Feasibility study for implementation of resuscitative balloon occlusion of the aorta in peri-arrest, exsanguinating trauma at an adult level 1 Australian trauma centre.

OBJECTIVE: This prospective, observational, interventional study sought to determine if the introduction of resuscitative balloon occlusion of the aorta (REBOA) at an Australian adult major trauma centre would improve survival for major trauma patients. METHODS: Patients aged 18-60 years, transported directly from scene with exsanguinating, sub-diaphragmatic haemorrhage and hypovolaemic shock (systolic BP <70 mmHg or hypovolaemic cardiac arrest) were eligible for recruitment and followed up until hospital discharge (ACTRN12618000550202). RESULTS: During the 14-month study period (17 January 2015 to 12 March 2016) 3032 patients were admitted direct from scene with an overall mortality of 97 (3.71%). Of these patients 3019 had trauma centre vital signs recorded in the data set (99.57%) and 1523 were between the ages of 18-60, including 143 patients with a shock index of >1.0 (4.74%). There were 13 (0.43%) patients with a systolic BP <70 mmHg and/or cardiorespiratory arrest on arrival. The mortality in this group was six out of 13 (46.15%). Of these 13 patients, there were two (0.07% of the total cohort) where REBOA was attempted. There were no eligible patients for whom REBOA was achieved. None of the six patients who died would have benefited from REBOA deployment. CONCLUSIONS: Despite considerable training and resource allocation to ensure 24-h availability, the introduction of REBOA failed to effectively demonstrate any impact on patient outcome. Despite retrospective literature supporting the introduction of REBOA, in this 14-month prospective study there was no evidence of benefit. Further studies may define indications and subgroups of patients who may benefit.

Accuracy of rapid disposition by emergency clinicians.

Objectives Rapid disposition protocols are increasingly being considered for implementation in emergency departments (EDs). Among patients presenting to an adult tertiary referral hospital, this study aimed to compare prediction accuracy of a rapid disposition decision at the conclusion of history and examination, compared with disposition following standard assessment. Methods Prospective observational data were collected for 1 month between October and November 2012. Emergency clinicians (including physicians, registrars, hospital medical officers, interns and nurse practitioners) filled out a questionnaire within 5min of obtaining a history and clinical examination for eligible patients. Predicted patient disposition (representing 'rapid disposition') was compared with final disposition (determined by 'standard assessment'). Results There were 301 patient episodes included in the study. Predicted disposition was correct in 249 (82.7%, 95% confidence interval (CI) 78.0-86.8) cases. Accuracy of predicting discharge to home appeared highest among emergency physicians at 95.8% (95% CI 78.9-99.9). Overall accuracy at predicting admission was 79.7% (95% CI 67.2-89.0). The remaining 20.3% (95% CI 11.0-32.8) were not admitted following standard assessment. Conclusion Rapid disposition by ED clinicians can predict patient destination accurately but was associated with a potential increase in admission rates. Any model of care using rapid disposition decision making should involve establishment of inpatient systems for further assessment, and a culture of timely inpatient team transfer of patients to the most appropriate treating team for ongoing patient management. What is known about the topic? In response to the National Emergency Access Targets, there has been widespread adoption of rapid-disposition-themed care models across Australia. Although there is emerging data that clinicians can predict disposition accurately, this data is currently limited. What does this paper add? Results of this study support the previously limited evidence that ED practitioners can accurately predict disposition early in the patient journey through ED, and that accuracy is similar across clinician groups. In addition to overall prediction accuracy, admission, discharge and treating team predictions were separately measured. These additional outcomes lend insight into safety and performance aspects relating to a rapid disposition model of care. What are the implications for practitioners? This study offers practical insights that could aid safe and efficient implementation of a rapid disposition model of care.

Use of ultrasound for non-trauma patients in the emergency department.

