Use of prothrombin complex concentrates: 4-year experience of a national aeromedical retrieval service servicing remote and rural areas.

INTRODUCTION: Prothrombin complex concentrates (PCCs) are recommended as first-line treatment for acquired or congenital factor II, VII, IX and X deficiencies in situations of major haemorrhage. The Emergency Medical Retrieval Service (EMRS) provides critical care and aeromedical retrieval to patients in remote and rural Scotland. It has an important role in the care of these patients. METHOD: We sought to determine the incidence of haemorrhage requiring PCC administration in our cohort of patients, and to assess compliance with current national guidelines regarding their storage and use. We searched our database for all patients that received PCCs, or met current guidelines for their administration, and followed them through to hospital discharge. We also conducted a telephone survey of all hospitals served by the EMRS to determine compliance with national standards. RESULTS: During the 42-month study period, 1170 retrieval missions were conducted. Twenty-six retrieved patients had a congenital or acquired clotting factor deficiency and seven met criteria for PCC administration. Of these, only three received PCCs prior to transfer to definitive care. Telephone survey revealed that all the rural general hospitals were served by the EMRS stock PCCs, but only one out of 15 GP-led community hospitals had access to PCCs. CONCLUSIONS: In the remote and rural setting where access to definitive care may be limited or delayed, timely administration of PCCs in appropriate patients may improve outcomes. As many rural hospitals do not have access to PCCs, the ability of the EMRS to provide this treatment may improve patient care.

Do peripheral blood cultures taken in the emergency department influence clinical management?

BACKGROUND: Blood cultures are routinely used to investigate suspected sepsis in the emergency department despite several studies showing their limited influence on patient management. OBJECTIVES: To quantify the use and clinical relevance of blood cultures obtained in the emergency department. METHODS: A retrospective study of blood cultures taken in the emergency department between 1 January 2003 and 31 December 2004. Microbiology results and patients' records were reviewed to determine the influence of positive cultures on subsequent patient management. RESULTS: 2213 blood cultures were taken in the emergency department over the study period. 132 (6%) yielded a positive result. Three positive cultures had incomplete information. Of the remaining 129 positive cultures, 30 (1.4% of all cultures) were "true positives" and 4 (0.18%) influenced subsequent patient management. CONCLUSIONS: Blood cultures taken in our emergency department (Southern General Hospital, Glasgow, UK) rarely yield bacterial growth, and over 2 years only four cultures seemed to directly influence patient management. Better guidelines are required for targeted use of blood cultures in the emergency department.

Do peripheral blood cultures taken in the emergency department influence clinical management?

BACKGROUND: Blood cultures are routinely used to investigate suspected sepsis in the emergency department despite several studies demonstrating their limited influence on patient management. OBJECTIVES: To quantify the use and clinical relevance of blood cultures obtained in the emergency department. METHODS: A retrospective study of blood cultures taken in the emergency department between 1 January 2003 and 31 December 2004. Microbiology results and patient records were reviewed to determine the influence of positive cultures on subsequent patient management. RESULTS: 2213 blood cultures were taken in the emergency department over the study period. 132 (6%) yielded a positive result. Three positive cultures cases had incomplete information. Of the remaining 129 positive cultures, 30 (1.4% of all cultures) were "true positives" and 4 (0.18%) influenced subsequent patient management. CONCLUSIONS: Blood cultures taken in our emergency department rarely yield bacterial growth and over 2 years, only four seemed to directly influence patient management. Better guidelines are required for targeted use of blood cultures in the emergency department.

Mortality after trauma intubation without drugs in Scottish emergency departments.

BACKGROUND: Trauma patients who are intubated without anaesthetic drugs in the pre-hospital phase of care have universally poor outcomes. This study aimed to determine the mortality of trauma patients intubated without drugs in emergency departments in Scotland. METHODS: This retrospective cohort study used the prospective Scottish Trauma Audit Group (STAG) database to identify how many patients were intubated and how many required drugs for intubation between 1 January 1999 and 31 December 2002. The mortality of those intubated with drugs and without drugs was determined from the database. RESULTS: 24,756 patients were included in the STAG database. There were 1469 intubations: 1287 with drugs and 182 without drugs. 92.5% of all intubations were for blunt trauma. There was no difference in the proportion of males or median age between groups. Median GCS was 8 (E1M5V2) in the drugs group and 3 (E1M1V1) in the no drugs group (p<0.001). Median ISS was higher in those intubated without drugs (33 versus 25, p<0.001). Median RTS and probability of survival were lower in those intubated without drugs (both p<0.001). Mortality was higher in those intubated without drugs (91.2% versus 29.4%, p<0.001). Sixteen patients, intubated without drugs, survived. These patients had a higher median respiratory rate (9 versus 0, p=0.013) and higher median systolic blood pressure (80 mmHg versus 0 mmHg, p=0.041) than non-survivors. CONCLUSION: Trauma patients in Scottish emergency departments who are intubated without drugs have high mortality rates. Outcomes are not universally fatal and aggressive resuscitation efforts may be of benefit to a small number of such patients.

Paracetamol and salicylate testing: routinely required for all overdose patients?

