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Naumann DN, Sellon E, Mitchinson S, Tucker H, Marsden MER, Norris-Cervetto E, Bafitis V, Smith T, Bradley R, Alzarrad A, Naeem S, Smith G, Dillane S, Humphrys-Eveleigh A, Wordsworth M, Sanchez-Thompson N, Bootland D, Brown L. Occult tension pneumothorax discovered following imaging for adult trauma patients in the modern major trauma system: a multicentre observational study. BMJ Mil Health 2024; 170:123-129. [PMID: 35584853 DOI: 10.1136/bmjmilitary-2022-002126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/08/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Tension pneumothorax following trauma is a life-threatening emergency and radiological investigation is normally discouraged prior to treatment in traditional trauma doctrines such as ATLS. Some trauma patients may be physiologically stable enough for diagnostic imaging and occult tension pneumothorax is discovered radiologically. We assessed the outcomes of these patients and compared them with those with clinical diagnosis of tension pneumothorax prior to imaging. METHODS A multicentre civilian-military collaborative network of six major trauma centres in the UK collected observational data from adult patients who had a diagnosis of traumatic tension pneumothorax during a 33-month period. Patients were divided into 'radiological' (diagnosis following CT/CXR) or 'clinical' (no prior CT/CXR) groups. The effect of radiological diagnosis on survival was analysed using multivariable logistic regression that included the covariates of age, gender, comorbidities and Injury Severity Score. RESULTS There were 133 patients, with a median age of 41 (IQR 24-61); 108 (81%) were male. Survivors included 49 of 59 (83%) in the radiological group and 59 of 74 (80%) in the clinical group (p=0.487). Multivariable logistic regression showed no significant association between radiological diagnosis and survival (OR 2.40, 95% CI 0.80 to 7.95; p=0.130). There was no significant difference in mortality between the groups. CONCLUSION Radiological imaging may be appropriate for selected trauma patients at risk of tension pneumothorax if they are considered haemodynamically stable. Trauma patients may be physiologically stable enough for radiological imaging but have occult tension pneumothorax because they did not have the typical clinical presentation. The historical dogma of the 'forbidden scan' no longer applies to such patients.
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Affiliation(s)
- David N Naumann
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - E Sellon
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S Mitchinson
- Emergency Department, Barts Health NHS Trust, London, UK
| | - H Tucker
- Emergency Department, St George's Healthcare NHS Trust, London, UK
| | - M E R Marsden
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- Emergency Department, Barts Health NHS Trust, London, UK
| | - E Norris-Cervetto
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - V Bafitis
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - T Smith
- Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - R Bradley
- Emergency Department, Barts Health NHS Trust, London, UK
| | - A Alzarrad
- Emergency Department, Barts Health NHS Trust, London, UK
| | - S Naeem
- Emergency Department, Barts Health NHS Trust, London, UK
| | - G Smith
- Emergency Department, Barts Health NHS Trust, London, UK
| | - S Dillane
- Emergency Department, St George's Healthcare NHS Trust, London, UK
| | | | - M Wordsworth
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- Department of Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - N Sanchez-Thompson
- Department of Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - D Bootland
- Emergency Department, Brighton and Sussex University Hospitals NHS Trust, Worthing, UK
| | - L Brown
- Emergency Department, Brighton and Sussex University Hospitals NHS Trust, Worthing, UK
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Barrett JW, Williams J, Skene SS, Griggs JE, Bootland D, Leung J, Da Costa A, Ballantyne K, Davies R, Lyon RM. Head injury in older adults presenting to the ambulance service: who do we convey to the emergency department, and what clinical variables are associated with an intracranial bleed? A retrospective case-control study. Scand J Trauma Resusc Emerg Med 2023; 31:65. [PMID: 37908011 PMCID: PMC10619243 DOI: 10.1186/s13049-023-01138-1] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/18/2023] [Indexed: 11/02/2023] Open
Abstract
OBJECTIVE Most older adults with traumatic brain injuries (TBI) reach the emergency department via the ambulance service. Older adults, often with mild TBI symptoms, risk being under-triaged and facing poor outcomes. This study aimed to identify whether sufficient information is available on the scene to an ambulance clinician to identify an older adult at risk of an intracranial haemorrhage following a head injury. METHODS This was a retrospective case-control observational study involving one regional ambulance service in the UK and eight emergency departments. 3545 patients aged 60 years and over presented to one regional ambulance service with a head injury between the 1st of January 2020 and the 31st of December 2020. The primary outcome was an acute intracranial haemorrhage on head computed tomography (CT) scan in patients conveyed to the emergency department (ED). A secondary outcome was factors associated with conveyance to the ED by the ambulance clinician. RESULTS In 2020, 2111 patients were conveyed to the ED and 162 patients were found to have an intracranial haemorrhage on their head CT scan. Falls from more than 2 m (adjusted odds ratio (aOR) 3.45, 95% CI 1.78-6.40), chronic kidney disease (CKD) (aOR 2.80, 95% CI 1.25-5.75) and Clopidogrel (aOR 1.98, 95% CI 1.04-3.59) were associated with an intracranial haemorrhage. Conveyance to the ED was associated with patients taking anticoagulant and antiplatelet medication or a visible head injury or head injury symptoms. CONCLUSION This study highlights that while most older adults with a head injury are conveyed to the ED, only a minority will have an intracranial haemorrhage following their head injury. While mechanisms of injury such as falls from more than 2 m remain a predictor, this work highlights that Clopidogrel and CKD are also associated with an increased odds of tICH in older adults following a head injury. These findings may warrant a review of current ambulance head injury guidelines.
