Association Between Hemorrhage Control Interventions and Mortality in US Trauma Patients With Hemodynamically Unstable Pelvic Fractures

Tanya Anand, Khaled El-Qawaqzeh, Adam Nelson, Hamidreza Hosseinpour, Michael Ditillo, Lynn Gries, Lourdes Castanon, Bellal Joseph

JAMA Surg. 2023 Jan 1;158(1):63-71.

 

Importance: Management of hemodynamically unstable pelvic fractures remains a challenge. Hemostatic interventions are used alone or in combination. There is a paucity of data on the association between the pattern of hemorrhage control interventions and outcomes after a severe pelvic fracture.

Objective: To characterize clinical outcomes and study the patterns of hemorrhage control interventions in hemodynamically unstable pelvic fractures.

Design, setting, and participants: In this cohort study, a retrospective review was performed of data from the 2017 American College of Surgeons Trauma Quality Improvement Program database, a national multi-institutional database of trauma patients in the United States. Adult patients (aged ≥18 years) with pelvic fractures who received early transfusions (≥4 units of packed red blood cells in 4 hours) and underwent intervention for pelvic hemorrhage control were identified. Use and order of preperitoneal pelvic packing (PP), pelvic angioembolization (AE), and resuscitative endovascular balloon occlusion of the aorta (REBOA) in zone 3 were examined and compared against the primary outcome of mortality. The associations between intervention patterns and mortality, complications, and 24-hour transfusions were further examined by backward stepwise regression analyses. Data analyses were performed in September 2021.

Main outcomes and measures: Primary outcomes were rates of 24-hour, emergency department, and in-hospital mortality. Secondary outcomes were major in-hospital complications.

Results: A total of 1396 patients were identified. Mean (SD) age was 47 (19) years, 975 (70%) were male, and the mean (SD) lowest systolic blood pressure was 71 (25) mm Hg. The median (IQR) Injury Severity Score was 24 (14-34), with a 24-hour mortality of 217 patients (15.5%), ED mortality of 10 patients (0.7%), in-hospital mortality of 501 patients (36%), and complication rate of 574 patients (41%). Pelvic AE was the most used intervention (774 [55%]), followed by preperitoneal PP (659 [47%]) and REBOA zone 3 (126 [9%]). Among the cohort, 1236 patients (89%) had 1 intervention, 157 (11%) had 2 interventions, and 3 (0.2%) had 3 interventions. On regression analyses, only pelvic AE was associated with a mortality reduction (odds ratio [OR], 0.62; 95% CI, 0.47 to 0.82; P < .001). Preperitoneal PP was associated with increased odds of complications (OR, 1.39; 95% CI, 1.07 to 1.80; P = .01). Increasing number of interventions was associated with increased 24-hour transfusions (β = +5.4; 95% CI, +3.5 to +7.5; P < .001) and mortality (OR, 1.57; 95% CI, 1.05 to 2.37; P = .03), but not with complications.

Conclusions and relevance: This study found that among patients with pelvic fracture who received early transfusions and at least 1 invasive pelvic hemorrhage control intervention, more than 1 in 3 died, despite the availability of advanced hemorrhage control interventions. Only pelvic AE was associated with a reduction in mortality.

 

Pelvic Compression Device (Binder) Application Training in Medical Students: A Manikin Study

Zafer Beşer, Ahmet Burak Oğuz, Ayça Koca, Sinan Genç, Ömer Yusuf Erdurmuş, Onur Polat

J Trauma Nurs. 2022 Nov-Dec;29(6):298-304.

 

Background: Correct application of external pelvic compression devices (binders) is crucial in managing multitrauma patients with suspected pelvic fractures to control hemorrhage. Yet, there is a lack of practical training standards for pelvic compression device application in medical school education.

Objective: This study aimed to evaluate simulation training of pelvic compression device application by medical students to determine the number of applications required to meet proficiency measured by correct application and timeliness.

Methods: This is an observational cross-sectional measurement study of a convenience sample of 132 volunteer senior medical students who participated in a 30-min theoretical and simulation training session on the application of pelvic compression devices. The study was conducted between January 1, 2020, and March 1, 2020. Two weeks after the training, the students performed 10 consecutive pelvic compression device applications, each followed by a 5-min feedback session break. Application step accuracy and timing were observed and recorded. The percentage of correct applications was compared by χ2 test.

Results: The correct application rate for the first application was 42.4%, with an average of 92 s, 95% confidence interval (CI): 91.00-93.72. The highest correct application rate occurred in the eighth application (97%, p < .001), with an average application time of 87 s, 95% CI: 85.62-87.72.

Conclusion: We found that at least eight pelvic compression device manikin applications were required to achieve proficiency.

 

Comparing the medical coverage provided by four contemporary military combat helmets against penetrating traumatic brain injury

John Breeze, R N Fryer, J Russell

BMJ Mil Health. 2022 Oct;168(5):395-398.

 

Introduction: Modern military combat helmets vary in their shapes and features, but all are designed to protect the head from traumatic brain injury. Recent recommendations for protection against energised projectiles that are characteristic of secondary blast injury is to ensure coverage of both the brain and brainstem.

Method: Graphical representations of essential coverage of the head (cerebral hemispheres, cerebellum and brainstem) within an anthropometrically sized model were superimposed over two standard coverage helmets (VIRTUS helmet, Advanced Combat Helmet (ACH)) and two 'high-cut' helmets (a Dismounted Combat Helmet (DCH)) and Combat Vehicle Crewman (CVC) helmet), both of which are designed to be worn with communications devices. Objective shotline coverage from representative directions of projectile travel (-30 to +30 degrees) was determined using the Coverage of Armour Tool (COAT).

Results: VIRTUS and ACH demonstrated similar overall coverage (68.7% and 69.5%, respectively), reflecting their similar shell shapes. ACH has improved coverage from below compared with VIRTUS (23.3% vs 21.7%) due to its decreased standoff from the scalp. The 'high-cut' helmets (DCH and CVC) had reduced overall coverage (57.9% and 52.1%), which was most pronounced from the side.

Conclusions: Both the VIRTUS and ACH helmets provide excellent overall coverage of the brain and brainstem against ballistic threats. Coverage of both would be improved at the rear by using a nape protector and the front using a visor. This is demonstrated with the analysis of the addition of the nape protector in the VIRTUS system. High-cut helmets provide significantly reduced coverage from the side of the head, as the communication devices they are worn with are not designed to provide protection from ballistic threats. Unless absolutely necessary, it is therefore recommended that high-cut helmets be worn only by those users with defined specific requirements, or where the risk of injury from secondary blast is low.

 

 

The effects of timing of prehospital tranexamic acid on outcomes after traumatic brain injury: Subanalysis of a randomized controlled trial

Alexandra M P Brito, Martin A Schreiber, James El Haddi, Eric N Meier, Susan E Rowell

J Trauma Acute Care Surg. 2023 Jan 1;94(1):86-92.

 

Background: Tranexamic acid (TXA) is an antifibrinolytic that has shown some promise in improving outcomes in traumatic brain injury (TBI), but only when given early after injury. We examined the association between timing of prehospital TXA administration and outcomes in patients with moderate to severe TBI.

Methods: Patients enrolled in the multi-institutional, double-blind randomized prehospital TXA for TBI trial with blunt or penetrating injury and suspected TBI (Glasgow Coma Scale score ≤ 12, SBP ≥90) who received either a 2-g TXA bolus or a 1-g bolus plus 1 g 8 hour infusion within 2 hours of injury were analyzed. Outcomes were compared between early administration (<45 minutes from injury) and late administration ≥45 minutes from injury) using a χ 2 , Fischer's exact test, t test, or Mann-Whitney U test as indicated. Logistic regression examined time to drug as an independent variable. A p value less than 0.05 was considered significant.

Results: Six hundred forty-nine patients met inclusion criteria (354 early and 259 late). Twenty-eight-day and 6-month mortalities, 6-month Glasgow Outcome Scale-Extended, and disability rating scale scores were not different between early and late administration. Late administration was associated with higher rates of deep venous thrombosis (0.8 vs. 3.4%, p = 0.02), cerebral vasospasm (0% vs. 2%, p = 0.01), as well as prolonged EMS transport and need for a prehospital airway ( p < 0.01).

Conclusion: In patients with moderate or severe TBI who received TXA within 2 hours of injury, no mortality benefit was observed in those who received treatment within 45 minutes of injury, although lower rates of select complications were seen. These results support protocols that recommend TXA administration within 45 minutes of injury for patients with suspected TBI.

 

The Difficult Airway Redefined

Matthew B Burgess, Steven G Schauer, R Lyle Hood, Robert A De Lorenzo

Prehosp Disaster Med. 2022 Dec;37(6):723-726.

 

Abstract

There is no all-encompassing or universally accepted definition of the difficult airway, and it has traditionally been approached as a problem chiefly rooted in anesthesiology. However, with airway obstruction reported as the second leading cause of mortality on the battlefield and first-pass success (FPS) rates for out-of-hospital endotracheal intubation (ETI) as low as 46.4%, the need to better understand the difficult airway in the context of the prehospital setting is clear. In this review, we seek to redefine the concept of the "difficult airway" so that future research can target solutions better tailored for prehospital, and more specifically, combat casualty care. Contrasting the most common definitions, which narrow the scope of practice to physicians and a handful of interventions, we propose that the difficult airway is simply one that cannot be quickly obtained. This implies that it is a situation arrived at through a multitude of factors, namely the Patient, Operator, Setting, and Technology (POST), but also more importantly, the interplay between these elements. Using this amended definition and approach to the difficult to manage airway, we outline a target-specific approach to new research questions rooted in this system-based approach to better address the difficult airway in the prehospital and combat casualty care settings.

 

 

 

A Framework for Case-Based Learning in Prehospital Medicine: The London's Air Ambulance Experience

Luca Carenzo, Chloe Baker, Steve Jones, Tom Hurst

Air Med J. 2022 Nov-Dec;41(6):521-525.

 

Abstract

Clinical governance is the framework around which health care organizations can maintain a higher standard of safety and care. One of the central aspects of clinical governance is continuous professional education, including case-based review and case-based learning. In this article, we present the case-based education process in use at London's Air Ambulance, a mature advanced prehospital system in London, UK. The case review process begins with an on-scene hot debrief, an informal process often involving other emergency services. This is usually followed by internal team feedback and debrief and patient follow-up. All cases are then reviewed over the next 24 to 48 hours by the duty prehospital consultant (attending) in the rapid review process. After this, certain cases are volunteered or selected for discussion in the twice weekly death and disability (D&D) meeting or the monthly dispatch meeting. A small subset of cases is highlighted through this process for full formal audit and presentation at the monthly clinical governance meetings based on their educational value. Another subset of cases involving a fatality is also discussed at the monthly clinical pathology correlation meeting with the input of local forensic pathologists. Organization of the process, structure of the meetings, and educational value are described in detail.

 

Trends in Prehospital Blood, Crystalloid, and Colloid Administration in Accordance With Changes in Tactical Combat Casualty Care Guidelines

Emily E Clarke, James Hamm, Andrew D Fisher, Michael D April, Brit J Long, Kennedy S Mdaki, Ronnie Hill, James A Bynum, Steven G Schauer

Mil Med. 2022 Oct 29;187(11-12):e1265-e1270.

 

Introduction: Hemorrhage is the leading threat to the survival of battlefield casualties. This study aims to investigate the types of fluids and blood products administered in prehospital trauma encounters to discover the effectiveness of Tactical Combat Casualty Care (TCCC) recommendations.

Materials and methods: This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry with a focus on prehospital fluid and blood administration in conjunction with changes in the TCCC guidelines. We collected demographic information on each patient. We categorized receipt of each fluid type and blood product as a binary variable for each casualty and evaluated trends over 2007-2020 both unadjusted and controlling for injury severity and mechanism of injury.

Results: Our original dataset comprised 25,897 adult casualties from January 1, 2007 through March 17, 2020. Most (97.3%) of the casualties were male with a median age of 25. Most (95.5%) survived to hospital discharge, and 12.2% of the dataset received fluids of any kind. Medical personnel used crystalloids in 7.4% of encounters, packed red blood cells in 2.0%, and whole blood in 0.5% with very few receiving platelets or freeze-dried plasma. In the adjusted model, we noted significant year-to-year increases in intravenous fluid administration from 2014 to 2015 and 2018 to 2019, with significant decreases noted in 2008-2009, 2010-2012, and 2015-2016. We noted no significant increases in Hextend used, but we did note significant decreases in 2010-2012. For any blood product, we noted significant increases from 2016 to 2017, with decreases noted in 2009-2013, 2015-2016, and 2017-2018. Overall, we noted a general spike in all uses in 2011-2012 that rapidly dropped off 2012-2013. Crystalloids consistently outpaced the use of blood products. We noted a small upward trend in all blood products from 2017 to 2019.

Conclusions: Changes in TCCC guidelines did not immediately translate into changes in prehospital fluid administration practices. Crystalloid fluids continue to dominate as the most commonly administered fluid even after the 2014 TCCC guidelines changed to use of blood products over crystalloids. There should be future studies to investigate the reasons for delay in guideline implementation and efforts to improve adherence.

Clinical use of tranexamic acid: evidences and controversies

Maria J Colomina, Laura Contreras, Patricia Guilabert, Maylin Koo, Esther M Ndez, Antoni Sabate

Braz J Anesthesiol. 2022 Nov-Dec;72(6):795-812.

 

Abstract

Tranexamic acid (TXA) significantly reduces blood loss in a wide range of surgical procedures and improves survival rates in obstetric and trauma patients with severe bleeding. Although it mainly acts as a fibrinolysis inhibitor, it also has an anti-inflammatory effect, and may help attenuate the systemic inflammatory response syndrome found in some cardiac surgery patients. However, the administration of high doses of TXA has been associated with seizures and other adverse effects that increase the cost of care, and the administration of TXA to reduce perioperative bleeding needs to be standardized. Tranexamic acid is generally well tolerated, and most adverse reactions are considered mild or moderate. Severe events are rare in clinical trials, and literature reviews have shown tranexamic acid to be safe in several different surgical procedures. However, after many years of experience with TXA in various fields, such as orthopedic surgery, clinicians are now querying whether the dosage, route and interval of administration currently used and the methods used to control and analyze the antifibrinolytic mechanism of TXA are really optimal. These issues need to be evaluated and reviewed using the latest evidence to improve the safety and effectiveness of TXA in treating intracranial hemorrhage and bleeding in procedures such as liver transplantation, and cardiac, trauma and obstetric surgery.

Prehospital Administration of Cefazolin in Trauma Patients

Kevin Collopy, Lisa Zimmerman, Abigail Marie Westmoreland, William F Powers 4th

Air Med J. 2022 Sep-Oct;41(5):447-450.

 

Objective: A lack of research has become a barrier to the common use of prehospital antibiotics. The objective of this study is to further the limited research of prehospital antibiotics through evaluating the clinical impact, safety, and reliability of prehospital cefazolin administration in trauma patients.

Methods: We completed a retrospective evaluation of adult trauma patients who were transported by a single air and ground critical care transport program between January 1, 2014, and June 30 2017. Two hundred eighty-two patients received prehospital cefazolin for deep wounds or open fractures before their arrival at a single level 2 trauma center during the study period. Patient demographics, mechanism of injury, injury type, infection rate, and identification of allergic reactions to cefazolin were also collected.

Results: Of 278 patients in the final analysis, 35.3% (n = 98) were diagnosed with an open fracture and 58.6% (n = 163) had a deep tissue injury. Eighty-two percent of prehospital open fracture diagnoses were confirmed in the emergency department. The overall infection rate was 6%; 31.3% of patients received a second dose of cefazolin in the emergency department during the study period. No patients receiving prehospital cefazolin had allergic or anaphylactic reactions. The overadministration rate was 5% (n = 14).

Conclusion: Prehospital providers reliably identified open fractures, and prehospital cefazolin administration was not associated with anaphylactic reactions. This study population's infection rate of open fractures caused by traumatic injury was found to be 6%, and there was a low inappropriate administration rate.

Field tourniquets in an austere military environment: A prospective case series.

D C Covey, Christopher E Gentchos

Injury. 2022 Oct;53(10):3240-3247.

Objective: Field tourniquets are often used for battlefield extremity injuries. Their effectiveness has been documented by a large combat theater trauma center. However, their use and effectiveness by an austere forward surgical team has not been reported. Aims of this study were to determine: Whether field tourniquets: (1) Were placed for appropriate indications; (2) significantly reduced hemorrhage as measured by transfusion requirements; (3) influenced vital signs and injury severity scores; and (4) did they cause limb amputation, changed amputation level, or other complications.

Methods: Twenty-five patients with 30 involved extremities presenting to a forward surgical team in Iraq met the inclusion criteria. We prospectively collected data regarding the presence, indications for, and effectiveness of field tourniquets based on the need for blood transfusion. We recorded any complications associated with their use.

Results: Tourniquets significantly reduced hemorrhage from penetrating injuries as measured by transfusion requirements. Those having major vascular injuries with effective tourniquets, a total of 12 units of blood were transfused (1.7 units/vascular injury; 2 units/patient). However, 19 units were transfused in patients (3.3 units/vascular injury; 3.8 units/patient) who had an ineffective or no tourniquet (p = 0.0006). Transfusion requirements were related the presence of an effective tourniquet regardless of concomitant injuries. The group with effective tourniquets and compressed hemorrhage presented with higher mean systolic (p = 0.003) and diastolic (p = 0.023) blood pressures than the group with no tourniquets or ineffective ones. Complications included one peroneal nerve palsy and no amputations resulted from tourniquet application.

Conclusion: Field tourniquets applied for penetrating injuries with severe bleeding can significantly reduce transfusion requirements and help maintain adequate blood pressure. Tourniquets were not the proximate cause of amputation and did not determine the choice of immediate amputation level.

The Big Five-Lifesaving Procedures in the Trauma Bay

Sagar B Dave, Jesse Shriki

Emerg Med Clin North Am. 2023 Feb;41(1):161-182.

 

Abstract

Although resuscitation in trauma requires a multidisciplinary and multifaceted approach, one of the Big Five procedures may need to be performed as lifesaving and improving intervention. Your patient's lives depend on understanding, timing, and techniques of these elusive and difficult-to-master procedures. This article focuses on and reviews these five critical procedures: cricothyroidotomy, burr hole craniotomy, resuscitative thoracotomy, emergent hysterotomy, and lateral canthotomy. Prepare the team, system, and yourself when performing any of these procedures. It is important to be facile with your equipment and familiar with the steps to maximize success.

Comparing a Novel Hand-Held Device for Chest Tube Insertion to the Traditional Open Tube Thoracostomy for Simple Pneumothorax in a Porcine Model

Joshua Dilday, Bethany Heidenreich, Holly Spitzer, Yousef Abuhakmeh, Eric Ahnfeldt, John Watt, Vincent J Mase Jr

J Spec Oper Med. 2022 Dec 16;22(4):41-45.

 

Background: Tube thoracostomy is the most effective treatment for pneumothorax, and on the battlefield, is lifesaving. In combat, far-forward adoption of open thoracostomy has not been successful. Therefore, the ability to safely and reliably perform chest tube insertion in the far-forward combat theatre would be of significant value. The Reactor is a hand-held device for tube thoracostomy that has been validated for tension pneumothorax compared to needle decompression. Here we investigate whether the Reactor has potential for simple pneumothorax compared to open thoracostomy. Treatment of pneumothorax before tension physiology ensues is critical.

Methods: Simple pneumothoraces were created in 5 in-vivo swine models and confirmed with x-ray. Interventions were randomized to open technique (OT, n = 25) and Reactor (RT, n = 25). Post-procedure radiography was used to confirm tube placement and pneumothorax resolution. Video Assisted Thoracoscopic Surgery (VATS) was used to evaluate for iatrogenic injuries. 50 chest tubes were placed, with 25 per group.

Results: There were no statistical differences between the groups for insertion time, pneumothorax resolution, or estimated blood loss (p = .91 and .83). Injury rates between groups varied, with 28% (n = 7) in the Reactor group and 8% (n = 2) the control group (p = .06). The most common injury was violation of visceral pleura (10%, n = 5, both groups) and violation of the mediastinum (8%, n = 4, both groups).

Conclusion: The Reactor device was equal compared to open thoracostomy for insertion time, pneumothorax resolution, and injury rates. The device required smaller incisions compared to tube thoracostomy and may be useful adjunct in simple pneumothorax management.

Trauma care in the tropics: addressing gaps in treating injury in rural and remote Australia

Geoffrey Phillip Dobson, Clinton Gibbs, Lee Poole, Ben Butson, Luke D Lawton, Jodie L Morris, Hayley L Letson

Rural Remote Health. 2022 Jan;22(1):6928.

Abstract

In Australia, over half a million people are admitted to hospital every year as a result of injury, and where you live matters. Rural populations have disproportionately higher injury hospitalisation rates (1.5-2.5-fold), higher rates of preventable secondary complications, higher mortality rates (up to fivefold), and higher costs (threefold) than patients injured in major cities. These disparities scale up rapidly with increased remoteness, and shift the service needle from 'scoop and run' to 'continuum of care'. Poorer outcomes, however, are not solely due to longer retrieval distances or delays; they arise from inefficiencies in one or more potentially modifiable factors in the chain of survival. After discussing the burden of injury in Australia, we present a brief history of retrieval services in Queensland and discuss how remoteness requires a different kind of service delivery with many moving parts from point of injury to definitive care. We next address the ongoing challenges for the Australian Trauma Registry, and how centralisation of data from the metropolitan cities masks the inequities in rural and remote trauma. There is an urgent need for accurate data from all service providers around Australia to inform state and federal governments, and we highlight the paucity of trauma data analysis in North Queensland. Last, we identify some major gaps in treating rural and remote polytrauma and en-route patient stabilisation, and discuss the relevance of combat casualty care research and practices. We conclude that a greater emphasis should be placed on collecting more robust trauma patient records, as only accurate data will drive change.

 

Efficacy of Tranexamic Acid in Blood Versus Crystalloid-Resuscitated Trauma/Hemorrhagic Shock

Fernando Dos Santos, Joyce B Li, Rafi Mazor, Federico Aletti, Erik B Kistler

J Surg Res. 2022 Nov;279:89-96.

Introduction: Whole blood (WB) or blood products are not always immediately available for repletion of lost intravascular volume in trauma/hemorrhagic shock (T/HS), and thus, resuscitation with crystalloid solutions is often necessary. Recently, we have shown enteral tranexamic acid (TXA) to be effective as a mild protease inhibitor in blood-resuscitated T/HS by counteracting proteolytic activity in and leaking from the gut with resultant preservation of systemic vascular integrity. We hypothesized that enteral TXA would improve hemodynamic stability after T/HS in the absence of blood reperfusion.

Methods: We directly compared resuscitation with enteral TXA versus intravenous (IV) TXA in conjunction with lactated Ringer's solution (LR) or WB reperfusion in an experimental T/HS model. Rats were subjected to laparotomy and exsanguinated to a mean arterial blood pressure of 35-40 mm Hg for 90 min, followed by LR or WB reperfusion and monitored for 120 min. TXA was administered via IV (10 mg/kg) or enteral infusion (150 mM) 20 min after establishment of hemorrhage for 150 min.

Results: Animals resuscitated with LR were unable to restore or maintain a survivable mean arterial blood pressure (>65 mm Hg), regardless of TXA treatment route. In contrast, rats reperfused with WB and given TXA either enterally or IV displayed hemodynamic improvements superior to WB controls.

Conclusions: Results suggest that the beneficial hemodynamic responses to enteral or IV TXA after experimental T/HS depend upon reperfusion of WB or components present in WB as TXA, regardless of delivery mode, does not have appreciable hemodynamic effects when paired with LR reperfusion.

Prehospital predictors of the need for transfusion in patients with major trauma

Holger Gaessler, Matthias Helm, Martin Kulla, Bjoern Hossfeld, Julia Riedel, Juergen Kerschowski, Ingeborg Bretschneider

Eur J Trauma Emerg Surg. 2022 Oct 12.

Purpose: Severe haemorrhage is a leading cause of early mortality following major trauma. By early identification of patients at risk, blood transfusion could already be initiated in the prehospital period. Aim of the study was to evaluate the extent to which prehospital lactate and base excess, which are known to be associated with trauma-induced coagulopathy, and additional clinical parameters are associated with the need for early transfusion.

Methods: In this prospective, single-centre observational study, trauma patients treated by a helicopter emergency medical service were included, regardless of the injury severity. Patients with coagulation-influencing drugs in long-term therapy were excluded. Blood samples obtained at the beginning of the prehospital treatment were analysed. Primary outcome was the association of lactate and base excess with the need for early transfusion (resuscitation room or immediate surgery). Receiver operating characteristic curves were created, and the area under the curve (AUROC) was calculated.

Results: Between 2015 and 2018, 21 out of 130 adult trauma patients received blood products during the early in-hospital treatment. Both prehospital lactate and base excess were associated with the transfusion (AUROC 0.731 and 0.798, respectively). The optimal calculated cut-off values were 4 mmol/l (lactate) and - 2.5 mmol/l (base excess). When circulatory instability and suspected relevant bleeding were included, the association further improved (AUROC 0.871 and 0.866, respectively).

Conclusion: Prehospital lactate and base excess could be used in combination with other clinical parameters as indicators of the need for early transfusion. This relationship has yet to be confirmed in the current validation study.

Association between three prehospital thoracic decompression techniques by physicians and complications: a retrospective, multicentre study in adults

Alan Garner, Elwyn Poynter, Ruth Parsell, Andrew Weatherall, Mary Morgan, Anna Lee

Eur J Trauma Emerg Surg. 2023 Feb;49(1):571-581.

 

Introduction: We sought to compare the complication rates of prehospital needle decompression, finger thoracostomy and three tube thoracostomy systems (Argyle, Frontline kits and endotracheal tubes) and to determine if finger thoracostomy is associated with shorter prehospital scene times compared with tube thoracostomy.

Methods: In this retrospective cohort study we abstracted data on adult trauma patients transported by three helicopter emergency medical services to five Major Trauma Service hospitals who underwent a prehospital thoracic decompression procedure over a 75-month period. Comparisons of complication rates for needle, finger and tube thoracostomy and between tube techniques were conducted. Multivariate models were constructed to determine the relative risk of complications and length of scene time by decompression technique.

Results: Two hundred and fifty-five patients underwent 383 decompression procedures. Fifty eight patients had one complication, and two patients had two complications. There was a weak association between decompression technique (finger vs tube) and adjusted risk of overall complication (RR 0.58, 95% CI: 0.33-1.03, P = 0.061). Recurrent tension physiology was more frequent in finger compared with tube thoracostomy (13.9 vs 3.2%, P < 0.001). Adjusted prolonged (80th percentile) scene time was not significantly shorter in patients undergoing finger vs tube thoracostomy (56 vs 63 min, P = 0.197), nor was the infection rate lower (2.7 vs 2.1%, P = 0.85).

Conclusions: There was no clear evidence for benefit associated with finger thoracostomy in reducing overall complication rates, infection rates or scene times, but the rate of recurrent tension physiology was significantly higher. Therefore, tube placement is recommended as soon as practicable after thoracic decompression.

Comparison of emergency airway management techniques in the performance of emergent Cricothyrotomy

Nicholas George, Gabriel Consunji, Jordan Storkersen, Fanglong Dong, Benjamin Archambeau, Richard Vara, Jan Serrano, Reza Hajjafar, Louis Tran, Michael M Neeki

Int J Emerg Med. 2022 May 30;15(1):24.

Introduction: Emergent cricothyrotomy (EC) is a rare and lifesaving procedure to secure a difficult airway when other methods have failed. Many techniques have been discussed in the literature. This study aimed to identify major techniques used to perform EC in a regional trauma center and evaluate outcomes associated with the techniques.

Methods: Patients who underwent EC at Arrowhead Regional Medical Center between 1-1-2009 and 1-1-2019 were reviewed for eligibility for this study. Patients' data were extracted from the trauma database. Chi-square tests were conducted to assess the difference on variables between the techniques.

Results: A total of 51 (0.17%) of these patients required EC and were included in the database. The two most prevalent techniques were the scalpel-bougie-tube (SBT) and the surgical cricothyrotomy technique (SCT). More than half (n = 27, 52.9%) of the cohort received the SBT. There was no statistically significant difference between the two techniques with regards to demographic variables, including age (p = 0.7528), injury severity score (ISS, p = 0.896), gender (p = 0.3709), and race (p = 0.8935). However, the SCT group had a statistically higher Glasgow Coma Scale (GCS) than the SBT group (p = 0.0036). There was no statistically significant difference in mortality or complications between these two groups (p = 0.2172 for mortality).

Discussion: Two techniques of EC were identified as preferred techniques. Both procedures were successful in securing an emergency airway, noting a difference in the time to completion of the two techniques. Given the rarity of the procedure, practitioners may choose the method based on their training and the availability of appropriate instruments.

Cric in the Dark: Surgical Cricothyrotomy in Low Light Tactical Environments.

Chandler W Getz, Sean M Stuart, Brent M Barbour, Jared M Verga, Paul J D Roszko, Emily E Friedrich

J Spec Oper Med. 2022 Dec 16;22(4):50-54.

 

Background: Surgical cricothyrotomy (SC) is a difficult procedure with high failure rates in the battlefield environment. The difficulty of this procedure is compounded in a low-light tactical environment in which white light cannot be used. This study compared the use of red-green (RG) light and red (R) light in the performance of SC in a low-light environment.

Materials and methods: Tactical Combat Casualty Care-certified navy corpsmen (n = 33) were provided 15 minutes of standardized instruction followed by hands-on practice with the Tactical CricKit and the H&H bougie-assisted Emergency Cricothyrotomy Kit. Participants acclimated to a dark environment for 30 minutes before performing SC on a mannequin with both devices using both R and RG light in a randomized order. Application time, success, participant preference, and participant confidence were analyzed.

Results: There were similarly high levels of successful placement (>87.5%) in all four cohorts. Light choice did not appear to affect placement time with either of the two kits. On Likert-scale surveys, participants reported that RG decreased difficulty (p < .0001) and increased confidence (p < .0001) in performing the procedure.

Conclusion: RG light increased confidence and decreased perceived difficulty when performing SC, though no differences in placement time or success were observed.

The effect of the Belmont rapid infuser on cold stored whole blood coagulability

Tatiana Hoyos Gomez, S James El Haddi, Sherri L Grimstead-Arnold, Martin A Schreiber

Injury. 2023 Jan;54(1):29-31

 

Introduction: With the large-scale use of whole blood in massive transfusion using rapid infusers/fluid warmers such as the Belmont, questions remain as to whether coagulation potency, platelet number and function are preserved. We aimed to study functional coagulation capacity and cell counts in whole blood before and after infusion through the Belmont rapid infuser utilizing TEG analysis and complete blood counts.

Methods: We evaluated 10 whole blood units before and after infusion through a Belmont Fluid Management System at a set rate of 200 mL/min and a temperature of 37.4 °C. Cell counts and thromboelastography function of the specimens were measured. Parameters were compared utilizing paired Student's t-tests and paired Wilcoxon Rank Sign tests.

Results: Platelet count, R time, and Maximum amplitude showed significant decreases (defined as p<0.05) after being infused through the Belmont. Hemoglobin, hematocrit, MCV, and alpha angle were not statistically different before and after infusion.

Conclusion: Infusion of cold stored whole blood in a Belmont infuser, appeared to decrease platelet counts and function as well as activate clotting factors as demonstrated by a shorter R time while not affecting red cell counts or fibrin cross-linking as measured by TEG parameters and cell counts. This suggests that while it is possible to transfuse whole blood through a rapid infuser, platelet quantity and function may be negatively impacted.

Hemostatic dressings based on poly(vinyl formal) sponges

O Goncharuk, O Korotych, Yu Samchenko, L Kernosenko, A Kravchenko, L Shtanova, O Tsуmbalуuk, T Poltoratska, N Pasmurtseva, I Mamyshev, E Pakhlov, O Siryk

Mater Sci Eng C Mater Biol Appl. 2021 Oct;129:112363. Epub 2021 Aug 9.

 

Abstract

The development of novel hemostatic agents is related to the fact that severe blood loss due to hemorrhage continues to be the leading cause of preventable death of patients with military trauma and the second leading cause of death of civilian patients with injuries. Herein we assessed the hemostatic properties of porous sponges based on biocompatible hydrophilic polymer, poly(vinyl formal) (PVF), which meets the main requirements for the development of hemostatic materials. A series of composite hemostatic materials based on PVF sponges with different porosities and fillers were synthesized by acetalization of poly(vinyl alcohol) with formaldehyde. Nano-sized aminopropyl silica, micro-sized calcium carbonate, and chitosan hydrogel were used to modify PVF matrixes. The physicochemical properties (pore size, elemental composition, functional groups, hydrophilicity, and acetalization degree) of the synthesized composite sponges were studied by gravimetrical analysis, optical microscopy, scanning electron microscopy combined with energy dispersive x-ray spectroscopy, infrared spectroscopy, and nuclear magnetic resonance. Hemostatic properties of the materials were assessed using a model of parenchymal bleeding from the liver of white male Wistar rat with a gauze bandage as a control. All investigated PVF-based porous sponges showed high hemostatic activity: upon the application of PVF-samples the bleeding decreased within 3 min by 68.4-94.4% (р < 0.001). The bleeding time upon the application of PVF-based composites decreased by 78.3-90.4% (p < 0.001) compared to the application of well-known commercial product Celox™.

Unit Collective Medical Training in the 75th Ranger Regiment

Simon Corona Gonzalez, Patricio F Vasquez, Harold R Montgomery, Curtis C Conklin, Zachary A Conaway, David M Pate, James F Lopata, Russ S Kotwal

J Spec Oper Med. 2022 Dec 16;22(4):28-39.

 

Abstract

The 75th Ranger Regiment's success with eliminating preventable death on the battlefield is innate to the execution of a continuous operational readiness training cycle that integrates individual and unit collective medical training. This is a tactical solution to a tactical problem that is solved by the entire unit, not just by medics. When a casualty occurs, the unit must immediately respond as a team to extract, treat, and evacuate the casualty while simultaneously completing the tactical mission. All in the unit must maintain first responder medical skills and medics must be highly proficient. Leaders must be prepared to integrate casualty management into any phase of the mission. Leaders must understand that (1) the first casualty can be anyone; (2) the first responder to a casualty can be anyone; (3) medical personnel manage casualty care; and (4) leaders have ownership and responsibility for all aspects of the mission. Foundational to training is a command-directed casualty response system which serves as a forcing function to ensure proficiency and mastery of the basics. Four programs have been developed to train individual and collective tasks that sustain the Ranger casualty response system: (1) Ranger First Responder, (2) Advanced Ranger First Responder, (3) Ranger Medic Assessment and Validation, and (4) Casualty Response Training for Ranger Leaders. Unit collective medical training incorporates tactical leader actions to facilitate the principles of casualty care. Tactical leader actions are paramount to execute a casualty response battle drill efficiently and effectively. Successful execution of this battle drill relies on a command-directed casualty response system and mastery of the basics through rehearsals, repetition, and conditioning.

 

The Untrained Public's Ability to Apply the Layperson Audiovisual Assist Tourniquet vs a Combat Application Tourniquet: A Randomized Controlled Trial

Craig Goolsby, Carl-Oscar Jonson, Eric Goralnick, Nicole Dacuyan-Faucher, Keke Schuler, Curt Kothera, Amit Shah, Jeremy Cannon, Erik Prytz

J Am Coll Surg. 2023 Jan 1;236(1):178-186.

Background: Although the Stop the Bleed campaign's impact is encouraging, gaps remain. These gaps include rapid skill decay, a lack of easy-to-use tourniquets for the untrained public, and training barriers that prevent scalability. A team of academic and industry partners developed the Layperson Audiovisual Assist Tourniquet (LAVA TQ)-the first audiovisual-enabled tourniquet for public use. LAVA TQ addresses known tourniquet application challenges and is novel in its design and technology.

Study design: This study is a prospective, randomized, superiority trial comparing the ability of the untrained public to apply LAVA TQ to a simulated leg vs their ability to apply a Combat Application Tourniquet (CAT). The study team enrolled participants in Boston, MA; Frederick, MD; and Linköping, Sweden in 2022. The primary outcome was the proportion of successful applications of each tourniquet. Secondary outcomes included: mean time to application, placement position, reasons for failed application, and comfort with the devices.

Results: Participants applied the novel LAVA TQ successfully 93% (n = 66 of 71) of the time compared with 22% (n = 16 of 73) success applying CAT (relative risk 4.24 [95% CI 2.74 to 6.57]; p < 0.001). Participants applied LAVA TQ faster (74.1 seconds) than CAT (126 seconds ; p < 0.001) and experienced a greater gain in comfort using LAVA TQ than CAT.

Conclusions: The untrained public is 4 times more likely to apply LAVA TQ correctly than CAT. The public also applies LAVA TQ faster than CAT and has more favorable opinions about its usability. LAVA TQ's highly intuitive design and built-in audiovisual guidance solve known problems of layperson education and skill retention and could improve public bleeding control.

Health and Safety Threats to Ukraine From Nonconventional Weapons: A Clear and Present Danger

Eric Goralnick, Peter R Chai, Timothy B Erickson

JAMA. 2022 Dec 20;328(23):2301-2302.

 

No abstract available

 

Antibiotic administration within 1 hour for open lower extremity fractures is not associated with decreased risk of infection

Areg Grigorian, Morgan Schellenberg, Kenji Inaba, Matthew Martin, Kazuhide Matsushima, Michael Lekawa, Jeffry Nahmias

J Trauma Acute Care Surg. 2023 Feb 1;94(2):226-231.

 

Background: Open fractures have a high risk of infection with limited data correlating timing of prophylactic antibiotic administration and rate of subsequent infection. The Trauma Quality Improvement Program has established a standard of antibiotic administration within 1 hour of arrival, but there is a lack of adequately powered studies validating this quality metric. We hypothesize that open femur and/or tibia fracture patients undergoing orthopedic surgery have a decreased risk of infectious complications (osteomyelitis, deep and superficial surgical site infection) if antibiotics are administered within 1 hour of presentation compared with administration after 1 hour.

Methods: The 2019 Trauma Quality Improvement Program was queried for adults with isolated (Abbreviated Injury Scale <1 for the head/face/spine/chest/abdomen/upper extremity) open femur and/or tibia fractures undergoing orthopedic surgery. Transfer patients were excluded. Patients receiving early antibiotics (EA) within 1 hour were compared with patients receiving delayed antibiotics (DA) greater than 1 hour from arrival.

Results: Of 3,367 patients identified, 2,400 (70.4%) received EA. Patients receiving EA had a higher rate of infections compared with DA (1.1% vs. 0.2%, p = 0.011). After adjusting for age, comorbidities, injury severity, nerve/vascular trauma to the lower extremity, washout of the femur/tibia performed in <6 hours, blood transfusion, and admission vitals, patients in the EA group had a similar associated risk of surgical site infection/osteomyelitis compared with the DA cohort ( p = 0.087). These results remained in subset analyses of patients with only femur, only tibia, and combined femur/tibia open fractures (all p > 0.05).

Conclusion: In this large national analysis, approximately 70% of isolated open femur or tibia fracture patients undergoing surgery received antibiotics within 1 hour. After adjusting for known risk factors of infection, there was no association between timing of antibiotic administration and infection. Reconsideration of the quality metric of antibiotic administration within 1 hour for open fractures appears warranted.

Complete Neurological Recovery After Emergency Burr Hole Placement Utilizing EZ-IO® for Epidural Hematoma

Marc Grossman, Alfred P See, Rebekya Mannix, Erin L Simon

J Emerg Med. 2022 Oct;63(4):557-560

 

Background: Post-traumatic epidural hematoma (EDH) accounts for 1-3% of pediatric closed head injury admissions. There is a 2.5:1 male predominance. Etiology varies by age; motor vehicle collisions are the primary cause of EDH in adolescents. Post-traumatic EDH accompanies up to 4% of adult head injuries, and is associated with 10% mortality in adults and 5% mortality in children. In North America, standard of care for post-traumatic EDH includes decompressive craniotomy or trepanation via burr hole. Such lifesaving care is typically provided in the operating room by consulting neurosurgery teams or other personnel trained in the use of burr hole equipment.

Case report: The case of a 17-year-old female patient who presented to a community emergency department (ED) after being involved in a motor vehicle collision is discussed. At the scene of the accident, she refused emergency medical services transport and was brought to the ED via private vehicle. She quickly decompensated in the ED and required intubation. Neurosurgical services were not available and transport to the nearest pediatric trauma center was delayed due to weather. Decompression and drainage of her EDH was accomplished with an EZ-IO® driver and intraosseous needle under virtual guidance of a pediatric neurosurgeon until definitive care could be obtained. The patient made a full neurologic recovery.

Why should an emergency physician be aware of this: EDHs have high morbidity and mortality. In settings without access to neurosurgical services, and where ED access to or familiarity with burr hole equipment is limited, the EZ-IO® device may be a temporizing and lifesaving intervention until definitive neurosurgical care can be obtained.

 

Performance Evaluation of the Solo-T and the Combat Application Tourniquet in a Perfused Cadaver Model

George J Holinga, John S Foor, Steven L Van Horn, James E McGuire

J Spec Oper Med. 2022 Sep 19;22(3):49-55

 

Purpose: We evaluated a 10.2-cm-wide, minimally elastic, adhesive wrap-based tourniquet (Solo-T or ST) alongside a 3.8-cm-wide windlass-based tourniquet (Combat Application Tourniquet Generation 7, or CAT) to determine if the tension wrap-tightened ST could deliver hemorrhage control equivalent to the windlass-tightened CAT.

Methods: A cadaver model was used to simulate lower-thigh femoral arterial hemorrhage at "normal" (146 ± 5mmHg) and "elevated" (471 ± 3mmHg) perfusion pressures (mean ± standard error). Three study participants used the ST and CAT to control hemorrhage during 48 timed trials. Arterial occlusion was established by Doppler ultrasound and tourniquet performance was quantified by under-tourniquet pressure cuffs.

Results: Participants achieved 100% (24/24) occlusion success rates and reported similar ease of use for both tourniquets. Occlusion and application times (mean ± standard error) were similar (p > .05) for the ST and CAT under "normal" (occlusion, ST: 25 ± 2 seconds, CAT: 22 ± 2 seconds; application, ST: 27 ± 2 seconds, CAT: 26 ± 2 seconds) and "elevated" (occlusion, ST: 24 ± 7 seconds, CAT: 24 ± 7 seconds; application, ST: 25 ± 7 seconds, CAT: 25 ± 7 seconds) perfusion alike. The ST mean completion pressures (mean ± standard error) were > 40% lower than the CAT under both "normal" perfusion (ST: 110 ± 20mmHg; CAT: 210 ± 30mmHg; p = 0.009) and "elevated" perfusion (ST: 190 ± 50mmHg; CAT: 340 ± 30mmHg; p = 0.03).

Conclusion: The adhesive wrap-based ST tourniquet delivered equivalent hemorrhage control performance at significantly lower completion pressures than the CAT.

 

Treating traumatic brain injury at sea: how to improve the skills and capabilities of the naval medical personnel.

Xin-Jie Hong, Kai-Wei Han, Rong-Bin Chen, Liang Zhao, Dan-Feng Zhang, Lei Jiang, Yi-Ming Li, Li-Quan Lv, Li-Jun Hou, Tao Xu

Mil Med Res. 2022 Dec 5;9(1):67.

Affiliations expand

 

No abstract available

Stop the Bleed

Lenworth Jacobs, Jane J Keating, Richard C Hunt, Frank K Butler, Peter T Pons, Mark Gestring, Eileen Bulger, Alexander Eastman, Jeffrey Kerby, Zain Hashmi, Jeremy Fridling, Kenji Inaba, Kazuhide Matsushima, Eric Goralnick, Nelya Melnitchouk, Vanessa Welten

Curr Probl Surg. 2022 Oct;59(10):101193

 

No abstract available

 

Inadvertent Radiation Exposures in Combat Zones: Risk of Contamination and Radiobiologic Consequences

Kirk Jensen, Vasyl Vasko

Mil Med. 2022 Oct 29;187(11-12):303-307

 

Abstract

On February 24, 2022, Russia began a military invasion of Ukraine. Missile and air strikes were reported throughout the country, shortly followed by a large ground invasion from multiple directions. Four major theaters developed: the Kyiv offensive, the Northeastern Ukraine offensive, the Eastern Ukraine offensive, and the Southern Ukraine offensive, with continued missile and air strikes far into Western Ukraine. Advancing Russian military units launched an attack and captured the Chernobyl nuclear station. Russian troops dug trenches into the area commonly known as the "Red Forest," violating the established radiation safety measures and threatening security within the Chernobyl Exclusion Zone. The placement of military units in such close proximity to the station also sparked concerns of possible damage occurring to the containment vessel constructed around the station's wrecked fourth reactor. There are 15 operating nuclear reactors in Ukraine. Each is vulnerable to an attack or sabotage that could precipitate a malfunction and possible release of radioactive isotopes. In this short commentary, we will discuss radiobiologic data obtained after the analysis of historical nuclear power plant (NPP) accidents and emphasize new challenges for nuclear security when NPPs are found and are possible targets within a conflict zone.

United States Military Fatalities During Operation Inherent Resolve and Operation Freedom's Sentinel

Russ S Kotwal, Jud C Janak, Jeffrey T Howard, Andrew J Rohrer, Howard T Harcke, John B Holcomb, Brian J Eastridge, Jennifer M Gurney, Stacy A Shackelford, Edward L Mazuchowski

Mil Med. 2022 May 11; Online ahead of print.

 

Background: Military operations provide a unified action and strategic approach to achieve national goals and objectives. Mortality reviews from military operations can guide injury prevention and casualty care efforts.

Methods: A retrospective study was conducted on all U.S. military fatalities from Operation Inherent Resolve (OIR) in Iraq (2014-2021) and Operation Freedom's Sentinel (OFS) in Afghanistan (2015-2021). Data were obtained from autopsy reports and other existing records. Fatalities were evaluated for population characteristics; manner, cause, and location of death; and underlying atherosclerosis. Non-suicide trauma fatalities were also evaluated for injury severity, mechanism of death, injury survivability, death preventability, and opportunities for improvement.

Results: Of 213 U.S. military fatalities (median age, 29 years; male, 93.0%; prehospital, 89.2%), 49.8% were from OIR, and 50.2% were from OFS. More OIR fatalities were Reserve and National Guard forces (OIR 22.6%; OFS 5.6%), conventional forces (OIR 82.1%; OFS 65.4%), and support personnel (OIR 61.3%; OFS 33.6%). More OIR fatalities also resulted from disease and non-battle injury (OIR 83.0%; OFS 28.0%). The leading cause of death was injury (OIR 81.1%; OFS 98.1%). Manner of death differed as more homicides (OIR 18.9%; OFS 72.9%) were seen in OFS, and more deaths from natural causes (OIR 18.9%; OFS 1.9%) and suicides (OIR 29.2%; OFS 6.5%) were seen in OIR. The prevalence of underlying atherosclerosis was 14.2% in OIR and 18.7% in OFS. Of 146 non-suicide trauma fatalities, most multiple/blunt force injury deaths (62.2%) occurred in OIR, and most blast injury deaths (77.8%) and gunshot wound deaths (76.6%) occurred in OFS. The leading mechanism of death was catastrophic tissue destruction (80.8%). Most fatalities had non-survivable injuries (80.8%) and non-preventable deaths (97.3%).

Conclusions: Comprehensive mortality reviews should routinely be conducted for all military operation deaths. Understanding death from both injury and disease can guide preemptive and responsive efforts to reduce death among military forces.

Prehospital canthotomy: A sight-saving procedure in case series

Akmez Latona, Nivene Saad, Michael Hogden, Alistair Tm Hamilton

Emerg Med Australas. 2022 Jun;34(3):428-433.

 

Objective: Orbital compartment syndrome (OCS) is a time critical condition, with ischaemic complications occurring after 90-120 min. In the prehospital setting, the diagnosis and management of OCS is challenging due to complex environmental considerations, competing clinical priorities, and limited equipment. This study aims to provide learning points on performing lateral canthotomy and cantholysis (LCC) in the prehospital setting.

Methods: We performed a retrospective audit of LCC in our service from January 2016 to December 2020 by retrieving demographic and clinical details from LifeFlight Retrieval Medicine electronic database using 'OCS' and 'LCC' as keywords.

Results: Three cases out of 7413 trauma missions were identified over the 5-year period. LCC was performed at the primary scene in two cases, while one patient underwent LCC at a rural hospital near the scene of injury. Clinical findings, aeromedical considerations, and radiological findings at the receiving facility, along with visual outcomes at time of discharge are discussed.

Conclusion: Prehospital LCC is rare. The Australian aeromedical context often involves lengthy transfers of trauma patients. Clinical diagnosis and management of OCS are highly challenging in the prehospital setting. It is important that prehospital physicians have access to appropriate equipment to perform LCC. They should be provided with suitable training and supported by a standard operating procedure.

Ocular Trauma and Traumatic Brain Injury on the Battlefield: A Systematic Review After 20 Years of Fighting the Global War on Terror

Ian Lee, Brian Davis, Boonkit Purt, Taylor DesRosiers

Mil Med. 2022 Jul 23;usac226. Online ahead of print.

 

Introduction: Operations Iraqi Freedom and Enduring Freedom saw higher rates of combat ocular trauma (COT) than any past U.S. conflict. The improvised explosive device, the signature weapon of the conflicts, as well as improved personal protective equipment and combat medical care all attributed to COT being the fourth most common injury sustained by wounded U.S. service members. This review describes the epidemiology, mechanisms, and treatment patterns and discusses the relationship of traumatic brain injuries (TBIs) to ocular injuries sustained by U.S. service members during the War on Terror.

Materials and methods: A mixed-methods review of the literature was conducted by extracting data from PubMed, Embase, and Cochrane research databases between December 15, 2020, and January 25, 2021, using the COVIDENCE review management software.

Results: Of 827 articles for review, 50 were deemed relevant. Articles were separated using the Birmingham Eye Trauma Terminology into open globe, closed globe, mixed/injury management only, and TBI. Seventeen articles were found to discuss data pertaining to particular databases. Overall, six articles discussed open-globe injuries in the setting of overall COT with a reported rate of 38-64%. Three articles discussed closed-globe injuries in the context of overall COT with a rate of 39-47%. Numerous articles discussed the relationship between COT and TBI. Within the Walter Reed Ocular Trauma Database, 40% of patients with ocular trauma had concomitant TBI. Additionally, the visual sequelae of ocular trauma ranged from 9% to 50% among reporting studies. Other ocular injury patterns receiving attention include neuro-ophthalmic and oculoplastic injuries. By far the most common mechanism of COT was blast injury (64-84%), with improvised explosive devices (IEDs) accounting for 51-69% of ocular injuries. Among the large reporting databases, 41-45% of COT required surgical treatment with an overall enucleation rate of 12-17%.