OBJECTIVES: To determine whether it is necessary to routinely measure serum salicylate levels in addition to serum paracetamol levels in alert overdose patients who deny ingestion of that substance. METHODS: Prospective observational study of overdose patients attending an urban emergency department. RESULTS: A total of 171 patients attended with an alleged overdose. Thirty-seven patients were excluded; 24 patients had a reduced conscious level (Glasgow Coma Scale <15), nine patients could not recall the time of overdose and four patients had a staggered overdose. In all, 47.0% (63/134) claimed to have taken paracetamol and 5.2% (7/134) claimed to have taken salicylate. No patient who denied taking paracetamol or salicylate subsequently tested positive for them. In all, 51.5% (69/134) of patients reported that they had taken alcohol at the time of their overdose. CONCLUSION: Given the relatively low clinical risk and evident symptoms and signs from salicylate overdose, routine testing may not be required for fully conscious asymptomatic patients who deny taking it. The risks of delayed toxicity and lack of initial symptoms in those ingesting paracetamol suggests that continued routine testing is necessary.

Blunt cervical spine injuries in Scotland 1995-2000.

BACKGROUND: In the Accident and Emergency Department, the management of patients who have sustained head injuries (HI) is often made more complicated by the suspicion of a cervical spine injury (CSI). This study aimed to evaluate the incidence of CSI in patients sustaining blunt head injuries in a Scottish population. METHODS: Retrospective analysis of prospectively collected data for a 5-year period from the Scottish Trauma Audit Group (STAG) database. Logistic regression and other comparisons were used to investigate the relationship between Glasgow coma score/scale (GCS) and the incidence of CSI. RESULTS: A total of 5154 patients met the criteria for the study and 273 of the HI patients had associated CSI giving an overall incidence of 5.3%. Patients presenting with GCS of 3 were almost three times more likely to have a CSI compared to patients with an initial GCS of 4 or more (12.5% versus 4.4%, chi(2)=62.9, d.f.=1, P<0.001). When patients with GCS of 3 were excluded, there was no evidence of an increase in the incidence of CSI with a lower GCS (logistic regression chi(2)=0.09, d.f.=1, P=0.75). CONCLUSION: The risk of CSI in patients with blunt head trauma and an admission GCS of > or =4 does not decrease as GCS increases. Patients with blunt head injuries who present with a GCS of 3 are much more likely to have a concomitant CSI. The overall incidence of 5.3% compares with published series from other countries.

Is spinal immobilisation necessary for all patients sustaining isolated penetrating trauma?

INTRODUCTION: Previous work suggests that patients with isolated penetrating trauma rarely require spinal immobilisation. This study aimed to identify the incidence of mechanically unstable, or potentially mechanically unstable, spinal column injuries in penetrating trauma patients. The study also aimed to identify the incidence of spinal cord injury as a result of penetrating trauma in Scotland. DESIGN: Retrospective analysis of prospectively collected data from the Scottish Trauma Audit Group (STAG). METHODS: Study patients were identified from the period 1992-1999. Patients coded for both penetrating trauma and spinal column or spinal cord injury were included. Case records, theatre notes and post mortem information were also examined. RESULTS: 34903 patients were available for study. Twenty-seven patients were coded as having had penetrating trauma and concurrent spinal injury. 15 were excluded as they also had a major blunt mechanism of injury or had no actual injury to the spinal cord or column. In the remaining 12 patients, four cervical, one combined cervical and thoracic and seven thoracic spinal cord injuries were identified. 11 were male and 11 were assaulted. One assault was due to a gunshot wound; 10 resulted from sharp weapons. Four complete cord transections and nine partial cord lesions were identified. All 12 patients with spinal cord injury associated with isolated penetrating trauma either had obvious clinical evidence of a spinal cord injury on initial assessment or were in traumatic cardiac arrest. All had spinal immobilisation. CONCLUSION: Fully conscious patients (GCS=15) with isolated penetrating trauma and no neurological deficit do not require spinal immobilisation.

Effect of patients' age on management of acute intracranial haematoma: prospective national study.

OBJECTIVE: To determine whether the management of head injuries differs between patients aged > or =65 years and those <65. DESIGN: Prospective observational national study over four years. SETTING: 25 Scottish hospitals that admit trauma patients. PARTICIPANTS: 527 trauma patients with extradural or acute subdural haematomas. MAIN OUTCOME MEASURES: Time to cranial computed tomography in the first hospital attended, rates of transfer to neurosurgical care, rates of neurosurgical intervention, length of time to operation, and mortality in inpatients in the three months after admission. RESULTS: Patients aged > or =65 years had lower survival rates than patients <65 years. Rates were 15/18 (83%) v 165/167 (99%) for extradural haematoma (P=0.007) and 61/93 (66%) v 229/249 (92%) for acute subdural haematoma (P<0.001). Older patients were less likely to be transferred to specialist neurosurgical care (10 (56%) v 142 (85%) for extradural haematoma (P=0.005) and 56 (60%) v 192 (77%) for subdural haematoma (P=0.004)). There was no significant difference between age groups in the incidence of neurosurgical interventions in patients who were transferred. Logistic regression analysis showed that age had a significant independent effect on transfer and on survival. Older patients had higher rates of coexisting medical conditions than younger patients, but when severity of injury, initial physiological status at presentation, or previous health were controlled for in a log linear analysis, transfer rates were still lower in older patients than in younger patients (P<0.001). CONCLUSIONS: Compared with those aged under 65 years, people aged 65 and over have a worse prognosis after head injury complicated by intracranial haematoma. The decision to transfer such patients to neurosurgical care seems to be biased against older patients.