OBJECTIVE: In the past decade, there has been substantial knowledge translation in the use of ultrasound (US) by critical care physicians to aid diagnosis of the non-trauma patient. This study aimed to determine emergency doctors' level of training in ultrasonography, pattern of US use in regular practice and barriers to US use for the non-trauma patient presenting to an emergency department. METHOD: A survey on the use of US in non-trauma patients was conducted, targeting all emergency physicians and emergency medicine trainees in a single adult tertiary referral centre. RESULTS: The response rate was 92.7% with 38 completed surveys analysed. A course in non-trauma US had been completed by 58% of respondents. The most common non-trauma formal US training was in vascular access (82%, 95% confidence interval [CI] 66.8-90.6), detection of abdominal aortic aneurysm (79%, 95% CI 63.7-88.9) and pericardial fluid (84%, 95% CI 69.6-92.6). Upon completion of formal training, US was used significantly more frequently for obtaining vascular access (odds ratio [OR] 12.0), detection of abdominal aortic aneurysms (OR 4.3) and detection of pericardial fluid (OR 15.5). Most doctors felt the greatest barriers to the use of US in the non-trauma patient were the lack of teaching, confidence in findings, experienced supervisors and time. CONCLUSIONS: Among ED personnel, use of US to diagnose several non-traumatic conditions was low, but specific training was associated with significantly more US use. Increased training and availability of US-experienced supervisors might further improve utility of this important adjunct to the practice of emergency medicine.

Trauma resuscitation errors and computer-assisted decision support.

HYPOTHESIS: This project tested the hypothesis that computer-aided decision support during the first 30 minutes of trauma resuscitation reduces management errors. DESIGN: Ours was a prospective, open, randomized, controlled interventional study that evaluated the effect of real-time, computer-prompted, evidence-based decision and action algorithms on error occurrence during initial resuscitation between January 24, 2006, and February 25, 2008. SETTING: A level I adult trauma center. PATIENTS: Severely injured adults. MAIN OUTCOME MEASURES: The primary outcome variable was the error rate per patient treated as demonstrated by deviation from trauma care algorithms. Computer-assisted video audit was used to assess adherence to the algorithms. RESULTS: A total of 1171 patients were recruited into 3 groups: 300 into a baseline control group, 436 into a concurrent control group, and 435 into the study group. There was a reduction in error rate per patient from the baseline control group to the study group (2.53 to 2.13, P = .004) and from the control group to the study group (2.30 to 2.13, P = .04). The difference in error rate per patient from the baseline control group to the concurrent control group was not statistically different (2.53 to 2.30, P = .21). A critical decision was required every 72 seconds, and error-free resuscitations were increased from 16.0% to 21.8% (P = .049) during the first 30 minutes of resuscitation. Morbidity from shock management (P = .03), blood use (P < .001), and aspiration pneumonia (P = .046) were decreased. CONCLUSIONS: Computer-aided, real-time decision support resulted in improved protocol compliance and reduced errors and morbidity. Trial Registration clinicaltrials.gov Identifier: NCT00164034.

B-type natriuretic peptide testing and the accuracy of heart failure diagnosis in the emergency department.

BACKGROUND: It is often difficult to diagnose heart failure (HF) accurately in patients presenting with dyspnea to the emergency department (ED). This study assessed whether B-type natriuretic peptide (BNP) testing in these patients improved the accuracy of HF diagnosis. METHODS AND RESULTS: Patients presenting to the Alfred and the Northern Hospital EDs with a chief complaint of dyspnea were enrolled prospectively from August 2005 to April 2007. Patients were randomly allocated to have BNP levels tested or not. The diagnostic gold standard for HF was determined by 1 cardiologist and 1 emergency or respiratory physician who, blinded to the BNP result, independently reviewed all available information. The ED diagnosis of HF in the non-BNP group showed a sensitivity, specificity, and accuracy of 65%, 92%, and 81%, respectively. The BNP group had a similar sensitivity, specificity, and accuracy of 66%, 90%, and 78%, respectively, for the diagnosis of HF in the ED. There was no significant difference between the BNP and non-BNP groups in any of the measures of diagnostic accuracy for HF. CONCLUSIONS: In the clinical setting of EDs, availability of BNP levels did not significantly improve the accuracy of a diagnosis of HF. Clinical Trial Registration- clinicaltrials.gov. Identifier: NCT00163709.

