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Low-normal levels of arterial carbon dioxide (PaCO2) are recommended in the acute phase of traumatic brain injury (TBI) to optimize oxygen and CO2 tension, and to maintain cerebral perfusion. End-tidal CO2 (ETCO2) may be used as a surrogate for PaCO2 when arterial sampling is less readily available. ETCO2 may not be an adequate proxy to guide ventilation and the effects on concomitant injury, time, and the impact of ventilatory strategies on the PaCO2-ETCO2 gradient are not well understood. The primary objective of this study was to describe the correlation and agreement between PaCO2 and ETCO2 in intubated adult trauma patients with TBI. This study was a retrospective analysis of prospectively-collected data of intubated adult major trauma patients with serious TBI, admitted to the East of England regional major trauma centre; 2015-2019. Linear regression and Welch's test were performed on each cohort to assess correlation between paired PaCO2 and ETCO2 at 24-hour epochs for 120 hours after admission. Bland-Altman plots were constructed at 24-hour epochs to assess the PaCO2-ETCO2 agreement. 695 patients were included, with 3812 paired PaCO2 and ETCO2 data points. The median PaCO2-ETCO2 gradient on admission was 0.8 [0.4-1.4] kPa, Bland Altman Bias of 0.96, upper (+2.93) and lower (-1.00), and correlation R2 0.149. The gradient was significantly greater in patients with TBI plus concomitant injury, compared to those with isolated TBI (0.9 [0.4-1.5] kPa vs. 0.7 [0.3-1.1] kPa, p<0.05). Across all groups the gradient reduced over time. Patients who died within 30 days had a larger gradient on admission compared to those who survived; 1.2 [0.7-1.9] kPa and 0.7 [0.3-1.2] kPa, p<0.005. Amongst adult patients with TBI, the PaCO2-ETCO2 gradient was greater than previously reported values, particularly early in the patient journey, and when associated with concomitant chest injury. An increased PaCO2-ETCO2 gradient on admission was associated with increased mortality.

In adult major trauma patients admission hypocalcaemia occurs in approximately half of cases and is associated with increased mortality. However, data amongst paediatric patients are limited. The objectives of this review were to determine the incidence of admission ionised hypocalcaemia in paediatric major trauma patients and to explore whether hypocalcaemia is associated with adverse outcomes. A systematic review was conducted following PRISMA guidelines. All studies including major trauma patients <18 years old, with an ionised calcium concentration obtained in the Emergency Department (ED) prior to the receipt of blood products in the ED were included. The primary outcome was incidence of ionised hypocalcaemia. Random-effects Sidik-Jonkman modelling was executed for meta-analysis of mortality and pH difference between hypo- and normocalcaemia, Odds ratio (OR) was the reporting metric for mortality. The reporting metric for the continuous variable of pH difference was Glass' D (a standardized difference). Results are reported with 95% confidence intervals (CIs) and significance was defined as p <0.05. Three retrospective cohort studies were included. Admission ionised hypocalcaemia definitions ranged from <1.00 mmol/l to <1.16 mmol/l with an overall incidence of 112/710 (15.8%). For mortality, modelling with low heterogeneity (I2 39%, Cochrane's Q p = 0.294) identified a non-significant (p = 0.122) estimate of hypocalcaemia increasing mortality (pooled OR 2.26, 95% CI 0.80-6.39). For the pH difference, meta-analysis supported generation of a pooled effect estimate (I2 57%, Cochrane's Q p = 0.100). The effect estimate of the mean pH difference was not significantly different from null (p = 0.657), with the estimated pH slightly lower in hypocalcaemia (Glass D standardized mean difference -0.08, 95% CI -0.43 to 0.27). Admission ionised hypocalcaemia was present in at least one in six paediatric major trauma patients. Ionised hypocalcaemia was not identified to have a statistically significant association with mortality or pH difference.

