1
|
Abstract
Aim Major trauma (MT) has traditionally been viewed as a disease of young men caused by high-energy transfer mechanisms of injury, which has been reflected in the configuration of MT services. With ageing populations in Western societies, it is anticipated that the elderly will comprise an increasing proportion of the MT workload. The aim of this study was to describe changes in the demographics of MT in a developed Western health system over the last 20 years. Methods The Trauma Audit Research Network (TARN) database was interrogated to identify all cases of MT (injury severity score >15) between 1990 and the end of 2013. Age at presentation, gender, mechanism of injury and use of CT were recorded. For convenience, cases were categorised by age groups of 25 years and by common mechanisms of injury. Longitudinal changes each year were recorded. Results Profound changes in the demographics of recorded MT were observed. In 1990, the mean age of MT patients within the TARN database was 36.1, the largest age group suffering MT was 0–24 years (39.3%), the most common causative mechanism was road traffic collision (59.1%), 72.7% were male and 33.6% underwent CT. By 2013, mean age had increased to 53.8 years, the single largest age group was 25–50 years (27.1%), closely followed by those >75 years (26.9%), the most common mechanism was low falls (39.1%), 68.3% were male and 86.8% underwent CT. Conclusions This study suggests that the MT population identified in the UK is becoming more elderly, and the predominant mechanism that precipitates MT is a fall from <2 m. Significant improvements in outcomes from MT may be expected if services targeting the specific needs of the elderly are developed within MT centres.
Collapse
Affiliation(s)
- A Kehoe
- Emergency Department, Derriford Hospital, Plymouth, UK Centre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - J E Smith
- Emergency Department, Derriford Hospital, Plymouth, UK Centre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Birmingham, UK
| | - A Edwards
- Trauma Audit Research Network (TARN), University of Manchester, Hope Hospital, Salford, UK
| | - D Yates
- Trauma Audit Research Network (TARN), University of Manchester, Hope Hospital, Salford, UK
| | - F Lecky
- Trauma Audit Research Network (TARN), University of Manchester, Hope Hospital, Salford, UK EMRiS Group, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| |
Collapse
|
2
|
Kehoe A, Smith JE, Bouamra O, Edwards A, Yates D, Lecky F. Older patients with traumatic brain injury present with a higher GCS score than younger patients for a given severity of injury. Emerg Med J 2016; 33:381-5. [DOI: 10.1136/emermed-2015-205180] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 12/29/2015] [Indexed: 11/03/2022]
|
3
|
Edwards RG, Kehoe A, Graham B, Smith J. INADVERTENT INTRA-ARTERIAL CANNULATION IN THE EMERGENCY DEPARTMENT: WHAT IS THE INCIDENCE AND HOW DO WE DETECT IT? Arch Emerg Med 2015. [DOI: 10.1136/emermed-2015-205372.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
4
|
Edwards RG, Kehoe A, Graham B, Smith J. INADVERTENT INTRA-ARTERIAL CANNULATION IN THE EMERGENCY DEPARTMENT: FEASIBILITY OUTCOMES FROM A PILOT STUDY. Arch Emerg Med 2015. [DOI: 10.1136/emermed-2015-205372.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
5
|
Kehoe A, Bullough R, Ainsley K, Wigginton O. TRAUMATIC COAGULOPATHY INFLUENCES OUTCOME IN PATIENTS WITH ISOLATED TRAUMATIC BRAIN INJURY:. J Accid Emerg Med 2015. [DOI: 10.1136/emermed-2015-205372.14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
6
|
Kehoe A, Rennie S, Smith JE. Glasgow Coma Scale is unreliable for the prediction of severe head injury in elderly trauma patients. Emerg Med J 2014; 32:613-5. [PMID: 25280479 DOI: 10.1136/emermed-2013-203488] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Accepted: 09/15/2014] [Indexed: 11/03/2022]
Abstract