B-type natriuretic peptide testing, clinical outcomes, and health services use in emergency department patients with dyspnea: a randomized trial.

BACKGROUND: B-type natriuretic peptide (BNP) is used to diagnose heart failure, but the effects of using the test on all dyspneic patients is uncertain. OBJECTIVE: To assess whether BNP testing alters clinical outcomes and health services use of acutely dyspneic patients. DESIGN: Randomized, single-blind study. Patients were assigned to a treatment group through randomized numbers in a sealed envelope. Patients were blinded to the intervention, but clinicians and those who assessed trial outcomes were not. SETTING: 2 Australian teaching hospital emergency departments. PATIENTS: 612 consecutive patients who presented with acute severe dyspnea from August 2005 to March 2007. INTERVENTION: BNP testing (n = 306) or no testing (n = 306). MEASUREMENTS: Admission rates, length of stay, and emergency department medications (primary outcomes); mortality and readmission rates (secondary outcomes). RESULTS: There were no between-group differences in hospital admission rates (85.6% [BNP group] vs. 86.6% [control group]; difference, -1.0 percentage point [95% CI, -6.5 to 4.5 percentage points]; P = 0.73), length of admission (median, 4.4 days [interquartile range, 2 to 9 days] vs. 5.0 days [interquartile range, 2 to 9 days]; P = 0.94), or management of patients in the emergency department. Test discrimination was good (area under the receiver-operating characteristic curve, 0.87 [CI, 0.83 to 0.91]). Adverse events were not measured. LIMITATION: Most patients were very short of breath and required hospitalization; the findings might not apply for evaluating patients with milder degrees of breathlessness. CONCLUSION: Measurement of BNP in all emergency department patients with severe shortness of breath had no apparent effects on clinical outcomes or use of health services. The findings do not support routine use of BNP testing in all severely dyspneic patients in the emergency department. PRIMARY FUNDING SOURCE: Janssen-Cilag.

Accuracy of current clinical diagnosis in recreational drug-related attendance to the emergency department.

OBJECTIVE: To determine the accuracy of current clinical diagnosis in recreational drug-related attendances to emergency by blood analysis. METHODS: A prospective convenience sample of 103 patients who attended hospital with suspected recreational drug-related presentations was collected. Doctors' clinical impression of drugs responsible for presentation was compared with a detailed forensic blood analysis for recreational drugs. RESULTS: Among 103 samples, 80 (78%, 95% confidence intervals [CI] 70-86%) were found to have correct clinical suspicion of the recreational drug responsible for clinical presentation confirmed by laboratory analysis. Clinical diagnosis was most accurate for gamma-hydroxy butyrate (GHB) (sensitivity 97%, specificity 91%) and less accurate for amphetamines (sensitivity 61%, specificity 79%), alcohol (sensitivity 42%, specificity 84%) and opiates (sensitivity 46%, specificity 100%). Multiple drug ingestion was found in 70% (95% CI 61-79%) of samples. Sensitivity and specificity of clinical impression for prediction of multiple drug ingestion presence is 75% (95% CI 66-83%) and 85% (95% CI 78-92%), respectively. CONCLUSION: Clinical diagnosis in recreational drug-related attendances to the ED was correct in most cases. Drugs, such as GHB, were the most accurately diagnosed. Inaccuracy in recognizing other drugs, like amphetamines, opiates and alcohol, occurs where a coingestant produces a more profound clinical picture. Multiple drug ingestion is a common scenario in recreational drug presentations to emergency.

Trauma reception and resuscitation.

