists, non-motorised scooter users, horse riders - were included. Patients who had a blood alcohol measurement were included, and intoxication was defined as a blood alcohol concentration ≥0.05 g/100 mL. There were 1323 patients included for analysis with data on presenting blood alcohol concentration. Alcohol was detected in 248 (18.7% 95% CI: 16.7-20.9) patients, whereas 211 (15.9% 95% CI: 14.1-18.0) were intoxicated. Among all included pedestrians, 161 (24.7%) were intoxicated among all included pedal-cyclists, 47 (7.3%) were intoxicated. Intoxicated patients were significantly younger, and a higher proportion were males and more likely to present after hours and on public holidays (P < 0.01). Survival to hospital discharge and inpatient rehabilitation requirements were similar among intoxicated and non-intoxicated patients. Intoxication was common among non-motorised road users, and the proportion of intoxicated patients in this subgroup appears unchanged over time despite public awareness programmes. The true burden of intoxication in non-motorised road users remains unknown because of a lack of routine testing. Legislation directed at testing for intoxication of non-motorised users and introduction of penalties should be considered to improve safety of all road users.
Publisher: Wiley
Date: 09-05-2018
Abstract: The Australian health system is generally well prepared for mass casualty events. Fortunately, there have been very few terrorist attacks and these have involved low numbers of casualties compared with events overseas. Nevertheless, Australian health professionals need to be prepared to treat mass casualties with blast and ballistic trauma. The US military and its allies including Australia have had extensive experience with mass casualty management in the Middle East and Afghanistan wars for more than a decade. To define their experience, they developed the Tactical Combat Casualty Care Guidelines that have saved many lives. It is now prudent to incorporate this knowledge and experience into civilian practice in Australia.
Publisher: Wiley
Date: 28-09-2010
DOI: 10.1111/J.1742-6723.2010.01331.X
Abstract: To investigate the usefulness of stress testing before discharge in patients assessed low to intermediate risk of acute coronary syndrome (ACS). A prospective observational study was undertaken of patients presenting to the ED with suspected myocardial ischaemia. After negative initial electrocardiogram (ECG) and serum troponin testing, patients were admitted to the emergency short stay unit (ESSU) for further evaluation using a chest pain protocol that included stress testing as the final risk stratification tool. The primary outcome measure was evidence of myocardial ischaemia at stress testing. Of the 300 patients enrolled and followed up, there were no deaths at 30 days and no myocardial infarcts in patients discharged from the short stay. Two patients (0.67%) had positive serum troponin levels at 6 h after the onset of chest pain and were diagnosed with non-ST segment elevation myocardial infarctions. Three patients (1%) had abnormal stress testing and were admitted to hospital from ESSU. On review, all three patients were high risk, according to The National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines. The present study showed that an ED short stay unit can effectively evaluate and manage patients with low and intermediate risk of ACS. The study suggests that patients with low and intermediate risk for ACS might safely be discharged after normal serial ECG and cardiac biomarkers, with a view to early outpatient stress testing. With strict adherence to admission criteria, there does not appear to be any benefit of stress testing before discharge.
Publisher: Wiley
Date: 25-06-2018
Abstract: Despite a policy of zero tolerance towards workplace violence (WPV) in Australian public hospital EDs, the incidence of WPV continues to increase. The aim of this study was to characterise security responses to WPV within an adult level 4 ED. A retrospective single-centre review of episodes of WPV perpetrated by adults occurring within the ED was conducted between 1 January 2013 and 31 December 2015. Cases were identified using a prospectively recorded security register that records all events of security personnel attendance. The presence of police officers on initial presentation was the primary exposure variable. There were 1853 violent episodes committed by 1224 patients requiring security intervention during the study period, with half the episodes (n = 916 49%) involving perpetrators who had committed at least two or more violent acts during the study period. Most cases (n = 1057, 57% 95% CI: 55-59) occurred in the absence of police presence. Only 144 (7.8%) cases were managed by the presence of security personnel without physical security interventions. EDs should not rely on police response to prevent or handle violence. The finding of a high proportion of events being perpetrated by repeat offenders indicate that data sharing between EDs for identification of perpetrators of WPV can be useful for prevention of future episodes. ACEM policy for WPV in EDs should encompass further details on security credentialing and preventive strategies towards minimisation of WPV in the Australian EDs.
Publisher: Elsevier BV
Date: 2015
DOI: 10.1016/J.RESUSCITATION.2014.10.017
Abstract: Cardio-pulmonary resuscitation (CPR) may generate sufficient cerebral perfusion pressure to make the patient conscious. The incidence and management of this phenomenon are not well described. This systematic review aims to identifying cases where CPR-induced consciousness is mentioned in the literature and explore its management options. The databases Medline, PubMed, EMBASE, Cinahl and the Cochrane Library were searched from their commencement to the 8th July 2014. We also searched Google (scholar) for grey literature. We combined MeSH terms and text words for consciousness and CPR, and included studies of all types. The search yielded 1997 unique records, of which 50 abstracts were reviewed. Nine reports, describing 10 patients, were relevant. Six of the patients had CPR performed by mechanical devices, three of these patients were sedated. Four patients arrested in the out-of-hospital setting and six arrested in hospital. There were four survivors. Varying levels of consciousness were described in all reports, including purposeful arm movements, verbal communication, and resuscitation interference. Management strategies directed at consciousness were offered to six patients and included both physical and chemical restraints. CPR-induced consciousness was infrequently reported in the medical literature, and varied in management. Given the increasing use of mechanical CPR, guidelines to identify and manage consciousness during CPR are required.
Publisher: Wiley
Date: 16-02-2007
DOI: 10.1111/J.1440-1754.2007.01035.X
Abstract: There is a paucity of population-based studies regarding the spectrum of paediatric head injury from mild through serious to fatal paediatric head injury. The aims of the present study were to determine the incidence, demographics and outcome of significant head injury in a state-wide population of children aged 0-15 years. A secondary aim was to determine if any serious head injuries were being missed under the current management protocols of the state-wide trauma system. A retrospective review of significant head injury in all paediatric patients over a period of 2 years was undertaken. Data were collected from the Victorian State Trauma Outcome Registry and Monitoring database, the Victorian Emergency Minimum Dataset and from the Victorian Institute of Forensic Medicine. The incidence of paediatric head injury in Victoria over the 2-year period was 765 per 100000 per year. The incidence of admitted head injuries was 75 per 100000 per year and the incidence of significant head injury was seven per 100000 or 151 children. Forty-one per cent of these injuries required surgical intervention. Mortality was 1.6 children per 100000. All patients who died presented with a Glasgow Coma Score (GCS) of 3 and had multiple other risk factors. There were no deaths in patients discharged from hospital. Demographic and clinical factors associated with higher mortality and morbidity was determined. The incidence of significant paediatric head injury was low. Deaths occurred early and were always associated with significant early clinical features of severe head injury. This highlights the importance of strategies for the prevention of head injuries. There appeared to be no serious head injuries missed during the study period.
Publisher: Elsevier BV
Date: 03-2011
Publisher: Wiley
Date: 10-02-2020
Publisher: Wiley
Date: 05-02-2018
Publisher: Wiley
Date: 27-09-2023
Publisher: Wiley
Date: 05-06-2019
Abstract: The role of serum troponin testing in patients presenting to the ED after syncope is unclear. The aim of this systematic review was to examine the practice and utility of troponin testing among patients presenting to the ED after syncope. We conducted a search of MEDLINE, Embase, Cochrane Library, Web of Science and Scopus databases from 1990 to February 2017 using keyword and subject headings for syncope and troponin testing. Design and results of the included studies are extracted. Studies were assessed for heterogeneity and the pooled proportion of measured troponin and positive troponin result described. There were nine studies included for analysis. Significant statistical heterogeneity among studies was observed (P < 0.001). Using the random effects model, the pooled proportion of patients presenting to the ED after syncope who had troponin measured was 0.64 (95% CI 0.46-0.82). Among patients who had been troponin tested, the pooled proportion who had a positive result was 0.19 (95% CI 0.13-0.26). Variability among reported outcomes prevented further meta-analysis. Troponin testing was commonly performed for the assessment of patients with syncope with a substantial proportion returning positive results. The correlation between raised troponin and patient outcomes was not adequately reported. It is possible that an elevated troponin may indicate serious illness, rather than myocardial damage alone.
Publisher: Elsevier BV
Date: 07-2017
DOI: 10.1016/J.INJURY.2017.05.021
Abstract: Road traffic injuries are the fifth leading cause of years of life lost, with pedestrians comprising 39% of all road deaths. International recognition of this public health issue has led to a reduction in road traffic deaths in many high-income countries. However data on non-motorised road users such as pedestrians is incomplete. Additionally, non-fatal injuries are poorly documented. The aim of this study was to identify the incidence of pedestrian traffic injury reported from high-income countries. A systematic review of the literature was conducted using MEDLINE, Scopus, PubMed and the Cochrane library. Studies were eligible for inclusion if they reported the incidence of pedestrian injury in a defined population from a high-income country defined using the World Bank atlas method for the 2016 fiscal year. A meta-analysis was performed on the population incidence of pedestrian traffic injury by world region. Seventeen studies were identified from eight high-income countries that satisfied the inclusion criteria. The pooled incidence of PTI in the European region was 68.8 per 100,000 population (95%CI 50-87.7, p<0.01) and 89.3 per 100,000 (95%CI 47.2-131.4, p<0.01) in the American region. The incidence of pedestrian traffic injury varied from 20 per 100,000 in Victoria, Australia to 203 per 100,000 in New York City, United States of America. Pedestrian mortality ranged from 0.9 to 14 per 100,000 population. Wide variation in population size, location and demographics was observed between studies. This review concluded a high burden of pedestrian trauma in HICs with in idual reports reporting from rates of 20 to 203 per 100,000 population. Recommended interventions directed at reducing the burden of pedestrian trauma were not universally present in the reported high-income countries. Implementation of such safety strategies and demonstration of improvement in pedestrian trauma rates and outcomes present directions for further research.
Publisher: Wiley
Date: 17-09-2023
Publisher: Wiley
Date: 12-2012
Abstract: Body packing is the term used to describe the ingestion of illicit substances for transport across control lines. Where the diagnosis of body packing is made independently in the ED, the issue of reporting the case to law enforcement officials poses a difficult scenario given the legal obligations of patient confidentiality. We describe a case of a body packer brought into the ED and subsequently reported to the police. The conflicts between patient confidentiality versus statutory exceptions to confidentiality along with case law regarding this scenario are discussed.
Publisher: Wiley
Date: 22-06-2014
Abstract: To determine trainee perspectives of the utility of a trainee research project (TRP) or the coursework pathway (CP) in completing the Trainee Research Requirement of the ACEM. A survey based on the ACEM learning objectives for research was sent to all trainees and Fellows who had completed or intending to complete the Trainee Research Requirement between 2010 and 2012. Participants were asked to rate the value of the TRP or CP on a scale of 1 to 10 (1 = 'not useful' and 10 = 'invaluable'). In addition, open-ended questions were asked for qualitative assessment. Survey response was 142/621 (23%). Most participants had undertaken the CP (113/142, 79%). Median scores were better for the CP compared with the TRP, and when results were dichotomised to scores of 1-5 as being not useful and 6-10 as being useful, a significantly higher proportion of participants rated the CP as being useful across all learning objectives (P ≤ 0.01). There was a bimodal distribution of scores for TRPs, with a minority of trainees reporting a very poor TRP experience. Cost was the most commonly cited negative aspect of the CP, whereas the TRP was perceived as time consuming and being difficult to attain. More ACEM trainees are undertaking the CP compared with a TRP. The CP was associated with better self-reported fulfilment of the ACEM learning objectives for research. There is scope for the ACEM to improve the experience of trainees wishing to undertake their own research projects.
Publisher: Wiley
Date: 08-2012
Publisher: SAGE Publications
Date: 06-06-2018
Abstract: Traumatic aortic injury is an uncommon condition. Timely diagnosis may enable early haemostatic resuscitation, essential to prevent worsening of the injury prior to definitive management. The aim of this study was to assess the utility of initial vital signs and presenting clinical characteristics to confirm or rule out aortic injury. A retrospective review of patients from The Alfred Trauma Registry was conducted. Patients presenting between January 2006 and July 2014 and diagnosed with aortic injury were identified. Demographics and presenting clinical characteristics were extracted. Sensitivity of in idual clinical variables for the detection of aortic injury was calculated. There were 77 patients identified with aortic injury, with an in-hospital mortality rate of 19.5% (95% CI: 10.6–28.3%). Of these, 68 (88.3%) patients presented after high-energy blunt mechanisms. Clinical signs and early chest X-ray findings were poorly sensitive to detect aortic injury. Patients who presented with hypotension had a greater severity of aortic injury, more commonly had associated abnormal investigation findings and were more likely to require blood products and inotropic agents (p 0.05). However, sensitivity of initial hypotension to rule out aortic injury was 39.0% (95% CI: 28.1–49.9%). The diagnosis of aortic injury was uncommon in hospital. Most injuries were secondary to high-velocity road traffic crashes or high falls. Clinical signs were not adequately sensitive to be used for the exclusion of aortic injury. We recommend a high degree of clinical suspicion and liberal imaging among cases where aortic injury is possible.
Publisher: Wiley
Date: 13-05-2007
DOI: 10.1111/J.1742-6723.2007.00965.X
Abstract: Australasian trauma centres receive relatively low numbers of penetrating injuries from stabbings. There is limited agreement regarding protocols to guide the management of haemodynamically stable patients with penetrating injuries. This has resulted in a wide variation in practice with anecdotally high negative laparotomy rates. The aim of the present study was to review the ED procedures, investigations and disposition of this group of patients. A retrospective review of all patients presenting with abdominal penetrating injury was undertaken over a 5 year period. Data on demographics, presenting features and management were collected. There were 109 patients who were haemodynamically stable (systolic blood pressure > 90) on arrival to the trauma centre. Diagnostic ED procedures and investigations consisted of wound exploration in 47 (43.1%) patients, focused abdominal sonography in trauma in 44 (40.4%) patients and a CT abdomen in 36 (33.0%) of patients. The sensitivity for focused abdominal sonography in trauma and CT when used together was 77.8%. There were 39 laparotomies performed with a negative laparotomy rate of 23.1%. There were 10 laparoscopies performed, none went on to require a laparotomy. Patients undergoing negative laparotomies spent significantly longer times in hospital than patients managed conservatively or those undergoing laparoscopies. The number of penetrating abdominal injuries remains low. Imaging alone cannot reliably exclude intraperitoneal injury. A greater utilization of ED wound exploration and laparoscopy based on agreed guidelines could improve management. An algorithm for the management of these patients is suggested.
Publisher: Wiley
Date: 14-06-2017
Abstract: A multidisciplinary approach that emphasised improved triage, early pelvic binder application, early administration of blood and blood products, adherence to algorithmic pathways, screening with focused sonography (FAST), early computed tomography scanning with contrast angiography, angio-embolisation and early operative intervention by specialist pelvic surgeons was implemented in the last decade to improve outcomes after pelvic trauma. The manuscript evaluated the effect of this multi-faceted change over a 12-year period. A retrospective cohort study was conducted comparing patients presenting with serious pelvic injury in 2002 to those presenting in 2013. The primary exposure and comparator variables were the year of presentation and the primary outcome variable was mortality at hospital discharge. Potential confounders were evaluated using multivariable logistic regression analysis. There were 1213 patients with a serious pelvic injury (Abbreviated Injury Scale ≥3), increasing from 51 in 2002 to 156 in 2013. Demographics, injury severity and presenting clinical characteristics were similar between the two time periods. There was a statistically significant difference in mortality from 20% in 2002 to 7.7% in 2013 (P = 0.02). The association between the primary exposure variable of being injured in 2013 and mortality remained statistically significant (adjusted odds ratio 0.10 95% confidence interval: 0.02-0.60) when adjusted for potential clinically important confounders. Multi-faceted interventions directed at the spectrum of trauma resuscitation from pre-hospital care to definitive surgical management were associated with significant reduction in mortality of patients with severe pelvic injury from 2002 to 2013. This demonstrates the effectiveness of an integrated, inclusive trauma system in achieving improved outcomes.
Publisher: Wiley
Date: 02-10-2023
Publisher: Elsevier BV
Date: 2014
DOI: 10.1016/J.INJURY.2013.01.010
Abstract: The use of intravenous oxygen carriers (packed red blood cells (PRBC), whole blood and synthetic haemoglobins (HBOCs) for selected pre-hospital trauma resuscitation cases has been reported, despite a lack of validated clinical indications. The aim of this study was to retrospectively identify a sub-group of adult major trauma patients most likely to benefit from pre-hospital oxygen carrier administration and determine the predictive relationship between pre-hospital shock index (SI) [pulse rate/systolic blood pressure] and haemorrhagic shock, blood transfusion and mortality. A retrospective review of adult major trauma patients recorded in The Alfred Trauma Registry was conducted. Patients were included if they received at least 1L of pre-hospital crystalloid and spent over 30 min in transit. The association of shock index and transfusion was determined. Patients were further sub-grouped by mode of transport to determine the population of trauma patients who could be included into prospective studies of intravenous oxygen carriers. There were 1149 patients included of whom 311 (21.9%) received an acute blood transfusion. The SI correlated well with transfusion practice. A SI ≥ 1.0, calculated after at least 1L of crystalloid transfusion, identified patients with a high specificity (93.5% 95% CI: 91.8-94.8) for receiving a blood transfusion within 4h of hospital arrival. While patients transported by helicopter had higher injury severity and blood transfusion requirement, there were no difference in physiological variables and outcomes when compared to patients transported by road car. A shock index ≥ 1.0 is an easily calculated variable that may identify patients for inclusion into trials for pre-hospital oxygen carriers. Shocked patients have high mortality rates whether transported by road car or by helicopter. The efficacy of pre-hospital intravenous oxygen carriers should be trialled using a shock index ≥ 1.0 despite fluid resuscitation as the clinical trigger for administration.
