The NICE head injury guidelines.
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Craniocerebral Trauma↗
Biomedical subjects
D W Yates
Publications and source records attributed to D W Yates.
Whiplash associated disorder in children attending the emergency department.
AIMS: To determine the incidence, severity, and clinical course of whiplash associated disorder (WAD) in children aged 4-16 years involved as passengers in car crashes. METHODS: Prospective surveillance of all paediatric attendances to three English urban emergency departments after car crashes over an eight month period. An initial structured telephone interview at day 2 after the car crash was performed. This was followed by clinical review of symptomatic patients on day 5 after the crash using the Quebec Task Force criteria for outcome assessment, with subsequent clinical review at 14, 28, and 56 days or until earlier symptom resolution. RESULTS: 105 children were identified as having been involved in car crashes as passengers. Forty nine children (47%) experienced symptoms of a WAD. Twenty nine children developed symptoms within 24 hours with the remainder developing symptoms by 48 hours. Forty children experienced a WAD grade 1 and nine children suffered a WAD grade 2 injury. The mean duration of symptoms was 8.8 days (range 3-70, SD 10.7). WAD grade 2 symptoms lasted significantly longer than WAD grade 1 symptoms. CONCLUSIONS: The incidence of WAD in children in this series was higher than in other studies. The clinical course was more favourable than that reported for adults.
Accidents, Traffic↗
Lack of change in trauma care in England and Wales since 1994.
UNLABELLED: To demonstrate trends in trauma care in England and Wales from 1989 to 2000. STUDY POPULATION: Database of the Trauma Audit and Research Network that includes hospital patients admitted for three days or more, those who died, were transferred or admitted to an intensive care or high dependency area. METHOD: To demonstrate trends in outcome, severity adjusted odds of death per year of admission to hospital were calculated for all hospitals (n=99) and 20 hospitals who had participated since 1989 (adjustments are for Injury Severity Score, age, and Revised Trauma Score). The grade of doctor initially seeing the injured patient in accident and emergency and median prehospital times per year of admission were calculated to demonstrate trends in the process of care. Trend analyses were carried out using simple linear regression (odds ratio versus year). RESULTS: The analysis shows a significant reduction in the severity adjusted odds of death of 3% per year over the 1989-2000 time period (p=0.001). During the period 1989-1994 the odds of death declined most steeply (on average 6% per year p=0.004). Between 1994 to 2000 no significant change occurred (p=0.35). This pattern was mirrored by the 20 permanent members where the odds of death also declined more steeply over the 1989-1994 period. The percentage of severely injured patients (ISS >15) seen by a consultant increased from 29 to 40 from 1989-1994 but has remained static subsequently. Median prehospital times for severely injured patients have not changed significantly since 1994 (51 to 45 minutes). CONCLUSION: Most of the case fatality reduction for trauma patients reaching hospital over the 1989-2000 time period occurred before 1995 when there was most marked change in the initial care of severely injured patients.
Adult↗
Head injury outcome prediction in the emergency department: a role for protein S-100B?
BACKGROUND: Biochemical markers released after head injury may reflect the degree of brain damage, which is related to subsequent disability. If the serum level of a marker were found to be related to outcome, then earlier identification and intervention would be possible. OBJECTIVE: To investigate the potential of the serum marker S-100B protein to predict the outcome after head injury. METHODS: Blood samples for S-100B concentrations were taken from 148 adults within six hours of a head injury (initial Glasgow coma score 4-15). Patients were recruited from the emergency departments of four hospitals in Greater Manchester, United Kingdom. Outcome was assessed in 119 patients (80%) at one month using the extended Glasgow outcome scale (GOSE). RESULTS: A significant inverse correlation between serum S-100B level and GOSE was found (Spearman's rho = -0.349, p < 0.0001). A serum S-100B concentration of > 0.32 micro g/l predicted severe disability (GOSE < 5) at one month with a sensitivity of 93% (95% confidence interval 68% to 100%), a specificity of 72% (54% to 79%), and a negative predictive value of 99% (93% to 100%). CONCLUSION: Serum S-100B concentration can be used in the emergency department to identify patients with head injury who are most likely to have a poor outcome at one month.
Adolescent↗
[CRASH--the first large randomized controlled study of head injuries].
CRASH (www.crash.lshtm.ac.uk) is already today the most extensive randomized controlled study of patients with head injuries which was implemented, but its completion and statistical evaluation will be possible only when it achieves the planned and necessary 20,000 enlisted patients. This calls for unselfish cooperation of physicians and nurses world-wide. In the Czech Republic so far six departments participate in the study and we would be glad if this number would increase substantially.
Adult↗
Trends in trauma care in England and Wales 1989-97. UK Trauma Audit and Research Network.