The hospital reception phase of major trauma management requires a great number of expedient decisions. However, despite widely taught programmes advocating a standardized, algorithmic approach to decision-making, there is an ongoing rate of human errors contributing to adverse outcomes. It is now time for a fundamental change in our approach to trauma resuscitation. Point-of-care computer technology linked to real-time decision-making and trauma team coordination may achieve error reduction through standardized decision-making and a corresponding reduction in preventable mortality and morbidity.

Prehospital intubation and chest decompression is associated with unexpected survival in major thoracic blunt trauma.

OBJECTIVE: Application of the Trauma and Injury Severity Score (TRISS) to a trauma population identifies patients with 'unexpected survival'. This study used TRISS analysis to identify 'unexpected survivors' suffering major thoracic trauma, who survived to hospital discharge. Further analysis determined prehospital interventions that appeared to contribute to 'unexpected survival'. METHODS: The present study was a single-centre, retrospective case review with comparative statistical analysis. Patients were identified from the Alfred Trauma Registry between 1 July 2002 and 30 June 2003. RESULTS: There were 336 adult trauma patients treated at The Alfred Trauma Centre with an Injury Severity Score >15 (major trauma) and at least one thoracic Anatomical Injury Score of 3 (severe) or greater. Of the eligible patients, 322/336 (95.8%, 95%[confidence interval] CI 95.1-96.5%) had complete data available for analysis. The study population mortality was 42/322 (13.0%, 95% CI 12.3-13.7%). There were 20 'unexpected survivors' (5.9%) and 5 (1.5%) 'unexpected deaths' on TRISS analysis. Chest decompression and/or endotracheal intubation prehospital was performed on 16/20 'unexpected survivors'. GCS for 'unexpected survivors' and 'expected deaths' (3.8 vs 3.5, P = 0.27) was not a predictor of survival. Respiratory rate per minute (16.2 vs 8.8, P = 0.01) and systolic blood pressure - mmHg (98 vs 80, P = 0.03) were significantly greater in the 'unexpected survivors' group compared with the 'expected death' group. CONCLUSION: For patients sustaining severe thoracic blunt trauma, prehospital intubation and chest decompression appear to be associated with unexpected survival. A low GCS at scene is not predictive of 'unexpected survival' or 'expected death'.

Complications of intercostal catheter insertion using EMST techniques for chest trauma.

BACKGROUND: The purpose of the present study was to determine the complication rates associated with intercostal catheter insertion (ICI) performed using Early Management of Severe Trauma (EMST) guidelines on trauma patients admitted through The Alfred Trauma Centre. METHODS: The Alfred Trauma Registry identified demographic and clinical data for patients who underwent ICI in the Alfred hospital following admission for trauma. The medical histories were subsequently reviewed for complications resulting from ICI. RESULTS: There were 211 ICI performed on 173 trauma patients at The Alfred Trauma Centre between July 2001 and June 2002. The mean injury severity score was 34. Mean age was 38 (range 15-82 years), with 77% of the patients being men. Chest injury was the result of blunt trauma in 90.2% and penetrating trauma in 9.8%. ICI occurred in the Trauma Centre (84%), operating theatre (6%), intensive care unit (9%) and in the general ward (1%). Eighty per cent of patients had a unilateral ICI. The indications for ICI were pneumothorax (45.7%), haemothorax (15.0%), haemopneumothorax (28.3%) and tension pneumothorax (7.5%). There were no insertional and 11 (5.2%) positional complications. The infection rate was 2.4% comprising two superficial and three deep (empyema thoraces) infections. No statistically significant association was found between infective complications and age, injury severity score (ISS), haemothorax, penetrating trauma, prehospital needle thoracostomy and time to ICI. There was no mortality arising from ICI complications. CONCLUSION: Intercostal catheter insertion for chest trauma performed in accordance with EMST guidelines has a low complication rate. Prehospital prophylactic chest decompression for ventilated patients with chest trauma, using a lateral rather than an anterior approach, may decrease the incidence of untreated tension pneumothorax.