Head Injury Evaluation and Ambulance Diagnosis (HOME) Study protocol: a feasibility study assessing the implementation of the Canadian CT Head Rule in the prehospital setting.

INTRODUCTION: Traumatic brain injury (TBI) is a common presentation in the prehospital environment. At present, paramedics do not routinely use tools to identify low-risk patients who could be left at scene or taken to a local hospital rather than a major trauma centre. The Canadian CT Head Rule (CCHR) was developed to guide the use of CT imaging in hospital. It has not been evaluated in the prehospital setting. We aim to address this gap by evaluating the feasibility and acceptability of implementing the CCHR to patients and paramedics, and the feasibility of conducting a full-scale clinical trial of its use. METHODS AND ANALYSIS: We will recruit adult patients who are being transported to an emergency department (ED) by ambulance after suffering a mild TBI. Paramedics will prospectively collect data for the CCHR. All patients will be transported to the ED, where deferred consent will be taken and the treating clinician will reassess the CCHR, blinded to paramedic interpretation. The primary clinical outcome will be neurosurgically significant TBI. Feasibility outcomes include recruitment and attrition rates. We will assess acceptability of the CCHR to paramedics using the Ottawa Acceptability of Decision Rules Instrument. Interobserver reliability of the CCHR will be assessed between paramedics and the treating clinician in the ED. Participating paramedics and patients will be invited to participate in semistructured interviews to explore the acceptability of trial processes and facilitators and barriers to the use of the CCHR in practice. Data will be analysed thematically. We anticipate recruiting approximately 100 patients over 6 months. ETHICS AND DISSEMINATION: This study was approved by the Health Research Authority and the Research Ethics Committee (REC reference: 22/NW/0358). The results will be published in a peer-reviewed journal, presented at conferences and will be incorporated into a doctoral thesis. TRIAL REGISTRATION NUMBER: ISRCTN92566288.

Top 10 (+1) tips to get started with in situ simulation in emergency and critical care departments.

Simulation is increasingly valued as a teaching and learning tool in emergency medicine. Bringing simulation into the workplace to train in situ offers a unique and effective training opportunity for the emergency department (ED) multiprofessional workforce. Integrating simulation in a busy department is difficult but can be done. In this article, we outline 10 tips to help make it happen.

Body surface mapping versus the standard 12 lead ECG in the detection of myocardial infarction amongst emergency department patients: a Bayesian approach.

OBJECTIVE: To determine if body surface mapping (BSM) is better than the standard 12 lead ECG in the diagnosis of acute myocardial infarction amongst emergency department patients. SETTING: A University affiliated inner-city emergency department. PARTICIPANTS: People presenting to an emergency department with symptoms compatible with myocardial ischaemia/infarction. MAIN OUTCOME MEASURES: Myocardial infarction as defined by either standard 12 lead ECG changes with associated cardiac marker rise, Troponin T >0.1 microg/ml at > 12 h or autopsy/surgical findings of fresh macroscopic infarction. RESULTS: BSM had an overall sensitivity of 47.1% versus 40% for the 12 lead ECG (P < 0.001). Specificity for the BSM was 85.6% versus 93.7% for the 12 lead ECG (P < 0.001). These findings were consistent for low/moderate and high risk subgroups. Bayesian analysis demonstrates that indiscriminate use of BSM would result in a clinically important overdiagnosis of myocardial infarction amongst emergency department patients. CONCLUSIONS: BSM has a higher sensitivity, but a lower specificity for the diagnosis of myocardial infarction.

Detection of evolving right ventricular infarct during right coronary artery stent insertion using PRIME ECG body surface mapping with colour map reconstruction.

UNLABELLED: We present the evolutionary changes of isolated right ventricular infarction (RVI) in a patient undergoing right coronary artery stenting using a novel imaging system. Twelve ECG and body surface maps were recorded at 30-s intervals during right coronary angioplasty, during which a right ventricular branch of the right coronary artery (RCA) occluded, resulting in a short-lived episode of chest pain and minor changes on a 12 lead ECG. Using computer-derived colour reconstruction of the ECG data, the changes of isolated right ventricular infarction is obvious, in contrast to the transient and equivocal changes seen on the 12 lead ECG. CONCLUSION: Isolated RVI may be missed on 12 lead ECG criteria. Body surface mapping (BSM) allows unequivocal diagnosis of isolated RVI by colour map reconstruction that is able to localise the ischaemic change.

Beyond the 12 lead: review of the use of additional leads for the early electrocardiographic diagnosis of acute myocardial infarction.

Despite known limitations, the standard 12 lead ECG is the principal risk stratification device for patients presenting with chest pain to the ED. However, it has a sensitivity of less than 60% for MI. One reason for this is that the standard placement of chest leads fails to interrogate many areas of the myocardium. Various workers have addressed this problem through the use of additional leads or body surface mapping. Additional leads on the posterior and right thoracic surface have been shown to give additional information, which may be important to the emergency physician. This review demonstrates the need for additional leads in the acute setting and makes recommendations about the utility of using additional leads in the ED.