Gim Tan

Emergency medicine in Sri Lanka: the inevitable evolution to a new specialty.

Sri Lanka is a low‐income country with a relatively advanced, equitable and accessible health‐care system offered to its 20 million populations free of charge through a national pro‐poor health policy. Its weaknesses in emergency services, however, surfaced in 2004 when it faced the Tsunami, the worst natural disaster of the world of the 21st century. Since then, the local health community with the assistance of the government and foreign aid agencies have embarked on a path to establish emergency services, improve its preparedness for disaster management and establishment of emergency medicine training. The present article traces this path and how it is evolving in the country.

Cryoprecipitate administration after trauma.

Objectives Haemorrhage remains among the most preventable causes of trauma death. Massive transfusion protocols, as part of ‘haemostatic resuscitation’, have been implemented in most trauma centres. Relative to the attention to the ideal ratio of red blood cells to fresh frozen plasma and platelets, cryoprecipitate treatment has been infrequently discussed. We aimed to outline the use of cryoprecipitate during trauma resuscitation and analyse outcomes in patients who received cryoprecipitate after hypofibrinogenaemia detection. Methods A retrospective review of registry data on all major trauma patients (Injury Severity Score>15) presenting to a level I trauma centre over a 4-year period (2008–2011) was conducted. We selected all patients who had received cryoprecipitate and then analysed patients who had received cryoprecipitate following the detection of hypofibrinogenaemia (<1.0 g/l). Mortality at hospital discharge among hypofibrinogenaemic patients who had received cryoprecipitate was compared with that among patients who had not received cryoprecipitate. Results Of 3996 trauma patients, 3571 had fibrinogen levels recorded. Most patients (n=3517, 98.5%) had initial fibrinogen counts of 1.0 g/l or higher, and cryoprecipitate was administered to a small proportion of these patients (n=126, 3.6%). Of the 54 patients with hypofibrinogenaemia on arrival, one patient died immediately and was excluded from further analysis. Of the 53 patients, 30 received cryoprecipitate and 28/53 died (53%). There was no difference in mortality between those who had received and those who had not received cryoprecipitate (14/30 vs. 14/23, P=0.31). Conclusion Administration of cryoprecipitate was uncommon during trauma resuscitation, even among patients with hypofibrinogenaemia on presentation. This study provides no evidence towards improved outcomes from administration of cryoprecipitate.

Emergency physician credentialing for resuscitative thoracotomy for trauma

Objective:  A low case incidence and variable skill level prompted the development of a credentialing programme and specific surgical training in resuscitative thoracotomy for emergency physicians at The Alfred, a Level 1 Adult Victorian Major Trauma Service.