Time-critical Condition Research Articles

Emergency management of orbital compartment syndrome: Lateral canthotomy and cantholysis case series

BackgroundOrbital compartment syndrome (OCS) is considered a time critical condition that requires urgent surgical decompression to preserve vision. This study aims to evaluate the current clinical criteria for performing a lateral canthotomy and cantholysis (LCC) in the emergency management of suspected traumatic OCS. MethodsA retrospective audit of patients with suspected traumatic OCS presenting to an adult major trauma centre between January 1, 2017, and August 1, 2022, was performed. Results20 patients with traumatic OCS treated with a LCC were identified. Five patients satisfied the definitive clinical criteria for LCC. The remaining 15 patients received LCC based on secondary clinical findings, or computed tomography (CT) findings suggestive of OCS. 17 patients received non-contrast CT scanning prior to LCC. Of the nine patients noted to regain baseline or close to baseline vision, only one was decompressed within two hours of injury. ConclusionDespite OCS being a clinical diagnosis, the signs and symptoms associated with OCS are difficult to elicit on presentation. Seeking imaging should not delay time to decompression when clinical diagnostic criteria are present. However, imaging may have a role in determining the need for orbital decompression where the absolute indications for LCC cannot be adequately assessed.

UnTWISTing the BALS: A study of predictive accuracy of clinical scoring tools for testicular torsion identification in adults.

Testicular torsion is an uncommon but time-critical condition in EDs. If the diagnosis is missed or delayed, there are significant medicolegal and patient fertility implications. Scoring tools are advocated for use in children but have limited validation in adults. The aim of the present study was to explore the predictive accuracy of the testicular torsion scoring tools, Testicular Workup for Ischemia and Suspected Torsion (TWIST) and Boettcher Alert Score (BALS), in adult patients with a final ED diagnosis of torsion. All patients with an ED working diagnosis of testicular torsion were identified retrospectively. Data collected from digital medical records included demographics, processes of care and clinical information. The outcome of interest was the predictive performance of the scores for a confirmed diagnosis of testicular torsion as adjudicated by an urologist or a surgeon. Fifty-four patients had complete clinical data, of whom 13 had confirmed torsion. The TWIST score had a high area under the receiver operating characteristics curve (AUROC) of 0.89 (95% confidence interval [CI] = 0.78-0.999) with a score of 6-7 corresponding to a positive predictive value (PPV) of 80% (95% CI = 38-96%). The BAL score had an AUROC of 0.79 (95% CI = 0.69-0.92). PPV for a score ≥2 was 38% (95% CI = 22-56%). A high TWIST score correlates to a high likelihood of torsion and can inform surgical decision-making in the absence of US.

An impact of treatment initiation timing on stroke outcome: bridging the time gap

<p><strong>Aim</strong> <br />Stroke treatment is a time-critical condition. Understanding the impact of timing and types of treatment on patient outcomes can help develop and optimize stroke management strategies. The study aimed to analyse the effect of different time intervals and mechanical thrombectomy methods on outcomes of stroke patients in Kazakhstan.<br /><strong>Methods</strong> <br />The patient data, including demographic information, clinical characteristics, and specific time intervals from stroke onset to hospital admission, stroke onset to surgery initiation, and hospital admission to surgery initiation were collected. A total<br />of 100 patients were analysed. Patients’ neurological status was evaluated using the National Institutes of Health Stroke Scale (NIHSS), Modified Rankin Scale (mRS), and Glasgow Coma Scale (GCS) before and after the surgical treatment.<br /><strong>Results</strong> <br />Most patients had concomitant arterial hypertension, and almost 25 % had diabetes mellitus. The average time from stroke onset to hospital admission was 123.2±7.6 minutes, and from hospital admission to surgery initiation, it was 134.7±13.1 minutes. A shorter duration from the onset of stroke to hospitalization and surgery was associated with better clinical outcomes. Our results demonstrated a statistically significant decrease in NIHSS, mRS after surgical treatment compared to baseline. The association between the extended time from stroke onset to hospitalization and<br />reduced survival rates was observed.<br /><strong>Conclusion</strong> <br />Our findings indicate the essential role of timely intervention in managing stroke patients, as well as the need for a<br />comprehensive and patient-centred approach to stroke care. </p>

