Injury Guidelines Research Articles

640 Improving Junior Doctors’ Knowledge and Confidence in Assessment, Management and Referral of Burns Patients in the Emergency Department, Royal Oldham Hospital

Abstract Aim There are currently no online trust guidelines for adult burn injuries. We aim to improve ED trainee knowledge and confidence in managing burns patients by delivering focused teaching and developing accessible online resources. Method A survey circulated to junior doctors assessed their confidence in managing minor and major burns injuries. Focused teaching on burns depth, management of burns wounds and when to refer was delivered to ED trainees after completion of the survey. Online tools and resources for assessment, management and referral of burns were developed using NICE and British Burns Association Guidelines. Resources were circulated to trainees and a survey repeated to assess confidence. Results Initial surveys demonstrated 71% felt confident in assessing minor burns and 46% for major burns. When managing minor burns 68% of juniors felt confident and 43% for major burns. Only 25% were aware of referral criteria to a burns centre for major burns and 32% for minor burns. Following focused teaching sessions, clinician confidence in assessment and management of all burns improved to 100%. Awareness of referral criteria rose to 85-92% for all burn injuries. Qualitative feedback was positive amongst different levels of health care professionals for the new resources. Conclusions Burns injuries are common, yet confidence is low amongst junior doctors in their management. This was compounded by a lack of local guidance. Focused teaching and implementation of accessible online departmental guidance has improved clinician confidence and helped ensure that patients presenting with burns are managed by confident clinicians according to national guidelines.

Emergency Medical Services Traumatic Brain Injury Protocols Do Not Reflect Brain Trauma Foundation Guidelines

Objectives Implementation of traumatic brain injury (TBI) guideline recommendations for prehospital care is associated with improved outcomes, but prehospital guideline uptake is frequently delayed. Our objective was to estimate how well TBI guidelines are reflected in a national sample of prehospital TBI protocols in 2012 and 2018, 5 and 11 years after guideline publication. Methods: A purposeful sample of publicly accessible prehospital protocols were obtained in 2012, and updates of those protocols were obtained in 2018. Guideline recommendations were codified into a 23-item tool that was used to dual-abstract each prehospital protocol set. Descriptive statistics and chi-square testing were used to compare differences. Fifty-three sets of protocols representing 25 states and multiple administrative structures were identified. Results: None of the protocols contained all twenty-three elements of the guidelines, and more than one-third (19/53, 35%) did not have a TBI-specific protocol. While some individual items appeared more frequently in 2018 than 2012, more than half of the reviewed protocols do not contain guidance on ventilation or definitions of hypoxemia, hypotension, or pupil asymmetry. Conclusions: Evaluation of a diverse sample of EMS protocols demonstrates a significant deficit in the adoption of TBI guidelines more than a decade after publication.

Abstract 386: Prehospital Capnography in Non-Intubated Traumatic Brain Injury Patients: Association Between End-Tidal CO2 and Level of Consciousness

Background: The EMS traumatic brain injury (TBI) guidelines encourage limiting prehospital intubation (ETI) to patients with profoundly depressed level of consciousness (LOC) and who cannot protect their airway or adequately ventilate without ETI. Thus, EMS providers may manage many TBI patients without intubating even when they have significant alterations in LOC. Monitoring End-Tidal CO2 by placing sensors in the nares (NC-CO2) of non-intubated patients may give providers valuable information about ventilatory status and trends. Study Objective: To evaluate the association between LOC and NC-CO2 in non-intubated TBI patients. Methods: Non-intubated cases from 6 EMS agencies reporting continuous monitor data (Philips MRx™) in the EPIC Study (NIH 1R01NS071049) were evaluated (4/13-3/17). Glasgow Coma Scale (GCS) was available from the EMS record in call cases. Comparisons in patient-level mean, median, lowest and highest NC-CO2 levels were made across GCS categories using clinically meaningful thresholds: <15, <12, <9, and 3. Statistics: Wilcoxon rank-sum test. Results: Included were 106 cases [median age: 47 (range: 9-91), 66% male]. The Table shows the NC-CO2 patterns and comparisons across the GCS categories. In no case was there a significant difference in NC-CO2 between the better vs. worse mental status cohort. Conclusion: We believe this is the first evaluation of the association between NC-CO2 and mental status in TBI. Patients that had significant (and even profound) decreases in LOC, but whom paramedics chose not to intubate, had remarkably similar NC-CO2 patterns compared to those with normal or near-normal mental status. This may support the overall approach of limiting ETI to those with airway/ventilatory compromise or impending hypoxia as there was no evidence of increasing NC-CO2, indicative of hypercapnia, in the non-intubated patients even when they had very depressed LOC.

Chinese expert consensus on echelons treatment of thoracic injury in modern warfare

The emergency treatment of thoracic injuries varies of general conditions and modern warfare. However, there are no unified battlefield treatment guidelines for thoracic injuries in the Chinese People’s Liberation Army (PLA). An expert consensus has been reached based on the epidemiology of thoracic injuries and the concept of battlefield treatment combined with the existing levels of military medical care in modern warfare. Since there are no differences in the specialized treatment for thoracic injuries between general conditions and modern warfare, first aid, emergency treatment, and early treatment of thoracic injuries are introduced separately in three levels in this consensus. At Level I facilities, tension pneumothorax and open pneumothorax are recommended for initial assessment during the first aid stage. Re-evaluation and further treatment for hemothorax, flail chest, and pericardial tamponade are recommended at Level II facilities. At Level III facilities, simple surgical operations such as emergency thoracotomy and debridement surgery for open pneumothorax are recommended. The grading standard for evidence evaluation and recommendation was used to reach this expert consensus.