Conclusions: The Global War on Terrorism saw an evolution in the types of ocular injuries sustained by U.S. service members compared to previous conflicts. The widespread use of IEDs led to injury patterns not encountered in previous conflicts. Weapons of today utilize blast and shrapnel as the mechanism for destruction. Sequelae such as TBIs and complicated head and neck trauma have pushed innovation in the field of ophthalmology. Improvements in medical technology and personal protective equipment have resulted in not only survival of previously life-threatening injuries, but also a greater chance of severe loss of vision. By analyzing ocular injury data from the trauma literature, improvements in education and training can lead to improvements in point-of-injury care and eye protection for the next generation of warfighters.

Implications of Neurological Directed-Energy Weapons for Military Medicine

Regan F Lyon, Joshua Gramm, Brian Branagan, Shannon C Houck

J Spec Oper Med. 2022 Sep 19;22(3):104-107

 

Abstract

Since 2016, there has been an increase in reported cases of intelligence officers and diplomats hearing pulsing sounds and experiencing neurophysiologic and cognitive symptoms. These varied and often intense symptoms manifest in ways similar to a traumatic brain injury (TBI) but without inciting trauma. Known formerly as "unconventionally acquired brain injury" (UBI), these events are now labeled "anomalous health incidents" (AHIs). Investigations of these incidents suggest reasons to be concerned that a specific type of neuroweapon may be the cause-a directed energy weapon (DEW). Neuroweapons that target the brain to influence cognition and behavior are leading to a new domain of warfare-neurowarfare. The implications and resultant stakes, especially for the Special Operations community, are significant. This article focuses specifically on the implications of DEWs as a neuroweapon causing UBIs/AHIs for military medical practitioners and suggests using a comprehensive strategy, analogous to that of chemical warfare or other weapons of mass destruction (WMD), to improve our preparedness for the medical repercussions of neurowarfare.

FINGER: A Novel Approach to Teaching Simple Thoracostomy

Andrew Merelman, Natalie Zink, Andrew D Fisher, Michael Lauria, Darren Braude

Air Med J. 2022 Nov-Dec;41(6):526-529.

 

Abstract

For decades, most prehospital clinicians have only been armed with needle thoracostomy to treat a tension pneumothorax, which has a significant failure rate. Following recent changes by the US military, more ground and air transport agencies are adopting simple thoracostomy, also commonly referred to as finger thoracostomy, as a successful alternative. However, surgical procedures performed by prehospital clinicians remain uncommon, intimidating, and challenging. Therefore, it is imperative to adopt a training strategy that is comprehensive, concise, and memorable to best reduce cognitive load on clinicians while in a high-acuity, low-frequency situation. We suggest the following mnemonic to aid in learning and retention of the key procedural steps: FINGER (Find landmarks; Inject lidocaine/pain medicine; No infection allowed; Generous incision; Enter pleural space; Reach in with finger, sweep, reassess). This teaching aid may help develop and maintain competence in the simple thoracostomy procedure, leading to successful treatment of both a tension pneumothorax and hemothorax.

Hypertonic Saline for Severe Traumatic Brain Injury With Herniation: A Military Prehospital Case Report

Randy Michael, Matthew Gaddy, Nicholas Antonino, Ryan Payne, Erik Scott DeSoucy, Jessica T Rush

J Spec Oper Med. 2022 Sep 19;22(3):98-100.

 

Abstract

Severe traumatic brain injury (sTBI) is a devastating injury with limited prehospital therapies available. The Joint Trauma System (JTS) Clinical Practice Guidelines recommend hypertonic saline (HTS) for casualties with sTBI and signs of impending or ongoing herniation (IOH), but its use by combat medics has never been reported in the literature. This report details the management of a pregnant patient with sTBI and signs of IOH, including the use of HTS, by US Air Force pararescumen in an austere prehospital setting. Treatment with HTS was followed by improvement in the patient's neurologic exam and successful evacuation to definitive care where her child was delivered alive. Additionally, we review the pathophysiology and signs of herniation, the mechanism of action of hyperosmotic therapies, and the rationale behind the use of HTS in the combat setting.

 

 

Airway Management for Army Reserve Combat Medics: An Interdisciplinary Workshop

Bradley M Miller, Chad Kinder, Rachel Smith-Steinert

J Spec Oper Med. 2019 Fall;19(3):64-70.

 

Background: An Army Reserve Combat Medic's training is focused on knowledge attainment, skill development, and building experience and training to prepare them to perform in austere conditions with limited resources like on the battlefield. Unfortunately, the exposure to skills they may be responsible for performing is limited. Research shows that greater than 90% of battlefield deaths occur in the prehospital setting, 24% of which are potentially survivable. Literature demonstrates that 91% of these deaths are related to hemorrhage; the remaining are related to other causes, including airway compromise. The skill and decision-making of this population are prime targets to optimize outcomes in the battlefield setting.

Methods: Army Reserve combat medics were selected to voluntarily participate in an educational intervention provided by anesthesia providers focusing on airway management. Participants completed a preintervention assessment to evaluate baseline knowledge levels as well as comfort with airway skills. Medics then participated in a simulated difficult airway scenario. Next, airway management was reviewed, and navigation of the difficult airway algorithm was discussed. The presentation was followed by simulations at four hands-on stations, which focused on fundamental airway concepts such as bag-mask ventilation and placement of oral airways, tracheal intubation, placement of supraglottic airways, and cricothyrotomy. Pre/post knowledge assessments and performance evaluation tools were used to measure the effectiveness of the intervention.

Results: Statistically significant results were found in self-reported confidence levels with airway skills (z = -2.803, p = .005), algorithm progression (z = -2.807, p = .005), and predicting difficulty with airway interventions based on the patient's features (z = -2.809, p = .005). Establishment of ventilation was completed faster after the intervention. More coherent and effective airway management was noted, new knowledge was gained, and implications from psychological research applied.

Conclusion: Supplementing the training of Army Reserve Combat Medics with the utilization of anesthesia providers is an effective platform. This exercise imparted confidence in this population of military providers. This is critical for decision-making capabilities, performance, and the prevention of potentially survivable mortality on the battlefield.

Prehospital extremity tourniquet placements-performance evaluation of non-EMS placement of a lifesaving device

Ava K Mokhtari, Sarah Mikdad, Casey Luckhurst, John Hwabejire, Jason Fawley, Jonathan J Parks, April E Mendoza, Haytham M A Kaafarani, George C Velmahos, Frank W Bloemers, Noelle N Saillant

Eur J Trauma Emerg Surg. 2022 Oct;48(5):4255-4265.

 

Background: The education of civilians and first responders in prehospital tourniquet (PT) utilization has spread rapidly. We aimed to describe trends in emergency medical services (EMS) and non-EMS PT utilization, and their ability to identify proper clinical indications and to appropriately apply tourniquets in the field.

Methods: A retrospective cohort study was conducted to evaluate all adult patients with PTs who presented at two Level I trauma centers between January 2015 and December 2019. Data were collected via an electronic patient query tool and cross-referenced with institutional Trauma Registries. Medically trained abstractors determined if PTs were clinically indicated (limb amputation, vascular hard signs, injury requiring hemostasis procedure, or significant documented blood loss). PTs were further designated as appropriately or inappropriately applied (based on tourniquet location, venous tourniquet, greater than 2-h ischemic time). Descriptive statistics and univariate analyses were performed.

Results: 146 patients met inclusion criteria. The incidence of yearly PT placements increased between 2015 and 2019, with an increase in placement by non-EMS personnel (police, firefighter, bystander, and patient). Improvised PTs were frequently utilized by bystanders and patients, whereas first responders had high rates of commercial tourniquet use. A high proportion of tourniquets were placed without indication (72/146, 49%); however, the proportion of PTs placed without a proper indication across applier groups was not statistically different (p = 0.99). Rates of inappropriately applied PTs ranged from 21 to 46% across all groups applying PTs.

Conclusions: PT placement was increasingly performed by non-EMS personnel. Present data indicate that non-EMS persons applied PTs at a similar performance level of those applied by EMS. Study LevelLevel III.

Prehospital interventions to reduce discomfort caused by immobilization in adult trauma victims: a scoping review protocol

Mauro Mota, Madalena Cunha, Eduardo Santos, Tito Abrantes, Filipe Melo, Mariana Monteiro, Margarida Reis Santos

JBI Evid Synth. 2022 Nov 1;20(11):2743-2750.

 

Objective: The objective of this review is to identify the level of discomfort caused by immobilization as reported by trauma victims, and to map all the interventions in the prehospital context where they have been implemented and evaluated in order to reduce discomfort in adult victims of trauma.

Introduction: Immobilization is a cause of discomfort for trauma victims, which has important implications for the deterioration of vital signs and quality of life. However, discomfort caused by immobilization remains an under-explored topic by the scientific community.

Inclusion criteria: This scoping review will consider studies of adult victims of trauma, aged 18 years or over, in prehospital emergency care. Studies that focus on interventions designed to reduce immobilization discomfort, implemented and evaluated by health professionals, of any form, duration, frequency, and dose will be considered.

Methods: An initial search of PubMed and CINAHL will be undertaken, followed by a second search for published and unpublished studies without time restrictions, in major health care-related electronic databases. Studies in English, French, Spanish, and Portuguese will be included. Data extraction will be performed independently by 2 reviewers in a tabular format and will include details about the level of discomfort, interventions, populations, study methods, and outcomes of interest. A narrative synthesis will accompany the results and will describe how they relate to the review objectives.

The association of delayed advanced airway management and neurological outcome after out-of-hospital cardiac arrest in Japan

Koshi Nakagawa, Ryo Sagisaka, Daigo Morioka, Shota Tanaka, Hiroshi Takyu, Hideharu Tanaka

Am J Emerg Med. 2022 Dec;62:89-95.

 

Introduction: The effectiveness of advanced airway management (AAM) for out-of-hospital cardiac arrest (OHCA) has been reported differently in each region; however, no study has accounted for the regional differences in the association between the timing of AAM implementation and neurological outcomes.

Objective: This study aimed to evaluate the association between the timing of patient or prefecture level AAM and a favorableneurological outcome defined by cerebral performance category 1 or 2 (CPC 1-2).

Methods: A retrospective cohort study was conducted using data from the All-Japan Utstein Registry between 2013 and 2017. We included patients aged ≥8 years with OHCA for whom AAM (i.e., supraglottic airway or endotracheal intubation) was performed in a prehospital setting (n = 182,913). We divided the patients into shockable (n = 11,740) and non-shockable (n = 171,173) cohorts based on the initial electrocardiogram rhythm. Multilevel logistic regression analysis estimated the association between AAM time (patient contact-to-AAM performance interval) at the patient level (1-min unit increments), prefecture level (> 9.2 min vs. ≤ 9.2 min) and CPC 1-2.

Results: A delay in AAM time was negatively associated with CPC 1-2 (adjusted odds ratio [AOR], 0.92, 0.96; 95% confidence interval [CI], 0.90-0.93, 0.95-0.97, respectively), regardless of initial rhythm. At the prefecture level, a delay in AAM time was negatively associated with CPC 1-2 (AOR, 0.77, 0.68; 95% CI, 0.58-1.04, 0.50-0.94, respectively) only in the non-shockable cohort.

Conclusion: A delay in AAM performance was negatively associated with CPC 1-2 in both shockable and non-shockable cohorts. Moreover, a delay in AAM performance at the prefecture level was negatively associated with CPC 1-2 in the non-shockable cohort.

 

Trends in prehospital pain management: two decades of point-of-injury care

Helit Nakar, Alex Sorkin, Roy Nadler, Avishai M Tsur, Shaul Gelikas, Guy Avital, Elon Glassberg, Tarif Bader, Lidar Fridrich, Jacob Chen, Avi Benov

Isr Med Assoc J. 2022 Sep;24(9):584-590.

 

Background: Pain control in trauma is an integral part of treatment in combat casualty care. More soldiers injured on the battlefield need analgesics for pain than life-saving interventions (LSIs). Early treatment of pain improves outcomes after injury, while inadequate treatment leads to higher rates of post-traumatic stress disorder (PTSD).

Objectives: To describe the experience of the Israel Defense Forces (IDF) Medical Corps with prehospital use of analgesia.

Methods: All cases documented in the IDF-Trauma Registry between January 1997 and December 2019 were examined. Data collection included analgesia administered, mechanism of injury, wound distribution, and life-saving interventions performed.

Results: Of 16,117 patients, 1807 (11.2%) had at least one documented analgesia. Demographics included 91.2% male; median age 21 years. Leading mechanism of injury was penetrating (52.9%). Of injured body regions reported, 46.2% were lower extremity wounds. Most common types of analgesics were morphine (57.2%) and fentanyl (27%). Over the two decades of the study period, types of analgesics given by providers at point of injury (POI) had changed. Fentanyl was introduced in 2013, and by 2019 was given to 39% of patients. Another change was an increase of casualties receiving analgesia from 5-10% until 2010 to 34% by 2019. A total of 824 LSIs were performed on 556 patients (30.8%) receiving analgesia and no adverse events were found in any of the casualties.

Conclusions: Most casualties at POI did not receive any analgesics. The most common analgesics administered were opioids. Over time analgesic administration has gained acceptance and become more commonplace on the battlefield.

 

Prehospital Use of Whole Blood for Ill and Injured Patients During Critical Care Transport

Philip S Nawrocki, Brendan Mulcahy, Michael Shukis, Matthew Poremba

Air Med J. 2022 Sep-Oct;41(5):451-457.

 

Objective: Hemodynamic instability and hemorrhagic shock are frequently encountered by emergency medical services providers managing ill and injured patients during critical care transport. Although many critical care transport services commonly transfuse crystalloids and/or packed red blood cells (PRBCs), the administration of whole blood (WB) in prehospital care is currently limited. WB contains PRBCs, plasma, and platelets in a physiologic ratio to aid in oxygen delivery to tissue as well as hemostasis. This study describes a single critical care transport program's experience using WB for critically ill and injured patients and reports important clinical and safety outcomes.

Methods: This study was a retrospective review of patients who were transported by a single rotor wing-based critical care transport service to 1 of 2 tertiary care receiving hospitals within a single health system. Patients who were transported between November 1, 2018, and November 30, 2019, and who received at least 1 unit of low-titer group O WB during critical care transport were included. The primary outcomes of interest included 24-hour mortality and the total 24-hour transfusion requirement. The safety outcomes included transfusion reactions, acute lung injury, acute kidney injury, and the incidence of venous thromboembolism.

Results: During the study period, there were 3,084 total patients transported by our critical care transport service. There were 71 patients who received prehospital WB, 64 of whom met the inclusion criteria. The top 3 indications for WB administration included blunt trauma (n = 27, 42.2%), gastrointestinal hemorrhage (n = 15, 23.4%), and penetrating trauma (n = 11, 17.2%). The median total number of blood components transfused within 24 hours was 4.0 (interquartile range, 2.0-9.5), and the overall 24-hour mortality rate was 21.9%.

Conclusions: The administration of WB by emergency medical services providers to critically ill and injured patients in the prehospital setting is feasible and is associated with low incidences of adverse events and transfusion reactions. Further research is needed to elucidate the benefits of WB relative to current prehospital standards of care.

Recommendations for Improving Stop the Bleed: A Systematic Review

Ryoma Nichols, Jordan Horstman

Mil Med. 2022 Oct 29;187(11-12):e1338-e1345.

 

Introduction: In response to mass casualty events, The Hartford Consensus brought together subject matter experts across multiple disciplines in health care and public safety to create guidelines and publications intended to improve survivability in active shooter events. Among the recommendations was the earlier recognition and treatment application of life-threatening hemorrhage control. These recommendations culminated in efforts to create the Stop the Bleed Campaign, which aims to empower the layperson to render aid in a life-threatening bleeding emergency. As of February 2020, the program has held over 86,000 courses, trained over 1.4 million attendees, and over 77,000 instructors since its inception. In addition to spreading within the United States, American College of Surgeons (ACS) Stop the Bleed (StB) classes have been held in 118 different countries. This systematic narrative review aims to answer the following research question: What does the ACS StB Initiative do well, and where can it improve?

Materials and methods: The following search terms were utilized: "Stop the Bleed," "American College of Surgeons," "bleeding control," "first-aid," tourniquet, "wound pack," "direct pressure" hemorrhage, and bystander. The inclusion criteria were that the article needed to speak to the program or some aspect of bystander first aid, the article needed to be in a civilian setting, the article needed to be more than a case study or overview, and the first aid tools needed to be in the StB curriculum. 4 databases were searched, which produced 138 articles for screening. One hundred four full-text articles were able to be retrieved, and 56 articles were determined to meet the inclusion criteria once the full text was reviewed.

Results: Fifty-six articles were included in the final review and were placed into the following categories: Needs Within the Community, Confidence and Knowledge, Training Modalities, Barriers and Gaps in Training, Instructor Selection, Skill Retention, and Patient Outcomes. The articles were then organized into each outcome for synthesis and reporting of the results. The program overwhelmingly improves short-term confidence, but gaps in skill retention, data collection on patient outcomes, and settings that would benefit were identified.

Conclusion: StB is an effective tool in building confidence in laypersons, which is its biggest strength. A review of the literature shows several areas where the curriculum and materials could be better developed. Research can also be further refined to better quantify the program's impact.

Prehospital decompression of tension pneumothorax: Have we moved the needle?

Jordan Osterman, Annika Bickford Kay, David S Morris, Shawn Evertson, Teresa Brunt, Sarah Majercik

Am J Surg. 2022 Dec;224(6):1460-1463.

 

Background: Needle thoracostomy (NT) is the first-line intervention for tension pneumothorax in the prehospital setting. This study examined the effect of ATLS curriculum and EMS protocol changes on patient selection and successful performance of the procedure.

Methods: This is a retrospective chart review of all patients presenting to a Level One Trauma Center from 2015 to 2020 after undergoing prehospital NT.

Results: Lateral NT placement increased significantly from 5.1% to 38.9%. Proper patient selection, defined as presence decompensated shock, respiratory distress, and diminished breath sounds increased from 23.1% to 27.8%. There was no difference in radiographic confirmation of the catheter in the pleural space. Iatrogenic injury rates decreased slightly from 28.2% to 16.7%.

Conclusions: Protocol and curriculum changes have fallen short in yielding improved NT success rates or patient selection. Continued development of EMS education on the performance of NT is indicated.

Management and outcomes of military penetrating neck injuries: An eleven-year retrospective case note review

Christopher Pickering, Jameel Muzaffar, Conor Reid, Benjamin Zakaria, Christopher Coulson, Neil Sharma, John Breeze

Injury. 2023 Jan;54(1):119-123.

 

Introduction: Penetrating Neck Injuries (PNIs) affected 3.2% of trauma patients attending US and UK deployed medical treatment facilities (MTFs) during the Iraq and Afghanistan conflicts. Injured military personnel requiring aeromedical evacuation for such injuries were managed at the Royal Centre for Defence Medicine (RCDM), Birmingham, UK. The aim of this paper was to review the management of PNI in both deployed MTFs and when evacuated back to the UK.

Patients and methods: A retrospective case note review was performed of all military patients who sustained PNI whilst on deployment overseas, and who were subsequently evacuated to RCDM between March 2003 and December 2014.

Results: Forty casualties who sustained PNI were identified, of which 28/40 (70%) sustained injury from explosive fragmentation, and 11/40 (28%) from gunshot wounds. Hard signs of PNI were present in 3/40 (7.5%) patients, soft signs in 14/40 (35%), no signs in 12/40 (30%), and unknown signs in 11/40 (28%) patients. Computed tomography angiography (CTA) was used in 39/40 (98%) patients, and was effective at ruling out significant injury, with 100% (29/29) of casualties with a negative CTA not developing vascular or aerodigestive injury. There were 9/29 (31%) patients who had surgical neck exploration despite both a negative CTA and absence of hard signs of PNI. There were 12/40 (30%) patients who required operative intervention at RCDM.

Conclusion: UK military surgeons in Role 3 MTFs had a low threshold for surgical exploration, even in the absence of CT findings or hard signs. This was likely due to the high-energy mechanisms responsible for military PNI, in addition to the limited availability of equipment and clinical expertise in visualising the larynx.

Correlation between prehospital and in-hospital hypotension and outcomes after traumatic brain injury

Amber D Rice, Chengcheng Hu, Daniel W Spaite, Bruce J Barnhart, Vatsal Chikani, Joshua B Gaither, Kurt R Denninghoff, Gail H Bradley, Jeffrey T Howard, Samuel M Keim, Bentley J Bobrow

Am J Emerg Med. 2023 Mar;65:95-103.

 

Background and objective: Hypotension has a powerful effect on patient outcome after traumatic brain injury (TBI). The relative impact of hypotension occurring in the field versus during early hospital resuscitation is unknown. We evaluated the association between hypotension and mortality and non-mortality outcomes in four cohorts defined by where the hypotension occurred [neither prehospital nor hospital, prehospital only, hospital only, both prehospital and hospital].

Methods: Subjects ≥10 years with major TBI were included. Standard statistics were used for unadjusted analyses. We used logistic regression, controlling for significant confounders, to determine the adjusted odds (aOR) for outcomes in each of the three cohorts.

Results: Included were 12,582 subjects (69.8% male; median age 44 (IQR 26-61). Mortality by hypotension status: No hypotension: 9.2% (95%CI: 8.7-9.8%); EMS hypotension only: 27.8% (24.6-31.2%); hospital hypotension only: 45.6% (39.1-52.1%); combined EMS/hospital hypotension 57.6% (50.0-65.0%); (p < 0.0001). The aOR for death reflected the same progression: 1.0 (reference-no hypotension), 1.8 (1.39-2.33), 2.61 (1.73-3.94), and 4.36 (2.78-6.84), respectively. The proportion of subjects having hospital hypotension was 19.0% (16.5-21.7%) in those with EMS hypotension compared to 2.0% (1.8-2.3%) for those without (p < 0.0001). Additionally, the proportion of patients with TC hypotension was increased even with EMS "near hypotension" up to an SBP of 120 mmHg [(aOR 3.78 (2.97, 4.82)].

Conclusion: While patients with hypotension in the field or on arrival at the trauma center had markedly increased risk of death compared to those with no hypotension, those with prehospital hypotension that was not resolved before hospital arrival had, by far, the highest odds of death. Furthermore, TBI patients who had prehospital hypotension were five times more likely to arrive hypotensive at the trauma center than those who did not. Finally, even "near-hypotension" in the field was strongly and independently associated the risk of a hypotensive hospital arrival (<90 mmHg). These findings are supportive of the prehospital guidelines that recommend aggressive prevention and treatment of hypotension in major TBI.

Intraosseous administration of freeze-dried plasma in the prehospital setting

Mor Rittblat, Lilach Gavish, Avishai M Tsur, Shaul Gelikas, Avi Benov, Amir Shlaifer

Isr Med Assoc J. 2022 Sep;24(9):591-595.

 

Background: Freeze dried plasma (FDP) is a commonly used replacement fluid in the prehospital setting when blood products are unavailable. It is normally administered via a peripheral intravenous (PIV) line. However, in severe casualties, when establishing a PIV is difficult, administration via intraosseous vascular access is a practical alternative, particularly under field conditions.

Objectives: To evaluate the indications and success rate of intraosseous administration of FDP in casualties treated by the Israel Defense Forces (IDF).

Methods: A retrospective analysis of data from the IDF-Trauma Registry was conducted. It included all casualties treated with FDP via intraosseous from 2013 to 2019 with additional data on the technical aspects of deployment collected from the caregivers of each case.

Results: Of 7223 casualties treated during the study period, intravascular access was attempted in 1744; intraosseous in 87 of those. FDP via intraosseous was attempted in 15 (0.86% of all casualties requiring intravascular access). The complication rate was 73% (11/15 of casualties). Complications were more frequent when the event included multiple casualties or when the injury included multiple organs. Of the 11 failed attempts, 5 were reported as due to slow flow of the FDP through the intraosseous apparatus. Complications in the remaining six were associated with deployment of the intraosseous device.

Prolonged tactical tourniquet application for extremity combat injuries during war against terrorism in the Sahelian strip

Alexandre Sabate-Ferris, Georges Pfister, Guillaume Boddaert, Jean-Louis Daban, Stéphane de Rudnicki, Alexandre Caubere, Thomas Demoures, Stéphane Travers, Fréderic Rongieras, Laurent Mathieu

Eur J Trauma Emerg Surg. 2022 Oct;48(5):3847-3854.

 

Purpose: This study reports on complications following extended tourniquet application in patients with combat extremity injuries treated by the French Military Health Service in the Sahelian strip.

Methods: A retrospective review was performed in a French forward medical treatment facility deployed in Gao, Mali, between 2015 and 2020. All patients treated for an extremity injury with the application of at least one tourniquet for a minimum of 3 h were included. Prehospital data were injury pattern, associated shock, tourniquet location, and duration. Subsequent complications and surgical procedures performed were analyzed.

Results: Eleven patients with a mean age of 27.4 years (range 21-35 years) were included. They represented 39% of all patients in whom a tourniquet was applied. They had gunshot wounds (n = 7) or multiple blast injuries (n = 4) and totaled 14 extremity injuries requiring tourniquet application. The median ISS was 13 (interquartile range: 13). Tourniquets were mostly applied proximally on the limb for a mean duration of 268 min (range 180-360 min). Rhabdomyolysis was present in all cases. The damage control surgeries included debridement, external fixation, vascular repair, and primary amputation. Ten injuries were complicated by compartment syndrome requiring leg or thigh fasciotomy in the field or after repatriation. Two severely injured patients died of their wounds, but the others had a favorable outcome even though secondary amputation was sometimes required.

Conclusions: Extended and proximal tourniquet applications led to significant morbidity related to compartment syndrome and rhabdomyolysis. Hemorrhagic shock, mass casualty incident, and tactical constraints often precluded revising the temporary tourniquet applied under fire.

Adult ECMO in the En Route Care Environment: Overview and Practical Considerations of Managing ECMO Patients During Transport

Valerie G Sams, Jess Anderson, John Hunninghake, Michael Gonzales

Curr Trauma Rep. 2022;8(4):246-258.

 

Purpose of review: The authors' experience as a part of the U.S. Military ECMO program to include the challenges and successes learned from over 200 transports via ground and air is key to the expertise provided to this article. We review the topic of ECMO transport from a historical context in addition to current capabilities and significant developments in transport logistics, special patient populations, complications, and our own observations and approaches to include team complement and feasibility.

Recent findings: ECMO has become an increasingly used resource during the last couple of decades with considerable increase during the Influenza pandemic of 2009 and the current COVID-19 pandemic. This has led to a corresponding increase in the air and ground transport of ECMO patients.

Summary: As centralized ECMO resources become available at health care centers, the need for safe and effective transport of patients on ECMO presents an opportunity for ongoing evaluation and development of safe practices.

Incidence of Airway Interventions in the Setting of Serious Facial Trauma

Steven G Schauer, Jason F Naylor, Andrew D Fisher, Tyson E Becker, Michael D April

J Spec Oper Med. 2022 Dec 16;22(4):18-21.

 

Background: Airway obstruction is the second leading cause of preventable death on the battlefield. Most airway obstruction occurs secondary to traumatic disruptions of the airway anatomical structures. Facial trauma is frequently cited as rationale for maintaining cricothyrotomy in the medics' skill set over the supraglottic airways more commonly used in the civilian setting.

Methods: We used a series of emergency department procedure codes to identify patients within the Department of Defense Trauma Registry (DoDTR) from January 2007 to August 2016. This is a sub-group analysis of casualties with documented serious facial trauma based on an abbreviated injury scale of 3 or greater for the facial body region.

Results: Our predefined search codes captured 28,222 DoDTR casualties, of which we identified 136 (0.5%) casualties with serious facial trauma, of which 19 of the 136 had documentation of an airway intervention (13.9%). No casualties with serious facial trauma underwent nasopharyngeal airway (NPA) placement, 0.04% underwent cricothyrotomy (n = 10), 0.03% underwent intubation (n = 9), and a single subject underwent supraglottic airway (SGA) placement (<0.01%). We only identified four casualties (0.01% of total dataset) with an isolated injury to the face.

Conclusions: Serious injury to the face rarely occurred among trauma casualties within the DoDTR. In this subgroup analysis of casualties with serious facial trauma, the incidence of airway interventions to include cricothyrotomy was exceedingly low. However, within this small subset the mortality rate is high and thus better methods for airway management need to be developed.

 

Blast Injury Patterns Among Israel Defense Forces Fatalities

Josef Daniel Shakargy, Sami Gendler, Tomer Talmy, Guy Shushan, Irina Radomislensky, Avishai M Tsur, Ofer Almog, Guy Avital, Avi Benov, Shaul Gelikas

Mil Med. 2022 Oct 7; Online ahead of print.

Introduction: The incidence of blast injuries on the battlefield has risen over the last several decades. In order to improve prevention and treatment, it is essential to understand the severity and bodily distribution of these injuries. This study aims to characterize blast injury patterns among IDF fatalities.

Materials and methods: This is a descriptive, retrospective study on postmortem reports of military-blast fatalities between the years 1982 and 2021. Body regions injured according to the Abbreviated Injury Scale (AIS) were described. The frequency of body region injury combinations was mapped, and the correlation between injured body regions was calculated using Pearson's coefficient. Analysis of a subgroup with a postmortem computed tomography (CT-PM) or autopsy was performed, describing severe (AIS ≥ 3) injury patterns.

Results: Overall, 222 fatalities suffered from blast injury, with most injuries affecting the upper and lower extremities (63.7% and 66.5%, respectively), followed by the head (57.1%) and the thorax (56.6%). The median number of injured body regions was 4 (interquartile range, 2-5). The most frequent injury combinations were the upper and lower extremities (51%), the upper extremities and the thorax (45%), and the lower extremities and the thorax (41%). In all, 47/222 (21.2%) fatalities had a documented autopsy or CT-PM report. Among the fatalities with CT-PM or autopsy, the head (63.8%) and the thorax (57.4%) were most frequently severely injured (AIS ≥ 3).

Conclusions: Among blast fatalities in the military setting, the extremities were most commonly injured. However, data suggest that the head and thorax are more likely to sustain severe blast injuries resulting in mortality. Blast injuries in this cohort were characterized by concomitant involvement of several regions. Development of protective gear to minimize the multisystem injuries inflicted by blast injuries is warranted and should be focused on distinct types and anatomical distribution of severe blast injuries as reported in this study.

 

A randomized comparative study of three supraglottic airway devices for controlled ventilation in anesthetized patients

Manoj Sharma, Bimla Sharma, Manish Gupta, Bhuwan Chand Panday, Chand Sahai, Jayashree Sood

J Anaesthesiol Clin Pharmacol. 2022 Apr-Jun;38(2):221-227. 2021 Nov 18.

 

Background and aims: The LMA® ProSeal™, LMA® Supreme™ and Ambu® AuraGain™ are second-generation supraglottic airway devices (SADs) with integrated gastric access. In this study, we compared the clinical performance of these three devices in adults for controlled ventilation in anesthetized paralysed patients.

Material and methods: Two hundred and seventy adults, American Society of Anesthesiologists (ASA) Physical Status I-III, undergoing elective surgical procedures, were randomized into three groups with 90 patients in each: Group 1: LMA® ProSeal™, Group 2: LMA® Supreme™ and Group 3: Ambu® AuraGain™. All the three devices were evaluated for oropharyngeal seal pressure (OSP) and other parameters: ease and the number of attempts at device placement, fibreoptic laryngeal view and intraoperative and postoperative complications.

Results: In the present study, the mean OSP was 38.9 ± 3.050 cm H2O in the LMA ProSeal™ group, 37.41 ± 4.097 cm H2O in LMA® Supreme™ group and 37.32 ± 3.740 cm H2O in Ambu® AuraGain™ group. The difference was found to be statistically significant (P = 0.006). The three groups were comparable for the ease of device insertion, number of attempts at device placement, fibreoptic laryngeal view, intraoperative and postoperative complications.

Conclusion: In this study, we found that the LMA® ProSeal™ provided the highest OSP in comparison to the other two devices, even though this difference is not clinically relevant. The use of Ambu® AuraGain™ was associated with difficult and lowest first-time insertion success rate (P < 0.001) along with an increased incidence of airway trauma as compared to the other two SADs.

Minor Procedures in Trauma

Jesse Shriki, Sagar B Dave

Emerg Med Clin North Am. 2023 Feb;41(1):143-159.

 

Abstract

Procedures such as central access and tube thoracostomy are integral in the care of the injured patient. However, both increasing life span and patient complexity of comorbidities can hinder procedural success. Careful forethought should be completed before, simply, charging ahead with a procedure. This article covers the details needed to be successful in carrying out these 2 procedural "staples" in trauma. From anatomy to pain control to postprocedural management, this article will be the building block for technical success. Understanding what you are doing and careful planning ahead are now more than ever crucial to patient care.

iTClamp-Mediated Wound Closure Speeds Control of Arterial Hemorrhage With or Without Additional Hemostatic Agents

Sean M Stuart, Megan L Bohan, Julie B Mclean, Alexandra C Walchak, Emily E Friedrich

J Spec Oper Med. 2022 Dec 16;22(4):87-92.

 

Background: Exsanguination is the leading cause of preventable posttraumatic death, especially in the prehospital arena. Traditional hemorrhage control methods involve packing the wound with hemostatic agents, providing manual pressure, and then applying a pressure dressing to stabilize the treatment. This is a lengthy process that frequently destabilizes upon patient transport. Conversely, the iTClamp, a compact wound closure device, is designed to rapidly seal wound edges mechanically, expediting clot formation at the site of injury.

Objectives: To determine the efficacy of the iTClamp with and without wound packing in the control of a lethal junction hemorrhage.

Methods: Given the limited available information regarding the efficacy of the iTClamp in conjunction with traditional hemostatic agents, this study used a swine model of severe junctional hemorrhage. The goal was to compare a multiagent strategy using the iTClamp in conjunction with XSTAT to the traditional method of Combat Gauze packing with pressure dressing application. Readouts include application time, blood loss, and rebleed occurrence.

Results: Mean application times of the iTClamp treatment alone or in conjunction with other hemostatic agents were at least 75% faster than the application time of Combat Gauze with pressure dressing. Percent blood loss was not significantly different between groups but trended the highest for Combat Gauze treated swine, followed by iTClamp plus XSTAT, iTClamp alone and finally iTClamp plus Combat Gauze.

Conclusion: The results from this study demonstrate that the iTClamp can be effectively utilized in conjunction with hemostatic packing to control junctional hemorrhages.

Speed, Skill Retention, and End User Perceptions of iTClamp Application by Navy Corpsmen on a Manikin Model of Femoral Hemorrhage

Sean M Stuart, Megan L Bohan, Emily E Friedrich

Mil Med. 2022 Nov 25;Online ahead of print.

 

Introduction: Tactical Combat Casualty Care guidelines recommend packing junctional wounds with gauze, applying direct pressure for 3 minutes, and then securing with an external pressure dressing. This method is time-consuming, which can be problematic in a combat environment. Alternatively, the iTClamp has documented efficacy and rapid application. However, no studies have evaluated device application by military prehospital medical providers, such as Navy corpsmen, or their user experience with the device.

Materials and methods: Research data derived from a protocol were approved by the Naval Medical Center Portsmouth's Institutional Review Board in compliance with all applicable federal regulations governing the protection of human subjects. Navy corpsmen with the current Tactical Combat Casualty Care certification applied the iTClamp or standard pressure dressing on a manikin model of femoral hemorrhage in a crossover study design. Each participant used both devices in a randomized fashion. Time to application was recorded, and participants completed Likert scale surveys to evaluate both devices for preference, ease of use, and physical assessment. A repeat assessment was performed 1 month later to assess skill atrophy. Repeated-measures ANOVA was used to compare application time. Likert scale survey data were analyzed using Mann-Whitney and Wilcoxon tests to compare survey data within and between time points, respectively.

Results: The application of the iTClamp was more than twice as fast as the application of pressure dressings at both the initial and follow-up evaluations. There was no statistically significant difference in application times between the first evaluation and the 30-day assessment of either device, indicating no atrophy in skill. While 65% and 52% of the participants expressed preference in for the iTClamp in their surveys during the initial and follow-up respective visits, the difference in preference was not statistically significant for either the initial or the follow-up survey. Open-ended survey responses yielded both perceived advantages and disadvantages for each treatment option.

Conclusions: In austere or hostile environments, speed of treatment and extrication can have significant implications for the safety of both the patient and the medical providers. Hemorrhage control interventions must be both effective and easy to use for a prehospital provider to ensure its efficacy in a live battlefield situation. The iTClamp is small, simple, and fast to use, but its wide adoption in the field may be based on limitations perceived by participants, including narrow indications for use. However, based on our findings, it is reasonable to field the iTClamp depending on provider preference.

 

Implementation of a low-titre whole blood transfusion program in a civilian helicopter emergency medical service

Geir Arne Sunde, Christopher Bjerkvig, Marit Bekkevold, Einar K Kristoffersen, Geir Strandenes, Øyvind Bruserud, Torunn Oveland Apelseth, Jon-Kenneth Heltne

Scand J Trauma Resusc Emerg Med. 2022 Dec 9;30(1):65.

 

Background: Early balanced transfusion is associated with improved outcome in haemorrhagic shock patients. This study describes the implementation and evaluates the safety of a whole blood transfusion program in a civilian helicopter emergency medical service (HEMS).

Methods: This prospective observational study was performed over a 5-year period at HEMS-Bergen, Norway. Patients in haemorrhagic shock receiving out of hospital transfusion of low-titre Group O whole blood (LTOWB) or other blood components were included. Two LTOWB units were produced weekly and rotated to the HEMS for forward storage. The primary endpoints were the number of patients transfused, mechanisms of injury/illness, adverse events and survival rates. Informed consent covered patient pathway from time of emergency interventions to last endpoint and subsequent data handling/storage.

Results: The HEMS responded to 5124 patients. Seventy-two (1.4%) patients received transfusions. Twenty patients (28%) were excluded due to lack of consent (16) or not meeting the inclusion criteria (4). Of the 52 (100%) patients, 48 (92%) received LTOWB, nine (17%) received packed red blood cells (PRBC), and nine (17%) received freeze-dried plasma. Of the forty-six (88%) patients admitted alive to hospital, 35 (76%) received additional blood transfusions during the first 24 h. Categories were blunt trauma 30 (58%), penetrating trauma 7 (13%), and nontrauma 15 (29%). The majority (79%) were male, with a median age of 49 (IQR 27-70) years. No transfusion reactions, serious complications or logistical challenges were reported. Overall, 36 (69%) patients survived 24 h, and 28 (54%) survived 30 days.

Conclusions: Implementing a whole blood transfusion program in civilian HEMS is feasible and safe and the logistics around out of hospital whole blood transfusions are manageable. Trial registration The study is registered in the ClinicalTrials.gov registry (NCT02784951).

Keywords: Blood transfusion; Haemorrhagic shock; Helicopter Emergency Medical Services; Low-titre group O whole blood; Out of hospital.

 

Contrast of oropharyngeal leak pressure and clinical performance of I-gel™ and LMA ProSeal™ in patients: A meta-analysis

Yuan Tan, Jingyao Jiang, Rurong Wang

PLoS One. 2022 Dec 15;17(12):e0278871.

 

Background: Conflicting outcomes have been reported for the i-gel™ and laryngeal mask airway (LMA) ProSeal™ in children and adults during general anesthesia. Randomized controlled trials (RCTs) that yielded wide contrast outcomes between i-gel™ and LMA ProSeal™ were included in this meta-analysis.

Methods: Two authors independently identified RCTs that compared i-gel™ with LMA ProSeal™ among patients receiving general anesthesia by performing searches in EMBASE, Cochrane, PubMed, and ScienceDirect. Discussion was adopted to resolve disagreements. Data were counted with Review Manger 5.3 and pooled by applying weighted mean difference (MD) and rlsk ratio (RR), and related 95% confidence intervals.

Results: A total of 33 RCTs with 2605 patients were included in the meta-analysis. I-gel™ provided a considerably lower oropharyngeal leak pressure [weighted average diversity (MD) = -1.53 (-2.89, -0.17), P = 0.03], incidence of blood staining on the supraglottic airway devices [RR = 0.44, (0.28, 0.69), P = 0.0003], sore throat [RR = 0.31 (0.18, 0.52), P<0.0001], and a short insertion time [MD = -5.61 (-7.71, -3.51), P<0.00001] than LMA ProSeal™. Compared with LMA ProSeal™, i-gel™ offered a significantly higher first-insertion success rate [RR = 1.03 (1.00, 1.06), P = 0.03] and ease of insertion [RR = 1.06 (1.01, 1.11), P = 0.03]. The gastric-tube-placement first insertion rate [RR = 1.04 (0.99, 1.10), P = 0.11], laryngospasm [RR = 0.76 (0.17, 3.31), P = 0.72], and cough [RR = 1.30 (0.49, 3.44), P = 0.60] between the two devices were similar.

Conclusions: Both devices could achieve a good seal to provide adequate ventilation. Compared with the used LMA ProSeal™, the i-gel™ was found to have fewer complications (blood stainning, sore throat) and offers certain advantages (short insertion time, higher first-insertion success rate and ease of insertion) in patients under general anesthesia.

Predicting Difficult Airway Intubation Based on Maxillofacial Trauma: A Retrospective Study

James Yang, Aakash Trivedi, Zoraida Alvarez, Ratul Bhattacharyya, Felippe Sartorato, Francesco Gargano, Benjamin Rebein, Jamshed Zuberi

Cureus. 2022 May 9;14(5):e24844.

 

Abstract

Purpose The purpose of this study was to determine which types of facial injuries in traumatic patients' wounds cause difficult intubation for anesthesiology team. By anticipating potential complications with airway management, the surgeons can be better prepared for emergent cricothyrotomy if needed. This could include prior to the planned procedure in the operating room (OR) as well as in emergent conditions in trauma bay. Methods Trauma patients with facial injuries in a level II trauma center from January 2007 to September 2017 that required intubation were evaluated for types of facial injury. Anesthesiology intubation documents were reviewed to determine which types of facial injuries were associated with difficult intubation per anesthesiology documentation. Results A total of 232 subjects were selected and it was found that patients with LeFort II facial fracture, bilateral mandibular fracture, and facial fracture associated with basilar skull fracture were noted to have difficult intubation by the anesthesiology team. Conclusion On the basis of CT imaging findings, our study demonstrates that certain types of facial fractures could pose difficult intubation. Surgeons should be aware of these injuries and be ready to intervene with emergent cricothyrotomy if necessary.

Effects of tranexamic acid treatment in severely and non-severely injured trauma patients

 

Francois-Xavier Ageron, Haleema Shakur-Still, Ian Roberts

Transfusion. 2022 Aug;62 Suppl 1(Suppl 1):S151-S157

 

 

Background: Urgent treatment with tranexamic acid (TXA) reduces bleeding deaths but there is disagreement about which patients should be treated. We examine the effects of TXA treatment in severely and non-severely injured trauma patients.

 

Study design and methods: We did an individual patient data meta-analysis of randomized trials with over 1000 trauma patients that assessed the effects of TXA on survival. We defined the severity of injury according to characteristics at first assessment: systolic blood pressure of less than 90 mm Hg and a heart rate greater than 120 beats per minute or Glasgow Coma Scale score of less than nine or any GCS with one or more fixed dilated pupils. The primary measure was survival on the day of the injury. We examined the effect of TXA on survival in severely and non-severely injured patients and how these effects vary with the time from injury to treatment.

 

Results: We obtained data for 32,944 patients from two randomized trials. Tranexamic acid significantly increased survival on the day of the injury (OR = 1.22, 95% CI 1.11-1.34; p < .01). The effect of tranexamic acid on survival in non-severely injured patients (OR = 1.25, 1.03-1.50) was similar to that in severely injured patients (OR = 1.22, 1.09-1.37) with no significant heterogeneity (p = .87). In severely and non-severely injured patients, treatment within the first hour after injury was the most effective.

 

 

Comparison of self versus expert-assisted feedback for cricothyroidotomy training: a randomized trial

 

Hasan Aldinc, Cem Gun, Serpil Yaylaci, Cigdem Ozkaya Senuren, Feray Guven, Melike Sahiner, Kamil Kayayurt, Suha Turkmen

 

BMC Med Educ. 2022 Jun 14;22(1):455

 

 

Background: The self-video feedback method may have the potential to provide a low-cost alternative to physician-driven simulation-based training. This study aimed to assess the utility of two video feedback methods by comparing the improvement in performing cricothyroidotomy procedure following self video feedback (trainees review their performance by themselves) and expert-assisted video feedback (trainees review their performance while an emergency physician provides additional feedback).

 

Methods: This study was pretest-posttest and two-group designed research performed at a university simulation center with 89 final-year medical students and used a cricothyroidotomy simulation model. After seeing an educational presentation and a best practice video, trainees were randomized into two groups; self video feedback group (SVFG) and expert-assisted video feedback group (EVFG). They performed the cricothyroidotomy before and after the feedback. The procedures were also recorded and scored by two emergency physicians.

 

Results: There was a statistically significant improvement between pre-feedback and post-feedback assessments in terms of scores received and time needed for the procedures in both SVFG and EVFG groups (p < 0.05). Additionally, the post-feedback assessment scores were higher and time needed for the procedure was lower in the EVFG when compared with SVFG (p < 0.05 for both).

 

Conclusions: Results demonstrated significant improvement in cricothyroidotomy performance with both types of video feedback method. Even though the improvement was better in the EVFG compared to the SVFG, the self video feedback may have value especially in situations where expert-assisted feedback is not possible.

 

Management of Severe Crush Injuries in Austere Environments: A Special Operations Perspective

 

Justin Lee Anderson, Meredith Cole, Dylan Pannell

 

J Spec Oper Med. 2022 May 31;22(2):43-47

 

 

Crush injuries present a challenging case for medical providers and require knowledge and skill to manage the subsequent damage to multiple organ systems. In an austere environment, in which resources are limited and evacuation time is extensive, a medic must be prepared to identify trends and predict outcomes based on the mechanism of injury and patient presentation. These injuries occur in a variety of environments from motor vehicle accidents (at home or abroad) to natural disasters and building collapses. Crush injury can lead to compartment syndrome, traumatic rhabdomyolysis, arrythmias, and metabolic acidosis, especially for patients with extended treatment and extrication times. While crush syndrome occurs due to the systemic effects of the injury, the onset can be as early as 1 hour postinjury. With a comprehensive understanding of the pathophysiology, diagnosis, management, and tactical considerations, a prehospital provider can optimize patient outcomes and be prepared with the tools they have on hand for the progression of crush injury into crush syndrome.

 

 

Pre-hospital tracheal intubation in severe traumatic brain injury: a systematic review and meta-analysis

Jordan Anderson, Annalize Ebeid, Catrin Stallwood-Hall

Br J Anaesth. 2022 Dec;129(6):977-984

 

Background: Severe traumatic brain injury (TBI) continues to be a leading cause of death, particularly in young adults. Severe TBI contributes to significant socioeconomic burden secondary to the long-term disability, impacting the individual and their family, and wider society. The aim of this study was to determine whether establishing a pre-hospital definitive airway was beneficial to mortality and morbidity when compared with no pre-hospital airway.

Methods: A literature search for all relevant studies was performed in Medline, Embase, Cochrane, EBSCO, and Emcare databases, with studies comparing effects of pre-hospital tracheal intubation vs noninvasive airway management on mortality in non-paediatric patients with severe TBI. There were 1025 studies that had abstracts screened from this search. This study was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results: We identified 19 studies that met inclusion criteria. The included studies identified no significant difference in mortality between pre-hospital and no pre-hospital tracheal intubation, with an odds ratio of 1.07 (95% CI, 0.72-1.57; P<0.001). The meta-analysis identified a trend favouring pre-hospital tracheal intubation with respect to long-term morbidity, with an odds ratio of 0.92 (95% CI, 0.51-1.67; P<0.001).

Conclusions: Management of traumatic brain injuries is a constantly evolving field, with ever-changing target parameters regarding management. There is growing evidence, based on the RCTs and recent studies, that pre-hospital tracheal intubation in patients with severe TBI is beneficial if performed by well-trained, experienced practitioners in accordance with current TBI guidelines.

Advanced interventions in the pre-hospital resuscitation of patients with non-compressible haemorrhage after penetrating injuries

E Ter Avest, L Carenzo, R A Lendrum, M D Christian, R M Lyon, C Coniglio, M Rehn, D J Lockey, Z B Perkins

Crit Care. 2022 Jun 20;26(1):184

 

Abstract

Early haemorrhage control and minimizing the time to definitive care have long been the cornerstones of therapy for patients exsanguinating from non-compressible haemorrhage (NCH) after penetrating injuries, as only basic treatment could be provided on scene. However, more recently, advanced on-scene treatments such as the transfusion of blood products, resuscitative thoracotomy (RT) and resuscitative endovascular balloon occlusion of the aorta (REBOA) have become available in a small number of pre-hospital critical care teams. Although these advanced techniques are included in the current traumatic cardiac arrest algorithm of the European Resuscitation Council (ERC), published in 2021, clear guidance on the practical application of these techniques in the pre-hospital setting is scarce. This paper provides a scoping review on how these advanced techniques can be incorporated into practice for the resuscitation of patients exsanguinating from NCH after penetrating injuries, based on available literature and the collective experience of several helicopter emergency medical services (HEMS) across Europe who have introduced these advanced resuscitation interventions into routine practice.

 

 

Whole Blood Storage Temperature Investigation in Austere Environments

 

Cesar O Avila, Samuel C Sayson, Bruce Bennett

 

J Spec Oper Med. 2022 Sep 19;22(3):19-21

 

 

Introduction: Military medical research has affirmed that early administration of blood products and timely treatment save lives. The US Navy's Expeditionary Resuscitative Surgical System (ERSS) is a Role 2 Light Maneuver team that functions close to the point of injury, administering blood products and providing damage-control resuscitation and surgery. However, information is lacking on the logistical constraints regarding provisions for and the stability of blood products in austere environments.

 

Methods: ERSS conducted a study on the United States Central Command (USCENTCOM) area of responsibility. Expired but properly stored units of stored whole blood (SWB) were subjected to five different storage conditions, including combinations of passive and active refrigeration. The SWB was monitored continuously, including for external ambient temperatures. The time for the SWB to rise above the threshold temperature was recorded.

