Emergency department resuscitative thoracotomy at an adult major trauma centre: Outcomes following a training programme with standardised indications.

OBJECTIVE: The objective of this study was to report the procedural incidence and patient outcomes after the 2009 introduction of an institutional resuscitative thoracotomy (RT) programme. Emergency physicians, general surgeons and emergency nursing trauma team members were trained to perform RT on thoracic trauma patients with an unresponsive systolic blood pressure (SBP) <70 mmHg within 30 min of arrival, prior to cardiothoracic team back-up. METHODS: A retrospective cohort study was conducted on patients who underwent RT from 2009 to 2017. The primary outcome measures were the incidence of the procedure and patients' survival to hospital discharge. Variables associated with survival were assessed using univariable logistic regression analyses. RESULTS: There were 12 399 major trauma patients, including 7657 with major thoracic trauma and 315 presenting with SBP <70 mmHg. There were 32 RTs performed (incidence of 0.4%; 95% confidence interval [CI] 0.3-0.6) among patients with major thoracic trauma and 10.2% (99% CI 7.3-13.4) among patients with major thoracic trauma and SBP <70 mmHg. There were eight (25%; 95% CI 13.2-42.1) survivors to hospital discharge and no late mortality (mean follow-up 2.8 years). Survival was significantly associated with the procedure performed within 30 min of arrival (odds ratio 0.09; 95% CI 0.01-0.67) while mortality was associated with the procedure being performed in the setting of traumatic cardiac arrest (odds ratio 18.3; 95% CI 2.4-140.4). CONCLUSIONS: A formal training and credentialing programme was associated with a low incidence of the procedure, yet achieved a survival rate of 25%, which is comparable to other reported literature.

Cryoprecipitate administration after trauma.

OBJECTIVES: Haemorrhage remains among the most preventable causes of trauma death. Massive transfusion protocols, as part of 'haemostatic resuscitation', have been implemented in most trauma centres. Relative to the attention to the ideal ratio of red blood cells to fresh frozen plasma and platelets, cryoprecipitate treatment has been infrequently discussed. We aimed to outline the use of cryoprecipitate during trauma resuscitation and analyse outcomes in patients who received cryoprecipitate after hypofibrinogenaemia detection. METHODS: A retrospective review of registry data on all major trauma patients (Injury Severity Score>15) presenting to a level I trauma centre over a 4-year period (2008-2011) was conducted. We selected all patients who had received cryoprecipitate and then analysed patients who had received cryoprecipitate following the detection of hypofibrinogenaemia (<1.0 g/l). Mortality at hospital discharge among hypofibrinogenaemic patients who had received cryoprecipitate was compared with that among patients who had not received cryoprecipitate. RESULTS: Of 3996 trauma patients, 3571 had fibrinogen levels recorded. Most patients (n=3517, 98.5%) had initial fibrinogen counts of 1.0 g/l or higher, and cryoprecipitate was administered to a small proportion of these patients (n=126, 3.6%). Of the 54 patients with hypofibrinogenaemia on arrival, one patient died immediately and was excluded from further analysis. Of the 53 patients, 30 received cryoprecipitate and 28/53 died (53%). There was no difference in mortality between those who had received and those who had not received cryoprecipitate (14/30 vs. 14/23, P=0.31). CONCLUSION: Administration of cryoprecipitate was uncommon during trauma resuscitation, even among patients with hypofibrinogenaemia on presentation. This study provides no evidence towards improved outcomes from administration of cryoprecipitate.

Staff exposure to ionizing radiation in a major trauma centre.

BACKGROUND: The purpose of the present paper was to determine the safety of staff members with regard to ionizing radiation in a major trauma centre in a 19-month period. METHODS AND RESULTS: A group of five doctors, five nurses and a trauma orderly wore personal radiation monitors under lead aprons while at work. The highest individual cumulative result after 586 days was 0.18 mSv for a nurse. If the exposure rate to ionizing radiation was constant, this would be equivalent to 0.114 mSv per year. Therefore the results are well below the recommended occupational dose limit of 20 mSv per year. CONCLUSION: Wearing of lead aprons during trauma resuscitation appears to be safe and provides adequate protection.

The dawn of emergency medicine in Vietnam.

In 2009 emergency medicine had not been officially established as a specialty in Vietnam. As a result of a non-government organization identifying the need to improve the delivery of emergency care, the Vietnam2010 Symposium in Emergency Medicine was held in Hue in March 2010. This involved 1 week of activity including: an Emergency Medicine Conference, providing lectures and practical workshops in topics of emergency medicine; a Deans' Conference, dedicated to the development of emergency medicine as a specialty; a Disaster and EMS Conference; and an Emergency Nursing Conference. Vietnam2010 was a high impact event and was successful in raising the profile of emergency medicine. It formalized key international linkages, showcased the role of the knowledge and skills relevant to emergency care and provided the impetus for emergency medicine specialization in Vietnam. A consensus document committing to the development of emergency medicine as a specialty in Vietnam was signed by multiple national and international governmental, university and emergency medicine representatives. Challenges included a tendency for international flagbearers from mature systems to promote the specialty according to local expectations, with a consequent emphasis on vertical specialty topics and on technology, and the running of medical and nursing conferences separately. Vietnam now needs a medium-term plan to develop the specialty to ensure these initial steps are translated into a sustainable capacity to provide emergency care nationally.

Chemical-biological-radiological (CBR) response: a template for hospital emergency departments.

Chemical, biological and radiological (CBR) incidents have the potential to shut down emergency departments that do not have an adequate CBR response. Secondary contamination also poses a threat to the safety and wellbeing of staff and other patients. On activation of a CBR response, "clean" and "contaminated" areas should be clearly marked, and all patients decontaminated before being allowed into the emergency department or outpatients department. Personal protective equipment (PPE) is needed for all staff. Staff using PPE must be monitored for signs of heat illness. Stocks of coveralls, bags for contaminated clothes, plastic sheeting for radiological incidents, barriers for crowd control, and selected drugs should be obtained. Staff required include medical, nursing, security, clerical, orderlies, patient care assistants and other staff, depending on the type of threat. An on-call roster that allows regular rotation of staff is needed. All hospital personnel should understand the response plan, and recognise that the emergency department and hospital is a community asset that requires protection.