An analysis of casualties presenting to military emergency departments in Iraq and Afghanistan

Background

During the past 17?years of conflict the deployed US military health care system has found new and innovative ways to reduce combat mortality down to the lowest case fatality rate in US history. There is currently a data dearth of emergency department (ED) care delivered in this setting. We seek to describe ED interventions in this setting.

An analysis of the pediatric casualties undergoing massive transfusion in Iraq and Afghanistan

BackgroundExisting data on pediatric massive transfusion as part of trauma resuscitation is limited. We report the characteristics of pediatric casualties associated with undergoing massive transfusion at US military treatment facilities during combat operations in Iraq and Afghanistan.MethodsWe queried the Department of Defense Trauma Registry (DODTR) for all pediatric subjects admitted to US and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. We stratified subjects by Centers for Disease Control age groupings: <1, 1–4, 5–9, 10–14, and 15–17 years. We defined a massive transfusion as 40 mL/kg of total blood products or more.ResultsFrom January 2007 through January 2016 there were 3439 pediatric casualties within the registry, of which 543 (15.7%) met criteria for receiving a massive transfusion. The median age of children undergoing massive transfusion was 9 years (IQR 5–12), male (73.4%), injured in Afghanistan (69.9%) and injured by explosives (60.4%). Compared to other pediatric casualties, subjects undergoing massive transfusion had higher composite injury severity scores (median 17 versus 9), higher incidence of tachycardia (86.8% versus 70.9%), increased incidence of hypotension (31.2% versus 7.5%), and decreased survival to hospital discharge (82.6% versus 91.6%). Specific to body regions, casualties undergoing massive transfusion more frequently had serious injuries to the head/neck (30.0% versus 22.8%), the thorax (22.8% versus 9.9%), abdomen (26.8% versus 6.9%), the extremities (42.1% versus 14.6%), while less frequently had serious injuries to the skin (5.3% versus 8.4%). All findings were significant.ConclusionsFurther research is needed to better translate the lessons learned from pediatric trauma care in the combat setting into the civilian setting in developed countries.Level of evidence: 3     

Cancer pain as the presenting problem in emergency departments: incidence and related factors

Goals of work  

Since emergency departments (ED) are designed to manage people with urgent and life-threatening conditions, cancer patients presenting with pain may not receive the appropriate care in the ED. The purpose of this study was to identify the incidence and factors related to ED visits by cancer patients with pain complaints.     

Trends in adult patients presenting to pediatric emergency departments

ObjectiveAdults presenting to pediatric emergency departments (PEDs) include those with complex chronic conditions (CCCs) often still followed by pediatric providers, and those without CCCs (non-CCCs). This paper describes recent trends in adults seen within PEDs, both by age subgroups and CCC status.MethodsData were retrospectively reviewed from the Pediatric Health Information System for PED visits between Jan 1, 2013 and Dec 31, 2017. Yearly visit rates were trended for all adult visits, age subgroups (18–21, 22–25, 26–40, and 41–95 years), and by CCC status. The most frequent diagnoses were reviewed for each adult age group and CCC category.ResultsRates of adult PED visits significantly increased from 3.7% in 2013 to 4.2% in 2017 (P < 0.0001). While the overall majority (88% overall and >70% for each age group) of adult PED patients were non-CCC, the rate of CCC patients increased overall (P < 0.0001), especially among older patients (41–95 years) from 8.7% in 2013 to 29% in 2017 (P < 0.0001). The most frequent CCC diagnoses were sickle cell disease (18–21 and 22–25 years), cardiac pathology (26–40 years), and hyperlipidemia (41–95 years). The most frequent non-CCC diagnoses were abdominal pain (18–21 years), pregnancy-related (22–25 and 26–40 years), and chest pain (41–95 years).ConclusionVisits to PEDs by adult patients have increased over time, with the majority of the population being represented by non-CCC adults. The results of this study can be used to guide specifics in adult medicine training during Pediatric Emergency Medicine fellowship and assist in continuing education efforts.     

Management of whiplash injuries presenting to accident and emergency departments in Wales

Methods: Questionnaires were sent to 76 full time accident and emergency staff across Wales inquiring into their management of soft tissue sprains/strains of the neck and soft collar use.

Results: The overall response rate was 74% (SHO 70%, registrar 65%, consultant 100%). Half of consultants and more than half of the middle grade and junior staff reported soft collar use in this condition. As required wear was most commonly recommended and instructions for use ranged from one day only to until the patient was pain free.

Conclusion: The study recommends treatment protocols for whiplash injuries prescribing regular analgesia, early home exercises with the help of an advice sheet, and physiotherapy if symptoms persist.

     

Radiography for back pain presenting to accident and emergency departments.