Publisher: BMJ
Date: 27-08-2018
DOI: 10.1136/BJOPHTHALMOL-2017-310428
Abstract: To assess incidence, risk factors, presentation and final visual outcome of patients with Acanthamoeba keratitis (AK) treated at the Royal Victorian Eye and Ear Hospital (RVEEH), Melbourne, Australia, over an 18-year period. A retrospective review of all cases of AK managed at RVEEH between January 1998 and May 2016 was performed. Data collected included age, gender, affected eye, signs and symptoms, time between symptoms and diagnosis, risk factors, presenting and final visual acuity (VA), investigations, medical treatment, surgical interventions and length of follow-up. A total of 36 eyes affected by AK in 34 patients were identified. There were 26 cases diagnosed early ( days) and 10 were diagnosed late (≥30 days). There were 31 (86.1%) cases associated with contact lens (CL). Signs associated with early AK included epithelial infiltrates, while signs of late AK included uveitis, ring infiltrate, endothelial plaque and corneal thinning (p .05). Surgical treatment was required in seven cases (19.4%). There were 29 (80.6%) cases that reported improved VA. Median best corrected final VA was worse in patients with late diagnosis (logarithm of minimal angle of resolution (logMAR) 0.5, IQR: 0.2–0.8), compared with patients with early diagnosis (logMAR 0.0, IQR: 0.0–0.3 p=0.01). Late diagnosis was associated with a prolonged disease period. AK was an uncommon cause of severe keratitis and was associated commonly with CL. Patients with late diagnosis had worse presenting and final VAs as well as a prolonged disease period, indicating need for early recognition and management.
Publisher: Future Medicine Ltd
Date: 12-2022
Abstract: Aim: To explore soft-shell padded headgear (HG) use, player behavior and injuries associated with HG in junior Australian football. Methods: Prospective case-crossover with head impact measurement, injury surveillance and video review. Results: 40 players (mean age: 12.43 years, standard deviation: 1.36) across 15 matches were observed. Frequency of head/neck (p = 0.916) or body (p = 0.883) contact events, and match incidents were similar between HG and no HG conditions. Without HG, females had higher frequency of body contacts compared with males (p = 0.015). Males sustained more body contacts with HG than without HG (p = 0.013). Conclusion: Use of HG in junior football was not associated with injury or head contact rate. Associations between HG use and body contact may differ across sexes. (ID: ACTRN12619001165178).
Publisher: Informa UK Limited
Date: 14-04-2020
Publisher: Wiley
Date: 04-2012
DOI: 10.1111/J.1445-5994.2011.02502.X
Abstract: A perceived risk of time-limited emergency department (ED) assessment of patients is inadequate workup leading to inappropriate disposition. The aim of this study was to examine the association of time to disposition plan (TDP) on ED length of stay (LOS) and correlate this to mortality. A retrospective review of data collected from ED information systems at three hospitals was conducted between June 2008 and October 2009. Included patients were admitted to a general medical unit. Patients were excluded if admitted to intensive care, coronary care, a cardiac monitored bed or required surgery in first 24 h or had an expected LOS of <48 h. Multivariate regression analysis was used to identify independent associations with mortality. A total of 10,107 patient episodes was analysed, of which 6768 patients (67.0%) had an ED LOS of ≥8 h. There was significant effect modification by ED LOS in the association of TDP and mortality. In the setting of longer ED LOS, a TDP of <4 h was associated with significantly higher mortality (OR 1.57, 95% CI: 1.28-1.92, P < 0.001), corrected for age, gender and triage category. This association was not significant when ED LOS was <8 h (OR 0.88, 95% CI: 0.60-1.27, P = 0.49). In the setting of prolonged ED LOS, completing ED assessment and management within 4 h of presentation was associated with significantly higher mortality. Further prospective studies are required to understand the relationship between rapid decision making in the ED and patient safety.
Publisher: Oxford University Press (OUP)
Date: 23-12-2016
DOI: 10.1136/POSTGRADMEDJ-2016-134491
Abstract: CT of the brain (CTB) is one of the most common radiological investigations performed in the emergency department (ED). Emergency clinicians rely upon this imaging modality to aid diagnosis and guide management. However, their capacity to accurately interpret CTB is unclear. This systematic review aims to determine this capacity and identify the potential need for interventions directed towards improving the ability of emergency clinicians in this important area. A systematic review of the literature was conducted without date restrictions. We searched MEDLINE, EMBASE and Cochrane databases and studies reporting the primary outcome of concordance of CTB interpretation between a non-radiologist and a radiology specialist were identified. Studies were assessed for heterogeneity and a subgroup analysis of pooled data based on medical specialty was carried out to specifically identify the concordance of ED clinicians. The quality of evidence was assessed using the GRADE criteria. There were 21 studies included in this review. Among the included studies, 12 reported on the concordance of emergency clinicians, 5 reported on radiology trainees and 4 on surgeons. Clinical and statistical heterogeneity between studies was high (I2=97.8%, p& .01). The concordance in the emergency subgroup was the lowest among all subgroups with a range of 0.63–0.95 and a clinically significant error rate ranging from 0.02 to 0.24. Heterogeneity and the presence of bias limit our confidence in these findings. However, the variance in the interpretation of CTB between emergency clinicians and radiologists suggests that interventions towards improving accuracy may be useful.
Publisher: Elsevier BV
Date: 11-2016
DOI: 10.1016/J.AENJ.2016.07.002
Abstract: Consciousness may occur during effective management of cardiac arrest and ranges from eye opening to interfering with rescuers' resuscitation attempts. Reported cases in the medical literature appear scant compared to anecdotal reports. The aim of this study was to evaluate health care providers' experience with consciousness during cardio-pulmonary resuscitation (CPR). A cross-sectional survey of 100 experienced health care professionals, including doctors, nurses and paramedics. Participants were asked about their experience with both CPR-non-interfering consciousness (e.g. eye opening, agonal breaths or mild restlessness) and CPR-interfering consciousness (e.g. purposeful movement, withdrawing from CPR, attempting to pull out airway-securing devices). A third of responders reported attending more than 100 cases of arrests, while another third had attended 20 or less arrests. The responders had a mean of 11 (SD 8.7) years of practice. Most responders (59 of 67) to the question had experienced CPR-non-interfering consciousness and reported experiencing it a median of 3 (IQR 1-5) times. CPR-interfering consciousness had been experienced by 51 of the 63 responders and was experienced overall 1 (IQR 1-3) time. Management of these cases varied widely with varied opinion on ideal management ranging from no action to sedation and/or paralysis. A guideline describing the management of this presentation was considered necessary by 40 out of 57 (70%) responders. Contrasting to a few reports in the medical literature, CPR-induced consciousness appears to be experienced more commonly during resuscitation. Management strategies varied widely and clinician opinion of ideal management was also varied. The desire for consensus guidelines on this topic exists. Acute care nurses are integral members of all resuscitation teams and in conjunction with other clinicians, ideally placed to develop, implement and disseminate such guidelines to delivering evidence based care to this sub-group of patients.
Publisher: The Geological Society of Finland
Date: 06-2018
Publisher: Copernicus GmbH
Date: 02-02-2022
Abstract: Abstract. Discovering ore deposits is becoming increasingly difficult, and this is particularly true in areas of glaciated terrains. As a potential exploration tool for such terrains, we test the vectoring capacities of trace element and sulfur isotope characteristics of pyrite, combined with quantitative statistical methods of whole-rock geochemical datasets. Our target is the Rajapalot gold–cobalt project in northern Finland, where metamorphosed Paleoproterozoic volcanic and sedimentary rocks of the Peräpohja belt host recently discovered gold prospects, which also have significant cobalt enrichment. The focus is particularly put on a single gold–cobalt prospect, known as Raja, an excellent ex le of this unusual cobalt-enriched gold deposit, common in the metamorphosed terranes of northern Finland. The major lithologies at Rajapalot comprise hibolite facies metamorphosed and polydeformed calcsilicate rocks that alternate with albitic units, mafic volcanic rocks, mica schist and quartzite. Mineralization at Rajapalot prospects is characterized by an older Co-mineralizing event and a younger high-grade Au mineralization with re-mobilization and re-deposition of Co. Detailed in situ laser ablation inductively coupled plasma mass spectrometry (LA-ICP-MS) is a powerful technique that produces robust trace element and sulfur isotope databases from paragenetically and texturally well-characterized pyrite from the Raja prospect. The results are treated with appropriate log-ratio transformations and used for multivariate statistical data analysis, such as the computation of principal components. Application of these methods revealed that elements such as Co, Ni, Cu, Au, As, Ag, Mo, Bi, Te, Se, Sn, U, Tl and W have high vectoring capacities to discriminate between Co-only and Au–Co zones, as well as between mineralization stages. The systematic pyrite study suggests that homogenous sulfur isotopic characteristics (+1.3 ‰ to +5.9 ‰) and positive loadings of Co, Se, As, Te, Bi and Au onto PC1 are reflective of an early stage of Co mineralization, while the opposing negative loadings of Mo, Ni, W, Tl, Cu and Ag along PC1 are associated with pyrites from the Au-mineralizing event. The sulfur isotopic signature of the latter pyrite type is between −1.2 ‰ and +7.4 ‰. Subtle patterns recognized from the whole-rock geochemistry favor an As–Au–Se–Te–W–U signature along the positive axis of PC1 for the localization of high-grade Au–Co zones, whereas the element group Ni, Cu, Co, Te, Se and As, which has negative loadings onto PC2, will predict Co-only zones. This study shows the efficiency of trace element geochemistry in mineral exploration targeting, which has the capacity to define future targets by characterizing the metallogenic potential of a host rock, as well as distinguishing various stages of mineralization.
Publisher: Wiley
Date: 2006
DOI: 10.1111/J.1445-2197.2006.03641.X
Abstract: Background: The Parkland formula is established as the ‘gold standard’ for initial fluid resuscitation for major burns. The purpose of this study was to review our fluid resuscitation practice for major burns to determine whether anecdotal observations of significant variations from the Parkland formula were wide spread and whether any difference could be used as a basis for a revision of fluid resuscitation in major burns. Methods: A retrospective review of 127 presentations to The Alfred Burns Unit with total body surface area (TBSA) affected ≥15% was conducted. A retrospective review of the resuscitation data from these patients was compared with the Parkland formula as well as other studies. Results: A total of 49 patients with complete data on fluid administration and uncomplicated burns were included in the analysis. Significantly larger volumes of fluid (5.58 mL/kg per %TBSA) were given to these patients in the first 24 h than predicted by the Parkland formula. Mean arterial pressure, pulse rate and urine output were at satisfactory levels. Clinically evident complications from fluid administration were minimal. Mortality was similar to that in other centres. Conclusion: Fluid resuscitation volumes significantly higher than those predicted by the Parkland formula were given, without adverse consequences. This retrospective review supports a prospective, multicentre, randomized, controlled study comparing this study with the Parkland formula, resulting in a better guide to initial fluid resuscitation in major burns.
Publisher: BMJ
Date: 23-07-2012
Abstract: Injured patients presenting with hypothermia, acidosis and coagulopathy have been identified at high risk of death. This study aimed to describe the presentation, management and outcome of major trauma patients presenting with the 'triad of death' and identify ways to improve survival. A retrospective, explicit chart review was undertaken on patients presenting to a level I adult major trauma centre with the 'triad of death'. These patients presented directly from the scene, were coagulopathic (international normalised ratio (INR) >1.5), hypothermic (temperature <35°C) and acidotic (pH <7.2) on arrival. There were 90 patients over an 8-year period, with an overall mortality of 47.8%. No significant differences were observed among demographics and injury severity scores between survivors and non-survivors. Extremes of systolic blood pressure and heart rate, a high activated partial thromboplastin time activated partial thromboplastin time, low fibrinogen counts, pH, bicarbonate, base excess and haemoglobin were present among survivors. There were no survivors in our cohort with an initial INR greater than 3.2. Survivors received significantly lower volumes of packed red blood cells. There has been little change in mortality over time in this subgroup of major trauma patients. While the presence of the triad alone does not determine futility, there were no survivors over 8 years with extreme coagulopathy with concurrent hypothermia and acidosis.
Publisher: Elsevier BV
Date: 06-2020
DOI: 10.1016/J.AUEC.2019.11.001
Abstract: Standards endorsed by the Australian Resuscitation Council in 2014 recommend that healthcare providers trained in cardiopulmonary resuscitation should have their skills refreshed at least annually and for those who infrequently perform resuscitation, more frequent refresher training is advised. Emergency nurses were given the opportunity to attend workstations to refresh their knowledge and skills essential to resuscitation practice. The aim of this manuscript was to report the perception of the nurses' experience following attendance at the workstations. Lesson plans were developed for six workstations. Consented participants were invited to complete an on-line evaluation survey of their experience following programme participation and at 6-months following programme attendance. Thematic analysis and descriptive statistics were used to report outcomes RESULTS: A total of 143 nurses working in the Emergency Department consented to participate. Following attendance at the workstations, most reported increased knowledge and skills (93.7 %), increased confidence (91.9 %) and that they practiced skills (91.9 %) during workstation participation. At 6-months follow-up the majority of nurses (97.1 %) found the programme to be beneficial and 82 (80.4 %) reported using the knowledge and skills gained from the programme in their clinical practice. Emergency nurses felt more confident in delivering patient care following attendance at the resuscitation workstations. Ongoing education was highly regarded by emergency nurses.
Publisher: Wiley
Date: 28-06-2008
DOI: 10.1111/J.1445-2197.2008.04579.X
Abstract: Severe traumatic head injury in the elderly has been associated with poor outcomes. However, there is currently no consensus to direct management in these patients. This study outlines the demographics, injury characteristics, management and outcome of the elderly trauma patients with severe head injury across a defined population. A retrospective review of all elderly patients (age >64 years) with a Glasgow Coma Scale (GCS) score of 8 or less, and confirmed intracranial pathology or fractured skull, was undertaken over a period of 40 months from July 2001 to September 2005. Data on patient demographics, injury cause, presenting clinical features and interventions were collected. In-hospital mortality was used as the primary outcome. There were 96 patients who met the inclusion criteria. One-third of the patients were managed palliatively, one-third supportively without surgery and another third underwent surgery. Overall mortality was 70.8% (n = 68). Older age and brainstem injuries were identified as independent predictors of mortality. Mortality was reported in all patients aged 85 years or older. Although overall outcomes were poor, careful consideration should be given to active treatment as favourable outcomes were possible even in the presence of extremely low GCS scores. Prediction of outcome on the basis of age and anatomical diagnoses may help in this decision-making.
Publisher: Elsevier BV
Date: 04-2020
Publisher: Elsevier BV
Date: 03-2016
DOI: 10.1016/J.BURNS.2015.08.009
Abstract: To develop a mathematical model of predicting mortality based on the admission characteristics of 6220 burn cases. Data on all the burn patients presenting to Institute of Burn Research, Southwest Hospital, Third Military Medical University from January of 1999 to December of 2008 were extracted from the departmental registry. The distributions of burn cases were scattered by principal component analysis. Univariate associations with mortality were identified and independent associations were derived from multivariate logistic regression analysis. Using variables independently and significantly associated with mortality, a mathematical model to predict mortality was developed using the support vector machine (SVM) model. The predicting ability of this model was evaluated and verified. The overall mortality in this study was 1.8%. Univariate associations with mortality were identified and independent associations were derived from multivariate logistic regression analysis. Variables at admission independently associated with mortality were gender, age, total burn area, full thickness burn area, inhalation injury, shock, period before admission and others. The sensitivity and specificity of logistic model were 99.75% and 85.84% respectively, with an area under the receiver operating curve of 0.989 (95% CI: 0.979-1.000 p<0.01). The model correctly classified 99.50% of cases. The subsequently developed support vector machine (SVM) model correctly classified nearly 100% of test cases, which could not only predict adult group but also pediatric group, with pretty high robustness (92%-100%). A mathematical model based on logistic regression and SVM could be used to predict the survival prognosis according to the admission characteristics.
Publisher: Wiley
Date: 11-2014
DOI: 10.5694/MJA13.00235
Abstract: To examine the effect of the "after-hours" (18:00-07:00) model of trauma care on a high-risk subgroup - patients presenting with acute traumatic coagulopathy (ATC). Retrospective analysis of data from the Alfred Trauma Registry for patients with ATC presenting between 1 January 2006 and 31 December 2011. Mortality at hospital discharge, adjusted for potential confounders, describing the association between after-hours presentation and mortality. There were 398 patients with ATC identified during the study period, of whom 197 (49.5%) presented after hours. Mortality among patients presenting after hours was 43.1%, significantly higher than among those presenting in hours (33.1% P = 0.04). Following adjustment for possible confounding variables of age, presenting Glasgow Coma Scale score, urgent surgery or angiography and initial base deficit, after-hours presentation was significantly associated with higher mortality at hospital discharge (adjusted odds ratio, 1.77 95% CI, 1.10-2.87). The after-hours model of care was associated with worse outcomes among some of the most critically ill trauma patients. Standardising patient reception at major trauma centres to ensure a consistent level of care across all hours of the day may improve outcomes among patients who have had a severe injury.
Publisher: Springer Science and Business Media LLC
Date: 11-07-2017
DOI: 10.1007/S40279-016-0582-1
Abstract: Concussion is common in the sporting arena and is often challenging to diagnose. The development of wearable head impact measurement systems has enabled measurement of head kinematics in contact sports. The objective of this systematic review was to determine the characteristics of head kinematics measured by an accelerometer system among male athletes diagnosed with concussion. A systematic search was conducted in July 2015. Inclusion criteria were English-language studies published after 1990 with a study population of male athletes, in any sport, where objectively measured biomechanical forces were reported in the setting of a concussive event. The random effects meta-analysis model was used to combine estimates of biomechanical force measurements in concussed athletes. Thirteen studies met the inclusion criteria, the majority of which were conducted with high school and college football teams in the US. Included studies measured a combination of linear and rotational acceleration. The meta-analysed mean peak linear head acceleration associated with a concussive episode was 98.68 g (95 % CI 82.36-115.00) and mean peak rotational head acceleration was 5776.60 rads/s Head impact monitoring through accelerometery has been shown to be useful with regard to characterising the kinematic load to the head associated with concussion. Future research with improved clinical outcome measures and head kinematic data may improve accuracy when evaluating concussion, and may assist with both interpretation of biomechanical data and the development and utilisation of implementation strategies for the technology.
Publisher: Springer Science and Business Media LLC
Date: 29-04-2019
DOI: 10.1007/S00068-019-01142-0
Abstract: Early identification of trauma patients at risk of developing acute traumatic coagulopathy (ATC) is important for initiating appropriate, coagulopathy-focused treatment. A clinical ATC prediction tool is a quick, simple method to evaluate risk. The COAST score was developed and validated in Australia but is yet to be validated on a European population. We validated the ability of the COAST score to predict coagulopathy and adverse bleeding-related outcomes on a large European trauma population. The COAST score was modified and applied to a retrospective cohort of trauma patients from the German Trauma Registry (TR-DGU). The primary outcome was coagulopathy defined as INR > 1.5 or aPTT > 60 s. Secondary outcomes were massive transfusion, blood product requirements, urgent surgery and mortality. The cohort included adult trauma patients with Injury Severity Score > 15 treated in Germany/Austria in 2012-2016. 15,370 cases were included, of which 10.9% were coagulopathic. The COAST score performed with sensitivity 21.6% and specificity 94.2% at a threshold of COAST ≥ 3. The AUROC was 0.625 (95% CI 0.61-0.64). The COAST score also identified patients who had more massive transfusions (15.3% v 1.6%), more emergency surgery (49.6% v 28.2%), and higher early (21.7% v 5.4%) and total in-hospital mortality (38.1% v 14.5%). This large retrospective study demonstrated that the modified COAST score predicts coagulopathy with low sensitivity but high specificity. A positive COAST score identified a group of patients with bleeding-related adverse outcomes. This score appears adequate to act as an inclusion criterion for clinical trials targeting ATC.
