Keith Porter

Tourniquet use in the civilian prehospital setting

Tourniquets are an effective means of arresting life-threatening external haemorrhage from limb injury. Their use has not previously been accepted practice for pre-hospital civilian trauma care because of significant concerns regarding the potential complications. However, in a few rare situations tourniquet application will be necessary and life-saving. This review explores the potential problems and mistrust of tourniquet use; explains the reasons why civilian pre-hospital tourniquet use may be necessary; defines the clear indications for tourniquet use in external haemorrhage control; and provides practical information on tourniquet application and removal. Practitioners need to familiarise themselves with commercial pre-hospital tourniquets and be prepared to use one without irrational fear of complications in the appropriate cases.

Review of the biomechanics and patterns of limb fractures

The pattern of a limb fracture can be determined by the material property of the bone and the characteristics of the deforming force. In this review we outline the composition and material properties of cortical and cancellous bone, and articular cartilage. We defi ne the biomechanics of fractures and describe the various fracture patterns that are seen clinically.

Humeral shaft fractures: a review of literature

Humeral shaft fracture account for nearly 3% of all fractures. Trauma specialists should be aware of a range of possible injuries, complications and be confident in their management. This article reviews the various aspects of humeral shaft fractures and details different treatment options available. We found that in the majority of cases non-operative management has excellent results provided attention is paid to follow up and rehabilitation.

Comparing mortality risk of patients with acute hip fractures admitted to a major trauma centre on a weekday or weekend

Proximal femoral fractures are a major public health concern with estimated annual direct and social costs amounting to £2 billion and average 30-day mortality risk of 7.5%. In response to the recent debate over out-of-hours hospital provision we investigated the ‘weekend effect’ at a major trauma centre, caring for acute injuries. A single centre, multi-surgeon review of 2060 patients performed. The distribution of patient and treatment variables compared in patients admitted on a weekday or the weekend. Fewer patients met performance indicators during weekend admission, time to surgery (63 vs. 71%) and time to geriatric review (86 vs. 91%). Weekend admission 30-day mortality was marginally lower than weekday (9.7% vs. 10.2%, OR 0.94, 95% CI 0.67 to 1.32, pu2009=u20090.7383). Increasing age, female gender, co-morbidities and confusion increased mortality risk. Binary regression analysis including these variables found no significant ‘weekend effect’. Despite the unit observing an increasing workload in the last five years, with meticulous workforce planning, senior doctor provisions and careful use of resources, it is possible to provide a seven-day fracture neck of femur service with no variation in thirty-day mortality by the day of admission.

Harness suspension and first aid management: development of an evidence-based guideline

The possibility of a fall into rope protection and subsequent suspension exists in some industrial situations. The action to take for the first aid management of rescued victims has not been clear, with some authors advising against standard first aid practices. To clarify the medical evidence relating to harness suspension the UK Health and Safety Executive commissioned an evidence-based review and guideline. Four key questions were posed relating to the incidence, circumstances, recognition and first aid management of the medical effects of harness suspension. A comprehensive literature search returned 60 potential papers with 29 papers being reviewed. The Scottish Intercollegiate Guideline Network (SIGN) methodology was used to critically review the selected papers and develop a guideline. A stakeholders workshop was held to review the evidence and draft recommendations. Nine papers formed the basis of the guideline recommendations. No data on the incidence of harness suspension syncope were found. Presyncopal symptoms or syncope are thought to occur with motionless suspension as a consequence of orthostasis leading to hypotension. There was no evidence of any other pathology, despite this being hypothesised by others. No evidence was found that showed the efficacy or safety of positioning a victim in a semirecumbent position. In any case of harness suspension, the standard UK first aid guidance for recovery of a semiconscious or unconscious person in a horizontal position should be followed. Other recommendations included areas for further research and proposals for standard data collection on falls into rope protection.

The pre-hospital management of life-threatening chest injuries: A consensus statement from the Faculty of Pre-Hospital Care, Royal College of Surgeons of Edinburgh

‘The pre-hospital management of chest injury: a consensus statement’ was originally published by the Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh in 2007. To update the pre-existing guideline, a consensus meeting of stakeholders was held by the Faculty of Pre-hospital Care in Coventry in November 2013. This paper provides a guideline for the pre-hospital management of patients with the life-threatening chest injuries of tension pneumothorax, open pneumothorax, massive haemothorax, flail chest (including multiple rib fractures), and cardiac tamponade.