In order to determine the relevance of radiographs of the lumbar spine in an A&E department 225 consecutive patients presenting in a 6-month period with acute back pain were studied. An analysis of the number of radiographs performed and their association with particular factors in the history and examination of the patient was performed. A total of 108 patients had radiographs (48%), with a total of seven fractures (6% of radiographs). All the patients with fractures had a history of direct trauma. Radiographs had no bearing on the decision to admit the patient. The indications for radiography of the lumbar spine in the A&E department are discussed.     

Detection of non-accidental injuries presenting at emergency departments

Objectives: To investigate whether cases of possible non-accidental injury as identified using five risk indicators give rise to any subjective concerns of child abuse.

Methods: Questionnaires were completed by the triage nurse and attending doctor for every child attending the general hospitals of the North Western Health Board, with an injury, during a six month period. The questionnaires included an assessment of subjective concerns about the injury occurrence and five risk indicators of child abuse.

Results: Children presenting with an injury who had two or more positive indicators failed to raise subjective concerns in the attending emergency department staff.

Conclusions: The introduction of a policy of identifying positive indicators from the five risk indicators of child abuse needs additional computer support within emergency departments.

     

Management of multiple burn casualties from the Volendam disaster in the emergency departments of general hospitals.

OBJECTIVE: To establish the level of medical care provided in the emergency department of general hospitals to the victims of the Volendam café fire on 1 January 2001. METHODS: A retrospective review was done based on a standardized chart, for all victims seen at the emergency departments of 19 hospitals. Diagnostic findings and logistic aspects were inventoried. Treatment described in the Emergency Management of Severe Burns protocol was used as a gold standard against which the care provided to the victims was assessed. RESULTS: Data from 233 patients were included in the analysis. The documentation rate was low. Suspected inhalation injury and burns were the most frequently documented diagnoses. Most patients with suspected inhalation injury, for whom treatment records were available, received oxygen therapy (81%). Intubation was performed in 43% of patients with suspected inhalation injury and 14% of the remaining patients required intubation after admission to the intensive care unit. Most patients with circulatory problems (83%) and/or more than 15% of total body surface area burned (97%), for whom treatment records were available, received intravenous lines. Pain treatment seemed to have had low priority. Two patients (3%) were re-admitted after having been released earlier from the emergency department. CONCLUSION: Treatment and triage of the burn casualties after the Volendam café fire was adequate. The documentation rate was low. Not all steps in diagnosis and treatment may be of equal importance in disaster circumstances.     

SEEC: An area approach to education in emergency departments

Providing education to nursing staff in a meaningful, timely, standardised and coordinated manner is a challenge for managers and educators of most emergency departments. The pressures of workload and diminished personnel resources have made providing education increasingly difficult. Education programs can become inequitable, spasmodic, interrupted, and have varying standards. In an area health service in Sydney's South West, a coordinated approach to address the development, coordination, delivery and evaluation of education in the six emergency departments was developed. This education approach began in the late 1990s when the Nurse educator at the major referral hospital brought together educational representatives (clinical nurse educator or clinical nurse specialist) from each of the six emergency departments. This group became known as South Western Sydney Area Health Service Emergency Educators Committee (SEEC). This group has continued to grow and develop and is now well recognised across the area health service as the group responsible for managing emergency department education.     

Necrotizing pneumonia and septic shock: suspecting CA-MRSA in patients presenting to Canadian emergency departments

We report a case of fatal necrotizing pneumonia and sepsis caused by community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) in an otherwise well, 48-year-old Canadian man with type 2 diabetes mellitus who had travelled to Texas. Despite therapy that included intravenous antibiotics, intravenous immune globulin and other supportive measures, the patient succumbed to his illness. Recently, CA-MRSA pneumonia has been reported in several countries. The virulence of this organism may in part be related to its ability to produce toxins, such as Panton-Valentine leukocidin. As rates of CA-MRSA increase worldwide, physicians should be aware of the potential for MRSA to cause life-threatening infections in patients presenting to Canadian emergency departments (EDs). Necrotizing pneumonia caused by MRSA must be considered in the differential diagnosis of acute, severe respiratory illness. Early recognition of this syndrome in the ED may help physicians initiate appropriate antibiotic therapy in a timely manner.     

Do patients presenting to accident and emergency departments have low serum anticonvulsant concentrations?

It is often felt that poorly controlled epileptic patients, who are taking anticonvulsant medication, are over represented in A&E departments compared to the general population. This A&E based study set out to determine whether such patients do have inadequate serum anticonvulsant levels, when they present following a seizure, to A&E departments. All epileptic patients, taking medication, who presented to the A&E departments of St. Bartholomew's and Hackney Hospitals, London, over a 4-month period were studied. Serum anticonvulsant concentrations were measured on their arrival in the departments. Forty-six patients were studied. Only 21% of anticonvulsant drug concentrations were within 'therapeutic' ranges. A total of 66% were below 'therapeutic' ranges and 13% were potentially toxic. The implication of these findings is discussed.