BACKGROUND: In 1988, the Royal College of Surgeons reported major deficiencies in trauma care in UK hospitals. We investigated whether and how that care has changed in the last decade by use of data collected by the UK Trauma Audit and Research Network. METHODS: We analysed injury-severity, process, and outcome variables from 91602 patients' records on the database at the end of 1997, collected from 97 (49% of trauma-receiving) hospitals in England, Wales, and two in Ireland. We did longitudinal analyses of odds of death, process variables, and individual hospitals' performance. We took account of potential selection bias from missing data and recruitment of new hospitals. FINDINGS: The severity-adjusted odds of death after trauma declined gradually from 1989 (odds ratio 1997/1989 0.63 [95% CI [0.49-0.82]). In 1997, the reduction in odds of death was significant even after adjustment for missing data (ratio 1997/1989 0.72 [0.55-0.92]) and recruitment of new hospitals (0.64 [0.44-0.93]). There was significant variability in the proportion of survivors (adjusted for severity of injury and age) between the highest and lowest 10% of UK hospitals. The time between the call to the emergency services and arrival at hospital increased from 32 min in 1989 to 45 min in 1997, irrespective of injury severity. The proportion of severely injured patients seen first by senior doctors increased from 32% to 60%. INTERPRETATION: Hospital care has made a valuable but variable contribution to reductions in case fatality after injury in the UK in the past 10 years, though further improvement is possible.
Aged↗
An extended Glasgow Coma Scale (GCS-E) with enhanced sensitivity to mild brain injury.
OBJECTIVE: The Glasgow Coma Scale-Extended (GCS-E) was developed to flag mild cases of concussion (corresponding to Grades I and II concussion as defined by the American Academy of Neurology) at the time of first contact with the health care system. SUBJECTS AND SETTING: The GCS-E was applied to 561 consecutive admissions with GCS scores of 13 to 15 at two hospitals in South Africa and two in the United Kingdom (UK). RESULTS: The amnesia scale was readily learned and reliably applied by emergency department staff without affecting the standard scoring of the GCS itself. Among patients with an admitting GCS of 15, 27% in the UK and 31% in South Africa reported amnesia of some duration. CONCLUSIONS: Wide use of the GCS-E would hold mild traumatic brain injury cases in the treatment loop, improve access to counselling, rehabilitation services, and personal injury compensation, and reduce the "cognitive dissonance" between victims of mild traumatic brain injury and treating professionals.
Adult↗
Placement of electrodes for defibrillation--a review of the evidence.
Defibrillation is the only reliable treatment for ventricular fibrillation. Its success depends on the passage of an adequate current through the chest rather than on the administration of a preset energy. The final determinant of both efficacy and cellular damage is myocardial current density. Therefore, the current should be evenly distributed with an average value that exceeds the defibrillation threshold throughout a critical mass of myocardium but does not cause further local dysfunction. The distribution of current is altered by the relative positions of the two electrodes. European guidelines for electrode (paddle) placement during defibrillation are based on empirical studies and traditional practice. However, there is increasing evidence to suggest that bi-axillary electrode placement may be superior to traditional antero-apical and antero-posterior positions.
Electric Countershock↗
Unexpected contribution of moderate traumatic brain injury to death after major trauma.
BACKGROUND: The cardiovascular reflex responses to injury and simple hemorrhage are coordinated in the central nervous system. Coincidental brain injury, which is present in 64% of trauma patients who die, could impair these homeostatic responses. The occurrence of hemorrhagic shock in the patient with head injury is also known to increase mortality. Therefore, there is a potential bidirectional interaction between traumatic brain injury and peripheral injury, which would result in an increased mortality when these two injuries coexist. Our objective was to test the hypothesis that moderate traumatic brain injury is an independent predictor of outcome in patients with multisystem trauma. METHODS: We carried out an analysis of the UK Trauma Audit and Research Network Database. Moderate traumatic brain injury was defined as an Abbreviated Injury Scale score of 3. The study population included 2,717 patients with multisystem injury: 378 patients had a moderate brain injury with peripheral injury, and 2,339 patients had extracranial injury alone. Mortality rates for both groups were compared at increasing injury severity. RESULTS: Moderate brain injury alone was associated with a mortality rate of 4.2%. However, when combined with extracranial injury, the risk of death was double that attributable to extracranial injury alone (odds ratio, 2.08; 95% confidence interval, 1.57-2.77). CONCLUSION: This study confirms that the coexistence of moderate traumatic brain injury with extracranial injury is associated with a doubling of the predicted mortality rate throughout the injury severity ranges studied.
Adolescent↗
Significance of vomiting after head injury.