Publisher: Wiley
Date: 11-06-2019
Abstract: A serum lactate level >2 mmol/L has been chosen as the preferred cut-off value for screening of patients with suspected sepsis. In patients with suspected sepsis presenting to the ED, we aimed to determine the outcomes of patients with initial lactate levels ≤2 mmoL/L, but abnormal bicarbonate or anion gaps (AGs). This prospective cohort study enrolled patients from an adult tertiary referral hospital who presented with suspected sepsis. The predictive value of lactate, bicarbonate and the AG for intensive care unit (ICU) admission and death at hospital discharge were evaluated using area under the receiver operating characteristic curves (AUROC). There were 441 patients with suspected sepsis enrolled from February 2016 to June 2017. There were 96 (22.0%) patients who were admitted to the ICU and at hospital discharge, 42 (9.6%) patients had died. There was no statistically significant difference between the AUROCs of lactate or bicarbonate level or AG to predict ICU admission (P = 0.17). There was no statistically significant difference between the AUROCs of lactate or bicarbonate level or AG to predict mortality at hospital discharge (P = 0.44). Among the 73 patients with normal lactate levels, but abnormal bicarbonate or AG, there were seven (9.6%) deaths. A normal lactate level alone should not be used to exclude life-threatening sepsis. Patients with metabolic acidosis characterised by low bicarbonate or high AG levels, but with normal lactate levels, have high rates of ICU requirement and mortality and should also be considered for early, aggressive therapy.
Publisher: Wiley
Date: 08-01-2018
Abstract: To determine variables that could facilitate safe discharge from the ED following a single high-sensitivity troponin I (HsTnI) result to exclude acute myocardial infarction (AMI). A retrospective cohort study was performed at a tertiary hospital of all patients that had serial HsTnI performed within 12 h of arrival to the ED over a 3 year period. The primary exposure variable of interest was a very low troponin initial result (HsTnI <5 ng/L). Medical record review and risk stratification score calculations were undertaken for all patients with the exposure variable of interest and an abnormal second troponin measurement (HsTnI ≥16 ng/L in women and HsTnI ≥26 ng/L in men). There were 11 970 patients who presented between 1 July 2013 and 30 June 2016 that had serial HsTnI measurements performed. Of these, 4172 (34.9%) patients had an initial HsTnI measurement <5 ng/L. Of the patients with an initial HsTnI <5 ng/L that met inclusion criteria, 56 (1.3%) had a second troponin result above the 99th percentile and 32 (0.8%) cases of non-ST elevation myocardial infarction were diagnosed as well as 15 (0.4%) cases of ST elevation myocardial infarction. There were 44 (93.6%) of all AMI cases that met criteria for high-risk presentations under the National Heart Foundation of Australia guidelines. The negative predictive value of an initial HsTnI <5 ng/L to exclude AMI was 98.9% (95% confidence interval 98.5-99.1). This supports the utilisation of a rapid rule out strategy to exclude AMI for patients that have an initial HsTnI measurement <5 ng/L in conjunction with a robust risk assessment.
Publisher: Elsevier BV
Date: 2009
DOI: 10.1016/J.IENJ.2008.07.007
Abstract: Head and neck injuries following the road traffic crashes (RTCs) are the most common cause of morbidity and mortality in most developed and developing countries and may also result in temporary or permanent disability. The aim of this study was to determine the incidence pattern of head and neck injuries, investigate its trend and identify the severity of injuries involved with road traffic crashes (RTCs) during the period 2001-2006. This is a retrospective descriptive hospital based study. The patients with head and neck injuries were seen and treated in the Accident and Emergency Department of the Hamad General Hospital and other Trauma Centers of the Hamad Medical Corporation following the road traffic crashes during the period 2001-2006. This study is a retrospective analysis of 6709 patients attended and treated at the Accident and Emergency and Trauma centers for head and neck injuries over a 6 year period. Head and neck injuries were determined according to the ICD 10 criteria. Of these, 3013 drivers, 2502 passengers, 704 pedestrians and 490 two wheel riders (motor bike and cyclists). Details of all the road traffic crash patients were compiled in the database of the Emergency Medical Services (EMS), and the data of patients with head and neck injuries were extracted from this database. A total of 6709 patients with head and neck injuries was reported during the study period. Majority of the victims were non-Qataris (68.7%), men (85.9%) and in the age group 20-44 years (68.5%). There were statistical significant differences in relation to age, nationality, gender, and accident during week ends for head and neck injuries (p<0.001). The male to female ratio for head and neck injury was 6.1:1. There was a disproportionately higher incidence of accidents during weekends (27.8%). Majority of the patients had mild injury (87.2%), followed by moderate (7.3%) and severe (5.5%). The highest frequency of head injury was among the young adults 20-44 years (68.5%). There was a remarkable increase in the incidence rate of head and neck injuries per 10,000 population in the year 2005 (18.2) compared to previous years and declined slightly in the year 2006 (17.1). Overall, the incidence of head and neck injuries from road traffic crashes are increasing. The present study findings provided an overview of head and neck injuries in Qatar from road traffic crashes. The incidence of head and neck injuries is still very high in Qatar, but the severity of injury was mild in most of the victims. The findings of the study highlighted the need for taking urgent steps for safety of people especially drivers and passengers.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2016
Publisher: Wiley
Date: 22-12-2020
Abstract: This prospective, observational, interventional study sought to determine if the introduction of resuscitative balloon occlusion of the aorta (REBOA) at an Australian adult major trauma centre would improve survival for major trauma patients. Patients aged 18-60 years, transported directly from scene with exsanguinating, sub-diaphragmatic haemorrhage and hypovolaemic shock (systolic BP 1.0 (4.74%). There were 13 (0.43%) patients with a systolic BP <70 mmHg and/or cardiorespiratory arrest on arrival. The mortality in this group was six out of 13 (46.15%). Of these 13 patients, there were two (0.07% of the total cohort) where REBOA was attempted. There were no eligible patients for whom REBOA was achieved. None of the six patients who died would have benefited from REBOA deployment. Despite considerable training and resource allocation to ensure 24-h availability, the introduction of REBOA failed to effectively demonstrate any impact on patient outcome. Despite retrospective literature supporting the introduction of REBOA, in this 14-month prospective study there was no evidence of benefit. Further studies may define indications and subgroups of patients who may benefit.
Publisher: Wiley
Date: 05-2006
DOI: 10.1111/J.1445-2197.2006.03723.X
Abstract: The aim was to study the epidemiology of significant adolescent head injury in a statewide population. A retrospective review of all significant adolescent (12-19 years old) head injuries over a period of 3 years was undertaken and compared with those of children (0-11 years old) and young adults (20-29 years old). The incidence of significant adolescent head injury was 19.2 per 100,000 adolescents per year. This compared to the incidence in children of 12.9 per 100,000 and in young adult of 14.7 per 100,000. Of all significant adolescent head injuries, 63.9% are managed at adult trauma centres. Demographics, pathology, neurosurgical management, length of intensive care unit stay, ventilated hours and length of hospital stay were similar to those of young adults and significantly different from those of children. Prehospital predictors of mortality were similar across all groups. Adolescent discharge destinations were similar to those of young adults and significantly different from those of children. The study emphasizes the incidence of and mortality from adolescent head injury. The pattern of adolescent head injury is different from that of children and supports current practice of treatment of a majority of adolescents in adult trauma centres. These differences have implications on planning for injury prevention and trauma management.
Publisher: Wiley
Date: 28-12-2017
Publisher: BMJ
Date: 17-06-2020
DOI: 10.1136/EMERMED-2019-208935
Abstract: Endotracheal intubation (ETI) is a commonly performed but potentially high-risk procedure in the emergency department (ED). Requiring more than one attempt at intubation has been shown to increase adverse events and interventions improving first-attempt success rate should be identified to make ETI in the ED safer. We introduced and examined the effect of a targeted bundle of airway initiatives on first-attempt success and adverse events associated with ETI. This prospective, interventional cohort study was conducted over a 2-year period at an Australian Major Trauma Centre. An online airway registry was established at the inception of the study to collect information related to all intubations. After 6 months, we introduced a bundle of initiatives including monthly audit, monthly airway management education and an airway management checklist. A time series analysis model was used to compare standard practice (ie, first 6 months) to the postintervention period. There were 526 patients, 369 in the intervention group and 157 in the preintervention comparator group. A total of 573 intubation attempts were performed. There was a significant improvement in first-attempt success rates between preintervention and postintervention groups (88.5% vs 94.6%, relative risk 1.07 95% CI 1.00 to 1.14, p=0.014). After the introduction of the intervention the first-attempt success rate increased significantly, by 13.4% (p=0.006) in the first month, followed by a significant increase in the monthly trend (relative to the preintervention trend) of 1.71% (p .001). The rate of adverse events were similar preintervention and postintervention (hypoxia 8.3% vs 8.9% (p=0.81) hypotension 8.3% vs 7.0% (p=0.62) any complication 27.4% vs 23.6% (p=0.35)). This bundle of airway management initiatives was associated with significant improvement in the first-attempt success rate of ETI. The introduction of a regular education programme based on the audit of a dedicated airway registry, combined with a periprocedure checklist is a worthwhile ED quality improvement initiative.
Publisher: Wiley
Date: 08-04-2014
Abstract: Early diagnosis of haemorrhagic shock (HS) might be difficult because of compensatory mechanisms. Clinical scoring systems aimed at predicting transfusion needs might assist in early identification of patients with HS. The Shock Index (SI) - defined as heart rate ided by systolic BP - has been proposed as a simple tool to identify patients with HS. This systematic review discusses the SI's utility post-trauma in predicting critical bleeding (CB). We searched the databases MEDLINE, Embase, CINAHL, Cochrane Library, Scopus and PubMed from their commencement to 1 September 2013. Studies that described an association with SI and CB, defined as at least 4 units of packed red blood cells (pRBC) or whole blood within 24 h, were included. Of the 351 located articles identified by the initial search strategy, five met inclusion criteria. One study pertained to the pre-hospital setting, one to the military, two to the in-hospital setting, and one included analysis of both pre-hospital and in-hospital values. The majority of papers assessed predictive properties of the SI in ≥10 units pRBC in the first 24 h. The most frequently suggested optimal SI cut-off was ≥0.9. An association between higher SI and bleeding was demonstrated in all studies. The SI is a readily available tool and may be useful in predicting CB on arrival to hospital. The evaluation of improved utility of the SI by performing and recording at earlier time-points, including the pre-hospital phase, is indicated.
Publisher: MDPI AG
Date: 15-09-2017
DOI: 10.3390/MIN7090171
Publisher: SAGE Publications
Date: 07-2010
DOI: 10.1177/0310057X1003800409
Abstract: We investigated whether there was an association between recombinant activated factor VII (rFVIIa) use in cardiac surgery and thromboembolic events by comparing cases in two medical registries. The incidence of thromboembolic events in patients undergoing cardiac surgery (except isolated coronary artery bypass grafts) who had received rFVIIa and were entered into the Australian and New Zealand Haemostasis Registry was compared with the background incidence in patients entered in the Australasian Society for Cardiac and Thoracic Surgeons database. Mortality, length of hospital stay and thromboembolic complications such as stroke, perioperative myocardial infarction and pulmonary embolism data were analysed. A total of 705 patients in the Registry were compared with 6554 patients in the Thoracic Surgeons database. The use of rFVIIa was independently associated with higher mortality (odds ratio 2.55, P .001) and longer hospital stay (odds ratio 1.54, P=0.020). However, multiple regression analyses showed no independent association between rFVIIa and stroke (odds ratio 1.0, P=0.994) or perioperative myocardial infarction (odds ratio 0.29, P=0.053), while the use of rFVIIa was associated with fewer pulmonary emboli (odds ratio 0.02, P .001). These findings indicate that patients who received rFVIIa had increased mortality and length of hospital stay, as expected, but that rFVIIa use was not associated with an increased incidence of stroke or perioperative myocardial infarction. In the absence of randomised controlled clinical trials, this analysis suggests that the off-label use of rFVIIa in cardiac surgery does not significantly increase thromboembolic events.
Publisher: Wiley
Date: 22-05-2017
Publisher: Wiley
Date: 02-03-2018
Abstract: Approximately, 80% of traumatic brain injuries are considered mild in severity. Mild traumatic brain injury (mTBI) may cause temporary or persisting impairments that can adversely affect an in idual's ability to participate in daily occupations and life roles. This study aimed to identify symptoms, factors predicting level of symptoms and functional and psycho-social outcomes for participants with mTBI three months following injury. Patients discharged from the Emergency Department of a major metropolitan hospital with a diagnosis of mTBI were contacted by telephone three months after injury. An interview with two questionnaires was administered: The Concussion Symptom Inventory (CSI) Scale and the Rivermead Head Injury Follow-Up Questionnaire (RHIFUQ). Data obtained were used to determine the type and prevalence of post-concussion symptoms and their impact on activity change. Sixty-three people with mTBI participated in the study. The majority of participants (81%) reported that all symptoms had resolved within the three-month time frame. Of those still experiencing symptoms, workplace fatigue (22%) and an inability to maintain previous workload/standards (17%) were reported. There is a small, but clinically significant, subgroup of patients who continue to experience symptoms three-month post-mTBI. Symptoms experienced beyond the expected three-month recovery timeframe have the potential to adversely affect an in idual's ability to participate in daily occupation and return to work.
Publisher: Wiley
Date: 28-10-2020
DOI: 10.1111/ACEM.14144
Publisher: Elsevier BV
Date: 08-2017
DOI: 10.1016/J.AENJ.2017.05.002
Abstract: Emergency nurses working in non-Major Trauma Service (non-MTS) facilities face the challenge of providing immediate care to seriously injured patients, despite infrequent presentations at their workplace. A one-day education programme endorsed by the Australian College of Nursing was developed to provide contemporary trauma education for nurses. The aim of this study was to report participants' perceptions of their experience of this programme. Peer reviewed lesson plans were developed to guide educational activities. Of 32 participants, 24 consented to and completed pre and post-programme surveys. Thematic analysis and descriptive statistics were used to report study findings. Most participants were nurses with greater than two years' experience in Emergency Nursing (92%). Trauma patient transfers each year from a non-MTS to a Major Trauma Service occurred infrequently eight nurses (33.3%) reported greater than10 trauma transfers per year. Participant expectations of the programme included personal growth, knowledge acquisition, increased confidence and a focus on technical skills. Participants reported the day to be worthwhile and valuable improved confidence, increased knowledge, and the opportunity to discuss current evidence based practice were highly regarded. Recommendations for future programmes included extending to two days and include burns and more complex pathophysiology. With centralisation of trauma care to major trauma services, frequent and continuing education of nurses is essential. Nurses from non-Major Trauma Service facilities in Victoria found this programme worthwhile as they gained knowledge and skills and increased confidence to care for trauma patients.
Publisher: Wiley
Date: 17-08-2020
Publisher: Elsevier BV
Date: 04-2018
DOI: 10.1016/J.INJURY.2018.03.007
Abstract: Blood loss estimation after trauma (i.e. physical injury) and early identification of potential sources of bleeding are important for planning of investigation and management of trauma. Long bone fractures have been reported to be associated with substantial volumes of blood loss requiring blood transfusion. The aim of this study was to assess rates and amounts of blood transfusion in the setting of isolated extra capsular femur fractures and to determine variables associated with the need for transfusion within the first 48 h of admission. A retrospective cohort study was conducted of patients in The Alfred Trauma Registry with isolated extra capsular femur fractures over a 7-year period. We compared patients with a femoral shaft fracture (FSF) to patients with either distal femur or proximal femur fractures (i.e. extremity fracture). We collected data potentially associated with blood transfusion within 48 h as well as operation details and patient outcomes. There were 293 patients included, of which 121 had FSF and 172 extremity fracture. 105 (36%) patients received a blood transfusion during their admission. Admission haemoglobin (AOR 0.92 95%CI 0.89-0.94, p < 0.01) was the only independently associated variable with blood transfusion within the first 48 h of hospital admission. Volume of blood transfused to patients with extra-capsular femoral fractures was low and usually in the post-operative period. FSF, compared to femoral extremity fractures, were not more likely to receive blood transfusion within the first 48 h of admission, and did not receive a higher volume of blood overall. In the setting of major trauma with haemorrhagic shock, alternate sources of bleeding should be sought.
Publisher: Wiley
Date: 07-07-2020
Abstract: To determine the population of patients where patient transfer may be prevented by assessment of a senior ED registrar at the referring hospital. Patients transferred from Caulfield Hospital, specialising in community services, rehabilitation, aged care and aged mental health to The Alfred Emergency and Trauma Centre, an adult major referral centre within the same clinical network were identified from 1 July 2016 to 31 December 2016. Medical records were reviewed independently by two clinicians to determine preventability of transfer and whether attendance by a senior ED registrar could have prevented the transfer. There were 221 patients included with a mean age of 73.6(15.1) years. The median time spent in the ED was 4 h (interquartile range 2-8) and 197 (89.1%) were admitted. There were 107 (48.6%) transfers deemed preventable or potentially preventable, with 104 preventable by attendance of a senior ED registrar. The most common indication for transfer was acute trauma (n = 55 24.9%), and the odds of a case being preventable or potentially preventable if transferred for the primary indication of trauma was 3.9 (95% confidence interval 2.1-7.1 P < 0.001). Among the preventable cases, the total cost of transfer was AU$105 984 over 6 months, not accounting for the costs of duplication of care. This proof-of-concept study suggests that strategies to expand the provision of acute care to outreach within specialist networks and reduce patient transfers should be further explored. An outreach programme for improved acute assessment of patients at the referring hospital particularly after acute trauma may prevent transfers, improving care pathways.
