PubMed Health⌕ Search

Biomedical subjects

D W Yates

Publications and source records attributed to D W Yates.

At least 19 recordsLinked to original sources
PubMed2000

Trends in trauma care in England and Wales 1989-97. UK Trauma Audit and Research Network.

BACKGROUND: In 1988, the Royal College of Surgeons reported major deficiencies in trauma care in UK hospitals. We investigated whether and how that care has changed in the last decade by use of data collected by the UK Trauma Audit and Research Network. METHODS: We analysed injury-severity, process, and outcome variables from 91602 patients' records on the database at the end of 1997, collected from 97 (49% of trauma-receiving) hospitals in England, Wales, and two in Ireland. We did longitudinal analyses of odds of death, process variables, and individual hospitals' performance. We took account of potential selection bias from missing data and recruitment of new hospitals. FINDINGS: The severity-adjusted odds of death after trauma declined gradually from 1989 (odds ratio 1997/1989 0.63 [95% CI [0.49-0.82]). In 1997, the reduction in odds of death was significant even after adjustment for missing data (ratio 1997/1989 0.72 [0.55-0.92]) and recruitment of new hospitals (0.64 [0.44-0.93]). There was significant variability in the proportion of survivors (adjusted for severity of injury and age) between the highest and lowest 10% of UK hospitals. The time between the call to the emergency services and arrival at hospital increased from 32 min in 1989 to 45 min in 1997, irrespective of injury severity. The proportion of severely injured patients seen first by senior doctors increased from 32% to 60%. INTERPRETATION: Hospital care has made a valuable but variable contribution to reductions in case fatality after injury in the UK in the past 10 years, though further improvement is possible.

Aged↗
PubMed2000

An extended Glasgow Coma Scale (GCS-E) with enhanced sensitivity to mild brain injury.

OBJECTIVE: The Glasgow Coma Scale-Extended (GCS-E) was developed to flag mild cases of concussion (corresponding to Grades I and II concussion as defined by the American Academy of Neurology) at the time of first contact with the health care system. SUBJECTS AND SETTING: The GCS-E was applied to 561 consecutive admissions with GCS scores of 13 to 15 at two hospitals in South Africa and two in the United Kingdom (UK). RESULTS: The amnesia scale was readily learned and reliably applied by emergency department staff without affecting the standard scoring of the GCS itself. Among patients with an admitting GCS of 15, 27% in the UK and 31% in South Africa reported amnesia of some duration. CONCLUSIONS: Wide use of the GCS-E would hold mild traumatic brain injury cases in the treatment loop, improve access to counselling, rehabilitation services, and personal injury compensation, and reduce the "cognitive dissonance" between victims of mild traumatic brain injury and treating professionals.

Adult↗
PubMed2000

Placement of electrodes for defibrillation--a review of the evidence.

Defibrillation is the only reliable treatment for ventricular fibrillation. Its success depends on the passage of an adequate current through the chest rather than on the administration of a preset energy. The final determinant of both efficacy and cellular damage is myocardial current density. Therefore, the current should be evenly distributed with an average value that exceeds the defibrillation threshold throughout a critical mass of myocardium but does not cause further local dysfunction. The distribution of current is altered by the relative positions of the two electrodes. European guidelines for electrode (paddle) placement during defibrillation are based on empirical studies and traditional practice. However, there is increasing evidence to suggest that bi-axillary electrode placement may be superior to traditional antero-apical and antero-posterior positions.

Electric Countershock↗
PubMed1999

Unexpected contribution of moderate traumatic brain injury to death after major trauma.

BACKGROUND: The cardiovascular reflex responses to injury and simple hemorrhage are coordinated in the central nervous system. Coincidental brain injury, which is present in 64% of trauma patients who die, could impair these homeostatic responses. The occurrence of hemorrhagic shock in the patient with head injury is also known to increase mortality. Therefore, there is a potential bidirectional interaction between traumatic brain injury and peripheral injury, which would result in an increased mortality when these two injuries coexist. Our objective was to test the hypothesis that moderate traumatic brain injury is an independent predictor of outcome in patients with multisystem trauma. METHODS: We carried out an analysis of the UK Trauma Audit and Research Network Database. Moderate traumatic brain injury was defined as an Abbreviated Injury Scale score of 3. The study population included 2,717 patients with multisystem injury: 378 patients had a moderate brain injury with peripheral injury, and 2,339 patients had extracranial injury alone. Mortality rates for both groups were compared at increasing injury severity. RESULTS: Moderate brain injury alone was associated with a mortality rate of 4.2%. However, when combined with extracranial injury, the risk of death was double that attributable to extracranial injury alone (odds ratio, 2.08; 95% confidence interval, 1.57-2.77). CONCLUSION: This study confirms that the coexistence of moderate traumatic brain injury with extracranial injury is associated with a doubling of the predicted mortality rate throughout the injury severity ranges studied.

Adolescent↗
PubMed1999

Significance of vomiting after head injury.

