Are prehospital deaths from trauma and accidental injury preventable? A direct historical comparison to assess what has changed in two decades.

BACKGROUND & OBJECTIVES: In 1994, Hussain and Redmond revealed that up to 39% of prehospital deaths from accidental injury might have been preventable had basic first aid care been given. Since then there have been significant advances in trauma systems and care. The exclusion of prehospital deaths from the analysis of trauma registries, giv en the high rate of those, is a major limitation in prehospital research on preventable death. We have repeated the 1994 study to identify any changes over the years and potential developments to improve patient outcomes. METHODS: We examined the full Coroner's inquest files for prehospital deaths from trauma and accidental injury over a three-year period in Cheshire. Injuries were scored using the Abbreviated-Injury-Scale (AIS-1990) and Injury Severity Score (ISS), and probability of survival estimated using Bull's probits to match the original protocol. RESULTS: One hundred and thirty-four deaths met our inclusion criteria; 79% were male, average age at death was 53.6 years. Sixty-two were found dead (FD), fifty-eight died at scene (DAS) and fourteen were dead on arrival at hospital (DOA). The predominant mechanism of injury was fall (39%). The median ISS was 29 with 58 deaths (43%) having probability of survival of >50%. Post-mortem evidence of head injury was present in 102 (76%) deaths. A bystander was on scene or present immediately after injury in 45% of cases and prior to the Emergency Medical Services (EMS) in 96%. In 93% of cases a bystander made the call for assistance, in those DAS or DOA, bystander intervention of any kind was 43%. CONCLUSIONS: The number of potentially preventable prehospital deaths remains high and unchanged. First aid intervention of any kind is infrequent. There is a potentially missed window of opportunity for bystander intervention prior to the arrival of the ambulance service, with simple first-aid manoeuvres to open the airway, preventing hypoxic brain injury and cardiac arrest.

Prehospital deaths from trauma: Are injuries survivable and do bystanders help?

BACKGROUND AND OBJECTIVES: Deaths from trauma occurring in the prehospital phase of care are typically excluded from analysis in trauma registries. A direct historical comparison with Hussain and Redmond's study on preventable prehospital trauma deaths has shown that, two decades on, the number of potentially preventable deaths remains high. Using updated methodology, we aimed to determine the current nature, injury severity and survivability of traumatic prehospital deaths and to ascertain the presence of bystanders and their role following the point of injury including the frequency of first-aid delivery. METHODS: We examined the Coroners' inquest files for deaths from trauma, occurring in the prehospital phase, over a three-year period in the Cheshire and Manchester (City), subsequently referred to as Manchester, Coronial jurisdictions. Injuries were scored using the Abbreviated-Injury-Scale (AIS-2008), Injury Severity Score (ISS) calculated and probability of survival estimated using the Trauma Audit and Research Network's outcome prediction model. RESULTS: One hundred and seventy-eight deaths were included in the study (one hundred and thirty-four Cheshire, forty-four Manchester). The World Health Organisation's recommendations consider those with a probability of survival between 25-50% as potentially preventable and those above 50% as preventable. The median ISS was 29 (Cheshire) and 27.5 (Manchester) with sixty-two (46%) and twenty-six (59%) respectively having a probability of survival in the potentially preventable and preventable ranges. Bystander presence during or immediately after the point of injury was 45% (Cheshire) and 39% (Manchester). Bystander intervention of any kind was 25% and 30% respectively. Excluding those found dead and those with a probability of survival less than 25%, bystanders were present immediately after the point of injury or "within minutes" in thirty-three of thirty-five (94%) Cheshire and ten of twelve (83%) Manchester. First aid of any form was attempted in fourteen of thirty-five (40%) and nine of twelve (75%) respectively. CONCLUSIONS: A high number of prehospital deaths from trauma occur with injuries that are potentially survivable, yet first aid intervention is infrequent. Following injury there is a potential window of opportunity for the provision of bystander assistance, particularly in the context of head injury, for simple first-aid manoeuvres to save lives.

The extent of soft tissue and musculoskeletal injuries after earthquakes; describing a role for reconstructive surgeons in an emergency response.

