Factors contributing to death of major trauma victims with haemorrhage: A retrospective case-control study.

OBJECTIVE: To identify factors associated with death secondary to haemorrhage following major trauma. METHODS: A retrospective case-control study was conducted on data from adult major trauma patients attending Christchurch Hospital ED between 1 June 2016 and 1 June 2020. Cases (those who died due to haemorrhage or multiple organ failure [MOF]), were matched to controls (those who survived) in a 1:5 ratio from the Canterbury District Health Board major trauma database. A multivariate analysis was used to identify potential risk factors for death due to haemorrhage. RESULTS: One thousand, five hundred and forty major trauma patients were admitted to Christchurch Hospital or died in ED during the study period. Of them, 140 (9.1%) died from any cause, most attributed to a central nervous system cause of death; 19 (1.2%) died from haemorrhage or MOF. After controlling for age and injury severity, having a lower temperature on arrival in ED was a significant modifiable risk factor for death. Additionally, intubation prior to hospital, increased base deficit, lower initial haemoglobin and lower Glasgow Coma Scale were risk factors associated with death. CONCLUSIONS: The present study reaffirms previous literature that lower body temperature on presentation to hospital is a significant potentially modifiable variable in predicting death following major trauma. Further studies should investigate whether all pre-hospital services have key performance indicators (KPIs) for temperature management, and causes for failure to reach these. Our findings should promote development and tracking of such KPIs where they do not already exist.

Use of the Sheathless Eaucath Is an Effective Strategy to Overcome Resistant Severe Radial Spasm.

Objectives: We aimed to assess the effectiveness of the sheathless Eaucath guiding catheter (SEGC) in overcoming severe spasm. Background: Radial spasm is a frequent challenge in transradial access (TRA) and can be difficult to manage. Methods: We performed a prospective observational study of 1000 consecutive patients undergoing coronary angiography with or without percutaneous coronary intervention. Patients with primary transfemoral access (TFA) or primary use of a sheathless guide catheter were excluded. Patients who developed angiographically confirmed severe spasm were treated with further sedation and vasodilators. If the conventional catheter would still not advance, it was exchanged for a SEGC. The primary endpoint was the successful passage of the SEGC through the radial with successful engagement of the coronary artery in patients with resistant severe spasm. Results: Primary TFA access was used in 58 (5.8%) and primary radial access with a SEGC in 44 (4.4%) patients. Of the remaining 898 patients, 888 (98.9%) had a radial sheath successfully inserted. Of these, 49 (5.5%) developed severe radial spasm with inability to advance the catheter. Following treatment with additional sedation and vasodilators, the severe spasm resolved in 5 (10.2%) patients. Passage of a SEGC was attempted in the remaining 44 patients with resistant severe spasm. Passage of the SEGC and engagement of coronary arteries were successful in all cases. There were no complications related to use of the SEGC. Conclusions: Our findings suggest that use of the SEGC for resistant severe spasm is highly effective, safe, and may reduce the need for conversion to TFA.

Paediatric exploratory ingestion presentations to Christchurch Hospital emergency department during 2019.

AIM: To quantify and describe presentations to a New Zealand tertiary hospital emergency department (ED) associated with paediatric exploratory ingestions (PEIs) during 2019 in comparison to 1999. METHODS: A retrospective descriptive study was conducted of PEI presentations by children under 7 years of age to Christchurch Hospital ED between 1 January and 31 December 2019. Data were studied for demographic and management details and compared to data from 1999. RESULTS: There were 111 PEI presentations in children under 7 years during 2019, out of 9,445 presentations for this age group (1.2%). The estimated incidence of PEIs was 223.8 per 100,000. PEI presentations relative to total paediatric presentations had reduced compared to 1999 (X2=94.7, p<0.001). Two year olds were most likely to have PEIs (odds ratio (OR)=15.01, 95% confidence interval (CI)=6.78, 33.22). Children of Asian (OR=0.50, 95% CI=0.26, 0.95) and Pacific (OR=0.34, 95% CI=0.12, 0.93) ethnicity were less likely to present with PEIs. Paracetamol was the most commonly ingested substance (15.3%), followed by opioids (11.7%). CONCLUSION: Paediatric presentations due to exploratory ingestions reduced between 1999 and 2019. However, there was a concerning increase in ingestions of medications like opioids that have a significant risk of toxicity at low doses.

Paediatric presentations to Christchurch Hospital Emergency Department during COVID-19 lockdown.

AIM: To describe the variation in volumes and types of paediatric presentations to a tertiary emergency department in New Zealand during the national level 4 lockdown for COVID-19. METHODS: A retrospective, comparative cohort study in Christchurch Hospital Emergency Department, New Zealand. RESULTS: There was a 37% reduction in all emergency presentations during the 33-day lockdown period. Paediatric presentations reduced significantly more than non-paediatric presentations (53% paediatric vs. 34% non-paediatric, P < 0.00001). The decrease in both overall and paediatric presentations was significantly different than similar periods in 2019 and 2018 (P < 0.00001). The proportion of New Zealand European paediatric presentations during lockdown increased by 6.09% (P = 0.01), while Pacific peoples decreased by 3.36% (P = 0.005). The proportion of <1-year-old presentations increased by 5.56% (P = 0.001), while 11-15 years decreased by 7.91% (P = 0.0001). Respiratory-related paediatric presentations decreased by 30% and proportional decreased by 4.92% (P = 0.001). CONCLUSION: This study has identified a significant reduction in paediatric presentations to a tertiary emergency department in New Zealand during the national Alert Level 4 Lockdown for COVID-19. The proportional increase in the <1-year-old group may suggest a greater need for community-based child health services during the COVID-19 pandemic. Mental health support services may also need to adapt and expand to provide adequate psychological support for children during this crisis. Recognising the needs of these vulnerable groups will be critical during the ongoing COVID-19 pandemic in addition to informing response plans for similar events in the future.

What influences clinicians to choose wisely?

AIM: To evaluate the effectiveness of awareness-raising by the Choosing Wisely campaign in a New Zealand public hospital to reduce routine pre-operative testing and to determine what can be done to bring about change in clinician behaviour. METHODS: Short, semi-structured, one on-one interviews were conducted with 15 doctors of varying seniority from general surgery who were exposed to the campaign between August and October 2018. The interviews covered four general topics including background information, asking about awareness and effectiveness of Choosing Wisely campaign, exploring barriers to changing clinician behaviour around pre-operative testing and exploring potential interventions which may be useful to change behaviour. Data were analysed using Braun and Clarke thematic analysis methodology. RESULTS: Four themes and 17 sub-themes emerged from the interviews. The main themes included awareness of Choosing Wisely, thoughts around pre-operative testing, barriers for changing clinician behaviour and strategies for reducing unnecessary pre-operative testing. CONCLUSION: The findings of this study suggest that a strategy that relies on revising guidelines and raising staff awareness alone is likely to be of limited effectiveness in reducing unnecessary pre-operative testing. In addition to increasing clinician awareness of evidence-based recommendations on unnecessary testing, other strategies may be needed to support behaviour change.