IntroductIonNeurological problems are common in secondary care; they result in 3-8% of emergency department attendances, 15-20% of medical unit admissions, 40% of inpatients on medical wards and many requests for inpatient consultation. [1][2][3][4][5][6][7] Studies have demonstrated the value of neurologists in confirming and making de novo neurological diagnoses, in revoking or changing at least one fifth of emergency or general physicians' neurological diagnoses and in reducing patients' length of stay in hospital. 4,[8][9][10][11][12][13][14] The long-term aspiration of the Association of British Neurologists is for all patients presenting to hospital with acute neurological problems to be assessed immediately by a neurologist. 8 However, most of these patients are never seen by a neurologist, and tend to be managed by general physicians. 5,6 A rapid access neurology clinic is one interim solution that could help manage patients with semi-urgent neurological problems who do not require admission to hospital. The rationale is that this clinic would enable patients who contact emergency services with neurological problems to be managed quickly by neurologists, potentially reducing hospital admissions 15 and targeting investigations appropriately. This service model seemed to be ideally suited to the workforce and geographical limitations in Edinburgh, where there is no on-site neurology service at the hospital housing the regional emergency department. MethodsStudy setting NHS Lothian delivers healthcare to a population of about 800,000. The ~380,000 adults living in Edinburgh who are the focus of this study are served by the Emergency Department at the Royal Infirmary of Edinburgh (RIE). At the time of this study in 2005, patients with acute neurological problems could obtain urgent assessment via several routes (Figure 1). Protocols were available to guide the management of some neurological conditions Acute neurological problems: frequency, consultation patterns and the uses of a rapid access neurology clinic ABstrAct In secondary care, some patients with acute neurological symptoms are never seen by a neurologist. Rapid access neurology clinics could provide patients with timely access to neurology services. We analysed a retrospective cohort of 12,024 consecutive patients attending the 'immediate care' area of the emergency department or the acute medical admissions unit of the Royal Infirmary of Edinburgh. A total of 1,036 patients (9%) presented with a neurological complaint, of whom 680 (66%) did not have any contact with neurology services. The most common problems were epileptic seizure, cerebrovascular diseases and headache. Of the patients with epileptic seizure or headache who were not seen by a neurologist, about 40% might have benefited from neurological assessment. Following the introduction of a weekly rapid access neurology clinic, the most common problems seen were headache, symptoms that turned out to be medically unexplained and epileptic seizure. We used the patient record to: categorise ...
Introduction Hypocalcemia at hospital presentation is associated with increased mortality in trauma patients with hemorrhagic shock. The 2019 updates to the Joint Trauma System Damage Control Resuscitation (DCR) Clinical Practice Guideline recommend calcium supplementation for ionized calcium (iCa) measurements <1.2 mmol/L. Ionized calcium goals for en route critical care (ERCC) following DCR are less defined, and the impact of in-flight hypocalcemia events among critically injured combat wounded is unknown. This study aimed to describe the association between hypocalcemia and mortality for combat-wounded with brain injury and polytrauma requiring transport by Critical Care Air Transport Teams (CCATT). Methods We performed a secondary analysis of a retrospective cohort of patients with moderate-to-severe traumatic brain injury transported by CCATT out of combat theater between January 2007 and May 2014. Additional inclusion criteria included polytrauma and at least one documented in-flight iCa measurement. We categorized exposures based on the minimum in-flight iCa measurement as severe hypocalcemia (iCa <0.9 mmol/L), hypocalcemia (iCa 0.9-1.11 mmol/L), and never hypocalcemic (iCa ≥1.12 mmol/L). The primary outcome measure was mortality. We calculated descriptive statistics and performed multivariate logistic regression to assess the association between hypocalcemia and mortality. Results We analyzed 190 subjects, with a median age of 24 years (interquartile range [IQR] 21 to 29 years) and 97.7% male gender. Explosive injuries (82.1%) and gunshot wounds (6.3%) were the most common mechanisms of injury. The median injury severity score was 34 (IQR 27 to 43). During the flight, 11.6% of patients had severe hypocalcemia, and 39.5% had hypocalcemia. Among patients with any hypocalcemia measurement in-flight (n = 97), 41.2% had hypocalcemia on pre-flight iCa, 28.9% received blood products in-flight, and 23.7% received in-flight calcium supplementation. Only 32.4% of patients with hypocalcemia or severe hypocalcemia in the setting of vasopressor administration received in-flight calcium supplementation. There was no significant difference in mortality between severe hypocalcemia (9.1%), hypocalcemia (5.3%), and never hypocalcemic (3.2%) patients even after controlling for pre-flight variables. Conclusion In-flight hypocalcemia events were common among critically ill combat-wounded polytrauma patients transported by CCATT but were not associated with differences in mortality. Future training should emphasize the need for calcium correction among ERCC patients requiring vasopressors. Future studies with larger sample sizes of patients receiving ERCC are needed to assess the association between in-flight calcium supplementation with clinical outcomes.
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