OBJECTIVES AND BACKGROUND Elderly patients comprise an ever-increasing proportion of major trauma patients. The presenting GCS in elderly patients with traumatic brain injury (TBI) may not reflect the severity of injury as accurately as it does in the younger patient population. However, GCS is often used as part of the decision tool to define the population transferred directly to a major trauma centre. The aim of this study was to explore the relationship between age and presenting GCS in patients with isolated TBI. METHODS A retrospective database review was undertaken using the Trauma Audit and Research Network database. All patients presenting to Derriford Hospital, Plymouth, between 1 January 2009 and 31 May 2014 with isolated TBI were included. Demographic, mechanistic, physiological, resource use and outcome data were collected. Abbreviated injury scale (AIS) was recorded for all patients. Patients were categorised into those older and younger than 65 years on presentation. Distribution of GCS, categorised into severe (GCS 3-8), moderate (GCS 9-12) and mild TBI (13-15), was compared between the age groups. Median GCS at each AIS level was also compared. RESULTS The distribution of GCS differed between young and old patients with TBI (22.1% vs 9.8% had a GCS 3-8, respectively) despite a higher burden of anatomical injury in the elderly group. Presenting GCS was higher in the elderly at each level of AIS. The difference was more apparent in the presence of more severe injury (AIS 5). CONCLUSIONS Elderly patients who have sustained isolated severe TBI may present with a higher GCS than younger patients. Triage tools using GCS may need to be modified and validated for use in elderly patients with TBI.
Collapse
Affiliation(s)
- A Kehoe
- Emergency Department, Derriford Hospital, Plymouth, UK
| | - S Rennie
- Emergency Department, Derriford Hospital, Plymouth, UK
| | - J E Smith
- Emergency Department, Derriford Hospital, Plymouth, UK Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Joint Medical Command, Birmingham, UK
| |
Collapse
|
7
|
Kelleher I, Devlin N, Wigman JTW, Kehoe A, Murtagh A, Fitzpatrick C, Cannon M. Psychotic experiences in a mental health clinic sample: implications for suicidality, multimorbidity and functioning. Psychol Med 2014; 44:1615-1624. [PMID: 24025687 DOI: 10.1017/s0033291713002122] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Recent community-based research has suggested that psychotic experiences act as markers of severity of psychopathology. There has, however, been a lack of clinic-based research. We wished to investigate, in a clinical sample of adolescents referred to a state-funded mental health service, the prevalence of (attenuated or frank) psychotic experiences and the relationship with (i) affective, anxiety and behavioural disorders, (ii) multimorbid psychopathology, (iii) global functioning, and (iv) suicidal behaviour. METHOD The investigation was a clinical case-clinical control study using semi-structured research diagnostic psychiatric assessments in 108 patients newly referred to state adolescent mental health services. RESULTS Psychotic experiences were prevalent in a wide range of (non-psychotic) disorders but were strong markers of risk in particular for multimorbid psychopathology (Z = 3.44, p = 0.001). Young people with psychopathology who reported psychotic experiences demonstrated significantly poorer socio-occupational functioning than young people with psychopathology who did not report psychotic experiences, which was not explained by multimorbidity. Psychotic experiences were strong markers of risk for suicidal behaviour. Stratified analyses showed that there was a greatly increased odds of suicide attempts in patients with a major depressive disorder [odds ratio (OR) 8.89, 95% confidence interval (CI) 1.59-49.83], anxiety disorder (OR 15.4, 95% CI 1.85-127.94) or behavioural disorder (OR 3.13, 95% CI 1.11-8.79) who also had psychotic experiences compared with patients who did not report psychotic experiences. CONCLUSIONS Psychotic experiences (attenuated or frank) are an important but under-recognized marker of risk for severe psychopathology, including multimorbidity, poor functioning and suicidal behaviour in young people who present to mental health services.
