Performance characteristics of five triage tools for major incidents involving traumatic injuries to children.

UNLABELLED: Context Triage tools are an essential component of the emergency response to a major incident. Although fortunately rare, mass casualty incidents involving children are possible which mandate reliable triage tools to determine the priority of treatment. OBJECTIVE: To determine the performance characteristics of five major incident triage tools amongst paediatric casualties who have sustained traumatic injuries. DESIGN, SETTING, PARTICIPANTS: Retrospective observational cohort study using data from 31,292 patients aged less than 16 years who sustained a traumatic injury. Data were obtained from the UK Trauma Audit and Research Network (TARN) database. Interventions Statistical evaluation of five triage tools (JumpSTART, START, CareFlight, Paediatric Triage Tape/Sieve and Triage Sort) to predict death or severe traumatic injury (injury severity score >15). Main outcome measures Performance characteristics of triage tools (sensitivity, specificity and level of agreement between triage tools) to identify patients at high risk of death or severe injury. RESULTS: Of the 31,292 cases, 1029 died (3.3%), 6842 (21.9%) had major trauma (defined by an injury severity score >15) and 14,711 (47%) were aged 8 years or younger. There was variation in the performance accuracy of the tools to predict major trauma or death (sensitivities ranging between 36.4 and 96.2%; specificities 66.0-89.8%). Performance characteristics varied with the age of the child. CareFlight had the best overall performance at predicting death, with the following sensitivity and specificity (95% CI) respectively: 95.3% (93.8-96.8) and 80.4% (80.0-80.9). JumpSTART was superior for the triaging of children under 8 years; sensitivity and specificity (95% CI) respectively: 86.3% (83.1-89.5) and 84.8% (84.2-85.5). The triage tools were generally better at identifying patients who would die than those with non-fatal severe injury. CONCLUSION: This statistical evaluation has demonstrated variability in the accuracy of triage tools at predicting outcomes for children who sustain traumatic injuries. No single tool performed consistently well across all evaluated scenarios.

In 'big bang' major incidents do triage tools accurately predict clinical priority?: a systematic review of the literature.

INTRODUCTION: The term "big bang" major incidents is used to describe sudden, usually traumatic,catastrophic events, involving relatively large numbers of injured individuals, where demands on clinical services rapidly outstrip the available resources. Triage tools support the pre-hospital provider to prioritise which patients to treat and/or transport first based upon clinical need. The aim of this review is to identify existing triage tools and to determine the extent to which their reliability and validity have been assessed. METHODS: A systematic review of the literature was conducted to identify and evaluate published data validating the efficacy of the triage tools. Studies using data from trauma patients that report on the derivation, validation and/or reliability of the specific pre-hospital triage tools were eligible for inclusion.Purely descriptive studies, reviews, exercises or reports (without supporting data) were excluded. RESULTS: The search yielded 1982 papers. After initial scrutiny of title and abstract, 181 papers were deemed potentially applicable and from these 11 were identified as relevant to this review (in first figure). There were two level of evidence one studies, three level of evidence two studies and six level of evidence three studies. The two level of evidence one studies were prospective validations of Clinical Decision Rules (CDR's) in children in South Africa, all the other studies were retrospective CDR derivation, validation or cohort studies. The quality of the papers was rated as good (n=3), fair (n=7), poor (n=1). CONCLUSION: There is limited evidence for the validity of existing triage tools in big bang major incidents.Where evidence does exist it focuses on sensitivity and specificity in relation to prediction of trauma death or severity of injury based on data from single or small number patient incidents. The Sacco system is unique in combining survivability modelling with the degree by which the system is overwhelmed in the triage decision system. The practicalities, training implications, performance characteristics and reliance on computer technology during a mass casualty incident require further evaluation.

Chest decompression during the resuscitation of patients in prehospital traumatic cardiac arrest.