 

Results: The main outcome of the study was the time for the SWB to rise above the recommended storage temperature. Average ambient temperature during the experiment involving conditions 1 through 4 was 25.6°C (78.08°F). Average ambient temperature during the experiment involving condition 5 was 34.8°C (94.64°F). Blood temperature reached the 6°C (42.8°F) threshold within 90 minutes in conditions 1 and 2, which included control and chemically activated ice packs in the thermal insulated chamber (TIC). Condition 2 included prechilling the TIC in a standard refrigerator to 4°C (39.2°F), which kept the units of SWB below the threshold temperature for 490 minutes (approximately 8 hours). Condition 4 entailed prechilling the TIC in a standard freezer to 0.4°C (32.72°F), thus keeping the units of SWB below threshold for 2,160 minutes (i.e., 36 hours). Condition 5 consisted of prechilling the TIC to 3.9°C (39.02°F) in the combat blood refrigerator, which kept the SWB units below the threshold for 780 minutes (i.e., 13 hours), despite a higher average ambient temperature of almost +10°C (50°F).

 

Conclusion: Combining active and passive refrigeration methods will increase the time before SWB rises above the threshold temperature. We demonstrate an adaptable approach of preserving blood product temperature despite refrigeration power failure in austere settings, thereby maintaining mission readiness to increase the survival of potential casualties.

 

The regional whole blood program in San Antonio, TX: A 3-year update on prehospital and in-hospital transfusion practices for traumatic and non-traumatic hemorrhage.

 

Maxwell A Braverman, Allison A Smith, Angelo V Ciaraglia, Jason S Radowsky, Steven G Schauer, Valerie G Sams, Leslie J Greebon, Michael D Shiels, Rachelle Babbitt Jonas, Samantha Ngamsuntikul, Elizabeth Waltman, Eric Epley, Tracee Rose, James A Bynum, Andre P Cap, Brian J Eastridge, Ronald M Stewart, Donald H Jenkins, Susannah E Nicholson; San Antonio Whole Blood Consortium

 

Transfusion. 2022 Aug;62 Suppl 1:S80-S89.

 

 

Abstract

 

Low titer type O Rh-D + whole blood (LTO + WB) has become a first-line resuscitation medium for hemorrhagic shock in many centers around the World. Showing early effectiveness on the battlefield, LTO + WB is used in both the pre-hospital and in-hospital settings for traumatic and non-traumatic hemorrhage resuscitation. Starting in 2018, the San Antonio Whole Blood Collaborative has worked to provide LTO + WB across Southwest Texas, initially in the form of remote damage control resuscitation followed by in-hospital trauma resuscitation. This program has since expanded to include pediatric trauma resuscitation, obstetric hemorrhage, females of childbearing potential, and non-traumatic hemorrhage. The objective of this manuscript is to provide a three-year update on the successes and expansion of this system and outline resuscitation challenges in special populations.

 

 

Review of Commercially Available Supraglottic Airway Devices for Prehospital Combat Casualty Care

 

Grant B Copeland, Danielius J Zilevicius, Carlos N Bedolla, Andres L Islas, Marisa N Guerra, Sophia J Salazar, Robert A De Lorenzo, Steven G Schauer, R Lyle Hood

 

Mil Med. 2022 Jul 1;187(7-8):e862-e876

 

 

Background: Airway obstruction is the second leading cause of potentially survivable death on the battlefield. The Committee on Tactical Combat Casualty Care lists airway optimization among the top 5 battlefield research and development priorities; however, studies show that combat medics lack access to the recommended supraglottic airway (SGA) devices. SGA devices are an alternative airway management technique to endotracheal tube intubation. Reports have shown SGA devices are easier to use and take fewer attempts to provide patent airflow to the patient when compared to endotracheal tube intubation. Military settings require a higher degree of skill to perform airway management on patients due to the environment, limited availability of equipment, and potential chaos of the battlefield. Finding the optimal SGA device for the military setting is an unmet need. The International Organization for Standardization describes basic functional requirements for SGA devices, as well as patient configurations and size limitations. Beyond that, no SGA device manufacturer states that their devices are intended for military settings.

 

Materials and methods: We conducted a market review of 25 SGA devices that may meet inclusion into the medics' aid bag. The company's official "Instructions for Use" document, Google Scholar, and FDA reports were reviewed to obtain information for each SGA device.

 

Results: Twenty-five commercially available SGA devices are explored from manufacturer online sources. A commercially available device list is shown later in this paper, which provides the device's features, indications, and contraindications based on the manufacturer's product information documentation.

 

Conclusions: There are a variety of devices that require further testing to determine whether they should be included in sets, kits, and outfits.

 

 

Field tourniquets in an austere military environment: A prospective case series

 

D C Covey, Christopher E Gentchos

 

Injury. 2022 Oct;53(10):3240-3247

 

 

Objective: Field tourniquets are often used for battlefield extremity injuries. Their effectiveness has been documented by a large combat theater trauma center. However, their use and effectiveness by an austere forward surgical team has not been reported. Aims of this study were to determine: Whether field tourniquets: (1) Were placed for appropriate indications; (2) significantly reduced hemorrhage as measured by transfusion requirements; (3) influenced vital signs and injury severity scores; and (4) did they cause limb amputation, changed amputation level, or other complications.

 

Methods: Twenty-five patients with 30 involved extremities presenting to a forward surgical team in Iraq met the inclusion criteria. We prospectively collected data regarding the presence, indications for, and effectiveness of field tourniquets based on the need for blood transfusion. We recorded any complications associated with their use.

 

Results: Tourniquets significantly reduced hemorrhage from penetrating injuries as measured by transfusion requirements. Those having major vascular injuries with effective tourniquets, a total of 12 units of blood were transfused (1.7 units/vascular injury; 2 units/patient). However, 19 units were transfused in patients (3.3 units/vascular injury; 3.8 units/patient) who had an ineffective or no tourniquet (p = 0.0006). Transfusion requirements were related the presence of an effective tourniquet regardless of concomitant injuries. The group with effective tourniquets and compressed hemorrhage presented with higher mean systolic (p = 0.003) and diastolic (p = 0.023) blood pressures than the group with no tourniquets or ineffective ones. Complications included one peroneal nerve palsy and no amputations resulted from tourniquet application.

 

Conclusion: Field tourniquets applied for penetrating injuries with severe bleeding can significantly reduce transfusion requirements and help maintain adequate blood pressure. Tourniquets were not the proximate cause of amputation and did not determine the choice of immediate amputation level.

 

 

 

Prehospital synergy: Tranexamic acid and blood transfusion in patients at risk for hemorrhage

 

Andrew-Paul Deeb, Lara Hoteit, Shimena Li, Francis X Guyette, Brian J Eastridge, Raminder Nirula, Gary A Vercruysse, Terence O'Keeffe, Bellal Joseph, Matthew D Neal, Jason L Sperry, Joshua B Brown

Affiliations expand

 

J Trauma Acute Care Surg. 2022 Jul 1;93(1):52-58

 

 

Background: Growing evidence supports improved survival with prehospital blood products. Recent trials show a benefit of prehospital tranexamic acid (TXA) administration in select subgroups. Our objective was to determine if receiving prehospital packed red blood cells (pRBC) in addition to TXA improved survival in injured patients at risk of hemorrhage.

 

Methods: We performed a secondary analysis of all scene patients from the Study of Tranexamic Acid during Air and ground Medical Prehospital transport trial. Patients were randomized to prehospital TXA or placebo. Some participating EMS services utilized pRBC. Four resuscitation groups resulted: TXA, pRBC, pRBC+TXA, and neither. Our primary outcome was 30-day mortality and secondary outcome was 24-hour mortality. Cox regression tested the association between resuscitation group and mortality while adjusting for confounders.

 

Results: A total of 763 patients were included. Patients receiving prehospital blood had higher Injury Severity Scores in the pRBC (22 [10, 34]) and pRBC+TXA (22 [17, 36]) groups than the TXA (12 [5, 21]) and neither (10 [4, 20]) groups (p < 0.01). Mortality at 30 days was greatest in the pRBC+TXA and pRBC groups at 18.2% and 28.6% compared with the TXA only and neither groups at 6.6% and 7.4%, respectively. Resuscitation with pRBC+TXA was associated with a 35% reduction in relative hazards of 30-day mortality compared with neither (hazard ratio, 0.65; 95% confidence interval, 0.45-0.94; p = 0.02). No survival benefit was observed in 24-hour mortality for pRBC+TXA, but pRBC alone was associated with a 61% reduction in relative hazards of 24-hour mortality compared with neither (hazard ratio, 0.39; 95% confidence interval, 0.17-0.88; p = 0.02).

 

Conclusion: For injured patients at risk of hemorrhage, prehospital pRBC+TXA is associated with reduced 30-day mortality. Use of pRBC transfusion alone was associated with a reduction in early mortality. Potential synergy appeared only in longer-term mortality and further work to investigate mechanisms of this therapeutic benefit is needed to optimize the prehospital resuscitation of trauma patients.

 

 

To Tranexamic Acid or Not to Tranexamic Acid? Accuracy of Antifibrinolytic Administration at Altitude.

 

Joseph DeVitis, Aaron Ziegler, Chad Barnhart, Alistair Chapman, Cathryn Chadwick, Matthew Dull, Charles Gibson, Tracy J Koehler, Alan T Davis, Gaby Iskander , Steffen Pounders 5, Laura Krech 5, Chelsea Starr Fisk

 

Air Med J . 2022 Mar-Apr;41(2):196-200

 

 

Objective: Tranexamic acid (TXA) has demonstrated a reduction in all-cause mortality in trauma patients with hemorrhage. Administering TXA in the prehospital setting presents unique challenges because the identification of bleeding is based on clinical suspicion without advanced imaging or diagnostic tools. The objective of this study was to examine whether prehospital suspicion of bleeding is validated by in-hospital computed tomographic imaging and examination and to determine if patients received TXA in the absence of hemorrhage. The study was conducted at a level 1 trauma center supported by air medical transport services.

 

Methods: This is a retrospective cohort study examining 88 trauma patients receiving prehospital TXA to treat suspected hemorrhage. Adult trauma patients who received TXA during the study period and were transported to our level 1 trauma center were included. A panel of trauma surgeons reviewed CT imaging and examination findings to retrospectively identify significant hemorrhage.

 

Results: Forty-three percent of patients who received TXA during air medical transport did not have confirmed hemorrhage upon arrival.

 

Conclusion: TXA was given to a significant number of patients who did not have confirmed hemorrhage upon arrival. We recommend that institutions using TXA perform this internal validation to ensure they are accurately identifying hemorrhage in the prehospital setting.

 

Efficacy of Tranexamic Acid in Blood Versus Crystalloid-Resuscitated Trauma/Hemorrhagic Shock.

 

Fernando Dos Santos, Joyce B Li, Rafi Mazor, Federico Aletti, Erik B Kistler

 

J Surg Res. 2022 Nov;279:89-96

 

 

Introduction: Whole blood (WB) or blood products are not always immediately available for repletion of lost intravascular volume in trauma/hemorrhagic shock (T/HS), and thus, resuscitation with crystalloid solutions is often necessary. Recently, we have shown enteral tranexamic acid (TXA) to be effective as a mild protease inhibitor in blood-resuscitated T/HS by counteracting proteolytic activity in and leaking from the gut with resultant preservation of systemic vascular integrity. We hypothesized that enteral TXA would improve hemodynamic stability after T/HS in the absence of blood reperfusion.

 

Methods: We directly compared resuscitation with enteral TXA versus intravenous (IV) TXA in conjunction with lactated Ringer's solution (LR) or WB reperfusion in an experimental T/HS model. Rats were subjected to laparotomy and exsanguinated to a mean arterial blood pressure of 35-40 mm Hg for 90 min, followed by LR or WB reperfusion and monitored for 120 min. TXA was administered via IV (10 mg/kg) or enteral infusion (150 mM) 20 min after establishment of hemorrhage for 150 min.

 

Results: Animals resuscitated with LR were unable to restore or maintain a survivable mean arterial blood pressure (>65 mm Hg), regardless of TXA treatment route. In contrast, rats reperfused with WB and given TXA either enterally or IV displayed hemodynamic improvements superior to WB controls.

 

Conclusions: Results suggest that the beneficial hemodynamic responses to enteral or IV TXA after experimental T/HS depend upon reperfusion of WB or components present in WB as TXA, regardless of delivery mode, does not have appreciable hemodynamic effects when paired with LR reperfusion.

 

 

Navy En-Route Care in Future Distributed Maritime Operations: A Review of Clinician Capabilities and Roles of Care

 

Ian F Eisenhauer, Benjamin D Walrath, Vikhyat S Bebarta, Matthew D Tadlock, Jay B Baker, Steven G Schauer

 

Prehosp Emerg Care. 2022 Aug 30;1-8

 

 

Objective: As the United States Navy transitions from Operation Iraqi Freedom/Operation Enduring Freedom to preparing for a near-peer competition, an increasing focus of wartime strategy relies upon a network of distributed naval assets for total sea control, known as Distributed Maritime Operations (DMO). Historically, embedded medical personnel have provided care at sea in times of war. Recent reviews of shipboard and evacuated mass casualty incidents have alluded to weaknesses in the existing Navy Medicine approach that will require advances in care provision to sustain high-quality care that would benefit from industry and civilian academic collaboration. To gain input from civilian prehospital expertise and insight, the current DMO and Navy En-Route Care (ERC) systems must be plainly described for non-Navy military and civilian leaders, clinicians, and researchers to understand.

 

Methods: N/A.

 

Results: In this review, we translate US Navy structure and vernacular into common civilian and non-Navy language, describe the maritime role-tiered ERC system, elucidate the medical assets on each naval warship, and discuss clinician levels and capabilities while deployed to help communicate the inherent challenges of US Navy maritime medical care during routine operations, casualty treatment, stabilization, and evacuation.

 

Conclusions: We describe the roles of care, clinician levels, and medical assets within the Navy ERC system for researchers and military leaders who aim to mitigate the inherent challenges of future maritime trauma care in the age of Distributed Maritime Operations. This paper lays the framework of the Navy deployed medical system to enable research in maritime en-route care, and prompt inclusion of identified solutions into common use in the US Navy.

 

 

Efficacy and safety of the second in-hospital dose of tranexamic acid after receiving the prehospital dose: double-blind randomized controlled clinical trial in a level 1 trauma center.

 

Ayman El-Menyar, Khalid Ahmed, Suhail Hakim, Ahad Kanbar, Saji Mathradikkal, Tariq Siddiqui, Hisham Jogol, Basil Younis, Ibrahim Taha, Ismail Mahmood, Ahmed Ajaj, Sajid Atique, Abubaker Alaieb, Ahmed Abdel-Aziz Bahey, Mohammad Asim, Guillaume Alinier, Nicholas R Castle, Ahammed Mekkodathil, Sandro Rizoli, Hassan Al-Thani

 

Eur J Trauma Emerg Surg. 2022 Aug;48(4):3089-3099

 

 

Background: Prehospital administration of tranexamic acid (TXA) to injured patients is increasing worldwide. However, optimal TXA dose and need of a second infusion on hospital arrival remain undetermined. We investigated the efficacy and safety of the second in-hospital dose of TXA in injured patients receiving 1 g of TXA in the prehospital setting. We hypothesized that a second in-hospital dose of TXA improves survival of trauma patients.

 

Methods: A prospective, double-blind, placebo-controlled randomized, clinical trial included adult trauma patients receiving 1 g of TXA in the prehospital settings. Patients were then blindly randomized to Group I (second 1-g TXA) and Group II (placebo) on hospital arrival. The primary outcome was 24-h (early) and 28-day (late) mortality. Secondary outcomes were thromboembolic events, blood transfusions, hospital length of stay (HLOS) and organs failure (MOF).

 

Results: A total of 220 patients were enrolled, 110 in each group. The TXA and placebo groups had a similar early [OR 1.000 (0.062-16.192); p = 0.47] and late mortality [OR 0.476 (95% CI 0.157-1.442), p = 0.18].The cause of death (n = 15) was traumatic brain injury (TBI) in 12 patients and MOF in 3 patients. The need for blood transfusions in the first 24 h, number of transfused blood units, HLOS, thromboembolic events and multiorgan failure were comparable in the TXA and placebo groups. In seriously injured patients (injury severity score > 24), the MTP activation was higher in the placebo group (31.3% vs 11.10%, p = 0.13), whereas pulmonary embolism (6.9% vs 2.9%, p = 0.44) and late mortality (27.6% vs 14.3%, p = 0.17) were higher in the TXA group but did not reach statistical significance.

 

Conclusion: The second TXA dose did not change the mortality rate, need for blood transfusion, thromboembolic complications, organ failure and HLOS compared to a single prehospital dose and thus its routine administration should be revisited in larger and multicenter studies.

 

 

Efficacy and safety of the second in-hospital dose of tranexamic acid after receiving the prehospital dose: double-blind randomized controlled clinical trial in a level 1 trauma center.

 

Ayman El-Menyar, Khalid Ahmed, Suhail Hakim, Ahad Kanbar, Saji Mathradikkal, Tariq Siddiqui, Hisham Jogol, Basil Younis, Ibrahim Taha, Ismail Mahmood, Ahmed Ajaj, Sajid Atique, Abubaker Alaieb, Ahmed Abdel-Aziz Bahey, Mohammad Asim, Guillaume Alinier, Nicholas R Castle, Ahammed Mekkodathil, Sandro Rizoli, Hassan Al-Thani

 

Eur J Trauma Emerg Surg. 2022 Aug;48(4):3089-3099

 

 

Background: Prehospital administration of tranexamic acid (TXA) to injured patients is increasing worldwide. However, optimal TXA dose and need of a second infusion on hospital arrival remain undetermined. We investigated the efficacy and safety of the second in-hospital dose of TXA in injured patients receiving 1 g of TXA in the prehospital setting. We hypothesized that a second in-hospital dose of TXA improves survival of trauma patients.

 

Methods: A prospective, double-blind, placebo-controlled randomized, clinical trial included adult trauma patients receiving 1 g of TXA in the prehospital settings. Patients were then blindly randomized to Group I (second 1-g TXA) and Group II (placebo) on hospital arrival. The primary outcome was 24-h (early) and 28-day (late) mortality. Secondary outcomes were thromboembolic events, blood transfusions, hospital length of stay (HLOS) and organs failure (MOF).

 

Results: A total of 220 patients were enrolled, 110 in each group. The TXA and placebo groups had a similar early [OR 1.000 (0.062-16.192); p = 0.47] and late mortality [OR 0.476 (95% CI 0.157-1.442), p = 0.18].The cause of death (n = 15) was traumatic brain injury (TBI) in 12 patients and MOF in 3 patients. The need for blood transfusions in the first 24 h, number of transfused blood units, HLOS, thromboembolic events and multiorgan failure were comparable in the TXA and placebo groups. In seriously injured patients (injury severity score > 24), the MTP activation was higher in the placebo group (31.3% vs 11.10%, p = 0.13), whereas pulmonary embolism (6.9% vs 2.9%, p = 0.44) and late mortality (27.6% vs 14.3%, p = 0.17) were higher in the TXA group but did not reach statistical significance.

 

Conclusion: The second TXA dose did not change the mortality rate, need for blood transfusion, thromboembolic complications, organ failure and HLOS compared to a single prehospital dose and thus its routine administration should be revisited in larger and multicenter studies.

 

 

 

Telesimulation to Improve Critical Decision-Making in Prehospital Airway Management: A Feasibility Study

 

David M French, Ragan A DuBose-Morris, Frances W Lee, Stanley J Sulkowski, Greig A Samuelson, Edward C Jauch

 

South Med J. 2022 Aug;115(8):639-644

 

 

Objectives: Telesimulation, in which learners and evaluators use technology to connect remotely to simulation-based learning activities, is effective for skills and decision-making review. Historical models in which learners are colocated with the simulation equipment have inherent issues, especially for emergency medical services (EMS) providers. This feasibility study placed the evaluators in the simulation center, whereas the learners were at a distance steering the scenario evolution through telehealth technologies.

 

Methods: Volunteer EMS providers across South Carolina with varying levels of training and experience completed difficult airway management scenarios focused on clinical decision making. The program consisted of pre- and postexperience examinations, a lecture, and increasingly complicated simulations using high-fidelity mannequins that were facilitated by local trainers under the direction of remote trainees. Audio and video content, including vital signs and cardiac monitoring, were live streamed. Participants worked in two-person teams with lead providers on each scenario clinically assessing and managing cases of anaphylaxis. Data were collected from the simulations using Laerdal software, as well as examination and survey results.

 

Results: A total of 24 participants completed all of the elements of the training. Trends toward improvement in times to bag-mask ventilation and initial epinephrine administration were noted. Average cognitive test scores increased by 9.6%, and learners reported improved comfort with simulation (75%, P ≥ 0.0001) and videoconferencing (83%, P ≥ 0.0001). They also reported high degrees of comfort with intubation (73.3%) following the training.

 

Conclusions: This method of telesimulation appears to be a viable addition to continuing EMS education and may address access issues for some providers.

 

 

Manual Pressure Points Technique for Massive Hemorrhage Control-A Prospective Human Volunteer Study

 

Regina Pikman Gavriely, Yotam Lior, Shaul Gelikas, Shiran Levy, Alon Ahimor, Elon Glassberg, Shachar Shapira, Avi Benov, Guy Avital

 

Prehosp Emerg Care. 2022 Sep 28;1-6 Online ahead of print

 

 

Background: While commonly thought to be effective for management of limb and junctional hemorrhage, the manual pressure points technique was excluded from leading prehospital guidelines over a decade ago following the publication of a single human-volunteers study presenting unfavorable results. This work aimed to re-assess the efficacy and feasibility of the femoral and supraclavicular pressure points technique for temporary hemorrhage control distal to the pressure point.

 

Methods: A prospective, non-randomized, human volunteer, controlled environment study. In the study 35 healthy male combat medics (age 21.1 ± 1.3 years) received brief training after which they were requested to apply pressure in the femoral and supraclavicular points in attempts to stop regional blood flow, measured distally by Doppler ultrasound. Success rates in achieving flow cessation in under 2 minutes, time required for achievement of flow cessation, and cumulative flow cessation duration within a 3-minute follow-up after initial success were measured.

 

Results: For the supraclavicular point, success rates were 97.1% with a mean time to success of 12.5 (±20.9) seconds, lasting for 76.2% (±23.7) of the follow-up time. For the femoral point, success rates were 100% with a mean time to success of 5.5 (±4.3) seconds, lasting for 98.7% (±3.8) of the follow-up time.

 

Conclusions: Manual pressure on the femoral and supraclavicular points is an applicable and efficient method for temporary hemorrhage control distal to the pressure point. As such, with additional study, this method may be considered for re-introduction to prehospital care guidelines and training programs.

 

 

Barriers and facilitators to the administration of prehospital tranexamic acid: a paramedic interview study using the theoretical domains framework.

 

Laura Goodwin, Helen Nicholson, Maria Robinson, Adam Bedson, Sarah Black, Kim Kirby, Hazel Taylor, Sarah Voss, Jonathan Benger

 

Emerg Med J. 2022 Jul;39(7):540-546

 

 

Background: Tranexamic acid (TXA) is an antifibrinolytic drug used to prevent bleeding. It was introduced as an intervention for post-traumatic haemorrhage across emergency medical services (EMS) in the UK during 2012. However, despite strong evidence of effectiveness, prehospital TXA administration rates are low. This study used the theoretical domains framework (TDF) to identify barriers and facilitators to the administration of TXA to trauma patients by EMS providers (paramedics) in the UK.

 

Methods: Interviews were completed with 18 UK paramedics from a single EMS provider organisation. A convenience sampling approach was used, and interviews continued until thematic saturation was reached. Semistructured telephone interviews explored paramedics' experiences of administering TXA to trauma patients, including identifying whether or not patients were at risk of bleeding. Data were analysed inductively using thematic analysis (stage 1). Themes were mapped to the theoretical domains of the TDF to identify behavioural theory-derived barriers and facilitators to the administration of TXA to trauma patients (stage 2). Belief statements were identified and assessed for importance according to prevalence, discordance and evidence base (stage 3).

 

Results: Barriers and facilitators to paramedics' administration of TXA to trauma patients were represented by 11 of the 14 domains of the TDF. Important barriers included a lack of knowledge and experience with TXA (Domain: Knowledge and Skills), confusion and restrictions relating to the guidelines for TXA administration (Domain: Social/professional role and identity), a lack of resources (Domain: Environmental context and resources) and difficulty in identifying patients at risk of bleeding (Domain: Memory, attention and decision processes).

 

Conclusions: This study presents a behavioural theory-based approach to identifying barriers and facilitators to the prehospital administration of TXA to trauma patients in the UK. It identifies multiple influencing factors that may serve as a basis for developing an intervention to increase prehospital administration of TXA.

 

 

Tranexamic acid is not inferior to placebo with respect to adverse events in suspected traumatic brain injury patients not in shock with a normal head computed tomography scan: A retrospective study of a randomized trial

 

Jordan W Harmer, Elizabeth N Dewey, Eric N Meier, Susan E Rowell, Martin A Schreiber

 

J Trauma Acute Care Surg. 2022 Jul 1;93(1):98-105.

 

 

Background: A 2-g bolus of tranexamic acid (TXA) has been shown to reduce 28-day mortality in a randomized controlled trial. This study investigates whether out-of-hospital TXA use is associated with adverse events or unfavorable outcomes in suspected traumatic brain injury (TBI) when intracranial hemorrhage (ICH) is absent on initial computed tomography.

 

Methods: This study used data from a 2015 to 2017, multicenter, randomized trial studying the effect of the following TXA doses on moderate to severe TBI: 2-g bolus, 1-g bolus plus 1-g infusion over 8 hours, and a placebo bolus with placebo infusion. Of the 966 participants enrolled, 395 with an initial computed tomography negative for ICH were included in this analysis. Fifteen adverse events (28-day incidence) were studied: myocardial infarction, deep vein thrombosis, seizure, pulmonary embolism, acute respiratory distress syndrome, cardiac failure, liver failure, renal failure, cerebrovascular accident, cardiac arrest, cerebral vasospasm, "any thromboembolism," hypernatremia, acute kidney injury, and infection. Other unfavorable outcomes analyzed include mortality at 28 days and 6 months, Glasgow Outcome Scale-Extended score of ≤4 at discharge and 6 months, intensive care unit-free days, ventilator-free days, hospital-free days, and combined unfavorable outcomes. In both study drug groups, the incidence of dichotomous outcomes and quantity of ordinal outcomes were compared with placebo.

 

Results: No statistically significant increase in adverse events or unfavorable outcomes was found between either TXA dosing regimen and placebo. Demographics and injury scores were not statistically different other than two methods of injury, which were overrepresented in the 1-g TXA bolus plus 1-g TXA infusion.

 

Conclusion: Administration of either a 2-g TXA bolus or a 1-g TXA bolus plus 1-g TXA 8-hour infusion in suspected TBIs without ICH is not associated with increased adverse events or unfavorable outcomes. Because the out-of-hospital 2-g bolus is associated with a mortality benefit, it should be administered in suspected TBI.

 

 

 

 

 

Use of Cold-Stored Whole Blood is Associated With Improved Mortality in Hemostatic Resuscitation of Major Bleeding: A Multicenter Study

 

Joshua P Hazelton, Anna E Ssentongo, John S Oh, Paddy Ssentongo, Mark J Seamon, James P Byrne, Isabella G Armento, Donald H Jenkins, Maxwell A Braverman, Caleb Mentzer, Guy C Leonard, Lindsey L Perea, Courtney K Docherty, Julie A Dunn, Brittany Smoot, Matthew J Martin, Jayraan Badiee, Alejandro J Luis, Julie L Murray, Matthew R Noorbakhsh, James E Babowice, Charles Mains, Robert M Madayag, Haytham M A Kaafarani, Ava K Mokhtari, Sarah A Moore, Kathleen Madden, Allen Tanner 2nd, Diane Redmond, David J Millia, Amber Brandolino, Uyen Nguyen, Vernon Chinchilli, Scott B Armen, John M Porter

 

Ann Surg. 2022 Oct 1;276(4):579-588.

 

 

Background: Blood component therapy (BCT) is the current standard for resuscitating trauma patients, with WB emerging as the blood product of choice. We hypothesized that the use of WB versus BCT alone would result in decreased mortality.

 

Methods: We performed a 14-center, prospective observational study of trauma patients who received WB versus BCT during their resuscitation. We applied a generalized linear mixed-effects model with a random effect and controlled for age, sex, mechanism of injury (MOI), and injury severity score. All patients who received blood as part of their initial resuscitation were included. Primary outcome was mortality and secondary outcomes included acute kidney injury, deep vein thrombosis/pulmonary embolism, pulmonary complications, and bleeding complications.

 

Results: A total of 1623 [WB: 1180 (74%), BCT: 443(27%)] patients who sustained penetrating (53%) or blunt (47%) injury were included. Patients who received WB had a higher shock index (0.98 vs 0.83), more comorbidities, and more blunt MOI (all P <0.05). After controlling for center, age, sex, MOI, and injury severity score, we found no differences in the rates of acute kidney injury, deep vein thrombosis/pulmonary embolism or pulmonary complications. WB patients were 9% less likely to experience bleeding complications and were 48% less likely to die than BCT patients ( P <0.0001).

 

Conclusions: Compared with BCT, the use of WB was associated with a 48% reduction in mortality in trauma patients. Our study supports the use of WB use in the resuscitation of trauma patients.

 

Risk factors and outcomes of unrecognised endobronchial intubation in major trauma patients

 

Guido Heyne, Sebastian Ewens, Holger Kirsten, Johannes Karl Maria Fakler, Orkun Özkurtul, Gunther Hempel, Sebastian Krämer, Manuel Florian Struck

 

Emerg Med J. 2022 Jul;39(7):534-539

 

 

Background: Emergency tracheal intubation during major trauma resuscitation may be associated with unrecognised endobronchial intubation. The risk factors and outcomes associated with this issue have not previously been fully defined.

 

Methods: We retrospectively analysed adult patients admitted directly from the scene to the ED of a single level 1 trauma centre, who received either prehospital or ED tracheal intubation prior to initial whole-body CT from January 2008 to December 2019. Our objectives were to describe tube-to-carina distances (TCDs) via CT and to assess the risk factors and outcomes (mortality, length of intensive care unit stay and mechanical ventilation) of patients with endobronchial intubation (TCD <0 cm) using a multivariable model.

 

Results: We included 616 patients and discovered 26 (4.2%) cases of endobronchial intubation identified on CT. Factors associated with an increased risk of endobronchial intubations were short body height (OR per 1 cm increase 0.89; 95% CI 0.84 to 0.94; p≤0.001), a high body mass index (OR 1.14; 95% CI 1.04 to 1.25; p=0.005) and ED intubation (OR 3.62; 95% CI 1.39 to 8.90; p=0.006). Eight of 26 cases underwent tube thoracostomy, four of whom had no evidence of underlying chest injury on CT. There was no statistically significant difference in mortality or length of stay although the absolute number of endobronchial intubations was small.

 

Conclusions: Short body height and high body mass index were associated with endobronchial intubation. Before considering tube thoracostomy in intubated major trauma patients suspected of pneumothorax, the possibility of unrecognised endobronchial intubation should be considered.

 

 

Performance Evaluation of the Solo-T and the Combat Application Tourniquet in a Perfused Cadaver Model

 

George J Holinga, John S Foor, Steven L Van Horn, James E McGuire

 

J Spec Oper Med. 2022 Sep 19;22(3):49-55.

 

 

Purpose: We evaluated a 10.2-cm-wide, minimally elastic, adhesive wrap-based tourniquet (Solo-T or ST) alongside a 3.8-cm-wide windlass-based tourniquet (Combat Application Tourniquet Generation 7, or CAT) to determine if the tension wrap-tightened ST could deliver hemorrhage control equivalent to the windlass-tightened CAT.

 

Methods: A cadaver model was used to simulate lower-thigh femoral arterial hemorrhage at "normal" (146 ± 5mmHg) and "elevated" (471 ± 3mmHg) perfusion pressures (mean ± standard error). Three study participants used the ST and CAT to control hemorrhage during 48 timed trials. Arterial occlusion was established by Doppler ultrasound and tourniquet performance was quantified by under-tourniquet pressure cuffs.

 

Results: Participants achieved 100% (24/24) occlusion success rates and reported similar ease of use for both tourniquets. Occlusion and application times (mean ± standard error) were similar (p > .05) for the ST and CAT under "normal" (occlusion, ST: 25 ± 2 seconds, CAT: 22 ± 2 seconds; application, ST: 27 ± 2 seconds, CAT: 26 ± 2 seconds) and "elevated" (occlusion, ST: 24 ± 7 seconds, CAT: 24 ± 7 seconds; application, ST: 25 ± 7 seconds, CAT: 25 ± 7 seconds) perfusion alike. The ST mean completion pressures (mean ± standard error) were > 40% lower than the CAT under both "normal" perfusion (ST: 110 ± 20mmHg; CAT: 210 ± 30mmHg; p = 0.009) and "elevated" perfusion (ST: 190 ± 50mmHg; CAT: 340 ± 30mmHg; p = 0.03).

 

Conclusion: The adhesive wrap-based ST tourniquet delivered equivalent hemorrhage control performance at significantly lower completion pressures than the CAT.

 

 

 

Is AVPU comparable to GCS in critical prehospital decisions? - A cross-sectional study

 

Srinivasa R Janagama, Jennifer A Newberry, Michael A Kohn, G V Ramana Rao, Matthew C Strehlow, Swaminatha V Mahadevan

 

Am J Emerg Med. 2022 Sep;59:106-110

 

 

Background: Advanced Trauma Life Support field triage utilizes the Glasgow Coma Scale (GCS) to assess the level of consciousness. However, prehospital care providers in low- and middle-income countries (LMICs) often use the Alert, Verbal, Pain, and Unresponsive (AVPU) scale to assess the level of consciousness. This study aimed to determine whether prehospital AVPU categorization correlates with mortality rates in trauma victims, similarly to GCS.

 

Methods: In this cross-sectional study conducted between November 2015 and January 2016, we enrolled a convenience sample of prehospital trauma-related field activations. The primary outcome measure was the probability of death within 48 h for each category of AVPU.

 

Results: In a convenience sample of 4514 activations, 1606 (35.6%) met exclusion criteria, four did not have AVPU, and four did not have GCS, leaving 2900 (64.2%) trauma activations with both AVPU and GCS available for analysis. Forty-eight-hour follow-up data were available for 2184 (75.3%) activations out of these 2900. The 48-h mortality rates for each category of AVPU were 1.1% (Alert), 4.3% (Verbal), 17.9% (Pain), 53.2% (Unresponsive); and, for each GCS-based injury severity category, they were 0.9% (Mild, GCS 13-15), 8.1% (Moderate, GCS 9-12), 43.5% (Severe, GCS ≤ 8). Overall, there was a statistically significant difference in GCS for each category of AVPU (p < 0.001) except between patients responding to verbal commands and those responding to pain (p = 0.18). The discriminative ability of AVPU (AUC 79.7% (95% CI 73.4-86.1)) and GCS (AUC 81.5% (95% CI 74.8-88.2)) for death within 48-h following hospital drop-off were comparable.

 

Conclusion: EMT assessments of AVPU and GCS relate to each other, and AVPU predicts mortality at 48 h. Future studies using AVPU to assess the level of consciousness in prehospital trauma protocols may simplify their global application without impacting the overall quality of care.

 

Hemostatic Effects of Bio-Zeolite Gauze and QuikClot Combat Gauze on Major Bleeding in Rabbits Acutely Exposed to High Altitude

 

Yi-Jun Jia, Wen-Qiong Du, Zhao-Wen Zong, Ren-Qing Jiang, Xin Zhong, Zhao Ye, Tan-Shi Li, Hao-Yang Yang, Li-Ping Xiao, Jie Fan

 

Prehosp Emerg Care. 2022 Sep 28;1-8.

 

 

Objective: Hemostatic gauze application is an effective way to control major bleeding, which is the most common cause of death in trauma in both civilian and military settings. Coagulation derangement after acute exposure to high altitude might alter the effects of hemostatic gauzes. The present study aimed to observe the hemostatic effects of bio-zeolite gauze (BZG) and QuikClot Combat Gauze® (QCG) on major bleeding in rabbits acutely exposed to high altitude.

 

Methods: Sixty rabbits were randomly and evenly divided into six groups. Animal models of simulated blast- and fragment-induced inguinal major bleeding were prepared in lower altitude and high-altitude areas, and BZG, QCG, and ordinary gauze without hemostatic material were used to control bleeding. The primary outcomes included immediate hemostasis rate, blood loss, and survival rate, while the secondary outcomes included hemodynamic parameters, laboratory examinations, and coagulation-relevant markers.

 

Results: The overall effects of BZG and QCG were better than those of ordinary gauze, with a higher immediate hemostatic rate, less blood loss, and higher survival rate at 90 min after gauze application and higher red blood cell and platelet counts and lower creatinine level at 30 min after gauze application in lower altitude. The concentrations of coagulation factor XII and factor X in rabbits acutely exposed to high altitude were significantly lower than those in lower altitude. At high altitude, the hemostatic effects of BZG did not decrease significantly compared to those in the lower altitude, whereas those of ordinary gauze and QCG decreased significantly at high altitude compared to those in the lower altitude.

 

Conclusions: Coagulation derangement after acute exposure to high altitude has negative effects on ordinary gauze and QCG but has no significant negative hemostatic effects on BZG.

 

 

Hypertonic Saline for Severe Traumatic Brain Injury With Herniation: A Military Prehospital Case Report

 

Randy Michael, Matthew Gaddy, Nicholas Antonino, Ryan Payne, Erik Scott DeSoucy, Jessica T Rush

 

J Spec Oper Med. 2022 Sep 19;22(3):98-100

 

 

Abstract

 

Severe traumatic brain injury (sTBI) is a devastating injury with limited prehospital therapies available. The Joint Trauma System (JTS) Clinical Practice Guidelines recommend hypertonic saline (HTS) for casualties with sTBI and signs of impending or ongoing herniation (IOH), but its use by combat medics has never been reported in the literature. This report details the management of a pregnant patient with sTBI and signs of IOH, including the use of HTS, by US Air Force pararescumen in an austere prehospital setting. Treatment with HTS was followed by improvement in the patient's neurologic exam and successful evacuation to definitive care where her child was delivered alive. Additionally, we review the pathophysiology and signs of herniation, the mechanism of action of hyperosmotic therapies, and the rationale behind the use of HTS in the combat setting.

 

 

 

Comparison of Changes in Vital Signs During Ground and Helicopter Emergency Medical Services and Hospital Interventions

 

Yasuyuki Kawai, Koji Yamamoto, Keita Miyazaki, Keisuke Takano, Hideki Asai, Kenichi Nakano, Hidetada Fukushima

 

Air Med J. 2022 Jul-Aug;41(4):391-395.

 

 

Objective: Few studies have evaluated the effects of helicopter emergency medical services (HEMS) alone. This single-center study compared the changes in vital signs during ground emergency medical services (GEMS), HEMS, and hospital interventions to assess the impact of HEMS interventions.

 

Methods: This retrospective observational study included 168 trauma patients older than 18 years of age who received HEMS. Patients with cardiac arrest or those who received medical attention before HEMS were excluded. We assessed 3 intervention phases (GEMS, HEMS, and hospital). The changes in heart rate, systolic blood pressure, respiratory rate, and shock index in response to interventions were calculated and divided by the intervention time, and the changes observed during the interventions were compared.

 

Results: No changes in vital signs were observed when receiving GEMS. Systolic blood pressure increased and shock index decreased after HEMS, whereas systolic blood pressure decreased and shock index increased during hospital interventions. Heart rate showed no significant change (P = .12), and respiratory rate showed very little change. Systolic blood pressure increased significantly during HEMS compared with the pre- and postintervention periods.

 

Conclusion: Changes in vital signs differed according to the intervention. Systolic blood pressure increased during HEMS but not with GEMS or hospital interventions.

 

 

 

Modified jaw thrust I-gel insertion technique in adults: a case series

 

Dileep Kumar

 

J Med Case Rep. 2022 Jul 5;16(1):262.

 

 

Background: The I-gel is a second-generation supraglottic airway device that is built with a noninflatable elliptical gel material cuff and has a wide semirigid stem. The I-gel supralaryngeal seal has shown promising efficacy for both spontaneous and controlled ventilation under general anesthesia. The recommended, standard I-gel insertion technique is relatively challenging due to its shape and cuff size. Usually, the I-gel becomes entrapped at the oral cavity and requires excessive force to negotiate across the oropharynx, resulting in insertion resistance, tongue obstruction, insertion failure, and intraoral trauma. This case series evaluated a modified jaw thrust I-gel insertion technique because it is claimed to allow smooth and atraumatic I-gel placement in adults.

 

Case presentation: In this case series, ten male and female Indo-Aryan group of Asian patients aged 18-60 years were recruited for I-gel device placement through a modified jaw thrust technique for short to intermediate surgical duration in below-umbilical surgical procedures. Patient consent was obtained, and baseline vital signs such as electrocardiogram, noninvasive blood pressure, and peripheral oxygen saturation readings were recorded. Following preoxygenation, propofol 2 mg/kg was administered for anesthesia induction and nalbuphine 0.1 mg/kg for analgesia. In all patients, an I-gel was placed by the modified jaw thrust technique. The patient's demographics, number of attempts, I-gel insertion resistance, and insertion time duration were recorded.

 

Conclusion: The findings showed a 100% first-attempt insertion rate along with negligible insertion resistance and convincing insertion time duration with modified jaw thrust I-gel insertion technique. However, a blood-stained I-gel was observed in one male patient at the time of removal. The patient's demographics such as age, weight, American Society of Anesthesiologists status, and surgical and anesthesia duration were found not to be significant. The modified jaw thrust I-gel insertion technique could be considered as an alternative in adults when difficulty is encountered with the standard I-gel insertion technique.

 

 

Pre-hospital blood products and calcium replacement protocols in UK critical care services: A survey of current practice

 

Caroline Leech, Eleri Clarke

 

Resusc Plus. 2022 Aug 5;11:100282. doi: 10.1016/j.resplu.2022.100282. eCollection 2022 Sep.

 

 

Introduction: In the United Kingdom, prehospital blood products are increasingly carried for the early resuscitation of hypovolaemia in patients who are shocked or in cardiac arrest. There is an association between hypocalcaemia and mortality in trauma patients, but no current national guidelines on the timing or dose of calcium replacement exist. The objective of this study was to establish the availability of prehospital blood products, and the current calcium replacement protocols used by UK prehospital services.

 

Methods: A cross sectional survey of all UK air ambulances and additional prehospital critical care organisations was conducted in April-May 2022 via an on-line questionnaire. The survey asked 11 questions about availability of prehospital blood products, calcium replacement for patients requiring prehospital blood products, and the use of point of care testing.

 

Results: There was a 100% response rate with 20/22 UK air ambulances carrying blood products and five additional prehospital services identified. There were 15 different combinations of prehospital blood products. 23/25 services had a standard operating procedure for the replacement of calcium. This was recommended before any blood product administration in 5 services (22%), during or after the 1st unit in 5 services (22%), during or after the 2nd unit in 6 services (26%) and during or after the 4th unit in 7 services (30%). Only six services carried point of care testing and no services routinely used this to measure calcium levels in patients requiring prehospital blood products.

 

Conclusion: In 2022, 91% of UK air ambulances carry prehospital blood products and there is significant variation between services in the combination of blood products provided. There is no consensus on the timing or dose of calcium replacement. Further prospective research should examine the association between traumatic bleeding and ionized calcium levels before and during blood product transfusion in order to produce more robust guidelines for routine calcium replacement.

 

 

FINGER: A Novel Approach to Teaching Simple Thoracostomy

 

Andrew Merelman, Natalie Zink, Andrew D Fisher, Michael Lauria, Darren Braude

 

Air Med J. 2022 Nov-Dec;41(6):526-529.

 

 

Abstract

 

For decades, most prehospital clinicians have only been armed with needle thoracostomy to treat a tension pneumothorax, which has a significant failure rate. Following recent changes by the US military, more ground and air transport agencies are adopting simple thoracostomy, also commonly referred to as finger thoracostomy, as a successful alternative. However, surgical procedures performed by prehospital clinicians remain uncommon, intimidating, and challenging. Therefore, it is imperative to adopt a training strategy that is comprehensive, concise, and memorable to best reduce cognitive load on clinicians while in a high-acuity, low-frequency situation. We suggest the following mnemonic to aid in learning and retention of the key procedural steps: FINGER (Find landmarks; Inject lidocaine/pain medicine; No infection allowed; Generous incision; Enter pleural space; Reach in with finger, sweep, reassess). This teaching aid may help develop and maintain competence in the simple thoracostomy procedure, leading to successful treatment of both a tension pneumothorax and hemothorax.

 

 

 

Femur fractures and hemorrhagic shock: Implications for point of injury treatment

 

Ilan Y Mitchnik, Tomer Talmy, Irina Radomislensky, Yigal Chechik, Amir Shlaifer, Ofer Almog, Sami Gendler

 

Injury. 2022 Oct;53(10):3416-3422.

 

 

Background: Femur shaft fractures (FSF) are perceived as potentially life-threatening injuries due to significant blood loss. However, these injuries are rarely the sole cause of hemorrhagic shock. Clinical practice guidelines for the prehospital management of FSF are inconsistent, especially concerning the use and timing of traction splinting which is postulated to reduce bleeding. We sought to understand the association between FSF and shock, and identify risk factors for shock among casualties with FSF.

 

Methods: This is a retrospective analysis of trauma casualties treated by Israeli Defense Forces (IDF) medical teams between the years 2000-2020 and suffering from isolated FSF. Prehospital data from the IDF-Medical Corps Trauma Registry was merged with hospitalization data from the Israeli National Trauma Registry. Isolated FSF was analyzed by excluding casualties with an Injury Severity Score ≥ 16 and an Abbreviated Injury Scale ≥ 3 in other anatomical regions. Shock was defined as systolic blood pressure ≤ 90 mmHg and/or heart rate ≥ 130 beats per minute. A case series review was performed for casualties in shock with isolated FSF injuries. Multivariable logistic regression was performed to assess for injury characteristics associated with shock.

 

Results: During the study period, we identified 213 patients with FSF (4.9%) of which 129 were isolated injuries. Overall, 9.9% and 26.3% of casualties had concurrent thoracic and abdominal injuries, respectively. Most FSF were due to motor vehicle accidents (60.1%) and shock was present in 17.1%. In isolated FSF patients, gunshot and explosive injury mechanisms were prevalent (65.0%) with severe shock being present in 8.5%. Open fractures were present in 72.7% of isolated FSF patients in shock. Open FSF injuries were characterized by prehospital bleeding which was difficult to control. In a multivariable logistic regression model, severe concomitant injuries were associated with increased odds of shock.

 

Conclusions: Shock rarely presents when FSF is the primary injury. Such casualties predominantly suffer from open FSF which may present as difficult to control thigh bleeding. Our findings do not support urgent prehospital leg traction splinting which may result in delayed evacuation to definitive care. Casualties with shock and FSF should be investigated for other sources of bleeding. Leg traction splinting should be reserved for suspected FSF injuries with shock or persistent thigh bleeding.

 

 

Association of Prehospital Needle Decompression With Mortality Among Injured Patients Requiring Emergency Chest Decompression

 

Daniel Muchnok, Allison Vargo, Andrew-Paul Deeb, Francis X Guyette, Joshua B Brown

 

JAMA Surg. 2022 Oct 1;157(10):934-940

 

 

Importance: Prehospital needle decompression (PHND) is a rare but potentially life-saving procedure. Prior studies on chest decompression in trauma patients have been small, limited to single institutions or emergency medical services (EMS) agencies, and lacked appropriate comparator groups, making the effectiveness of this intervention uncertain.

 

Objective: To determine the association of PHND with early mortality in patients requiring emergent chest decompression.

 

Design, setting, and participants: This was a retrospective cohort study conducted from January 1, 2000, to March 18, 2020, using the Pennsylvania Trauma Outcomes Study database. Patients older than 15 years who were transported from the scene of injury were included in the analysis. Data were analyzed between April 28, 2021, and September 18, 2021.

 

Exposures: Patients without PHND but undergoing tube thoracostomy within 15 minutes of arrival at the trauma center were the comparison group that may have benefited from PHND.

 

Main outcomes and measures: Mixed-effect logistic regression was used to determine the variability in PHND between patient and EMS agency factors, as well as the association between risk-adjusted 24-hour mortality and PHND, accounting for clustering by center and year. Propensity score matching, instrumental variable analysis using EMS agency-level PHND proportion, and several sensitivity analyses were performed to address potential bias.

 

Results: A total of 8469 patients were included in this study; 1337 patients (11%) had PHND (median [IQR] age, 37 [25-52] years; 1096 male patients [82.0%]), and 7132 patients (84.2%) had emergent tube thoracostomy (median [IQR] age, 32 [23-48] years; 6083 male patients [85.3%]). PHND rates were stable over the study period between 0.2% and 0.5%. Patient factors accounted for 43% of the variation in PHND rates, whereas EMS agency accounted for 57% of the variation. PHND was associated with a 25% decrease in odds of 24-hour mortality (odds ratio [OR], 0.75; 95% CI, 0.61-0.94; P = .01). Similar results were found in patients who survived their ED stay (OR, 0.68; 95% CI, 0.52-0.89; P < .01), excluding severe traumatic brain injury (OR, 0.65; 95% CI, 0.45-0.95; P = .03), and restricted to patients with severe chest injury (OR, 0.72; 95% CI, 0.55-0.93; P = .01). PHND was also associated with lower odds of 24-hour mortality after propensity matching (OR, 0.79; 95% CI, 0.62-0.98; P = .04) when restricting matches to the same EMS agency (OR, 0.74; 95% CI, 0.56-0.99; P = .04) and in instrumental variable probit regression (coefficient, -0.60; 95% CI, -1.04 to -0.16; P < .01).

Conclusions and relevance: In this cohort study, PHND was associated with lower 24-hour mortality compared with emergent trauma center chest tube placement in trauma patients. Although performed rarely, PHND can be a life-saving intervention and should be reinforced in EMS education for appropriately selected trauma patients.

 

 

 

Use of tranexamic acid in major trauma: a sex-disaggregated analysis of the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH-2 and CRASH-3) trials and UK trauma registry (Trauma and Audit Research Network) data

Tim Nutbeam, Ian Roberts, Lauren Weekes, Haleema Shakur-Still, Amy Brenner, Francois-Xavier Ageron

Br J Anaesth. 2022 Aug;129(2):191-199

 

Background: Women are less likely than men to receive some emergency treatments. This study examines whether the effect of tranexamic acid (TXA) on mortality in trauma patients varies by sex and whether the receipt of TXA by trauma patients varies by sex.

Methods: First, we conducted a sex-disaggregated analysis of data from the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH)-2 and CRASH-3 trials. We used interaction tests to determine whether the treatment effect varied by sex. Second, we examined data from the Trauma and Audit Research Network (TARN) to explore sex differences in the receipt of TXA. We used logistic regression models to estimate the odds ratio for receipt of TXA in females compared with males. Results are reported as n (%), risk ratios (RR), and odds ratios (OR) with 95% confidence intervals.