OBJECTIVES: To determine whether the presence and severity of post-traumatic vomiting can predict the risk of a skull vault fracture in adults and children. METHODS: Data were analysed relating to a consecutive series of 5416 patients including children who presented to an emergency service in the United Kingdom during a 1 year study period with a principal diagnosis of head injury. Characteristics studied were age, sex, speed of impact, level of consciousness on arrival, incidence of skull fracture, and the presence and severity of post-traumatic vomiting. RESULTS: The overall incidence of post-traumatic vomiting was 7% in adults and 12% in children. In patients with a skull fracture the incidence of post-traumatic vomiting was 28% in adults and 33% in children. Post-traumatic vomiting was associated with a fourfold increase in the relative risk for a skull fracture. Nausea alone did not increase the risk of a skull fracture and multiple episodes of vomiting were no more significant than a single episode. In patients who were fully alert at presentation, post-traumatic vomiting was associated with a twofold increase in relative risk for a skull fracture. CONCLUSION: These results support the incorporation of enquiry about vomiting into the guidelines for skull radiography. One episode of vomiting seems to be as significant as multiple episodes.

Adult↗
PubMed1995

Doctors' legal position in treating temporarily incompetent patients.

Doctors in accident and emergency departments are sometimes presented with patients with potentially life threatening conditions who refuse to consent to treatment. The doctors then face a dilemma: to withhold necessary treatment or to act against a patient's express wishes. Two such cases are presented, and we asked a lawyer, two medical ethicists, a psychiatrist, and an accident and emergency physician to comment on the implications.

Adult↗
PubMed1995

Triage: a literature review 1985-1993.

Following an extensive literature review of Accident and Emergency (A & E) nursing from 1985-1993, the authors focused upon triage. A wide range of issues related to triage and its use in A & E departments are examined. An appendix is included to clarify major research finds in this area. Many of the claims made regarding triage require further investigation.

Emergency Nursing↗
PubMed1995

Grief support in accident and emergency nursing: a literature review 1985-1993.

On completing a wide ranging review of literature related to Accident and Emergency (A & E) nursing, the authors chose to focus upon grief support. The literature ranges from personal experiences to large scale research. A table of studies is included to clarify major research findings in this area. The article concludes by recommending long term support for bereaved relatives and research to demonstrate the value of support for relatives in the community.

Emergency Nursing↗
PubMed1995

Standardized comparison of performance indicators in trauma: a new approach to case-mix variation.

An institution's trauma survival rate can be compared with that predicted by TRISS using definitive outcome-based evaluation. This examines W, the difference between actual and predicted survival rates; Z, the statistical significance of this difference; and M, a measure of the similarity of injury severity mix to the prediction data base. However, it is possible for two institutions with the same survival rate within each band of injury severity to have very different W and Z scores whilst retaining a similar M score. Clearly this is unsatisfactory. A new statistic, Ws, is therefore proposed, which is standardized with respect to injury severity mix, producing more accurate comparisons between different institutions. Confidence intervals are used to graphically illustrate the magnitude of Ws, its direction, accuracy, and statistical significance. Data from the U.K. Major Trauma Outcome Study are used to demonstrate the calculations and presentation of Ws and its advantages.

Diagnosis-Related Groups↗
PubMed1994

Trauma audit--closing the loop.

The philosophy of medical audit and methods of data collection and statistical analysis have been extensively reviewed but less has been written about the effect of audit on medical practice. The measurement of performance is only valuable if it identifies areas of concern and stimulates appropriate change. This paper describes the work of the Salford Trauma Audit Group which has been developed at Hope Hospital, the problems that have been recognized, the strategies that have been introduced to effect change and their influence on management and outcome. Analysis of performance reveals an initial fall in adjusted mortality rate from severe injury after the introduction of resuscitation teams, the adherence to Advanced Trauma Life Support protocols and an integrated multidisciplinary approach to trauma care. Problems remain and there is continuing concern about trauma management in the hospital. This has been reinforced by performance feedback through the Trauma Audit Group which has attracted the interest of senior clinicians in several specialties.

Emergencies↗
PubMed1994

Mild head injury--a positive approach to management.

It is estimated that 1.4 million patients each year attend Accident and Emergency (A&E) departments in the UK with a head injury. The vast majority are, in retrospect, diagnosed as a 'mild' injury. There is evidence to suggest that many develop short term morbidity and some long term problems. The incidence is unknown. Early recognition and treatment many hasten recovery. A national postal survey of A&E departments revealed a general unawareness for this morbidity. Written advice given to patients on discharge from the departments was exclusively concerned with the symptoms expected if serious complications developed. A description of the common symptoms of fatigue, poor memory and concentration were not given to the patients in a written format. Arrangements for follow up are, in the majority of hospitals, unstructured. We recommend a positive approach to the management and follow up of mild head injury. This should recognize the common problems experienced by these patients and cater for their needs. More interest and research is required into this aspect of head injury.

Craniocerebral Trauma↗
PubMed1994

The emergency department and the community: a model for improved cooperation.