Postpartum Hemorrhage

Postpartum hemorrhage (PPH) affects about 4% of all deliveries in high-income countries and continues to rise, a trend attributable to the increase in caesarean section rates and maternal morbidity. Preventive measures such as the precautionary administration of uterotonics effectively reduce the risk of severe bleeding irrespective of birth mode. As a time-critical condition and a significant contributor to adverse maternal outcomes, PPH needs to be diagnosed early by measuring, not estimating, blood losses. Institutional treatment algorithms should be available to guide stage-based interdisciplinary management without delay. The main therapy goals are to identify the etiology and stop the bleeding by using uterotonics and mechanical and surgical interventions, to restore hemodynamic stability by volume and transfusion therapy and to optimize hemostasis by laboratory- and viscoelastic assay-guided factor replacement. This review highlights current recommendations for prevention, diagnosis and treatment of PPH.

Emergency Department Evaluation of Priapism: Etiology and Consultation

Introduction: Priapism is a time-critical condition requiring immediate evaluation and management to avoid significant sequela. Management of this condition is significantly variable, dependent upon the underlying cause, and often instituted by a consultant rather than the treating emergency physician. Objectives: To determine etiologic factors contributing to priapism treatment and determine if treatments initiated in the emergency department (ED) contribute to an improved disposition metric. Methods: We conducted a multi-center, retrospective study of patients with priapism caused by multiple different etiologies. Study subjected were located at 15 hospitals by chart review and conducted a computer-assisted chart review to locate patients with priapism for each hospital over a 2-year period. Results: We evaluated 236 patients during the study period; 8 excluded for chart unavailable and 6 with non-priapism diagnosis on review. Median age was 39 years (IQR 22-52). Pediatrics, defined as less than 21 years of age, comprised 4% of patients (N=9). Overall, 85% (N=188) were discharged. Erectile dysfunction medications (EDM) were the most common identifiable cause; involving 23% (N=52). The remaining were sickle cell 20% (N=45), antipsychotic medications 14% (N=30), cocaine 2% (N=4), the remainder without an identifiable etiology. Overall, intrapenile procedures occurred in 56% (N=125) of patients. EDM was associated with significantly less intrapenile procedures compared to other etiologies, 15% (N=58) (p = 0.009), and also had a 2% (N=1) admission rate, significantly less compared to other etiologies (p=0.009). Further, consulting urology did not significantly increase mean length of stay, with difference of 19 minutes (p=0.64) when compared to ED intervention alone. Conclusion: Priapism as a result of EDM, the most frequent etiology, was associated with less frequent emergent intrapenile procedures and significantly less admissions and urology consultation does not significantly lengthen disposition times.

Early identification and characterisation of stroke to support prehospital decision-making using artificial intelligence: a scoping review protocol

IntroductionStroke is a time-critical condition and one of the leading causes of mortality and disability worldwide. To decrease mortality and improve patient outcome by improving access to optimal treatment, there...

High Rates of Recurrent Revascularization in Acute Limb Ischemia – A National Surgical Quality Improvement Program Study

