Occult tension pneumothorax discovered following imaging for adult trauma patients in the modern major trauma system: a multicentre observational study

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.

Feasibility of Prehospital Emergency Anesthesia in the Cabin of an AW169 Helicopter Wearing Personal Protective Equipment During Coronavirus Disease 2019

OBJECTIVE

Prehospital emergency anesthesia in the form of rapid sequence intubation (RSI) is a critical intervention delivered by advanced prehospital critical care teams. Our previous simulation study determined the feasibility of in-aircraft RSI. We now examine whether this feasibility is preserved in a simulated setting when clinicians wear personal protective equipment (PPE) for aerosol-generating procedures (AGPs) for in-aircraft, on-the-ground RSI.

METHODS

Air Ambulance Kent Surrey Sussex is a helicopter emergency medical service that uses an AW169 cabin simulator. Wearing full AGP PPE (eye protection, FFP3 mask, gown, and gloves), 10 doctor-paramedic teams performed RSI in a standard "can intubate, can ventilate" scenario and a "can't intubate, can't oxygenate" (CICO) scenario. Prespecified timings were reported, and participant feedback was sought by questionnaire.

RESULTS

RSI was most commonly performed by direct laryngoscopy and was successfully achieved in all scenarios. The time to completed endotracheal intubation (ETI) was fastest (287 seconds) in the standard scenario and slower (370 seconds, P = .01) in the CICO scenario. The time to ETI was not significantly delayed by wearing PPE in the standard (P = .19) or CICO variant (P = .97). Communication challenges, equipment complications, and PPE difficulties were reported, but ways to mitigate these were also reported.

CONCLUSION

In-aircraft RSI (aircraft on the ground) while wearing PPE for AGPs had no significant impact on the time to successful completion of ETI in a simulated setting. Patient safety is paramount in civilian helicopter emergency medical services, but the adoption of in-aircraft RSI could confer significant patient benefit in terms of prehospital time savings, and further research is warranted.

Feasibility of Prehospital Rapid Sequence Intubation in the Cabin of an AW169 Helicopter

OBJECTIVE

Prehospital rapid sequence intubation (RSI) is an important aspect of prehospital care for helicopter emergency medical services (HEMS). This study examines the feasibility of in-aircraft (aircraft on the ground) RSI in different simulated settings.

METHODS

Using an AW169 aircraft cabin simulator at Air Ambulance Kent Surrey Sussex, 3 clinical scenarios were devised. All required RSI in a "can intubate, can ventilate" (easy variant) and a "can't intubate, can't ventilate" scenario (difficult variant). Doctor-paramedic HEMS teams were video recorded, and elapsed times for prespecified end points were analyzed.

RESULTS

Endotracheal intubation (ETI) was achieved fastest outside the simulator for the easy variant (median = 231 seconds, interquartile range = 28 seconds). Time to ETI was not significantly longer for in-aircraft RSI compared with RSI outside the aircraft, both in the easy (p = .14) and difficult variant (p = .50). Wearing helmets with noise distraction did not impact the time to intubation when compared with standard in-aircraft RSI, both in the easy (p = .28) and difficult variant (p = .24).

CONCLUSION

In-aircraft, on-the-ground RSI had no significant impact on the time to successful completion of ETI. Future studies should prospectively examine in-cabin RSI and explore the possibilities of in-flight RSI in civilian HEMS services.

Community emergency medicine: taking the ED to the patient: a 12-month observational analysis of activity and impact of a physician response unit

BACKGROUND AND OBJECTIVES

International and national health policies advocate greater integration of emergency and community care. The Physician Response Unit (PRU) responds to 999 calls 'taking the Emergency Department to the patient'. Operational since 2001, the service was reconfigured in September 2017. This article presents service activity data and implications for the local health economy from the first year since remodelling.

METHODS

A retrospective descriptive analysis of a prospectively maintained database was undertaken. Data collected included dispatch information, diagnostics and treatments undertaken, diagnosis and disposition. Treating clinical teams recorded judgments whether patients managed in the community would have been (1) conveyed to an emergency department (ED)and (2) admitted to hospital, in the absence of the PRU. Hospital Episode Statistics data and NHS referencing costs were used to estimate the monetary value of PRU activity.