Publisher: SAGE Publications
Date: 18-07-2018
Abstract: Morbidity and mortality meetings are held at all Australian major trauma centres and provide a forum to identify problems and improve practices. Meetings should focus on addressing factors in the system to prevent similar errors occurring, rather than in idual culpability. This paper describes current meeting practices and assesses the use of a systems approach. This proof of concept study used a convenience s le of four Australian major trauma centres. Trauma leaders at each centre were surveyed regarding morbidity and mortality meeting practices. The use of a systems approach was measured by assessing practices against the London Protocol for Systems Analysis of Clinical Incidents. Meeting participants were also surveyed regarding perceptions of the objectives and effectiveness of meetings. This study found variable utilisation of a systems approach. Cases are not routinely analysed for contributing system factors and effective processes are not always used to correct problems that are identified. Meeting practices also vary between centres in terms of frequency, case selection criteria and use of audit filters. Participants generally view quality improvement as the most important objective of meetings. Morbidity and mortality meeting practices vary between Australian major trauma centres and a systems approach has not been fully adopted.
Publisher: Wiley
Date: 19-12-2020
Abstract: This retrospective observational study aimed to compare the impact of the Prevent Alcohol and Risk‐Related Trauma Youth (P.A.R.T.Y.) Program when delivered as In‐hospital or Outreach models to rural and regional students. The study population were consented participants from regional areas between 2013 and 2017 who completed pre‐programme, immediately post‐programme and 3–5 months post‐programme surveys. Responses from the metropolitan In‐hospital programme participants and regional Outreach programme participants were analysed within groups across the three time points. The primary outcome variable was a change in self‐reported perception of driving after drinking alcohol. Secondary outcome variables were designating a safe driver after drinking, perception of risk of injury if not wearing a seatbelt, risks of injury if undertaking physical risk‐taking activities and likelihood of the programme changing perceptions. There were 1314 participants invited to participate and 547 (42%) sets of complete surveys were received, of whom 296 (54%) were Outreach participants. Pre‐programme, a significantly lower proportion of Outreach participants reported ‘definitely not’ to driving after drinking (84% vs 91%), and perceived a ‘definite’ likelihood of sustaining injury if not wearing a seatbelt (57% vs 66%). Outreach participants displayed improvements in likelihood to drive after drinking alcohol immediately post‐programme and on follow up ( P = 0.028). Responses to all other secondary outcome measures demonstrated some improvement. Although demographically similar, baseline perceptions toward alcohol, risk‐taking and injury differed between groups. Improvements in perception were demonstrated across both models. These findings support P.A.R.T.Y. as an injury prevention initiative for regional youth.
Publisher: Elsevier BV
Date: 09-2012
DOI: 10.1016/J.INJURY.2011.01.033
Abstract: The use of recombinant factor VIIa (rFVIIa) in trauma patients is usually part of rescue therapy when haemorrhage and coagulopathy have not responded to conventional treatment. In this scenario, trauma patients are likely to have one or more components of the 'triad of death' (coagulopathy, acidosis and hypothermia). The aim of this study was to report on the outcome of trauma patients with the 'triad of death' immediately prior to receiving rFVIIa. Trauma patients receiving rFVIIa with the 'triad of death' were identified from the Australia and New Zealand Haemostasis Registry (ANZHR) and included in the study. The 'triad of death' was defined as an INR of >1.5, serum pH of <7.2 and a core temperature of <35 °C. Pre-dose clinical signs, investigations, adverse events and outcomes were analysed. There were 2792 patients in the ANZHR, of which 386 were trauma patients and 45 patients had the 'triad of death'. Patients with the 'triad of death' were significantly older and had higher injury severity scores than other trauma patients, with a mortality of 68.9%. Survivors were significantly less acidaemic (p<0.001) and had significantly less packed red blood cell (PRBC) transfusion prior to rFVIIa administration (p=0.041) than non-survivors with the triad of death. In the face of refractory bleeding, coagulopathy, acidosis and hypothermia following conventional resuscitation, the use of rFVIIa in trauma patients was associated with survival in 31% of patients and may be considered as a management option. Administration of rFVIIa in patients with a pH of <6.91 appears futile.
Publisher: Wiley
Date: 16-07-2020
Publisher: SAGE Publications
Date: 02-09-2021
DOI: 10.1177/18333583211037171
Abstract: Alcohol use is a key preventable risk factor for serious injury. To effectively prevent alcohol-related injuries, we rely on the accurate surveillance of alcohol involvement in injury events. This often involves the use of administrative data, such as International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) coding. To evaluate the completeness and accuracy of using administrative coding for the surveillance of alcohol involvement in major trauma injury events by comparing patient blood alcohol concentration (BAC) with ICD-10-AM coding. This retrospective cohort study examined 2918 injury patients aged ≥18 years who presented to a major trauma centre in Victoria, Australia, over a 2-year period, of which 78% ( n = 2286) had BAC data available. While 15% of patients had a non-zero BAC, only 4% had an ICD-10-AM code suggesting acute alcohol involvement. The agreement between blood alcohol test results and ICD-10-AM coding of acute alcohol involvement was fair ( κ = 0.33, 95% confidence interval: 0.27–0.38). Of the 341 patients with a non-zero BAC, 82 (24.0%) had ICD-10-AM codes related to acute alcohol involvement. Supplementary factors Y90 Evidence of alcohol involvement determined by blood alcohol level codes, which specifically describe patient BAC, were assigned to just 29% of eligible patients with a non-zero BAC. ICD-10-AM coding underestimated the proportion of alcohol-related injuries compared to patient BAC. Given the current role of administrative data in the surveillance of alcohol-related injuries, these findings may have significant implications for the implementation of cost-effective strategies for preventing alcohol-related injuries.
Publisher: CSIRO Publishing
Date: 2008
DOI: 10.1071/AH080246
Abstract: The aim of this study was to pilot a program to encourage shift breaks for emergency department doctors and analyse the effects of breaks on tiredness and fatigue as well as possible effects on overall departmental performance. During Phase 1, medical staff were asked to fill out a survey regarding their working day at the end of every shift. A 30-minute uninterrupted break was promoted during Phase 2 by provision of a cover doctor on the roster as well as educational sessions and posters. There were 233 completed surveys received over the 4-week period. Only 33% of shifts worked included an uninterrupted break in Phase 1, which improved significantly to 60% during Phase 2. Subjective tiredness was significantly lower at the end of a shift when a break was taken (P 0.001), while fatigue levels were also lower, but not significant (P = 0.060). There were significant improvements in some key performance indicators.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2019
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2017
Publisher: BMJ
Date: 25-10-2018
DOI: 10.1136/EMERMED-2016-205950
Abstract: Skin and soft tissue infections (SSTIs) are commonly treated in ED observation units (EDOUs). The management failure rate in this setting is high, as evidenced by a large proportion of patients requiring inpatient admission. This systematic review sought to quantify the management failure rate and identify risk factors associated with management failure. Searches of six databases and grey literature were conducted with no limits on publication year or language. Manuscripts describing patients admitted to an EDOU setting (≤24 hours planned admission to EDOU) with a primary diagnosis of cellulitis or other SSTIs were included. Variables associated with failure of management, defined as inpatient admission, stay hours (4 hours in ED, 24 hours in EDOU) or death, were extracted. A narrative description of variables associated with failure of EDOU admission was conducted. There were 1119 unique articles identified through the literature search. Following assessment, 10 studies were included in the final systematic review, 9 of which reported the management failure rate (range 15%–38%). The presence of fever, a high total white blood cell count and known methicillin-resistant Staphylococcus aureus exposure were the most commonly reported variables associated with management failure. A higher rate of EDOU management failure in SSTIs than the generally accepted rate of 15% was observed in most studies identified by this review. Risk factors identified were varied, but presence of a fever and elevated inflammatory markers were commonly associated with failure of EDOU admission by multiple studies. Recognition of risk factors and the increased application of clinical decision tools may help to improve disposition of patients at high risk for clinical deterioration or management failure.
Publisher: SAGE Publications
Date: 30-11-2022
DOI: 10.1177/14604086221131106
Abstract: The neutrophil-to-lymphocyte ratio has been proposed as a marker of systemic inflammation in major trauma patients that is associated with in-hospital mortality. However, the initial neutrophil-to-lymphocyte ratio does not appear to be predictive of in-hospital mortality. The aim of this study is to determine the discriminative ability of the neutrophil-to-lymphocyte ratio profile over 48 h as a predictor of in-hospital mortality following major trauma. This was a case-control study involving all major trauma patients meeting the criteria for inclusion into the Alfred Health Trauma Registry who presented directly from the scene of injury over a 24-month period. Patients were then ided into two groups, cases being major trauma patients who died at hospital discharge and controls being patients who survived. We extracted data for Day 0, Day 1 and Day 2 neutrophil-to-lymphocyte ratio values for each patient. The primary outcome was mortality at hospital discharge. Data were extracted for 1689 major trauma patients, of which 72% were male, the median age was 49 years (IQR 31–68) and most (90%) patients presented after a blunt mechanism of injury. There were 165 cases that were compared to 1524 controls. Patients who died were older ( p 0.001), and had higher injury severity scores ( p 0.001) and lower revised trauma scores ( p 0.001). Analysis of response profiles demonstrated a significant difference between the trajectories of the neutrophil-to-lymphocyte ratio over time ( p 0.001). The profile of neutrophil-to-lymphocyte ratio over 48 h after injury shows promise as a prognostic tool in trauma and warrants further investigation.
Publisher: Wiley
Date: 06-01-2021
Abstract: The aim of the present study was to describe the epidemiology and clinical features of patients presenting to the ED with suspected and confirmed COVID‐19 during Australia's ‘second wave’. The COVID‐19 ED (COVED) Project is an ongoing prospective cohort study in Australian EDs. This analysis presents data from 12 sites across four Australian states for the period from 1 July to 31 August 2020. All adult patients who met the criteria for ‘suspected COVID‐19’ and underwent testing for SARS‐CoV‐2 in the ED were eligible for inclusion. Study outcomes included a positive SARS‐CoV‐2 test result, mechanical ventilation and in‐hospital mortality. There were 106 136 presentations to the participating EDs and 12 055 (11.4% 95% confidence interval [CI] 11.2–11.6) underwent testing for SARS‐CoV‐2. Of these, 255 (2%) patients returned a positive result. Among positive cases, 13 (5%) received mechanical ventilation during their hospital admission compared to 122 (2%) of the SARS‐CoV‐2 negative patients (odds ratio 2.7 95% CI 1.5–4.9, P = 0.001). Nineteen (7%) SARS‐CoV‐2 positive patients died in hospital compared to 212 (3%) of the SARS‐CoV‐2 negative patients (odds ratio 2.3 95% CI 1.4–3.7, P = 0.001). Strong clinical predictors of the SARS‐CoV‐2 test result included self‐reported fever, sore throat, bilateral infiltrates on chest X‐ray, and absence of a leucocytosis on first ED blood tests ( P 0.05). In this prospective multi‐site study during Australia's ‘second wave’, a substantial proportion of ED presentations required SARS‐CoV‐2 testing and isolation. Presence of SARS‐CoV‐2 on nasopharyngeal swab was associated with an increase in the odds of death and mechanical ventilation in hospital.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2014
Publisher: Wiley
Date: 17-01-2017
Abstract: Research underpins evidence-based practice, but there are significant barriers to conducting research relevant to each clinical discipline. Understanding these barriers could allow strategies to reduce their impact. The present study was undertaken to understand specific barriers to research for emergency medicine (EM) trainees. EM trainees attending research short courses were surveyed. Free-text responses were classified into themes and a list of pre-specified potential barriers was used for ranking purposes. The responders (n = 61/90 67.8%) were young, mostly male with low confidence in leading a research project and limited previous research experience. There were 155 unique barriers identified from 55 respondents, which fitted into nine categories. The most frequently perceived barrier was time (29%), followed by skills (22.6%) and cultural factors (19.4%). Most trainees (n = 54/56, 96.4%) believed that the barriers could be overcome. Strategies suggested included protection of time, mentoring and education, as well as top-down improved research culture. Barriers to research in EM are similar to other specialities and were perceived to be manageable. Reorganisation and refocus of the Australasian College for Emergency Medicine training curriculum may be an option to foster an environment to promote research.
Publisher: Elsevier BV
Date: 09-2015
DOI: 10.1016/J.JOCN.2015.02.030
Abstract: The aim of this systematic review was to determine whether ethanol is neuroprotective or associated with adverse effects in the context of traumatic brain injury (TBI). Approximately 30-60% of TBI patients are intoxicated with ethanol at the time of injury. We performed a systematic review of the literature using a combination of keywords for ethanol and TBI. Manuscripts were included if the population studied was human subjects with isolated moderate to severe TBI, acute ethanol intoxication was studied as an exposure variable and mortality reported as an outcome. The included studies were assessed for heterogeneity. A meta-analysis was performed and the pooled odds ratio (OR) for the association between ethanol and in-hospital mortality reported. There were seven studies eligible for analysis. A statistically significant association favouring reduced mortality with ethanol intoxication was found (OR 0.78 95% confidence interval 0.73-0.83). Heterogeneity among selected studies was not statistically significant (p=0.25). Following isolated moderate-severe TBI, ethanol intoxication was associated with reduced in-hospital mortality. The retrospective nature of the studies, varying definitions of brain injury, degree of intoxication and presence of potential confounders limits our confidence in this conclusion. Further research is recommended to explore the potential use of ethanol as a therapeutic strategy following TBI.
Publisher: Wiley
Date: 22-01-2017
Abstract: This study aimed to quantify the rate of transfer of care or overstay from cellulitis management in the emergency short stay unit (ESSU) and to identify risk factors during initial assessment associated with transfer of care or overstay. A retrospective cohort study was conducted including cellulitis patients diagnosed with and admitted to the ESSU at a metropolitan adult tertiary referral centre. Data abstracted included patient demographics, comorbidities, initial investigations and initial vital signs. Transfer of care or overstay were defined as inpatient admission or a stay in ESSU >28 h, respectively. Of the 451 included patients, 157 (34.8%) met the criteria for transfer of care or overstay. These criteria included admission to hospital inpatient units (115 patients, 73.2%) and patients who overstayed the ESSU time period (42 patients, 26.8%). Variables independently associated with transfer of care or overstay were obesity (adjusted odds ratio [OR] 4.33 95% confidence interval [CI] 1.38-15.59), i.v. drug use (adjusted OR 2.15 95% CI 1.03-4.51), white blood cell count (adjusted OR 1.09 95% CI 1.02-1.16 per 1 × 10 Transfer of care or overstay after admission to ESSU was high among patients with cellulitis. Variables independently associated with transfer of care or overstay were obesity, i.v. drug use, elevated white blood cell count and elevated C-reactive protein. Awareness of these variables can inform appropriate guidelines for ESSU admission, potentially improving patient flow and reducing length of stay in the ED and hospital.
Publisher: Wiley
Date: 25-04-2012
DOI: 10.1111/J.1742-6723.2012.01556.X
Abstract: Early detection of acute traumatic coagulopathy (ATC) might be useful to guide trauma resuscitation. This study aimed to compare results from a point-of-care (POC) international normalised ratio (INR) measuring device with plasma INR in acute trauma patients. This was a single-centre, prospective, blinded comparative study. All trauma patients meeting trauma call-out criteria in a major trauma centre were screened. Patients predicted to have ATC were identified by the Coagulopathy of Severe Trauma score and a convenience s le of 72 patients included in this study. Whole blood was used to measure INR at the bedside, whereas blood from the same s le was sent to the hospital laboratory for plasma INR testing. Agreement between the laboratory and bedside INR was determined using a Bland-Altman plot. There were 38 (52.8%) patients with ATC by laboratory measure, defined as INR >1.5 or activated partial thrombin time >60 s, whereas the POC system identified 28 (38.9%) patients with an INR >1.5. Assuming the laboratory measure as the gold standard, the POC system had a specificity of 88.2% (95% confidence interval 71.6-96.2) and a sensitivity of 63.1% (95% confidence interval 46.0-77.7). Bland-Altman plots demonstrated inadequate agreement between the two methods of INR measurement for the major trauma patient. POC INR measurements using this method during the trauma reception and resuscitative phases cannot be used to identify or exclude patients with ATC. Further studies are required to determine if there is any role for POC INR measures during trauma resuscitation.
Publisher: Mary Ann Liebert Inc
Date: 15-02-2018
Abstract: This systematic review and meta-analysis aimed to determine the prognostic value of S-100β protein to identify patients with post-concussion symptoms after a mild traumatic brain injury (mTBI). A search strategy was submitted to seven databases from their inception to October 2016. In idual patient data were requested. Cohort studies evaluating the association between S-100β protein level and post-concussion symptoms assessed at least seven days after the mTBI were considered. Outcomes were dichotomized as persistent (≥3 months) or early (≥7 days <3 months). Our search strategy yielded 23,298 citations of which 29 studies including between seven and 223 patients (n = 2505) were included. Post-concussion syndrome (PCS) (16 studies) and neuropsychological symptoms (9 studies) were the most frequently assessed outcomes. The odds of having persistent PCS (odds ratio [OR] 0.62, 95% confidence interval [CI]: 0.34-1.12, p = 0.11, I
Publisher: Elsevier BV
Date: 09-2016
Publisher: BMJ
Date: 06-2021
DOI: 10.1136/BMJOPEN-2020-044320
Abstract: To assess the association between soft-shell headgear (HG) use and sports-related concussion (SRC). Secondary objectives were to assess the association between HG and superficial head injury and investigate potential increase in injury risk among HG users. A systematic search in Ovid MEDLINE, Cochrane Library, Scopus, PsycINFO and SPORTDiscus was conducted in April 2020. Inclusion criteria were youth , English language, in vivo studies published after 1980 that evaluated SRC and other injury incidence in HG users compared with non-users. Incidence rates of SRC, superficial head injury or other injuries. Eight studies were eligible. The majority (n=5) reported no difference in the rate of SRC among HG users versus non-users. One rugby study identified significantly lower risk of SRC for non-HG users (risk ratio (RR) 0.63 95% CI 0.41 to 0.98) compared with HG users, whereas a cross-sectional survey of soccer players indicated higher risk of SRC for non-HG users (RR 2.65 95% CI 1.23 to 3.12) compared with HG users. Three of the four studies investigating superficial head injury found no significant differences with HG use, though the soccer survey reported reduced risk among HG users (RR 1.86 95% CI 0.09 to 0.11). Increased incidence of injuries to all body regions for rugby HG users was reported in two studies with adjusted RRs of 1.16 (95% CI 1.04 to 1.29) and 1.23 (95% CI 1.00 to 1.50). HG use was not associated with reduced rates of SRC or superficial head injury in youth soccer and rugby. The possibility of increased injury risk to all body regions for rugby HG users was raised. The need for research specific to youth and female athletes was highlighted. CRD42018115310.