We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to review outcomes of acute limb ischemia (ALI) patients following open surgical intervention for ALI. A previously validated tool was used to identify ALI patients in NSQIP undergoing open surgical revascularization from 2012 to 2017. Multivariable analysis was performed for the primary outcome of reoperation and secondary outcome of readmission and infection. A total of 2,878 ALI patients underwent open revascularization; 35.7% were transfers from another acute care hospital. A total of 13.8% required reoperation and 7.9% required readmission within 30days. A total of 32% of reoperations were recurrent revascularization, representing 4.4% of all ALI patients. A total of 58.7% of patients were female and either overweight or obese. Younger age (odds ratio OR 0.991 [0.984-0.999], P=0.02), underweight patients (OR 1.159 [0.667-2.01], P=0.05), pre-operative steroid use (OR 1.61 [1.07-2.41], P=0.02), and perioperative transfusion (OR 2.02 [1.04-3.95], P=0.04) predicted reoperations. This registry series demonstrates all-cause ALI patients are a different population than PAD with different risk factors. Despite being a time-critical condition, ALI has higher interhospital transfer rates than ACS or ruptured aneurysm. Following open revascularization, ALI outcomes are worse than ACS but better than ruptured AAA. These outcomes do not appear related to patient factors in contrast to revascularization for chronic PAD.

Prehospital canthotomy: A sight-saving procedure in case series.

ObjectiveOrbital compartment syndrome (OCS) is a time critical condition, with ischaemic complications occurring after 90–120 min. In the prehospital setting, the diagnosis and management of OCS is challenging due to complex environmental considerations, competing clinical priorities, and limited equipment. This study aims to provide learning points on performing lateral canthotomy and cantholysis (LCC) in the prehospital setting.MethodsWe performed a retrospective audit of LCC in our service from January 2016 to December 2020 by retrieving demographic and clinical details from LifeFlight Retrieval Medicine electronic database using ‘OCS’ and ‘LCC’ as keywords.ResultsThree cases out of 7413 trauma missions were identified over the 5‐year period. LCC was performed at the primary scene in two cases, while one patient underwent LCC at a rural hospital near the scene of injury. Clinical findings, aeromedical considerations, and radiological findings at the receiving facility, along with visual outcomes at time of discharge are discussed.ConclusionPrehospital LCC is rare. The Australian aeromedical context often involves lengthy transfers of trauma patients. Clinical diagnosis and management of OCS are highly challenging in the prehospital setting. It is important that prehospital physicians have access to appropriate equipment to perform LCC. They should be provided with suitable training and supported by a standard operating procedure.

Acute aortic syndromes in India: The need for a nationwide program to increase awareness

Acute aortic dissection is a rare, but potentially life-threatening and time-critical condition that is frequently misdiagnosed. Therefore, its prompt and proper diagnosis is vital to increase a patient's chance of survival and to prevent grievous complications. Raising awareness and educating the general population and healthcare professionals about an aortic dissection is mandatory, for early diagnosis and improving the chances of survival.

Exploring Features Contributing to the Early Prediction of Sepsis Using Machine Learning.

The increasing availability of electronic health records and administrative data and the adoption of computer-based technologies in healthcare have significantly focused on medical informatics. Sepsis is a time-critical condition with high mortality, yet it is often not identified in a timely fashion. The early detection and diagnosis of sepsis can increase the likelihood of survival and improve long-term outcomes for patients. In this paper, we use SHapley Additive exPlanations (SHAP) analysis to explore the variables most highly associated with developing sepsis in patients and evaluating different supervised learning models for classification. To develop our predictive models, we used the data collected after the first and the fifth hour of admission and evaluated the contribution of different features to the prediction results for both time intervals. The results of our study show that, while there is a high level of missing data during the early stages of admission, this data can be effectively utilized for the early prediction of sepsis. We also found a high level of inconsistency between the contributing features at different stages of admission, which should be considered when developing machine learning models.