BACKGROUND: Earthquakes are the leading cause of natural disaster-related mortality and morbidity. Soft tissue and musculoskeletal injuries are the predominant type of injury seen after these events and a major reason for admission to hospital. Open fractures are relatively common; however, they are resource-intense to manage. Appropriate management is important in minimising amputation rates and preserving function. This review describes the pattern of musculoskeletal and soft-tissue injuries seen after earthquakes and explores the manpower and resource implications involved in their management. METHODS: A Medline search was performed, including terms "injury pattern" and "earthquake," "epidemiology injuries" and "earthquakes," "plastic surgery," "reconstructive surgery," "limb salvage" and "earthquake." Papers published between December 1992 and December 2012 were included, with no initial language restriction. RESULTS: Limb injuries are the commonest injuries seen accounting for 60 % of all injuries, with fractures in more than 50 % of those admitted to hospital, with between 8 and 13 % of these fractures open. After the first few days and once the immediate lifesaving phase is over, the management of these musculoskeletal and soft-tissue injuries are the commonest procedures required. CONCLUSIONS: Due to the predominance of soft-tissue and musculoskeletal injuries, plastic surgeons as specialists in soft-tissue reconstruction should be mobilised in the early stages of a disaster response as part of a multidisciplinary team with a focus on limb salvage.

The UK medical response to the Sichuan earthquake.

BACKGROUND: At 14:48 on 12 May 2008 an earthquake of magnitude 8.0 struck the Wenchuan area of Sichuan province, China. A decision to offer/receive UK medical assistance was agreed at a Sino/British political level and a medical team was despatched to the earthquake area. METHODS: This study describes the team's experience during the immediate aftermath of the earthquake and the following 18 months, during which there have been joint developments in emergency medicine, disaster planning/preparedness and the management of spinal cord injury. RESULTS: The long-term disability following sudden onset natural disaster and the wider impact on healthcare delivery may prove to be a greater burden to the country than the immediate medical needs, and, accordingly, emergency international aid may need to widen its focus. Although international teams usually arrive too late to support resuscitative measures, they can respond to specific requests for specialised assistance, for example plastic and reconstructive surgery to assist with the ongoing management of complex injury, relieve those who have worked continuously through the disaster, and when required maintain routine day-to-day services while local staff continue to manage the disaster. The timing of this does not necessarily need to be immediate. CONCLUSIONS: To maximise its impact, the team planned from the outset to build a relationship with Chinese colleagues that would lead to a sharing of knowledge and experience that would benefit major incident responses in both countries in the future. This has been established, and the linkage of emergency humanitarian assistance to longer term development should be considered by others the next time international emergency humanitarian assistance is contemplated.

Cardiopulmonary arrest in general wards: a retrospective study of referral patterns to an intensive care facility and their influence on outcome.

OBJECTIVE: To analyse the effect on outcome of referral to specialist facilities after cardiopulmonary arrest in a general ward. METHODS: A retrospective analysis of resuscitation records of 743 patients in whom cardiopulmonary resuscitation was performed in a general ward between 1988 and 1992. After successful initial cardiopulmonary resuscitation, patients were identified as transferred to coronary care unit (CCU) or intensive care unit (ITU), or as staying in a general ward. MAIN OUTCOME MEASURE: Survival to discharge home. RESULTS: There were 322 initial survivors, of whom 148 (20% of the overall total) survived to be discharged from hospital; 63% of those transferred to CCU and 48% of those transferred to ITU survived to discharge, compared with 28% of those who stayed on the ward (P < 0.001). Of those aged less than 65 years, 75% survived to discharge after transfer to CCU and 54% after transfer to ITU, compared with 44% of those who stayed on the ward (P = 0.023); the respective figures for those over 65 years were: CCU 25%, ITU 34%, ward 25% (P = 0.014). Only half of those aged more than 65 years were transferred to a specialist facility, compared with 90% of those aged less than 65. CONCLUSIONS: Transfer to a specialist care facility after resuscitation from cardiopulmonary arrest has an influence on outcome. Age as an independent factor is not an appropriate criterion to use in deciding on transfer. The decision to arrange transfer must always be taken by the most experienced person available, and in line with peer reviewed guidelines.

A comparison of symptoms experienced following minor head injury and acute neck strain (whiplash injury).

The symptoms reported by patients who have experienced minor head or minor neck injury are compared. Symptoms were identified using a questionnaire-based out-patients interview. Rank order correlation analyses were carried out on data obtained at 2 and 6-12 weeks post-injury. Data on 24 head-injured and 29 neck-injured patients are presented. There was a significant rank order correlation at both assessments but neck injured patients reported more phobia (fear of travelling in car) and depression, and head-injured more dizziness. It is likely that neck-injury contributes to the symptomatology experienced after minor head injury, and vice-versa.

Non-specific abdominal pain: a safe diagnosis?