Results: Overall, 20 211 polytrauma patients (CRASH-2) and 12 737 patients with traumatic brain injuries (CRASH-3) were included in our analysis. TXA reduced the risk of death in females (RR=0.69 [0.52-0.91]) and in males (RR=0.80 [0.71-0.90]) with no significant heterogeneity by sex (P=0.34). We examined TARN data for 216 364 patients aged ≥16 yr with an Injury Severity Score ≥9 with 98 879 (46%) females and 117 485 (54%) males. TXA was received by 7198 (7.3% [7.1-7.4%]) of the females and 19 697 (16.8% [16.6-17.0%]) of the males (OR=0.39 [0.38-0.40]). The sex difference in the receipt of TXA increased with increasing age.

Conclusions: Administration of TXA to patients with bleeding trauma reduces mortality to a similar extent in women and men, but women are substantially less likely to be treated with TXA.

 

 

A Descriptive Analysis of Battlefield First Responder and Combat Lifesaver Interventions during the Role 1 Phase of Care

Matthew W Paulson, John D Hesling, Jerome T McKay, Vikhyat S Bebarta, Kathleen Flarity, Sean Keena, Jason F Naylor, Andrew D Fisher, Michael D April, Steven G Schauer

Med J (Ft Sam Houst Tex). 2021 Jul-Sep;(PB 8-21-07/08/09):25-30.

 

Background: Battlefield first responders (BFR) are the first non-medical personnel to render critical lifesaving interventions for combat casualties, especially for massive hemorrhage where rapid control will improve survival. Soldiers receive medical instruction during initial entry training (IET) and unit-dependent medical training, and by attending the Combat Lifesaver (CLS) course. We seek to describe the interventions performed by BFRs on casualties with only BFRs listed in their chain of care within the Prehospital Trauma Registry (PHTR).

Methods: This is a secondary analysis of a dataset from the PHTR from 2003-2019. We excluded encounters with a documented medical officer, medic, or unknown prehospital provider at any time in their chain of care during the Role 1 phase to isolate only casualties with BFR medical care.

Results: Of the 1,357 encounters in our initial dataset, we identified 29 casualties that met inclusion criteria. Pressure dressing was the most common intervention (n=12), followed by limb tourniquets (n=4), IV fluids (n=3), hemostatic gauze (n=2), and wound packing (n=2). Bag-valve-masks, chest seals, extremity splints, and nasopharyngeal airways (NPA) were also used (n=1 each). Notably absent were backboards, blizzard blankets, cervical collars, eye shields, pelvic splints, hypothermia kits, chest tubes, supraglottic airways (SGA), intraosseous (I/O) lines, and needle decompression (NDC).

Conclusions: Despite limited training, BFRs employ vital medical skills in the prehospital setting. Our data show that BFRs largely perform medical interventions within the scope of their medical knowledge and training. Better datasets with efficacy and complication data are needed.

 

 

 

Manual Pressure Points Technique for Massive Hemorrhage Control-A Prospective Human Volunteer Study

Regina Pikman Gavriely, Yotam Lior, Shaul Gelikas, Shiran Levy, Alon Ahimor, Elon Glassberg, Shachar Shapira, Avi Benov, Guy Avital

Prehosp Emerg Care. 2022 Sep 28;1-6. Online ahead of print.

 

Background: While commonly thought to be effective for management of limb and junctional hemorrhage, the manual pressure points technique was excluded from leading prehospital guidelines over a decade ago following the publication of a single human-volunteers study presenting unfavorable results. This work aimed to re-assess the efficacy and feasibility of the femoral and supraclavicular pressure points technique for temporary hemorrhage control distal to the pressure point.

Methods: A prospective, non-randomized, human volunteer, controlled environment study. In the study 35 healthy male combat medics (age 21.1 ± 1.3 years) received brief training after which they were requested to apply pressure in the femoral and supraclavicular points in attempts to stop regional blood flow, measured distally by Doppler ultrasound. Success rates in achieving flow cessation in under 2 minutes, time required for achievement of flow cessation, and cumulative flow cessation duration within a 3-minute follow-up after initial success were measured.

Results: For the supraclavicular point, success rates were 97.1% with a mean time to success of 12.5 (±20.9) seconds, lasting for 76.2% (±23.7) of the follow-up time. For the femoral point, success rates were 100% with a mean time to success of 5.5 (±4.3) seconds, lasting for 98.7% (±3.8) of the follow-up time.

Conclusions: Manual pressure on the femoral and supraclavicular points is an applicable and efficient method for temporary hemorrhage control distal to the pressure point. As such, with additional study, this method may be considered for re-introduction to prehospital care guidelines and training programs.

 

 

Tranexamic Acid Was Not Associated with Increased Complications in High-Risk Patients with Intertrochanteric Fracture

Steven B Porter, Aaron C Spaulding, Christopher M Duncan, Benjamin K Wilke, Mark W Pagnano, Matthew P Abdel

J Bone Joint Surg Am. 2022 Jul 6;104(13):1138-1147

 

Background: For elective total joint arthroplasty, tranexamic acid (TXA) is considered safe and efficacious. However, evidence of TXA's safety in high-risk patients undergoing nonelective surgery for hip fracture is sparse. This study aimed to assess whether TXA administration to high-risk patients with an intertrochanteric (IT) hip fracture increased the risk of thromboembolic complications or mortality.

Methods: All patients treated surgically for IT hip fracture between 2015 and 2019 across 4 hospitals of a single hospital system were considered. High- versus low-risk patients and those receiving TXA versus no TXA treatment were identified. Propensity scores adjusted for risk differences between patient groups with TXA and no TXA administration were calculated for (1) high-risk patients (n = 141) and (2) the entire population (n = 316). Postoperative mortality, deep venous thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), and stroke within 90 days of surgery were evaluated.

Results: No association between TXA administration and increased risk of mortality or complications in either group was identified. Specifically, out of 282 matched high-risk patients, no differences in mortality (odds ratio [OR], 0.97 [95% confidence interval (CI), 0.90, 1.05]), DVT (OR, 0.97 [95% CI, 0.93, 1.00]), PE (OR 1.00 [95% CI, 0.95, 1.05]), MI (OR, 1.04 [95% CI, 0.98, 1.10]), or stroke (OR, 1.00 [95% CI, 0.95, 1.05]) were identified.

Conclusions: In our review of propensity-matched high-risk patients undergoing surgical repair for IT fracture, we found that TXA administration compared with no TXA administration was not associated with an increased risk of mortality, DVT, PE, MI, or stroke within 90 days of surgery.

 

"A" stands for airway - Which factors guide the need for on-scene airway management in facial fracture patients?

Tero Puolakkainen, Miika Toivari, Tuukka Puolakka, Johanna Snäll

BMC Emerg Med. 2022 Jun 15;22(1):110

 

Background: Numerous guidelines highlight the need for early airway management in facial trauma patients since specific fracture patterns may induce airway obstruction. However, the incidence of these hallmark injuries, including flail mandibles and posterior displacement of the maxilla, is contentious. We aim to evaluate specific trauma-related variables in facial fracture patients, which affect the need for on-scene versus in-hospital airway management.

Methods: This retrospective cohort study included all patients with any type of facial fracture, who required early airway management on-scene or in-hospital. The primary outcome variable was the site of airway management (on-scene versus hospital) and the main predictor variable was the presence of a traumatic brain injury (TBI). The association of fracture type, mechanism, and method for early airway management are also reported. Altogether 171 patients fulfilled the inclusion criteria.

Results: Of the 171 patients included in the analysis, 100 (58.5) had combined midfacial fractures or combination fractures of facial thirds. Altogether 118 patients (69.0%) required airway management on-scene and for the remaining 53 patients (31.0%) airway was secured in-hospital. A total of 168 (98.2%) underwent endotracheal intubation, whereas three patients (1.8%) received surgical airway management. TBIs occurred in 138 patients (80.7%), but presence of TBI did not affect the site of airway management. Younger age, Glasgow Coma Scale-score of eight or less, and oro-naso-pharyngeal haemorrhage predicted airway management on-scene, whereas patients who had fallen at ground level and in patients with facial fractures but no associated injuries, the airway was significantly more often managed in-hospital.

Conclusions: Proper preparedness for airway management in facial fracture patients is crucial both on-scene and in-hospital. Facial fracture patients need proper evaluation of airway management even when TBI is not present.

 

 

A systematic review of the timing of intubation in patients with traumatic brain injury: pre-hospital versus in-hospital intubation

Archchana Radhakrishnan, Claire McCahill, Ranjit Singh Atwal, Sumitra Lahiri

Eur J Trauma Emerg Surg. 2022 Aug 12. Online ahead of print.

 

Purpose: The objective of this systematic review was to examine current evidence on the risks versus benefit of pre-hospital intubation when compared with in-hospital intubation in adult patients with traumatic brain injuries.

Methods: We conducted electronic searches of PubMed, Medline, Embase, CIANHL and the Cochrane library up to March 2021. Data extracted compared mortality, length of hospital and intensive care stay, pneumonia and functional outcomes in traumatic brain injured patients undergoing pre-hospital intubation versus in-hospital intubation. The risk of bias was assessed using the Grading of Recommendations Assessment, Development and Evaluation.

Results: Ten studies including 25,766 patients were analysed. Seven were retrospective studies, two prospective cohort studies and one randomised control study. The mean mortality rate in patients who underwent pre-hospital intubation was 44.5% and 31.98% for in-hospital intubation. The odds ratio for an effect of pre-hospital intubation on mortality ranged from 0.31 (favouring in-hospital intubation) to 3.99 (favouring pre-hospital). The overall quality of evidence is low; however, the only randomised control study showed an improved functional outcome for pre-hospital intubation at 6 months.

Conclusions: The existing evidence does not support widespread pre-hospital intubation in all traumatic brain injured patients. This does not, however, contradict the need for the intervention when there is severe airway compromise; instead, it must be assessed by experienced personnel if a time critical transfer to hospital is more advantageous. Favourable neurological outcomes highlighted by the randomised control trial favours pre-hospital intubation, but further research is required in this field.

 

 

Comparative evaluation of Intubating Laryngeal Mask Airway (ILMA), I-gel and Ambu AuraGain for blind tracheal intubation in adults

Riniki Sarma, Rakesh Kumar, Neera Gupta Kumar, Munisha Agarwal, Manoj Bhardwaj, Saud Ahmed Ansari, G P Deepak

J Anaesthesiol Clin Pharmacol. 2022 Jan-Mar;38(1):130-136.

 

Background and aims: The supraglottic airway devices (SADs) that allow direct (without an intermediary device like Aintree or airway exchange catheters) tracheal intubation can be invaluable for field use in conditions ideally managed by intubation. Whilst fiberscope-guided intubation is the method of choice, if these 'direct-intubation' SADs could provide high success rates for blind tracheal intubation, their scope of use can increase tremendously. Our study assesses intubating laryngeal mask airway (ILMA), i-gel and Ambu AuraGain for blind tracheal intubation in adults.

Material and methods: Ninety adults undergoing elective surgery were randomized into three equal groups. After induction of anesthesia, the group-specific SAD was inserted and on achieving adequate ventilation, blind tracheal intubation was attempted over two attempts. Success rates and time of achieving adequate device placement and tracheal intubation through these were evaluated. Data were analyzed using SPSS version 17.0 and P < 0.05 was considered statistically significant.

Results: All three devices could achieve adequate ventilation within two allowed attempts. Successful tracheal intubation rates were significantly better with ILMA than i-gel on first attempt (87% vs. 27%, P < 0.001) and after second attempt that was supplemented with optimization maneuvers (100% vs. 40%, P < 0.001). No patient could be intubated through Ambu AuraGain within two attempts. Time taken for successful tracheal intubation did not differ significantly (P = 0.205) with ILMA or i-gel.

Conclusion: Out of ILMA, I-gel and Ambu AuraGain, ILMA is the best device for blind tracheal intubation in adults with normal airways.

 

 

Hypothermia in the Combat Trauma Population

Steven G Schauer, Michael D April, Andrew D Fisher, Wells L Weymouth, Joseph K Maddry, Kevin R Gillespie, Jose Salinas, Andrew P Cap

Prehosp Emerg Care. 2022 Sep 19;1-7. Online ahead of print.

 

Background: The MARCH (Massive hemorrhage, Airway, Respirations, Circulation, and Hypothermia/Head injuries) algorithm taught to military medics includes interventions to prevent hypothermia. As possible sequelae from major trauma, hypothermia is associated with coagulopathy and lower survival. This paper sought to define hypothermia within our combat trauma population using an outcomes-based method, and determine clinical variables associated with hypothermia.

Methods: This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry focused on casualties who received prehospital care. A receiver operating curve was constructed and Youden's index was used to define hypothermia within the predetermined population based on mortality risk. A multivariable regression model was used to identify associations.

Results: There were 23,243 encounters that met the inclusion criteria for this study with patients having received prehospital care and documentation of at least one emergency department temperature. An optimal threshold of 36.2° C was found to predict mortality; 3,159 casualties had temperatures below this threshold (14%). Survival to discharge was lower among casualties with hypothermia (91% versus 98%). Hypothermic casualties were less likely to undergo blanket application (38% versus 40%). However, they had higher proportions with Hypothermia Prevention and Management Kit application (11% versus 7%) and radiant warming (2% versus 1%). On multivariable regression modeling, none of the hypothermia interventions were associated with a decreased likelihood of hypothermia. Non-hypothermia interventions associated with hypothermia included prehospital intubation (OR 1.57, 95% CI 1.45-1.69) and blood product administration.

Conclusions: Hypothermia, including a single recorded low temperature in the patient care record, was associated with worse outcomes in this combat trauma population. Prehospital intubation was most strongly associated with developing hypothermia. Prehospital warming interventions were not associated with a reduction in hypothermia risk. Our dataset suggests that current methods for prehospital warming are inadequate.

 

Evidence-based principles of time, triage and treatment: Refining the initial medical response to massive casualty incidents.

Stacy A Shackelford, Michael A Remley, Sean Keenan, Russ S Kotwal, Jay B Baker, Jennifer Gurney, Stephen Rush, Paul Friedrichs

J Trauma Acute Care Surg. 2022 Aug 1;93(2S Suppl 1):S160-S164.

 

Background: The overall approach to massive casualty triage has changed little in the past 200 years. As the military and civilian organizations prepare for the possibility of future large-scale combat operations, terrorist attacks and natural disasters, potentially involving hundreds or even thousands of casualties, a modified approach is needed to conduct effective triage, initiate treatment, and save as many lives as possible.

Methods: Military experience and review of analyses from the Department of Defense Trauma Registry are combined to introduce new concepts in triage and initial casualty management.

Results: The classification of the scale of massive casualty (MASCAL) incidents, timeline of life-saving interventions, immediate first pass actions prior to formal triage decisions during the first hour after injury, simplification of triage decisions, and the understanding that ultra-MASCAL will primarily require casualty movement and survival needs with few prehospital life-saving medical interventions are discussed.

Conclusion: Self aid, bystander, and first responder interventions are paramount and should be trained and planned extensively. Military and disaster planning should not only train these concepts, but should seek innovations to extend the timelines of effectiveness and to deliver novel capabilities within the timelines to the greatest extent possible.

 

Alternative routes to intravenous tranexamic acid for postpartum hemorrhage: A systematic search and narrative review

Haleema Shakur-Still, Stanislas Grassin-Delyle, Kopalasuntharam Muhunthan, Homa K Ahmadzia, David Faraoni, Monica Arribas, Ian Roberts

Int J Gynaecol Obstet. 2022 Jun;158 Suppl 1(Suppl 1):40-45

 

Objective: To review available data on tranexamic acid (TXA) plasma concentration needed to inhibit fibrinolysis and the time to achieve this concentration when giving TXA by different routes in humans. To identify ongoing trials assessing alternatives to intravenous TXA administration.

Methods: We updated two previous systematic reviews by searching MEDLINE, EMBASE, OviSP, and ISI Web of Science from database inception to July 2021. We also searched the WHO International Clinical Trials Registry Platform for ongoing trials to July 2021. Titles and abstracts were screened for relevant trials. Two reviewers independently reviewed and agreed the trials to be included.

Results: Plasma TXA concentrations over 10 mg/L provide near maximal inhibition of fibrinolysis, with concentrations over 5 mg/L providing partial inhibition. Oral TXA tablets take about 1 h to reach a plasma concentration of 5 mg/L in postpartum women. Studies in healthy volunteers and shocked trauma patients show that intramuscular TXA achieves a plasma level of over 10 mg/L within 15 min. One trial is ongoing to determine the pharmacokinetics of intramuscular and oral solution TXA in pregnant women.

Conclusion: Intramuscular TXA in healthy volunteers and shocked trauma patients reaches therapeutic concentration rapidly. Oral TXA tablets take too long to reach the minimum therapeutic concentration in postpartum women.

 

 

Is intravenous tranexamic acid effective in reduction of blood loss during pelvic and acetabular surgery?

Mohamed M F Sharaby, Younes M El-Deeb

Int Orthop. 2022 Aug;46(8):1721-1729.

 

Purpose: Pelvic and acetabular surgery is associated with one of the highest amounts of blood loss. Tranexamic acid is a good choice to reduce blood loss during this type of surgery. However, being antifibrinolytic drug, the chance to have coagulation complications including DVT is a risk that should be considered particularly in such major trauma patients with the body's response to trauma and with possible prolonged bed stay. The aim of this study is to evaluate the effectiveness of intravenous tranexamic acid injection during pelvic and acetabular surgery for reduction of blood loss during surgery and after surgery and to evaluate any possible complications for its use.

Methods: This prospective randomized clinical trial includes 97 patients divided between two groups; group 1 (G1) which received TXA, while the second group (G2) is the control group. The primary outcome measures were total blood loss (TBL), allogenic blood units transfused, and the blood lost intra-operatively (IBL). The TBL was calculated by the haemoglobin balance method while the intra-operative blood loss was measured by the gravimetric method. Any complications related to the drug were evaluated particularly DVT.

Results: The study showed significantly less TBL (G1 = 829.7 ± 219.2, G2 = 1036.9 ± 314.9) and blood transfusion (G1 = 52.4 ± 40 g, G2 = 89.4 ± 60.6 g) in G1 compared to the G2.

Conclusion: This study proved the possible reduction of TBL and the need of blood transfusion by the use of TXA in pelvic and acetabular injuries.

 

Kabul airport suicide attack: report of a mass casualty

 

Ornella Spagnolello, Sofia Gatti, Shekiba Esmati, Mir Abdul Azim Shahir, Gina Portella

 

Eur J Trauma Emerg Surg. 2022 Aug;48(4):2687-2688

 

 

Mass casualty events (MCE) are rare in high-income countries and feasible to manage, as a vast emergency services network is usually available. On the contrary, resources in Afghanistan are scarce, and these events are frequent. EMERGENCY-NGO has been active since 1999 with three hospitals in Kabul, Lashkar Gah and Anabah, and a network of 39 first aid posts around the country, treating war

victims without any discrimination and free of charge. Western media mostly underreport the frequent MCE caused by bombings, conflagrations or terrorist attacks. Nevertheless, despite being similar to many others, the terrorist attack at Kabul International Airport (26th August) was exceptionally covered. As the organization has always been on the frontline in responding to MCE in Afghanistan, we will attempt to supplement the publicly available information by reporting on the medical response efforts.

 

 

 

The U.S. Armed Services Blood Program support to U.S. Central Command 2014-2021: Transformation of combat trauma resuscitation through blood product innovation and expansion of blood availability far forward

 

Audra L Taylor, Jason B Corley, Andrew P Cap, Matthew T Swingholm, Erika T Nance, Richard Gonzales, Jennifer M Gurney, Stacey Shackelford, Jeffrey C Hebert, Jessica D Hughes, Karen Royster, George A Hestilow, Colleen L Cordrick, Jonathan Hoiles, Kathleen Whitlock, Robin Whitacre, Becky Pederson

 

Transfusion. 2022 Aug;62 Suppl 1:S167-S176.

 

 

Background: The United States Armed Services Blood Program (ASBP) faced complex blood supply challenges during two decades of military operations in the U.S. Central Command (CENTCOM) and through an adaptive, responsive, and agile system, gained valuable insights on blood product usage in combat casualty care.

 

Study design and methods: A retrospective review of blood product introduction and utilization trends was compiled from ASBP data collected during CENTCOM operations from 2014 through 2021.

 

Results: During the study period, several blood products were introduced to the CENTCOM area of operations including Low Titer O Whole Blood (LTOWB), Cold-Stored Platelets (CSP), Liquid Plasma (LP), and French Freeze Dried Plasma (FDP) manufactured from U.S. sourced donor plasma, all while expanding Walking Blood Bank capabilities. There was a gradual substitution of component therapy for whole blood; blood utilization peaked in 2017. Transfusion of Fresh Whole Blood (FWB) from Walking Blood Banks decreased as fully pre-tested LTOWB was supplied by the ASBP. LTOWB was initially supplied in citrate-phosphate-dextrose (CPD) anticoagulant (21-day shelf life) but was largely replaced with LTOWB in citrate-phosphate-dextrose-adenine (CPDA-1) anticoagulant (35-day shelf life) by 2019. Implementation of prehospital transfusion and expansion of surgical and resuscitation teams led to an increase in the number of sites receiving blood.

 

Discussion: ASBP introduced new products to its inventory in order to meet changing blood product demands driven by changes in the Joint Trauma System Clinical Practice Guidelines and operational demands. These products were adopted into clinical practice with a resultant evolution in transfusion strategies.

 

 

Efficacy of tracheal tube introducers and stylets for endotracheal intubation in the prehospital setting: a systematic review and meta-analysis

 

Jaden Tollman, Zubair Ahmed

 

Eur J Trauma Emerg Surg. 2022 Jun;48(3):1723-1735.

 

 

Purpose: Tracheal tube introducers and stylets remain some of the most widely used devices for aiding practitioners in performing endotracheal intubation (ETI). The purpose of this systematic review is to evaluate the efficacy of tracheal tube introducers and stylets for ETI in the prehospital setting.

 

Methods: A literature search was conducted on the 2nd of March 2021 across PubMed, Embase (Ovid) and the Cochrane Central Register of Controlled Trials (CENTRAL) to identify relevant studies. Included studies had their data extracted and both a quality assessment and statistical analysis were performed.

 

Results: The summary estimate of prehospital studies with video technology showed a statistically significant increase in first pass ETI success in favour of bougies (RR 1.15, CI 1.10-1.21, p < 0.0001). The summary estimates of prehospital studies without video technology and simulation studies with and without video technology showed no statistical difference between methods for first pass or overall ETI success. Some of the highest success rates were recorded by devices that incorporated video technology. Stylets lead to a shorter time to ETI while bougies were easier to use. Neither device was associated with a higher rate of ETI complications than the other.

 

Conclusion: Both tracheal tube introducers and stylets function as efficacious aids to intubation in the prehospital environment. Where video technology is available, bougies could offer a statistically significant advantage in terms of first pass ETI success. Where video technology is unavailable, a combination of clinical scenario, practitioner expertise and personal preference might ultimately guide the choice of device.

 

The effect of prehospital tranexamic acid on outcome in polytrauma patients with associated severe brain injury

 

Karlijn J P van Wessem, Denise Jochems, Luke P H Leenen

 

Eur J Trauma Emerg Surg. 2022 Jun;48(3):1589-1599.

 

 

Introduction: Tranexamic acid (TXA) has shown to be beneficial in selected patients with hemorrhagic shock. Recently, TXA has gained interest in isolated traumatic brain injury (TBI) patients with variable results. There are limited data on TXA in polytrauma with associated TBI. This study investigated the role of TXA in severely injured patients with associated severe TBI.

 

Methods: A 7.5-year prospective cohort study was performed to investigate the relation between prehospital TXA and mortality in consecutive trauma patients with associated severe TBI (Abbreviated Injury Scale (AIS)head ≥ 3) admitted to a Level-1 Trauma Center ICU. Indication for prehospital TXA administration was (suspicion of) hemorrhagic shock, and/or systolic blood pressure (SBP) ≤ 90 mmHg. Demographics, data on physiology, resuscitation, and outcomes were prospectively collected.

 

Results: Two hundred thirty-four patients (67% males) with median age of 49 years and ISS 33 (98% blunt injuries) were included. Thirteen patients (6%) developed thromboembolic complications; mortality rate was 24%. Fifty-one percent of patients received prehospital TXA. TXA patients were younger, had more deranged physiology on arrival, and received more crystalloids and blood products ≤ 24 h. There was, however, no difference in overall outcome between TXA patients and no-TXA patients.

 

Conclusions: Despite having a more deranged physiology TXA patients had similar outcome compared to no-TXA patients who were much older. Thromboembolic complication rate was low. Prehospital tranexamic acid has no evident effect on outcome in polytrauma patients with associated critical brain injury.

 

Prehospital administration of broad-spectrum antibiotics for sepsis patients: A systematic review and meta-analysis

 

Joseph Varney, Karam R Motawea, Omneya A Kandil, Hashim T Hashim, Kimberly Murry, Jaffer Shah, Ahmed Shaheen, Joy Akwari, Ahmed K Awad, Amanda Rivera, Mostafa R Mostafa, Sarya Swed, Dina M Awad

 

Health Sci Rep. 2022 Apr 1;5(3):e582

 

 

Background and aims: Some studies have suggested that earlier initiation of antibiotics has shown positive outcomes in sepsis patients. We aimed to do a systematic review and meta-analysis to evaluate the effect of prehospital administration of antibiotics on 28 days mortality and length of stay in hospital and intensive care unit for sepsis patients.

 

Methods: We formulated a search strategy and used it on search databases PubMed, Scopus, Web of Science, and Embase. We then screened the records for eligibility and included controlled studies, either clinical trials or cohort studies reporting prehospital antibiotic administration for sepsis patients. We excluded duplicates, books, conferences' abstracts, case reports, editorials, letters, author responses, not English studies, and studies with nonavailable full text. Animal and lab studies were also excluded.

 

Results: The total number of studies identified is 1811, 19 were eligible for systematic review and 4 for meta-analysis (three cohort and one clinical trial). The total number of sepsis patients in the four included studies in the 28 days mortality outcome was 3523 (1779 took prehospital antibiotics and 1744 did not take prehospital antibiotics). Of 1779 who took the antibiotics, 190 died, and of 1744 who did not take antibiotics, 292 died (95% confidence interval 0.68-0.97, p = 0.02).

 

Conclusion: This meta-analysis reveals that receiving prehospital antibiotics can significantly lower mortality in sepsis patients compared to patients who do not receive prehospital antibiotics. However, more clinical trials and multicenter prospective studies with high sample sizes are needed to get strong evidence supporting our findings.

 

Randomized trial of three airway management techniques for restricted access in a simulated pediatric scenario

 

Arnim Vlatten, Tristan Dumbarton, David Vlatten, John Adam Law

 

Am J Emerg Med. 2022 Sep;59:67-69.

 

 

Purpose: Emergency pediatric airway management during restricted access to the head is challenging and may relate to an entrapped motor vehicle trauma. Video laryngoscopy and supraglottic airways have separately been described to facilitate face-to-face airway management. We hypothesized that video laryngoscopy might be superior to direct laryngoscopy or supraglottic device use to establish ventilation during face-to-face airway management, studied in a simulated pediatric entrapped motor vehicle scenario.

 

Methods: Ethics approval was obtained from local REB. 45 experienced airway practitioners managed the airway of a pediatric manikin representing a 6 year old (SimJunior). With a cervical collar applied and in the sitting position, the manikin's head was only accessible from the left anterolateral side. Following a standardized demonstration, airway management using a Macintosh #2 blade (DL), a Storz C-MAC® D-Blade (VL) and a #2.5 LMA Supreme™ (SGD) was performed once each in a random order. Outcomes included success rate, time to ventilation (TTV), percentage of glottic opening (POGO) for DL and VL and ease of use on a 10-point Likert scale (VAS). Data was analyzed using analysis of variance for TTV and VAS and t-test for POGO. Statistical significance was deemed at P < 0.05. Data are presented as median and interquartile range.

 

Results: Success rate was 95% for both DL and SGD and 93% for VL. TTV was significantly less with SGD compared to DL and VL. TTV was 31 s (28, 35) for DL, 46 s (31, 62) for VL and 20 s (17, 24) for SGD. POGO was significantly improved with VL (100%) compared to DL (80%). Participants rated SGD significantly easier to use than VL, but not easier than DL.

 

Discussion: All three techniques have high success rates. Time to establish ventilation with the SGD was significantly faster compared to DL and VL and participants rated SGD easiest to use. The utility of VL was limited due to significantly longer time to ventilation, despite significantly improved view compared to DL, similar to adult studies. Since time and success are clinically important, this study suggests that supraglottic devices should be considered for primary emergency pediatric airway management in situations with restricted access to the head.

 

 

Application of Hemostatic Tourniquet on Wounded Extremities in Modern "Trench" Warfare: The View of a Vascular Surgeon

 

Vladyslav Yatsun

 

Mil Med. 2022 Jul 13; Online ahead of print.

 

 

Introduction: Blood vessel injuries in modern military conflicts account for 12% of all wounds (1), and 50%-95% of these involve arterial damage in extremities (3, 5). Furthermore, 10%-15% of all deaths on the battlefield occur due to extremity hemorrhage (2). Therefore, tourniquets and compression dressings continue to be the main methods of controlling extremity hemorrhage (4).

 

Materials and methods: The article analyzes the use of hemostatic tourniquets on wounded extremities for personnel that were provided second-level medical care by a Forward Surgical Team (FST) of one of the field hospitals of the Armed Forces of Ukraine.In these clinical cases, care was provided at the FST base in one of the district hospitals and during visits to civilian frontline hospitals by a vascular surgeon. This FST provided medical care to all severely and moderately injured or wounded in the area.The analysis included both military and civilians delivered with hemostatic tourniquets on their extremities.

 

Results and discussion: Assistance was provided to 69 wounded or injured, including 5 civilians. In all, 102 tourniquets were applied on 95 extremities. Tourniquets were applied on all 95 (100%) extremities including 21 (22.1%) upper extremities and 74 (77.9%) lower extremities. In 5 cases, tourniquets were applied on 3 extremities, in 16 cases on 2 extremities, and in 48 cases on 1 extremity. Combat Application Tourniquets (CAT) were used in 81 (85.3%) cases, Esmarch type in 10 (10.5%) cases, and improvised tourniquets in 4 (4.2%) cases. Duration of tourniquet application was less than 1 hour in 27 cases, 1-2 hours in 18 cases, 2-3 hours in 15 cases, and over 3 hours in 9 cases.The level of primary blood loss at the time of admission was categorized as <1 L in 44 (63.7%) cases, 1.0-1.5 L in 11 (11.5%) cases, 1.5-2.0 L in 7 (7.2%) cases, 2.0-2.5 L in 3 (3.1%) cases, and >2.5 L in 4 (4.2%) cases. Main arteries were damaged in 14 extremities in 12 (17.4%) wounded. Main veins were damaged in 4 (5.8%) cases without the involvement of the main arteries. Damage to the branches of arteries and veins was seen in 53 (76.8%) of the wounded. Surgical procedures performed included main artery reconstruction in 6, ligation of main arteries in 2, main vein ligation in 4, primary amputations of extremities in 9, and surgical debridement with ligation of arterial and/or venous branches in 37 cases. Reasons for excessive blood loss (>1.0 L) included delayed tourniquet application in 8 cases, inadequate tourniquet application in 12 cases, and bleeding secondary to injuries of the chest/abdominal cavity or head in 5 cases.

 

 

Tips, tricks, and thoughts on the future of prehospital blood transfusions

 

Mark H Yazer, Andrew Beckett, Jason Corley, Dana V Devine, Nicholas M Studer, Audra L Taylor, Kevin R Ward, Andrew P Cap

 

Transfusion. 2022 Aug;62 Suppl 1:S224-S230.

 

 

No abstract available

 

 

 

Attitudes towards the Utilization of Intraosseous Access in Prehospital and Emergency Medicine Nursing Personnel

 

Matjaž Žunkovič, Andrej Markota, Amadeus Lešnik

 

Medicina (Kaunas). 2022 Aug 12;58(8):1086.

 

Abstract

 

 

Background and Objectives: Insertion of an intraosseous access device enables intravascular access for critically ill patients in a prehospital and emergency department setting even when intravenous access is not possible. The aim of our study was to assess the attitudes of prehospital and emergency department nursing staff towards the utilization of intraosseous access devices. Materials and Methods: We performed quantitative research using a closed-ended structured questionnaire distributed to prehospital unit and associated emergency department nursing staff serving a population of around 200,000 inhabitants. Results: We distributed 140 questionnaires, and 106 were returned and completed. Of these, 69 (65.1%) respondents needed more than three attempts to achieve peripheral intravenous access at least once in the last year and 29 (27.4%) required central venous access because of impossible intravenous access. In the last five years, 8 (7.5%) respondents used endotracheal route for administration of medications. Despite this, only 48 (45.3%) of respondents have ever used the intraosseous route. Also, 79 (74.5%) respondents received at least some training in obtaining IO access; however, 46 (43.4%) answered that education regarding intraosseous access is not sufficient, and 92 (86.8%) answered that they wanted additional training regarding intraosseous access. Conclusions: Prehospital and emergency department nursing staff are aware of the importance of intraosseous access and understand the need for additional education and certification in this field.

The diagnostic accuracy of prehospital triage tools in identifying patients with traumatic brain injury: A systematic review

Naif Alqurashi, Ahmed Alotaibi, Steve Bell, Fiona Lecky, Richard Body

Injury 2022 Jun;53(6):2060-2068.

Introduction: Prehospital care providers are usually the first responders for patients with traumatic brain injury (TBI). Early identification of patients with TBI enables them to receive trauma centre care, which improves outcomes. Two recent systematic reviews concluded that prehospital triage tools for undifferentiated major trauma have low accuracy. However, neither review focused specifically on patients with suspected TBI. Therefore, we aimed to systematically review the existing evidence on the diagnostic performance of prehospital triage tools for patients with suspected TBI.

Methods: A comprehensive search of the current literature was conducted using Medline, EMBASE, CINAHL Plus and the Cochrane library (inception to 1st June 2021). We also searched Google Scholar, OpenGrey, pre-prints (MedRxiv) and dissertation databases. We included all studies published in English language evaluating the accuracy of prehospital triage tools for TBI. We assessed methodological quality and risk of bias using a modified Quality Assessment of Diagnostic Studies (QUADAS-2) tool. Two reviewers independently performed searches, screened titles and abstracts and undertook methodological quality assessments. Due to the heterogeneity in the population of interest and prehospital triage tools used, a narrative synthesis was undertaken.

Results: The initial search identified 1787 articles, of which 8 unique eligible studies met the inclusion criteria (5 retrospective, 2 prospective, 1 mixed). Overall, sensitivity of triage tools studied ranged from 19.8% to 87.9% for TBI identification. Specificity ranged from 41.4% to 94.4%. Two decision tools have been validated more than once: HITS-NS (2 studies, sensitivity 28.3-32.6%, specificity 89.1-94.4%) and the Field Triage Decision Scheme (4 studies, sensitivity 19.8-64.5%, specificity 77.4%-93.1%). Existing tools appear to systematically under-triage older patients.

Conclusion: Further efforts are needed to improve and optimise prehospital triage tools. Consideration of additional predictors (e.g., biomarkers, clinical decision aids and paramedic judgement) may be required to improve diagnostic accuracy.

Emergency cricothyroidotomy in difficult airway simulation - a national observational study of Air Ambulance crew performance

Åke Erling L Andresen, Jo Kramer-Johansen, Thomas Kristiansen

BMC Emerg Med. 2022 Apr 9;22(1):64

Background: Advanced prehospital airway management includes complex procedures carried out in challenging environments, necessitating a high level of technical and non-technical skills. We aimed to describe Norwegian Air Ambulance-crews' performance in a difficult airway scenario simulation, ending with a "cannot intubate, cannot oxygenate"-situation.

Methods: The study describes Air Ambulance crews' management of a simulated difficult airway scenario. We used video-observation to assess time expenditure according to pre-defined time intervals and technical and non-technical performance was evaluated according to a structured evaluation-form.

Results: Thirty-six crews successfully completed the emergency cricothyroidotomy with mean procedural time 118 (SD: ±70) seconds. There was variation among the crews in terms of completed procedural steps, including preparation of equipment, patient- monitoring and management. The participants demonstrated uniform and appropriate situational awareness, and effective communication and resource utilization within the crews was evident.

Conclusions: We found that Norwegian Air Ambulance crews managed a prehospital "cannot intubate, cannot oxygenate"-situation with an emergency cricothyroidotomy under stressful conditions with effective communication and resource utilization, and within a reasonable timeframe. Some discrepancies between standard operating procedures and performance are observed. Further studies to assess the impact of check lists on procedural aspects of airway management in the prehospital environment are warranted.

Management of Severe Crush Injuries in Austere Environments: A Special Operations Perspective

Justin Lee Anderson, Meredith Cole, Dylan Pannell

J Spec Oper Med. 2022 May 31;22(2):43-47

Abstract

Crush injuries present a challenging case for medical providers and require knowledge and skill to manage the subsequent damage to multiple organ systems. In an austere environment, in which resources are limited and evacuation time is extensive, a medic must be prepared to identify trends and predict outcomes based on the mechanism of injury and patient presentation. These injuries occur in a variety of environments from motor vehicle accidents (at home or abroad) to natural disasters and building collapses. Crush injury can lead to compartment syndrome, traumatic rhabdomyolysis, arrythmias, and metabolic acidosis, especially for patients with extended treatment and extrication times. While crush syndrome occurs due to the systemic effects of the injury, the onset can be as early as 1 hour postinjury. With a comprehensive understanding of the pathophysiology, diagnosis, management, and tactical considerations, a prehospital provider can optimize patient outcomes and be prepared with the tools they have on hand for the progression of crush injury into crush syndrome.

Comprehensive Review of Chest Tube Management: A Review

Devon Anderson, Sarah A Chen, Luis A Godoy, Lisa M Brown, David T Cooke

JAMA Surg. 2022 Mar 1;157(3):269-274

Importance: Thoracostomy, or chest tube placement, is used in a variety of clinical indications and can be lifesaving in certain circumstances. There have been developments and modifications to thoracostomy tubes, or chest tubes, over time, but they continue to be a staple in the thoracic surgeon's toolbox as well as adjacent specialties in medicine. This review will provide the nonexpert clinician a comprehensive understanding of the types of chest tubes, indications for their effective use, and key management details for ideal patient outcomes.

Observations: This review describes the types of chest tubes, indications for use, techniques for placement, common anatomical landmarks that are encountered with placement and management, and an overview of complications that may arise with tube thoracostomy. In addition, the future direction of chest tubes is explored, as well as the management of chest tubes during the COVID-19 pandemic.

Conclusions and relevance: Chest tube management is subjective, but the compilation of data can inform best practices and safe application to successfully manage the pleural space and ameliorate acquired pleural space disease.

Prehospital body temperature measurement in trauma patients: A literature review

Mozdalefa Azarkane, Tim W H Rijnhout, Heather McLellan, Edward C T H Tan

Injury. 2022 Jun;53(6):1737-1745

Objectives: Accidental hypothermia in trauma patients can contribute to cardiorespiratory dysfunction, acidosis, and coagulopathy, causing increased morbidity and mortality. The early recognition of the clinical signs of hypothermia and the accurate measurement of body temperature by prehospital care providers are essential to avoid deterioration. This review provides an overview of studies that examine the reliability of different core temperature measurement options, with a focus on the prehospital setting.

Methods: A search was performed in PubMed, Embase, Cochrane Library, and CINAHL using combinations of the Medical Subject Headings terms "ambulances," "emergency medical services," "thermometers," "body temperature," "hypothermia," and "body temperature regulation." Studies up to October 2021 were included, and different measurement options were listed and discussed. Eligible studies included those that identified the specific type of thermometer and focused on the out-of-hospital environment.

Results: The search strategy yielded 521 studies, five of which met the eligibility criteria. Four studies focused on tympanic temperature measurement, and one focused on temporal artery temperature measurement. Among the noninvasive options, tympanic temperature measurement was most frequently identified as a reliable option for out-of-hospital use.

Conclusion: A thermistor-based tympanic thermometer that features insulation of the ear and a temperature probe with a cap is likely the most suitable option for prehospital body temperature measurement in trauma patients. These results are based on outdated literature with currently more novel temperature measurement devices available. Future studies are necessary to provide strong recommendations regarding temperature measurement due to emerging technology, the lack of studies, and the heterogeneity of existing studies.

 

Head Wounds Received During Force-on-Force Training With Non-lethal Ammunition

Adam T Biggs, Matthew R Doubrava, Lanny F Littlejohn

Mil Med. 2022 May 3;187(5-6):e787-e791

Abstract

Close quarters combat training is designed to replicate the mental and physiological stressors of firing upon an adversary while in close proximity. One method to replicate combat stressors is to use non-lethal training ammunition specifically designed for force-on-force exercises. These rounds can be fired from slightly modified service-issued weapons and provide a pain sensation upon striking the opponent. The current investigation presents a case study of several injuries when these rounds impacted the head directly, which is a primary area of concern for safety issues. Most impacts produced initial swelling that reduced substantially within the first few hours. Approximately 24 hours later, the swelling disappeared entirely with a visible contusion near the impact center. Bruising would typically clear within a few days. However, another example produced sufficient bleeding to require intervention before continuing with the training exercises and sanguineous crust or scabbing rather than the typical contusion. Pain was minimal for all wounds after only several days, which aligns with previous research on pain from non-lethal training ammunition wounds. Based on the head wounds observed here, loss of eyesight is a realistic possibility. Eye protection should be a requisite across all force-on-force training exercises without exception. This case study documents some potential hazards of force-on-force training, but more importantly, it further highlights the need for medically informed training standards about engagement distances and personal protective equipment.

Relevance of Deployment Experience and Clinical Practice Characteristics on Military Critical Care Air Transport Team Readiness: A Study of Simulation Construct Validity

Daniel J Brown, Lane Frasier, F Eric Robinson, Mark Cheney, William T Davis, Ann Salvator, Mark Andresen, Melissa Proctor, Ryan Earnest, Timothy Pritts, Richard Strilka

Mil Med. 2022 May 27; Online ahead of print

Introduction: The Critical Care Air Transport Team (CCATT) Advanced course utilizes fully immersive high-fidelity simulations to train CCATT personnel and assess their readiness for deployment. This study aims to (1) determine whether these simulations correctly discriminate between students with previous deployment experience ("experienced") and no deployment experience ("novices") and (2) examine the effects of students' clinical practice environment on their performance during training simulations.

Materials and methods: Critical Care Air Transport Team Advanced student survey data and course status (pass/no pass) between March 2006 and April 2020 were analyzed. The data included students' specialty, previous exposure to the CCATT Advanced course, previous CCATT deployment experience, years in clinical practice (<5, 5-15, and >15 years), and daily practice of critical care (yes/no), as well as a description of the students' hospital to include the total number of hospital (<100, 100-200, 201-400, and >400) and intensive care unit (0, 1-10, 11-20, and >20) beds. Following descriptive analysis and comparative tests, multivariable regression was used to identify the predictors of passing the CCATT Advanced course.

Results: A total of 2,723 surveys were analyzed: 841 (31%) were physicians (MDs), 1,035 (38%) were registered nurses, and 847 (31%) were respiratory therapists (RTs); 641 (24%) of the students were repeating the course for sustainment training and 664 (24%) had previous deployment experience. Grouped by student specialty, the MDs', registered nurses', and RTs' pass rates were 92.7%, 90.6%, and 85.6%, respectively. Multivariable regression results demonstrated that deployment experience was a robust predictor of passing. In addition, the >15 years in practice group had a 47% decrease in the odds of passing as compared to the 5 to 15 years in practice group. Finally, using MDs as the reference, the RTs had a 61% decrease in their odds of passing. The daily practice of critical care provided a borderline but nonsignificant passing advantage, whereas previous CCATT course exposure had no effect.

Conclusion: Our primary result was that the CCATT Advanced simulations that are used to evaluate whether the students are mission ready successfully differentiated "novice" from "experienced" students; this is consistent with valid simulation constructs. Finally, novice CCATT students do not sustain their readiness skills during the period between mandated refresher training.

Tactical Combat Casualty Care Maritime Scenario: Shipboard Missile Strike

Frank K Butler Jr, Todd Burkholder, Michael Chernenko, James Chimiak, James Chung, Miguel Cubano, Jennifer M Gurney, Andrew B Hall, John B Holcomb, Joseph Kotora, Mark Lenart, Ann Long, Wayne Papalski, Thomas A Rich, Mike Tripp, Stacy A Shackelford, Matt D Tadlock, Jeffrey W Timby, Brendon Drew

J Spec Oper Med. 2022 May 31;22(2):9-28

Abstract

The types of injuries seen in combat action on a naval surface ship may be similar in many respects to the injuries seen in ground combat, and the principles of care for those injuries remain in large part the same. However, some contradistinctions in the care of combat casualties on a ship at sea must be highlighted, since this care may entail a number of unique challenges and different wounding patterns. This paper presents a scenario in which a guided missile destroyer is struck by a missile fired from an unmanned aerial vehicle operated by an undetermined hostile entity. Despite the presence of casualties who require care, the primary focus of a naval vessel that has just been damaged by hostile action is to prevent the ship from sinking and to conserve the fighting force on board the ship to the greatest extent possible. The casualties in this scenario include sailors injured by both blast and burns, as well as a casualty with a non-fatal drowning episode. Several of the casualties have also suffered the effects of a nearby underwater explosion while immersed. Challenges in the care of these casualties include delays in evacuation, the logistics of obtaining whole blood for transfusion while at sea, and transporting the casualties to the next higher level of care aboard a Casualty Receiving and Treatment Ship. As the National Defense Strategy pivots to a focus on the potential for maritime combat, the medical community must continue to maintain readiness by preparing fo.

 

Prehospital blood transfusion for haemorrhagic shock

Michael Cardinale, Quentin Mathais, Pierre Esnault, Jean Cotte

Lancet Haematol. 2022 Jun;9(6):e395

No abstract available

Opioid sparing effect of ketamine in military prehospital pain management-A retrospective study

Bar Cohen, Tomer Talmy, Shaul Gelikas, Irina Radomislensky, Diana Kontorovich-Chen, Barak Cohen, Avi Benov, Guy Avital

J Trauma Acute Care Surg. 2022 Aug 1;93(2S Suppl 1):S71-S77

Background: Opioids are the most commonly used analgesics in acute trauma, but are limited by slow onset and significant adverse effects. Ketamine is an effective and widely used analgesic. This study was aimed to evaluate the effectiveness and opioid-sparing effects of ketamine when used in prehospital military trauma setting.

Methods: A retrospective analysis of a prehospital military trauma registry between 2014 and 2020. Inclusion criteria were 16 years or older, two or more documented pain assessments, at least one indicating severe pain, and administration of opioids and/or low-dose ketamine. Joint hypothesis testing was used to compare casualties who received opioids only to those who received ketamine on outcomes of pain score reduction and opioid consumption.

Results: Overall, 382 casualties were included. Ninety-one (24%) received ketamine (21 as a single analgesic), with a mean dose of 29 mg (standard deviation, 11). Mean reduction in pain scores (on an 11-point scale) was not significantly different; 4.3-point (2.8) reduction in the ketamine group and 3.7 points (2.4) in the opioid-only group ( p = 0.095). Casualties in the ketamine group received a median of 10 mg (interquartile range, 3.5-25) of morphine equivalents (MEs) compared with a median of 20 ME (10, 20) in the opioid-only group. In a multivariable multinomial logistic regression, casualties in the ketamine group were significantly more likely to receive a low (1-10 ME) rather than a medium (11-20 ME) dose of opioids compared with the opioid-only group (odds ratio, 0.032; 95% confidence interval, 0.14-0.75).

Conclusion: The use of ketamine in the prehospital military setting as part of a pain management protocol was associated with a low rather than medium dose of opioids in a multivariable analysis, while the mean reduction in pain scores was not significantly different between groups. Using ketamine as a first-line agent may further reduce opioid consumption with a similar analgesic effect.

 

Lessons Learned on the Battlefield Applied in a Civilian Setting

Pierre-Yves Cordier, Clement Benoit, Frederik Belot-De Saint Leger, Ghislain Pauleau, Yvain Goudard

J Spec Oper Med. 2021 Spring;21(1):102-105.

 

Abstract

We report the case of a civilian 27-year-old man treated in a military hospital in France who sustained multiple stab wounds, including one in the left groin, with massive external bleeding. When first responders arrived, the patient was in hemorrhagic shock. A tourniquet and two intraosseous catheters were placed to start resuscitative care. On the patient's arrival at the hospital, bleeding was not controlled, so a junctional tourniquet was put in place and massive transfusion was started. Surgical exploration revealed a laceration of the superficial femoral artery and a disruption of the femoral vein. Vascular damage control was achieved by a general surgeon and consisted of primary repair of the superficial femoral artery injury and venous ligation. The patient was discharged from the intensive care unit after 2 days and from the hospital after 8 days. This case illustrates some of the persistent challenges shared between military and civilian trauma care. The external control of junctional hemorrhage is not easily achievable in the field, and junctional tourniquets have been therefore incorporated in the Tactical Combat Casualty Care guidelines. French lyophilized plasma was used for massive transfusion because it has been proven to be a logistically superior alternative to fresh-frozen plasma. Management of vascular wounds by nonspecialized surgeons is a complex situation that requires vascular damage-control skills; French military surgeons therefore follow a comprehensive structured surgical training course that prepares them to manage complex penetrating trauma in austere environments. Finally, in this case, lessons learned on the battlefield were applied to the benefit of the patient.

Opioid administration in the prehospital setting for patients sustaining traumatic injuries: An evaluation of national emergency medical services data

Michael K Dalton, Robert S Semco, Alexander J Ordoobadi, Eric Goralnick, John Chovanes, Ali Salim, Molly P Jarman

Injury. 2022 Sep;53(9):2923-2929

Introduction: Despite concerns about long-term dependence, opioids remain the mainstay of treatment for acute pain from traumatic injuries. Additionally, early pain management has been associated with improved long-term outcomes in injured patients. We sought to identify the patterns of prehospital pain management across the United States.

Methods: We used 2019 national emergency medical services (EMS) data to identify the use of pain management for acutely injured patients. Opioid specific dosing was calculated in morphine milligram equivalents (MME). The effects of opioids as well as adverse events were identified through objective patient data and structured provider documentation.

Results: We identified a total of 3,831,768 injured patients, 85% of whom were treated by an advanced life support (ALS) unit. There were 269,281 (7.0%) patients treated with opioids, including a small number of patients intubated by EMS (n = 1537; 0.6%). The median opioid dose was 10 MME [IQR 5-10] and fentanyl was the most commonly used opioid (88.2%). Patients treated with opioids had higher initial pain scores documented by EMS than those not receiving opioids (median: 9 vs 4, p<0.001), and had a median reduction in pain score of 3 points (IQR 1-5) based on the final prehospital pain score. Adverse events associated with opioid administration, including episodes of altered mental status (n = 453; 0.2%) and respiratory compromise (n = 252; 0.1%), were rare. For patients with severe pain (≥8/10), 27.3% of patients with major injuries (ISS ≥15) were treated with opioids, compared with 24.8% of those with moderate injuries (ISS 9-14), and 21.4% of those with minor (ISS 1-8) injuries (p<0.001).