Improved emergency care may be achieved by closer integration of hospital and community management. This has been promoted in Salford by the appointment of an Emergency Services Practice Manager jointly funded by the Family Health Services Authority and Salford Health Authority. Communication has improved, complementary working relationships developed and health promotion initiatives established.

Attitude of Health Personnel↗
PubMed1993

Biomechanical factors in patient selection for radiography after head injury.

In order to assess the predictive value of certain biomechanical parameters for skull fracture after head injury, a prospective analysis was undertaken of a series of 5416 head-injured patients. In each case an assessment was made at presentation as to the velocity of impact and the physical properties of the impacting agent. The incidence of skull vault fracture was then calculated for injuries sustained at different velocities and for different types of contact. The incidence of fracture was also calculated with respect to the presence of post-traumatic amnesia (PTA). The incidences (95 per cent confidence intervals) of skull fracture at low, medium and high speeds were 0.17 (0.0427-0.433), 1.99 (1.47-2.63) and 10.2 (7.41-12.6) per cent respectively. Fractures tended to occur with greater frequency after impacts against broad hard surfaces or small objects rather than against broad soft objects. The percentage incidence of fracture in adults suffering more than 5 min of PTA was 17.93 (12.4-23.5) compared with 0.674 (0.372-1.1) in those without amnesia. Patient selection for skull radiography after an apparently minor head injury can be guided by an assessment of post-traumatic amnesia and the biomechanics of the injury.

Adolescent↗
PubMed1993

Trauma audit: clinical judgement or statistical analysis?

Comparisons have been made between two methods currently used to assess the effectiveness of management of major trauma. These are the review of fatal cases by senior clinicians and the use of statistical analysis of severity scores. The former was assessed by a re-examination of the Coroners' reports of 508 patients reviewed by senior clinicians at the request of The Royal College of Surgeons of England Working Party on the Management of Patients with Major Injuries. The latter was based on the 665 fatalities on the files of the UK Major Trauma Outcome Study. The two groups of patients had comparable age and sex profiles and broadly similar ranges of injury severity. There were major differences between and inconsistencies within the two assessments. Clinicians more frequently judged death avoidable in those with very severe injuries. In contrast, the statistical analysis suggested, paradoxically, that the proportion of avoidable deaths in those patients who had minor injuries was less than the proportion of avoidable deaths in those who had more serious injuries. These variations underline the limited values of retrospective peer review and will not encourage clinicians to adopt currently available statistical methods. Further refinements of anatomical and physiological scoring systems and their integration to provide a statistically valid and clinically acceptable measure of outcome are essential prerequisites to the wider introduction and success of trauma audit.

Adolescent↗
PubMed1993

Regional cerebral blood flow and carbon dioxide reactivity after noncerebral injury in the rat.

A loss of cerebral autoregulation and vascular reactivity to CO2 has been reported after a direct head injury; however, little has been published concerning the effect of CO2 after peripheral injury. In the present study, the effects of extracranial injury (bilateral hindlimb ischaemia followed by reperfusion) were studied on regional cerebral blood flow in the hypothalamus and cortex and on the changes in these blood flows induced by altering PaCO2 in the conscious rat. After release of the tourniquets, when fluid was being lost from the circulation into the postischaemic hindlimbs, there was a decrease in regional cerebral blood flow (rCBF). Administration of CO2 at this time markedly increased rCBF. There was no evidence that cerebrovascular responsiveness to hypercapnia was impaired after peripheral injury in the rat.

Animals↗
PubMed1992

Preliminary analysis of the care of injured patients in 33 British hospitals: first report of the United Kingdom major trauma outcome study.

OBJECTIVE: To measure the effectiveness of management of major trauma in the United Kingdom. DESIGN: Review of the care of all seriously injured patients seen over two years. SETTING: 33 hospitals which receive patients who have sustained major trauma. SUBJECTS: 14,648 injured patients admitted for more than three days, transferred or admitted into an intensive care bed, or dying from their injuries. MAIN OUTCOME MEASURE: Death or survival in hospital within three months of the injury. RESULTS: 21% of seriously injured patients (1299) took longer than one hour to reach hospital. Time before arrival at hospital was not related to severity of injury. A senior house officer was in charge of initial hospital resuscitation in 57% (826/1445) of patients with an injury severity score > or = 16. More senior staff were commonly responsible for definitive operations, but only 46% (165/355) of patients judged to require early operation arrived in theatre within two hours. Mortality for 6111 patients sustaining blunt trauma and treated in the 14 busiest hospitals was significantly higher (actual 408, predicted 295.6, p < 0.001) than in a comparable North American dataset. Large differences in the 14 hospitals assessed could not be explained by variations in case load or facilities. In contrast, the outcome of the 4.1% (597) of patients with penetrating injuries was better than that of a comparable group in the United States. Analysis of the 415 penetrating injuries with complete data showed that 15 patients died (19.3 predicted; p = 0.04). CONCLUSIONS: The initial management of major trauma in the United Kingdom remains unsatisfactory. There are delays in providing experienced staff and timely operations. Mortality varies inexplicably between hospitals and, for blunt trauma, is generally higher than in the United States.

Emergency Medical Services↗