Randomised feasibility study of prehospital recognition and antibiotics for emergency patients with sepsis (PhRASe)

Severe sepsis is a time critical condition which is known to have a high mortality rate. Evidence suggests that early diagnosis and early administration of antibiotics can reduce morbidity and mortality from sepsis. The prehospital phase of emergency medical care may provide the earliest opportunity for identification of sepsis and delivery of life-saving treatment for patients. We aimed to assess the feasibility of (1) paramedics recognising and screening patients for severe sepsis, collecting blood cultures and administering intravenous antibiotics; and (2) trial methods in order to decide whether a fully-powered trial should be undertaken to determine safety and effectiveness of this intervention. Paramedics were trained in using a sepsis screening tool, aseptic blood culture collection and administration of intravenous antibiotics. If sepsis was suspected, paramedics randomly allocated patients to intervention or usual care using scratchcards. Patients were followed up at 90 days using linked anonymised data to capture length of hospital admission and mortality. We collected self-reported health-related quality of life at 90 days. We pre-specified criteria for deciding whether to progress to a fully-powered trial based on: recruitment of paramedics and patients; delivery of the intervention; retrieval of outcome data; safety; acceptability; and success of anonymised follow-up. Seventy-four of the 104 (71.2%) eligible paramedics agreed to take part and 54 completed their training (51.9%). Of 159 eligible patients, 146 (92%) were recognised as eligible by study paramedics, and 118 were randomised (74% of eligible patients, or 81% of those recognised as eligible). Four patients subsequently dissented to be included in the trial (3%), leaving 114 patients recruited to follow-up. All recruited patients were matched to routine data outcomes in the Secure Anonymised Information Linkage Databank. Ninety of the 114 (79%) recruited patients had sepsis or a likely bacterial infection recorded in ED. There was no evidence of any difference between groups in patient satisfaction, and no adverse reactions reported. There were no statistically significant differences between intervention and control groups in Serious Adverse Events (ICU admissions; deaths). This feasibility study met its pre-determined progression criteria; an application will therefore be prepared and submitted for funding for a fully-powered multi-centre randomised trial.Trial registration: ISRCTN36856873 sought 16th May 2017; https://doi.org/10.1186/ISRCTN36856873

Health Inequalities of STEMI Care Before Implementation of a New Regional Network: A Prefecture-Level Analysis of Social Determinants of Healthcare in Yunnan, China.

As one of the most serious types of coronary heart disease, ST-elevation myocardial infarction (STEMI) faces huge challenges in the equal management and care of patients due to its life-threatening and time-critical condition. Health inequalities such as sex and age differences in STEMI care have been reported from developed countries. However, limited outcomes have been investigated and the major drivers of inequality are still unclear, especially in under-developed areas. This study aimed to explore the major drivers of health inequalities in STEMI care before implementation of a new regional network in the south-west of China. Prefecture-level data of STEMI patients before the implementation of a regional network were analysed retrospectively. Drivers of inequality were identified from six social determinants of health, namely area of residence, ethnicity, sex, age, education and occupation. Outcomes of STEMI care included timely presentation, reperfusion therapy, timely reperfusion therapy, heart failure, inpatient mortality, length of hospital stay, hospital costs, and various intervals of ischaemic time. A total of 376 STEMI patients in the research area before implementation of the STEMI network were included. Compared with urban residents, rural patients were significantly less likely to have timely presentation (odds ratio [OR]=0.47, 95% CI: 0.28-0.80, P=.004) and timely reperfusion therapy (OR=0.32, 95% CI: 0.14-0.70, P=.005). Rural residents were less likely to present to hospital promptly than urban residents (HR=0.65, 95% CI=0.52-0.82, P<.001). In the first 3 hours of percutaneous coronary intervention (PCI) reperfusion delay and first 6 hours of total ischaemic time, rural patients had a significantly lower probability to receive prompt PCI (hazard ratio [HR]=0.40, 95% CI: 0.29-0.54, P<.001) and reperfusion therapy (HR=0.37, 95% CI: 0.25-0.56, P<.001) compared to urban patients. Rural residents were a major vulnerable group before implementation of the regional STEMI network. No obvious inequalities in ethnicity, sex, age, education or occupation existed in STEMI care in Chuxiong Prefecture of China.

From ER to OR-Type A aortic dissection delay dilemma.