Conclusion: The use of opioids in the prehospital setting significantly reduced pain among injured patients with few adverse events. Despite its efficacy and safety, the majority of patients with major injuries and severe pain do not receive opioid analgesia in the prehospital setting.

 

En Route Critical Care Evacuations From Rarely Utilized Partner Medical Treatment Facilities: A Case Series With Lessons Learned

William T Davis, Mark Cheney, Wesley Trueblood, Shane Runyon, Inez Cruz, Melissa Clemons, Richard Strilka

Mil Med. 2022 Mar 29; Online ahead of print

Abstract

Retaining lessons learned from Critical Care Air Transport (CCAT) missions is essential given the recent decrease in operational currency among CCAT personnel. The objective of this case series was to identify and analyze logistical lessons learned from recent critical care transports involving foreign medical treatment facilities with sufficient detail for the CCAT community to incorporate these lessons into future readiness and sustainment training. The provider from each mission submitted a mission narrative with lessons learned. A qualitative analysis of lessons learned described themes from the lessons, as well as similarities and differences from included missions. Three missions were reviewed and four distinct mission stages were identified: (1) pre-mission, (2) at U.S. aircraft, (3) away from U.S. aircraft, and (4) post-mission. Pre-mission lessons learned included the need for professional civilian attire for deployed CCAT teams and the limited availability of pre-mission clinical information. Lessons learned at the aircraft included the following: the need for flexible mission timelines, coordinate and pre-plan transitions with foreign medical teams when possible, and plan for difficult environmental conditions if flight line transfer is required. Lessons learned away from the aircraft included communication challenges between CCAT and the aircraft, contingency planning for narcotic transports, and equipment interoperability issues. Post-mission lessons learned included the need for written communication to disseminate information to the CCAT community. This case series described logistical challenges that present during transport missions involving foreign hospitals. This published series will enable dissemination to the en route care community for possible incorporation into future training.

Prehospital synergy: Tranexamic acid and blood transfusion in patients at risk for hemorrhage

Andrew-Paul Deeb, Lara Hoteit, Shimena Li, Francis X Guyette, Brian J Eastridge, Raminder Nirula, Gary A Vercruysse, Terence O'Keeffe, Bellal Joseph, Matthew D Neal, Jason L Sperry, Joshua B Brown

J Trauma Acute Care Surg. 2022 Jul 1;93(1):52-58

Background: Growing evidence supports improved survival with prehospital blood products. Recent trials show a benefit of prehospital tranexamic acid (TXA) administration in select subgroups. Our objective was to determine if receiving prehospital packed red blood cells (pRBC) in addition to TXA improved survival in injured patients at risk of hemorrhage.

Methods: We performed a secondary analysis of all scene patients from the Study of Tranexamic Acid during Air and ground Medical Prehospital transport trial. Patients were randomized to prehospital TXA or placebo. Some participating EMS services utilized pRBC. Four resuscitation groups resulted: TXA, pRBC, pRBC+TXA, and neither. Our primary outcome was 30-day mortality and secondary outcome was 24-hour mortality. Cox regression tested the association between resuscitation group and mortality while adjusting for confounders.

Results: A total of 763 patients were included. Patients receiving prehospital blood had higher Injury Severity Scores in the pRBC (22 [10, 34]) and pRBC+TXA (22 [17, 36]) groups than the TXA (12 [5, 21]) and neither (10 [4, 20]) groups (p < 0.01). Mortality at 30 days was greatest in the pRBC+TXA and pRBC groups at 18.2% and 28.6% compared with the TXA only and neither groups at 6.6% and 7.4%, respectively. Resuscitation with pRBC+TXA was associated with a 35% reduction in relative hazards of 30-day mortality compared with neither (hazard ratio, 0.65; 95% confidence interval, 0.45-0.94; p = 0.02). No survival benefit was observed in 24-hour mortality for pRBC+TXA, but pRBC alone was associated with a 61% reduction in relative hazards of 24-hour mortality compared with neither (hazard ratio, 0.39; 95% confidence interval, 0.17-0.88; p = 0.02).

Conclusion: For injured patients at risk of hemorrhage, prehospital pRBC+TXA is associated with reduced 30-day mortality. Use of pRBC transfusion alone was associated with a reduction in early mortality. Potential synergy appeared only in longer-term mortality and further work to investigate mechanisms of this therapeutic benefit is needed to optimize the prehospital resuscitation of trauma patients.

Ketamine Boluses Are Associated with a Reduction in Intracranial Pressure and an Increase in Cerebral Perfusion Pressure: A Retrospective Observational Study of Patients with Severe Traumatic Brain Injury

Bradley A Dengler, Oliver Karam, Colleen A Barthol, Aaron Chance, Laura E Snider, Clare M Mundy, Michael T Bounajem, William C Johnson, Moustafa M Maita, Paola M Mendez-Gomez, Ali Seifi, Shaheryar Hafee

Crit Care Res Pract. 2022 May 21;2022:3834165.

Background: Increased intracranial pressure (ICP) and hypotension have long been shown to lead to worse outcomes in the severe traumatic brain injury (TBI) population. Adequate sedation is a fundamental principle in TBI care, and ketamine is an attractive option for sedation since it does not commonly cause systemic hypotension, whereas most other sedative medications do. We evaluated the effects of ketamine boluses on both ICP and cerebral perfusion pressure (CPP) in patients with severe TBI and refractory ICP.

Methods: We conducted a retrospective review of all patients admitted to the neurointensive care unit at a single tertiary referral center who had a severe traumatic brain injury with indwelling intracranial pressure monitors. We identified those patients with refractory intracranial pressure who received boluses of ketamine. We defined refractory as any sustained ICP greater than 20 mmHg after the patient was adequately sedated, serum Na was at goal, and CO2 was maintained between 35 and 40 mmHg. The primary outcome was a reduction in ICP with a subsequent increase in CPP.

Results: The patient cohort consisted of 44 patients with a median age of 30 years and a median presenting Glasgow Coma Scale (GCS) of 5. The median reduction in ICP after administration of a ketamine bolus was -3.5 mmHg (IQR -9 to +1), and the postketamine ICP was significantly different from baseline (p < 0.001). Ketamine boluses led to an increase in CPP by 2 mmHg (IQR -5 to +12), which was also significantly different from baseline (p < 0.001).

Conclusion: In this single-institution study of patients with severe traumatic brain injury, ketamine boluses were associated with a reduction in ICP and an increase in CPP. This was a retrospective review of 43 patients and is therefore limited in nature, but further randomized controlled trials should be performed to confirm the findings.

The recovery position for maintenance of adequate ventilation and the prevention of cardiac arrest: A systematic review

Matthew J Douma, Anthony J Handley, Ella MacKenzie, James Raitt, Aaron Orkin, David Berry, Jason Bendall, Domhnall O'Dochartaigh, Christopher Picard, Jestin N Carlson, Therese Djärv, David A Zideman, Eunice M Singletary

Resusc Plus. 2022 Apr 29;10:100236

Aim: To conduct a systematic review of the use of the recovery position in adults and children with non-traumatic decreased levels of responsiveness changes outcomes in comparison with other positioning strategies.

Methods: We searched Medline (Ovid), Embase, Cochrane Library, CINAHL, medRxiv and Google Scholar from inception to 15 March 2021 for studies involving adults and children in an out-of-hospital, first aid setting who had reduced levels of responsiveness of non-traumatic aetiology but did not require resuscitative interventions. We used the ROBINS-I tool to assess risk of bias and GRADE methodology to determine the certainty of evidence.

Results: Of 17,947 citations retrieved, three prospective observational studies and four case series were included. The prone and semi-recumbent positions were associated with a decreased rate of suspected aspiration pneumonia in acute poisoning. Use of the recovery position in paediatric patients with decreased levels of responsiveness was associated with a deceased admission rate and the prone position was the position most commonly associated with sudden unexpected death in epilepsy. High risk of bias, imprecision and indirectness of evidence limited our ability to perform pooled analyses.

Conclusion: We identified a limited number of observational studies and case series comparing outcomes following use of the recovery position with outcomes when other patient positions were used. There was limited evidence to support or revise existing first aid guidance; however, greater emphasis on the initial assessment of responsiveness and need for CPR, as well as the detection and management of patient deterioration of a person identified with decreased responsiveness, is recommended.

An Analysis of the Incidence of Hypocalcemia in Wartime Trauma Casualties

Mireya A Escandon, Ashley D Tapia, Andrew D Fisher, Stacy A Shackelford, Vikhyat S Bebarta, Franklin L Wright, Susannah E Nicholson, Ronnie Hill, James A Bynum, Steven G Schauer

Med J (Ft Sam Houst Tex). 2022 Apr-Jun;(Per 22-04/05/06):17-21.

Objective: Background: Massive transfusion protocols implement the use of blood products to restore homeostasis. Citrated blood products are required for massive transfusions and can induce hypocalcemia, resulting in decreased cardiac contractility. Recent data suggests that major trauma alone is associated with hypocalcemia. This phenomenon remains poorly described. We seek to characterize the incidence and risk factors for early hypocalcemia in the setting of combat trauma.

Materials and methods: This is a secondary analysis of previously described data from the Department of Defense Trauma Registry from January 2007 to March 2020. In this sub-analysis, we selected only casualties that had at least one ionized calcium measurement. We defined hypocalcemia as an ionized calcium level of less than 1.2mmol/L.

Results: Within our study database, there were 142 adult casualties that met inclusion with at least one calcium value documented. We found 72 (51%) experienced at least one episode of hypocalcemia. Median composite injury severity score (ISS) was significantly lower in the control cohort compared to those with hypocalcemia (9 versus 15, p=0.010). Survival was similar between the two groups (97% versus 90%, p=0.166). On multivariable analysis when evaluating serious injuries by body region, only serious injuries to the extremities were significantly associated with developing hypocalcemia (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.00-2.21). When comparing prehospital interventions, only intravenous (IV) fluid administration was associated with high proportions experiencing hypocalcemia (25% versus 43%, p=0.029). In the multivariable model adjusted for ISS, mechanism of injury, and patient category, IV fluids were associated with the development of hypocalcemia (OR 2.48, 95% CI 1.03-5.94). When comparing vital signs, only respiratory rates were noted to be higher in the hypocalcemia cohort (18.6 versus 20.4, p=0.048).

Conclusions: Approximately half of combat casualties with available ionized calcium (iCa) level were hypocalcemic. Prehospital IV fluid use was associated with the development of hypocalcemia. Our study has implications for forward-staged medical teams with limited laboratory analysis capabilities. Additional research is needed to determine whether calcium replacement improves survival from traumatic injury and to identify the specific indications and timing for calcium replacement. This study will help inform a clinical study intended to aid in the development of clinical practice guidelines for deployed medical personnel.

Analgesia and Sedation for Tactical Combat Casualty Care: TCCC Proposed Change 21-02

Andrew D Fisher, Taylor T DesRosiers, Wayne Papalski, Michael A Remley, Steven G Schauer, Michael D April, Virginia Blackman, Jacob Brown, Frank K Butler Jr, Cord W Cunningham, Jennifer M Gurney, John B Holcomb, Harold R Montgomery, Margaret M Morgan, Sergey M Motov, Stacy A Shackelford, Timothy Sprunger, Brendon Drew

J Spec Oper Med. 2022 May 31;22(2):154-165

Abstract

Analgesia in the military prehospital setting is one of the most essential elements of caring for casualties wounded in combat. The goals of casualty care is to expedite the delivery of life-saving interventions, preserve tactical conditions, and prevent morbidity and mortality. The Tactical Combat Casualty Care (TCCC) Triple Option Analgesia guideline provided a simplified approach to analgesia in the prehospital combat setting using the options of combat medication pack, oral transmucosal fentanyl, or ketamine. This review will address the following issues related to analgesia on the battlefield: 1. The development of additional pain management strategies. 2. Recommended changes to dosing strategies of medications such as ketamine. 3. Recognition of the tiers within TCCC and guidelines for higher-level providers to use a wider range of analgesia and sedation techniques. 4. An option for sedation in casualties that require procedures. This review also acknowledges the next step of care: Prolonged Casualty Care (PCC). Specific questions addressed in this update include: 1) What additional analgesic options are appropriate for combat casualties? 2) What is the optimal dose of ketamine? 3) What sedation regimen is appropriate for combat casualties?

Mechanical Ventilation: A Review for Special Operations Medical Personnel

Jonathan Friedman, Seth M Assar

J Spec Oper Med. 2022 May 31;22(2):97-102

Abstract

Mechanical ventilation is machine-delivered flow of gases to both oxygenate and ventilate a patient who is unable to maintain physiological gas exchange, and positive-pressure ventilation (PPV) is the primary means of delivering invasive mechanical ventilation. The authors review invasive mechanical ventilation to give the Special Operations Force (SOF) medic a comprehensive conceptual understanding of a core application of critical care medicine.

Comparison of emergency airway management techniques in the performance of emergent Cricothyrotomy

Nicholas George, Gabriel Consunji, Jordan Storkersen, Fanglong Dong, Benjamin Archambeau, Richard Vara 3, Jan Serrano, Reza Hajjafar, Louis Tran, Michael M Neeki

Int J Emerg Med. 2022 May 30;15(1):24

Introduction: Emergent cricothyrotomy (EC) is a rare and lifesaving procedure to secure a difficult airway when other methods have failed. Many techniques have been discussed in the literature. This study aimed to identify major techniques used to perform EC in a regional trauma center and evaluate outcomes associated with the techniques.

Methods: Patients who underwent EC at Arrowhead Regional Medical Center between 1-1-2009 and 1-1-2019 were reviewed for eligibility for this study. Patients' data were extracted from the trauma database. Chi-square tests were conducted to assess the difference on variables between the techniques.

Results: A total of 51 (0.17%) of these patients required EC and were included in the database. The two most prevalent techniques were the scalpel-bougie-tube (SBT) and the surgical cricothyrotomy technique (SCT). More than half (n = 27, 52.9%) of the cohort received the SBT. There was no statistically significant difference between the two techniques with regards to demographic variables, including age (p = 0.7528), injury severity score (ISS, p = 0.896), gender (p = 0.3709), and race (p = 0.8935). However, the SCT group had a statistically higher Glasgow Coma Scale (GCS) than the SBT group (p = 0.0036). There was no statistically significant difference in mortality or complications between these two groups (p = 0.2172 for mortality).

Discussion: Two techniques of EC were identified as preferred techniques. Both procedures were successful in securing an emergency airway, noting a difference in the time to completion of the two techniques. Given the rarity of the procedure, practitioners may choose the method based on their training and the availability of appropriate instruments.

 

Committee on Surgical Combat Casualty Care position statement on the use of single surgeon teams and invited commentaries

Jennifer M Gurney, Shane D Jensen, Brian J Gavitt, Theodore D Edson, Shaun R Brown, Cord W Cunningham, Brendon G Drew, Matthew J Eckert, Andrew B Hall, John B Holcomb, Brian S Knipp, Richard N Lesperance, Travis M Polk, Martin A Schreiber, Matthew D Tadlock, Stacy A Shackelford

J Trauma Acute Care Surg. 2022 Aug 1;93(2S Suppl 1):S6-S11

Background: Over the last 20 years of war, there has been an operational need for far forward surgical teams near the point of injury. Over time, the medical footprint of these teams has decreased and the utilization of mobile single surgeon teams (SSTs) by the Services has increased. The increased use of SSTs is because of a tactical mobility requirement and not because of proven noninferiority of clinical outcomes. Through an iterative process, the Committee on Surgical Combat Casualty Care (CoSCCC) reviewed the utilization of SSTs and developed an expert-opinion consensus statement addressing the risks of SST utilization and proposed mitigation strategies.

Methods: A small triservice working group of surgeons with deployment experience, to include SST deployments, developed a statement regarding the risks and benefits of SST utilization. The draft statement was reviewed by a working group at the CoSCCC meeting November 2021 and further refined. This was followed by an extensive iterative review process, which was conducted to ensure that the intended messaging was clear to senior medical leaders and operational commanders. The final draft was voted on by the entire CoSCCC membership. To inform the civilian trauma community, commentaries were solicited from civilian trauma leaders to help put this practice into context and to further the discussion in both military and civilian trauma communities.

Results: After multiple revisions, the SST statement was finalized in January 2022 and distributed to the CoSCCC membership for a vote. Of 42 voting members, there were three nonconcur votes. The SST statement underwent further revisions to address CoSCCC voting membership comments. Statement commentaries from the President of the American Association for the Surgery for Trauma, the chair of the Committee on Trauma, the Medical Director of the Military Health System Strategic Partnership with the American College of Surgeons and a recently retired military surgeon we included to put this military relevant statement into a civilian context and further delineate the risks and benefits of including the trauma care paradigm in the Department of Defense (DoD) deployed trauma system.

Conclusion: The use of SSTs has a role in the operational environment; however, operational commanders must understand the tradeoff between tactical mobility and clinical capabilities. As SST tactical mobility increases, the ability of teams to care for multiple casualty incidents or provide sustained clinical operations decreases. The SST position statement is a communication tool to inform operational commanders and military medical leaders on the use of these teams on current and future battlefields.

US Central Command military blood utilization practices 2011 to 2020

Andrew B Hall, Iram Qureshi, Heidi McMinn, Joshua Kuper, Jennifer M Gurney, Matthew D Tadlock, Sylvain Cardin

J Trauma Acute Care Surg. 2022 Aug 1;93(2S Suppl 1):S30-S34

Background: Military involvement in Afghanistan ended in 2021, and while low-intensity troop engagements continue globally, casualty numbers are dwindling. To understand the clinical and operational connections between blood utilization and clinical paradigm shifts in resuscitation strategies, a review of blood product utilization and the changes in the last decade was conducted within the US Central Command area of responsibility. The intent of this review was to assess patterns of blood use during the last decade of the United States' involvement in the most recent major conflicts to potentially inform future blood requirements.

Methods: Blood product and types transfused between January 1, 2011, and December 31, 2020, were acquired from the Medical Situational Awareness in Theater blood reports. All reported blood usage data in the US Central Command area of responsibility were queried.

Results: Packed red blood cells and fresh frozen plasma (FFP) usage showed no statistically significant change over time ( τb = 0.24, p = 0.3252; τb = -0.47, p = 0.0603). Fresh and stored whole blood (SWB) use increased overtime ( τb = 0.69, p = 0.0056; τb = 0.83, p = 0.0015). A strong inverse relationship was found between SWB and FFP usage ( r = -0.68, p = 0.0309) and liquid plasma and FFP usage ( r = -0.65, p = 0.0407) over time.

Conclusion: Whole blood usage increased significantly over time with a preference for SWB. Component therapy is anticipated to remain a critical element of resuscitation in the event of large-scale combat operations secondary to supply chain and longer storage times.

The role of tranexamic acid in traumatic brain injury

Stephen Honeybul, Kwok M Ho, Jeffrey V Rosenfeld

J Clin Neurosci. 2022 May;99:1-4

Abstract

Evidence from recent trials evaluating efficacy of antifibrinolytic agents in the context of traumatic brain injury may lead to changes in the management of patients with traumatic brain injury. Tranexamic acid (TXA) reduces the proteolytic action of plasmin on fibrin clots, resulting in an inhibition of fibrinolysis and stabilisation of established blood clots. There has been significant interest in use of the drug as a therapeutic agent in the context of severe haemorrhage; however, considerable controversies regarding its efficacy remain. A number of trials have demonstrated a small but significant decrease in mortality following its administration, but the results have been somewhat inconsistent and may not be generalisable. The results of the CRASH-3 trial were that there was no statistical difference in the number of traumatic brain injury related deaths (18.5% with TXA and 19.8% with placebo; relative risk [RR] 0·94; 95% confidence interval [CI] 0·86-1·02). Nonetheless, there was a subgroup of patients for whom TXA appeared to provide benefit, and this was in patients with mild and moderate injury (with a Glasgow Coma Score > 8). This is potentially a very important finding that may have huge potential implications; however, we believe it does not currently provide indisputable evidence to support the administration of TXA to all patients with TBI. Further work is required to better define the subset of patients who may benefit as well as to evaluate the long-term functional benefit in order to determine which types of severe traumatic brain injury patients would derive more benefits than harms from TXA.

Intranasal ketamine versus intranasal fentanyl on pain management in isolated traumatic patients

Mehdi Nasr Isfahani, Omid Shokoohi, Keihan Golshani

J Res Med Sci. 2022 Jan 29;27:1

Background: Given the inadequate control of pain in patients with the trauma that refer to the emergency departments, the rapid onset of action of intranasal administration in pain management, and the avoidance of administering opioid medications, the present study aimed at evaluating the effect of intranasal ketamine versus intranasal fentanyl on pain management in isolated traumatic patients.

Materials and methods: The current study was performed on 125 patients that were divided into the following three groups: control group (n = 41), 1 mg/kg intranasal ketamine group (n = 40), and 1 μg/kg intranasal fentanyl group (n = 44). Then pain scores, heart rate, respiratory rate, blood pressure, and oxygen saturation were recorded at baseline, 5, 10, 15, 30, and 40 min after the intervention.

Results: Visual analog scale (VAS) scores of patients in the intranasal ketamine group 5 and 10 min after the intervention were 61.50 ± 20.45 and 55.00 ± 21.96, respectively. The mentioned scores were significantly lower than the VAS scores of patients in the control group with the mean of 72.44 ± 22.11 and 66.59 ± 24.25 and the VAS scores of patients in the intranasal fentanyl group with the mean of 71.59 ± 22.09 and 65.00 ± 22.87 at 5 and 10 min after the intervention, respectively (P < 0.05).

Conclusion: Given the onset of action in < 10 min, intranasal ketamine can be proposed as an appropriate analgesic medication in pain reduction of patients with isolated limb injuries. Moreover, the incidence rate and severity of adverse effects were insignificantly higher in the intranasal ketamine group as compared with the intranasal fentanyl group.

Pain management of nalbuphine and sufentanil in patients admitted intensive care unit of different ages

Kaiqiang Ji, Xiaoying Gong, Ting Luan, Xiaopeng Gao, Bin Zang

BMC Emerg Med. 2022 Mar 26;22(1):50

Background: Pain relief for patients in the intensive care unit (ICU) can improve treatment outcomes and reduce the burden on doctors and nurses. This study aims to report the clinical analgesic and sedative effects of nalbuphine and sufentanil on ICU patients.

Methods: This study retrospectively analyzed the medical records of 87 critically ill patients who received nalbuphine or sufentanil infusion in the ICU, including demographic data, diagnosis, Acute Physiology and Chronic Health Evaluation (APACHE) II, Critical Care Pain Observation Tool (CPOT), Richmond Agitation-Sedation Scale (RASS), systolic and diastolic blood pressure, heart rate and blood oxygen saturation (SpO2). The primary outcomes of this study were CPOT and RASS scores. The secondary outcomes were hemodynamic changes, including systolic blood pressure, diastolic blood pressure, heart rate, and SpO2. The adverse events recorded during pain management, such as hypoxemia, respiration depression and bradycardia, were also collected and analyzed.

Results: None of the patients in both groups experienced episode of hypoxemia, respiration depression and bradycardia. However, age-stratified analyses showed that nalbuphine has a better analgesic effect than sufentanil for patients aged ≤ 60 (P < 0.05). In contrast, sufentanil showed a better analgesic effect than nalbuphine for patients aged > 60 ( P < 0.05). Furthermore, nalbuphine has a significantly better sedative effect than sufentanil for patients aged ≤ 60 (P < 0.05).

Conclusion: ICU patients of different age groups may be suitable for different analgesics. For patients under the age of 60, nalbuphine has better analgesia and sedation than sufentanil, and does not cause respiratory depression and drastic hemodynamic changes.

The Future of Prehospital Critical Care

Adam Johnson, Max Dodge, Andrew D Fisher

J Spec Oper Med. 2022 May 31;22(2):116-118

Abstract

As technology improves, the capabilities of prehospital providers increase. Innovations and realizations from military counterparts are being transitioned to civilian emergency care with the same hopes of increasing survivability of patients. Looking to the future, the incorporation of drone aircraft in the critical care field will likely impact the way medicine is practiced. Education is the key to improving outcomes in the prehospital setting.

Travel-Associated Venous Thromboembolism

Isla McKerrow Johnson, Joseph Shatzel, Sven Olson, Tovah Kohl, Andrew Hamilton, Thomas G DeLoughery

Wilderness Environ Med. 2022 Jun;33(2):169-178

Introduction: Long-distance travel is assumed to be a risk factor for venous thromboembolism (VTE). However, the available data have not clearly demonstrated the strength of this relationship, nor have they shown evidence for the role of thromboprophylaxis.

Methods: We performed a systematic review of the literature. We also summarized available guidelines from 5 groups.

Results: We found 18 studies that addressed this question. Based on the data presented in the review, we conclude that there is an association between VTE and length of travel, but this association is mild to moderate in effect size with odds ratios between 1.1 and 4. A dose-response relationship between VTE and travel time was identified, with a 26% higher risk for every 2 h of air travel (P=0.005) starting after 4 h. The quality of evidence for both travel length and thromboprophylaxis was low. However, low-risk prophylactic measures such as graduated compression stockings were shown to be effective in VTE prevention. There is heterogeneity among the different practice guidelines. The guidelines generally concur that no prophylaxis is necessary in travelers without known thrombosis risk factors and advocate for conservative treatment such as compression stockings over pharmacologic prophylaxis.

Conclusions: We conclude air travel is a risk factor for VTE and that there is a dose relationship starting at 4 h. For patients with risk factors, graduated compression stockings are effective prophylaxis.

Development of Data-Driven Triage Systems for Identifying Mortally Wounded Casualties-Implications for Future Large-Scale Combat Operations

Sara Johnson, Ryann S Lauby, Michael D April, Joseph K Maddry, Luke Hofmann, Kevin Gillespie, Jose Salinas, Steven G Schauer

Med J (Ft Sam Houst Tex). 2022 Apr-Jun;(Per 22-04/05/06):32-39.

Background: Uncontested air movement and advances for medical care of combat casualties have resulted in a decreased case fatality rate. However, in future large-scale combat operations, the military has established a plan for multidomain operations to defeat near-peer adversaries. Prolonged casualty care and mass casualty scenarios will become more prevalent. Prehospital friendly scoring systems such as the shock index (SI) and revised trauma score (RTS) may provide useful triage data. Development of accurate, data-driven, triage systems will be key to optimize management of resources, care, and transport of combat casualties.

Methods: We included data from the Department of Defense Trauma Registry between 01 January 2007 to 17 March 2020. Data comprised of adult US military or coalition service members for analysis as the baseline cohort, and those who died within 24 hours were included in the early death cohort. We performed statistical analysis on demographics and injury data, SI and RTS to measure the receiver operating characteristics (ROC) of each value to predict early death.

Results: The early death cohort had a significantly higher injury severity score (25 vs. 5) and a higher percentage of serious injuries in every body region than the baseline cohort. The early death cohort sustained serious injuries to the head and neck at a rate five times that of the baseline cohort (43.4% vs 8.1%) with odds ratio (OR) of death 8.0 (95% confidence interval 5.7-11.1) followed by skin (13.6% versus 1.9%) with an OR of 6.3 (95% CI 3.8-10.3). The mean SI was 1.21 versus 0.80. The revised trauma score (RTS) was 4.18 versus 7.34. The RTS had a higher area under the receiver operating characteristic (0.896 versus 0.716 for SI).

Conclusions: Serious injuries to the head and skin were most strongly associated with death within the first 24 hours. The RTS appears to be a more accurate tool than SI alone for assessing injury mortality. Military medical personnel should consider these factors when triaging casualties during future conflicts in resource limited settings with delayed evacuation.

Association of Tranexamic Acid Administration With Mortality and Thromboembolic Events in Patients With Traumatic Injury: A Systematic Review and Meta-analysis

Vivien Karl, Sophie Thorn, Tim Mathes, Simone Hess, Marc Maegele

JAMA Netw Open. 2022 Mar 1;5(3):e220625

Importance: Tranexamic acid is widely available and used off-label in patients with bleeding traumatic injury, although the literature does not consistently agree on its efficacy and safety.

Objective: To examine the association of tranexamic acid administration with mortality and thromboembolic events compared with no treatment or with placebo in patients with traumatic injury in the literature.

Data sources: On March 23, 2021, PubMed, Embase, and the Cochrane Library were searched for eligible studies published between 1986 and 2021.

Study selection: Randomized clinical trials and observational studies investigating tranexamic acid administration compared with no treatment or placebo among patients with traumatic injury and traumatic brain injury who were 15 years or older were included. Included studies were published in English or German. The electronic search yielded 1546 records, of which 71 were considered for full-text screening. The selection process was performed independently by 2 reviewers.

Data extraction and synthesis: The study followed the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were extracted by 2 independent reviewers and pooled using the inverse-variance random-effects model.

Main outcomes and measures: Outcomes were formulated before data collection and included mortality at 24 hours and 28 and 30 days (1 month) as well as the incidence of thromboembolic events and the amount of blood products administered. Owing to missing data, overall mortality was added and the amount of blood products administered was discarded.

Results: Thirty-one studies with a total of 43 473 patients were included in the systematic review. The meta-analysis demonstrated that administration of tranexamic acid was associated with a significant decrease in 1-month mortality compared with the control cohort (risk ratio, 0.83 [95% CI, 0.71-0.97]; I2 = 35%). The results of meta-analyses for 24-hour and overall mortality and thromboembolic events were heterogeneous and could not be pooled. Further investigations on clinical heterogeneity showed that populations with trauma and trial conditions differed markedly.

Conclusions and relevance: These findings suggest that tranexamic acid may be beneficial in various patient populations with trauma. However, reasonable concerns about potential thromboembolic events with tranexamic acid remain.

 

The Newest Battlefield Opioid, Sublingual Sufentanil: A Proposal to Refine Opioid Usage in the U.S. Military

Sharon Y Kim, Chester C Buckenmaier, Edmund G Howe, Kwang H Choi

Mil Med. 2022 Mar 28;187(3-4):77-83

Abstract

There is an ongoing opioid epidemic in the USA, and the U.S. military is not immune to the health threat. To combat the epidemic, the Department of Defense (DoD) and Department of Veterans' Affairs (DVA) issued new clinical practice guidelines and launched the Opioid Safety Initiative aimed at reducing opioid prescriptions. Furthermore, the DoD continually refined opioid protocols for acute pain on the battlefield, evolving from intramuscular morphine to intravenous morphine administration to oral transmucosal fentanyl citrate lollipops (Actiq) to finally sublingual sufentanil tablets (SSTs, Dsuvia). Interestingly, the newest introduction of SSTs into the military sparked great controversy, as there are concerns over the drug's potential for misuse. However, although the opioid crisis may understandably foster an aversion to new candidate opioids, the therapeutic benefits of effective opioids in acute trauma settings should not be overlooked. SSTs may offer an improved analgesic option to meet the battlefield's unmet needs with its non-invasive, sublingual delivery system and favorable pharmacologic properties that mitigate the risk for side effects, addiction, and adverse outcomes. Accordingly, this commentary aims to (1) review the evolution of opioid use on the battlefield and discuss the medical benefits and limitations of SSTs in acute trauma settings, (2) highlight the importance of chronic pain management post-deployment through evidence-based non-opioid modalities, and (3) explore avenues of future research. Ultimately, we propose that SSTs are an important improvement from existing battlefield opioids and that refining, not abandoning, opioid usage will be key to effectively managing pain in the military.

Warfighter Personal Protective Equipment and Combat Wounds

Michael J Klausner, Jerome T McKay, Vikhyat S Bebarta, Jason F Naylor, Andrew D Fisher, Kristine D Isherwood, James Bynum, Steven G Schauer

Med J (Ft Sam Houst Tex). 2021 Apr-Jun;(PB 8-21-04/05/06):72-77.

Background: Personal protective equipment (PPE) is crucial to force protection and preservation. Innovation in PPE has shifted injury patterns, with protected body regions accounting for decreased proportions of battlefield trauma relative to unprotected regions. Little is known regarding the PPE in use by warfighters at the time of injury.

Methods: We queried the Prehospital Trauma Registry (PHTR) for all encounters from 2003-2019. This is a sub-analysis of casualties with documented PPE at the time of medical encounter. When possible, encounters were linked to the Department of Defense Trauma Registry (DODTR) for outcome data. Serious injuries are defined as an abbreviated injury scale of 3 or greater.

Results: Of 1,357 total casualty encounters in the PHTR, 83 were US military with documented PPE. We link 62 of this cohort to DODTR. The median composite Injury Severity Score (ISS) was 6 (Interquartile range (IQR) 4-21), and 11 casualties (18%) had an ISS >25. The most seriously injured body regions were the extremities (21%), head/neck (16%), thorax (16%), and abdomen (10%). PPE worn at time of injury included helmet (91%), eye protection (73%), front (75%) and rear plates (77%), left/right plates (65%), tactical vest (46%), groin protection (12%), neck protection (6%), pelvic shield (3%), and deltoid protection (3%).

Conclusion: Our data set demonstrates that the extremities were the most commonly injured body region, followed by head/neck, and thorax. PPE designed for the extremities and neck are also among the least commonly worn protective equipment.

 

Effectiveness and safety of tranexamic acid in pediatric trauma: A systematic review and meta-analysis

Emily Kornelsen, Nathan Kuppermann, Daniel K Nishijima, Lily Y Ren, Maggie Rumantir, Peter J Gill, Yaron Finkelstein

Am J Emerg Med. 2022 May;55:103-110

Objective: Trauma is the leading cause of childhood death in the United States. Our goal was to determine the effectiveness of tranexamic acid (TXA) in improving survival in pediatric trauma.

Methods: MEDLINE (OVID), Embase (OVID), Cochrane Central Register databases, CINAHL (EBSCO), Web of Science (Clarivate Analytics), and grey literature sources were searched for publications reporting survival and safety outcomes in children receiving TXA in acute trauma, with no language restrictions, published until February 11, 2021. Two independent researchers assessed studies for eligibility, bias, and quality. Data on the study setting, injury type, participants, design, interventions, TXA dosing and outcomes were extracted. The primary outcome was survival in children who received TXA following trauma. Forest plots of effect estimates were constructed for each study. Heterogeneity was assessed and data were pooled by meta-analysis using a random-effects model.

Results: Fourteen articles met inclusion criteria - six single-institution and eight multicentre retrospective cohort studies. Overall, TXA use was not associated with increased survival in pediatric trauma (adjusted odds ratio [aOR]: 0.61, 95% CI: 0.30-1.22) after adjustment for patient-level variables, such as injury severity. Increased survival was documented in the subset of children experiencing trauma in combat settings (aOR for mortality: 0.31, 95% CI: 0.14-0.68). There were no differences in the odds of thromboembolic events (OR 1.15, 95% CI: 0.46-2.87) in children who received TXA versus not.

Conclusions: The utility of TXA in children with trauma is unclear. Guidelines supporting TXA use in pediatric trauma may not be based on the available evidence of its use in this context. Rigorous trials measuring survival and other meaningful outcomes and exploring optimal TXA dosing are urgently needed. Study Registration (PROSPERO): CRD42020157683.

 

United States Military Fatalities During Operation Inherent Resolve and Operation Freedom's Sentinel

Russ S Kotwal, Jud C Janak, Jeffrey T Howard, Andrew J Rohrer, Howard T Harcke, John B Holcomb, Brian J Eastridge, Jennifer M Gurney, Stacy A Shackelford, Edward L Mazuchowski

Mil Med. 2022 May 11; Online ahead of print.

Background: Military operations provide a unified action and strategic approach to achieve national goals and objectives. Mortality reviews from military operations can guide injury prevention and casualty care efforts.

Methods: A retrospective study was conducted on all U.S. military fatalities from Operation Inherent Resolve (OIR) in Iraq (2014-2021) and Operation Freedom's Sentinel (OFS) in Afghanistan (2015-2021). Data were obtained from autopsy reports and other existing records. Fatalities were evaluated for population characteristics; manner, cause, and location of death; and underlying atherosclerosis. Non-suicide trauma fatalities were also evaluated for injury severity, mechanism of death, injury survivability, death preventability, and opportunities for improvement.

Results: Of 213 U.S. military fatalities (median age, 29 years; male, 93.0%; prehospital, 89.2%), 49.8% were from OIR, and 50.2% were from OFS. More OIR fatalities were Reserve and National Guard forces (OIR 22.6%; OFS 5.6%), conventional forces (OIR 82.1%; OFS 65.4%), and support personnel (OIR 61.3%; OFS 33.6%). More OIR fatalities also resulted from disease and non-battle injury (OIR 83.0%; OFS 28.0%). The leading cause of death was injury (OIR 81.1%; OFS 98.1%). Manner of death differed as more homicides (OIR 18.9%; OFS 72.9%) were seen in OFS, and more deaths from natural causes (OIR 18.9%; OFS 1.9%) and suicides (OIR 29.2%; OFS 6.5%) were seen in OIR. The prevalence of underlying atherosclerosis was 14.2% in OIR and 18.7% in OFS. Of 146 non-suicide trauma fatalities, most multiple/blunt force injury deaths (62.2%) occurred in OIR, and most blast injury deaths (77.8%) and gunshot wound deaths (76.6%) occurred in OFS. The leading mechanism of death was catastrophic tissue destruction (80.8%). Most fatalities had non-survivable injuries (80.8%) and non-preventable deaths (97.3%).

Conclusions: Comprehensive mortality reviews should routinely be conducted for all military operation deaths. Understanding death from both injury and disease can guide preemptive and responsive efforts to reduce death among military forces.

An Updated Review of Improvised Ground Evacuation Platforms for Austere Special Operations Casualty Transport

Joseph A Mazarella, Timothy B Pekari, Ivan J Antosh

Med J (Ft Sam Houst Tex). 2022 Apr-Jun;(Per 22-04/05/06):56-61

Introduction: In 2018, the Expeditionary Resuscitative Surgical Team 3 (ERST-3) published a retrospective review on the ground casualty evacuation (CASEVAC) options available to a Special Operations Forces (SOF) unit in the Horn of Africa. Seventeen months following their deployment, ERST-7 provided an update on the improvised ground evacuation platforms in the same area of operations and what has and has not worked based on combat experience and new literature.

Methods: This publication is an update to a retrospective review of various modes of ground transportation used by ERST-7 during their deployment with Special Operations Command Africa from July 2020 to January 2021. The authors excluded all hand-carried litter and air evacuation platforms. The authors discuss litter setup, necessary modifications, litter capacity, strengths and weaknesses, and any recommendations for a Mine-Resistant Ambush Protected (MRAP) vehicle, a full-size pickup truck, and a mid-size pickup truck based on their use during the ERST-7 deployment. The authors also used previous literature to support their recommendations.

Results: The SOF unit to which ERST-7 was assigned still uses two of the four platforms included in the original study. The authors recommend continued use of the MRAP for patient extraction with a solely widthwise patient configuration, weather-proofing the open beds of MRAPs, and outfitting all MRAPs for Tactical Combat Casualty Care (TCCC) if the CASEVAC-designated MRAP is disabled. The pickup trucks functioned well for expedient CASEVAC under non-hostile conditions. However, they should be a last resort for CASEVAC outside friendly-controlled areas due to inadequate cover and concealment for patients and medical personnel providing enroute care.

Conclusions: Vehicles of opportunity available to SOF personnel are constantly changing. Continuous evaluation of local platforms is crucial, especially for partner force personnel who may not have access to dedicated air and ground MEDEVAC platforms. The authors recommend baseline readiness training on CASEVAC scenarios for those units traveling to areas without MEDEVAC assets.

Keywords: CASEVAC; austere; casualty evacuation; ground evacuation; medical evacuation; patient transport; prolonged field care; special operations.

Prehospital extremity tourniquet placements-performance evaluation of non-EMS placement of a lifesaving device

Ava K Mokhtari, Sarah Mikdad, Casey Luckhurst, John Hwabejire, Jason Fawley, Jonathan J Parks, April E Mendoza, Haytham M A Kaafarani, George C Velmahos, Frank W Bloemers, Noelle N Saillant

Eur J Trauma Emerg Surg. 2022 May 10. Online ahead of print.

Background: The education of civilians and first responders in prehospital tourniquet (PT) utilization has spread rapidly. We aimed to describe trends in emergency medical services (EMS) and non-EMS PT utilization, and their ability to identify proper clinical indications and to appropriately apply tourniquets in the field.

Methods: A retrospective cohort study was conducted to evaluate all adult patients with PTs who presented at two Level I trauma centers between January 2015 and December 2019. Data were collected via an electronic patient query tool and cross-referenced with institutional Trauma Registries. Medically trained abstractors determined if PTs were clinically indicated (limb amputation, vascular hard signs, injury requiring hemostasis procedure, or significant documented blood loss). PTs were further designated as appropriately or inappropriately applied (based on tourniquet location, venous tourniquet, greater than 2-h ischemic time). Descriptive statistics and univariate analyses were performed.

Results: 146 patients met inclusion criteria. The incidence of yearly PT placements increased between 2015 and 2019, with an increase in placement by non-EMS personnel (police, firefighter, bystander, and patient). Improvised PTs were frequently utilized by bystanders and patients, whereas first responders had high rates of commercial tourniquet use. A high proportion of tourniquets were placed without indication (72/146, 49%); however, the proportion of PTs placed without a proper indication across applier groups was not statistically different (p = 0.99). Rates of inappropriately applied PTs ranged from 21 to 46% across all groups applying PTs.

Conclusions: PT placement was increasingly performed by non-EMS personnel. Present data indicate that non-EMS persons applied PTs at a similar performance level of those applied by EMS. Study LevelLevel III.

The new face of war: Craniofacial injuries from Operation Inherent Resolve

Daniel C Neubauer, Macario Camacho, Eamon B O'Reilly, Matthew Brice, Jennifer M Gurney, Matthew J Martin

J Trauma Acute Care Surg. 2022 Aug 1;93(2S Suppl 1):S49-S55

Background: During the last 20 years of conflict in the Middle East, improvements in body armor and the use of improvised explosive devices have resulted in an increased incidence of complex craniofacial trauma (CFT). Currently, CFT comprises up to 40% of all casualties. We present new data from the recent conflict in Iraq and Syria during Operation Inherent Resolve.

Methods: Data were collected for patients treated at role 1, role 2, and role 3 facilities in Iraq and Syria over a 1-year period. During this time, a specialized head & neck surgical augmentation team was deployed and colocated with the central role 3 facility. Data included for this cross-sectional study are as follows: injury type and mechanism, triage category, initial managing facility and subsequent levels of care, and procedures performed.

Results: Ninety-six patients sustained CFT over the study period. The most common injuries were soft tissue (57%), followed by cranial (44%) and orbital/facial (31%). Associated truncal and/or extremity injuries were seen in 46 patients (48%). There were marked differences in incidence and pattern of injuries between mechanisms (all p < 0.05). While improvised explosive devices had the highest rate of cranial and truncal injuries, gunshot wounds and blunt mechanisms had higher incidences of orbital/facial and neck injuries. Overall, 45% required operative interventions including complex facial reconstruction, craniotomy, and open globe repair. Mortality was 6% with 83% due to associated severe brain injury. Most patients were local nationals (70%) who required discharge or transfer to the local health care system.

Conclusion: Complex craniofacial trauma is increasingly seen by deployed surgeons, regardless of subspecialty training or location. Deployment of a centrally located head and neck team greatly enhances the capabilities for forward deployed management of CFT, with excellent outcomes for both US and local national patients.

Clinical Characteristics of Patients Undergoing Needle Thoracostomy in a Canadian Helicopter Emergency Medical Service

Graham Newton, Gudrun Reay, Catherine M Laing, Kathryn King-Shier

Prehosp Emerg Care. 2022 May-Jun;26(3):400-405

Objective: Needle thoracostomy (NT) can be a life-saving procedure when used to treat tension pneumothorax. However, there is some question regarding the efficacy of NT in the prehospital setting. Failure to treat tension pneumothorax in a helicopter emergency medical service (HEMS) setting may prove especially deleterious to the patient due to gas expansion with increasing altitude. This study's objective was to identify the characteristics of patients treated with NT in a Canadian HEMS setting and the factors that may influence outcomes following NT use.Methods: This was a retrospective chart review of prehospital records from a Canadian HEMS service. Patients aged 18 years and older who underwent at least one NT attempt using a 14-gauge 8.3 cm needle from 2012 to 2018 were identified. Charts were reviewed to collect demographic data, NT procedural characteristics, vital signs, and clinical response metrics. Descriptive statistics were used to characterize the study sample and overall event characteristics. Binary logistic regression was performed to identify variables associated with a clinical response to the initial NT treatment.Results: 163 patients (1.3%) of 12,407 patients attended received NT. A positive clinical response to NT was recorded in 37% (n = 77) of the total events (n = 208), the most common of which was an improvement in blood pressure (BP) (18.8%, n = 39). Initial NT was associated with a low likelihood of clinical improvement in patients presenting with blunt trauma (OR = 0.18; p = .021; 95% CI [.04, .77]), CPR prior to NT (OR = 0.14; p = .02; 95% CI [.03, .73]), or in those who received bilateral NT treatment (OR = 0.13; p < .01; 95% CI [.05, .37]). A pretreatment BP < 90 mmHg was predictive of a positive clinical response to initial NT (OR = 3.33; p = .04; 95% CI [1.09, 10.20]).Conclusions: Only a small portion of patients in the setting of a Canadian HEMS service were treated with NT. Patients most likely to receive NT were males who had suffered blunt trauma. NT may have questionable benefit for patients presenting with blunt trauma, in cardiac arrest, or requiring bilateral NT.

Burn injuries in US service members: 2001-2018

Katheryne G Perez, Susan L Eskridge, Mary C Clouser, Jill M Cancio, Leopoldo C Cancio, Michael R Galarneau

Burns. 2022 Mar 23; Online ahead of print.

Introduction: Burns are an important cause of battlefield injury, accounting for 5-20% of the combat injury burden. To date, no report has examined the full range of burns, from mild to severe, resulting from post-9/11 conflicts. The present study leverages the Expeditionary Medical Encounter Database (EMED), a Navy-maintained health database describing all service member medical encounters occurring during deployment, to capture, quantify and characterize burn-injured service members and the injuries they sustained while deployed in support of post-9/11 operations.

Methods: The EMED was queried for all surviving service members with at least one burn injury, identified using injury-specific Abbreviated Injury Scale codes. Demographic and additional injury information were also obtained from the EMED.

Results: From 2001 through 2018, 2507 deployed service members sustained 5551 burns. Blasts accounted for 82% of injuries, largely attributed to the use of improvised explosive devices. Concurrent injury was common, with 30% sustaining a traumatic brain injury and 10% sustaining inhalation injury. Most burns were small, with 92% involving< 20% TBSA; 85% of burns involved< 10% TBSA. The head and the hands were the most commonly affected areas, accounting for 48% of all burns, with 80% of service members sustaining at least one burn to these areas.

Conclusion: The majority of burns tend to be small in size, with the head and hands most commonly affected. As these areas are often left uncovered by the uniform, prevention measures, particularly improvement in and increased usage of personal protective gear, may help reduce these injuries and their consequences.

Arctic Tactical Combat Casualty Care

Kyle Samblanet, Molly Booy

J Spec Oper Med. 2022 Jun 1;22(2):127-128

No abstract available

Training on a virtual reality cricothyroidotomy simulator improves skills and transfers to a simulated procedure

Ganesh Sankaranarayanan, Coleman A Odlozil, Salman S Hasan, Rehma Shabbir, Di Qi, Melih Turkseven, Suvranu De, Geoffrey Funk, Rebecca J Weddle

Trauma Surg Acute Care Open. 2022 Mar 1;7(1):e000826

Objective: The virtual airway skills trainer (VAST) is a virtual reality simulator for training in cricothyroidotomy (CCT). The goal of the study is to test the effectiveness of training and transfer of skills of the VAST-CCT.

Methods: Two groups, control (no training) and simulation (2 weeks of proficiency-based training), participated in this study. Subjects in the control condition did not receive any training on the task whereas those in the simulation received a proficiency-based training on the task during a period of 2 weeks. Two weeks post-training, both groups performed CCT on the TraumaMan to demonstrate the transfer of skills.

Results: A total of (n=20) subjects participated in the study. The simulation group performed better than the control group at both the post-test (p<0.001) and retention test (p<0.001) on the simulator. The cumulative sum analysis showed that all subjects in the simulation group reached proficiency with acceptable failure rate within the 2 weeks of training. On the transfer test, the simulation group performed better on skin cut (p<0.001), intubation (p<0.001) and total score (p<0.001) than the control group.

Conclusions: The VAST-CCT is effective in training and skills transfer for the CCT procedure.

Efficiency of laryngeal mask airway ProtectorTM and i-gel® as a conduit in Aintree catheter-guided fibreoptic tracheal intubation: a randomised clinical trial

Kemal T Saracoglu, Ayse Turan, Asli Aydas, Mehmet Yilmaz

Anaesthesiol Intensive Ther. 2022;54(2):120-126

Background: Fibreoptic intubation through a supraglottic airway device (SAD) is recom-mended in difficult airway management algorithms. The Difficult Airway Society published a guideline describing the details of this technique in 2011. This study was designed to compare the efficiency of two different 2nd generation SADs as a conduit for Aintree catheter-guided fibreoptic tracheal intubation.

Methods: 80 adult patients with an ASA score of 1-3 undergoing elective surgical procedures were included in the study. The patients were intubated after randomization to two groups: the i-gel group and the laryngeal mask airway (LMA) Protector group. SAD insertion time and tracheal intubation time were recorded separately. Demographic data, changes in haemodynamic parameters during the procedure, and complications were noted.

Results: In the LMA Protector and i-gel groups, the number of attempts (1.14 ± 0.35 vs. 1.24 ± 0.49 times, P = 0.394), device insertion time (14.89 ± 8.11 vs. 17.84 ± 16.59 seconds, P = 0.896), and the need for an optimization manoeuvre (43.2% vs. 37.8%, P = 0.813) were similar (P > 0.05). The fibreoptic laryngeal appearance scale and haemodynamic parameters were similar (P > 0.05). However, the airway complication rate was significantly higher in the LMA Protector group than in the i-gel group (21.6% vs. 2.7%, P = 0.013). The most common complications were bronchospasm and bloody secretion on SAD.

Conclusions: With the stable haemodynamic parameters, acceptable insertion time and lower complication rate, we concluded that the i-gel may be preferable in fibre-optic tracheal intubation. The rigid structure of the LMA Protector compared to the i-gel might contribute to this result.