Collapse
Affiliation(s)
- I Kelleher
- Department of Psychiatry, Royal College of Surgeons in Ireland, Education and Research Centre, Beaumont Hospital, Dublin, Ireland
| | - N Devlin
- Department of Psychiatry, Royal College of Surgeons in Ireland, Education and Research Centre, Beaumont Hospital, Dublin, Ireland
| | - J T W Wigman
- Maastricht University, Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - A Kehoe
- University College Dublin, Catherine McAuley Research Centre, Dublin, Ireland
| | - A Murtagh
- Department of Psychiatry, Royal College of Surgeons in Ireland, Education and Research Centre, Beaumont Hospital, Dublin, Ireland
| | - C Fitzpatrick
- University College Dublin, Catherine McAuley Research Centre, Dublin, Ireland
| | - M Cannon
- Department of Psychiatry, Royal College of Surgeons in Ireland, Education and Research Centre, Beaumont Hospital, Dublin, Ireland
| |
Collapse
|
8
|
Smith JE, Kehoe A, Harrisson SE, Russell R, Midwinter M. Outcome of penetrating intracranial injuries in a military setting. Injury 2014; 45:874-8. [PMID: 24398079 DOI: 10.1016/j.injury.2013.12.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 11/22/2013] [Accepted: 12/06/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND Penetrating intracranial injuries are common in the deployed military medical environment. Early assessment of prognosis includes initial conscious level. There has been no previous identification of different outcomes depending on mechanism of penetrating injury. The aim of this study was to define outcome from penetrating head injury in our population, and to compare outcome between gunshot wound (GSW) and blast fragment injury, in order to detect a difference in survival. METHODS A retrospective database review was undertaken using the UK Joint Theatre Trauma Registry (JTTR) between the dates 2003 and 2011 to identify all cases of penetrating head injury. Data collected included mechanism of injury, first recorded GCS, injury severity score (ISS), abbreviated injury scale (AIS) head score, concomitant extracranial injury, surgical intervention, hospital length of stay, and survival. RESULTS 813 patients sustained a penetrating head injury, of whom 625 were injured by blast fragmentation and 188 were injured by GSW; overall 336 patients (41.3%) died. There was a significant difference between survival from GSW (41.5%) and blast fragment (63.8%; p<0.001). In addition, the GCS in patients injured by GSW was significantly lower than that in patients injured by blast fragment. 157 cases sustained isolated head injury (79 GSW, 78 blast). The difference in injury severity between these groups was marked; median AIS was higher in the GSW group, survival lower (42% vs. 88%; p<0.001) and distribution of GCS categories less favourable (p<0.001). 338 of 343 patients (98.5%) with a best recorded GCS>5, survived to discharge. CONCLUSION Most patients who present following penetrating intracranial injury, who have a GCS>5, survive to discharge. There is a significant difference in survival to hospital discharge following penetrating injury caused by blast fragment compared to those caused by GSW, partly attributable to a difference in injury severity. This is the first study to specifically highlight and define this difference.
Collapse
Affiliation(s)
- J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Joint Medical Command, Birmingham, UK; Emergency Department, Derriford Hospital, Plymouth, UK.
| | - A Kehoe
- Emergency Department, Derriford Hospital, Plymouth, UK
| | - S E Harrisson
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Joint Medical Command, Birmingham, UK; Department of Neurosurgery, Wessex Neurological Centre, Southampton, UK
| | - R Russell
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Joint Medical Command, Birmingham, UK
| | - M Midwinter
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Joint Medical Command, Birmingham, UK
| |
Collapse
|
9
|
Jenkins P, Rogers J, Kehoe A, Smith JE. An evaluation of the use of a two-tiered trauma team activation system in a UK major trauma centre. Emerg Med J 2014; 32:364-7. [PMID: 24668398 DOI: 10.1136/emermed-2013-203402] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 03/01/2014] [Indexed: 11/03/2022]
Abstract
OBJECTIVES AND BACKGROUND Appropriate activation of multidisciplinary trauma teams improves outcome for severely injured patients but can disrupt normal service in the rest of the hospital. Derriford Hospital uses a two-tiered trauma team activation system. The emergency department trauma team (EDTT) is activated in response to a significant traumatic mechanism; the hospital trauma team (HTT) is activated when this mechanism coexists with physiological abnormality or specific anatomical injury. The aim of this study was to compare characteristics, process measures and outcomes between patients treated by EDTTs or HTTs to evaluate the approach in a UK setting. METHODS A retrospective database review was performed using Trauma Audit Research Network (TARN) and the local source trauma database. Patients who activated a trauma team between 1 April and 30 September 2012 were included. Patients were categorised according to the type of trauma team activated. Data included time to X-rays, time to CT, time to intubation, numbers discharged from ED, intensive care unit admission, injury severity score and mortality. RESULTS During the study period, 456 patients activated a trauma team with 358 EDTT and 98 HTT activations. Patients seen by the ED team were significantly less likely to have severe injury or require hospital admission, intubation, emergency operation or blood transfusion. Differences in time taken to key investigations were statistically but not clinically significant. CONCLUSIONS A two-tiered trauma team activation system is an efficient and cost-effective way of dealing with trauma patients presenting to a major trauma centre in the UK.