IntroductionHypocalcaemia forms part of the ‘diamond of death’ in major trauma, alongside hypothermia, acidosis and coagulopathy. In adults, admission hypocalcaemia prior to transfusion is associated with increased mortality, increased blood transfusion requirements and coagulopathy. Data on paediatric major trauma patients are limited. This systematic review and meta-analysis aims to describe and synthesise the available evidence relevant to paediatric trauma, admission hypocalcaemia and outcome.Methods and analysisThe Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines will be used to construct this review. A planned literature search for articles in the English language will be conducted from inception to the date of searches using MEDLINE on the EBSCO platform, CINAHL on the EBSCO platform and Embase on the Ovid platform. The grey literature will also be searched. Both title and abstract screening and full-text screening will be done by two reviewers, with an adjudicating third reviewer. Heterogeneity will be assessed using the I2 test, and the risk of bias will be assessed using the ROBINS-I tool. A meta-analysis will be undertaken using ratio measures (OR) and mean differences for measures of effect. When possible, the estimate of effect will be presented along with a CI and a p value.Ethical review and disseminationEthical review is not required, as no original data will be collected. Results will be disseminated through peer-reviewed publications and at academic conferences.PROSPERO registration numberCRD42023425172.

IntroductionPaediatric major trauma patients with more severe injuries and physiological or biochemical abnormalities as a result of the injury are more likely to require invasive management in the form of an operation/interventional radiology (IR). Adverse psychological outcomes, such as post-traumatic stress disorder, anxiety, depression and adjustment disorder, are frequently observed in paediatric patients with major trauma. Similarly, it is recognised that children and adolescents who have invasive management are also at an increased risk of adverse psychological outcomes. However, it is not known to what extent major trauma patients requiring invasive management are at risk of adverse psychological outcomes compared with those managed conservatively. This study aims to determine whether paediatric major trauma patients who require an operation/IR have increased odds of having an adverse psychological outcome compared with those who are managed conservatively.Methods and analysisThe Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines will be used to construct this review. The databases Medline (via Ovid), Embase (via Ovid), PsycInfo (via Ebscohost) and Cinahl (via Ebscohost) will be searched from inception to February 2025. Both title and abstract screening and full-text screening will be done by two reviewers, with an adjudicating third reviewer. For randomised controlled trials, the Cochrane Risk of Bias Tool will be employed, while for non-randomised studies, the Newcastle-Ottawa Quality Assessment Scale will be used. We will assess bias using contoured funnel plots (with p set at 0.01, 0.05 and 0.10), non-parametric trim-fill analysis, leave-one-out analysis and Galbraith plotting. We will execute formal (Egger) testing for funnel plot asymmetry and also calculate prediction intervals if sufficient study N of 10 is accrued. Certainty and confidence in cumulative evidence will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.Ethics and disseminationEthical review is not required as no original data will be collected. Results will be disseminated through peer-reviewed publications and at academic conferences.PROSPERO registration numberCRD42025643459.

IntroductionMild traumatic brain injury (mTBI) is a leading cause of morbidity and mortality, with approximately 1 out of 200 people each year sustaining an mTBI in Europe. There is a growing awareness that recovery may take months or years. However, the exact time frame of recovery remains ill-defined in the literature. This systematic review aims to record the range of outcome measures used for mTBI and understand the time to recovery for different outcomes.Methods and analysisThis protocol complies with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guideline. A prespecified literature search for articles in the English language will be conducted from database inception to the date of searches using MEDLINE and EMBASE. A trial search was conducted on 5 October 2023 with refinement of the search criteria following this. For each study, screening of the title, abstract and full text, as well as data extraction, will be done by two reviewers, with an adjudicating third reviewer if required. The risk of bias will be assessed using the Cochrane risk of bias tool for clinical trials and the Newcastle Ottawa score for cohort studies. The primary outcome is the time to resolution of symptoms in mTBI patients who have a full recovery, using any validated outcome measure. Results will be categorised by symptom groups, including but not limited to post-concussive symptoms, mental health, functional recovery and health-related quality of life. For mTBI patients who do not recover, this review will also explore the time to the plateau of symptoms and the sequelae of these symptoms. Where possible, meta-analysis will be undertaken, with a narrative review undertaken when this is not possible. Subgroup analyses of patients aged over 64 years, and patients with repetitive head injury, are planned.Ethical review and disseminationEthical review is not required, as no original data will be collected. Results will be disseminated through peer-reviewed publications and academic conferences.PROSPERO registration numberCRD42023462797.