BACKGROUND: Tension and bilateral pneumothorax can cause or contribute to death following trauma. A surgical incision (thoracostomy) or needle decompression through the chest wall rapidly treats these conditions. Resuscitation of patients in traumatic cardiac arrest focuses on treating common and reversible life-threatening conditions. A study was undertaken to observe the practice, findings and outcome of chest decompression when performed as part of the resuscitation strategy of these patients by air ambulance crews. METHODS: Patients in prehospital traumatic cardiac arrest were identified over a 39-month period from an air ambulance database. The use of thoracostomy or needle decompression was identified together with indications, findings and outcome. Primary outcome was return of cardiac output by arrival at hospital. RESULTS: 18 of 37 cases underwent chest decompression (17 thoracostomy, 1 needle decompression). Four patients had a return of cardiac output (3 tension pneumothorax, 1 bilateral pneumothorax). Six further cases were positive for intrathoracic injury. In 2 cases the injuries identified were incompatible with life and resuscitation efforts were consequently ceased. CONCLUSIONS: Chest decompression in traumatic cardiac arrest identifies and treats a high proportion of potentially life-ending injuries and should be considered as part of the resuscitation effort of patients in traumatic cardiac arrest. In a proportion of patients, non-survivable injuries are identified which guide resuscitation efforts.

Influence of air ambulance doctors on on-scene times, clinical interventions, decision-making and independent paramedic practice.

BACKGROUND: Critics of air ambulance doctors question their contribution and believe on-scene time is prolonged. Two helicopter emergency medical service (HEMS) models operate in the West Midlands, one with doctors and the other without. A study was undertaken to compare on-scene time, management and decision-making between the two units. METHOD: Cases were assessed over an 18-month period, identifying on-scene time, incidence of rapid sequence induction (RSI), management of patients with a Glasgow Coma Scale (GCS) score of 3, femoral fracture, pneumothorax or those with myocardial infarction. RESULTS: There were 5275 HEMS activations during the study period. The presence of a doctor had no effect on on-scene time (27 (2) min vs 26 (2) min, p = NS). Advanced management of femoral fractures (nerve block, ketamine or RSI), pneumothorax (chest drain) or RSI (when patients were matched for GCS score) by doctors took no longer than conventional paramedic management. Doctors performed RSI on 38% of trauma patients and 13% of medical patients with a GCS score <15. Patients were more likely to be treated and discharged from the scene when seen by a doctor (8.7% vs 4.6%, p<0.001) and were less likely to be transported to hospital (27% vs 44%, p<0.001). For patients with a GCS score of 3, doctors were more likely to cease resuscitation efforts and confirm death at the scene (70% vs 16%, p<0.001). CONCLUSIONS: Appropriately trained HEMS doctors provide advanced management and decision-making. This is without a negative effect on on-scene time, even when performing complex procedures. They are more likely to declare death or discharge patients at the scene, increasing the availability of this limited resource.

Non-invasive ventilation and continuous positive pressure ventilation in emergency departments: where are we now?

A number of emergency departments have introduced non-invasive positive pressure ventilation (NIV) and continuous positive airway pressure (CPAP) for patients presenting with acute respiratory failure. It is thought that early non-invasive respiratory support will avoid the need for invasive ventilation in many cases. This literature review studied current knowledge of NIV and CPAP in the acute setting with the aim of creating simple guidelines for hospitals initiating early non-invasive ventilatory support in emergency departments. NIV is effective in reducing intubation and mortality rates in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) and CPAP is effective in reducing mortality in patients with cardiogenic pulmonary oedema, especially when implemented early. NIV and CPAP were also found to be effective in some other causes of acute respiratory failure. There is a role for non-invasive respiratory support in emergency departments.

Ambulance alerting to hospital: the need for clearer guidance.

BACKGROUND: The decision by paramedics to alert a receiving hospital to the imminent arrival of a critically ill patient is currently based on the crew's clinical judgement. AIMS: To evaluate the efficiency of current alerting practice and to assess the need for objective guidelines. METHODS: Data were collected in the Birmingham Heartlands Hospital, Birmingham, UK, over 1 week in February 2005. All alerted patients and all critically ill patients brought to the emergency department over this time period were identified. These two groups were studied to find those patients who were alerted but not critically ill, those who were critically ill but not alerted, and those who were both alerted and critically ill. The presenting conditions were identified and compared between groups. RESULTS: 454 patients were brought by ambulance to the emergency department during the study week. Of the 27 alerted patients, 23 were critically ill, leaving four patients alerted inappropriately. 29 of the 52 critically ill patients had not been alerted by ambulance crews. Most (n = 22) of these patients were adults with medical conditions. CONCLUSIONS: Ambulance crews do not alert hospitals to critically ill patients adequately. The Modified Early Warning Score should be considered to be the basis of a prehospital tool to aid their decision.

