Emergency medicine journal : EMJ
-
Recent events involving a significant number of casualties have emphasised the importance of appropriate preparation for receiving hospitals, especially Emergency Departments, during the initial response phase of a major incident. Development of a mass casualty resilience and response framework in the Northern Trauma Network included a review of existing planning assumptions in order to ensure effective resource allocation, both in local receiving hospitals and system-wide.Existing planning assumptions regarding categorisation by triage level are generally stated as a ratio for P1:P2:P3 of 25%:25%:50% of the total number of injured survivors. This may significantly over-, or underestimate, the number in each level of severity in the case of a large-scale incident. ⋯ Despite the heterogeneity of data and range of incident type there is sufficient evidence to suggest that current planning assumptions are incorrect and a more refined model is required. An important finding is the variation in proportion of critical cases depending upon the mechanism. For example, a greater than expected proportion results from incidents involving a building fire whereas the existing model may over-estimate critical caseload in more 'conventional' incidents such as a transportation accident or even in terrorism-related incidents.A new model suggesting the proportions of casualties expected by severity categorisation and incident type is shown in table 2. A more detailed investigation is planned to further refine and develop this model.emermed;34/12/A865-a/T1F1T1Table 1emermed;34/12/A865-a/T2F2T2Table 2.
-
It is hypothesised that a single injection fascia iliaca compartment block (FICB) administered in the pre-operative setting provides better analgesic control for traumatic hip fractures and is not associated with major adverse effects. Systemic analgesics, whilst effective, could lead to cardiovascular, respiratory and cognitive impairment. As a consequence, undertreatment of acute pain remains prevalent in adult patients with hip fractures, with a consistent decline seen in analgesic administration with age. ⋯ Out of 3757 citations, eight RCTs were included in the final quantitative analysis, comprising of 645 participants. Acute pain was significantly reduced in FICB during positioning and movement, standardised mean difference (SMD)=-1.82 (95% CI:-2.26 to -1.38, p<0.00001) but was variable at rest (p=0.20). There was a reduced incidence of analgesia breakthrough (n=57 versus n=73), drowsiness/sedation (n=1 versus n=22), desaturation (n=0 versus n=4) and nausea and vomiting (n=3 versus n=7) in the FICB arm. There were similar numbers of patients across both arms that reported localised bruising (n=3). Only one study was at low risk of bias.emermed;34/12/A891-a/F1F1F1Figure 1emermed;34/12/A891-a/F2F2F2Figure 2 CONCLUSIONS: FICB is superior in controlling acute pre-operative pain in adult patients with traumatic hip fractures. The benefit is more evident during positioning and mobilisation of the limb. FICB has a better safety profile and reduces dependency on systemic analgesia.
-
Review Meta Analysis
1 Patient acceptability and feasibility of HIV testing in emergency departments in the UK - a systematic review and meta-analysis.
NICE 2016 HIV testing guidelines now include the recommendation to offer HIV testing in Emergency Departments, in areas of high prevalence,1 to everyone who is undergoing blood tests. 23% of England's local authorities are areas of high HIV prevalence (>2/1000) and are therefore eligible.2 So far very few Emergency Departments have implemented routine HIV testing. This systematic review assesses evidence for two implementation considerations: patient acceptability (how likely a patient will accept an HIV test when offered in an Emergency Department), and feasibility, which incorporates staff training and willingness, and department capacity, (how likely Emergency Department staff will offer an HIV test to an eligible patient), both measured by surrogate quantitative markers. ⋯ For an Emergency Department considering introducing routine HIV testing, this review suggests an opt-out publicity-lead strategy. Utilising oral fluid and blood tests would lead to the greatest proportion of eligible patients accepting an HIV test. For individual staff who are consenting patients for HIV testing, it may be encouraging to know that there is >50% chance the patient will accept an offer of testing.emermed;34/12/A860-a/T1F1T1Table 1Summary table of data extracted from final 7 studies, with calculated acceptability and feasibility if appropriate, and GRADE score. Studies listed in chronological order of data collection. GRADE working group evidence grades: 4= high quality, 3= moderate quality, 2= low quality, 1 or below = very low quality. (*study conclusion reports this figure is inaccurate)emermed;34/12/A860-a/F1F2F1Figure 1Patients accepting HIV tests, and being offered HIV tests, as a proportion of the eligible sample REFERENCES: National Institute for Health and Care Excellence, Public Health England. HIV testing: Increasing uptake among people who may have undiagnosed HIV. 2016 1 December 2016.Public Health England. HIV prevalence by Local Authority of residence to end December 2015. Table No.1: 2016. Public Health Engand; 2016.
-
Review
BET 2: Sharing decisions for patients with suspected cardiac chest pain in the emergency department.
A short-cut review was carried out to establish whether shared decision making used alongside a decision aid can lead to greater patient satisfaction, lower healthcare resource use and non-inferior clinical outcomes in patients with suspected acute coronary syndromes. Four studies were directly relevant to the question. ⋯ The clinical bottom line is that the use of shared decision-making tools in the ED for management of patients with low-risk chest pain appears to be beneficial to the patient and the physician. Use of these shared decision-making tools appears to increase patient knowledge and satisfaction, while decreasing decision conflict and resource use, without causing additional negative outcomes for the patient.
-
Review Meta Analysis
11 Topical nsaids for analgesia in traumatic corneal abrasions: a systematic review and meta-analysis.
Traumatic corneal abrasions are common ocular presenTations in the ED. There is no consensus regarding the most appropriate analgesia for this condition. Topical non-steroidal anti-inflammatory drugs (NSAIDs) have been suggested as pain-relief to minimise systemic adverse events associated with oral analgesia. ⋯ The findings of the included studies do not provide strong evidence to support the use.