Publisher: Wiley
Date: 08-2010
DOI: 10.1111/J.1742-6723.2010.01309.X
Abstract: To establish the incidence and pattern of injuries in patients presenting to hospital with tram-related injuries. Data on tram-related injury pertaining to 2001-2008 calendar years were extracted from three datasets: the population-based Victorian State Trauma Registry for major trauma cases, the Victorian Emergency Minimum Dataset for ED presentations and the National Coroners' Information System for deaths. Incidence rates adjusted for the population of Melbourne, and trends in the incidence of tram-related ED presentations and major trauma cases, were analysed and presented as incidence rate ratios (IRR). There were 1769 patients who presented to ED after trauma related to trams in Melbourne during the study period. Of these, 107 patients had injuries classified as major trauma. There was a significant increase in the rate of ED presentations (IRR 1.03, P = 0.010) with falls (46%) the most commonly reported mechanism. Most falls occurred inside the trams. There was also a significant increase in the incidence rates of major trauma cases (IRR 1.12, P = 0.006) with pedestrians accounting for most major trauma cases. Most cases of trauma related to trams have minor injuries and are discharged following ED management. Primary prevention of falls in trams and the separation of pedestrians from trams are key areas requiring immediate improvement. In the face of increasing trauma associated with trams, continuing safety surveillance and targeted public safety messages are important to sustain trams as safe and effective mode of transport.
Publisher: Elsevier BV
Date: 09-2007
Publisher: MDPI AG
Date: 28-09-2019
Abstract: Background and objectives: Prompt identification of patients with acute traumatic coagulopathy (ATC) is necessary to expedite appropriate treatment. An early clinical prediction tool that does not require laboratory testing is a convenient way to estimate risk. Prediction models have been developed, but none are in widespread use. This systematic review aimed to identify and assess accuracy of prediction tools for ATC. Materials and Methods: A search of OVID Medline and Embase was performed for articles published between January 1998 and February 2018. We searched for prognostic and predictive studies of coagulopathy in adult trauma patients. Studies that described stand-alone predictive or associated factors were excluded. Studies describing prediction of laboratory-diagnosed ATC were extracted. Performance of these tools was described. Results: Six studies were identified describing four different ATC prediction tools. The COAST score uses five prehospital variables (blood pressure, temperature, chest decompression, vehicular entrapment and abdominal injury) and performed with 60% sensitivity and 96% specificity to identify an International Normalised Ratio (INR) of .5 on an Australian single centre cohort. TICCS predicted an INR of .3 in a small Belgian cohort with 100% sensitivity and 96% specificity based on admissions to resuscitation rooms, blood pressure and injury distribution but performed with an Area under the Receiver Operating Characteristic (AUROC) curve of 0.700 on a German trauma registry validation. Prediction of Acute Coagulopathy of Trauma (PACT) was developed in USA using six weighted variables (shock index, age, mechanism of injury, Glasgow Coma Scale, cardiopulmonary resuscitation, intubation) and predicted an INR of .5 with 73.1% sensitivity and 73.8% specificity. The Bayesian network model is an artificial intelligence system that predicted a prothrombin time ratio of .2 based on 14 clinical variables with 90% sensitivity and 92% specificity. Conclusions: The search for ATC prediction models yielded four scoring systems. While there is some potential to be implemented effectively in clinical practice, none have been sufficiently externally validated to demonstrate associations with patient outcomes. These tools remain useful for research purposes to identify populations at risk of ATC.
Publisher: Elsevier BV
Date: 05-2015
DOI: 10.1016/J.INJURY.2014.12.009
Abstract: Detecting occult bleeding can be challenging and may delay resuscitation. The Shock Index (SI) defined as heart rate ided by systolic blood pressure has attracted attention. Prediction models using combinations of pre-hospital SI (phSI) and the trauma centre SI (tcSI) values may be effective in identifying patients requiring massive blood transfusions (MT). To explore whether combinations of the phSI and the tcSI augment MT prediction. The scores were retrospectively developed using all major trauma patients that presented to The Alfred Hospital between 2006 and 2012. The first PH and TC observations were used. To avoid exclusion of the 'sickest' patients, the SI was imputed to 2 where SBP was missing, but HR was present. We developed 4 models. (i) 'Dichotomised', defined as positive when both phSI and tcSI were ≥1. (ii) 'Formulaic', defined by logistic regression analysis. (iii) 'Combination', defined pragmatically based on the logistic regression. (iv) 'Trending', defined as: tcSI minus phSI. There were 6990 major trauma patients and 360 (5.2%) received MT. There were 1371 cases with either phSI or tcSI missing and were thus excluded from the analysis. The 'Dichotomised' had higher positive predictive value than the tcSI with a further 5 per 100 patients identified. The 'Formulaic' model, defined as: log Odds (MT)=2.16×tcSI+0.89×phSI-5.42, and the 'Combination' model, defined as: phSI×0.5+tcSI, performed equally (AUROC 0.83 versus 0.83, χ(2)=0.86, p=0.35). The 'Formulaic' performed marginally, but statistically significantly, more accurate than the tcSI alone (AUROC 0.83 versus 0.82, χ(2)=6.89, p<0.01). An 'Upward Trending' SI was observed in 1758 patients, revealing a 4.6-fold univariate association with MT (OR 4.55 95%CI 2.64-7.83), and an AUROC of 0.79 (95%CI 0.74-0.83). The 'Downward Trending' SI was protective against MT (OR 0.44 95%CI 0.34-0.57). The initial pre-hospital SI is associated with MT. However, this relationship did not clinically augment MT decision when combined with the in-hospital SI. The simplicity of the SI makes it a favourable option to explore further. Computer-assisted technology in data capturing, analysis and prognostication presents avenues for further research.
Publisher: Elsevier BV
Date: 06-2020
Publisher: Wiley
Date: 11-05-2019
Abstract: Patients with supraventricular tachycardia commonly present to the ED. There is a lack of consensus regarding assessment of these patients. Our aim was to determine the utility of troponin and four other investigations (full blood examination, electrolyte levels, thyroid function tests and chest X-rays) commonly requested for these patients. MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (January 1992-March 2017) were searched for randomised controlled trials and observational studies (of s le size greater than 10). Our search strategy yielded no randomised controlled trials and seven observational studies with significant statistical heterogeneity among selected studies (I
Publisher: Elsevier BV
Date: 05-2017
DOI: 10.1016/J.INJURY.2017.02.013
Abstract: The National Emergency X-Radiography Utilization Study (NEXUS) criteria are used to assess the need for imaging to evaluate cervical spine integrity after injury. The aim of this study was to assess the sensitivity of the NEXUS criteria in older blunt trauma patients. Patients aged 65 years or older presenting between 1st July 2010 and 30th June 2014 and diagnosed with cervical spine fractures were identified from the institutional trauma registry. Clinical examination findings were extracted from electronic medical records. Data on the NEXUS criteria were collected and sensitivity of the rule to exclude a fracture was calculated. Over the study period 231,018 patients presented to The Alfred Emergency & Trauma Centre, of whom 14,340 met the institutional trauma registry inclusion criteria and 4035 were aged ≥65years old. Among these, 468 patients were diagnosed with cervical spine fractures, of whom 21 were determined to be NEXUS negative. The NEXUS criteria performed with a sensitivity of 94.8% [95% CI: 92.1%-96.7%] on complete case analysis in older blunt trauma patients. One-way sensitivity analysis resulted in a maximum sensitivity limit of 95.5% [95% CI: 93.2%-97.2%]. Compared with the general adult blunt trauma population, the NEXUS criteria are less sensitive in excluding cervical spine fractures in older blunt trauma patients. We therefore suggest that liberal imaging be considered for older patients regardless of history or examination findings and that the addition of an age criterion to the NEXUS criteria be investigated in future studies.
Publisher: Elsevier BV
Date: 07-2013
Publisher: SAGE Publications
Date: 25-02-2015
Abstract: Blunt cerebrovascular injury is an infrequent, but potentially devastating cause of morbidity following blunt trauma. Most recommendations regarding treatment of blunt cerebrovascular injury advocate the use of antithrombotic medications, based on biased evidence. We aim to describe the experience with blunt cerebrovascular injury at a major trauma center and to validate the benefits of antithrombotic treatment in blunt cerebrovascular injury. A retrospective cohort study of all adult ( years) patients diagnosed with blunt cerebrovascular injury at a major trauma center over a 6-year period. Outcomes were assessed and analyzed to determine neurological sequelae related specifically to blunt cerebrovascular injury. Blunt cerebrovascular injury had an incidence of 0.57% in our patient population and 97 patients were initially included for analysis. In subsequent analysis, 39 patients (40.2%) were deemed nonassessable and were excluded, leaving 44 treated and 14 untreated patients. There were no differences between the groups in neurological change or outcome. Three treated patients suffered hemorrhagic complications. While there is an association between treatment of blunt cerebrovascular injury with antithrombotics and improved outcomes, selection bias influences these results. Accounting for this bias, the association is no longer demonstrable and treatment does not appear to alter the outcome.
Publisher: Wiley
Date: 04-2014
Abstract: Following findings of the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH-2) trial, tranexamic acid (TxA) use post trauma is becoming widespread. However, issues of generalisability, applicability and predictability beyond the context of study sites remain unresolved. Internal and external validity of the CRASH-2 trial are currently lacking and therefore incorporation of TxA into routine trauma resuscitation guidelines appears premature. The Pre-hospital Antifibrinolytics for Traumatic Coagulopathy and Haemorrhage (PATCH)-Trauma study is a National Health and Medical Research Council-funded randomised controlled trial of early administration of TxA in severely injured patients likely to have acute traumatic coagulopathy. The study population chosen has high mortality and morbidity and is potentially most likely to benefit from TxA's known mechanisms of action. This and further trials involving appropriate s le populations are required before evidence based guidelines on TxA use during trauma resuscitation can be developed.
Publisher: Elsevier BV
Date: 02-2018
Publisher: Wiley
Date: 10-11-2011
DOI: 10.1111/J.1445-2197.2010.05535.X
Abstract: The epidemiology of patients with acute scrotal pain presenting to the emergency department (ED) is largely unknown. Urgent surgical referral is recommended for patients presenting with suspected testicular torsion. However, we have noted an increasing use of Doppler ultrasound (US) as an adjunctive tool in the evaluation of patients with acute scrotal pain. This study aimed to retrospectively review the presentation of patients with acute scrotal pain to a tertiary ED and the use of ultrasound in the assessment of acute scrotal pain. An explicit chart review was performed including all patients presenting to an adult tertiary ED between 2003 and 2008 with acute scrotal pain. The timing of presentation, initial assessment, review by the Urology team and the use of US were recorded. The diagnosis recorded at hospital discharge was the primary end point, while follow-up at outpatient clinic or private urologist rooms was used as a secondary end point. There were 329 patients with acute scrotal pain during the study period, with 294 patients included in the study. Of these, 173 (58.8%) had a US scan performed in the ED. There were 44 (15.0%) patients who underwent scrotal exploration, with 19 having a prior US. There was a significant increase in the use of US over the study period. Colour-flow duplex Doppler ultrasonography appeared to play an increasing role in the assessment for patients presenting with acute testicular pain. Rapid and more reliable assessments of these patients may be possible through greater education of emergency personnel in ultrasonography techniques.
Publisher: Elsevier BV
Date: 11-2014
DOI: 10.1016/J.AENJ.2014.06.001
Abstract: The use of NBs as a mode of analgesia for #NOF in the ED is not common practice despite the reported clinical benefits of quicker onset of pain relief, decreased use of additional analgesia and decreased amounts of analgesia required when more than one mode of analgesia is prescribed. This study aims to test the hypothesis that the implementation of educational and awareness strategies increases knowledge, and implementation of the evidence based use of nerve blocks NB's, as a mode of analgesia for elderly patients with a fractured neck of femur (#NOF) in the Emergency Department (ED). A retrospective clinical audit of medical records using explicit chart review pre and post implementation. Implementation of educational and awareness strategies on pain management to clinical staff in the ED resulted in a significant increase in the administration of NBs, use of multimodal analgesia, and a reduction in average milligrams of morphine administrated to elderly patients with #NOF. The number of older people with #NOF presenting to the ED in Australia is increasing and historically, pain management in this group of patients could be improved. This study demonstrated that an audit, intervention and re-audit design that focused on the implementation of educational and promotional strategies informed by evidence on current and best practice standards were successful in improving delivery of analgesia to elderly patients with #NOF in the ED.
Publisher: Wiley
Date: 28-05-2018
DOI: 10.1111/ACEM.13432
Abstract: The ability of emergency physicians (EPs) to identify hydronephrosis using point-of-care ultrasound (POCUS) has been assessed in the past using computed tomography (CT) scans as the reference standard. We aimed to determine the ability of EPs to identify and grade hydronephrosis on POCUS using the consensus interpretation of POCUS by emergency radiologists as the reference standard. The study was conducted at an urban academic emergency department (ED) as a secondary analysis of previously collected ultrasound data from the EP-performed POCUS databank. Patients were eligible for inclusion if they had both POCUS and CT scanning performed during the index ED visit. Two board-certified emergency radiologists and six EPs interpreted each POCUS study independently. The interpretations were compared with the consensus interpretation by emergency radiologists. Additionally, the POCUS interpretations were also compared with the corresponding CT findings. Institutional approval was obtained for conducting this study. All the analyses were performed using Stata MP 14.0 (StataCorp). A total of 651 patient image-data sets were eligible for inclusion in this study. Hydronephrosis was reported in 69.6% of POCUS examinations by radiologists and 72.7% of CT scans (p = 0.22). Using the consensus radiology interpretation of POCUS as the reference standard, EPs had an overall sensitivity of 85.7% (95% confidence interval [CI] = 84.3%-87.0%), specificity of 65.9% (95% CI = 63.1%-68.7%), positive likelihood ratio of 2.5 (95% CI = 2.3-2.7), and negative likelihood ratio of 0.22 (95% CI = 0.19-0.24) for hydronephrosis. When using CT scan as the reference standard, the EPs had an overall sensitivity of 81.1% (95% CI = 79.6% to 82.5%), specificity of 59.4% (95% CI = 56.4%-62.5%), positive likelihood ratio of 2.0 (95% CI = 1.8-2.2), and negative likelihood ratio of 0.32 (95% CI = 0.29-0.35) for hydronephrosis. The specificity of EPs was improved to 94.6% (95% CI = 93.7%-95.4%) for categorizing the degree of hydronephrosis as "moderate or severe" versus "none or mild," with positive likelihood ratio of 6.33 (95% CI = 5.3-7.5) and negative likelihood ratio of 0.69 (95% CI = 0.66-0.73). Emergency physicians were found to have moderate to high sensitivity for identifying hydronephrosis on POCUS when compared with the consensus interpretation of the same studies by emergency radiologists. These POCUS findings by EPs produced more definitive results when at least moderate degree of hydronephrosis was present.
Publisher: Elsevier BV
Date: 2018
DOI: 10.1016/J.INJURY.2017.08.024
Abstract: Pulmonary thromboembolism (PTE) is a dangerous complication of traumatic injury, with varied risk profiles and treatment options. This review aims to describe reported incidence and variables associated with PTE among severely injured patients. Searches were conducted using PubMed, Cochrane and MEDLINE. Relevant studies were identified by two independent reviewers based on predetermined inclusion criteria. Incidence of PTE was the primary outcome measure. Variables associated with PTE was the secondary outcome measure. The Newcastle-Ottawa Scale was used to assess quality of included studies. There were eight studies that satisfied inclusion criteria. The diagnosed incidence of PTE in these populations ranged from 0.35 to 24%. The most common variables associated with PTE were pelvic or lower limb injury, chest injury, higher total Injury Severity Score, male sex and age. Variables that were less commonly associated with PTE were previous warfarin use, head injury, high serum lactate, soft tissue injury, more than one operation, more than three days on a ventilator, presence of a subclavian central venous catheter, need for a blood transfusion, systolic blood pressure <90mmHg, abdominal injury, presence of a deep venous thrombosis, inferior vena cava filter placement and isolated liver spleen or spinal injuries. The reported incidence of PTE after major trauma is variable and dependent on inclusion criteria, diagnostic criteria and study design. Identified variables differed to those reported for venous thromboembolism in other populations. It is difficult to predict populations at risk of clinically significant PTE following injury using available evidence. Further studies linked to patient-specific variables will assist in more precise risk-stratification and interventions.
Publisher: Wiley
Date: 24-11-2015
Abstract: Despite efforts to restructure mental health (MH) services across Victoria, the social and economic burden of MH illness continues to grow. This study compares MH presentations to EDs with a study undertaken 10 years earlier. The article is a retrospective observational study of MH presentations to four Victorian EDs between May and October 2013. Subjects were included if the presentation was MH related as determined by an International Classification of Diseases (version 10) discharge diagnosis, they were referred to an emergency crisis assessment team or had a documented presenting psychiatric complaint. Variables were extracted from electronic medical records and compared with 2004 data from a previous published study. There were 5659 MH presentations over the 5 months compared with 2788 in 2004. The median ED length of stay decreased from 4:18 h in 2004 to 3:20 h in 2013 (P 4 h from 52.5% to 35.4% (P < 0.001). There was a 22-fold increase in short stay units as discharge destination from 0.9% to 20.2% (P < 0.001). Patients presenting with concurrent meth hetamine exposure doubled from 2.2% of presentations to 4.3% (P < 0.001). Despite increasing MH-related presentations, changes in ED practice have allowed improvements in delivery of care through a shortened ED length of stay and the virtual elimination of very long stays over 24 h. However, there continues to be significant variability in management and performance across hospital sites. Identifying which interventions lead to standout site performance, and subsequent application more broadly, may improve future ED delivery of care.
Publisher: Elsevier BV
Date: 05-2016
Publisher: Elsevier BV
Date: 09-2015
Publisher: Wiley
Date: 05-08-2022
Abstract: Language that implies a conclusion not supported by the evidence is common in the medical literature. The hypothesis of the present study was that medical journal publications are more likely to use misleading language for the interpretation of a demonstrated null (i.e. chance or not statistically significant) effect than a demonstrated real (i.e. statistically significant) effect. This was an observational study of the medical literature with a systematic s ling method. Articles published in The Journal of the American Medical Association , The Lancet and The New England Journal of Medicine over the last two decades were eligible. The language used around the P ‐value was assessed for misleadingness (i.e. either suggesting an effect existed when a real effect did not exist or vice versa). There were 228 unique manuscripts examined, containing 400 statements interpreting a P ‐value proximate to 0.05. The P ‐value was between 0.036 and 0.050 for 303 (75.8%) statements and between 0.050 and 0.064 for 97 (24.3%) statements. Forty‐four (11%) of the statements were misleading. There were 40 (41.2%) false‐positive sentences, implying statistical significance when the P ‐value was .05, and four (1.3%) false‐negative sentences, implying no statistical significance when the P ‐value .05 (relative risk 31.2 95% confidence interval 11.5–85.1 P 0.0001). The proportion of included manuscripts containing at least one misleading sentence was 16.2% (95% confidence interval 12.0–21.6). Among a random selection of sentences in prestigious journals describing P ‐values close to 0.05, 1 in 10 are misleading ( n = 44, 11%) and this is more prevalent when the P ‐values are above 0.05 compared to below 0.05. Caution is advised for researchers, clinicians and editors to align with the context and purpose of P ‐values.