The impact of a new regional air ambulance service on a large general hospital.

BACKGROUND: Helicopter air ambulance crews are influenced in their selection of the destination hospital for their patients by several factors including: distance from the scene; facilities, on site specialties, and senior cover of the receiving hospital; and the proximity of the helicopter landing area to the emergency department (ED). Only a limited number of hospitals have landing sites adjacent to the ED from which patients can be taken directly into the department (primary landing sites). Helicopter crews will often elect to over fly hospitals that do not have primary landing sites because secondary land transfers will add delays in delivering patients. Birmingham Heartlands Hospital has an elevated helideck adjacent to the ED. In October 2003, the Warwickshire and Northamptonshire Air Ambulance (WNAA) service was launched; the hospital sits on the western periphery of the area served by the service. METHODS: Prospective data was collated on all patients brought by WNAA to Heartlands Hospital between 1 October 2003 and 31 August 2004. RESULTS: In the 10 month period after the launch of the service, the helicopter delivered 83 patients to the ED; 74 of these were "off patch". This additional workload generated 163 ward days, 19 operative procedures, and 85 intensive care unit, high dependency unit, or coronary care unit days. The direct costs of this additional workload approached 160,000 pounds sterling. CONCLUSIONS: In future discussions on the cost effectiveness of air ambulances, it will be important to consider both the direct and indirect costs to the receiving hospitals arising from the redistribution of emergency workload.

The nasopharyngeal airway: dispelling myths and establishing the facts.

The nasopharyngeal airway (NPA) is a simple airway adjunct used by various healthcare professionals. It has some advantages over the oropharyngeal airway (OPA) but despite this it appears to be used less frequently. This may be due to fears over intracranial placement in cases of possible basal skull fracture. This fear, promulgated by training, is based solely on two single case reports and relative risk needs to be put into clinical context. Widely taught methods of sizing NPAs are based upon the width of the patient's nostril or little finger, MRI data demonstrate that these methods are inaccurate. Ideal NPA length measured at nasal endoscopy correlates with subject height, this is independent of subject sex, and is a far more accurate determinant and easy to use in the clinical setting. Average height females require a Portex size 6 NPA and average height males a size 7 Portex NPA. This knowledge provides a rapid method of NPA selection.

Impact of the Department of Health initiative to equip and train acute trusts to manage chemically contaminated casualties.

BACKGROUND: Before 1999, there was no national model or standard doctrine for managing casualties from chemical incidents in the UK. A Department of Health (DoH) initiative to prepare the National Health Service (NHS) for chemical incidents was launched in the same year. This led to the distribution of an NHS standard chemical personal protective equipment suit (CPPE) together with a new single half day training package (Structured Approach to Chemical Casualties (SACC)) in 2001. OBJECTIVES: To assess the impact of the DoH initiative on acute hospital and ambulance trusts. To identify deficiencies in the design and operational deployment of the new CPPE, training initiative, and decontamination procedures at hospital level. METHOD: A survey to assess progress in specific areas of chemical incident preparedness and two simulated incidents with "live" chemically contaminated casualties conducted in two acute trusts. Umpires evaluated the operational performance against DoH SACC standards. RESULTS: There has been marked improvement in many aspects of preparedness for chemical incidents since the original National Focus survey. Some deficiencies remain and this study identified areas for further work. In the live casualty exercises, hospital staff complied well with SACC protocols. Some practical difficulties were encountered with the deployment of the CPPE and in some aspects of the operational response, leading to some delays in the delivery of care to the casualties and to the integrity of the uncontaminated (clean) zones within the hospitals. CONCLUSION: Problems with the design and deployment of the CPPE, together with training difficulties have been fed back into the planning and development process.