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Affiliation(s)
- J W Barrett
- South East Coast Ambulance Service NHS FT, Crawley, UK.
- University of Surrey, Guildford, UK.
| | - J Williams
- South East Coast Ambulance Service NHS FT, Crawley, UK
- Paramedic Clinical Research Unit, University of Hatfield, Hatfield, UK
| | | | - J E Griggs
- University of Surrey, Guildford, UK
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
| | - D Bootland
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
- University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - J Leung
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - A Da Costa
- Medway Maritime Hospital NHS FT, Gillingham, UK
| | - K Ballantyne
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - R Davies
- South East Coast Ambulance Service NHS FT, Crawley, UK
| | - R M Lyon
- University of Surrey, Guildford, UK
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
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Jeyanathan J, Bootland D, Al-Rais A, Leung J, Wijesuriya J, Banks L, Breen T, DeCoverly R, Curtis L, McHenry A, Wright D, Griggs JE, Lyon RM. Lessons learned from the first 50 COVID-19 critical care transfer missions conducted by a civilian UK Helicopter Emergency Medical Service team. Scand J Trauma Resusc Emerg Med 2022; 30:6. [PMID: 35033171 PMCID: PMC8760584 DOI: 10.1186/s13049-022-00994-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 01/04/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has placed exceptional demand on Intensive Care Units, necessitating the critical care transfer of patients on a regional and national scale. Performing these transfers required specialist expertise and involved moving patients over significant distances. Air Ambulance Kent Surrey Sussex created a designated critical care transfer team and was one of the first civilian air ambulances in the United Kingdom to move ventilated COVID-19 patients by air. We describe the practical set up of such a service and the key lessons learned from the first 50 transfers. METHODS Retrospective review of air critical care transfer service set up and case review of first 50 transfers. RESULTS We describe key elements of the critical care transfer service, including coordination and activation; case interrogation; workforce; training; equipment; aircraft modifications; human factors and clinical governance. A total of 50 missions are described between 18 December 2020 and 1 February 2021. 94% of the transfer missions were conducted by road. The mean age of these patients was 58 years (29-83). 30 (60%) were male and 20 (40%) were female. The mean total mission cycle (time of referral until the time team declared free at receiving hospital) was 264 min (range 149-440 min). The mean time spent at the referring hospital prior to leaving for the receiving unit was 72 min (31-158). The mean transfer transit time between referring and receiving units was 72 min (9-182). CONCLUSION Critically ill COVID-19 patients have highly complex medical needs during transport. Critical care transfer of COVID-19-positive patients by civilian HEMS services, including air transfer, can be achieved safely with specific planning, protocols and precautions. Regional planning of COVID-19 critical care transfers is required to optimise the time available of critical care transfer teams.
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Affiliation(s)
- J Jeyanathan
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - D Bootland
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - A Al-Rais
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - J Leung
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - J Wijesuriya
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - L Banks
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - T Breen
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - R DeCoverly
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - L Curtis
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - A McHenry
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - D Wright
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - J E Griggs
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
- University of Surrey, Guildford, UK
| | - R M Lyon
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK.
- University of Surrey, Guildford, UK.