Background Helicopter EMS (HEMS) is an important component of prehospital trauma scene response care worldwide, including for traumatic brain injury (TBI), a major cause of mortality in injured patients. Our objective was to perform a meta-analysis (MA) of trauma HEMS scene responses to patients with severe head injury to determine whether air medical response is associated with improved survival. Methods A broad and systematic search of the literature was conducted from the years 1970–2024. We included studies with the outcome of mortality in HEMS vs. the control of ground EMS (GEMS) in trauma scene transports (adult or pediatric) with severe TBI as defined by Glasgow Coma Score (GCS) < 9 or Head Abbreviated Injury Score (AIS Head ) ≥ 3. A random effects restricted maximum likelihood MA was conducted, with post-analysis evaluation for bias. Results Of 21 HEMS outcomes studies evaluating TBI, 15 were eligible for MA, and effect estimates were HEMS-favorable in 13 and statistically significant in 9. The null hypothesis of no HEMS association with TBI survival was rejected ( p  < .01) for both the GCS < 9 and the AIS Head 3+ groups. Heterogeneity measures supported generation of a pooled effect estimate for the GCS < 9 group: HEMS survival OR 1.37 (95% CI 1.23–1.53, I 2 0%) but not for the AIS Head 3+ group (for which HEMS had statistically significant association with improved survival in six of eight studies, but to different degrees with resulting I 2 of 93%). There were no signs of small-study (publication) or other substantial bias, with overall evaluation of moderate to low risk of bias. Conclusions The available evidence suggests a survival benefit associated with HEMS scene response for patients with severe head injuries as defined by GCS < 9. For this group, at the median mortality from all studies (24%), HEMS scene response to TBI saves one life for every 19 transports (95% CI for number needed to treat, 15–28).

Antibiotics are one of the most prescribed medications in pediatric emergency departments. Antimicrobial stewardship programs assist in the reduction of antibiotic use in pediatric patients. However, the establishment of antimicrobial stewardship programs in pediatric EDs remains challenging. Recent studies provide evidence that common infectious diseases treated in the pediatric ED, including acute otitis media, tonsillitis, community-acquired pneumonia, preseptal cellulitis, and urinary-tract infections, can be treated with shorter antibiotic courses. Moreover, there is still controversy regarding the actual need for antibiotic treatment and the optimal dosing scheme for each infection.

Pediatric sepsis is a major cause of morbidity and mortality worldwide, with outcomes dependent on timely recognition and rigorous management. As clinical management of pediatric sepsis depends on early recognition and initial therapeutic steps, targeted educational materials for healthcare workers in these early phases of care are warranted. Findings of this review highlight and compare the role of traditional educational methods (e.g., lectures) to alternative teaching methods (e.g., use of virtual reality) in educating healthcare workers about pediatric sepsis. Overall, there is a gradual shift from traditional, teacher-centered, transmissive teaching methods to more collaborative, reflective, and learner-centered approaches. These pedagogical approaches, despite some potential limitations, offer opportunities to use technological enhancements and Artificial Intelligence (AI) to enhance teaching and learning across various methods.

While many paediatric patients have a penicillin allergy label, most do not have a true allergy. The penicillin allergy label is associated with a lifetime risk of avoidable use of broad-spectrum antibiotics, higher healthcare costs, and poorer clinical outcomes. In this review, we present different types of penicillin allergies, de-labelling approaches, and significance on paediatric patients. We also discuss parental perspectives regarding penicillin de-labelling in the emergency setting. We highlight that despite the challenges posed by barriers such as overcrowding and the need for quick patient turnover in the PED, the availability of resources and expertise in managing potential allergic reactions makes the PED an ideal environment where PCN de-labelling can be both feasible and effective. We show that further education of both parents and healthcare professionals is essential to overcoming misconceptions, alleviating safety concerns, fostering trust in the de-labelling process, and normalising de-labelling in the PED.