Publisher: Elsevier BV
Date: 2012
DOI: 10.1016/J.INJURY.2010.10.015
Abstract: Acute traumatic coagulopathy is observed in 10-25% of patients post major trauma and its management forms an integral part of haemostatic resuscitation. The identification and treatment of this coagulopathy is difficult and there is uncertainty regarding optimal therapeutic guidelines during the early phases of trauma resuscitation. This study aimed to examine the association between acute coagulopathy and early deaths post major trauma. A retrospective review of data over a 5 year period was performed to determine the associations between variables considered to contribute to mortality for adult major trauma patients (Injury Severity Score (ISS)>15) receiving blood transfusions as part of their initial resuscitation. Early death, defined as death in ED, or death in the operating theatre (OT), Intensive Care Unit (ICU) or wards within 24 h of admission was the primary end-point. Patients with non-survivable head injury on initial imaging were excluded. Univariate associations were calculated and multivariable logistic regression analysis was used to determine independent associations with mortality. There were 772 patients included in this study with a median ISS of 29 (19-41), with 91.7% blunt trauma. All-cause in-hospital mortality was 17.5%, while 77 (9.7%) patients died early. Increasing age (OR 1.04), a GCS of 3-8 (OR 5.05), and the presence of acute coagulopathy (OR 8.77) were significant independent variables associated with early death. Acute traumatic coagulopathy, independent of injury severity, transfusion practice or other physiological markers for haemorrhage, was associated with early death in major trauma patients requiring a blood transfusion. Early recognition and management of coagulopathy, independent of massive transfusion guidelines, may improve outcome from trauma resuscitation. Further studies are required for the early recognition of acute traumatic coagulopathy to enable the development of an evidence base for management.
Publisher: Oxford University Press (OUP)
Date: 2019
DOI: 10.1186/S41038-019-0160-5
Abstract: Early control of haemorrhage and optimisation of physiology are guiding principles of resuscitation after injury. Improved outcomes have been previously associated with single, timely interventions. The aim of this study was to assess the association between multiple timely life-saving interventions (LSIs) and outcomes of traumatic haemorrhagic shock patients. A retrospective cohort study was undertaken of injured patients with haemorrhagic shock who presented to Alfered Emergency & Trauma Centre between July 01, 2010 and July 31, 2014. LSIs studied included chest decompression, control of external haemorrhage, pelvic binder application, transfusion of red cells and coagulation products and surgical control of bleeding through angio-embolisation or operative intervention. The primary exposure variable was timely initiation of ≥ 50% of the indicated interventions. The association between the primary exposure variable and outcome of death at hospital discharge was adjusted for potential confounders using multivariable logistic regression analysis. The association between total pre-hospital times and pre-hospital care times (time from ambulance at scene to trauma centre), in-hospital mortality and timely initiation of ≥ 50% of the indicated interventions were assessed. Of the 168 patients, 54 (32.1%) patients had ≥ 50% of indicated LSI completed within the specified time period. Timely delivery of LSI was independently associated with improved survival to hospital discharge (adjusted odds ratio (OR) for in-hospital death 0.17 95% confidence interval (CI) 0.03–0.83 p = 0.028). This association was independent of patient age, pre-hospital care time, injury severity score, initial serum lactate levels and coagulopathy. Among patients with pre-hospital time of ≥ 2 h, 2 (3.6%) received timely LSIs. Pre-hospital care times of ≥ 2 h were associated with delayed LSIs and with in-hospital death (unadjusted OR 4.3 95% CI 1.4–13.0). Timely completion of LSI when indicated was completed in a small proportion of patients and reflects previous research demonstrating delayed processes and errors even in advanced trauma systems. Timely delivery of a high proportion of LSIs was associated with improved outcomes among patients presenting with haemorrhagic shock after injury. Provision of LSIs in the pre-hospital phase of trauma care has the potential to improve outcomes.
Publisher: CSIRO Publishing
Date: 2017
DOI: 10.1071/AH15052
Abstract: Objectives Rapid disposition protocols are increasingly being considered for implementation in emergency departments (EDs). Among patients presenting to an adult tertiary referral hospital, this study aimed to compare prediction accuracy of a rapid disposition decision at the conclusion of history and examination, compared with disposition following standard assessment. Methods Prospective observational data were collected for 1 month between October and November 2012. Emergency clinicians (including physicians, registrars, hospital medical officers, interns and nurse practitioners) filled out a questionnaire within 5 min of obtaining a history and clinical examination for eligible patients. Predicted patient disposition (representing ‘rapid disposition’) was compared with final disposition (determined by ‘standard assessment’). Results There were 301 patient episodes included in the study. Predicted disposition was correct in 249 (82.7%, 95% confidence interval (CI) 78.0–86.8) cases. Accuracy of predicting discharge to home appeared highest among emergency physicians at 95.8% (95% CI 78.9–99.9). Overall accuracy at predicting admission was 79.7% (95% CI 67.2–89.0). The remaining 20.3% (95% CI 11.0–32.8) were not admitted following standard assessment. Conclusion Rapid disposition by ED clinicians can predict patient destination accurately but was associated with a potential increase in admission rates. Any model of care using rapid disposition decision making should involve establishment of inpatient systems for further assessment, and a culture of timely inpatient team transfer of patients to the most appropriate treating team for ongoing patient management. What is known about the topic? In response to the National Emergency Access Targets, there has been widespread adoption of rapid-disposition-themed care models across Australia. Although there is emerging data that clinicians can predict disposition accurately, this data is currently limited. What does this paper add? Results of this study support the previously limited evidence that ED practitioners can accurately predict disposition early in the patient journey through ED, and that accuracy is similar across clinician groups. In addition to overall prediction accuracy, admission, discharge and treating team predictions were separately measured. These additional outcomes lend insight into safety and performance aspects relating to a rapid disposition model of care. What are the implications for practitioners? This study offers practical insights that could aid safe and efficient implementation of a rapid disposition model of care.
Publisher: Wiley
Date: 13-08-2021
Abstract: The aim of the present study was to describe the characteristics and outcomes of patients presenting to Australian EDs with suspected and confirmed COVID‐19 during 2020, and to determine the predictors of in‐hospital death for SARS‐CoV‐2 positive patients. This analysis from the COVED Project presents data from 12 sites across four Australian states for the period from 1 April to 30 November 2020. All adult patients who met local criteria for suspected COVID‐19 and underwent testing for SARS‐CoV‐2 in the ED were eligible for inclusion. Study outcomes were mechanical ventilation and in‐hospital mortality. Among 24 405 eligible ED presentations over the whole study period, 423 tested positive for SARS‐CoV‐2. During the ‘second wave’ from 1 July to 30 September 2020, 26 (6%) of 406 SARS‐CoV‐2 patients received invasive mechanical ventilation, compared to 175 (2%) of the 9024 SARS‐CoV‐2 negative patients (odds ratio [OR] 3.5 95% confidence interval [CI] 2.3–5.2, P 0.001), and 41 (10%) SARS‐CoV‐2 positive patients died in hospital compared to 312 (3%) SARS‐CoV‐2 negative patients (OR 3.2 95% CI 2.2–4.4, P = 0.001). For SARS‐CoV‐2 positive patients, the strongest independent predictors of hospital death were age (OR 1.1 95% CI 1.1–1.1, P 0.001), higher triage category (OR 3.5 95% CI 1.3–9.4, P = 0.012), obesity (OR 4.2 95% CI 1.2–14.3, P = 0.024) and receiving immunosuppressive treatment (OR 8.2 95% CI 1.8–36.7, P = 0.006). ED patients who tested positive for SARS‐CoV‐2 had higher odds of mechanical ventilation and death in hospital. The strongest predictors of death were age, a higher triage category, obesity and receiving immunosuppressive treatment.
Publisher: Wiley
Date: 14-01-2020
DOI: 10.1111/BCP.14128
Publisher: Elsevier BV
Date: 07-2018
DOI: 10.1016/J.AUCC.2017.06.003
Abstract: Traumatic brain injury (TBI) is a significant public health issue. Assessing pupil reactivity is a crucial aspect of its management and the pupillometer has been shown to be a more objective tool compared to the standard penlight. Its use, however, is not widespread. To investigate the paucity in uptake, we examined the frequency of use of pupillometers (NeurOptics An online cross-sectional survey. Surveys were distributed five months after the introduction of pupillometers (in May 2015) to ICU doctors and nurses working in a quaternary referral centre providing state services for trauma. The survey included sections on: questions on demographics and experience, methods of conventional pupillary assessment in patients with TBI, experience of using the pupillometer, and questions on barriers to its use. Responses were collated as discrete variables and summarised using counts and proportions. Comparisons among proportions were undertaken using the chi-squared test and reported with 95% confidence intervals. A total of 79 responses were recorded, predominantly 94.9% (n=75) from nursing staff. A total of 50 (63.3%) responders were using the pupillometers, with a mean frequency-of-use rating of 4.67 out of 10 and a mean user-friendliness rating of 6.28 out of 10. There was no association between frequency of use and user-friendliness (p=0.36). The main identified barriers to its use included a lack of education with regards to its use, a perceived lack of clinical significance, a lack of standardisation of documenting findings, and difficulties with access to disposable patient shields (Smartguards). There was good adoption of the technology in the early phases of ICU implementation with user-friendliness rated favourably. In this paper we identify barriers to use and discuss possible solutions to increase clinical utility.
Publisher: BMJ
Date: 06-2020
DOI: 10.1136/BMJOPEN-2019-033236
Abstract: To assess the effect of a mobile phone application for prehospital notification on resuscitation and patient outcomes. Longitudinal prospective cohort study with preintervention and postintervention cohorts. Major trauma centre in India. Injured patients being transported by ambulance and allocated to red (highest) and yellow (medium) triage categories. A prehospital notification application for use by ambulance and emergency clinicians to notify emergency departments (EDs) of an impending arrival of a patient requiring advanced lifesaving care. The primary outcome was the proportion of eligible patients arriving at the hospital for which prehospital notification occurred. Secondary outcomes were the availability of a trauma cubicle, presence of a trauma team on patient arrival, time to first chest X-ray, and ED and in-hospital mortality. Data from January 2017 to January 2018 were collected with 208 patients in the preintervention and 263 patients in the postintervention period. The proportion of patients arriving after prehospital notification improved from 0% to 11% (p .001). After the intervention, more patients were managed with a trauma call-out (relative risk (RR) 1.30 95% CI: 1.10 to 1.52) a trauma bay was ready for more patients (RR 1.47 95% CI: 1.05 to 2.05) and a trauma team leader present for more patients (RR 1.50 95% CI: 1.07 to 2.10). There was no difference in time to the initial chest X-ray (p=0.45). There was no association with mortality at hospital discharge (RR 0.94 95% CI: 0.72 to 1.23), but the intervention was associated with significantly less risk of patients dying in the ED (RR 0.11 95% CI: 0.03 to 0.39). The prehospital notification application for severely injured patients had limited uptake but implementation was associated with improved trauma reception and reduction in early deaths. Quality improvement efforts with ongoing data collection using the trauma registry are indicated to drive improvements in trauma outcomes in India. NCT02877342 .
Publisher: SAGE Publications
Date: 02-09-2021
Abstract: Pre-existing disease is a common contributor to mortality and morbidity after injury and resuscitation of injured patients are often altered in hospital based on comorbidities. However, this is uncommon in the pre-hospital phase of care where patients are managed according to clinical practice guidelines. This study aimed to quantify the prevalence of cardiovascular disease (CVD) and liver disease among trauma patients attended by pre-hospital clinicians but who died prior to reaching hospital and assess associations with age. This was a retrospective review of pre-hospital trauma deaths in the state of Victoria, Australia between 01 Jan 2008 and 31 Dec 2014. The inclusion criteria were (a) patients attended by pre-hospital clinicians, (b) deceased before arrival to hospital, (c) evidence of recent trauma and (d) underwent a full autopsy. Cardiovascular and liver disease status were extracted from autopsy reports. There were 1043 patients included in this study. Most patients were male (77.1%). Intentional self-harm was significantly more common in patients aged ≥65 years (17.4%). CVD was prevalent in 495 (47.5% 95%CI: 44.4–50.5) cases with myocardial fibrosis the most common abnormality detected. All sub-groups of CVD demonstrated a significant association with increasing age, except right ventricular hypertrophy. Liver disease was present in 235 (22.5% 95%CI: 20.1-25.2) patients and most common among patients aged 35–64 years. CVD was prevalent in almost half of all injured patients included in this study while liver disease was present in about a fifth. The prevalence of CVD was associated with increasing age, while liver disease was more common among middle-aged patients. This high prevalence in our population indicates that pre-existing cardiovascular and liver disease be considered when tailoring pre-hospital life-saving interventions for injured patients.
Publisher: AMPCo
Date: 07-2009
DOI: 10.5694/J.1326-5377.2009.TB02666.X
Abstract: To examine the response of the Victorian State Trauma System to the February 2009 bushfires. A retrospective review of the strategic response required to treat patients with bushfire-related injury in the first 72 hours of the Victorian bushfires that began on 7 February 2009. Emergency department (ED) presentations and initial management of patients presenting to the state's adult burns centre (The Alfred Hospital [The Alfred]) were analysed, as well as injuries and deaths associated with the fires. There were 414 patients who presented to hospital EDs as a result of the bushfires. Patients were triaged at the emergency scene, at treatment centres and in hospital. National and statewide burns disaster plans were activated. Twenty-two patients with burns presented to the state's burns referral centres, of whom 18 were adults. Adult burns patients at The Alfred spent 48.7 hours in theatre in the first 72 hours. There were a further 390 bushfire-related ED presentations across the state in the first 72 hours. Most patients with serious burns were triaged to and managed at burns referral centres. Throughout the disaster, burns referral centres continued to have substantial surge capacity. Most bushfire victims either died, or survived with minor injuries. As a result of good prehospital triage and planning, the small number of patients with serious burns did not overload the acute health care system.
Publisher: Elsevier BV
Date: 04-2018
DOI: 10.1016/J.EURURO.2017.11.001
Abstract: Renal colic is a common, acute presentation of urolithiasis that requires immediate pain relief. European Association of Urology guidelines recommend nonsteroidal anti-inflammatory drugs (NSAIDs) as the preferred analgesia. However, the fear of NSAID adverse effects and the uncertainty about superior analgesic effect have maintained the practice of advocating intravenous opioids as the initial analgesia. The objective of this systematic review and meta-analysis was to compare the safety and efficacy of NSAIDs with opioids and paracetamol (acetaminophen) for the management of acute renal colic. Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, World Health Organization International Clinical Trials Registry Platform, Google Scholar, and the reference list of retrieved articles were searched up to December 2016 without language restrictions. Two reviewers independently assessed eligible studies using the Cochrane Collaboration tool for assessing and reporting the risk of bias and abstracted data using predefined data fields. From 468 potentially relevant studies, 36 randomized controlled trials (RCTs) including 4887 patients, published between 1982 and 2016, were included in this systematic review. The treatment effect observed indicated marginal benefit of NSAIDs over opioids in initial pain reduction at 30min (11 RCTs, n=1985, mean difference [MD] -5.58, 95% confidence interval [CI] -10.22 to -0.95 heterogeneity I NSAIDs were equivalent to opioids or paracetamol in the relief of acute renal colic pain at 30min. There was less vomiting and fewer requirements for rescue analgesia with NSAIDs compared with opioids. Patients treated with NSAIDs required less rescue analgesia compared with paracetamol. Despite observed heterogeneity among the included studies and the overall quality of evidence, the findings of a lower need for rescue analgesia and fewer adverse events, in conjunction with the practical advantages of ease of delivery, suggest that NSAIDs should be the preferred analgesic option for patients presenting to the emergency department with renal colic. In kidney stone-related acute pain episodes in patients with adequate renal function, treatment with nonsteroidal anti-inflammatory drugs offers effective and most sustained pain relief, with fewer side effects, when compared with opioids or paracetamol.
Publisher: Springer Science and Business Media LLC
Date: 18-01-2016
Publisher: AMPCo
Date: 2006
Publisher: SAGE Publications
Date: 12-07-2023
DOI: 10.1177/20494637231189031
Abstract: The prescription of opioids in emergency care has been associated with harm, including overdose and dependence. The aim of this trial was to assess restriction of access to oxycodone (ROXY), in combination with education and guideline modifications, versus education and guideline modifications alone (standard care) to reduce oxycodone administration in the Emergency Department (ED). An unblinded, active control, randomised controlled trial was conducted in an adult tertiary ED. Participants were patients aged 18–75 years who had analgesics administered in the ED. The primary intervention was ROXY, through removal of all oxycodone immediate release tablets from the ED imprest, with availability of a small supply after senior clinician approval. The intervention did not restrict prescription of discharge medications. The primary outcome measure was oxycodone administration rates. Secondary outcomes were administration rates of other analgesic medications, time to initial analgesics and oxycodone prescription on discharge. There were 2258 patients eligible for analysis. Oxycodone was administered to 80 (6.1%) patients in the ROXY group and 221 (23.3%) patients in the standard care group (relative risk (RR) 0.26 95% CI: 0.21 to 0.33 p .001). Tapentadol was prescribed more frequently in the ROXY group (RR 2.17 95% CI: 1.71–2.74), while there were no differences in prescription of other analgesic medications. On discharge, significantly fewer patients were prescribed oxycodone (RR 0.51 95% CI: 0.39–0.66) and no differences were observed in prescription rates of other analgesic medications. There was no difference in time to first analgesic (HR 0.94 95% CI: 0.86–1.02). Restricted access to oxycodone was superior to education and guideline modifications alone for reducing oxycodone use in the ED and reducing discharge prescriptions of oxycodone from the ED. The addition of simple restrictive interventions is recommended to enable rapid changes to clinician behaviour to reduce the potential harm associated with the prescribing of oxycodone in the ED.