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Griggs JE, Jeyanathan J, Joy M, Russell MQ, Durge N, Bootland D, Dunn S, Sausmarez ED, Wareham G, Weaver A, Lyon RM. Mortality of civilian patients with suspected traumatic haemorrhage receiving pre-hospital transfusion of packed red blood cells compared to pre-hospital crystalloid. Scand J Trauma Resusc Emerg Med 2018; 26:100. [PMID: 30454067 PMCID: PMC6245557 DOI: 10.1186/s13049-018-0567-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 11/06/2018] [Indexed: 12/20/2022] Open
Abstract
Background Major haemorrhage is a leading cause of mortality following major trauma. Increasingly, Helicopter Emergency Medical Services (HEMS) in the United Kingdom provide pre-hospital transfusion with blood products, although the evidence to support this is equivocal. This study compares mortality for patients with suspected traumatic haemorrhage transfused with pre-hospital packed red blood cells (PRBC) compared to crystalloid. Methods A single centre retrospective observational cohort study between 1 January 2010 and 1 February 2015. Patients triggering a pre-hospital Code Red activation were eligible. The primary outcome measure was all-cause mortality at 6 hours (h) and 28 days (d), including a sub-analysis of patients receiving a major and massive transfusion. Multivariable regression models predicted mortality. Multiple Imputation was employed, and logistic regression models were constructed for all imputed datasets. Results The crystalloid (n = 103) and PRBC (n = 92) group were comparable for demographics, Injury Severity Score (p = 0.67) and mechanism of injury (p = 0.73). Observed 6 h mortality was smaller in the PRBC group (n = 10, 10%) compared to crystalloid group (n = 19, 18%). Adjusted OR was not statistically significant (OR 0.48, CI 0.19–1.19, p = 0.11). Observed mortality at 28 days was smaller in the PRBC group (n = 21, 26%) compared to crystalloid group (n = 31, 40%), p = 0.09. Adjusted OR was not statistically significant (OR 0.66, CI 0.32–1.35, p = 0.26). A statistically significant greater proportion of the crystalloid group required a major transfusion (n = 62, 60%) compared to the PRBC group (n = 41, 40%), p = 0.02. For patients requiring a massive transfusion observed mortality was smaller in the PRBC group at 28 days (p = 0.07). Conclusion In a single centre UK HEMS study, in patients with suspected traumatic haemorrhage who received a PRBC transfusion there was an observed, but non-significant, reduction in mortality at 6 h and 28 days, also reflected in a massive transfusion subgroup. Patients receiving pre-hospital PRBC were significantly less likely to require an in-hospital major transfusion. Further adequately powered multi-centre prospective research is required to establish the optimum strategy for pre-hospital volume replacement in patients with traumatic haemorrhage.
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Affiliation(s)
- J E Griggs
- Kent, Surrey & Sussex Air Ambulance Trust, Redhill Aerodrome, Redhill, RH1 5YP, UK.
| | - J Jeyanathan
- Kent, Surrey & Sussex Air Ambulance Trust, Redhill Aerodrome, Redhill, RH1 5YP, UK.,Academic Department of Military Anaesthesia and Critical Care, London, UK
| | - M Joy
- University of Surrey, Guildford, GU2 7XH, UK
| | - M Q Russell
- Kent, Surrey & Sussex Air Ambulance Trust, Redhill Aerodrome, Redhill, RH1 5YP, UK
| | - N Durge
- Kent, Surrey & Sussex Air Ambulance Trust, Redhill Aerodrome, Redhill, RH1 5YP, UK.,Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK
| | - D Bootland
- Kent, Surrey & Sussex Air Ambulance Trust, Redhill Aerodrome, Redhill, RH1 5YP, UK.,Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, UK
| | - S Dunn
- Kent, Surrey & Sussex Air Ambulance Trust, Redhill Aerodrome, Redhill, RH1 5YP, UK
| | - E D Sausmarez
- Kent, Surrey & Sussex Air Ambulance Trust, Redhill Aerodrome, Redhill, RH1 5YP, UK
| | - G Wareham
- Kent, Surrey & Sussex Air Ambulance Trust, Redhill Aerodrome, Redhill, RH1 5YP, UK
| | - A Weaver
- Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK
| | - R M Lyon
- Kent, Surrey & Sussex Air Ambulance Trust, Redhill Aerodrome, Redhill, RH1 5YP, UK.,University of Surrey, Guildford, GU2 7XH, UK
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