Primary Survey June 2016

Mary Dawood, Associate Editor

Helping people do the things they want to do

Figure 1

Being a patient in hospital can be a disconcerting experience, this is especially true for older patients who desperately want to stay in the familiar surroundings of their own homes. Getting frail elderly patients safely discharged from the ED can pose significant risk so it was very reassuring to read in this issue a paper from Scotland about the role and potential of the Occupational Therapist in the ED. In “The view from here” Kristin James opens the window for us on the practicalities of daily living that are suddenly jeopardized for the older person by an emergency admission. She describes how the expert intervention and advice of an occupational therapist can tip the balance and be the difference between safe discharge home or admission as an inpatient. Do read this paper, it conveys a simple message about seeing the patient in the context of their life and not just the presenting problem, but also, how the OT’s in the ED “can help people to do the things they want to do”.

How effective are health promotion campaigns?

I often wonder how effective large scale expensive health promotion campaigns are and to what extent the target audiences are receptive to such information? This thought must have also crossed the minds of Mellon and colleagues from Dublin who undertook a study in a cohort of stroke survivors to examine their knowledge of stroke warning signs, risk factors and help seeking behaviour when faced with symptoms. A secondary aim of their study was to examine the association between patient characteristics, stroke awareness and onset-to-door (OTD) time when stroke symptoms occurred. They concluded that changing health seeking behaviour during stroke onset is not a simple process and indeed is fraught with complexity. Their findings provide a basis for further stroke educational campaigns which suggest the need for multiple interventions at different levels to focus on improving the publics’ stroke knowledge, and recognition of symptoms. This approach hopefully could minimize the delays to hospital arrival that continue to be a barrier to effective treatment.

Also in this issue, the need for health education weaves its way into another paper from the other side of the world. Cullen and colleagues in Australia and New Zealand sought to examine whether time to presentation with possible acute coronary syndrome (ACS) has any association with one year outcome. Well, perhaps unsurprisingly, their findings suggest it does. They collected data from adult patients presenting with suspected ACS to two ED’s in both countries and followed them up prospectively for a year. They found that there is an independent association between time to presentation and one year cardiac outcomes following initial attendance in ED with possible cardiac chest pain. The authors of this paper again reiterate the need for effective public health campaigns to improve health outcomes in these patients.

Appearances can be deceptive

Increasing longevity in western societies has seen a corresponding increase in the incidence of major trauma in the elderly. Traumatic brain injury (TBI) is not uncommon and its severity is traditionally classified using the Glasgow Coma Scale (GCS). One might expect elderly trauma patients to score a lower GCS than their younger counterparts. However two recent small studies suggest that the elderly may present with a higher GCS than younger patients with an equivalent anatomical severity of TBI. In this issue, Kehoe and colleagues in the UK set out to confirm this finding by interrogating the trauma audit research network (TARN) database of all adult cases of severe isolated TBI between 1988–2013. They concluded that the GCS is higher in older patients at each level of injury severity irrespective of mechanism of injury or type of intracranial injury and the difference is more apparent the more severe the injury. This paper is a must read for pre hospital and hospital clinicians managing major trauma, we should not allow an unexpectedly high GCS lull us into a false sense of security. These older patients may be more severely injured than initial findings suggest and irrespective of age, early neurosurgical intervention may be indicated to improve outcomes.

After reading the Kehoe paper I would recommend a thought provoking paper by Battle and colleagues in the UK who investigated current management of the anti-coagulated trauma patient in ED’s. Again this study concerns the older trauma patient where there is a lack of consensus regarding management of this group. A survey exploring management strategies of anti-coagulated trauma patients was developed with two patient scenarios concerning assessment of coagulation status, reversal of INR, management of hypertension and management strategies for each patient. 106 respondents from 166 hospitals replied with 24% of respondents working in major trauma units. The results of the survey highlighted both similarities and variation in practice and the authors felt this may reflect the differences evident in the available guidelines for these patients. Clearly there is a need for consensus and an evidence based guideline to ensure optimal management of this group.

Pre hospital identification of sepsis

Severe sepsis is still the commonest cause of death in critically ill patients making the need for early identification and intervention as urgent as ever. Emergency Medical Services (EMS) practitioners are often the first contact for these patients yet the importance of their role and the crucial part they play in identifying septic patients has not been widely discussed in the literature. So I was keen to read in this issue a systematic review by Lane and colleagues from Canada of studies that evaluated the pre hospital identification or treatment of patients with sepsis by EMS. No randomized controlled trials were found but review of 16 cohort studies suggests that EMS practitioners can identify sepsis patients with modest sensitivity and specificity using vital signs criteria. However the authors caution that the included studies were characterized by high heterogeneity and thus further research in this area is needed. So back to the drawing board on this one!

Be sure to look at the wrist X-ray in the Image section. Wrist injuries are common and very much core business in emergency settings, so we should be competent in interpreting images particularly of common fractures. Every so often there is a variation on a theme and this one is interesting. Read the history and spot the injury.