Publisher: Wiley
Date: 04-2013
Abstract: In the past decade, there has been substantial knowledge translation in the use of ultrasound (US) by critical care physicians to aid diagnosis of the non-trauma patient. This study aimed to determine emergency doctors' level of training in ultrasonography, pattern of US use in regular practice and barriers to US use for the non-trauma patient presenting to an emergency department. A survey on the use of US in non-trauma patients was conducted, targeting all emergency physicians and emergency medicine trainees in a single adult tertiary referral centre. The response rate was 92.7% with 38 completed surveys analysed. A course in non-trauma US had been completed by 58% of respondents. The most common non-trauma formal US training was in vascular access (82%, 95% confidence interval [CI] 66.8-90.6), detection of abdominal aortic aneurysm (79%, 95% CI 63.7-88.9) and pericardial fluid (84%, 95% CI 69.6-92.6). Upon completion of formal training, US was used significantly more frequently for obtaining vascular access (odds ratio [OR] 12.0), detection of abdominal aortic aneurysms (OR 4.3) and detection of pericardial fluid (OR 15.5). Most doctors felt the greatest barriers to the use of US in the non-trauma patient were the lack of teaching, confidence in findings, experienced supervisors and time. Among ED personnel, use of US to diagnose several non-traumatic conditions was low, but specific training was associated with significantly more US use. Increased training and availability of US-experienced supervisors might further improve utility of this important adjunct to the practice of emergency medicine.
Publisher: Springer Science and Business Media LLC
Date: 12-2016
DOI: 10.1007/S00068-015-0605-X
Abstract: The management of haemodynamically stable patients who present following a penetrating abdominal injury (PAI) remains variable between mandatory surgical exploration and more selective non-operative approaches. The primary aim of this study was to assess compliance with an algorithm guiding selective non-operative management of haemodynamically stable patients with PAI. The secondary aim was to examine the association between compliance and unnecessary laparotomies. This was a retrospective cohort study involving all patients with PAI that presented to a major trauma centre from January 2007 to December 2011. Data were extracted from the trauma registry and patients' electronic medical records. There were 189 patients included in the study, of which 79 (41.8 %) patients complied with the algorithm. The laparotomy rate in the setting of algorithm compliance was significantly lower than algorithm non-compliance (12.7 vs. 68.2 % p < 0.01) as were unnecessary laparotomy rates (0 vs. 33.3 % p = 0.03). Among haemodynamically stable patients presenting with PAI, compliance with an algorithm guiding selective non-operative management was low, but associated with lower laparotomy and lower unnecessary laparotomy rates. Improved compliance with algorithms directed towards selective non-operative management of PAI should be encouraged with stringent vigilance towards patient safety.
Publisher: Hamad bin Khalifa University Press (HBKU Press)
Date: 10-05-2017
Abstract: Background: Cardiac injury is uncommon, but it is important to diagnose, in order to prevent subsequent complications. Extended focused assessment with sonography in trauma (eFAST) allows rapid evaluation of the pericardium and thorax. The objective of this study was to describe cardiac injuries presenting to a major trauma centre and the diagnostic performance of eFAST in detecting haemopericardium as well as broader cardiac injuries. Methods: Data of patients with severe injuries and diagnosed cardiac injuries (Injury Severity Score and AIS 2008 codes for cardiac injuries) were extracted from The Alfred Trauma Registry over a four-year period from July 2010 to June 2014. The initial eFAST results were compared to those of the final diagnosis, which were determined after analysing imaging results and intraoperative findings. Results: Thirty patients who were identified with cardiac injuries met the inclusion criteria. Among these, 22 patients sustained injuries under the scope of eFAST, of which a positive eFAST scan in the pericardium was reported in 13 (59%) patients, while nine (41%) patients had a negative scan. This resulted in a sensitivity of 59% (95% CI: 36.7%–78.5%). The sensitivity of detecting any cardiac injuries was lower at 43.3% (95% CI: 26.0–62.3). Conclusions: The low sensitivities of eFAST for detecting cardiac injuries and haemopericardium demonstrate that a negative result cannot be used in isolation to exclude cardiac injuries. A high index of suspicion for cardiac injury remains essential. Adjunct diagnostic modalities are indicated for the diagnosis of cardiac injury following major trauma.
Publisher: Wiley
Date: 21-09-2023
DOI: 10.1111/ANS.18055
Abstract: After trauma, clearance of the cervical spine refers to the exclusion of underlying serious injuries. Accurate assessment of computed tomography (CT) is commonly required prior to clearance of the cervical spine. Delays to clearance can lead to prolonged immobilization with associated patient discomfort and adverse effects. This systematic review aimed to determine performance of non‐radiologists to evaluate cervical spine CT. MEDLINE, EMBASE, Cochrane library with sources of grey literature and reference lists of selected articles were appraised from inception to April 2021. We included manuscripts that reported discordance in CT cervical spine interpretation between non‐radiologists and radiologists. The Newcastle–Ottawa scale (NOS) was used to assess quality of included studies and statistical heterogeneity was assessed using the I 2 statistic. There were 43 studies identified for eligibility and 4 manuscripts included in the final analysis. There were two studies that reported on the performance of radiology residents, one study on the performance of surgical residents and one on emergency physicians. The pooled discordance was 0.25 (95%CI 0.21–0.28) but was lower for radiology residents (range 0.007–0.05). There was significant statistical heterogeneity ( I 2 = 99.6%, P 0.001) among studies. There is a paucity of evidence documenting the ability of non‐radiologists in accurately interpreting CT of the cervical spine. A number of discordant findings suggest that studies with larger s le sizes are indicated to accurately ascertain the ability of non‐radiologists in this area.
Publisher: Elsevier BV
Date: 04-2007
DOI: 10.1016/J.JTCVS.2006.10.028
Abstract: Single-lung transplantation for chronic obstructive pulmonary disease can cause unique postoperative problems that might require independent lung ventilation. We evaluated preoperative and immediate postoperative factors to predict the need for independent lung ventilation. We retrospectively studied 170 patients who received a single-lung transplant over a 15-year period, 20 (12%) of whom required independent lung ventilation. Patients requiring independent lung ventilation were similar in age, sex, ischemic time, and donor characteristics to those who required conventional ventilation. Patients receiving independent lung ventilation had a greater degree of preoperative airflow limitation, more hyperinflation, lower postoperative PaO2/fraction of inspired oxygen ratios, more radiologic mediastinal shift, and more transplant lung infiltrate on the postoperative chest radiograph. Multivariate logistic regression analysis showed that independent lung ventilation was associated with increasing levels of recipient hyperinflation (percentage total lung capacity compared with predicted value odds ratio, 1.04 95% confidence interval, 1.01-1.07 P = .032) and reduced early postoperative PaO2/fraction of inspired oxygen ratio (odds ratio, 0.97 95% confidence interval, 0.95-0.99 P = .005). Length of ventilation and intensive care unit stay and mortality were higher in the independent lung ventilation group. Among patients who survived to hospital discharge, there were no differences in long-term mortality between the 2 groups. The need for independent lung ventilation in patients undergoing single-lung transplantation for obstructive lung disease is predicted by the combination of increased hyperinflation measured on recipients' preoperative lung function tests and a low PaO2/fraction of inspired oxygen ratio, indicating graft dysfunction in the immediate postoperative period.
Publisher: Elsevier BV
Date: 2018
DOI: 10.1016/J.INJURY.2017.08.056
Abstract: Computed tomography of the brain (CTB) has a fundamental role in the diagnosis and management of traumatic brain injury (TBI). There may be substantial discordance between initial CTB interpretation by emergency clinicians and the final radiology report. This study aimed to assess the utility of a structured reporting template in improving the accuracy of CTB interpretation by emergency clinicians. A prospective pre- and post-intervention cohort study was undertaken using a study population of emergency medicine trainees. The CTB reporting template was created with consultation from radiology, emergency medicine and trauma specialists. Participants reported on a set of randomly selected trauma CTBs first without, and then with, the reporting template. Each case was independently assessed for concordance with the radiology report by two blinded assessors (including a radiologist) and the proportion of concordant reports in each phase calculated. There were 26 participants recruited to the study who reported on a total of 320 CTBs. In the pre-intervention phase, 121 (76%) cases were concordant with the radiology report compared to 147 (92%) post-intervention (p<0.01). The AUROC was 0.84 (95% CI: 0.78-0.89) pre-intervention and improved to 0.94 (95% CI: 0.88-0.99) with the intervention (p=0.01). A higher level of baseline accuracy was observed in advanced trainees (78%) compared to basic trainees (72%), but both improved to a similar level of 92% with the use of the CTB reporting template. There was a marked reduction in false negative errors, with increased identification of critical diagnoses such as cerebral herniation and diffuse axonal injury. The use of the CTB reporting template significantly increased the accuracy of emergency medicine trainees and reduced the number of missed critical diagnoses. Reporting templates may represent an effective strategy to improve CTB interpretation and enhance the initial care of head injured patients.
Publisher: Elsevier BV
Date: 2015
DOI: 10.1016/J.INJURY.2014.08.050
Abstract: Red blood cell (RBC) transfusion is often essential during trauma resuscitation but is associated with high cost and potential adverse outcomes. This study aimed to determine the incidence of potentially avoidable RBC transfusions (PAT) among adult major trauma patients. A retrospective review of data collected by Registry on patients presenting between Jan 2006 and Dec 2011 was conducted. Eligible patients received at least 1 unit of RBC in the first 24h following presentation to the Emergency Department (ED). Episodes of PAT were determined according to haemodynamic stability and post-transfusion haemoglobin levels. There were 621 patients included, of whom 224 (36.1% 95% CI: 32.3-40.0) received PAT. Of them, 132 (58.9%) were haemodynamically stable on arrival and did not require a surgical procedure. Patients with PAT had significantly lower injury severity scores (30 vs 34, p<0.01), higher presenting systolic blood pressure (129 vs 112mm Hg, p<0.01) and a lower frequency of a shock index ≥1 (24.1 vs 65.0%, p<0.01), compared to those without PAT. They also had a significantly lower mortality (13.4 vs 21.7%, p<0.01). PAT after trauma was common and often delivered to haemodynamically stable patients who did not require surgical procedures. Clinical decision pathways for trauma resuscitation should aim to limit PAT.
Publisher: S. Karger AG
Date: 12-12-2023
DOI: 10.1159/000526217
Abstract: b i Introduction: /i /b The aim of this systematic review was to investigate whether viscoelastic haemostatic assays (VHAs) offer comparative diagnostic ability of acute traumatic coagulopathy (ATC) compared to the standard laboratory coagulation tests (SLCT). ATC is a complication of major trauma characterized by dysfunctional blood clotting, leading to an increased bleeding risk. Additionally, we aimed to analyse the association of VHA with blood product use and health outcomes. b i Methods: /i /b The search protocol was pre-published and completed on December 2, 2020, assessing manuscripts from 2000 until the present. We searched MEDLINE, Embase, Cochrane Central, BIOSIS, Emcare, CINAHL, and additional online resources and referenced lists. Included were manuscripts that quantitatively reported the detection of ATC using VHAs and SLCTs. A meta-analysis was undertaken including observational studies that reported on patients with injuries to all body regions and results analysed using a random-effects model and reported using pooled odds ratio with 95% confidence intervals (CI). b i Results: /i /b There were 14 observational studies and one randomized control trial involving 2,715 participants that satisfied inclusion criteria. We observed significant heterogeneity in the definitions of ATC, study design, setting, and patient population. Among observational studies that reported on patients with injuries to all body regions, VHAs were associated with higher odds of diagnosing ATC compared to SLCT (pooled OR 2.4 95% CI: 1.4–4.1). There was inadequate evidence to suggest VHAs were associated with reduced blood product usage or lower mortality. b i Conclusion: /i /b VHAs detected more patients with ATC compared to SLCTs. However, the clinical significance and applicability of this finding remains unknown as translation to management was not adequately reported.
Publisher: BMJ
Date: 03-2021
DOI: 10.1136/BMJOPEN-2020-046522
Abstract: Haemorrhage causes most preventable prehospital trauma deaths and about a third of in-hospital trauma deaths. Tranexamic acid (TXA), administered soon after hospital arrival in certain trauma systems, is an effective therapy in preventing or managing acute traumatic coagulopathy. However, delayed administration of TXA appears to be ineffective or harmful. The effectiveness of prehospital TXA, incidence of thrombotic complications, benefit versus risk in advanced trauma systems and the mechanism of benefit remain uncertain. The Pre-hospital Anti-fibrinolytics for Traumatic Coagulopathy and Haemorrhage (The PATCH-Trauma study) is comparing TXA, initiated prehospital and continued in hospital over 8 hours, with placebo in patients with severe trauma at risk of acute traumatic coagulopathy. We present the trial protocol and an overview of the statistical analysis plan. There will be 1316 patients recruited by prehospital clinicians in Australia, New Zealand and Germany. The primary outcome will be the eight-level Glasgow Outcome Scale Extended (GOSE) at 6 months after injury, dichotomised to favourable (GOSE 5–8) and unfavourable (GOSE 1–4) outcomes, analysed using an intention-to-treat (ITT) approach. Secondary outcomes will include mortality at hospital discharge and at 6 months, blood product usage, quality of life and the incidence of predefined adverse events. The study was approved by The Alfred Hospital Research and Ethics Committee in Victoria and also approved in New South Wales, Queensland, South Australia, Tasmania and the Northern Territory. In New Zealand, Northern A Health and Disability Ethics Committee provided approval. In Germany, Witten/Herdecke University has provided ethics approval. The PATCH-Trauma study aims to provide definitive evidence of the effectiveness of prehospital TXA, when used in conjunction with current advanced trauma care, in improving outcomes after severe injury. NCT02187120 .
Publisher: Wiley
Date: 25-06-2019
Abstract: To determine the relationships between: (i) total ED length of stay (EDLOS) and in-hospital mortality, ward clinical deterioration and (ii) between time of bed request, ward transfer and in-hospital mortality, with a particular focus on patients transferred just prior to a 4 h EDLOS. Retrospective cohort study using data from three acute care hospitals in Melbourne, Australia. Adult patients admitted from the ED to a non-monitored ward within 8 h. Patients were sub-grouped by EDLOS EDLOS 3.5-4 h compared to 0-3.5 h and 4-8 h. In-hospital mortality, number of medical emergency team (MET)/cardiac arrest team (CAT) events. A total of 24 746 patients were included: 4396 patients with EDLOS 240 min. Mortality overall was 2.2% (n = 545), highest mortality was seen with EDLOS >4 h (2.4%, n = 399) and lowest in patients with EDLOS 3.5-4 h (1.5%, n = 63, OR 0.67 [95% CI: 0.47-0.93, P = 0.02]). Time from bed request to transfer of >240 min was associated with increased odds of death at hospital discharge (adjusted OR 1.39 [95% CI: 1.08-1.78]). There was no difference in rate of MET calls within 24 h between groups (3.5-4 h = 64 [1.5%], <3.5 h = 60 [1.5%], 4-8 h = 235 [1.4%]). Both shorter time in ED and shorter time between bed request and ward transfer were independently associated with improved outcomes. Whole of hospital measures to reduce length of stay in the ED should focus on shorter ward transfer times after bed request.
Publisher: Saudi Medical Journal
Date: 03-2019
Publisher: Elsevier BV
Date: 05-2020
Publisher: Wiley
Date: 27-02-2022
Abstract: The wide‐spread use of an initial ‘Glasgow Coma Scale (GCS) 8 or less’ to define and dichotomise ‘severe’ from ‘mild’ or ‘moderate’ traumatic brain injury (TBI) is an out‐dated research heuristic that has become an epidemiological convenience transfixing clinical care. Triaging based on GCS can delay the care of patients who have rapidly evolving injuries. Sole reliance on the initial GCS can therefore provide a false sense of security to caregivers and fail to provide timely care for patients presenting with GCS greater than 8. Nearly 50 years after the development of the GCS – and the resultant misplaced clinical and statistical definitions – TBI remains a heterogeneous entity, in which ‘best practice’ and ‘prognoses’ are poorly stratified by GCS alone. There is an urgent need for a paradigm shift towards more effective initial assessment of TBI.
Publisher: Elsevier BV
Date: 09-2010
Publisher: Discover STM Publishing Ltd.
Date: 2020
Publisher: Wiley
Date: 07-03-2018
DOI: 10.1002/JPPR.1381
Publisher: Wiley
Date: 31-10-2022
Abstract: The objectives of the present study were to report the proportion of older teenagers, including the subgroup operating a motor vehicle, presenting to an adult major trauma centre after injury with a positive blood alcohol concentration (BAC) over a 12‐year period. This was a registry‐based cohort study, including all patients aged 16–19 years presenting to an adult major trauma centre in Victoria, Australia from January 2008 to December 2019 and included in the trauma registry. A Poisson regression model was used to test for change in incidence of positive BAC associated trauma and summarised using incidence rate ratios (IRRs) and 95% confidence intervals (CIs). There were 1658 patients included for analysis and alcohol was detected in 368 (22.2% 95% CI 20.2–24.3). Most alcohol positive presentations were on weekend days ( n = 207 56.3%) and most were males ( n = 307). Over the 12‐year period, there was a reduction in the incidence of older teenagers presenting with a positive BAC (IRR 0.95 95% CI 0.93–0.98 P = 0.001). Among patients presenting after trauma in the setting of operating a motor vehicle ( n = 545), alcohol was detected in 80 (14.7%) with no significant change in incidence of positive BAC (IRR 0.95 95% CI 0.89–1.02 P = 0.17). A substantial proportion of older teenagers included in the registry had alcohol exposure prior to trauma. Despite a modest down‐trending incidence, the need for continuing preventive measures is emphasised. In particular, preventive efforts should be targeted at male, older teenagers undertaking drinking activities on weekend days and driving motor vehicles.
Publisher: Springer Science and Business Media LLC
Date: 17-10-2014
DOI: 10.1007/S00068-013-0341-Z
Abstract: Pancreatic enzymes are routinely measured during reception of trauma patients to assess for pancreatic injury despite conflicting evidence on their utility. The aim of this study was to investigate the utility of routine initial serum lipase measurement for the diagnosis of acute pancreatic trauma. Lipase measurements were introduced as part of the trauma pathology panel and requested on all patients who presented to an adult major trauma service and met trauma call-out criteria. Clinical records of these patients were extracted from the trauma registry and retrospectively reviewed. The performance of an initial serum lipase level measured on presentation to detect pancreatic trauma was determined. There were 2,580 patients included in the study, with 17 patients diagnosed with pancreatic trauma. An elevated lipase was recorded in 390 patients. Statistically significant associations were observed for elevated lipase in patients with pancreatic trauma, head injury, acute alcohol ingestion and massive blood transfusion. As a test for pancreatic trauma, an abnormal serum lipase result had a specificity of 85.3 % (95 % CI 83.8-86.6), sensitivity of 76.5 % (95 % CI 49.8-92.2), positive predictive value of 3.3 % (95 % CI 1.8-5.8) and negative predictive value of 99.8 % (95 % CI 99.4-99.9). Higher cut-offs of serum lipase did not result in better performance. A normal serum lipase result can be a useful adjunct to exclude pancreatic injury. A positive lipase result, regardless of the cut-off used, was not reliably associated with pancreatic trauma, and should not be used to guide further assessment.