RESULTS

1924 patients were attended, averaging 5.3 per day. 1289 (67.0%) patients were managed in the community. Based on the opinion of the treating team, 945 (73.3%) would otherwise have been conveyed to hospital, and 126 (9.7%) would subsequently have been admitted. The service was estimated to deliver a reduction of 868 inpatient bed days and generate a net economic benefit of £530 107.

CONCLUSIONS

The PRU model provides community emergency medical care and early patient contact with a senior clinical decision-maker. It engages with community providers in order to manage 67.0% of patients in the community. We believe the PRU offers an effective model of community emergency medicine and helps to integrate local emergency and community providers.

Pharmacokinetics of butorphanol in broiler chickens

Butorphanol tartrate (2 mg/kg) was injected intravenously in 18 healthy broiler chickens to study its pharmacokinetics. Plasma samples were analysed by a highly sensitive high-performance liquid chromatography with diode-array detection method and pharmacokinetic parameters were calculated from the mean pooled data. With non-compartmental analysis, the terminal half-life (T(1/2.z)) was 71.3 minutes, clearance was 67.6 ml/minute/kg and the apparent volume of distribution was 6.9 l/kg. The concentration-time curve was also fitted to a two-compartmental model. In this analysis, elimination half-life (T(1/2β)) was 69.3 minutes, clearance was 74.6 ml/minute/kg and volume of distribution at steady state was 5.6 l/kg. The micro rate constants k(21), k(12) and k(10) were 0.034, 0.050 and 0.029, respectively. Butorphanol was well distributed in the chickens with rapid clearance. It remained above the minimum effective concentration for analgesia in mammals for approximately two hours in the chickens.

Effects of age on the electroencephalographic response to castration in lambs anaesthetised using halothane in oxygen

AIM

To use the electroencephalogram (EEG) to ascertain whether the response of the cerebral cortex to the noxious stimulus of castration varied with age in lambs.

METHODS

Two groups of East Friesian lambs were selected according to age; the mean age of the younger group (n=21) was 12 (SD 2) days and the older group (n=20) was 29 (SD 1) days. Anaesthesia was induced via mask using 4% halothane in oxygen, and maintained using 1.5% halothane in oxygen at a flow rate of 4 L/min. Once a stable plane of anaesthesia had been achieved, data collection of EEG and electrocardiographic (ECG) readings commenced, and the lambs were castrated 15 min later, using rubber rings. Median and 95% spectral edge frequencies (F95) and total EEG power (ptot) were derived from data from the EEG.

RESULTS

Following castration, there was an increase in the median frequency (F50) in the younger lambs (p=0.002), and an increase in ptot in both groups (p=0.05), which was of greater magnitude in the older lambs. There were no significant changes in the F95. Both younger and older lambs exhibited a transient bradycardia (p=0.001 and p=0.01, respectively).

CONCLUSIONS

These differences in the cortical response between the two groups suggest that 2-week-old lambs undergo a qualitatively different perception of the noxious stimulus of castration compared to 4-week-old lambs.

Changes in the roles and responsibilities of nurses

There is still confusion over expanded and extended nursing roles. Role extension often involves a task-centred approach to adopting traditional medical responsibilities. The "augmented role' describes a way of legitimising this extension of the nursing role.

Are nurses independent and autonomous practitioners?

The purpose of this paper is to review the present position of nursing as a developing profession. The author considers the forces stimulating change and the extent to which nurse practitioners hold professional independence and practise nursing from an autonomous base.

A review of the health promotion and health beliefs of traditional and Project 2000 student nurses

In this study it was proposed that a more rigorous theoretical component in nursing education courses would produce a nurse who was a proficient health educator and promotor of health. A sound knowledge base will enable the student to develop positive attitudes and beliefs towards promoting health and providing health education as a part of nursing practice. To test this hypothesis, two groups of students were asked to complete a questionnaire and the answers subsequently compared. The results and data analysis supported the hypothesis only in a limited way and a further study on a larger group of students would provide greater insight into the question.