Hand hygiene and aseptic technique in the emergency department.

Hand hygiene and simple aseptic measures before invasive procedures are effective in reducing rates of healthcare-associated infection. The perceived urgency of a clinical situation in the emergency department, however, may influence medical staff's compliance with good practice in infection control. The aims of this prospective, single-blinded, observational study were twofold. First, to assess doctors' compliance with good practice in hand hygiene between patient episodes and asepsis during invasive procedures in the emergency department. Second, to assess the effect of clinical urgency on compliance with good practice in hand hygiene and asepsis during invasive procedures. Good practice standards for asepsis in invasive procedures and hand hygiene between patient episodes were compiled from a literature search. Doctors' compliance with these standards was observed in two emergency departments (UK and New Zealand). Observed clinical cases were classified as immediate, urgent and non-urgent based on the triage system. There was poor compliance with good practice guidelines for asepsis in invasive procedures in both centres. Staff achieved high compliance with the guidelines in only 27% of cases in the UK and 58% of cases in New Zealand. Clinical urgency did not appear to adversely affect compliance with aseptic good practice. Hand hygiene between patient consultations was very low at 14% in the UK and 12% in New Zealand. Asepsis and hand hygiene was poor in both the UK and New Zealand emergency departments. There may be a need for some compromise in standards of asepsis in very sick patients due to the urgency of the clinical situation. Compliance in all situations especially non-urgent procedures needs to be improved.

Introduction of the Taser into British policing. Implications for UK emergency departments: an overview of electronic weaponry.

The Taser is a development of the stun gun. It has recently been introduced into British policing as a "less lethal" weapon to fill the operational gap between the baton and the gun for controlling potentially dangerous and violent suspects. It is inevitable that "tasered" victims will be brought to hospitals. A review of clinical experience with electronic weaponry is presented. Suggestions for managing "tasered" subjects are provided.

Head injuries: a prospective observational study evaluating the potential impact of the Galasko report on Accident and Emergency departments.

In June 1999, the Galasko report of the Royal College of Surgeons of England recommended that in the next 5 years, the Accident and Emergency (A&E) departments should admit and supervise head-injured patients for up to 48 h. A prospective observational study was carried out for a 6 weeks period at the A&E department of Birmingham Heartland's Hospital to identify the potential impact of implementation of the Galasko report. The cost implications of this perceived additional workload were considered.Of the 786 head-injured patients seen during study period, 665 (85%) were discharged home directly from the A&E department. Of the remaining 121 patients, who were hospitalized, 76 (63%) were admitted to the A&E observation ward (AEOW) and 19 (16%) patients were admitted to a paediatric ward. All of these patients were discharged home within 24 h. The remaining 21% patients were admitted to other specialities and had prolonged stays in hospital. All of the 9% of the patients admitted under orthopaedics would have been admitted to the AEOW if the Galasko recommendations were implemented leading to an extra 22 bed days over the 6 weeks study period. The estimated annual cost of admission alone for these patients would be pound 38,200. Our study has demonstrated an expected additional workload and cost implications on a single A&E department.

Wounding patterns and human performance in knife attacks: optimising the protection provided by knife-resistant body armour.