Publisher: Elsevier BV
Date: 03-2017
Publisher: Wiley
Date: 21-10-2013
DOI: 10.1111/ANS.12417
Abstract: The effectiveness of massive transfusion protocols (MTPs) has been assumed from low quality studies with multiple biases. This review aimed to (i) evaluate the association between the institution of an MTP and mortality and (ii) determine the effect of MTPs on transfusion practice post trauma. A systematic review of studies that examined patient outcomes before and after the institution of an MTP in the same centre was conducted. The design and results of each study were described. Heterogeneity was assessed using the Q test and the I(2) statistic. Odds ratios (ORs) for dichotomous outcomes from each study were pooled. There were eight studies that satisfied inclusion criteria with marked heterogeneity in study populations (I(2) = 72.1%, P = 0.001). Two studies showed significantly improved mortality following implementation of an MTP, and six studies showed no significant change. Pooled OR for the effect of an MTP on short-term mortality was 0.73 (95% confidence interval: 0.48-1.11). The effect of MTPs on transfusion practice was varied. Despite the popularity of MTPs and directives mandating their use in trauma centres, in before-after studies, MTPs have not always been associated with improved mortality. Evidence-based standardization of MTPs, improved compliance and analysis of broader endpoints were identified as areas for further research.
Publisher: Hindawi Limited
Date: 22-03-2021
DOI: 10.1111/JCPT.13414
Abstract: Thrombolysis with Alteplase (rtPA) improves functional outcome among selected patients after acute ischaemic stroke. Benefits are most pronounced with early intervention. Our aim is to assess door to needle time (DTNT) for acute stroke after a stroke call-out redesign including addition of an emergency medicine (EM) pharmacist to the team. A retrospective cohort of stroke patients who received rtPA was compared to a prospective cohort after stroke callout re-design in an adult major referral hospital in metropolitan Melbourne, Australia. All patients who presented during EM pharmacist working hours and were thrombolysed in the ED for stroke from December 2011-June 2014 pre and July 1 There were 218 patients eligible, 64 patients pre and 122 patients post implementation were included. The cohorts were similar in demographics. There was a significant association of time to thrombolysis (HR 1.61 95% CI: 1.18-2.20 p = 0.003) with the intervention. Median DTNT improved from 73 (IQR 52-111) min to 61 (IQR 47-80) min (p = 0.012). Interrupted time-series analysis did not demonstrate intervention at the single time-point of implementation of the intervention to be associated with the improvement. Re-design of the stroke call-out team that included addition of an EM pharmacist was associated with improvements in DTNT. The effect of in idual interventions at one point in time could not be demonstrated.
Publisher: Springer Science and Business Media LLC
Date: 06-2017
DOI: 10.1007/S40266-017-0472-8
Abstract: Falls are a leading cause of preventable hospitalizations from long-term care facilities (LTCFs). Polypharmacy and falls-risk medications are potentially modifiable risk factors for falling. This study investigated whether polypharmacy and falls-risk medications are associated with fall-related hospital admissions from LTCFs compared with hospital admissions for other causes. This was a hospital-based, case-control study of patients aged ≥65 years hospitalized from LTCFs. Cases were patients with falls and fall-related injuries, and controls were patients admitted for infections. Conditional logistic regression was used to calculate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between polypharmacy (defined as the use of nine or more regular pre-admission medications) and falls-risk medications (categorized as psychotropic medications and those that can cause orthostatic hypotension) with fall-related hospital admissions. There was no association between polypharmacy and fall-related hospital admissions (adjusted OR 0.97, 95% CI 0.63-1.48) however, the adjusted odds of fall-related hospital admissions increased by 16% (95% CI 3-30%) for each additional falls-risk medication. Medications that can cause orthostatic hypotension (adjusted OR 1.25, 95% CI 1.06-1.46), but not psychotropic falls-risk medications (adjusted OR 1.02, 95% CI 0.88-1.18) were associated with fall-related hospital admissions. The association between medications that can cause orthostatic hypotension and fall-related hospital admissions was strongest among residents with polypharmacy (adjusted OR 1.44, 95% CI 1.08-1.92). Polypharmacy was not an independent risk factor for fall-related hospital admissions however, medications that can cause orthostatic hypotension were associated with fall-related hospital admissions, particularly among residents with polypharmacy. Falls-risk should be considered when prescribing medications that can cause orthostatic hypotension.
Publisher: SAGE Publications
Date: 07-04-2020
Abstract: Exposure to head acceleration events (HAEs) has been associated with player sex, player position, and player experience in North American football, ice hockey, and lacrosse. Little is known of these factors in professional Australian football. Video analysis allows HAE verification and characterization of important determinants of injury. To characterize verified HAEs in the nonhelmeted contact sport of professional Australian football and investigate the association of sex, player position, and player experience with HAE frequency and magnitude. Descriptive epidemiology study. Professional Australian football players wore a nonhelmeted accelerometer for 1 match, with data collected across 14 matches. HAEs with peak linear accelerations (PLAs) ≥30 g were verified with match video. Verified HAEs were summarized by frequency and median PLA and compared between the sexes, player position, and player experience. Characterization of match-related situations of verified HAEs was conducted, and the head impact rate per skill execution was calculated. 92 male and 118 female players were recruited during the 2017 season. Male players sustained more HAEs (median, 1 IQR, 0-2) than female players (median, 0 IQR, 0-1 P = .007) during a match. The maximum PLAs incurred during a match were significantly higher in male players (median, 61.8 g IQR, 40.5-87.1) compared with female players (median, 44.5 g IQR, 33.6-74.8 P = .032). Neither player position nor experience was associated with HAE frequency. Of all verified HAEs, 52% (n = 110) occurred when neither team had possession of the football, and 46% (n = 98) were caused by contact from another player attempting to gain possession of the football. A subset of HAEs (n = 12 5.7%) resulted in players seeking medical aid and/or being removed from the match (median PLA, 58.8 g IQR, 34.0-89.0), with 2 (male) players diagnosed with concussion after direct head impacts and associated PLAs of 62 g and 75 g, respectively. In the setting of catching (marking) the football, female players exhibited twice the head impact rate (16 per 100 marking contests) than male players (8 per 100 marking contests). Playing situations in which players have limited control of the football are a common cause of impacts. Male players sustained a greater exposure to HAEs compared with female players. Female players, however, sustained higher exposure to HAEs than male players during certain skill executions, possibly reflecting differences in skill development. These findings can therefore inform match and skill development in the emerging professional women’s competition of Australian football.
Publisher: Informa UK Limited
Date: 07-12-2022
DOI: 10.1080/13825585.2020.1857327
Abstract: This investigation assessed the relationship between subjective self-reports and objective measures of prospective memory with forty-eight healthy, community-dwelling older-adults (> 65 years). The Prospective and Retrospective Memory Questionnaire provided the self-report data, the Cambridge Prospective Memory Test was used as a clinic-based test, and the Telephone Task (telephoning the examiner at irregular, pre-scheduled times across one week) was used as a naturalistic measure. The self-reported difficulties were negatively associated with performance on the naturalistic task,
Publisher: Informa UK Limited
Date: 19-02-2021
Publisher: Informa UK Limited
Date: 20-11-2018
DOI: 10.1080/02699052.2017.1385097
Abstract: This systematic review aimed to determine the prognostic value of neuron-specific enolase (NSE) to predict post-concussion symptoms following mild traumatic brain injury (TBI). Seven databases were searched for studies evaluating the association between NSE levels and post-concussion symptoms assessed ≥ 3 months (persistent) or ≥ 7 days < 3 months (early) after mild TBI. Two researchers independently screened studies for inclusion, extracted data and appraised quality using the Quality in Prognostic Studies (QUIPS) tool. The search strategy yielded a total of 23,298 citations from which 8 cohorts presented in 10 studies were included. Studies included between 45 and 141 patients (total 608 patients). The outcomes most frequently assessed were post-concussion syndrome (PCS, 12 assessments) and neuropsychological performance deficits (10 assessments). No association was found between an elevated NSE serum level and PCS. Only one study reported a statistically significant association between a higher NSE serum level and alteration of at least three cognitive domains at 2 weeks but this association was no longer significant at 6 weeks. Overall, risk of bias of the included studies was considered moderate. Early NSE serum level is not a strong independent predictor of post-concussion symptoms following mild TBI.
Publisher: Wiley
Date: 17-11-2012
DOI: 10.1111/J.1423-0410.2011.01564.X
Abstract: Early prediction of massive transfusion (MT) post-trauma may reduce mortality by earlier delivery of blood products. A clinical prediction tool (PWH score) for this purpose was developed at the Prince of Wales Hospital, Hong Kong. The aims of this study were to apply this tool to major trauma patients in Victoria, Australia and compare the score to the Assessment of Blood Consumption (ABC) score and the Trauma-Associated Severe Haemorrhage (TASH) score. A retrospective review of patients entered into the The Alfred Trauma Registry between January 2006 and December 2009 was conducted. The performance of the PWH score to predict MT defined by 5 units of packed red blood cells in 4 h was compared with the ABC and TASH scores. Included patients presented to the Emergency & Trauma Centre from the scene and had had complete datasets with respect to the components of the three scores. There were 1234 patients included in the study with 195 (15·8%) receiving a MT and an overall mortality of 14·0%. The PWH score had an area under the receiver operating characteristics (ROC) curve of 0·842 (95% CI: 0·820-0·862). The area under the ROC curve of the PWH score was significantly less than that of the TASH score (χ(2)=19·8, P<0·001) and significantly greater than that of the ABC score (χ(2)=9·3, P=0·002). The PWH score performs with similar accuracy when applied to an Australian population as in its derivation population. The relative simplicity of the PWH score makes it a viable tool for clinical use, although utility of such tools may be more suited for research in determining inclusion or exclusion criteria for comparative outcome studies.
Publisher: Wiley
Date: 02-02-2018
DOI: 10.1111/VOX.12637
Abstract: Management of major haemorrhage as a result of trauma is particularly challenging when blood is not an option (BNAO). Evidence on therapeutic strategies in this situation is limited. The aim of this study was to evaluate the management and outcomes of patients who identified themselves as Jehovah's Witnesses (who usually refuse blood products) with traumatic haemorrhage at an Australian major trauma centre. A retrospective review of patients from The Alfred Trauma Registry was conducted, including patients who were Jehovah's Witnesses presenting between January 2010 and January 2017. We examined demographics, injury characteristics, clinical progress, therapeutic interventions and outcomes at hospital discharge. There were 34 patients meeting inclusion criteria, with 50% suffering major trauma. Anaemia was a clinical problem for 13 (38·2%) patients, with haemoglobin levels reaching a nadir of 69·7 g/l (95% CI: 56·7-82·7) on average 5·1 days (95% CI: 2·5-7·7) post admission. Various strategies were employed to reduce blood loss including six (46·2%) patients receiving tranexamic acid, nine (29·2%) patients receiving oral or intravenous iron and five (38·5%) receiving erythropoietin. Three patients received packed red cells, and two patients received synthetic haemoglobin-based oxygen carriers. Numerous therapeutic strategies were employed inconsistently in this unique population of patients. Augmenting circulatory volume with an oxygen carrier acceptable to JW patients presents a novel approach to be considered in adjunct to other strategies. An international resource centre would assist clinicians faced with anaemia and BNAO.
Publisher: AMPCo
Date: 03-2010
Publisher: BMJ
Date: 09-06-2016
DOI: 10.1136/EMERMED-2015-205450
Abstract: During assessment after injury, the log roll examination, in particular palpation of the thoracolumbar spine, has low sensitivity for detecting spinal injury. The manoeuvre itself requires a pause during trauma resuscitation. The aim of this study was to assess the utility of the log roll examination in unconscious trauma patients for the diagnosis of soft tissue and thoracolumbar spine injuries. A retrospective cohort study was undertaken, reviewing the cases of unconscious (Glasgow Coma Scale (GCS) 12, abbreviated injury scale 2008) patients from the Alfred Trauma Registry, over a 2-year period from January 2011 to December 2012. Log roll examination findings, as documented in the medical record, were compared with CT reports. Out of the 624 screened records, 222 (35.6%) were excluded as the log roll or CT/MRI had not been performed. There were a total of 2028 major trauma presentations to the Alfred Hospital Emergency and Trauma Centre during the study period. Excluded cases comprised 147 patients who did not have a documented log roll, and 75 patients who did not have a CT or MRI. Of the 402 cases that met inclusion criteria, 35.3% had a thoracolumbar fracture, and the sensitivity of log roll examination was found to be 27.5%, with a specificity of 91%. The negative likelihood ratio for abnormalities on log roll was low (0.8). Examination of the back in unconscious trauma patients could be limited to visual inspection only to allow identification of penetrating wounds and other soft tissue injuries (including of the posterior scalp) and removal of foreign bodies, in patients planned for CT scans. The low sensitivity and poor negative likelihood ratio suggest that a normal log roll examination does not accurately predict the absence of bony injury to the thoracolumbar spine.
Publisher: Wiley
Date: 21-05-2015
DOI: 10.1111/ACEM.12687
Abstract: The rapid uptake of nurse practitioner (NP) services in Australia has outpaced evaluation of this service model. A randomized controlled trial was conducted to compare the effectiveness of NP service versus standard medical care in the emergency department (ED) of a major referral hospital in Australia. Patients presenting with pain were randomly assigned to receive either standard ED medical care or NP care. Primary investigators were blinded to treatment allocation for data analyses. The primary outcome measure was the proportion of patients receiving analgesia within 30 minutes from being seen by care group. Secondary outcome measures were time to analgesia from presentation and documentation of and changes in pain scores. There were 260 patients randomized 128 received standard care (medical practitioner led), and 130 received NP care. Two patients needed to be excluded due to incomplete consent forms. The proportion of patients who received analgesia within 30 minutes from being seen was 49.2% (n = 64) in the NP group and 29.7% (n = 38) in the standard group, a difference of 19.5% (95% confidence interval [CI] = 7.9% to 31.2% p = 0.001). Of 165 patients who received analgesia, 64 (84.2%) received analgesia within 30 minutes in the NP group compared to 38 (42.7%) in the standard care group, a difference in proportions of 41.5% (95% CI = 28.3% to 54.7% p < 0.001). The mean (±SD) time from being seen to analgesia was 25.4 (±39.2) minutes for NP care and 43.0 (±35.5) minutes for standard care, a difference of 17.6 minutes (95% CI = 6.1 to 29.1 minutes p = 0.003). There was a difference in the median change in pain score of 0.5 between care groups, but this was not statistically significant (p = 0.13). Nurse practitioner service effectiveness was demonstrated through superior performance in achieving timely analgesia for ED patients.
Publisher: Wiley
Date: 17-12-2020
DOI: 10.1111/VOX.12875
Abstract: Haemorrhage-associated calcium loss may lead to disruption of platelet function, intrinsic and extrinsic pathway-mediated haemostasis and cardiac contractility. Among shocked major trauma patients, we aimed to investigate the association between admission hypocalcaemia and adverse outcomes. Data were extracted from the Alfred Trauma Registry and the Alfred Applications and Knowledge Management Department for all adult major trauma patients presenting directly from the scene with a shock index ≥1 from 1 July 2014 to 30 June 2018. Patients with pre-hospital blood transfusion were excluded. Ionized hypocalcaemia was defined as 1·5. Multivariable logistic regression analysis was used to assess the association between admission hypocalcaemia and acute traumatic coagulopathy that was adjusted for Injury Severity Score, initial GCS, bicarbonate and lactate. There were 226 patients included in final analysis with 113 (50%) patients recording ionized hypocalcaemia on presentation prior to any blood product transfusion. Ionized hypocalcaemia was associated with coagulopathy in patients with shock index ≥1 (adjusted OR 2·9 95% CI: 1·01-8·3, P = 0·048). Admission ionized hypocalcaemia was also associated with blood transfusion requirement in the first 24 h post-admission in 62·5% of hypocalcaemic patients as compared to 37·5% of normocalcaemic patients (P < 0·001). Admission ionized hypocalcaemia was associated with death at hospital discharge (25·6% among hypocalcaemic patients compared to 15·0% of normocalcaemic patients (P = 0·047)). Hypocalcaemia was a common finding in shocked trauma patients and was independently associated with acute traumatic coagulopathy. The early, protocolized administration of calcium to trauma patients in haemorrhagic shock warrants further assessment in randomized controlled trials.
Publisher: Wiley
Date: 31-05-2023
DOI: 10.1111/ACEM.14745
Abstract: Transfusion of a high ratio of plasma to packed red blood cells (PRBCs), to treat or prevent acute traumatic coagulopathy, has been associated with survival after major trauma. However, the effect of prehospital plasma on patient outcomes has been inconsistent. The aim of this pilot trial was to assess the feasibility of transfusing freeze‐dried plasma with red blood cells (RBCs) using a randomized controlled design in an Australian aeromedical prehospital setting. Patients attended by helicopter emergency medical service (HEMS) paramedics with suspected critical bleeding after trauma managed with prehospital RBCs were randomized to receive 2 units of freeze‐dried plasma (Lyoplas N‐w) or standard care (no plasma). The primary outcome was the proportion of eligible patients enrolled and provided the intervention. Secondary outcomes included preliminary data on effectiveness, including mortality censored at 24 h and at hospital discharge, and adverse events. During the study period of June 1 to October 31, 2022, there were 25 eligible patients, of whom 20 (80%) were enrolled in the trial and 19 (76%) received the allocated intervention. Median time from randomization to hospital arrival was 92.5 min (IQR 68–101.5 min). Mortality may have been lower in the freeze‐dried plasma group at 24 h (RR 0.24, 95% CI 0.03–1.73) and at hospital discharge (RR 0.73, 95% CI 0.24–2.27). No serious adverse events related to the trial interventions were reported. This first reported experience of freeze‐dried plasma use in Australia suggests prehospital administration is feasible. Given longer prehospital times typically associated with HEMS attendance, there is potential clinical benefit from this intervention and rationale for a definitive trial.
No related grants have been discovered for Biswadev Mitra.