Aortic dissection (AD) remains a life-threatening and time-critical condition. The classical presentation involves sudden onset, sharp "tearing" chest pain radiating to the back. However, it can present with a myriad of symptoms, leading to a high occurrence of misdiagnosis and delay in treatment. A review of the available literature published on AD and diagnostic delays. A systematic review of the literature performed via PubMed and Google scholar using key search terms such as "type A," "aortic dissection," "delay," "misdiagnosis," and synonyms. The Boolean operator used to narrow results specifically to diagnostic elements of AD. A current lack of data collection has impeded the systematic analysis and review of this condition making it difficult to assess reasons for delay. A review of the literature showed a large variation in the presentation of those that have acute AD. Often the presentation mimics other more common conditions such as acute coronary syndrome. Lack of awareness amongst clinicians means that it is often not considered as a differential. Furthermore, the lack of a discriminator for patients being triaged leads to diagnostic delay; this is exacerbated by limited accessibility to diagnostic tests such as CT. Based on the current literature, collaborative data collection, regular audit, national guidance, and communication between Royal Colleges will improve awareness, reduce diagnostic delays, and shine greater light on the issue.

The influence of nurse allocated triage category on the care of patients with sepsis in the emergency department: A retrospective review

Background‘Gold standard’ sepsis care encompasses the recognition and treatment of sepsis within one hour of emergency department (ED) presentation. Early treatment of patients with sepsis reduces mortality. The aim of this study was to examine the effect that the nurse allocated Australasian Triage Scale (ATS) Category allocation had on ED patient treatment for severe sepsis and septic shock. MethodsA two-year retrospective observational cohort study from a single major metropolitan ED, including all patients with severe sepsis or septic shock. ResultsSixty patients were included in this study. Sepsis was recognised at triage for the majority of patients (n=38, 63%), and most were allocated an ATS Category Two (n=39). Almost half of the patients received all elements of the sepsis bundle within one hour of arrival (n=27,45%). Patients allocated an ATS Category One or Two had a shorter time to lactate collection (p=0.003), blood culture procurement (p=0.009) and intravenous antibiotic administration (p=0.021) compared with patients who were allocated ATS Category Three or Four. ConclusionsMost patients presenting with sepsis were recognised by the triage nurse and allocated a high acuity ATS category accordingly. As sepsis is a time-critical condition and a high acuity triage allocation reduces time to treatment, we recommend all Australian EDs should implement a standard approach to sepsis triage by allocating an ATS Category of One or Two to all patients suspected of having sepsis, thus reflecting the urgency of their disease.

Value Utilization of Emergency Medical Services Air Transport in Acute Ischemic Stroke.

Determining whether a patient has a time-critical medical condition requiring helicopter Emergency Medical Services (HEMS) transportation is a challenge with acute ischemic stroke (AIS). Although HEMS is largely accepted as improving outcomes in time-sensitive conditions, overtriage of patients ineligible for acute stroke therapies places patients and providers at unnecessary risk and wastes limited health care resources. We sought to identify how accurate our triage system was at identifying high-yield EMS transfers. A better triage system would decrease the volume of low flight value HEMS transfers. We conducted a retrospective study during a 1-year period. Low flight value was defined by acute therapy eligibility and presenting medical status. Of 141 AIS patients transferred by HEMS, 23 (16%) were deemed of low flight value; 14 (61%) were outside the acute treatment time window for either intravenous tissue plasminogen activator or endovascular therapy (EVT); 5 patients (22%) were ineligible for EVT (National Institute of Health Stroke Scale<6); 2 patients (9%) were ineligible for EVT (Modified Rankin Scale≥3); and 2 patients (9%) were flown despite negative angiographic studies performed at transferring institution. Thirteen (57%) of the patients were interfacility transfers as opposed to direct HEMS transport from the field. HEMS transport for AIS patients plays a crucial role in delivering the best evidence-based care. However, a significant percent of patients did not meet criteria for its optimal utilization, most commonly due to expired treatment windows. Furthermore, low flight value transfers were initiated in spite of physician evaluation > 50% of the time. These results represent a unique opportunity to coordinate education and build effective triage paradigms across a system of stroke care.