 

Simulation-based education improves military trainees' skill performance and self-confidence in tourniquet placement: A randomized controlled trial

Ross J Scalese, S Barry Issenberg, Matthew Hackett, Richard D Rodriguez, Angel A Brotons, Marco Gonzalez, James J Geracci, Carl I Schulman

J Trauma Acute Care Surg. 2022 Aug 1;93(2S Suppl 1):S56-S63

Background: Tactical Combat Casualty Care (TCCC) is the standard of care for stabilization and treatment of military trauma patients. The Department of Defense has mandated that all service members receive role-based TCCC training and certification. Simulation education can increase procedural skills by providing opportunities for deliberate practice in safe, controlled environments. We developed and evaluated the effectiveness of a simulation-based TCCC training intervention to improve participants' skill performance and self-confidence in tourniquet placement.

Methods: This study was a single-blinded, randomized trial with waitlist controls. Army Reserve Officers Training Corp cadets from a single training battalion comprised the study population. After randomization and baseline assessment of all participants, group A alone received focused, simulation-based TCCC tourniquet application training. Three months later, all participants underwent repeat testing, and after crossover, the waitlist group B received the same intervention. Two months later, all cadets underwent a third/final assessment. The primary outcome was tourniquet placement proficiency assessed by total score achieved on a standardized eight-item skill checklist. A secondary outcome was self-confidence in tourniquet application skill as judged by participants' Likert scale ratings.

Results: Forty-three Army Reserve Officers Training Corp cadets completed the study protocol. Participants in both group A (n = 25) and group B (n = 18) demonstrated significantly higher performance from baseline to final assessment at 5 months and 2 months, respectively, following the intervention. Mean total checklist score of the entire study cohort increased significantly from 5.53 (SD = 2.00) at baseline to 7.56 (SD = 1.08) at time 3, a gain of 36.7% ( p < 0.001). Both groups rated their self-confidence in tourniquet placement significantly higher following the training.

Conclusion: A simulation-based TCCC curriculum resulted in significant, consistent, and sustained improvement in participants' skill proficiency and self-confidence in tourniquet placement. Participants maintained these gains 2 months to 5 months after initial training.

 

How effective are different models of pelvic binders: results of a study using a Pelvic Emergency Simulator

Uwe Schweigkofler, Dennis Wincheringer, Jörg Holstein, Tobias Fritz, Reinhard Hoffmann, Tim Pohlemann, Steven C Herath

Eur J Trauma Emerg Surg. 2022 Apr;48(2):847-855

Background: The application of pelvic binders in the preclinical and early clinical phase is advisable to avoid or treat C-problems in unstable and potential bleeding pelvic ring fractures, even if the clinical effectivity is not completely proved. The use for pathologies in the posterior pelvic ring is still debatable.

Questions/purposes: We determined if there is a difference in achievable compression in the dorsal pelvic ring depending on position and pelvic binder model. Can this effect be tested with a simplified artificial model?

Methods: We simulated a Tile type C fracture within the established pelvic emergency trainer and measured in a test series the effectivity of reduction with a non-invasive stabilization technique using 3 different pelvic binders.

Results: Any therapeutic effect of a pelvic binder with compression to the posterior pelvic ring requires at first a reduction maneuver. While the compression effect in the symphysis depends only on positioning of the binder, in the posterior pelvic ring, the result varies with the used model. The achievable pressure in the SI joint with a pelvic binder is only 20-25% (33.5-47 N) compared to the C-Clamp values (156 N).

Conclusions: The use of pelvic binders for non-invasive pelvic ring stabilization, even with a posterior pathology, could be proven in a simplified fracture model. A proper fracture reduction and an adequate device positioning influence the effectiveness.

Traumatic eye injuries: management principles for the prehospital setting

Felipe Serrano, Lawrence B Stack, R Jason Thurman, Lara Phillips, Wesley H Self

JEMS. 2013 Dec;38(12):56-62.

No abstract available

Evidence-based principles of time, triage and treatment: Refining the initial medical response to massive casualty incidents

Stacy A Shackelford, Michael A Remley, Sean Keenan, Russ S Kotwal, Jay B Baker, Jennifer Gurney, Stephen Rush, Paul Friedrichs

J Trauma Acute Care Surg. 2022 Aug 1;93(2S Suppl 1):S160-S164

Background: The overall approach to massive casualty triage has changed little in the past 200 years. As the military and civilian organizations prepare for the possibility of future large-scale combat operations, terrorist attacks and natural disasters, potentially involving hundreds or even thousands of casualties, a modified approach is needed to conduct effective triage, initiate treatment, and save as many lives as possible.

Methods: Military experience and review of analyses from the Department of Defense Trauma Registry are combined to introduce new concepts in triage and initial casualty management.

Results: The classification of the scale of massive casualty (MASCAL) incidents, timeline of life-saving interventions, immediate first pass actions prior to formal triage decisions during the first hour after injury, simplification of triage decisions, and the understanding that ultra-MASCAL will primarily require casualty movement and survival needs with few prehospital life-saving medical interventions are discussed.

Conclusion: Self aid, bystander, and first responder interventions are paramount and should be trained and planned extensively. Military and disaster planning should not only train these concepts, but should seek innovations to extend the timelines of effectiveness and to deliver novel capabilities within the timelines to the greatest extent possible.

Prehospital aortic blood flow control techniques for non-compressible traumatic hemorrhage

Changgui Shi, Song Li, Zhinong Wang, Hongliang Shen

Injury. 2021 Jul;52(7):1657-1663

Abstract

Non-compressible hemorrhage in the junctional areas and torso could be life-threatening and its prehospital control remains extremely challenging. The aim of this review was to compare commonly used techniques for the control of non-compressible hemorrhage in prehospital settings, and thereby provide evidence for further improvements in emergency care of traumatic injuries. Three techniques were reviewed including external aortic compression (EAC), abdominal aortic junctional tourniquet (AAJT), and resuscitative endovascular balloon occlusion of the aorta (REBOA). In prehospital settings, all three techniques have demonstrated clinical effectiveness for the control of severe hemorrhage. EAC is a cost- and equipment-free, easy-to-teach, and immediately available technique. In contrast, AAJT and REBOA are expensive and require detailed instructions or systematic training. Compared with EAC, AAJT and REBOA have greater potentials in the management of traumatic hemorrhage. AAJT can be used not only in the junctional areas but also in pelvic and bilateral lower limb injuries. However, both AAJT and REBOA should be used for a limited time (less than 1 hour) due to possible consequences of ischemia and reperfusion. Compared with EAC and AAJT, REBOA is invasive, requiring femoral arterial access and intravascular guidance and inflation. Mortality from non-compressible hemorrhage could be reduced through the prehospital application of aortic blood flow control techniques. EAC should be considered as the first-line choice for many non-compressible injuries that cannot be managed with conventional junctional tourniquets. In comparison, AAJT or REBOA is recommended for better control of the aorta blood flow in prehospital settings. Although these three techniques each have advantages, their use in trauma is not widespread. Future studies are warranted to provide more data about their safety and efficacy.

Training trial of critical care paramedics for non-medical authorisation of blood

Hazel Smith, Heidi Doughty

Br Paramed J. 2022 Mar 1;6(4):55-59

Abstract

The use of pre-hospital blood transfusion by air ambulance crews is increasing. Blood transfusion is traditionally 'authorised' by doctors, not prescribed. However, there is an increasing interest in extending the capability of authorisation to other practitioners - that is, non-medical authorisation (NMA). A UK framework for nurses and midwives has existed since 2007, but training for critical care paramedics (CCPs) has been limited. The Resuscitation with Pre-Hospital Blood Products (RePHILL) trial was launched in 2016, requiring pre-hospital administration of red cells and LyoPlas. Authorisation was initially restricted to doctors, leading to missed recruitment by paramedic-only crews. The trial protocol was amended in 2019 to permit NMA following suitable training and stakeholder consultation. We present a targeted training programme designed to support paramedic-led transfusion within the framework of the pre-hospital trial. We considered the knowledge and skills required for NMA and compared this with baseline knowledge from paramedic training to identify the training gap. We examined examples of existing military and civilian NMA training to develop a targeted programme for a single air ambulance. The four elements of our training programme were pre-course online training, previous trial participation, face-to-face training and competency assessment. Training was delivered to three CCPs, who cascaded the training to 14 colleagues. The training time was one morning, including a face-to-face session and assessment. Novel topics included physiological triggers for transfusion and transfusion risks in the pre-hospital environment. Paramedics were encouraged to recognise and report new patterns of adverse events. Reflective feedback suggests the programme provided CCPs the knowledge to autonomously recruit trial patients and authorise transfusion.

 

Optimal Out-of-Hospital Blood Pressure in Major Traumatic Brain Injury: A Challenge to the Current Understanding of Hypotension

Daniel W Spaite, Chengcheng Hu, Bentley J Bobrow, Bruce Barnhart, Vatsal Chikani, Joshua B Gaither, Kurt R Denninghoff, Gail H Bradley, Amber D Rice, Jeffrey T Howard, Samuel M Keim

Ann Emerg Med. 2022 Jul;80(1):46-59

Study objective: Little is known about the out-of-hospital blood pressure ranges associated with optimal outcomes in traumatic brain injuries (TBI). Our objective was to evaluate the associations between out-of-hospital systolic blood pressure (SBP) and multiple hospital outcomes without assuming any predefined thresholds for hypotension, normotension, or hypertension.

Methods: This was a preplanned secondary analysis from the Excellence in Prehospital Injury Care (EPIC) TBI study. Among patients (age ≥10 years) with major TBIs (Barell Matrix type 1 and/or Abbreviated Injury Scale-head severity ≥3) and lowest out-of-hospital SBPs of 40 to 299 mmHg, we utilized generalized additive models to summarize the distributions of various outcomes as smoothed functions of SBP, adjusting for important and significant confounders. The subjects who were enrolled in the study phase after the out-of-hospital TBI guideline implementation were used to validate the models developed from the preimplementation cohort.

Results: Among 12,169 included cases, the mortality model revealed 3 distinct ranges: (1) a monotonically decreasing relationship between SBP and the adjusted probability of death from 40 to 130 mmHg, (2) lowest adjusted mortality from 130 to 180 mmHg, and (3) rapidly increasing mortality above 180 mmHg. A subanalysis of the cohorts with isolated TBIs and multisystem injuries with TBIs revealed SBP mortality patterns that were similar to each other and to that of the main analysis. While the specific SBP ranges varied somewhat for the nonmortality outcomes (hospital length of stay, ICU length of stay, discharge to skilled nursing/inpatient rehabilitation, and hospital charges), the patterns were very similar to that of mortality. In each model, validation was confirmed utilizing the postimplementation cohort.

Conclusion: Optimal adjusted mortality was associated with a surprisingly high SBP range (130 to 180 mmHg). Below this level, there was no point or range of inflection that would indicate a physiologically meaningful threshold for defining hypotension. Nonmortality outcomes showed very similar patterns. These findings highlight how sensitive the injured brain is to compromised perfusion at SBP levels that, heretofore, have been considered adequate or even normal. While the study design does did not allow us to conclude that the currently recommended treatment threshold (<90 mmHg) should be increased, the findings imply that the definition of hypotension in the setting of TBI is too low. Randomized trials evaluating treatment levels significantly higher than 90 mmHg are needed.

 

Battlefield pain summit 2022: Expert consensus statements

Thomas R Stark, Nathan L Davidson, Jeremy W Cannon, Travis M Polk, Stacy A Shackelford, Jonathan D Stallings, Andrew P Cap, Battlefield Pain Research Steering Committee and Panel Discussion Members

J Trauma Acute Care Surg. 2022 Aug 1;93(2S Suppl 1):S12-S15

Background: Battlefield pain occurs in combat casualties who experience multiple severe injuries. The nature of battlefield scenarios requires a distinct approach to battlefield pain research. A battlefield pain summit was thus convened to identify shortcomings in the current understanding of battlefield pain management, review the current state of battlefield pain research, and shape the direction of future research.

Methods: On January 10 to 11, 2022, a hybrid in-person and virtual meeting hosted by the US Army Institute of Surgical Research defined research priorities for the Combat Casualty Care Research Program's Battlefield Pain research portfolio. Summit participants identified the following key focus areas under the umbrella of battlefield pain research: battlefield injury patterns; use of ketamine and nonopioid analgesics; analgesic delivery systems; the impact of analgesia on performance, cognition, and survival; training methods; battlefield regional anesthesia; and research models. Preliminary statements presented during the summit were refined and rank ordered through a Delphi process.

Results: Consensus was achieved on 7 statements addressing ideal analgesic properties, delivery systems, operational performance concerns, and pain training. Ketamine was identified as safe and effective for battlefield use, and further research into nonopioid analgesics represented a high priority.

Conclusion: The 7 consensus statements that emerged from this battlefield pain summit serve as a template to define the near-term research priorities for military-specific battlefield pain research.

 

The Importance of Acknowledging an Intermediate Category of Airway Management Devices in the Prehospital Setting

Laurent Suppan, Christophe Alain Fehlmann, Loric Stuby, Mélanie Suppan

Healthcare (Basel). 2022 May 23;10(5):961

Abstract

Prehospital airway devices are often classified as either basic or advanced, with this latter category including both supraglottic airway (SGA) devices and instruments designed to perform endotracheal intubation (ETI). Therefore, many authors analyze the impact of SGA and ETI devices jointly. There are however fundamental differences between these instruments. Indeed, adequate airway protection can only be achieved through ETI, and SGA devices all have relatively low leak pressures which might compromise both oxygenation and ventilation when lung compliance is decreased. In addition, there is increasing evidence that SGA devices reduce carotid blood flow in case of cardiac arrest. Nevertheless, SGA devices might be particularly useful in the prehospital setting where many providers are not experienced enough to safely perform ETI. Compared to basic airway management (bag-valve-mask) devices, SGA devices enable better oxygenation, decrease the odds of aspiration, and allow for more reliable capnometric measurement by virtue of their enhanced airtightness. For all these reasons, we strongly believe that SGA devices should be categorized as "intermediate airway management devices" and be systematically analyzed separately from devices designed to perform ETI.

Success Rate on Endotracheal Intubation with Prone versus Kneeling Position in Mannequin Model with Limitation of Neck Movement: A Cross Over Study

Panvilai Tangkulpanich, Chetsadakon Jenpanitpong, Jirayoot Patchkrua, Chappawit Silarak, Nattagit Srinaowech, Natthaphong Thiamdao, Chaiyaporn Yuksen

Open Access Emerg Med. 2022 Apr 19;14:177-182

Purpose: Endotracheal intubation is a lifesaving procedure for airway management but is more complex when performed in patients lying on the ground and requiring cervical spine immobilization. This study aims to compare the optimal technique between prone and kneeling positions in increasing intubation success rate on these prehospital trauma patients.

Patients and methods: This study was an experimental study on a mannequin. Paramedic students performed intubation on the supine mannequin, which was applied with a rigid cervical collar and manual in-line stabilization. The participants were randomly assigned to intubate in a prone or kneeling position as the first method, then perform another method seven days later. Study outcomes include the percentage of successful intubation, time to perform intubation successfully, and Cormack and Lehane's classification of laryngeal view.

Results: Thirty-nine participants were enrolled in this study; 22 were male (56.41%). The mean age, weight, and height were 23.15 ± 4.75 years, 67.38 ± 17.39 kg, and 167.36 ± 8.70 cm., respectively. The percentage of successful intubation in prone (37 [94.90%]) was higher than kneeling position (35 [89.74%]), but there was no statistically significant (p-value = 0.675). Time to intubation successfully, the number of attempts, and Cormack & Lehane's laryngeal view classification were not significantly different between prone and kneeling groups (p-value = 0.808, 0.814, and 0.948, respectively).

Conclusion: Intubation with the prone or kneeling position on a mannequin, lying on the ground with cervical spine immobilization, has no statistical difference. Both intubation approaches appear to be effective in successful and rapid intubation, proper glottic visualization and low attempts.

Battle Injury Patterns Sustained Noncombatant Military Occupational Specialty Service Members

Giselle Tapia, Jason F Naylor, Michael D April, Steven G Schauer

Med J (Ft Sam Houst Tex). 2022 Apr-Jun;(Per 22-04/05/06):78-82

Background: The US military has been engaged in the Global War on Terrorism for nearly 2 decades. This asymmetric warfare has exposed many noncombat military occupational specialties (MOS) personnel to combat. We assessed what proportion of casualties were combat versus noncombat MOS personnel.

Methods: This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry (DODTR). We included US military casualties sustaining battle injuries from January 2007 to March 2020 with a documented MOS. We classified each casualty as combat versus noncombat MOS personnel.

Results: There were 2,037 casualties who met inclusion for this analysis. Within these groups, there were 1,554 (76%) combat and 483 (24%) noncombat personnel. The median ages were 24 and 25, with more males among the combat MOS personnel (99% versus 93%). Army personnel comprised the largest proportion of both groups (78% versus 75%) with most injured by explosive (73% versus 78%). Median injury severity scores were similar (9 in both groups) as was survival (98% versus 98%). The annual proportion of battle injuries comprised of noncombat MOS personnel fluctuated year-to-year. The proportion of noncombat personnel with a medic in their chain of care was similar to combat personnel (25% versus 26%), as was the proportion undergoing medical evacuation by ground (11% versus 11%) or air (87% versus 86%). All prehospital interventions occurred in similar proportions except for ketamine administration (8% combat versus 3% noncombat MOS personnel).

Conclusions: Our study showed noncombat MOS personnel comprised nearly one in four casualties. Injury patterns were similar between combat and noncombat MOS personnel with nearly identical consumption of resources except for ketamine. More data is necessary on noncombatant MOS personnel battle injury patterns to guide commanders and medical leaders for future mission planning in resource constrained environments.

Tranexamic acid - A narrative review for the emergency medicine clinician

Kellie Wang, Ruben Santiago

Am J Emerg Med. 2022 Jun;56:33-44

Introduction: Over the last decade, tranexamic acid (TXA) has been incorporated into treatment algorithms for a multitude of emergent conditions and the evidence surrounding its role in emergency medicine continues to evolve.

Objective: The objective of this literature review is to provide an evidence-based approach to the utilization of TXA in the emergency department.

Discussion: The most robust trials suggest TXA may offer a modest improvement in mortality in patients at risk of significant bleeding from trauma, but is not beneficial in spontaneous intracranial hemorrhage or gastrointestinal bleeding. The role of TXA in other clinical scenarios is less clear and requires clinical judgment.

Conclusion: Tranexamic acid appears to be a reasonable adjunct for the emergency medicine clinician to consider in the management of many hemorrhagic conditions and angiotensin converting enzyme inhibitor-induced angioedema. Additional high-quality research in these areas is needed to further identity patients who may benefit most from TXA.

Safety and Efficacy of Sufentanil and Fentanyl Analgesia in Patients with Traumatic Brain Injury: A Retrospective Study

Wenhan Xia, Chunli Yang

Med Sci Monit. 2022 May 13;28:e934611

BACKGROUND This study aimed to retrospectively assess and compare the safety and efficacy of sufentanil and fentanyl in the treatment of patients with traumatic brain injury.

MATERIAL AND METHODS A total of 85 patients with traumatic brain injury from June 2016 to September 2018 were included in this study, and were enrolled into a sufentanil group and a fentanyl group according to different treatment methods. The patients in both groups were assessed with the Critical care Pain Observation Tool (CPOT) for analgesic score, and Richmond Agitation-Sedation Scale (RASS) for sedation score.

RESULTS The scores of CPOT and RASS in the 2 groups were significantly lower than before treatment (P<0.05), but there was no significant difference between the 2 groups (P>0.05). The heart rate (HR), rate of spontaneous respiration (RR), and mean arterial pressure (MAP) of the 2 groups were significantly lower than before treatment (P<0.05), and the RR of the sufentanil group was significantly lower than that of the fentanyl group at all time points after treatment (P<0.001).

CONCLUSIONS Sufentanil has a rapid onset of effect, and it is safe, stable, and effective for patients with traumatic brain injury in the intensive care unit (ICU). Compared with fentanyl, sufentanil can also effectively shorten mechanical ventilation time, time to obtain satisfactory sedation and analgesia, and the length of hospitalization in the ICU.

 

Descriptive Analysis of Intratheater Critical Care Air Transport Team Patient Movements During Troop Drawdown: Afghanistan (2017-2019)

S Whitney Zingg, Joel Elterman, Melissa Proctor, Ann Salvator, Mark Cheney, Jonathan Hare, William T Davis, Nathan Rosenberry, Daniel J Brown, Ryan Earnest, F Eric Robinson, Timothy A Pritts, Richard Strilka

Mil Med. 2022 Apr 21; Online ahead of print

Background: The majority of critical care air transport (CCAT) flights are regulated, meaning that a theater-validating flight surgeon has confirmed that the patient is medically cleared for flight and that evacuation is appropriate. If the conditions on the ground do not allow for this process, the flight is unregulated. Published data are limited regarding CCAT unregulated missions to include the period of troop drawdown at the end of the Afghanistan conflict. The objective of our study was to characterize the unregulated missions within Afghanistan during troop drawdown and compare them to regulated missions during the same timeframe.

Study design: We performed a retrospective review of all CCAT medical records of patients transported via CCAT within Afghanistan between January 2017 and December 2019. We abstracted data from the records, including mission characteristics, patient demographics, injury descriptors, preflight military treatment facility procedures, CCAT procedures, in-flight CCAT treatments, in-flight events, and equipment issues. Following descriptive and comparative analysis, a Cochran-Armitage test was performed to evaluate the statistical significance of the trend in categorical data over time. Multivariable regression was used to assess the association between vasopressors and preflight massive transfusions, preflight surgical procedures, injury patterns, and age.

Results: We reviewed 147 records of patients transported via CCAT: 68 patients were transported in a regulated fashion and 79 on an unregulated flight. The number of patients evacuated increased year-over-year (n = 22 in 2017, n = 57 in 2018, and n = 68 in 2019, P < .001), and the percentage of missions that were unregulated grew geometrically (14%, n = 3 in 2017; 37%, n = 21 in 2018; and 81%, n = 55 in 2019, P < .001). During the time studied, CCAT teams were being used more to decompress forward surgical teams (FST) and, therefore, they were transporting patients just hours following initial damage control surgery in an unregulated fashion. In 2 instances, CCAT decompressed an FST following a mass casualty, during which aeromedical evacuation (AE) crews assisted with patient care. For the regulated missions, the treatments that were statistically more common were intravenous fluids, propofol, norepinephrine, any vasopressors, and bicarbonate. During unregulated missions, the statistically more common treatments were ketamine, fentanyl, and 3% saline. Additional analysis of the mechanically ventilated patient subgroup revealed that vasopressors were used twice as often on regulated (38%) vs. unregulated (13%) flights. Multivariable regression analysis demonstrated that traumatic brain injury (TBI) was the only significant predictor of in-flight vasopressor use (odds ratio = 3.53, confidence interval [1.22, 10.22], P = .02).

Conclusion: During the troop drawdown in Afghanistan, the number of unregulated missions increased geometrically because the medical footprint was decreasing. During unregulated missions, CCAT providers used ketamine more frequently, consistent with Tactical Combat Casualty Care guidelines. In addition, TBI was the only predictor of vasopressor use and may reflect an attempt to adhere to unmonitored TBI clinical guidelines. Interoperability between CCAT and AE teams is critical to meet mass casualty needs in unregulated mission environments and highlights a need for joint training. It remains imperative to evaluate changes in mission requirements to inform en route combat casualty care training.

The diagnostic accuracy of prehospital triage tools in identifying patients with traumatic brain injury: A systematic review

Naif Alqurashi, Ahmed Alotaibi, Steve Bell, Fiona Lecky, Richard Body

Injury. 2022 Feb 12; Online ahead of print

 

Introduction: Prehospital care providers are usually the first responders for patients with traumatic brain injury (TBI). Early identification of patients with TBI enables them to receive trauma centre care, which improves outcomes. Two recent systematic reviews concluded that prehospital triage tools for undifferentiated major trauma have low accuracy. However, neither review focused specifically on patients with suspected TBI. Therefore, we aimed to systematically review the existing evidence on the diagnostic performance of prehospital triage tools for patients with suspected TBI.

Methods: A comprehensive search of the current literature was conducted using Medline, EMBASE, CINAHL Plus and the Cochrane library (inception to 1st June 2021). We also searched Google Scholar, OpenGrey, pre-prints (MedRxiv) and dissertation databases. We included all studies published in English language evaluating the accuracy of prehospital triage tools for TBI. We assessed methodological quality and risk of bias using a modified Quality Assessment of Diagnostic Studies (QUADAS-2) tool. Two reviewers independently performed searches, screened titles and abstracts and undertook methodological quality assessments. Due to the heterogeneity in the population of interest and prehospital triage tools used, a narrative synthesis was undertaken.

Results: The initial search identified 1787 articles, of which 8 unique eligible studies met the inclusion criteria (5 retrospective, 2 prospective, 1 mixed). Overall, sensitivity of triage tools studied ranged from 19.8% to 87.9% for TBI identification. Specificity ranged from 41.4% to 94.4%. Two decision tools have been validated more than once: HITS-NS (2 studies, sensitivity 28.3-32.6%, specificity 89.1-94.4%) and the Field Triage Decision Scheme (4 studies, sensitivity 19.8-64.5%, specificity 77.4%-93.1%). Existing tools appear to systematically under-triage older patients.

Conclusion: Further efforts are needed to improve and optimise prehospital triage tools. Consideration of additional predictors (e.g., biomarkers, clinical decision aids and paramedic judgement) may be required to improve diagnostic accuracy.

 

The Safety of High-Dose Intranasal Fentanyl in the Pediatric Emergency Department

Tucker Anderson, Camden Harrell, Mark Snider, Rudy Kink

Pediatr Emerg Care. 2022 Feb 1;38(2):e447-e450

 

Objectives: This study aimed to determine if the use of intranasal (IN) fentanyl in the pediatric emergency department of 2 to 5 μg/kg at doses greater than 100 μg is associated with adverse events in pediatric patients.

Methods: We performed a retrospective chart review of patients receiving IN fentanyl at an urban, tertiary care emergency department in Memphis, TN, from January 1, 2011, to December 31, 2017. All adverse events documented through the hospital's voluntary safety reporting system involving IN fentanyl were reviewed to determine patient outcomes.

Results: A total of 3205 patients received greater than 100 μg of IN fentanyl during the study period from 2011 to 2017. The average (SD) patient age was 13.7 (2.65) years, ranging from 5 to 18 years. The mean (SD) initial dose was 162 (30) μg ranging from 102 to 265 μg (2 doses were given greater than 200 μg in the study period). Initial average (SD) dose for weight was 2.62 (0.5) μg/kg. A total of 13 adverse events were documented, with only 3 occurring at doses greater than 100 μg. No patients required the reversal agent naloxone or invasive respiratory support.

Conclusions: To our knowledge, this is the first study using doses greater than 100 μg of IN fentanyl in a pediatric population. Our results indicate that fentanyl can be safely administered at doses of greater than 100 μg without any clinically significant adverse outcomes observed for 7 years of use. It is our hope that this information will increase utilization of IN fentanyl for treatment of acute pain in emergency departments and in the prehospital setting.

 

Committee on Surgical Combat Casualty Care Position: Statement on Single-Surgeon Teams

Anonymous

J Spec Oper Med. Spring 2022;22(1):144-145

 

No abstract available

Comparison of I-gel and LMA Protector in Laparoscopic Cholecystectomy: A Randomized Controlled Trial

D E Ari, S Abitagaoglu, C Koksal, A YildirimAr, D Emrem, M Ustun

Niger J Clin Pract. 2022 Jan;25(1):90-96

 

Aims: Comparison of the use of I-gel and Laringeal Mask Airway (LMA) Protector in laparoscopic cholecystectomy regarding the time and ease of insertion for supraglottic airway devices (SAD) and gastric tube (GT), airway sealing capacity, and postoperative complications.

Patients and methods: Sixty-four American Society of Anaesthesiologists (ASA) I-III patients undergoing laparoscopic cholecystectomy were randomly allocated into two groups. After anesthesia induction, LMA Protector was inserted in Group LPRO (LMA Protector) (n = 33) and I-gel was inserted in Group IGEL (I-gel) (n = 31) patients. Time of SAD insertion, number of attempts, time, and ease of GT insertion were recorded. The peak inspiratory pressure (PIP) and oropharyngeal leak pressure (OLP) were measured at the time of SAD insertion, 10 min after insertion, 10 min after pneumoperitoneum, and just before the termination of pneumoperitoneum. The presence of bloodstains on SAD, sore throat, hoarseness, nausea, and pain in swallowing was assessed postoperatively. A P value of < 0.05 was accepted as statistically significant.

Result: Two patients in Group LPRO needed endotracheal intubation and were excluded from the study. The SAD insertion time was shorter in Group IGEL than in Group LPRO (13 ± 7.4 s vs. 18.8 ± 9.8 s). The number of attempts and success rate on the first attempt were similar in both groups. GT insertion time was shorter in Group IGEL than Group LPRO (11 ± 7.7 s vs. 21 ± 11 s). The insertion of GT was easier in Group IGEL. The OLP levels decreased during the pneumoperitoneum in Group LPRO while they remained constant in Group IGEL.

Conclusion: We observed that I-gel offers more stable airway sealing and easier GT insertion advantages when compared with LMA Protector in laparoscopic cholecystectomy.

Haemodynamic effects of a prehospital emergency anaesthesia protocol consisting of fentanyl, ketamine and rocuronium in patients with trauma: a retrospective analysis of data from a Helicopter Emergency Medical Service

Ewoud Ter Avest , Dassen Ragavan3, Joanne Griggs, Michael Dias, Sophie A Mitchinson, Richard Lyon

Affiliations expand

BMJ Open. 2021 Dec 20;11(12):e056487

 

Objectives: Prehospital rapid sequence induction (RSI) of anaesthesia is an intervention with significant associated risk. In this study, we aimed to investigate the haemodynamic response over time of a prehospital RSI protocol of fentanyl, ketamine and rocuronium in a heterogeneous population of trauma patients.

Design, setting and participant: We performed a retrospective study of all trauma patients who received a prehospital RSI for trauma by a physician staffed Helicopter Emergency Medical Service in the UK between 1 June 2018 and 1 February 2020.

Primary outcome measure: Primary outcome was defined as the incidence of clinically relevant hypotensive (systolic blood pressure (SBP) or mean arterial pressure (MAP) >20% below baseline, with an absolute SBP <90 mm Hg or MAP <65 mm Hg) or hypertensive (SBP or MAP >20% above baseline) episodes in the first 10 minutes post-RSI.

Results: In total, 322 patients were included. 204 patients (63%) received a full-dose induction of 3 μg/kg fentanyl, 2 mg/kg ketamine and 1 mg/kg rocuronium, whereas 128 patients (37%) received a reduced-dose induction. Blood pressures decreased on average 12 mm Hg (95% CI 7 to 16) in the full-dose group and 6 mm Hg (95% CI 1 to 11) in the reduced-dose group, p=0.10). A hypotensive episode (mean SBP drop 53 mm Hg) was noted in 29 patients: 17 (8.3%) receiving a full dose and 12 (10.2%) receiving a reduced-dose induction, p=0.69. The blood pressure nadir was recorded on average 6-8 min after RSI. A hypertensive episode was present in 22 patients (6.8%). The highest blood pressures were recorded in the first 3 min after RSI.

Conclusion: Prehospital induction of anaesthesia for trauma with fentanyl, ketamine and rocuronium is not related to a significant change in haemodynamics in most patients. However, a (delayed) hypotensive response with a significant drop in SBP should be anticipated in a minority of patients irrespective of the dose regimen chosen.

 

Prehospital Mechanical Ventilation: An NAEMSP Position Statement and Resource Document

Amado Alejandro Baez, Zaffer Qasim, Susan Wilcox, William B Weir, Patrick Loeffler, Bradley Michael Golden, Daniel Schwartz, Michael Levy

Prehosp Emerg Care. 2022;26(sup1):88-95

 

Abstract

Airway emergencies and respiratory failure frequently occur in the prehospital setting. Patients undergoing advanced airway management customarily receive manual ventilations. However, manual ventilation is associated with hypo- and hyperventilation, variable tidal volumes, and barotrauma, among other potential complications. Portable mechanical ventilators offer an important strategy for optimizing ventilation and mitigating ventilatory complications.EMS clinicians, including those performing emergency response as well as interfacility transports, should consider using mechanical ventilation after advanced airway insertion.Prehospital mechanical ventilation techniques, strategies, and parameters should be disease-specific and should mirror in-hospital best practices.EMS clinicians must receive training in the general principles of mechanical ventilation as well as detailed training in the operation of the specific system(s) used by the EMS agency.Patients undergoing mechanical ventilation must receive appropriate sedation and analgesia.

A prospective study comparing two methods of pre-hospital triage for trauma

C Bagnato, K Ranzato, A Giarraca, P Restelli, S Saronni 2, G Gadda, O Chiara, S Cimbanassi

Updates Surg. 2022 Mar 20;1-9

 

Abstract

We conducted a prospective study comparing two different pre-hospital triage tools for trauma: the American College of Surgeons Committee on Trauma (ACS-COT) field triage decision scheme and the TRENAU score. The main objective was to evaluate which triage tool was more appropriate in the setting of Lombardy's trauma system. Data were collected from the population of trauma patients admitted to Niguarda hospital in Milan from January to June 2021. RStudio and Excel were used for data analysis. For each triage tool performance measures, Receiver Operating Characteristics (ROC) curves, and overtriage and undertriage rates were obtained. A total of 1439 injured patients admitted through 118 pre-hospital Emergency Medical Services (EMS) were included in the study. The ACS-COT triage tool showed a good accuracy but an excessive overtriage rate (59%). The TRENAU triage tool had a moderately good accuracy and a low overtriage rate (23%) while maintaining an acceptable undertriage rate (3.9%). The TRENAU triage tool proved to be efficient in optimizing the use of resources dedicated to trauma care while resulting safe for the injured patient. In a modern trauma system such as Lombardy's it would be more appropriate to adopt the TRENAU score over the ACS-COT field triage decision scheme.

Use of Knives and Multitools to Perform a Cadaveric Limb Amputation

Russell A Baker, Kevin Worth, Nima Pourrajabi, Joseph Martin, Sara Mitchell, Sunny Baker

J Spec Oper Med. Spring 2022;22(1):71-75

 

Background: An austere field amputation can be a life-saving procedure for an entrapped patient when standard equipment is not available or operable. The objective of this study was to use hand tools to perform cadaveric amputations in < 2 minutes.

Methods: Timed guillotine amputation of the extremities on three cadavers was attempted using four available hand tools: a multitool, a rescue tool, a hunting knife, and a fixedblade knife. The primary outcome was successful amputation of the extremity in < 2 minutes.

Results: Amputation success was different among the tools. The multitool amputated 78% of attempts; the hunting knife, 67%; the rescue knife, 56%; and the fixed-blade knife, 44%. The distal tibia/fibula and radius/ ulna were amputated successfully in 100% of attempts, whereas none of the tools could amputate the femur. The multitool received the best subjective ranking - 1.4 (p = .001) - by amputators, with the fixed-blade knife receiving the worst score.

Conclusions: In the rare circumstance that an emergent field amputation requires a hand tool, the multitool is a capable instrument for a distal extremity amputation.

Are Pelvic Binders an Effective Prehospital Intervention?

Abdulai Bangura, Cynthia E Burke, Blessing Enobun, Nathan N O'Hara, Joshua L Gary, Doug Floccare, Timothy Chizmar, Andrew N Pollak, Gerard P Slobogean

Prehosp Emerg Care. 2022 Jan 25;1-7

Objective: Widespread adoption of prehospital pelvic circumferential compression devices (PCCDs) by emergency medical services (EMS) systems has been slow and variable across the United States. We sought to determine the frequency of prehospital PCCD use by EMS providers. Secondarily, we hypothesized that prehospital PCCD use would improve early hemorrhagic shock outcomes.

Methods: We conducted a single-center retrospective cohort study of 162 unstable pelvic ring injuries transported directly to our center by EMS from 2011 to 2020. Included patients received a PCCD during their resuscitation (prehospital or emergency department). Prehospital treatment details were obtained from the EMS medical record. The primary outcome was the proportion of patients who received a PCCD by EMS before hospital arrival. Secondarily, we explored factors associated with receiving a prehospital PCCD, and its association with changes in vital signs, blood transfusion, and mortality.

Results: EMS providers documented suspicion of a pelvic ring fracture in 85 (52.8%) patients and 52 patients in the cohort (32.2%) received a prehospital PCCD. Wide variation in prehospital PCCD use was observed based on patient characteristics, geographic location, and EMS provider level. Helicopter flight paramedics applied a prehospital PCCD in 46% of the patients they transported (38/83); in contrast, the EMS organizations geographically closest to our hospital applied a PCCD in ≤5% of cases (2/47). Other predictors associated with receiving a prehospital PCCD included lower body mass index (p = 0.005), longer prehospital duration (p = 0.001) and lower Injury Severity Score (p < 0.05). We were unable to identify any improvements in clinical outcomes associated with prehospital PCCD, including early vital signs, number of blood transfusions within 24 hours, or mortality during admission (p > 0.05).

Conclusion: Our results demonstrate wide practice variation in the application of prehospital PCCDs. Although disparate PCCD application across the state is likely explained by differences across EMS organizations and provider levels, our study was unable to identify any clinical benefits to the prehospital use of PCCDs. It is possible that the benefits of a prehospital PCCD can only be observed in the most displaced fracture patterns with the greatest early hemodynamic instability.

 

Comparison of the clinical performance of i-gel and Ambu laryngeal masks in anaesthetised paediatric patients: A meta-analysis

Di Bao, Yun Yu, Wei Xiong, Ya-Xin Wang, Yi Liang, Lu Li, Bin Liu, Xu Jin

World J Clin Cases. 2022 Feb 6;10(4):1242-1254

 

Background: Paediatric supraglottic airway devices (SGAs) are widely used in routine anaesthesia and serve as primary or back-up devices for difficult airway management. The inflatable Ambu laryngeal masks and non-inflatable i-gel are two improvements of SGAs based on classic laryngeal masks. The clinical performance and safety of these two devices in paediatric patients are still unclear and warrant further investigation.

Aim: To perform a systematic review and meta-analysis on the clinical performance and safety of Ambu laryngeal masks and i-gel in anaesthetised paediatric patients.

Methods: MEDLINE, Embase, Web of Science and Cochrane Central Register of Controlled Trials were searched from inception dates to April 2020. We identified published randomised controlled trials (RCTs) in which the intervention involved the use of Ambu laryngeal masks and i-gel in anaesthetised paediatric patients (age < 18 years). We assessed the oropharyngeal leak pressure (OLP) as the primary outcome. The secondary outcomes were insertion time, success rate of insertion on the first attempt, and incidence of adverse events.

Results: After searching for all relevant trials published up to April 2020, data from seven RCTs with a total of 667 paediatric patients (323 and 344 participants in the i-gel and Ambu groups, respectively) were evaluated. The mean OLP in anaesthetised paediatric patients was lower in the Ambu group [21.82 cmH2O for Ambu vs 23.98 cmH2O for i-gel, P = 0.003, 95% confidence interval (CI): -3.58 to -0.75, I 2 = 68%, Mantel-Haenszel random model]. We did not find any clear evidence of differences between the devices in terms of insertion time, success rate of insertion, and incidence of adverse events except for blood staining (risk ratio 5.86, 95%CI: 1.76 to 19.46, P = 0.004, I 2 = 0, fixed-effect model).

Conclusion: The i-gel airway may provide a better seal and is therefore probably more suitable than the Ambu laryngeal mask airway in anaesthetised paediatric patients. However, the evidence is insufficient to allow making firm conclusions or to guide clinical practice, owing to the small number of relevant published studies.

 

Low-Cost Model for Battlefield Wound and Hemorrhage Training

James T Bates, Christopher W Kelly, Joshua E Lane

Mil Med. 2022 Jan 7; Online ahead of print

 

Introduction: Exsanguination is the leading cause of preventable death on the battlefield and in austere environments. Multiple courses have been developed to save lives by stopping hemorrhage. Training for this requires simulation models; however, many models are expensive, preventing the further expansion of this life-saving training. We present a low-cost model for hemorrhage training and realistic moulage based on simple medical supplies and grocery store meats.

Materials and methods: Wound packing training was completed by use of a block of pork shoulder roast with an incision simulating a wound and IV tubing connected to a syringe with fake blood. Hemostasis was obtained with proper wound packing by the student, causing the bleeding to be tamponaded. Wound moulage utilized remaining supplies of pork roast being attached to patient actors or mannequins and adorned with fake blood creating wounds with the appearance and feel of real tissues.

Results: Tactical Combat Casualty Care (TCCC) training was completed at a small military medical facility with a start-up cost of less than $70 and a single course as cheap as $15. These methods have been utilized to establish other TCCC training centers while keeping costs low.

Conclusions: We present low-cost models for simulating massive hemorrhage for wound packing with pork roast and realistic moulage. These methods can be utilized for other hemorrhage training courses such as TCCC, Advanced Wilderness Life Support, and Stop the Bleed.

An Analysis of Ketamine Doses Administrated to Nonintubated Casualties Prehospital

Grace E Bebarta, Vikhyat S Bebarta, Andrew D Fisher, Michael D April, Andrew J Atkinson, Laura L McGhee, Steven G Schauer

Mil Med. 2021 Dec 4; Online ahead of print

Introduction: Previous studies demonstrate that a significant proportion of casualties do not receive pain medication prehospital after traumatic injuries. To address possible reasons, the U.S. Military has sought to develop novel delivery methods to aid in administration of pain medications prehospital. We sought to describe the dose and route of ketamine administered prehospital to help inform materiel solutions.

Materials and methods: This is a secondary analysis of a previously described dataset focused on prehospital data within the Department of Defense Trauma Registry from 2007 to 2020. We isolated encounters in which ketamine was administered along with the amount dosed and the route of administration in nonintubated patients.

Results: Within our dataset, 862 casualties met inclusion for this analysis. The median age was 28 and nearly all (98%) were male. Most were battle injuries (88%) caused by explosives (54%). The median injury severity score was 10 with the extremities accounting to the most frequent seriously injured body region (38%). The mean dose via intravenous route was 50.4 mg (n = 743, 95% CI 46.5-54.3), intramuscular was 66.7 mg (n = 234, 95% CI 60.3-73.1), intranasal was 56.5 mg (n = 10, 39.1-73.8), and intraosseous was 83.3 mg (n = 34, 66.3-100.4). Most had a medic or CLS in their chain of care (87%) with air evacuation as the primary mechanism of evacuation (86%).

Conclusions: The average doses administered were generally larger than the doses recommended by Tactical Combat Casualty Care guidelines. Currently, guidelines may underdose analgesia. Our data will help inform materiel solutions based on end-user requirements.

Pre-Hospital Administration of Opioids in Trauma Patients: Is Dose Associated With Outcomes?

Letitia Bible, Omar Obaid, Muhammad Khurrum, Mei Goh, Ahmad Hammad, Daniel James Kitts, Tanya Anand, Meera Kapadia, Bellal Joseph

J Surg Res. 2021 Dec;268:634-642

 

Background: Opioids are commonly used as an analgesic agent in the prehospital setting. Current efforts to prevent and control prescription opioid overuse are focused on the in-hospital and post-discharge phases. The aim of our study was to assess the associations between pre-hospital opioids use and in-hospital outcomes among trauma patients.

Methods: We performed a 2 year (2016-2017) retrospective analysis of our Level-I trauma center database. We included all adult trauma patients (age > 18y) who received pre-hospital opioids (Fentanyl (F) or Morphine-Sulfate (MS)). Outcome measures were emergency-department (ED) hypotension (SPB < 90 mmHg), ED intubation, prescription opioid medication upon discharge, and mortality. Multivariate logistic regression was performed.

Results: In total, 709 patients were included in the analysis. Cutoff values of 200 mcg F and 15 mg MS were significantly associated with adverse outcomes. Overall, the ED hypotension rate was 14.4%, ED intubation rate was 6%, and ED mortality rate was 3.1%. On regression analysis, higher dosages of both pre-hospital F and pre-hospital MS were independently associated with increased odds of ED hypotension, ED intubation, and discharge on opioid medications, but not with ED mortality.

Conclusion: Pre-hospital administration of high dose opioids is associated with increased odds of adverse outcomes. Collaborative efforts to standardize and control the overuse of opioids should target the pre-hospital setting to limit opioid associated adverse effects.

 

 

Casualty Evacuation (CASEVAC) Platform Review and Case Series of US Military Enroute Critical Care Team With Contract Personnel Recovery Services in an Austere Environment

Nathan Lewis Boyer, Joseph Anthony Mazarella, Erick E Thronson, Daniel B Brillhart

J Spec Oper Med. Winter 2021;21(4):99-103.

 

Abstract

In a rapidly changing operational environment, in which there has been an emphasis on prolonged field care and limited evacuation platforms, military providers must practice to the full scope of their training to maximize outcomes. In addition to pushing military providers further into combat zones, the Department of Defense has relied on contracted personnel to help treat and evacuate servicemembers. This article is a retrospective review on the interoperability of the expeditionary resuscitative surgical team (ERST) and a contracted personnel recovery (CPR) team in a far-forward austere environment and will discuss actual patient transport case reviews that used multiple evacuation platforms across thousands of miles of terrain. To effectively incorporate CPR personnel into a military transport team model, we recommend including cross-training on equipment and formularies, familiarization with CPR evacuation platforms, and mass casualty (MASCAL) exercises that incorporate the different platforms available.

Prehospital Trauma Airway Management: An NAEMSP Position Statement and Resource Document

Sabina Braithwaite, Christopher Stephens, Kyle Remick, Whitney Barrett, Francis X Guyette, Michael Levy, Christopher Colwell

Prehosp Emerg Care. 2022;26(sup1):64-71

 

Abstract

Definitive management of trauma is not possible in the out-of-hospital environment. Rapid treatment and transport of trauma casualties to a trauma center are vital to improve survival and outcomes. Prioritization and management of airway, oxygenation, ventilation, protection from gross aspiration, and physiologic optimization must be balanced against timely patient delivery to definitive care. The optimal prehospital airway management strategy for trauma has not been clearly defined; the best choice should be patient-specific. NAEMSP recommends:The approach to airway management and the choice of airway interventions in a trauma patient requires an iterative, individualized assessment that considers patient, clinician, and environmental factors.Optimal trauma airway management should focus on meeting the goals of adequate oxygenation and ventilation rather than on specific interventions. Emergency medical services (EMS) clinicians should perform frequent reassessments to determine if there is a need to escalate from basic to advanced airway interventions.Management of immediately life-threatening injuries should take priority over advanced airway insertion.Drug-assisted airway management should be considered within a comprehensive algorithm incorporating failed airway options and balanced management of pain, agitation, and delirium.EMS medical directors must be highly engaged in assuring clinician competence in trauma airway assessment, management, and interventions.

Prehospital Care: An International Comparison of Independently Developed Training Courses

Per P Bredmose, Jeff Hooper, Sandra Viggers, Joacim Linde, Cliff Reid, Gareth Grier, Stefan Mazur

Air Med J. Jan-Feb 2022;41(1):73-77

 

Objective: Prehospital and retrieval medicine (PHRM) occurs in a complex work environment. Appropriate training is essential to ensure high standards of clinical care and logistic decision making. Before commencing the role, PHRM doctors have varying levels of experience. This narrative review article aims to describe and compare 6 internationally accepted PHRM courses.

Methods: Six PHRM course directors were asked to describe their course in terms of education methods used, course content, and assessment processes. Each of the directors contributed to the discussion process.

Results: Although developed independently, all 6 courses use a comparable combination of lectures, simulations, and discussion groups. The amount of each pedagogical modality varies between the courses.

Conclusion: We have identified significant similarities and some important differences among some well-accepted independently developed PHRM courses worldwide. Differences in content and the methods of delivery appear linked to the background of participants and service case mix. The authors believe that even in the small niche of PHRM, courses need to be tailored to the participants and the "destination of the participants" (ie, where they are going to use their skills).

Pre-hospital oral transmucosal fentanyl citrate for trauma analgesia: preliminary experience and implications for civilian mass casualty response

Luca Carenzo, Adam McDonald, Gareth Grier

Br J Anaesth. 2022 Feb;128(2):e206-e208

 

No abstract available

The effect of tranexamic acid dosing regimen on trauma/hemorrhagic shock related glycocalyx degradation and endothelial barrier permeability: an in vitro model

Michael Carge, Lawrence N Diebel, David M Liberati

J Trauma Acute Care Surg. 2022 Jan 20. Online ahead of print

Background: Improved outcomes with early tranexamic acid (TXA) following trauma hemorrhagic shock (T/HS) may be related to its anti-fibrinolytic as well as anti-inflammatory properties. Previous in vitro studies have shown that early TXA administration protects against T/HS endothelial barrier dysfunction and associated glycocalyx degradation. An intact endothelial glycocalyx (EGC) may protect against subsequent neutrophil mediated tissue injury. We postulated that early TXA administration would mitigate against glycocalyx damage and resultant neutrophil adherence and transmigration through the endothelial barrier. This was studied in vitro using a microfluidic flow platform.

Methods: Human umbilical vein endothelial cell (HUVEC) monolayers were subjected to control or shock conditions (hypoxia + epinephrine) followed by administration of TXA 90 or 180 minutes later.

Results: "Early" TXA administration protected against glycocalyx degradation, biomarkers of increased permeability and the development of a fibrinolytic phenotype. This was associated with decreased neutrophil endothelial adherence and transmigration. There were no differences in low vs. high TXA concentrations. The protective effects were only significant with "early" TXA administration.

Conclusions: There was a concentration and temporal effect of TXA administration on EGC degradation. This was associated with "vascular leakiness" as indexed by the relative ratio of Ang2/1 and PMN transmigration. TXA if administered in patients with T/HS should be administered "early"; this includes in the prehospital setting.

Prehospital Airway Management: A Systematic Review

Nancy Carney, Annette M Totten, Tamara Cheney, Rebecca Jungbauer, Matthew R Neth, Chandler Weeks, Cynthia Davis-O'Reilly, Rongwei Fu, Yun Yu, Roger Chou, Mohamud Daya

Prehosp Emerg Care. 2021 Jul 20;1-12

 

Objective: To assess comparative benefits and harms across three airway management approaches (bag valve mask [BVM], supraglottic airway [SGA], and endotracheal intubation [ETI]) used by prehospital emergency medical services (EMS) to treat patients with trauma, cardiac arrest, or medical emergencies, and how they differ based on techniques and devices, EMS personnel and patient characteristics.

Data sources: We searched electronic citation databases (Ovid® MEDLINE®, CINAHL®, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus®) from 1990 to September 2020.

Review methods: We followed Agency for Healthcare Research and Quality Effective Health Care Program Methods guidance. Outcomes included mortality, neurological function, return of spontaneous circulation (ROSC), and successful advanced airway insertion. Meta-analyses using profile-likelihood random effects models were conducted, with analyses stratified by study design, emergency type, and age.