Collapse
Affiliation(s)
- P Jenkins
- University of Plymouth, Plymouth, UK
| | - J Rogers
- Emergency Department, Derriford Hospital, Plymouth, UK
| | - A Kehoe
- Emergency Department, Derriford Hospital, Plymouth, UK
| | - J E Smith
- Emergency Department, Derriford Hospital, Plymouth, UK Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK College of Emergency Medicine, UK
| |
Collapse
|
10
|
Jenkins PE, Rogers J, Kehoe A, Smith J. SEE AND TREAT FOR MAJOR TRAUMA? AN EVALUATION OF THE USE OF A TWO-TIERED TRAUMA TEAM ACTIVATION SYSTEM IN A UK MAJOR TRAUMA CENTRE. Arch Emerg Med 2013. [DOI: 10.1136/emermed-2013-203113.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
11
|
Rickard AC, Smith JE, Newell P, Bailey A, Kehoe A, Mann C. Salt or sugar for your injured brain? A meta-analysis of randomised controlled trials of mannitol versus hypertonic sodium solutions to manage raised intracranial pressure in traumatic brain injury. Emerg Med J 2013; 31:679-83. [PMID: 23811861 DOI: 10.1136/emermed-2013-202679] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Rising intracranial pressure (ICP) is a poor prognostic indicator in traumatic brain injury (TBI). Both mannitol and hypertonic sodium solutions are used to treat raised ICP in patients with TBI. OBJECTIVE This meta-analysis compares the use of mannitol versus hypertonic sodium solutions for ICP control in patients with TBI. DATA SOURCES AND STUDY ELIGIBILITY Randomised clinical trials in adults with TBI and evidence of raised ICP, which compare the effect on ICP of hypertonic sodium solutions and mannitol. METHODS The primary outcome measure is the pooled mean reduction in ICP. Studies were combined using a Forest plot. RESULTS Six studies were included, comprising 171 patients (599 episodes of raised ICP). The weighted mean difference in ICP reduction, using hypertonic sodium solutions compared with mannitol, was 1.39 mm Hg (95% CI -0.74 to 3.53). LIMITATIONS Methodological differences between studies limit the conclusions of this meta-analysis. CONCLUSIONS The evidence shows that both agents effectively lower ICP. There is a trend favouring the use of hypertonic sodium solutions in patients with TBI.
Collapse
Affiliation(s)
- A C Rickard
- Emergency Department, Derriford Hospital, Plymouth, UK
| | - J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK
| | - P Newell
- Centre for Biostatistics, Bioinformatics and Biomarkers, Plymouth University, Plymouth, UK
| | - A Bailey
- Centre for Biostatistics, Bioinformatics and Biomarkers, Plymouth University, Plymouth, UK
| | - A Kehoe
- Emergency Department, Derriford Hospital, Plymouth, UK
| | - C Mann
- Emergency Department, Musgrove Park Hospital, Taunton, UK
| |
Collapse
|
12
|
Abstract
This review describes the evidence exploring the use of a two-tier trauma team activation system, reviewing the background, history, data available and potential benefits and downsides. The current evidence suggests that a two-tier system may be a lean, cost-effective system, focussed on patient outcome, which could be implemented throughout the UK. Despite its current use in some hospitals, there is limited data from similar systems supporting this in a UK setting. Specific activation criteria need to be validated to ensure appropriate activation of trauma teams, ensuring optimal patient outcome and ensuring best practice.