Outcome among patients who call the emergency medical service (EMS) due to dizziness

BackgroundPatient with dizziness are challenging in prehospital care.The aim was to describe final diagnosis among patients assessed by EMS as suffering from dizziness with focus on time-critical conditions. MethodsConsecutive patients assessed by an EMS clinician during 12 months in a single large EMS system in Gothenburg, Sweden (660,000 inhabitants), were assessed. The study comprised patients given ESS code 11 dizziness. The main end-point was the final diagnosis (ICD code). ResultsThere were 58,575 primary missions, of which 2,048 (3.5%) were assessed as ESS code 11 (dizziness). Of these, 161 (8%) were excluded. Among the remaining 1887 cases, there were 230 different ICD codes and 96 (5%) had a time-critical condition. The majority (88%) had a cerebrovascular disease. The most typical symptoms among time-critical conditions were an acute onset (63%) and nausea, vomiting (61%). When compared with non-time-critical conditions, those with time-critical conditions were older and had a higher median systolic blood pressure at EMS arrival. ConclusionAmong primary missions by the EMS, 3.5% had dizziness. Of these, 5% had a time-critical condition and the majority had a cerebrovascular disease. Instruments to identify time-critical conditions among patients seen by EMS due to dizziness are required.

The predictive value of variables measurable in the ambulance and the development of the Predict Sepsis screening tools: a prospective cohort study

BackgroundDespite sepsis being a time critical condition with a high mortality, it is often not identified in a timely fashion. The aim of the current study was to create a screening tool based on bedside measurable variables predictive of sepsis among ambulance patients with infection according to clinical judgment by ambulance personnel.MethodsProspective cohort study of 551 adult patients presenting with suspected infection, performed in the ambulance setting of Stockholm during 2017–2018. 18 variables were measured in the ambulance (8 keywords related to medical history, 6 vital signs, 4 point-of-care blood tests, in addition to age, gender, and comorbidity. Logistic regression, area under the curve (AUC) and classification trees were used to study the association with sepsis. The AUC, sensitivity, specificity, predictive values and likelihood ratios were used to evaluate the predictive ability of sepsis screening models.ResultsThe six variables with the strongest association with sepsis were: systolic blood pressure ≤ 100 mmHg, temperature > 38.5 °C, GCS < 15, lactate > 4 mmol/L, gastrointestinal symptoms, and a history of acute altered mental status. These were combined into the Predict Sepsis screening tool 1, with a sensitivity of 0.90, specificity 0.41, AUC 0.77; 95% confidence interval [CI] 0.73–0.81, PPV 0.52, and NPV 0.86. Combining a history of acute altered mental status with GCS < 15 and excluding lactate in the Predict Sepsis screening tool 2 did not noticeably affect the AUC. In addition, the AUCs of these models did not differ noticeably when compared to a model including vital signs alone, with novel calculated cut-offs; the Predict Sepsis screening tool 3.ConclusionsSystolic blood pressure ≤ 100 mmHg, temperature > 38.5 °C, GCS < 15, lactate > 4 mmol/L, gastrointestinal symptoms, and a history of acute altered mental status demonstrated the strongest association with sepsis. We present three screening tools to predict sepsis with similar sensitivity. The results indicated no noticeable increase of predictive ability by including symptom-variables and blood tests to a sepsis screening tool in the current study population.Trial registrationNCT03249597.