Aims and ObjectivesIntraosseous (IO) administration of medication, fluids and blood products is accepted practice for critically injured patients in whom intravenous (IV) access is not immediately available. However, there are concerns that the high intramedullary pressures resulting from IO infusion may cause bone marrow intravasation and subsequent fat embolisation. The aim of this Systematic Review is to synthesise the existing evidence describing fat intravasation, fat embolism, and Fat Embolism Syndrome (FES) in IO infusion for major trauma patients. Method and DesignA systematic search of MEDLINE, CINAHL and Embase was conducted using the terms “intraosseous” “fat embolism” “fat intravasation” and “fat embolism syndrome”. Two authors independently screened studies for eligibility and risk of bias. All studies reporting novel data on IO-associated fat emboli were included. PROSPERO number CRD42023399333. Adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Results and ConclusionIn total, twenty-seven abstracts were identified and n=7 met full inclusion criteria (table 1). All papers were large animal translational studies. The overall risk of bias was high. Fat intravasation and fat embolisation were observed to be near-universal following IO infusion, but of uncertain clinical significance. In one study, high infusion pressures were associated with immediate cardiovascular instability which was attributed to FES. The initial IO flush appeared to be the procedure with the highest intramedullary pressure. No conclusions could be made on FES from the study methodologies. Intraosseous catheters remain a useful intervention in the armamentarium of trauma clinicians. Although their use is widely accepted, there is a paucity of evidence exploring the risks of fat embolisation in IO infusions. The existing data is of low quality with a high risk of bias. Despite this, pulmonary fat emboli after IO infusion are common. More research is needed to quantify the clinical significance of fat embolism and FES after IO infusion in adult major trauma patients. Abstract 1995 Table 1Systematic review of pulmonary fat emboli associated with intraosseous (IO) use in seven controlled swine studies Authors Study Population Bone Flush Infusion method IO system used Relevant outcome measure Relevant results Plewa et al. 1995.doi:10.1111/j.1553-2712.1995.tb03275.xn= 16, weight 5.9-12.3kg Proximal tibia 1 ml NaCl 0.9% 3-way tap, manual pressure Jamshidi Post-mortem analysis of lung tissue No fat emboli Fiallos et al. 1997. doi:10.1097/00000441-199708000-00008 n= 33, mean weight 30.9kg Proximal tibia 3 ml NaCl 0.9% Pressure bag at 300 mmHg Sussman Raszynsky Post-mortem analysis of lung tissue Fat emboli in all lung samples Hasan et al. 2001. doi:10.1097/00130478-200104000-00007 n= 28, mean weight 30.9kg Proximal tibia 3 ml NaCl 0.9% Various Sur fast Post-mortem analysis of lung tissue Approximately 30% had fat emboli in lung tissue Rubal et al. 2014. doi:10.3109/10903127.2014.980475 n= 35, mean weight 50kg Proximal or distal tibia Various Various EZIO arrow Post-mortem analysis of lung tissue Fat emboli in all lung samples Auten et al. 2019. doi:10.1016/j.jss.2019.09.005 n= 36, mean weight 80kg Proximal humerus 10 ml NaCl 0.9% Various EZIO Post-mortem analysis of lung tissue 97% had fat emboli in lung tissue Kristiansen, et al. 2021. doi:10.1186/s13049-021-00986-z n=28, mean weight 22.8kg Proximal tibia 10 ml NaCl 0.9% Pressure bag at 300 mmHg EZIO arrow Post-mortem analysis of lung tissue Fat emboli in all lung samples Sulava et al 2021. doi:10.1016/j.jss.2021.04.035 n= 48, mean weight 76.7kg Various 3 ml NaCl 0.9% Pressure bag at 360 mmHg EZIO and FAST Post-mortem analysis of lung tissue Approximately 80% had fat emboli in lung tissue