Predicting outcomes after blunt chest wall trauma: development and external validation of a new prognostic model.

INTRODUCTION: Blunt chest wall trauma accounts for over 15% of all trauma admissions to Emergency Departments worldwide. Reported mortality rates vary between 4 and 60%. Management of this patient group is challenging as a result of the delayed on-set of complications. The aim of this study was to develop and validate a prognostic model that can be used to assist in the management of blunt chest wall trauma. METHODS: There were two distinct phases to the overall study; the development and the validation phases. In the first study phase, the prognostic model was developed through the retrospective analysis of all blunt chest wall trauma patients (n = 274) presenting to the Emergency Department of a regional trauma centre in Wales (2009 to 2011). Multivariable logistic regression was used to develop the model and identify the significant predictors for the development of complications. The model's accuracy and predictive capabilities were assessed. In the second study phase, external validation of the model was completed in a multi-centre prospective study (n = 237) in 2012. The model's accuracy and predictive capabilities were re-assessed for the validation sample. A risk score was developed for use in the clinical setting. RESULTS: Significant predictors of the development of complications were age, number of rib fractures, chronic lung disease, use of pre-injury anticoagulants and oxygen saturation levels. The final model demonstrated an excellent c-index of 0.96 (95% confidence intervals: 0.93 to 0.98). CONCLUSIONS: In our two phase study, we have developed and validated a prognostic model that can be used to assist in the management of blunt chest wall trauma patients. The final risk score provides the clinician with the probability of the development of complications for each individual patient.

Drainage of an extradural haematoma by intraosseous needle in a remote hospital.

We report the case of an intraosseous needle used to drain an acute extra-dural haematoma in a remote hospital. An 18 yr. old female attended the Emergency Department, after sustaining a closed head injury from a fall. After a CT scan, she was diagnosed with a large acute extradural haematoma (EDH). Prior to air ambulance transfer to the Neurosurgical Centre, she developed a fixed dilated pupil and hemodynamic instability. The Neurosurgeon advised that an intraosseous (IO) needle drainage would prevent brain stem herniation. An Emergency Medicine (EM) consultant drained 60 ml of blood and clot via an IO needle. The pupil and cardiovascular status normalised. The patient underwent neurosurgical drainage with full neurological recovery. We believe that this is the first IO drainage of an EDH at a remote hospital followed by full neurological recovery.

Comparison of two clinical scoring systems in risk stratification of non-ST elevation acute coronary syndrome patients in predicting 30-day outcomes.

BACKGROUND: Non-ST elevation acute coronary syndromes (NSTEACS) confer a broad range of risk of adverse outcomes following presentation to an emergency department. This study compares the Thrombolysis in Myocardial Infarction (TIMI) risk scoring system with the used but untested, Cheshire, Merseyside and North Wales Cardiac Network (CMNW) NSTEACS risk stratification system in predicting the adverse outcomes of re-admission to hospital with either a NSTEACS or death at 30 days post presentation. METHOD: Once a diagnosis of NSTEACS was made, patients were risk scored, then case notes were retrieved 30 days later. Primary adverse outcome of death and secondary adverse outcome of NSTEACS at 30 days was analysed using a ROC curve. RESULTS: 104 patients were included in the study diagnosed as having NSTEACS. Of these patients, 11 (11%) were initially diagnosed as having unstable angina (UA) (troponin I negative, <0.07), 43 (41%) non-ST elevation myocardial infarction Group 1 (troponin I 0.07-0.49) and 50 (48%) had non-ST elevation myocardial infarction Group 2 (troponin I ≥0.50). For death at 30 days, the CMNW risk c-statistic is 0.845 (95% CI 0.728 to 0.962, asymptotic significance 0.02) and TIMI 0.670 (CI 0.493 to 0.847, asymptotic significance 0.25). NSTEACS at 30 days (including NSTEMI and UA), the CMNW risk c-statistic is 0.466 (95% CI 0.345 to 0.586, asymptotic significance 0.616), TIMI 0.418 (CI 0.281 to 0.555, asymptotic significance 0.231). CONCLUSIONS: The CMNW score categorised more patients as higher risk, who suffered death at 30 days than the TIMI score.

The impact of consultant delivered service in emergency medicine: the Wrexham Model.

OBJECTIVE: Consultant based delivery of emergency service is perceived to add value. This study aims to demonstrate the impact of such a service model based on consultant working in a UK emergency department. METHODS: This retrospective study was based on the emergency department of a district general hospital. Activity data was analysed for 2009. Workload and admission rates were compared between consultants, middle grade doctors and senior house officers (SHOs). Admission rates were compared against two similar departments. Data from night shifts allowed consultant activity to be contrasted with middle grades and SHOs. Time spent in the department, admission rates, patients who left without treatment, discharged outright and clinic returns were used for comparison. RESULTS: Consultants often saw more patients than SHOs or middle grade doctors. This was on top of their traditional duties of senior opinion. On comparison of activity at night shifts, they admitted fewer (25.2% vs 30.3%, p=0.026), had fewer leaving without treatment (1.6% vs 5.1%, p<0.001), discharged more outright (59.8% vs 47.5%, p<0.001), referred fewer to clinic (5.7% vs 6.6%, p=0.49) and had a faster turnaround time (p<0.001: Priority 2, 3 and 4) for every triage category. Some of the comparisons were clinically but not statistically significant. CONCLUSION: A consultant based service delivery offers many advantages. These cannot be matched by either junior or middle grades. This would be in addition to the consultants' supervisory role. Consultant expansion is urgently required to achieve this sustainably. A further study evaluating the cost benefits of this service model is now underway.