OBJECTIVES: To determine whether the presence and severity of post-traumatic vomiting can predict the risk of a skull vault fracture in adults and children. METHODS: Data were analysed relating to a consecutive series of 5416 patients including children who presented to an emergency service in the United Kingdom during a 1 year study period with a principal diagnosis of head injury. Characteristics studied were age, sex, speed of impact, level of consciousness on arrival, incidence of skull fracture, and the presence and severity of post-traumatic vomiting. RESULTS: The overall incidence of post-traumatic vomiting was 7% in adults and 12% in children. In patients with a skull fracture the incidence of post-traumatic vomiting was 28% in adults and 33% in children. Post-traumatic vomiting was associated with a fourfold increase in the relative risk for a skull fracture. Nausea alone did not increase the risk of a skull fracture and multiple episodes of vomiting were no more significant than a single episode. In patients who were fully alert at presentation, post-traumatic vomiting was associated with a twofold increase in relative risk for a skull fracture. CONCLUSION: These results support the incorporation of enquiry about vomiting into the guidelines for skull radiography. One episode of vomiting seems to be as significant as multiple episodes.
Adult↗
Towards the practical application of recent advances.
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Evidence-Based Medicine↗
Doctors' legal position in treating temporarily incompetent patients.
Doctors in accident and emergency departments are sometimes presented with patients with potentially life threatening conditions who refuse to consent to treatment. The doctors then face a dilemma: to withhold necessary treatment or to act against a patient's express wishes. Two such cases are presented, and we asked a lawyer, two medical ethicists, a psychiatrist, and an accident and emergency physician to comment on the implications.
Adult↗
Triage: a literature review 1985-1993.
Following an extensive literature review of Accident and Emergency (A & E) nursing from 1985-1993, the authors focused upon triage. A wide range of issues related to triage and its use in A & E departments are examined. An appendix is included to clarify major research finds in this area. Many of the claims made regarding triage require further investigation.
Emergency Nursing↗
Grief support in accident and emergency nursing: a literature review 1985-1993.
On completing a wide ranging review of literature related to Accident and Emergency (A & E) nursing, the authors chose to focus upon grief support. The literature ranges from personal experiences to large scale research. A table of studies is included to clarify major research findings in this area. The article concludes by recommending long term support for bereaved relatives and research to demonstrate the value of support for relatives in the community.
Emergency Nursing↗
Standardized comparison of performance indicators in trauma: a new approach to case-mix variation.
An institution's trauma survival rate can be compared with that predicted by TRISS using definitive outcome-based evaluation. This examines W, the difference between actual and predicted survival rates; Z, the statistical significance of this difference; and M, a measure of the similarity of injury severity mix to the prediction data base. However, it is possible for two institutions with the same survival rate within each band of injury severity to have very different W and Z scores whilst retaining a similar M score. Clearly this is unsatisfactory. A new statistic, Ws, is therefore proposed, which is standardized with respect to injury severity mix, producing more accurate comparisons between different institutions. Confidence intervals are used to graphically illustrate the magnitude of Ws, its direction, accuracy, and statistical significance. Data from the U.K. Major Trauma Outcome Study are used to demonstrate the calculations and presentation of Ws and its advantages.
Diagnosis-Related Groups↗
Trauma audit--closing the loop.
The philosophy of medical audit and methods of data collection and statistical analysis have been extensively reviewed but less has been written about the effect of audit on medical practice. The measurement of performance is only valuable if it identifies areas of concern and stimulates appropriate change. This paper describes the work of the Salford Trauma Audit Group which has been developed at Hope Hospital, the problems that have been recognized, the strategies that have been introduced to effect change and their influence on management and outcome. Analysis of performance reveals an initial fall in adjusted mortality rate from severe injury after the introduction of resuscitation teams, the adherence to Advanced Trauma Life Support protocols and an integrated multidisciplinary approach to trauma care. Problems remain and there is continuing concern about trauma management in the hospital. This has been reinforced by performance feedback through the Trauma Audit Group which has attracted the interest of senior clinicians in several specialties.
Emergencies↗
Mild head injury--a positive approach to management.
It is estimated that 1.4 million patients each year attend Accident and Emergency (A&E) departments in the UK with a head injury. The vast majority are, in retrospect, diagnosed as a 'mild' injury. There is evidence to suggest that many develop short term morbidity and some long term problems. The incidence is unknown. Early recognition and treatment many hasten recovery. A national postal survey of A&E departments revealed a general unawareness for this morbidity. Written advice given to patients on discharge from the departments was exclusively concerned with the symptoms expected if serious complications developed. A description of the common symptoms of fatigue, poor memory and concentration were not given to the patients in a written format. Arrangements for follow up are, in the majority of hospitals, unstructured. We recommend a positive approach to the management and follow up of mild head injury. This should recognize the common problems experienced by these patients and cater for their needs. More interest and research is required into this aspect of head injury.
Craniocerebral Trauma↗
The emergency department and the community: a model for improved cooperation.
Improved emergency care may be achieved by closer integration of hospital and community management. This has been promoted in Salford by the appointment of an Emergency Services Practice Manager jointly funded by the Family Health Services Authority and Salford Health Authority. Communication has improved, complementary working relationships developed and health promotion initiatives established.
Attitude of Health Personnel↗