Patient characteristics, triage utilisation, level of care, and outcomes in an unselected adult patient population seen by the emergency medical services: a prospective observational study

BackgroundCrowding in the emergency department (ED) is a safety concern, and pathways to bypass the ED have been introduced to reduce the time to definitive care. Conversely, a number of low-acuity patients in the ED could be assessed by the emergency medical services (EMS) as requiring a lower level of care. The limited access to primary care in Sweden leaves the EMS nurse to either assess the patient as requiring the ED or to stay at the scene. This study aimed to assess patient characteristics and evaluate the initial assessment by and utilisation of the ambulance triage system and the appropriateness of non-transport decisions.MethodsA prospective observational study including 6712 patients aged ≥16 years was conducted. The patient records with 72 h of follow-up for non-transported patients were reviewed. Outcomes of death, time-critical conditions, complications within 48 h and final hospital assessment were evaluated. The Mann-Whitney U test, Fisher’s exact test, and Spearman’s rank correlation were used for statistical analysis.ResultsThe median patient age was 66 years, and the most common medical history was a circulatory diagnosis. Males received a higher priority from dispatchers and were more frequently assessed at the scene as requiring hospital care. A total of 1312 patients (19.7%) were non-transported; a history of psychiatric disorders or no medical history was more commonly noted among these patients. Twelve (0.9%) of the 1312 patients not transported were later admitted with time-critical conditions. Full triage was applied in 77.4% of the cases, and older patients were triaged at the scene as an ‘unspecific condition’ more frequently than younger patients. Overall, the 30-day mortality was 4.1% (n = 274).ConclusionsAge, sex, medical history, and presentation all appear to influence the initial assessment. A number of patients transported to ED could be managed at a lower level of care. A small proportion of the non-transported patients were later diagnosed with a time-critical condition, warranting improved assessment tools at the scene and education of the personnel focusing on the elderly population. These results may be useful in addressing resource allocation issues aiming at increasing patient safety.

Prehospital amputation: a scoping review

Background: Where limbs or extremities become entrapped and it is not possible to extricate a patient in time to prevent death, or because of a deterioration or scene safety emergency, prehospital amputation is an option to enable extrication. Aims: This study aimed to analyse accounts of prehospital amputation and identify factors that may influence practice as well as areas for further research. Methods: A search of multiple databases (AMED, BNI, CINAHL, EMCARE, Google Scholar and PubMed) and additional literature for accounts of prehospital amputation was carried out. Results: Thirteen sources of evidence describing 20 cases of prehospital amputation (18) or dismemberment (2) in a variety of settings between 1975 and 2019 were identified. Prehospital amputation was reported following structural collapse (8), industrial accidents (6), road traffic crashes (5) and rail incidents (1). The procedure was undertaken for a range of reasons, including unsuccessful traditional extrication attempts (7), time-critical patient condition (6), a risk of further extrication attempts causing structural destabilisation (5) and dismemberment of deceased victims (2). The equipment used to perform the amputation was not reported in 14 cases. Outcomes were reported in 17 accounts, with all patients surviving to hospital. Conclusion: Prehospital amputation is performed extremely rarely and accounts in the literature are limited. The situations and environments in which prehospital amputation is reported vary and specialist teams are often required. Further review of guidance and studies on techniques may be beneficial.

Population Coverage of Trauma Systems: What Do Helicopters Add?

Trauma is a time-critical condition. Helicopters are thought to enhance the accessibility to trauma centers, but this benefit is poorly quantified. The aim of this study was to conduct a geographical analysis of the added benefit provided by helicopters, over ground transport. This study uses geospatial analysis. Helicopter bases and Level I and II designated trauma centers were geocoded. 60-minute drive-time and elliptical flight-time isochrones were mapped with ArcGIS™ (Esri, Redlands, CA). Calculations included allowance for mission ground time (MGT). We compared the proportion of the population that could be taken to Level I and II trauma centers, within 60 minutes, by road and by air. Using a 30-minute MGT model, helicopters permit 279,317 additional residents (5.8%) access to a Level I trauma center within 60 minutes. Using the 20-minute MGT model, 1,089,177 more residents (22.8%) would have access to Level I trauma center care. The benefits were marginally greater for access to Level I and II trauma center care. Helicopters enhance access to specialist trauma center care, but the benefit is small and dependent on MGT. Consideration should be given to the siting of helicopters, particularly in relation to trauma patients, MGT, and the timely response of EMS when determining the triage for helicopter transport.