Enhancing national resilience: the citizenAID initiative

Se presenta un caso del conocido como hombro de Chopart, una artropatia neuropatica como consecuencia de siringomielia en una paciente de 62 anos con antecedentes durante 5 anos en su hombro. La clinica y la RMN de la columna cervical permitieron el diagnostico. El tratamiento fue conservador con una buena evolucionEvents in Europe in the last year have shown there is a realistic threat to public safety in the UK from shooting, stabbing and bombing incidents. In an interview with BBC on 31 July 2016, the Metropolitan Police Commissioner stated that an attack within UK was a case of ‘when not if’. citizenAID empowers the public to take action to save lives and thereby enhance national resilience.

Man or machine? An experimental study of prehospital emergency amputation

Objective Prehospital emergency amputation is a rare procedure, which may be necessary to free a time-critical patient from entrapment. This study aimed to evaluate four techniques of cadaveric lower limb prehospital emergency amputation. Method A guillotine amputation of the distal femur was undertaken in fresh frozen self-donated cadavers. A prehospital doctor conducted a surgical amputation with Gigli saw or hacksaw for bone cuts and firefighters carried out the procedure using the reciprocating saw and Holmatro device. The primary outcome measures were time to full amputation and the number of attempts required. The secondary outcomes were observed quality of skin cut, soft tissue cut and CT assessment of the proximal bone. Observers also noted the potential risks to the rescuer or patient during the procedure. Results All techniques completed amputation within 91u2005s. The reciprocating saw was the quickest technique (22u2005s) but there was significant blood spattering and continuation of the cut to the surface under the leg. The Holmatro device took less than a minute. The quality of the proximal femur was acceptable with all methods, but 5u2005cm more proximal soft tissue damage was made by the Holmatro device. Conclusions Emergency prehospital guillotine amputation of the distal femur can effectively be performed using scalpel and paramedic shears with bone cuts by the Gigli saw or fire service hacksaw. The reciprocating saw could be used to cut bone if no other equipment was available but carried some risks. The Holmatro cutting device is a viable option for a life-threatening entrapment where only firefighters can safely access the patient, but would not be a recommended primary technique for medical staff.

RTAS--Case fatality rate, crash injury rate and motor vehicles: Time trends between a developed and developing country

Introduction: RTCs (road traffic collisions) are one of the most common preventable causes of death and disability worldwide, and a major public health problem in developing countries. We aim to investigate changes in numbers of motor vehicles, case fatality rate and crash injury rate over 10 years in the UK and Sri Lanka, and factors affecting this relationship. Method: We utilised audit of government records and patient directed questionnaires (ethical approval obtained in both countries). Factors, e.g. environmental causes, visual impairment, pedestrian factors, wearing seatbelts, speed of vehicles, whether fatigued at accident were investigated. Results were analysed using percentages and chi squared analysis. Results: We demonstrated numbers of motor vehicles have risen in both countries; crash injury rates rising in the UK whilst remaining stable in Sri Lanka and case fatality rate decreasing in both countries. 325 patients took part in the survey at the Sri Lankan end, with 83 at the UK end. Number of motor vehicles was higher in the UK yet the case fatality rate, but not crash injury rate was greater in Sri Lanka. Results including environmental causes, e.g. poor lighting were worse in Sri Lanka as was, visual impairment lack of seatbelt usage and speed of vehicles, which may contribute towards the higher case fatality rate. The majority of results were significantly different between the two countries. Discussion: We discuss how factors investigated may impact on differences in case fatality, crash injury rate and number of motor vehicles between the two countries and propose recommendations to reduce case fatality and crash injury rates, e.g. target ‘vulnerable’ groups, e.g. young males for risk prevention, adequate lighting of roads both within/outside city limits, reflective clothing to be worn by vulnerable road user groups, enforcement of seatbelt laws and regular eyesight checks. Keywords: Road traffic collisions; Epidemiology; Developing country; Developed country