BACKGROUND: Stab attacks generate high loads, and to defeat them, armour needs to be of a certain thickness and stiffness. Slash attacks produce much lower loads and armour designed to defeat them can be far lighter and more flexible. METHODS AND SUBJECTS: Phase 1: Human performance in slash attacks: 87 randomly selected students at the Royal Military College of Science were asked to make one slash attack with an instrumented blade on a vertically mounted target. No instructions on how to slash the target were given. The direction, contact forces and velocity of each attack were recorded. Phase 2: Clinical experience with edged weapon attacks: The location and severity of all penetrating injuries in patients attending the Glasgow Royal Infirmary between 1993 and 1996 were charted on anatomical figures. RESULTS: Phase 1: Two types of human slash behaviour were evident: a 'chop and drag' blow and a 'sweep motion' type of attack. 'Chop and drag' attacks had higher peak forces and velocities than sweep attacks. Shoulder to waist blows (diagonal) accounted for 82% of attacks, 71% of attackers used a long diagonal slash with an average cut length of 34 cm and 11% used short diagonal attacks with an average cut length of 25 cm. Only 18% of attackers slashed across the body (short horizontal); the average measured cut length of this type was 28 cm. The maximum peak force for the total sample population was 212 N; the maximum velocity was 14.88 m s(-1). The 95 percentile force for the total sample population was 181 N and the velocity was 9.89 m s(-1). Phase 2: 431 of the 500 patients had been wounded with edged weapons. The average number of wounds sustained by victims in knife assaults was 2.4. The distribution of wounds by frequency and severity are presented. CONCLUSIONS: Anti-slash protection is required for the arms, neck, shoulders, and thighs. The clinical experience of knife-attack victims provides information on the relative vulnerabilities of different regions of the body. It is anticipated that designing a tunic-type of Police uniform that is inherently stab and slash resistant will eventually replace the current obvious and often bulky extra protective vest. Attempts at making a combined garment will need to be guided by ergonomic considerations and field testing. A similar anatomical regional risk model might also be appropriate in the design of anti-ballistic armour and combined anti-ballistic and knife-resistant armour.

An email audit of prehospital doctor activity in an area of the West Midlands.

OBJECTIVES: To describe the nature and extent of prehospital doctor activity in an area of the West Midlands by review of group email. To explore the use of email as a means of data collection among a group of prehospital doctors. METHODS: A retrospective review of data collected by a prehospital organisation's email based internet group. RESULTS: Nearly half of prehospital doctor calls were to road traffic accidents and nearly half of these were "serious". Road traffic accidents involving pedestrians, trees, and motorcycles often resulted in fatalities. Doctors frequently performed medical interventions at scene. Midazolam and ketamine were administered commonly; the indications for their use varied. At two cases on scene anaesthesia was maintained for over an hour with ketamine. CONCLUSIONS: There remains a role for prehospital doctors. Email provides a very useful medium to share information and facilitate audit among a group of doctors who do not meet on a regular basis or work in the same institution. A computerised proforma to be filled by doctors after each prehospital call is proposed in an attempt to standardise and gather information for future audit and discussion.

TB or not TB: an unusual sore finger.

A 25 year old Afro-Carribean presented to the accident and emergency department with a painful swelling of the little finger. Radiology revealed periosteal elevation and a bone scan showed a hot spot in the proximal phalanx, suggestive of a tumour or an infection. He gave a history of recurrent chest infections in the past, the chest radiograph revealed apical lesions and loculated pleural effusion. Bronchoscopy washings were positive for acid fast bacillus suggestive of pulmonary tuberculosis with tuberculous dactylitis. A detailed history and high index of suspicion is important as delay in diagnosis can have serious consequences for the patient.

Ultrasound assessment of the vulnerability of the internal organs to stabbing: determining safety standards for stab-resistant body armour.

Stab-resistant body armour may not always prevent the passage of a blade into the human body. The depth to which a knife may 'safely' enter the human body before it breaches the internal organs was explored by ultrasound scanning of 25 healthy volunteers. Variations in the minimum skin-to-organ distances for the organs as a function of posture are described. To determine the optimum body coverage by stab-resistant armour, the movement during the breathing cycle and the maximum exposure of the organs beneath the lower costal margin at full inspiration were measured. Although the population studied was small, trends in the vulnerability of the internal organs to the passage of a blade into the body were identified.

Hyponatraemic convulsion secondary to desmopressin treatment for primary enuresis.

The case of a 6 year old child who presented with convulsions and coma after unsupervised self administration of intranasal desmopressin (DDAVP) for nocturnal enuresis is presented. Children with enuresis can be embarassed by their condition and may believe that multiple doses of their nasal spray may bring about a rapid resolution. Water intoxication is an uncommon but serious adverse effect of treatment with intranasal DDAVP. These patients may present with seizure, mental state changes, or both. Basic management consists of stopping the drug, fluid restriction, and suppressive treatment for seizures. Recovery is usually rapid and complete. Administration of the nasal spray in children should be supervised by parents to prevent highly motivated children from accidental overdose. The risks of high fluid intake need to be carefully explained to both parents and children.