Results: We included 99 studies involving 630,397 patients. We found few differences in primary outcomes across airway management approaches. For survival, there was no difference for BVM versus ETI or SGA in adult and pediatric patients with cardiac arrest or trauma. For neurological function, there was no difference for BVM versus ETI and SGA versus ETI in pediatric patients with cardiac arrest. There was no difference in BVM versus ETI in adults with cardiac arrest, but improved neurological function with BVM or ETI versus SGA. There was no difference in ROSC for patients with cardiac arrest for BVM versus ETI or SGA in adults and pediatrics, or SGA versus ETI in pediatrics. There was higher frequency of ROSC in adults with SGA versus ETI. For successful advanced airway insertion, there was higher first-pass success with SGA versus ETI for all patients except adult medical patients (no difference), and no difference in overall success using SGA versus ETI in adults.

Conclusions: The currently available evidence does not indicate benefits of more invasive airway approaches based on survival, neurological function, ROSC, or successful airway insertion. Strength of evidence was low or moderate; most included studies were observational. This supports the need for high-quality randomized controlled trials to advance clinical practice and EMS education and policy, and improve patient-centered outcomes…

 

Percutaneous delivery of self-propelling hemostatic powder for managing non-compressible abdominal hemorrhage: a proof-of-concept study in swine

Massimo F Cau, Nabil Ali-Mohamad, James R Baylis, Veronika Zenova, Adele Khavari, Nuoya Peng, Andrew McFadden, Fergal Donnellan, Daniel R Owen, David F Schaeffer, Chandrasekaran Nagaswami, Rustem I Litvinov, John W Weisel, Joao Rezende-Neto, Hugh A Semple, Andrew Beckett, Christian J Kastrup

Injury. 2022 Jan 15; Online ahead of print

 

Introduction: Non-compressible intra-abdominal hemorrhage (NCIAH) is a major cause of preventable death on the battlefield and in civilian trauma. Currently, it can only be definitively managed with surgery, as there are limited strategies for controlling ongoing NCIAH in the prehospital environment. We hypothesized that a self-propelling thrombin-containing powder (SPTP) could increase survival in a swine model of NCIAH when delivered percutaneously into the closed abdomen using an engineered spray system.

Materials and methods: Nineteen swine underwent surgical laparotomy followed by a Grade V liver injury that created massive hemorrhage, before closing the abdomen with sutures. Animals either received treatment with standard of care fluid resuscitation (n=9) or the SPTP spray system (n=10), which consisted of a spray device and a 14 Fr catheter. Using the spray system, SPTP was delivered into a hemoperitoneum identified using a focused assessment with sonography in trauma (FAST) exam. Lactated Ringer's solution was administered to all animals to maintain a mean arterial pressure (MAP) of >50 mmHg. The primary outcome was percentage of animals surviving at three hours following injury.

Results: In the swine model of NCIAH, a greater percentage of animals receiving SPTP survived to three hours, although differences were not significant. The SPTP spray system increased the median survival of animals from 1.6 hr in the fluid resuscitation group to 4.3 hr. The SPTP spray system delivered a total mass of 18.5 ± 1.0 g of SPTP. The mean change in intra-abdominal pressure following SPTP delivery was 5.2 ± 1.8 mmHg (mean ± SEM). The intervention time was 6.7 ± 1.7 min. No adverse effects related to the SPTP formulation or the spray system were observed. SPTP was especially beneficial in animals that had either severely elevated lactate concentrations or low mean arterial pressure of <35 mmHg shortly after injury.

Conclusions: This demonstrates proof-of-concept for use of a new minimally invasive procedure for managing NCIAH, which could extend survival time to enable patients to reach definitive surgical care.

Clinical Performance Comparison of LMA Protector™ Cuff Pilot™ and LMA Supreme™ When Used in Anesthetized, Non-paralyzed Patients

Weng Ken Chan, Chian Yong Liu

Cureus. 2022 Mar 15;14(3):e23176

 

Abstract

Introduction The advancement of supraglottic airways (SGAs) has eased airway management, especially for anesthetists. There were functional improvements implemented to the newer SGA. We aim to assess the clinical performance of laryngeal mask airway (LMA) Protector™ Cuff Pilot™ (Teleflex Inc., Wayne, Pennsylvania, USA) against LMA Supreme™ (Teleflex Inc., Wayne, Pennsylvania, USA), in terms of oropharyngeal leak pressure (OLP), successful insertion attempts, mean insertion time, ease of gastric tube insertion, laryngeal view, and incidence of sore throat among anesthetized, non-paralyzed patients undergoing general anesthesia. Methods In this prospective single-blinded study, 60 patients were randomized to use either LMA Protector™ Cuff Pilot™ or LMA Supreme™. Both groups received standard monitoring and induction regimes. Post-insertion, a bronchoscope was used to verify its position. A gastric tube was inserted and OLP was measured. Patients were assessed during the post-operative period for sore throats. Results LMA Protector™ Cuff Pilot™ was comparable to LMA Supreme™ in terms of mean OLP (30.72±8.60 vs 27.23±8.09 cmH2O, P = 0.114), first successful attempt (P = 0.312), mean insertion time (27.72±9.45 vs 24.37±6.46 seconds, P = 0.116), and grade 1 laryngeal view (51.7% vs 36.7%, P = 0.244). At first attempt, LMA Protector™ Cuff Pilot™ had a lower success rate of gastric tube insertion than LMA Supreme™ (55.17% vs 96.67%, P <0.001). The incidence of the blood-stained device and sore throat post-operatively were comparable between the two groups. Conclusion LMA Protector™ Cuff Pilot™ was comparable to LMA Supreme™ in terms of overall clinical performance, except for the first successful gastric tube insertion. Improvements should be made to the gastric channel for easier gastric tube insertion in the LMA Protector™ Cuff Pilot™.

Evaluation of a novel emergency front of neck access device in a benchtop model of obesity

Sunil K Chauhan, Myles Monaghan, Conan L McCaul

Ir J Med Sci. 2022 Feb;191(1):413-420

 

Background: Emergency front of neck access (eFONA) is a critical step in oxygenation in cases of unrelieved airway obstruction. Multiple techniques are used in clinical practice without agreement regarding the optimal approach. We evaluated a novel device, the Cric-Guide (CG), a channelled bougie introducer that enters the airway in a single action and compared it with a scalpel-bougie-tube (SBT) technique in laboratory benchtop model.

Methods: Seven anaesthesiologists attempted eFONA on both obese and non-obese models using both techniques in randomized order on an excised porcine trachea with an intact larynx with variable subcutaneous tissue depth. The primary outcome was successful tracheal cannulation. Secondary outcomes included false passage rate, time and tissue injury.

Results: Anaesthesiologists performed 4 cricothyroidotomies on each model with each device. The CG was more successful in airway cannulation (47/56 [89.4%] vs. 33/56 [58.9%], P = 0.007). This difference was observed in the obese model only. The CG was associated with fewer false passages than the standard technique in the obese model (8/56 [14.3%] vs. 23/56 [41.1%], P = 0.006). There were no significant differences in time to completion or injury patterns between the techniques in the obese model, but the SBT was faster in the non-obese model. There was no difference in the proportion of specimens injured.

Conclusion: The Cric-Guide device was more successful than the standard SBT technique in airway cannulation in an obese neck model and with equivalent frequency and distribution of injury but performed equivalently in the non-obese model.

Development and validation of a prehospital-stage prediction tool for traumatic brain injury: a multicentre retrospective cohort study in Korea

Yeongho Choi, Jeong Ho Park, Ki Jeong Hong, Young Sun Ro, Kyoung Jun Song, Sang Do Shin

BMJ Open. 2022 Jan 12;12(1):e055918

 

Objectives: Predicting diagnosis and prognosis of traumatic brain injury (TBI) at the prehospital stage is challenging; however, using comprehensive prehospital information and machine learning may improve the performance of the predictive model. We developed and tested predictive models for TBI that use machine learning algorithms using information that can be obtained in the prehospital stage.

Design: This was a multicentre retrospective study.

Setting and participants: This study was conducted at three tertiary academic emergency departments (EDs) located in an urban area of South Korea. The data from adult patients with severe trauma who were assessed by emergency medical service providers and transported to three participating hospitals between 2014 to 2018 were analysed.

Results: We developed and tested five machine learning algorithms-logistic regression analyses, extreme gradient boosting, support vector machine, random forest and elastic net (EN)-to predict TBI, TBI with intracranial haemorrhage or injury (TBI-I), TBI with ED or admission result of admission or transferred (TBI with non-discharge (TBI-ND)) and TBI with ED or admission result of death (TBI-D). A total of 1169 patients were included in the final analysis, and the proportions of TBI, TBI-I, TBI-ND and TBI-D were 24.0%, 21.5%, 21.3% and 3.7%, respectively. The EN model yielded an area under receiver-operator curve of 0.799 for TBI, 0.844 for TBI-I, 0.811 for TBI-ND and 0.871 for TBI-D. The EN model also yielded the highest specificity and significant reclassification improvement. Variables related to loss of consciousness, Glasgow Coma Scale and light reflex were the three most important variables to predict all outcomes.

Conclusion: Our results inform the diagnosis and prognosis of TBI. Machine learning models resulted in significant performance improvement over that with logistic regression analyses, and the best performing model was EN.

Antibiotic Prophylaxis in Torso, Maxillofacial, and Skin Traumatic Lesions: A Systematic Review of Recent Evidence

Enrico Cicuttin, Massimo Sartelli, Emanuele Scozzafava, Dario Tartaglia, Camilla Cremonini, Bruno Brevi, Niccolò Ramacciotti, Serena Musetti, Silvia Strambi, Mauro Podda, Fausto Catena, Massimo Chiarugi, Federico Coccolini

Antibiotics (Basel). 2022 Jan 21;11(2):139

Abstract

Use of antibiotic prophylaxis (AP) in trauma patients is a common practice. However, considering the increasing rates of antibiotic resistance, AP use should be questioned and limited only to specific cases. We performed a systematic review of recent literature (from year 2000), aiming to summarize the state of the art on efficacy and appropriateness of AP in patients with traumatic injuries of torso, maxillofacial complex and skin (including burns). Twenty-six articles were selected. In thoracic trauma, AP could be useful in reducing infective complications in tube thoracostomy for penetrating trauma. In maxillo-facial trauma, AP could find a role in the peri-operative trauma setting in the case of a graft or prosthetic implant. In abdominal trauma, there is a lack of consensus on the definition of contamination, infection, antibiotic therapy, and prophylaxis. In burned patients, routine AP is not suggested. In the case of human bites to the extremities, AP could find an indication. Future studies should focus on the subcategories of patients at higher risk of infection, identifying those who would benefit from AP. Attention to antimicrobial stewardship and guidelines focused on AP in trauma are required, to reduce antibiotic abuse, and increase quality research.

Emergency Subglottic Airway Training and Assessment of Skills Retention of Attending Anesthesiologists With Simulation Mastery-Based Learning

Carlee A Clark, Robert A Mester, Amanda T Redding, Dulaney A Wilson, Lydia L Zeiler, Wanda R Jones, Jerry G Reves, Scott T Reeves, John J Schaefer

Anesth Analg. 2022 Feb 10. Online ahead of print.

 

Background: Although included within the American Society of Anesthesiologists difficult airway algorithm, the use of "invasive airway access" is rarely needed clinically. In conjunction with highly associated morbidity and liability risks, it is a challenge for the average anesthesiologist to develop and maintain competency. The advancement of high-fidelity simulators allows for practice of rarely encountered clinical scenarios, specifically those requiring invasive subglottic airway techniques.

Methods: Sixty board-certified academic anesthesiologists were enrolled and trained in dyads in a simulation-based, mastery-based learning (MBL) course directed at 2 emergency airway subglottic techniques: transtracheal jet ventilation (TTJV) and bougie cricothyrotomy (BC). Performance metrics included: pretest, posttest, specific skill step error tracking, and 15-month period retest. All were pretested and trained once on the Melker cricothyrotomy (MC) kit. All pretest assessment, training, posttesting, and 15-month retesting were performed by a single expert clinical and educational airway management faculty member.

Results: Initial testing showed a success rate of 14.8% for TTJV, 19.7% for BC, and 25% for MC. After mastery-based practice, all anesthesiologists achieved successful invasive airway placement with TTJV, BC, and MC. Repeated performance of each skill improved speed with zero safety breaches. BC was noted to be the fastest performed technique. Fifteen months later, retesting showed that 80.4% and 82.6% performed successful airway securement for TTJV and BC, respectively. For safety, average placement time and costs, MC was discarded after initial training results.

Conclusions: We discovered that only ~20% of practicing anesthesiologists were able to successfully place an invasive airway in a simulated life or death clinical setting. Using mobile simulation (training performed in department conference room) during a 2.5-hour session using mastery-based training pedagogy, we increased our success rate of invasive airway placement to 100%, while also increasing the successful speed to ventilation (TTJV, 32 seconds average; BC, 29 seconds average). Finally, we determined that there was a 15-month 80% retention rate of the airway skills learned, indicating that skills last at least a year before retraining is required using this training methodology.

Trends in Prehospital Blood, Crystalloid, and Colloid Administration in Accordance With Changes in Tactical Combat Casualty Care Guidelines

Emily E Clarke, James Hamm, Andrew D Fisher, Michael D April, Brit J Long, Kennedy S Mdaki, Ronnie Hill, James A Bynum, Steven G Schauer

Mil Med. 2021 Dec 22; Online ahead of print

 

Introduction: Hemorrhage is the leading threat to the survival of battlefield casualties. This study aims to investigate the types of fluids and blood products administered in prehospital trauma encounters to discover the effectiveness of Tactical Combat Casualty Care (TCCC) recommendations.

Materials and methods: This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry with a focus on prehospital fluid and blood administration in conjunction with changes in the TCCC guidelines. We collected demographic information on each patient. We categorized receipt of each fluid type and blood product as a binary variable for each casualty and evaluated trends over 2007-2020 both unadjusted and controlling for injury severity and mechanism of injury.

Results: Our original dataset comprised 25,897 adult casualties from January 1, 2007 through March 17, 2020. Most (97.3%) of the casualties were male with a median age of 25. Most (95.5%) survived to hospital discharge, and 12.2% of the dataset received fluids of any kind. Medical personnel used crystalloids in 7.4% of encounters, packed red blood cells in 2.0%, and whole blood in 0.5% with very few receiving platelets or freeze-dried plasma. In the adjusted model, we noted significant year-to-year increases in intravenous fluid administration from 2014 to 2015 and 2018 to 2019, with significant decreases noted in 2008-2009, 2010-2012, and 2015-2016. We noted no significant increases in Hextend used, but we did note significant decreases in 2010-2012. For any blood product, we noted significant increases from 2016 to 2017, with decreases noted in 2009-2013, 2015-2016, and 2017-2018. Overall, we noted a general spike in all uses in 2011-2012 that rapidly dropped off 2012-2013. Crystalloids consistently outpaced the use of blood products. We noted a small upward trend in all blood products from 2017 to 2019.

Conclusions: Changes in TCCC guidelines did not immediately translate into changes in prehospital fluid administration practices. Crystalloid fluids continue to dominate as the most commonly administered fluid even after the 2014 TCCC guidelines changed to use of blood products over crystalloids. There should be future studies to investigate the reasons for delay in guideline implementation and efforts to improve adherence.

Advanced medical monitoring for the battlefield: a review on clinical applicability of compensatory reserve measurements for early and accurate hemorrhage detection

Victor A Convertino, Sylvain Cardin

J Trauma Acute Care Surg. 2022 Mar 8. Online ahead of print

 

Abstract

Hemorrhagic shock remains the leading cause of mortality in civilian trauma and battlefield settings. The ability of combat medics and other military medical personnel to obtain early identification and assessment of a bleeding casualty is hampered by the use of standard vital signs (VS) that fail to provide early predictive indicators of the onset of shock because of compensatory mechanisms. Over the past decade, the emergence and application of new technologies that incorporate the use of artificial intelligence have revealed that continuous, real-time arterial waveform analysis (AWFA) reflects the recruitment of such compensatory mechanism. As such, AWFA can provide early hemorrhage detection (HD) and indication of the onset of overt shock compared with standard VS. In this report, we provide for the first time a summary of clinical data collected in patients with varying conditions of blood loss, sepsis and resuscitation with direct comparison of AWFA and standard VS. Receiver Operating Characteristic Area Under the Curve data clearly demonstrate that AWFA provides greater accuracy with early indicators for changes in blood volume compared to standard VS. A consistently greater sensitivity generated by AWFA compared to VS is associated with its ability to provide earlier HD while higher specificity reflects its propensity to distinguish 'poor' compensators (i.e., those with relatively low tolerance to blood loss) from 'good' compensators. The data presented in this report demonstrate that integration of AWFA into medical monitoring capabilities has the potential to improve clinical outcomes of casualties by providing earlier and individualized assessment of blood loss and resuscitation.

Review of Commercially Available Supraglottic Airway Devices for Prehospital Combat Casualty Care

Grant B Copeland, Danielius J Zilevicius, Carlos N Bedolla, Andres L Islas, Marisa N Guerra, Sophia J Salazar, Robert A De Lorenzo, Steven G Schauer, R Lyle Hood

Mil Med. 2022 Feb 17; Online ahead of print

 

Background: Airway obstruction is the second leading cause of potentially survivable death on the battlefield. The Committee on Tactical Combat Casualty Care lists airway optimization among the top 5 battlefield research and development priorities; however, studies show that combat medics lack access to the recommended supraglottic airway (SGA) devices. SGA devices are an alternative airway management technique to endotracheal tube intubation. Reports have shown SGA devices are easier to use and take fewer attempts to provide patent airflow to the patient when compared to endotracheal tube intubation. Military settings require a higher degree of skill to perform airway management on patients due to the environment, limited availability of equipment, and potential chaos of the battlefield. Finding the optimal SGA device for the military setting is an unmet need. The International Organization for Standardization describes basic functional requirements for SGA devices, as well as patient configurations and size limitations. Beyond that, no SGA device manufacturer states that their devices are intended for military settings.

Materials and methods: We conducted a market review of 25 SGA devices that may meet inclusion into the medics' aid bag. The company's official "Instructions for Use" document, Google Scholar, and FDA reports were reviewed to obtain information for each SGA device.

Results: Twenty-five commercially available SGA devices are explored from manufacturer online sources. A commercially available device list is shown later in this paper, which provides the device's features, indications, and contraindications based on the manufacturer's product information documentation.

Conclusions: There are a variety of devices that require further testing to determine whether they should be included in sets, kits, and outfits.

 

Novel Technologies and Techniques for Prehospital Airway Management: An NAEMSP Position Statement and Resource Document

Catherine R Counts, Justin L Benoit, Graham McClelland, James DuCanto, Lauren Weekes, Andrew Latimer, Mohamed Hagahmed, Francis X Guyette

Prehosp Emerg Care. 2022;26(sup1):129-136

 

Abstract

Novel technologies and techniques can influence airway management execution as well as procedural and clinical outcomes. While conventional wisdom underscores the need for rigorous scientific data as a foundation before implementation, high-quality supporting evidence is frequently not available for the prehospital setting. Therefore, implementation decisions are often based upon preliminary or evolving data, or pragmatic information from clinical use. When considering novel technologies and techniques. NAEMSP recommends:Prior to implementing a novel technology or technique, a thorough assessment using the best available scientific data should be conducted on the technical details of the novel approach, as well as the potential effects on operations and outcomes.The decision and degree of effort to adopt, implement, and monitor a novel technology or technique in the prehospital setting will vary by the quality of the best available scientific and clinical information:• Routine use - Technologies and techniques with ample observational but limited or no interventional clinical trial data, or with strong supporting in-hospital data. These techniques may be reasonably adopted in the prehospital setting. This includes video laryngoscopy and bougie-assisted intubation. • Limited use - Technologies and techniques with ample pragmatic clinical use information but limited supporting scientific data. These techniques may be considered in the prehospital setting. This includes suction-assisted laryngoscopy and airway decontamination and cognitive aids. • Rare use - Technologies and techniques with minimal clinical use information. Use of these techniques should be limited in the prehospital setting until evidence exists from more stable clinical environments. This includes intubation boxes.The use of novel technologies and techniques must be accompanied by systematic collection and assessment of data for the purposes of quality improvement, including linkages to patient clinical outcomes.EMS leaders should clearly identify the pathways needed to generate high-quality supporting scientific evidence for novel technologies and techniques.

Resuscitation with blood products in patients with trauma-related haemorrhagic shock receiving prehospital care (RePHILL): a multicentre, open-label, randomised, controlled, phase 3 trial

Nicholas Crombie, Heidi A Doughty, Jonathan R B Bishop, Amisha Desai, Emily F Dixon, James M Hancox, Mike J Herbert, Caroline Leech, Simon J Lewis, Mark R Nash, David N Naumann, Gemma Slinn, Hazel Smith, Iain M Smith, Rebekah K Wale, Alastair Wilson, Natalie Ives, Gavin D Perkins, RePHILL collaborative group

Lancet Haematol. 2022 Apr;9(4):e250-e261

 

Background: Time to treatment matters in traumatic haemorrhage but the optimal prehospital use of blood in major trauma remains uncertain. We investigated whether use of packed red blood cells (PRBC) and lyophilised plasma (LyoPlas) was superior to use of 0·9% sodium chloride for improving tissue perfusion and reducing mortality in trauma-related haemorrhagic shock.

Methods: Resuscitation with pre-hospital blood products (RePHILL) is a multicentre, allocation concealed, open-label, parallel group, randomised, controlled, phase 3 trial done in four civilian prehospital critical care services in the UK. Adults (age ≥16 years) with trauma-related haemorrhagic shock and hypotension (defined as systolic blood pressure <90 mm Hg or absence of palpable radial pulse) were assessed for eligibility by prehospital critial care teams. Eligible participants were randomly assigned to receive either up to two units each of PRBC and LyoPlas or up to 1 L of 0·9% sodium chloride administered through the intravenous or intraosseous route. Sealed treatment packs which were identical in external appearance, containing PRBC-LyoPlas or 0·9% sodium chloride were prepared by blood banks and issued to participating sites according to a randomisation schedule prepared by the co-ordinating centre (1:1 ratio, stratified by site). The primary outcome was a composite of episode mortality or impaired lactate clearance, or both, measured in the intention-to-treat population. This study is completed and registered with ISRCTN.com, ISRCTN62326938.

Findings: From Nov 29, 2016 to Jan 2, 2021, prehospital critical care teams randomly assigned 432 participants to PRBC-LyoPlas (n=209) or to 0·9% sodium chloride (n=223). Trial recruitment was stopped before it achieved the intended sample size of 490 participants due to disruption caused by the COVID-19 pandemic. The median follow-up was 9 days (IQR 1 to 34) for participants in the PRBC-LyoPlas group and 7 days (0 to 31) for people in the 0·9% sodium chloride group. Participants were mostly white (62%) and male (82%), had a median age of 38 years (IQR 26 to 58), and were mostly involved in a road traffic collision (62%) with severe injuries (median injury severity score 36, IQR 25 to 50). Before randomisation, participants had received on average 430 mL crystalloid fluids and tranexamic acid (90%). The composite primary outcome occurred in 128 (64%) of 199 participants randomly assigned to PRBC-LyoPlas and 136 (65%) of 210 randomly assigned to 0·9% sodium chloride (adjusted risk difference -0·025% [95% CI -9·0 to 9·0], p=0·996). The rates of transfusion-related complications in the first 24 h after ED arrival were similar across treatment groups (PRBC-LyoPlas 11 [7%] of 148 compared with 0·9% sodium chloride nine [7%] of 137, adjusted relative risk 1·05 [95% CI 0·46-2·42]). Serious adverse events included acute respiratory distress syndrome in nine (6%) of 142 patients in the PRBC-LyoPlas group and three (2%) of 130 in 0·9% sodium chloride group, and two other unexpected serious adverse events, one in the PRBC-LyoPlas (cerebral infarct) and one in the 0·9% sodium chloride group (abnormal liver function test). There were no treatment-related deaths.

Interpretation: The trial did not show that prehospital PRBC-LyoPlas resuscitation was superior to 0·9% sodium chloride for adult patients with trauma related haemorrhagic shock. Further research is required to identify the characteristics of patients who might benefit from prehospital transfusion and to identify the optimal outcomes for transfusion trials in major trauma. The decision to commit to routine prehospital transfusion will require careful consideration by all stakeholders.

Association of Hypocalcemia With Mortality of Combat Casualties With Brain Injury and Polytrauma Transported by Critical Care Air Transport Teams

William T Davis, Patrick C Ng, Kimberly L Medellin, Julie E Cutright, Allyson A Araña, Richard J Strilka, Derek M Sorensen, Joseph K Maddry

Mil Med. 2022 Feb 17;usac029.Online ahead of print

 

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.

Fluid Resuscitation in Tactical Combat Casualty Care; TCCC Guidelines Change 21-01. 4 November 2021

Travis G Deaton, Jonathan D Auten, Richard Betzold, Frank K Butler Jr, Terence Byrne, Andrew P Cap, Benjamin Donham, Joseph J DuBose, Andrew D Fisher, James Hancock, Victor Jourdain, Ryan M Knight, Lanny F Littlejohn, Matthew J Martin, Kevin Toland, Brendon Drew

J Spec Oper Med. Winter 2021;21(4):126-137

 

Abstract

Hemorrhagic shock in combat trauma remains the greatest life threat to casualties with potentially survivable injuries. Advances in external hemorrhage control and the increasing use of damage control resuscitation have demonstrated significant success in decreasing mortality in combat casualties. Presently, an expanding body of literature suggests that fluid resuscitation strategies for casualties in hemorrhagic shock that include the prehospital use of cold-stored or fresh whole blood when available, or blood components when whole blood is not available, are superior to crystalloid and colloid fluids. On the basis of this recent evidence, the Committee on Tactical Combat Casualty Care (TCCC) has conducted a review of fluid resuscitation for the combat casualty who is in hemorrhagic shock and made the following new recommendations: (1) cold stored low-titer group O whole blood (CS-LTOWB) has been designated as the preferred resuscitation fluid, with fresh LTOWB identified as the first alternate if CS-LTOWB is not available; (2) crystalloids and Hextend are no longer recommended as fluid resuscitation options in hemorrhagic shock; (3) target systolic blood pressure (SBP) resuscitation goals have been redefined for casualties with and without traumatic brain injury (TBI) coexisting with their hemorrhagic shock; and (4) empiric prehospital calcium administration is now recommended whenever blood product resuscitation is required.

Applying Pharmacogenomic Guidelines to Combat Medical Care

Jesse DeLuca, Thomas Oliver, Chad Hulsopple, Daniel Selig, Elaine Por, Clesson Turner, Lydia Hellwig, Jeffrey Livezey

Mil Med. 2021 Dec 30;187(Suppl 1):18-24

Abstract

 

Pharmacogenomics is a pillar of personalized medicine that has the potential to deliver optimized treatment in many medical settings. Military medicine in the deployed setting is unique and therefore warrants separate assessment pertaining to its potential capabilities and impact. Pharmacogenomics for United States Active Duty Service Members medical care in the deployed setting has not, to our knowledge, been previously reviewed. We present potential applications of pharmacogenomics to forward medical care through two comprehensive references for deployed medical care, the Tactical Combat Casualty Care Guidelines (TCCC) and Emergency War Surgery (EWS) fifth edition. All drugs within the deployment manuals, TCCC guidelines and EWS book, were identified and the list was cross-referenced to the Clinical Pharmacogenetics Implementation Consortium guidelines and genes-drugs interactions list as well as the Food and Drug Administration Table of Pharmacogenomics Biomarkers in Drug Labeling. Ten pharmacologic categories were identified, consisting of 15 drugs, along with the classes, aminogylcosides, beta-blockers, and volatile anesthetics. Drugs and pharmacogenomics liabilities were tabulated. Eight specific drugs or classes are expounded upon given the belief of the authors of their potential for impacting future treatment on the battlefield in the setting of prolonged field care. This review outlines several genes with liabilities in the prolonged field care setting and areas that may produce improved care with further study.

Austere Fasciotomy: Alternative Equipment for Performance in the Field

Erik Scott DeSoucy, Christopher W Hewitt, Scotty Bolleter

J Spec Oper Med. Spring 2022;22(1):81-86

 

Background: Acute compartment syndrome (ACS) following extremity trauma requires rapid fasciotomy to avoid significant morbidity and limb loss. Four-compartment fasciotomy of the leg is a surgical procedure typically performed in the operating room; however, casualties who cannot be rapidly transported may need fasciotomies in the prehospital setting. In the absence of traditional operating instruments (e.g., scalpel, long Metzenbaum scissors, electrocautery), alternative means of fasciotomy may be needed. We undertook a proof-of-concept study using cadaver models to determine whether leg fasciotomies could be performed with alternative devices compared with the surgical standard.

Methods: Two-incision, four-compartment fasciotomies were performed on fresh, never-frozen, non-embalmed cadaver legs using a scalpel for the initial skin incision, followed by release of the fascia using one of the following instruments: 5.5-in curved Mayo scissors; Benchmade rescue hook (model BM-5BLKW); rescue hook on the Leatherman Raptor multitool (model 831741-FFP); Leatherman Z-Rex multitool rescue hook (model LM93408); or No. 10 PenBlade (model PB-M-10- CAS). The procedures were performed by a surgeon. Skin and fascia incisional lengths were recorded along with a subjective impression of the performance for each device. Post-procedural dissection was performed to identify associated injuries to the muscle, superficial peroneal nerve, and the greater saphenous vein (GSV).

Results: All devices were able to adequately release the fascia in all four compartments. All rescue hooks (Benchmade, Raptor, and Z-Rex) required a "pull technique" and a skin incision of equal length to the fascia incision. The PenBlade was used in a "push technique," similar to the standard scissor fasciotomy through a smaller skin incision. There was one superficial peroneal nerve transection with the rescue hooks, but there were no GSV injuries or significant muscle damage with any instrument.

Conclusion: Four-compartment fasciotomy can be performed with readily available alternative equipment such as rescue hooks and the PenBlade. Hook-type devices require longer skin incisions compared with scissors and the PenBlade. In contested environments, patients with ACS may require fasciotomy prior to evacuation to surgical teams; training combat medics in the use of these alternative instruments in the field may preserve life and limb.

Prehospital Airway Management Training and Education: An NAEMSP Position Statement and Resource Document

Maia Dorsett, Ashish R Panchal, Christopher Stephens, Andra Farcas, William Leggio, Christopher Galton, Rickquel Tripp, Tom Grawey

Prehosp Emerg Care. 2022;26(sup1):3-13

 

Abstract

Abstract Airway management competency extends beyond technical skills to encompass a comprehensive approach to optimize patient outcomes. Initial and continuing education for airway management must therefore extend beyond a narrow focus on psychomotor skills and task completion to include appreciation of underlying pathophysiology, clinical judgment, and higher-order decision making. NAEMSP recommends:Active engagement in deliberate practice should be the guiding approach for developing and maintaining competence in airway management.EMS learners and clinicians must be educated in an escalating approach to airway management, where basic airway maneuvers form the central focus.Educational activities should extend beyond fundamental knowledge to focus on the development of clinical judgment.Optimization of patient outcomes should be valued over performance of individual airway management skills.Credentialing and continuing education activities in airway management are essential to advance clinicians beyond entry-level competency.Initial and continuing education programs should be responsive to advances in the evidence base and maintain adaptability to re-assess content and expected outcomes on a continual basis.

Pro-Con Debate: Prehospital Blood Transfusion-Should It Be Adopted for Civilian Trauma?

Roman Dudaryk, Catherine Heim, Kurt Ruetzler, Evan G Pivalizza

Anesth Analg. 2022 Apr 1;134(4):678-682

 

Abstract

Exsanguination is the leading cause of death in severely injured patients; nevertheless, prehospital blood transfusion (PHT) remains a controversial topic. Here, we review the pros and cons of PHT, which is now routine in treatment of military trauma patients in the civilian setting. While PHT may improve survival in those who suffer blunt injury or require prolonged transport from the site of injury, PHT for civilian trauma generally is not supported by high-quality evidence. This article was originally presented as a pro-con debate at the 2020 meeting of the European Society of Anesthesiology and Intensive Care.

 

Prehospital Use of the Esophageal Tracheal Combitube Supraglottic Airway Device: A Retrospective Cohort Study

Hubert Dufour-Neyron, Katherine Tanguay, Alexandra Nadeau, Marcel Emond, Jessica Harrisson, Sébastien Robert, Nicolas Capolla-Daneau, Mathieu Groulx, Pierre-Hugues Carmichael, Eric Mercier

J Emerg Med. 2022 Mar;62(3):324-331

 

Background: In the province of Quebec (Canada), paramedics use the esophageal tracheal Combitube (ETC) for prehospital airway management.

Objectives: Our main objective was to determine the proportion of patients with successful ventilation achieved after ETC use. Our secondary aim was to determine the number of ETC insertion attempts required to ventilate the patient.

Method: This is a retrospective cohort study. All patients who had ≥1 attempt to insert an ETC during prehospital care between January 1, 2017 and December 31, 2018 were included. Prehospital and in-hospital data were extracted. Successful ventilation was defined as thorax elevation, lung sounds on chest auscultation, or positive end-tidal capnography after ETC insertion.

Results: A total of 580 emergency medical services interventions (99.3% cardiac arrests) were included. Most patients were men (62.5%) with a mean age 67.0 years (SD 17.6 years), and 35 (13.1%) of the 298 patients transported to emergency department survived to hospital discharge. Sufficient information to determine whether ventilation was successful or not was available for 515 interventions. Ventilation was achieved during 427 (82.7%) of these interventions. The number of ETC insertion attempts was available for 349 of the 427 successful ETC use. Overall, the first insertion resulted in successful ventilation during 294 interventions for an overall proportion of first-pass success ranging between 57.1% and 72.1%.

Conclusion: Proportions of successful ventilation and ETC first-pass success are lower than those reported in the literature with supraglottic airway devices. The reasons explaining these lower rates and their impact on patient-centered outcomes need to be studied.

 

Opioids for Treatment of Pre-hospital Acute Pain: A Systematic Review

Kristian Dahl Friesgaard, Gunn Elisabeth Vist, Per Kristian Hyldmo, Lasse Raatiniemi, Jouni Kurola, Robert Larsen, Poul Kongstad, Vidar Magnusson, Mårten Sandberg, Marius Rehn, Leif Rognås

Pain Ther. 2022 Mar;11(1):17-36

 

Introduction: Acute pain is a frequent symptom among patients in the pre-hospital setting, and opioids are the most widely used class of drugs for the relief of pain in these patients. However, the evidence base for opioid use in this setting appears to be weak. The aim of this systematic review was to explore the efficacy and safety of opioid analgesics in the pre-hospital setting and to assess potential alternative therapies.

Methods: The PubMed, EMBASE, Cochrane Library, Centre for Reviews and Dissemination, Scopus, and Epistemonikos databases were searched for studies investigating adult patients with acute pain prior to their arrival at hospital. Outcomes on efficacy and safety were assessed. Risk of bias for each included study was assessed according to the Cochrane approach, and confidence in the evidence was assessed using the GRADE method.

Results: A total of 3453 papers were screened, of which the full text of 125 was assessed. Twelve studies were ultimately included in this systematic review. Meta-analysis was not undertaken due to substantial clinical heterogeneity among the included studies. Several studies had high risk of bias resulting in low or very low quality of evidence for most of the outcomes. No pre-hospital studies compared opioids with placebo, and no studies assessed the risk of opioid administration for subgroups of frail patients. The competency level of the attending healthcare provider did not seem to affect the efficacy or safety of opioids in two observational studies of very low quality. Intranasal opioids had a similar effect and safety profile as intravenous opioids. Moderate quality evidence supported a similar efficacy and safety of synthetic opioid compared to morphine.

Conclusions: Available evidence for pre-hospital opioid administration to relieve acute pain is scarce and the overall quality of evidence is low. Intravenous administration of synthetic, fast-acting opioids may be as effective and safe as intravenous administration of morphine. More controlled studies are needed on alternative routes for opioid administration and pre-hospital pain management for potentially more frail patient subgroups.

Prehospital Iliac Crest Intraosseous Whole Blood Infusion

George H Fulghum 3rd, Brian Gravano, Andrew Foudrait, Stephen C Rush, Lorenzo Paladino

J Spec Oper Med. Winter 2021;21(4):90-93.

 

Abstract

Low-titer cold-stored O-positive whole blood (LTCSO+WB) resuscitation therapy is the cornerstone of military hemorrhagic shock resuscitation. During the past 19 years, improved patient outcomes have shown the importance of this intervention in shock treatment. Iliac crest intraosseous (IO) placement is an alternative when peripheral sites such as the humeral head and tibia are not available options. To date, no study has explored the administration of LTCSO+WB through an iliac crest IO in the military prehospital setting. Contingency procedures for vascular access are necessary for casualties with severe trauma to all four extremities, and the iliac crest is a viable option. The literature supports situational advantages over other peripheral IO sites.

Use of Walking Blood Bank at Point of Injury During Combat Operations: A Case Report

Matthew Gaddy, Alan Fickling, Vanessa C Hannick, Stacy A Shackelford

J Spec Oper Med. Winter 2021;21(4):94-98

 

Abstract

The US Military Tactical Combat Casualty Care guidelines recommend blood products as the preferred means of fluid resuscitation in trauma patients;, however, most combat units do not receive blood products prior to executing combat operations. This is largely due to logistical limitations in both blood supply and transfusion equipment. Further, the vast majority of medics are not trained in transfusion protocol. For many medics, the logistical constraints for cold-stored blood products favor the use of Walking Blood Bank (WBB), however few cases have been reported of WBB implementation at the point of injury during real world combat operations. This case report reviews one case of successful transfusion using WBB procedures at point of injury during combat. It highlights not only the feasibility, but also the necessity, for implementation of this practice on a larger scale.

 

Injuries after cricothyroidotomy using different equipment

Tomasz M Gaszynski

Eur J Anaesthesiol. 2022 Feb 1;39(2):175-176

 

No abstract available

 

Wilderness Medical Society Clinical Practice Guidelines on Anaphylaxis

Flavio G Gaudio, David E Johnson, Kelly DiLorenzo, Arian Anderson, Martin Musi, Tod Schimelpfenig, Drew Leemon, Caroline Blair-Smith, Jay Lemery

Wilderness Environ Med. 2022 Mar;33(1):75-91

 

Abstract

The Wilderness Medical Society convened a panel to review the literature and develop evidence-based clinical practice guidelines on the treatment of anaphylaxis, with an emphasis on a field-based perspective. The review also included literature regarding the definition, epidemiology, clinical manifestations, and prevention of anaphylaxis. The increasing prevalence of food allergies in the United States raises concern for a corresponding rise in the incidence of anaphylaxis. Intramuscular epinephrine is the primary treatment for anaphylaxis and should be administered before adjunctive treatments such as antihistamines, corticosteroids, and inhaled β agonists. For outdoor schools and organizations, selecting a method to administer epinephrine in the field is based on considerations of cost, safety, and first responder training, as well as federal guidelines and state-specific laws.

 

 

Pharmacokinetics of tranexamic acid after intravenous, intramuscular, and oral routes: a prospective, randomised, crossover trial in healthy volunteers

Stanislas Grassin-Delyle, Michaela Semeraro, Elodie Lamy, Saïk Urien, Iléana Runge, Frantz Foissac, Naim Bouazza, Jean-Marc Treluyer, Monica Arribas, Ian Roberts, Haleema Shakur-Still

Br J Anaesth. 2022 Mar;128(3):465-472

 

Background: In response to the World Health Organization call for research on alternative routes for tranexamic acid (TXA) administration in women with postpartum haemorrhage, we examined the pharmacokinetics of TXA after i.v., i.m., or oral administration.

Methods: We conducted a randomised, open-label, crossover trial in 15 healthy volunteers who received i.v. TXA 1 g, i.m. TXA 1 g, or oral TXA solution 2 g. Blood samples were drawn up to 24 h after administration. Tranexamic acid concentration was measured with liquid chromatography-mass spectrometry, and the parameters of the pharmacokinetic models were estimated using population pharmacokinetics.

Results: The median time to reach a concentration of 10 mg L-1 was 3.5 min for the i.m. route and 66 min for the oral route, although with the oral route the target concentration was reached in only 11 patients. Median peak concentrations were 57.5, 34.4, and 12.8 mg L-1 for i.v., i.m., and oral routes, respectively. A two-compartment open model with body weight as the main covariate best fitted the data. For a 70 kg volunteer, the population estimates were 10.1 L h-1 for elimination clearance, 15.6 L h-1 for intercompartmental clearance, 7.7 L for the volume of central compartment, and 10.8 L for the volume of the peripheral compartment. Intramuscular and oral bioavailabilities were 1.0 and 0.47, respectively, showing that i.m. absorption is fast and complete. Adverse events were mild and transient, mainly local reactions and low-intensity pain.

Conclusions: The i.m. (but not oral) route appears to be an efficient alternative to i.v. tranexamic acid. Studies in pregnant women are needed to examine the impact of pregnancy on the pharmacokinetics.

Tranexamic Acid for Acute Spontaneous Intracerebral Hemorrhage: A Meta-Analysis of Randomized Controlled Trials

Yu Guo, Xin-Mei Guo, Rui-Li Li, Kai Zhao, Qiang-Ji Bao, Jin-Cai Yang, Qiang Zhang, Ming-Fei Yang

Front Neurol. 2021 Dec 20;12:761185.

 

Background: The role of tranexamic acid (TXA) in preventing hematoma expansion (HE) in patients with acute spontaneous intracerebral hemorrhage (ICH) remains unclear. We aim to investigate the efficacy and safety of TXA in acute spontaneous ICH with a particular focus on subgroups.

Methods: Randomized controlled trials (RCTs) were retrieved from CENTRAL, Clinicaltrials.gov, EMBASE, PubMed, and WHO ICTRP. The primary outcome measurement was HE. The secondary outcome measurements included 3-month poor functional outcome (PFO), 3-month mortality, and major thromboembolic events (MTE). We conducted subgroup analysis according to the CT markers of HE (standard-risk population and high-risk population) and the time from onset to randomization (>4.5 and ≤4.5 h).

Results: We identified seven studies (representing five RCTs) involving 2,650 participants. Compared with placebo, TXA may reduce HE on subsequent imaging (odd ratio [OR] 0.825; 95% confidence interval [CI] 0.692-0.984; p = 0.033; I2 = 0%; GRADE: moderate certainty). TXA and placebo arms did not differ in the rates of 3-month PFO, 3-month mortality, and MTE. Subgroup analysis indicated that TXA reduced the risk of HE in the high-risk population with CT markers of HE (OR 0.646; 95% CI 0.503-0.829; p = 0.001; I2 = 0 %) and in patients who were treated within 4.5 h of symptom onset (OR 0.823; 95% CI 0.690-0.980; p = 0.029; I2 = 0%), but this protective effect was not observed in the standard-risk population and patients who were treated over 4.5 h of symptom onset.

Conclusions: Tranexamic acid (TXA) may decrease the risk of HE in patients with acute spontaneous ICH. Importantly, the decreased risk was observed in patients who were treatable within 4.5 h and with a high risk of HE, but not in those who were treatable over 4.5 h and in standard-risk population. However, PFO or mortality at 3 months did not significantly differ between patients who received TXA and those who received placebo. TXA is safe for acute spontaneous ICH without increasing MTE.

Whole blood at the tip of the spear: A retrospective cohort analysis of warm fresh whole blood resuscitation versus component therapy in severely injured combat casualties

Jennifer M Gurney, Amanda M Staudt, Deborah J Del Junco, Stacy A Shackelford, Elizabeth A Mann-Salinas, Andrew P Cap, Philip C Spinella, Matthew J Martin

Surgery. 2022 Feb;171(2):518-525

 

Background: Death from uncontrolled hemorrhage occurs rapidly, particularly among combat casualties. The US military has used warm fresh whole blood during combat operations owing to clinical and operational exigencies, but published outcomes data are limited. We compared early mortality between casualties who received warm fresh whole blood versus no warm fresh whole blood.

Methods: Casualties injured in Afghanistan from 2008 to 2014 who received ≥2 red blood cell containing units were reviewed using records from the Joint Trauma System Role 2 Database. The primary outcome was 6-hour mortality. Patients who received red blood cells solely from component therapy were categorized as the non-warm fresh whole blood group. Non- warm fresh whole blood patients were frequency-matched to warm fresh whole blood patients on identical strata by injury type, patient affiliation, tourniquet use, prehospital transfusion, and average hourly unit red blood cell transfusion rates, creating clinically unique strata. Multilevel mixed effects logistic regression adjusted for the matching, immortal time bias, and other covariates.

Results: The 1,105 study patients (221 warm fresh whole blood, 884 non-warm fresh whole blood) were classified into 29 unique clinical strata. The adjusted odds ratio of 6-hour mortality was 0.27 (95% confidence interval 0.13-0.58) for the warm fresh whole blood versus non-warm fresh whole blood group. The reduction in mortality increased in magnitude (odds ratio = 0.15, P = .024) among the subgroup of 422 patients with complete data allowing adjustment for seven additional covariates. There was a dose-dependent effect of warm fresh whole blood, with patients receiving higher warm fresh whole blood dose (>33% of red blood cell-containing units) having significantly lower mortality versus the non-warm fresh whole blood group.

Conclusion: Warm fresh whole blood resuscitation was associated with a significant reduction in 6-hour mortality versus non-warm fresh whole blood in combat casualties, with a dose-dependent effect. These findings support warm fresh whole blood use for hemorrhage control as well as expanded study in military and civilian trauma settings.

 

 

Hypertonic Saline Compared to Mannitol for the Management of Elevated Intracranial Pressure in Traumatic Brain Injury: A Meta-Analysis

Chengchen Han, Fan Yang, Shengli Guo, Jianning Zhang

Front Surg. 2022 Jan 7;8:765784

 

Background: We performed a meta-analysis to evaluate the effect of hypertonic saline compared to mannitol for the management of elevated intracranial pressure in traumatic brain injury.

Methods: A systematic literature search up to July 2021 was performed and 17 studies included 1,392 subjects with traumatic brain injury at the start of the study; 708 of them were administered hypertonic saline and 684 were given mannitol. They were reporting relationships between the effects of hypertonic saline compared to mannitol for the management of elevated intracranial pressure in traumatic brain injury. We calculated the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) to assess the effect of hypertonic saline compared to mannitol for the management of elevated intracranial pressure in traumatic brain injury using the dichotomous or continuous method with a random or fixed-effect model.

 Results: Hypertonic saline had significantly lower treatment failure (OR, 0.38; 95% CI, 0.15-0.98, p = 0.04), lower intracranial pressure 30-60 mins after infusion termination (MD, -1.12; 95% CI, -2.11 to -0.12, p = 0.03), and higher cerebral perfusion pressure 30-60 mins after infusion termination (MD, 5.25; 95% CI, 3.59-6.91, p < 0.001) compared to mannitol in subjects with traumatic brain injury. However, hypertonic saline had no significant effect on favorable outcome (OR, 1.61; 95% CI, 1.01-2.58, p = 0.05), mortality (OR, 0.59; 95% CI, 0.34-1.02, p = 0.06), intracranial pressure 90-120 mins after infusion termination (MD, -0.90; 95% CI, -3.21-1.41, p = 0.45), cerebral perfusion pressure 90-120 mins after infusion termination (MD, 4.28; 95% CI, -0.16-8.72, p = 0.06), and duration of elevated intracranial pressure per day (MD, 2.20; 95% CI, -5.44-1.05, p = 0.18) compared to mannitol in subjects with traumatic brain injury.

Conclusions: Hypertonic saline had significantly lower treatment failure, lower intracranial pressure 30-60 mins after infusion termination, and higher cerebral perfusion pressure 30-60 mins after infusion termination compared to mannitol in subjects with traumatic brain injury. However, hypertonic saline had no significant effect on the favorable outcome, mortality, intracranial pressure 90-120 mins after infusion termination, cerebral perfusion pressure 90-120 mins after infusion termination, and duration of elevated intracranial pressure per day compared to mannitol in subjects with traumatic brain injury. Further studies are required to validate these findings.

Supplemental oxygen for traumatic brain injury: A systematic review

Thea Ellehammer Hansen, Rasmus Ejlersgaard Christensen, Josefine Baekgaard, Jacob Steinmetz, Lars S Rasmussen

Acta Anaesthesiol Scand. 2022 Mar;66(3):307-316

 

Background: Oxygen supplementation is recommended after traumatic brain injury (TBI) but excessive oxygen may be harmful. The aim of this study was to investigate the effect of supplemental oxygen or high/low inspiratory oxygen fraction (FiO2 ) for TBI patients on in-hospital mortality.

Methods: We searched Medline (Pubmed), EMBASE and the Cochrane Library for interventional and observational studies fulfilling the following criteria: TBI patients >17 years (population); initial use of supplemental oxygen/high (≥0.6) FiO2 (intervention) vs no supplemental oxygen/low (<0.6) FiO2 (control) for spontaneously breathing or mechanically ventilated TBI patients, respectively with in-hospital mortality as primary outcome. Secondary outcomes were 30-day and 1-year mortality, length of stay in hospital or intensive care unit, days on mechanical ventilation, complications, and neurological impairment.

Results: We screened 4846 citations. Two interventional studies comparing high vs low FiO2 for mechanically ventilated TBI patients were included. No difference in in-hospital mortality was found. The first study found a statistically significant shorter length of stay in the intensive care unit for the high FiO2 -group (6.5 [4.6-11.4] vs. 11.4 [5.8-17.2] days, p = 0.02). The second study found a lower disability at 6 months in the high FiO2 -group with low disability in 25 (73.5%) vs. 15 (44.1%), moderate disability in 9 (26.5%) vs. 16 (47.1%), and severe disability in 0 (0.0%) vs. 3 (8.8%), p = 0.02.

Conclusion: Evidence on the effect of initial use of high/low FiO2 for TBI patients on in-hospital mortality was extremely limited. Evidence on the use of supplemental oxygen for spontaneously breathing TBI patients is lacking.

Prehospital Simple Thoracostomy Does Not Improve Patient Outcomes Compared to Needle Thoracostomy in Severely Injured Trauma Patients

Charles T Harris, Sharven Taghavi, Emily Bird, Juan Duchesne, Tomas Jacome, Danielle Tatum

Am Surg. 2022 Feb 10; Online ahead of print

 

Background: ATLS suggests simple thoracostomy (ST) after failure of needle thoracostomy (NT) in thoracic trauma. Some EMS agencies have adopted ST into their practice. We sought to describe our experience implementing ST in the prehospital setting, hypothesizing that prehospital ST would reduce failure rates and improve outcomes compared to NT.