Non-specific abdominal pain (NSAP) is a benign condition with low morbidity. This follow-up study of 82 patients discharged from an emergency department after presenting with abdominal pain, during 1 calendar month, has shown that only 9.6% were diagnosed as having NSAP. It has been shown previously that 34.9% to 45.6% of patients presenting to an emergency department with abdominal pain will have NSAP. One large study showed that 88% of NSAP had improved or resolved at 2-3 weeks without specific treatment and few required subsequent hospitalization. In this study a number of patients were given diagnoses which could not be supported from the history or investigations. This is a potentially dangerous practice. NSAP is a diagnosis of exclusion and the patient may be reassured that the condition is most likely benign or self limiting and allowed home.

Uses and abuses of statistical models for evaluating trauma care.

OBJECTIVE: A statistical model is a powerful tool for evaluating trauma care. With accident and emergency clinicians becoming more aware of the importance of monitoring their department's performance, there is a danger that such models may be inappropriately applied to new sets of trauma cases, resulting in misleading evaluations. The primary objective is to present a method for assessing whether an existing survival probability model can be correctly applied to a different data set. METHODS: Correct and incorrect utilization of statistical models for evaluating the mortality of trauma patients are presented. Circumstances that may lead to the modification of an existing model, and the use of statistical models for evaluating different aspects of trauma care, are suggested.

Are pre-hospital deaths from accidental injury preventable?

OBJECTIVE: To determine what proportion of pre-hospital deaths from accidental injury--deaths at the scene of the accident and those that occur before the person has reached hospital--are preventable. DESIGN: Retrospective study of all deaths from accidental injury that occurred between 1 January 1987 and 31 December 1990 and were reported to the coroner. SETTING: North Staffordshire. MAIN OUTCOME MEASURES: Injury severity score, probability of survival (probit analysis), and airway obstruction. RESULTS: There were 152 pre-hospital deaths from accidental injury (110 males and 42 females). In the same period there were 257 deaths in hospital from accidental injury (136 males and 121 females). The average age at death was 41.9 years for those who died before reaching hospital, and their average injury severity score was 29.3. In contrast, those who died in hospital were older and equally likely to be males or females. Important neurological injury occurred in 113 pre-hospital deaths, and evidence of airway obstruction in 59. Eighty six pre-hospital deaths were due to road traffic accidents, and 37 of these were occupants in cars. On the basis of the injury severity score and age, death was found to have been inevitable or highly likely in 92 cases. In the remaining 60 cases death had not been inevitable and airway obstruction was present in up to 51 patients with injuries that they might have survived. CONCLUSION: Death was potentially preventable in at least 39% of those who died from accidental injury before they reached hospital. Training in first aid should be available more widely, and particularly to motorists as many pre-hospital deaths that could be prevented are due to road accidents.

The significance of patient appearance in predicting severity of injury.

The observations of pallor, sweating, agitation and restlessness, at the time of an injured patient's admission to the resuscitation room, were compared with other more complex indices of injury severity and the ability of each observation to predict mortality was observed. The number of positive observations was significantly related to the Revised Trauma Score and the Injury Severity Score, and pallor was significantly related to mortality. The observation that an injured patient is pale is an important index of severity.

CPR and the RCP (1). Training of doctors in NHS hospitals.

Six years after the Royal College of Physicians published its report, most hospitals in the UK with acute coronary beds fail to train or test their doctors adequately in the skills of cardiopulmonary resuscitation. Doctors want more training, and consultants try to give it, but there is a lack of funds for this basic yet critical task.

A trauma center for the United Kingdom.

In July 1991, a pilot trauma center was established in the United Kingdom as part of a government-funded evaluation of trauma services. The North Staffordshire Hospital is at the center of a trauma system that serves 2 million people. This system involves the five surrounding hospitals and the ambulance service. Key developments have been the provision of a consultant trauma team leader in the center 24 hours a day, closer networking of all the hospitals, and an expansion of the paramedic training program. Two comparator sites have been identified and are also being studied. The results of this three-year experiment are being evaluated independently and by the trauma research group of Keele University. Whatever the outcome, the project will have a significant influence on the future development of trauma care in the United Kingdom.

The North Staffordshire Trauma System.

The first trauma centre in the UK has been established at the North Staffordshire Hospital in Stoke-on-Trent. The early development of this centre and the wider system within which it functions is described. The Trauma Centre and corresponding evaluation project by the University of Sheffield have been funded by the Department of Health. The outcome for injured patients treated in the new trauma system over a 4-year period will be compared with outcomes from existing systems in and around comparator sites in Preston and Hull. These findings will inform the debate on the future of trauma care in the UK.