Posterior fracture dislocation of shoulder with anatomical neck fracture

Posterior fracture dislocation of anatomical neck of humerus is a rare injury and possesses challenges in management due to the scarcity of literature and absence of any recommended guidelines for such injuries. Treatment options available are internal fixation and hemiarthroplasty depending on injury pattern, duration of injury, bone stock available for secure fixation, and vascularity of the head fragment. We present a case report of posterior fracture dislocation of anatomical neck humerus in a 35-year-old male patient treated by open reduction and internal fixation by deltopectoral approach. This case report is unique as the fixation method (Herbert screws) used in this case resulted in a good functional outcome and has not been described previously in literature for this injury pattern.

Brain Injury Guidelines for Small Head Injuries.

Brain Injury Guidelines for Small Head Injuries.

Concussion management by paediatricians: A national survey of Canadian paediatricians

Objective: To assess the use of concussion/mild traumatic brain injury (mTBI) guidelines, criteria used in the initiation of return-to-play (RTP) and management of RTP for brain injured children and youth by Canadian paediatricians.Methods: A cross-sectional survey was mailed through the Canadian Paediatric Surveillance Program to ∼2600 paediatric specialists and sub-specialists.Results: Of 809 respondents (31%), 503 encountered newly diagnosed paediatric concussion/mTBI within the past 12 months, reporting ∼6900 cases. Of the respondents, 96.7% (95% CI = 94.7–98.6%) reported using one or more of the presented concussion/mTBI guidelines in the management of their patients. The most frequently reported criteria (>50%) used to determine asymptomatic status were: free from all concussion symptoms, by patient report (92%), by proxy report (76%), normal physical examination (65%), in school full-time, with usual school performance (53%). Most respondents (84.9%) did not initiate RTP immediately after their patients became asymptomatic. The median time waiting before initiating RTP was 7 days. The median duration of the RTP sequence was 7 days, with considerable variation reported.Conclusions: Canadian paediatricians frequently encounter patients with concussion/mTBI. Their concussion/mTBI care appears to be consistent with current guidelines, but also shows practice variation, particularly when current guidelines become less proscriptive.

Deep Partial Thickness Burn after Contact with a Meal Ready-To-Eat Heater

A case of a Meal Ready-To-Eat heater injury resulting in a deep partial thickness burn is presented. The patient was treated as an outpatient at our battalion aid station. By establishing the depth, extent, and severity of a burn injury, a decision can be made regarding whether outpatient or inpatient therapy is appropriate. A brief description of the Meal Ready-To-Eat heater injury and general guidelines for the outpatient management of burns are presented.

Management of Ocular Injuries and Emergnencies.

Common emergent scenarios - recommended guidelines for timing of ophthalmologic and other specialized evaluation the epidemiology of ocular trauma - a preventable ocular emergency ocular evaluation evaluation of paediatric ocular trauma radiographic and echographic imaging studies timing guidelines for emergent surgery preoperative preparation and anaesthesia injuries of the lid and lacrimal system orbital trauma infection of the lacrimal system, eyelids and orbit ocular and periocular inflammatory syndromes ocular burns non-infectious disorders of the conjunctiva and cornea infectious conjunctivitis and keratitis corneoscleral lacerations and ruptures injuries of the anterior segment.

The reduction of slip and fall injuries: Part I — Guidelines for the practitioner

This chapter presents several guidelines for slip and fall injuries. Various solutions may be applied for reducing slip and fall injuries. Housekeeping walkthroughs are a traditional form of industrial safety practice against slip and fall injuries. Auditing the janitorial process of floor finishing is equally significant and should be introduced in work environments. The finish and polish industry have spent considerable time in developing sophisticated polishes, which, by and large, are known to reduce, rather than increase, the coefficient of friction on a wide range of rigid surfaces. In some cases, janitors use oil-treated mops to remove dust. Excessive use of such oils can result in softening of many floor surfaces with a concomitant increase in slipperiness. As part of the prevention of slips and falls, any task analysis carried out should involve consideration of slips and falls. Such analysis should concentrate on changes of illumination, including the changes of floor coloring, which might conceal a change in coefficients of friction among adjacent surfaces. Floor surface specification may be applied to determine the static coefficient of friction of floors.

Cerebral concussions: Review of mechanism, recognition and care

Cerebral concussion is an entity common primarily to collision and contact sports, but which can occur in any environment. The mechanisms of injury can include direct trauma, rotational, acceleration/deceleration forces, forces transmitted to the head as a result of force to another part of the body or through a series of blows. Subsequent classifications include Grade I (mild). Grade II (moderate) and Grade III (severe). Although the primary designating factors include the effect on consciousness and memory, the evaluator must be aware of additional signs and the potential for a deteriorating condition due to hemorrhage. A review of common injury mechanisms, signs, symptoms, evaluation process, grading, emergency care, and guidelines for return to participation and injury prevention are presented.

Admission guidelines for head injuries: variance with clinical practice in accident and emergency units in the UK.

Guidelines for the initial management of head injuries were formulated by neurosurgeons and a multidisciplinary group of clinicians and administrators attending a seminar convened by the UK Department of Health and Social Security (DHSS). Analysis of data collected previously by the Royal College of Radiologists in nine accident and emergency units in the UK shows that admitting practice varied between centres and was very different from that recommended subsequently in the guidelines. Only 49 per cent (range 22 to 71 per cent) of patients who had skull X-rays and possessed symptoms and signs warranting admission were admitted to hospital and 14 per cent (range 1 to 20 per cent) of those without appropriate symptoms and signs were admitted. Rates of admission for patients with a history of unconsciousness, which according to the guidelines is not a criterion for admission, were up to ten-fold higher than for comparable patients with no such history. Implementation of the guidelines could have a substantial effect on clinical practice and could reduce admissions of patients who had skull X-rays by up to 46 per cent.