Collapse
Affiliation(s)
- P Jenkins
- University of Plymouth, Plymouth, UK
| | - A Kehoe
- Emergency Department, Derriford Hospital, Plymouth, UK
| | - JE Smith
- Emergency Department, Derriford Hospital, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research &Academia), Medical Directorate, Joint Medical Command, Birmingham, UK
| |
Collapse
|
13
|
Potter D, Kehoe A, Smith JE. The sensitivity of pre-hospital and in-hospital tools for the identification of major trauma patients presenting to a major trauma centre. ACTA ACUST UNITED AC 2013. [DOI: 10.1136/jrnms-99-16] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AbstractThe identification of major trauma patients before arrival in hospital allows the activation of an appropriate trauma response. The Wessex triage tool (WTT) uses a combination of anatomical injury assessment and physiological criteria to identify patients with major trauma suitable for triage direct to a major trauma centre (MTC), and has been adopted by the South-West Peninsula Trauma Network (PTN). A retrospective database review, using the Trauma Audit Research Network (TARN) database, was undertaken to identify a population of patients presenting to Derriford Hospital with an injury severity score (ISS) > 15. The WTT was then applied to this population to identify the sensitivity of the tool. The sensitivity of the WTT at identifying patients with an ISS>15 was 53%. One of the reasons for this finding was that elderly patients who are defined as having major trauma due to the nature of their injuries, but who did not have a mechanism to suggest they had sustained major trauma (such as a fall from standing height), were not identified by these triage tools. The implications of this are discussed.
Collapse
|
14
|
Potter D, Kehoe A, Smith JE. The sensitivity of pre-hospital and in-hospital tools for the identification of major trauma patients presenting to a major trauma centre. J R Nav Med Serv 2013; 99:16-19. [PMID: 23691858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The identification of major trauma patients before arrival in hospital allows the activation of an appropriate trauma response. The Wessex triage tool (WTT) uses a combination of anatomical injury assessment and physiological criteria to identify patients with major trauma suitable for triage direct to a major trauma centre (MTC), and has been adopted by the South-West Peninsula Trauma Network (PTN). A retrospective database review, using the Trauma Audit Research Network (TARN) database, was undertaken to identify a population of patients presenting to Derriford Hospital with an injury severity score (ISS) >15. The WTT was then applied to this population to identify the sensitivity of the tool. The sensitivity of the WTT at identifying patients with an ISS> 15 was 53%. One of the reasons for this finding was that elderly patients who are defined as having major trauma due to the nature of their injuries, but who did not have a mechanism to suggest they had sustained major trauma (such as a fall from standing height), were not identified by these triage tools. The implications of this are discussed.
Collapse
Affiliation(s)
- D Potter
- Emergency Department, Derriford Hospital, Plymouth, UK
| | | | | |
Collapse
|
15
|
Kehoe A, Jones A, Marcus S, Nordmann G, Pope C, Reavley P, Smith C. Current controversies in military pre-hospital critical care. J ROY ARMY MED CORPS 2011; 157:S305-9. [PMID: 22049812 DOI: 10.1136/jramc-157-03s-09] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- A Kehoe
- MDHU Derriford, Derriford Hospital, Plymouth.
| | | | | | | | | | | | | |
Collapse
|
16
|
Kehoe A, Sheehan L, Davies G, David L. 13: Reliability of Dispatch Criteria for Activation of a Helicopter-Based Out-of-Hospital EMS System. Ann Emerg Med 2008. [DOI: 10.1016/j.annemergmed.2008.01.281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|