Methods: This was a retrospective review of adult trauma patients who received prehospital ST or NT from 2017 to 2020.

Results: There were 48 patients with 64 procedures included. 83.7% were male and 65.8% injured by penetrating mechanism and of median (IQR) age of 31 (25-46) years. 28 (43.8%) procedures were NT and 36 (56.3%) were ST. Rates of improved patient response (P = .15), noted return of blood/air (P = .19), and return of spontaneous circulation (P = .62) did not differ. On-scene times were higher for ST (16.8 vs 11.5 minutes; P < .02). Overall mortality did not differ between ST and NT (68.2% vs 46.4%, respectively; P = .125). For patients that survived beyond the ED, procedure-related complication rates were 2 of 21 patients (9.5%) in ST and 1 of 12 (8.3%) in NT. In penetrating trauma, simple thoracostomy had longer on-scene time and total prehospital time.

Discussion: ST did not improve success rates of ROSC and was associated with prolonged prehospital times, especially in penetrating trauma patients. Given the benefit of "scoop and run" in urban penetrating trauma, consideration should be given to direct transport in lieu of ST. Use of ST in blunt trauma should be evaluated prospectively.

 

Characteristics and Outcomes of Prehospital Tourniquet Use for Trauma in the United States

Zain G Hashmi, Parker J Hu, Jan O Jansen, Frank K Butler, Jeffrey D Kerby, John B Holcomb

Prehosp Emerg Care. 2022 Feb 3; Online ahead of print

 

Introduction: The use of the extremity tourniquet in military environments has reduced preventable deaths due to exsanguinating hemorrhage, leading to increased use in civilian settings. However, the outcomes of contemporary prehospital tourniquet use in civilian settings are not well-described nationally. The objective of this study was to describe the characteristics and outcomes following prehospital tourniquet use by emergency medical services (EMS) in the United States.

Methods: All trauma activations reported to the National EMS Information System 2019 (NEMSIS) were included. Patients who had ≥1 tourniquet applied were identified. Descriptive analyses were used to compare characteristics between tourniquet and no-tourniquet cohorts. Coarsened exact matching was performed to generate a k2k match (on age, sex, lowest-systolic blood pressure, initial patient acuity, provider's initial impression, injury mechanism, and presence of upper/lower extremity injuries) and used to compare outcomes. Trauma patients who may have potentially benefited from tourniquet application (extremity injury, shock index ≥1 and no documented tourniquet application) were identified.

Results: A total of 7,161 tourniquets were applied among 4,571,379 trauma activations (1.6/1000 activations). Patients in the tourniquet cohort were younger (40 ± 18 vs 52 ± 26 mean ± SD years), more hypotensive (16.1% vs. 2.5%) and had higher initial acuity (65.0% critical/emergent vs. 20.6%) [p < 0.01 for all]. A total of 7,074 patients in the tourniquet cohort were matched with 7,074 patients in the non-tourniquet cohort. Post-match analysis revealed that the patients in tourniquet cohort had a higher final acuity (80.8% vs. 75.0%, p < 0.01), lower scene-time (15.4 ± 13.6 vs. 17.0 ± 14.2 mean ± SD minutes, p < 0.01), and higher survival-to-hospital (83.6% vs. 75.1%, p < 0.01). A total of 141,471 trauma patients who may have potentially benefited from tourniquet application were identified.

Conclusion: Prehospital tourniquet use by EMS in the United States is associated with lower scene-time and improved survivability to hospital. Results indicate that patients might benefit from wider tourniquet use in the civilian prehospital setting.

Abdominal Compartment Syndrome: A Life-Threatening Condition in Air Medical Transportation of Multiple Trauma Patients

Ebrahim Hazrati, Hamze Shahali

Air Med J. Jan-Feb 2022;41(1):151-157

 

Abstract

A 41-year-old male farmer was injured in a land mine explosion. After initial resuscitation, the emergency physician coordinated with the hospital and air medical crew for the patient's evacuation. The evacuation was started by a Bell 214C helicopter, and the patient's clinical condition deteriorated during flight with increased abdominal pain and distension, tachycardia, tachypnea, hypotension, and loss of consciousness. Intra-abdominal (vesical) pressure of 23 mm Hg, findings of in-flight bedside ultrasound, and echocardiography indicated intra-abdominal hypertension with abdominal compartment syndrome. The emergency physician started medical management quickly based on the World Society of Abdominal Compartment Syndrome, but after 15 minutes the intra-abdominal pressure was still > 20 mm Hg. Despite the in-flight difficult condition, the risk of vascular or neural damages, and infection, the emergency physician performed a midline decompression laparotomy and, when the intra-abdominal pressure reached about 11 mm Hg, temporarily covered the wound with a Bogota bag. After the patient's intra-abdominal pressure stabilized, permanent abdominal wound repair was performed by the surgeon, and he was discharged from the hospital.

The Myths of Uncontrolled Emergence Reactions and Consideration to Stop Mandatory, Protocolled Midazolam Coadministration With Ketamine

Hugh M Hiller, Brendon Drew, Andrew D Fisher, Matthew Cuthrell, James C Spradling

J Spec Oper Med. Spring 2022;22(1):49-54

 

Abstract

Ketamine continues to demonstrate its utility and safety in the austere and prehospital environment, but myths persist regarding the frequency of behavioral disturbances and unpleasant reactions. These myths have led to protocolled midazolam co-administration. Properties of midazolam and other benzodiazepines have the potential to cause significant morbidity and potential mortality. Because of this risk, benzodiazepines should only be administered when the treating provider determines that the patient's symptoms warrant it. We also present evidence that agitation and altered mental status (AMS) encountered with ketamine occurs during titration of lower pain control regimens and is much less likely to occur with higher doses. As such, in most prehospital situations, the treatment for this "incomplete dissociation" is more ketamine, not the addition of a potentially dangerous benzodiazepine.

 

Prehospital Plasma Transfusion: What Does the Literature Show?

Bryon P Jackson, Jason L Sperry, Mark H Yazer

Transfus Med Hemother. 2021 Oct 14;48(6):358-365

 

Background: Early initiation of blood products transfusion after injury has been associated with improved patient outcomes following traumatic injury. The ability to transfuse patients' plasma in the prehospital setting provides a prime opportunity to begin resuscitation with blood products earlier and with a more balanced plasma: RBC ratio than what has traditionally been done. Published studies on the use of prehospital plasma show a complex relationship between its use and improved survival.

Summary: Examination of the literature shows that there may be a mortality benefit from the use of prehospital plasma, but that it may be limited to certain subgroups of trauma patients. The likelihood of realizing these survival benefits appears to be predicted by several factors including the type of injury, length of transport time, presence of traumatic brain injury, and total number of blood products transfused, whether the patient required only a few products or a massive transfusion. When taken as a whole the evidence appears to show that prehospital plasma may have a mortality benefit that is most clearly demonstrated in patients with blunt injuries, moderate transfusion requirements, traumatic brain injury, and/or transport time greater than 20 min, as well as those who demonstrate a certain cytokine expression profile.

Key messages: The evidence suggests that a targeted use of prehospital plasma will most likely maximize the benefits from the use of this limited resource. It is also possible that prehospital plasma may best be provided through whole blood as survival benefits were greatest in patients who received both prehospital plasma and RBCs.

Prehospital Drug Assisted Airway Management: An NAEMSP Position Statement and Resource Document

Jeffrey L Jarvis, John W Lyng, Brian L Miller, Michael C Perlmutter, Heidi Abraham, Ritu Sahni

Prehosp Emerg Care. 2022;26(sup1):42-53

 

Abstract

Airway management is a critical intervention for patients with airway compromise, respiratory failure, and cardiac arrest. Many EMS agencies use drug-assisted airway management (DAAM) - the administration of sedatives alone or in combination with neuromuscular blockers - to facilitate advanced airway placement in patients with airway compromise or impending respiratory failure who also have altered mental status, agitation, or intact protective airway reflexes. While DAAM provides several benefits including improving laryngoscopy and making insertion of endotracheal tubes and supraglottic airways easier, DAAM also carries important risks. NAEMSP recommends:DAAM is an appropriate tool for EMS clinicians in systems with clear guidelines, sufficient training, and close EMS physician oversight. DAAM should not be used in settings without adequate resources.EMS physicians should develop clinical guidelines informed by evidence and oversee the training and credentialing for safe and effective DAAM.DAAM programs should include best practices of airway management including patient selection, assessmenct and positioning, preoxygenation strategies including apneic oxygenation, monitoring and management of physiologic abnormalities, selection of medications, post-intubation analgesia and sedation, equipment selection, airway confirmation and monitoring, and rescue airway techniques.Post-DAAM airway placement must be confirmed and continually monitored with waveform capnography.EMS clinicians must have the necessary equipment and training to manage patients with failed DAAM, including bag mask ventilation, supraglottic airway devices and surgical airway approaches.Continuous quality improvement for DAAM must include assessment of individual and aggregate performance metrics. Where available for review, continuous physiologic recordings (vital signs, pulse oximetry, and capnography), audio and video recordings, and assessment of patient outcomes should be part of DAAM continuous quality improvement.

 

Early Tranexamic Acid in Intracerebral Hemorrhage: A Meta-Analysis of Randomized Controlled Trials

Xu Jiao, Mingfei Li, Lulu Li, Xinyu Hu, Xiaohui Guo, Yun Lu

Front Neurol. 2021 Dec 6;12:721125

 

Objective: Intracranial hemorrhage (ICH) is a common complication of traumatic brain, in which tranexamic acid has been recommended as an additional therapy to prevent a second bleeding. However, the effect of early administration of tranexamic acid for ICH patients remains controversial.

Methods: A systematic search was performed in Cochrane Library, Medline, Embase, and Web of Science. Poor outcome refers to significant hemorrhage growth, new intracranial hemorrhage, new focal cerebral ischaemic lesions, the need for neurosurgery, or death. Study heterogeneity and publication bias were estimated.

 Results: Seven randomized controlled trials involving 3,192 participants were included in our meta-analysis. Tranexamic acid administration in ICH patients was associated with better outcomes of hematoma expansion (odd ratios [OR] 0.79; 95% confidence interval (CI) CI, 0.67-0.93; I 2 = 0%; P = 0.006) and growth of hemorrhagic lesions (weighted mean difference [WMD], -1.97 ml; 95% CI, -2.94 to -1.00; I 2 = 14%; P < 0.001) than the placebo. No difference was found between the mortality, poor outcome, neurosurgical intervention, new bleeding, and the duration of hospital stay. Moreover, no publication bias was found.

Conclusion: Our analysis reveals that the early treatment with tranexamic acid can significantly reduce the incidence of hematoma expansion and the volume of hemorrhagic lesion, but does not exert considerable effects on mortality, poor outcome, neurosurgery, rebleeding, and the duration of stay.

Adequacy of probabilistic prehospital antibiotic therapy for septic shock

Romain Jouffroy 1, Basile Gilbert 2, Anna Hassan 3, Jean-Pierre Tourtier 4, Emmanuel Bloch-Laine 5, Patrick Ecollan 6, Josiane Boularan 7, Vincent Bounes 2, Benoit Vivien 8, Papa Gueye 9

Am J Emerg Med. 2022 Mar;53:80-85

 

Background: Guidelines on sepsis management recommend early recognition, diagnosis and treatment, especially early antibiotic therapy (ABT) administration in order to reduce septic shock (SS) mortality. However, the adequacy of probabilistic prehospital ABT remains unknown.

Methods: From May 2016 to March 2021, all consecutive patients with SS cared for by a prehospital mICU intervention were retrospectively analyzed.

Results: Among 386 patients retrospectively analyzed, 119 (33%) received probabilistic prehospital ABT, among which 74% received a 3rd generation cephalosporin: 31% cefotaxime and 42% ceftriaxone. No patient had a serious adverse effect related to ABT administration. Overall mortality rate on day-30 was 29%. Among the 119 patients with prehospital ABT, bacteriological identification was obtained for 81 (68%) patients with adequate prehospital ABT for 65 patients (80%) of which 10 (15%) deceased on day-30. Conversely, among the 16 (20%) patients with inadequate prehospital ABT, 9 patients (56%) were deceased on day-30. Prehospital adequate ABT was significantly different between alive and deceased patients on day-30 (p = 4.10-3). After propensity score matching, a significant association between adequate prehospital ABT administration and day-30 mortality was observed (aOR = 0.09 [0.01-0.47]). Inverse probability treatment weighting with multivariable logistic regression reported a day-30 mortality decrease in the adequate prehospital ABT group: aOR = 0.70 [0.53-0.93].

Conclusions: Among SS cared for by a mICU, probabilistic prehospital ABT is adequate most of the time and associated with a day-30 mortality decrease. Further prospective studies are needed to confirm these results and the weight of prehospital ABT in the prehospital bundle of care for SS.

Effect of single dose intravenous tranexamic acid on blood loss in tangential excision of burn wounds - A double blind randomised controlled trial

Ajai K, Parmod Kumar, Mohsina Subair, Ramesh Kumar Sharma

Burns. 2021 Aug 30; Online ahead of print

 

Introduction: This study was carried out to evaluate role of intravenous tranexamic acid (TXA) in reducing blood loss during tangential excision of burns.

Methods: This was a single center, prospective double-blinded parallel arm superiority randomized placebo-controlled trial. Patients (15-55 years) with deep dermal thermal burns <30% undergoing tangential excision were randomly assigned (1:1) to TXA and placebo groups. Patients in TXA and placebo groups received injection TXA 15 mg/kg and 10 ml saline respectively, 10 min preoperatively. Primary outcome was volume of blood loss per square centimeter area of burn excised. Secondary outcomes were total volume of blood loss, postoperative hemoglobin, intraoperative fluid requirement, blood transfusion, graft take and length of hospitalization (LOH).

Results: Thirty patients were included. Both groups were comparable in terms of Body Mass Index (BMI) preoperative hemoglobin, area of burn excised, duration of surgery and the intraoperative temperature. The average blood loss per square centimeter burn area excised was found to be significantly lower in TXA when compared to placebo group (mean difference: 0.28 ± 0.025 ml/cm2; p = 0.000). The total volume of blood loss was lower in TXA group (258.7 ± 124.10 ml vs 388.1 ± 173.9 ml; p = 0.07). None of the patients required transfusion. The requirement of intra-operative fluids was similar between the two groups (crystalloids: p = 0.236; colloids: p = 0.238). Postoperative hemoglobin, length of hospitalization and graft-take were comparable between the two groups.

Conclusion: TXA reduced blood loss per unit burn area of tangential excision in <30%TBSA burn, however, we found no significant effect on postoperative Hb and transfusion.

Sublingual Sufentanil May Reduce Risk for Psychiatric Sequalae and Chronic Pain Following Combat Trauma: Editorial for the Newest Battlefield Opioid, Sublingual Sufentanil

Sharon Y Kim, Chester C Buckenmaier Iii, Edmund Howe, Kwang Choi

Mil Med. 2022 Mar 10; Online ahead of print

 

No abstract available

 

Evaluation of the insertion parameters and complications of the i-gel Plus airway device for maintaining patent airway during planned procedures under general anaesthesia: a protocol for a prospective multicentre cohort study

Olga Klementova, Taranpreet Kaur Bhoday, Jakub Werner, Ana M Lopez, Will Donaldson, Erik Lichnovsky, Tomasz Gaszyński, Tomas Henlin, Jan Bruthans, Jitka Ulrichova, Martin Lukes, Jan Blaha, Michal Kral, Lidia Gomez, Raquel Berge, Jonathan Holland, Francis McAleavey, Shiva Arava, Lubica Merjava Skripecka, Sebastian Sobczyk, Tomas Tyll, Pavel Michalek

BMJ Open. 2021 Dec 20;11(12):e053215

 

Introduction: Supraglottic airway devices represent a less invasive method of airway management than tracheal intubation during general anaesthesia. Their continued development is focused mainly on improvements in the insertion success rate and minimalisation of perioperative and postoperative complications. The i-gel Plus is a novel, anatomically preshaped supraglottic airway device which achieves a perilaryngeal seal due to a non-inflatable cuff made of a soft thermoplastic elastomer. The purpose of this cohort study is to assess the success rate of the i-gel Plus use during elective procedures under general anaesthesia, its intraoperative performance, and the degree of postoperative complications.

Methods and analysis: This is a multicentre, prospective, interventional cohort study. The enrolment will take place in seven centres in four European countries. We plan to enrol 2000 adult patients in total, who are scheduled for elective surgery under general anaesthesia, and with an indication for use of a supraglottic airway device for management of their airway. The study is projected to run over a period of 18 months. The primary outcome of the study is the total success rate of the i-gel Plus insertion in terms of successful ventilation and oxygenation through the device. Secondary outcomes include perioperative parameters, such as insertion time, seal/leak pressures, number of insertion attempts and postoperative adverse events and complications. Postoperative follow-up will be performed at 1 hour, 24 hours in all patients, and for selected patients at 3 and 6 months.

Ethics and dissemination: The cohort study has received the following ethical approvals: General University Hospital Prague, University Hospital Olomouc, University Military Hospital Prague, University Hospital Barcelona, University Hospital Lodz, Antrim Area Hospital, Craigavon Area Hospital, Office for Research Ethics Committees Northern Ireland. The results will be published in peer-reviewed journals and presented at relevant anaesthesia conferences.

Prehospital Use of Ultrathin Reflective Foils

Sylweriusz Kosiński, Paweł Podsiadło, Tomasz Darocha, Mathieu Pasquier, Konrad Mendrala, Tomasz Sanak, Ken Zafren

Wilderness Environ Med. 2022 Mar;33(1):134-139

 

Abstract

Ultrathin reflective foils (URFs) are widely used to protect patients from heat loss, but there is no clear evidence that they are effective. We review the physics of thermal insulation by URFs and discuss their clinical applications. A conventional view is that the high reflectivity of the metallic side of the URF is responsible for thermal protection. In most circumstances, the heat radiated from a well-clothed body is minimal and the reflecting properties of a URF are relatively insignificant. The reflection of radiant heat can be impaired by condensation and freezing of the moisture on the inner surface and by a tight fit of the URF against the outermost layer of insulation. The protection by thermal insulating materials depends mostly on the ability to trap air and increases with the number of covering layers. A URF as a single layer may be useful in low wind conditions and moderate ambient temperature, but in cold and windy conditions a URF probably best serves as a waterproof outer covering. When a URF is used to protect against hypothermia in a wilderness emergency, it does not matter whether the gold or silver side is facing outward.

Provider Perception of Time During Trauma Resuscitation: A Prospective Quantitative Trauma Video Review Analysis

Kali M Kuhlenschmidt, Elias Choi, Kazi Moonmoon, James Blackwell, Paul B Comish, Courtney Balentine, Jennifer Grant, Caroline Park, Linda A Dultz, Thomas Shoultz, Michael W Cripps, Ryan P Dumas

J Surg Res. 2022 Feb 18;274:207-212

Introduction: Delays in transition to the next phase of care result in increased mortality. Prehospital literature suggests emergency medical service technicians underestimate transport times by as much as 20%. What remains unknown is clinician perception of time during the trauma resuscitation. We sought to determine if clinicians have an altered perception of time. We hypothesized that clinicians underestimate time, resulting in delay of care.

Methods: Clinicians at a large level 1 trauma center completed a post-trauma activation survey on the perceived elapsed time to complete three specific resuscitation endpoints. The primary study endpoint was the time to the next phase of care, defined as leaving the trauma bay to go to the operating room, interventional radiology, computerized tomography or time of death. The data from the surveys were linked and compared with recorded videos of the resuscitations. The difference in perceived versus actual time, along with confounding variables, was used to assess the impact of perception of time on the time to the next phase of care using a stepwise multivariate linear model.

Results: There were 284 complete surveys and videos, culminating in 543 time points. The median perceived versus actual time (minutes [interquartile range]) to the next phase of care was 20 [10-25] versus 26 [19-40] (P < 0.001). Overall, clinicians underestimated time by 28%, such that if the resuscitation lasted 20 min, the clinician's perception was that 14.4 min elapsed. Differences in the perceived versus actual time in the procedure group impacted time to the next phase of care (P = 0.01).

Conclusions: Clinicians have significant gaps in the perception of time during trauma resuscitations. This misperception occurs during procedures and correlates with an increase in the length of time to the next phase of care.

Effectiveness of Pre-Hospital Tourniquet in Emergency Patients with Major Trauma and Uncontrolled Haemorrhage: A Systematic Review and Meta-Analysis

Roberto Latina, Laura Iacorossi, Alice Josephine Fauci, Annalisa Biffi, Greta Castellini, Daniela Coclite, Daniela D'Angelo, Silvia Gianola, Veronica Mari, Antonello Napoletano, Gloria Porcu, Matteo Ruggeri, Primiano Iannone, Osvaldo Chiara, On Behalf Of Inih-Major Trauma

Int J Environ Res Public Health. 2021 Dec 6;18(23)

 

Abstract

Trauma is one of the leading causes of uncontrolled haemorrhage, death, and disability. Use of a tourniquet can be considered an optimal anti-haemorrhagic resource, in pre-hospital and emergency settings, and its lifesaving effect is clinically contradictory. This review aims to assess the clinical efficacy of the tourniquet in the emergency pre-hospital care setting for the management of haemorrhage. We conducted the systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, the PRISMA statement. We searched the following electronic databases: EMBASE, MEDLINE, and Cochrane-CENTRAL. All studies included were appraised for risk of bias. Prevalent primary outcomes were mortality and use of blood products. Secondary outcomes were related to adverse effects. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach (GRADE). Four studies were involved (1762 trauma patients). The adjusted odds ratio (aOR) of 0.47 (95% confidence Interval (CI) 0.19-1.16; three studies; 377 patients) for overall mortality estimates did not give a clear indication of the benefits of emergency pre-hospital tourniquets (PH-TQ) versus no pre-hospital tourniquet (NO PH-TQ) placement. The adjusted mean difference for blood product use was -3.28 (95% CI -11.22, 4.66) for packed red blood cells (pRBC) and -4.80 (95% CI -5.61, -3.99) for plasma, respectively. The certainty of evidence was downgraded to very low for all outcomes. Our results suggest an unclear effect of emergency pre-hospital tourniquet placement on overall mortality and blood product use. However, this systematic review highlights the availability of only observational studies and the absence of high quality RCTs assessing the efficacy of PH-TQs. Randomized controlled trials are needed.

 

Effect of Placement of a Supraglottic Airway Device vs Endotracheal Intubation on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest in Taipei, Taiwan: A Cluster Randomized Clinical Trial

An-Fu Lee, Yu-Chun Chien, Bin-Chou Lee, Wen-Shuo Yang, Yao-Cheng Wang, Hao-Yang Lin, Edward Pei-Chuan Huang, Kah-Meng Chong, Jen-Tang Sun, Matthew Huei-Ming, Ming-Ju Hsieh, Wen-Chu Chiang

JAMA Netw Open. 2022 Feb 1;5(2):e2148871

 

Importance: Prehospital advanced airway management with either initial endotracheal intubation (ETI) or initial supraglottic airway (SGA) insertion in patients with out-of-hospital cardiac arrest (OHCA) remains controversial.

Objective: To compare the effectiveness of ETI and SGA in patients with nontraumatic OHCA.

Design, setting, and participants: The Supraglottic Airway Device vs Endotracheal intubation (SAVE) trial was a multicenter cluster randomized clinical trial conducted in Taipei City, Taiwan. Individuals aged 20 years or older who experienced nontraumatic OHCA requiring advanced airway management and were treated by participating emergency medical service agencies were enrolled from November 11, 2016, to December 31, 2019. The final day of follow-up was February 19, 2020.

Interventions: Four advanced life support ambulance teams were divided into 2 randomization clusters, with each cluster assigned to either ETI or SGA in a biweekly period.

Main outcomes and measures: The primary outcome of the SAVE trial was sustained return of spontaneous circulation (ROSC) (≥2 hours) after resuscitation. Secondary outcomes included prehospital ROSC, survival to hospital discharge, and favorable neurologic outcome, defined as a cerebral performance category score less than or equal to 2. Prespecified subgroups and the association between time to advanced airways were explored. Per protocol and intention-to-treat analysis were performed.

Results: A total of 936 patients (517 in the ETI group and 419 in the SGA group) were included in the primary analysis (median age, 77 [IQR, 62-85] years; 569 men [60.8%]). The first-attempt airway success rates were 77% with ETI (n = 413) and 83% with SGA (n = 360). Sustained ROSC was 26.9% (n = 139) in the ETI group vs 25.8% (n = 108) in the SGA group. The odds ratio of sustained ROSC was 1.02 (95% CI, 0.98-1.06) in the ETI group vs SGA group. The odds ratio of ETA vs SGA was 1.04 (95% CI, 1.02-1.07) for prehospital ROSC, 1.00 (95% CI, 0.94-1.06) for survival to hospital discharge, and 0.99 (95% CI, 0.94-1.03) for cerebral performance category scores less than or equal to 2.

Conclusions and relevance: In this randomized clinical trial, among patients with OHCA, initial airway management with ETI did not result in a favorable outcome of sustained ROSC compared with SGA device insertion.

 

Performance comparison of intraosseous devices and setups for infusion of whole blood in a cadaveric swine bone model

Katherine J Lee, Morgan M McGuire, Warren C Harvey, William D Bianchi, Alec D Emerling, Erin R Reilly, Vikhyat S Bebarta, Jason J Lopez, Gregory J Zarow, Jonathan D Auten

Am J Emerg Med. 2022 Apr;54:58-64

 

Objectives: Intraosseous (IO) access can provide a critical bridge for blood product infusion when peripheral venous access is not obtainable. Successful pressurized IO infusion requires flow rates sufficient to preserve life, but with infusion pressures low enough to avoid clinical complications (e.g., hemolysis, bone damage, fat emboli). However, the optimal method for pressured IO delivery of blood was unknown.

Methods: Three trained physicians infused 500 mL of whole blood through a 15-gauge, 45 mm IO catheter into fresh, high bone density cadaveric swine proximal humeri. Participants applied eight different pressure infusion strategies: (1) gravity, (2) pressure bag, (3) pressure bag actively maintained at or above 300 mmHg, (4) hand pump, (5) hand pump with pressure bag, (6) push-pull with 10 mL syringe, (7) push-pull with 60 mL syringe, and a (8) Manual Rapid Infuser in a randomized within-subjects design (30 trials per method, 240 trials total). The primary outcomes of flow rates, mean and peak pressures, and user ratings were contrasted using ANOVA at p < 0.05.

Results: The Manual Rapid Infuser conferred the highest flow rates (199 ± 3 mL/min) and most favorable user ratings, but also the highest mean and peak pressures. Push-pull conferred the next highest flow rates (67 ± 5 mL/min for 60 mL, 56 ± 2 mL/min for 10 mL) and pressures, with intermediate-to-high user ratings. Hand pump flow rates were essentially identical with (45 ± 4 mL/min) or without (44 ± 3 mL/min) pressure bag, with high user ratings without a pressure bag. Pressure bag and gravity methods conferred low flow rates and user ratings.

Conclusions: Some pressured IO infusion methods can achieve flow rates adequate to serve as a resuscitative bridge in the massively hemorrhaged trauma victim, but flow rates and pressures vary greatly across IO pressurized infusion methods. Manual Rapid Infuser and push-pull methods conferred high flow rates but also relatively high pressures, highlighting the importance of using in vivo models in future research to assess the possible clinical complications of using these promising methods. Combined, present findings highlight the importance of studying pressurized IO methods towards preserving the life of the critically injured trauma victim.

 

Development and evaluation of a mass casualty medicine simulation method using figurines

Antoine Lefevre-Scelles, Vincent Barege, Mélanie Roussel, Florent Gachet, Louis Sibert, Thomas Clavier, Cédric Damm

Br J Anaesth. 2022 Feb;128(2):e210-e212

 

No abstract available

 

Development and Validation of a Simplified Prehospital Triage Model Using Neural Network to Predict Mortality in Trauma Patients: The Ability to Follow Commands, Age, Pulse Rate, Systolic Blood Pressure and Peripheral Oxygen Saturation (CAPSO) Model

Yun Li, Lu Wang, Yuyan Liu, Yan Zhao, Yong Fan, Mengmeng Yang, Rui Yuan, Feihu Zhou, Zhengbo Zhang, Hongjun Kang

Front Med (Lausanne). 2021 Dec 10;8:810195

 

Objective: Most trauma scoring systems with high accuracy are difficult to use quickly in field triage, especially in the case of mass casualty events. We aimed to develop a machine learning model for trauma mortality prediction using variables easy to obtain in the prehospital setting.

Methods: This was a retrospective prognostic study using the National Trauma Data Bank (NTDB). Data from 2013 to 2016 were used for model training and internal testing, and data from 2017 were used for validation. A neural network model (NN-CAPSO) was developed using the ability to follow commands (whether GCS-motor was <6), age, pulse rate, systolic blood pressure (SBP) and peripheral oxygen saturation, and a new score (the CAPSO score) was developed based on logistic regression. To achieve further simplification, a neural network model with the SBP variable removed (NN-CAPO) was also developed. The discrimination ability of different models and scores was compared based on the area under the receiver operating characteristic curve (AUROC). Furthermore, a reclassification table with three defined risk groups was used to compare NN-CAPSO and other models or scores.

Results: The NN-CAPSO had an AUROC of 0.911(95% confidence interval 0.909 to 0.913) in the validation set, which was higher than the other trauma scores available for prehospital settings (all p < 0.001). The NN-CAPO and CAPSO score both reached the AUROC of 0.904 (95% confidence interval 0.902 to 0.906), and were no worse than other prehospital trauma scores. Compared with the NN-CAPO, CAPSO score, and the other trauma scores in reclassification tables, NN-CAPSO was found to more accurately classify patients to the right risk groups. \

Conclusions: The newly developed CAPSO system simplifies the method of consciousness assessment and has the potential to accurately predict trauma patient mortality in the prehospital setting.

 

Early Prehospital Tranexamic Acid Following Injury Is Associated With a 30-day Survival Benefit: A Secondary Analysis of a Randomized Clinical Trial

Shimena R Li, Francis Guyette, Joshua Brown, Mazen Zenati, Katherine M Reitz, Brian Eastridge, Raminder Nirula, Gary A Vercruysse, Terence O'Keeffe 6, Bellal Joseph 6, Matthew D Neal, Brian S Zuckerbraun, Jason L Sperry

Ann Surg. 2021 Sep 1;274(3):419-426

 

Objective: We sought to characterize the timing of administration of prehospital tranexamic acid (TXA) and associated outcome benefits.

Background: TXA has been shown to be safe in the prehospital setting post-injury.

Methods: We performed a secondary analysis of a recent prehospital randomized TXA clinical trial in injured patients. Those who received prehospital TXA within 1 hour (EARLY) from time of injury were compared to those who received prehospital TXA beyond 1 hour (DELAYED). We included patients with a shock index of >0.9. Primary outcome was 30-day mortality. Kaplan-Meier and Cox Hazard regression were utilized to characterize mortality relationships.

Results: EARLY and DELAYED patients had similar demographics, injury characteristics, and shock severity but DELAYED patients had greater prehospital resuscitation requirements and longer prehospital times. Stratified Kaplan-Meier analysis demonstrated significant separation for EARLY patients (N = 238, log-rank chi-square test, 4.99; P = 0.03) with no separation for DELAYED patients (N = 238, log-rank chi-square test, 0.04; P = 0.83). Stratified Cox Hazard regression verified, after controlling for confounders, that EARLY TXA was associated with a 65% lower independent hazard for 30-day mortality [hazard ratio (HR) 0.35, 95% confidence interval (CI) 0.19-0.65, P = 0.001] with no independent survival benefit found in DELAYED patients (HR 1.00, 95% CI 0.63-1.60, P = 0.999). EARLY TXA patients had lower incidence of multiple organ failure and 6-hour and 24-hour transfusion requirements compared to placebo.

Conclusions: Administration of prehospital TXA within 1 hour from injury in patients at risk of hemorrhage is associated with 30-day survival benefit, lower incidence of multiple organ failure, and lower transfusion requirements.

 

Noninvasive ventilation in prehospital emergencies

Cristina López López, Francisco Ávila Rodríguez, Fernando Ayuso Baptista

Emergencias. 2022 Feb;34(1):3-4.

 

No abstract available

 

Physician Oversight of Air-Based Emergency Medical Services: A Joint Position Statement of NAEMSP, ACEP, and AMPA

John Lyng, Brandon Bleess, Justin Fairless, Francis X Guyette, Christian Martin-Gill, Michael T Steuerwald, Doug Swanson, their respective organizations

Prehosp Emerg Care. May-Jun 2021;25(3):449-450

 

No abstract available

 

Prehospital Manual Ventilation: An NAEMSP Position Statement and Resource Document

John W Lyng, Francis X Guyette, Michael Levy, Nichole Bosson

Prehosp Emerg Care. 2022;26(sup1):23-31

 

Abstract

Manual ventilation using a self-inflating bag device paired with a facemask (bag-valve-mask, or BVM ventilation) or invasive airway (bag-valve-device, or BVD ventilation) is a fundamental airway management skill for all Emergency Medical Services (EMS) clinicians. Delivery of manual ventilations is challenging. Several strategies and adjunct technologies can increase the effectiveness of manual ventilation. NAEMSP recommends: All EMS clinicians must be proficient in bag-valve-mask ventilation. BVM ventilation should be performed using a two-person technique whenever feasible. EMS clinicians should use available techniques and adjuncts to achieve optimal mask seal, improve airway patency, optimize delivery of the correct rate, tidal volume, and pressure during manual ventilation, and allow continual assessment of manual ventilation effectiveness.

 

Prehospital Supraglottic Airways: An NAEMSP Position Statement and Resource Document

John W Lyng, Kimberly T Baldino, Darren Braude, Christie Fritz, Juan A March, Timothy D Peterson, Allen Yee

Prehosp Emerg Care. 2022;26(sup1):32-41

 

Abstract

Supraglottic airway (SGA) devices provide effective conduits for oxygenation and ventilation and may offer protection from gastric aspiration. SGA devices are widely used by EMS clinicians as both rescue and primary airway management devices. While in common use for more than four decades, major developments in SGA education, science, and technology have influenced clinical strategies of SGA insertion and use in prehospital airway management for patients of all ages. NAEMSP recommends:SGAs have utility as a primary or secondary EMS airway intervention. EMS agencies should select SGA strategies that best suit available resources and local clinician skillset, as well as the nature of their clinical practice setting.EMS agencies that perform endotracheal intubation must also equip their clinicians with SGA devices and ensure adequate training and competence.In select situations, drug-assisted airway management may be used by properly credentialed EMS clinicians to facilitate SGA insertion.Confirmation of initial and continuous SGA placement using waveform capnography is strongly encouraged as a best practice.When it is functioning properly, EMS clinicians should refrain from converting an SGA to an endotracheal tube. The decision to convert an SGA to an endotracheal tube must consider the patient's condition, the effectiveness of SGA ventilations, and the clinical context and course of initial SGA insertionSGA training, competency, and clinical use must be continuously evaluated by EMS agencies using focused quality management programs.

Prehospital Tranexamic Acid (TXA) in Patients with Traumatic Brain Injury (TBI)

Marc Maegele

Transfus Med Rev. 2021 Oct;35(4):87-90

 

Abstract

Traumatic brain injury (TBI) remains a significant medical and socioeconomic challenge. The initial injury may be complicated by haemostatic derangements leading to exacerbation of lesions and haemorrhagic progression. The results from the CRASH-3 trial have promoted the implementation of the antifibrinolytic tranexamic acid (TXA) into prehospital Emergency Medical Services (EMS) protocols. Very recently, the efficacy and safety of early out-of-hospital TXA compared to placebo was assessed in patients with moderate or severe TBI in a prospective, multicenter phase II trial, e.g. "The Prehospital TXA for TBI"-trial. Simultaneously, the results from a retrospective analysis of prospectively collected observational data into the Dutch pre-hospital TBI database were published which had assessed whether prehospital administration of TXA may be associated with mortality and functional outcomes in patients with severe TBI. Both studies are reviewed against their limitations and windows of opportunity are highlighted.

Effect of age on the efficacy of tranexamic acid: An analysis of heterogeneity of treatment effect within the CRASH-2 dataset

Martin A C Manoukian, Daniel J Tancredi, Daniel K Nishijima

Am J Emerg Med. 2022 Mar;53:37-40

Background: Trauma is a major cause of morbidity and mortality in older adults and will become more common as the population ages. Tranexamic acid (TXA) is a lysine analogue frequently used in the setting of significant trauma with hemorrhage. The aim of this study is to investigate the heterogeneity of treatment effect of TXA as it relates to patient age during trauma care.

Methods: We included patients from the CRASH-2 trial who were randomized within 3 h of injury. Patients were stratified into age groups <26 years, 26 to 35 years, 36 to 45 years, 46 to 55 years, and >55 years. Multiple logistic regression models were utilized to evaluate adjusted odds ratios (OR) with 95% confidence intervals (CI) for mortality. Heterogeneity of treatment effect was evaluated using Akaike and Bayesian information criteria to determine the optimum logistic regression model after which a Wald Chi-square test was utilized to evaluate statistical significance.

Results: On univariate analysis, TXA administration decreased mortality within the <26 years cohort (decrease of 2.1%, 95% CI 0.2 to 4.0), 46 to 55 years cohort (decrease 6.7%, 95% CI 2.7 to 10.7), and >55 years cohort (decrease of 5.3%, 95% CI 0.4 to 10.3). On adjusted analysis, when compared to the 36 to 45 years cohort, the <26 year cohort experienced a decreased mortality (OR 0.72, 95% CI 0.62 to 0.85) whereas the >55 year cohort experienced increased mortality (OR 1.8, 95% CI 1.5 to 2.2). Assessment for heterogeneity of treatment effect of TXA administration between groups approached but did not reach statistical significance (p = 0.11).

Conclusions: Mortality related to trauma increases with age, however, there does not appear to be heterogeneity of treatment effect for TXA administration among different age groups.

Austere Lower Extremity Splinting: A Head-To-Head Comparison of A New Novel 1-Step Spray-On Splint Verse Standard Splinting

Kevin D Martin, Tyler Webb, Thuan Ly, Adam T Growth

Foot Ankle Orthop. 2022 Jan 21;7(1):2473011421S00351

Introduction/Purpose: Fracture immobilization in low resource environments is a critical and common aspect of austere medical care. However, there are few studies that critically investigate the efficacy and consistency of current practices. The purpose of this study was to compare austere immobilization techniques for lower extremity fractures while validating a splint application evlauation score sheet.

Methods: Six orthopaedic surgical residents and 2 medical students participated in a prospective analysis of austere splinting techniques that utilized a cadaveric model with a distal third tibia-fibula fracture. Each participant was observed and scored by 3 Orthopaedic surgeons. All scoring was independent using a Likert scale based on 10 splinting criteria, including quality of radiographic reduction and time to completion. The participants utilized standard equipment that included structural aluminum malleable (SAM) splints and 6-inch ACE wraps in their first attempt. A second immobilization attempt was done with a 1-step spray-on foam splint. After each splinting attempt the reduction was verified with radiographic imaging.

Results: The 1-step spray-on foam splinting technique was significantly superior (P <.05) in all parameters. Respectively yielding a mean score of 42.3 (range: 38-50), safety 4.7 (range: 3-5), longitudinal traction 4.5 (range: 3-5), time 136 seconds (range: 99-162). The standard splinting resulted in a mean score of 34.2 (22 - 46), safety 2.8 (range: 1- 5), longitudinal traction 4.1 (range: 3-5), time 169.5 seconds (range: 94-254). No catastrophic failures were noted in either group. A strong interobserver reliability was established.

Conclusion: A 1-step spray-on foam splinting technique demonstrated consistent superiority in reducing fracture motion, potential soft-tissue damage, and sustained longitudinal traction as compared to the standard technique. Secondly, our results validate our splinting evaluation criteria allowing for further utilization in training austere splinting.

 

Static Rope Rescue Operations in Western Norway: A Retrospective Analysis of 141 Missions

Håvard Mattingsdal, Håkon B Abrahamsen, Espen Fevang, Stephen J M Sollid

Wilderness Environ Med. 2022 Mar 18; Online ahead of print.

 

Introduction: The Norwegian national standard for rescuers describes medical and rescue requirements for helicopter emergency medical services (HEMS) technical crew members, but there is a lack of scientific data supporting these requirements and their safety relevance. The study aims to analyze the rescue profile of Norwegian HEMS static rope human external cargo operations, emphasizing terrain challenges and additional safety measures utilized on-site.

Methods: We conducted a retrospective descriptive analysis of static rope missions performed in daylight by 3 HEMS bases in Western Norway in the period 2015 to 2019. The analysis measures evacuation methods, terrain, on-site safety measures, and medical treatment.

Results: Out of 8352 primary HEMS and search and rescue missions, a total of 141 (2%) static rope missions were performed by the 3 HEMS bases in Western Norway. The most commonly used evacuation method was triangle harness (62%) and a static rope length of 30 m (81%). Ninety-two (65%) missions were completed in simple terrain, 38 (27%) in challenging terrain, and 11 (8%) in complex terrain. There were no reported accidents, but a small number of adverse events were registered. The most frequent medical intervention administered on-site was pain management, followed by spinal immobilization.

Conclusions: Thirty-five percent of the static rope missions performed by HEMS in Western Norway were completed in challenging or complex terrain, requiring additional safety measures on-site. The most common safety measure needed was the ability to operate in a mountain or alpine environment. Our findings support the safety relevance of a national standard for rescuers.

Prehospital Noninvasive Ventilation: An NAEMSP Position Statement and Resource Document

Andrew M McCoy, Dylan Morris, Kaori Tanaka, Angela Wright, Francis X Guyette, Christian Martin-Gill

Prehosp Emerg Care. 2022;26(sup1):80-87

 

Abstract

Noninvasive ventilation (NIV), including bilevel positive airway pressure and continuous positive airway pressure, is a safe and important therapeutic option in the management of prehospital respiratory distress. NAEMSP recommends:NIV should be used in the management of prehospital patients with respiratory failure, such as those with chronic obstructive pulmonary disease, asthma, and pulmonary edema.NIV is a safe intervention for use by Emergency Medical Technicians.Medical directors must assure adequate training in NIV, including appropriate patient selection, NIV system operation, administration of adjunctive medications, and assessment of clinical response.Medical directors must implement quality assessment and improvement programs to assure optimal application of and outcomes from NIV.Novel NIV methods such as high-flow nasal cannula and helmet ventilation may have a role in prehospital care.

Is Prehospital Ketamine Associated With a Change in the Prognosis of PTSD?

Ted Melcer, G Jay Walker, Judy L Dye, Benjamin Walrath, Andrew J MacGregor, Katheryne Perez, Michael R Galarneau

Mil Med. 2022 Feb 1;Online ahead of print.

 

Introduction: Ketamine is an alternative to opioids for prehospital analgesia following serious combat injury. Limited research has examined prehospital ketamine use, associated injuries including traumatic brain injury (TBI) and PTSD outcomes following serious combat injury.

Materials and methods: We randomly selected 398 U.S. service members from the Expeditionary Medical Encounter Database who sustained serious combat injuries in Iraq and Afghanistan, 2010-2013. Of these 398 patients, 213 individuals had charted prehospital medications. Clinicians reviewed casualty records to identify injuries and all medications administered. Outcomes were PTSD diagnoses during the first year and during the first 2 years postinjury extracted from military health databases. We compared PTSD outcomes for patients treated with either (a) prehospital ketamine (with or without opioids) or (b) prehospital opioids (without ketamine).

Results: Fewer patients received prehospital ketamine (26%, 56 of 213) than only prehospital opioids (69%, 146 of 213) (5%, 11 of 213 received neither ketamine nor opioids). The ketamine group averaged significantly more moderate-to-serious injuries, particularly lower limb amputations and open wounds, compared with the opioid group (Ps < .05). Multivariable regressions showed a significant interaction between prehospital ketamine (versus opioids) and TBI on first-year PTSD (P = .027). In subsequent comparisons, the prehospital ketamine group had significantly lower odds of first-year PTSD (OR = 0.08, 95% CI [0.01, 0.71], P = .023) versus prehospital opioids only among patients who did not sustain TBI. We also report results from separate analyses of PTSD outcomes among patients treated with different prehospital opioids only (without ketamine), either morphine or fentanyl.

Conclusions: The present results showed that patients treated with prehospital ketamine had significantly lower odds of PTSD during the first year postinjury only among patients who did not sustain TBI. These findings can inform combat casualty care guidelines for use of prehospital ketamine and opioid analgesics following serious combat injury.

Arterial Blood Gases and Arterial Lines in the Prehospital Setting: A Systematic Literature Review and Survey of Current United Kingdom Helicopter Emergency Medical Services

Sarah Morton, Pascale Avery, Jessie Payne, Matthew OMeara

Air Med J. Mar-Apr 2022;41(2):201-208

 

Objective: Prehospital guidelines state that monitoring should match in-hospital standards, but consensus on the use of arterial blood gases (ABGs) and arterial lines remains unclear. The aim was to perform a systematic literature review and survey of UK helicopter emergency medical services (HEMS) use and perceptions of ABGs and arterial lines.

Methods: A systematic literature review was conducted for arterial lines and ABGs and prehospital care. Additionally, two questionnaires were distributed to all UK HEMS (questionnaire 1: current clinical practice and questionnaire 2: clinicians' opinions).

Results: From 1,028 results, 13 studies (10 ABGs and 3 arterial lines) were included, demonstrating it is feasible to obtain ABGs and place arterial lines in the prehospital setting. There were concerns about practical difficulties for ABGs and the time taken for arterial lines. Survey responses were obtained from all UK HEMS (N = 22). Six services carry equipment for performing ABGs and nine services for arterial lines. Clinicians expressed concerns relating to the time taken to perform both procedures, but most believed it would allow better monitoring and more targeted treatment.

Conclusion: The evidence of benefit for both procedures remains poor. Overall, there may be clinical benefits, but these are likely to be patient specific and require further investigation.

Prediction of early acute kidney injury after trauma using prehospital systolic blood pressure and lactate levels: A prospective validation study

Toru Nasu, Kentaro Ueda, Shuji Kawashima, Yuko Okishio, Kosei Kunitatsu, Yasuhiro Iwasaki, Seiya Kato

Injury. 2022 Jan;53(1):81-85

 

Background: Acute kidney injury (AKI) after trauma is a major complication independently associated with a prolonged hospital stay and increased mortality. We previously reported that the prehospital systolic blood pressure (SBP) and early hospital arterial lactate level, along with specific cut-off values, show good performance in the early prediction of AKI using AUC-ROC [1]. The purpose of this study was to prospectively validate whether or not these parameters are predictive of newly occurring AKI after trauma.

Methods: This was a prospective review of trauma patients who were admitted to a single trauma center from January to December 2019. Patients who were <16 years old, who had burns, and who had chronic kidney disease were excluded. AKI was defined according to the Risk, Injury, Failure, Loss of the kidney function, and End-stage kidney disease (RIFLE) classification based on serum creatinine alone. Patients with a low prehospital SBP (≤126 mmHg) and high lactate levels (≥2.5 mmol/L) were defined as the high-risk group, and other patients were defined as the low-risk group.

Results: A total of 489 trauma patients were admitted to our center, of whom 403 were eligible for the study. The high-risk group consisted of 38 patients, and the low-risk group consisted of 365 patients. The incidence of severe AKI in Stage Injury and Failure was significantly higher in the high-risk group (5 patients, 13.2%) than in the low-risk group (7 patients, 1.9%), with an odds ratio of 7.75 and 95% confidence interval of 2.33-25.77.

Conclusions: These predictors showed good performance in the early prediction of severe AKI after trauma. Early prediction of the high-risk groups for severe AKI after trauma prompting early treatment may help improve the prognosis of trauma patients.

 

Pre-Hospital Blood Transfusion: A Pro-Con Debate

Naveen Nathan

Anesth Analg. 2022 Apr 1;134(4):674

 

No abstract available

Pediatric Prehospital Wound Prophylaxis in Iraq and Afghanistan

Jason F Naylor, Michael D April, Guyon J Hill, Steven G Schauer

Mil Med. 2020 Jan 7;185(Suppl 1):73-76

 

Background: Infectious complications of war wounds are a significant source of mortality and morbidity. Tactical Combat Casualty Care (TCCC) guidelines recommend prehospital moxifloxacin, ertapenem, or cefotetan for "all open combat wounds." We describe the prehospital administration of antibiotics to pediatric trauma patients.

Methods: We queried the Department of Defense Trauma Registry for all pediatric subjects admitted to United States and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016.

Results: During this time, there were 3,439 pediatric encounters which represented 8.0% of all admissions. Prehospital providers administered a total of 216 antibiotic doses to 210 subjects. Older children received antibiotics more frequently than younger children, were more likely to be male, located in Afghanistan, and injured by explosive with the majority surviving to hospital discharge. Cefazolin and ceftriaxone were the most frequently utilized antibiotics.

Conclusions: The most frequently administered antibiotics were cephalosporins. TCCC recommended agents for adult prehospital wound prophylaxis were infrequently administered to pediatric casualties. Administration rates of pediatric prehospital wound prophylaxis may be improved with pediatric-specific TCCC guidelines recommending cephalosporins as first-line agents, fielding of a TCCC-oriented Broselow tape, and training prehospital providers on administration of antimicrobials.

Clinical Characteristics of Patients Undergoing Needle Thoracostomy in a Canadian Helicopter Emergency Medical Service

Graham Newton, Gudrun Reay, Catherine M Laing, Kathryn King-Shier

Prehosp Emerg Care. 2021 Apr 19;1-12

 

Objective: Needle thoracostomy (NT) can be a life-saving procedure when used to treat tension pneumothorax. However, there is some question regarding the efficacy of NT in the prehospital setting. Failure to treat tension pneumothorax in a helicopter emergency medical service (HEMS) setting may prove especially deleterious to the patient due to gas expansion with increasing altitude. This study's objective was to identify the characteristics of patients treated with NT in a Canadian HEMS setting and the factors that may influence outcomes following NT use.

Methods: This was a retrospective chart review of prehospital records from a Canadian HEMS service. Patients aged 18 years and older who underwent at least one NT attempt using a 14-gauge 8.3 cm needle from 2012 to 2018 were identified. Charts were reviewed to collect demographic data, NT procedural characteristics, vital signs, and clinical response metrics. Descriptive statistics were used to characterize the study sample and overall event characteristics. Binary logistic regression was performed to identify variables associated with a clinical response to the initial NT treatment.

Results: 163 patients (1.3%) of 12,407 patients attended received NT. A positive clinical response to NT was recorded in 37% (n = 77) of the total events (n = 208), the most common of which was an improvement in blood pressure (BP) (18.8%, n = 39). Initial NT was associated with a low likelihood of clinical improvement in patients presenting with blunt trauma (OR = 0.18; p = .021; 95% CI [.04, .77]), CPR prior to NT (OR = 0.14; p = .02; 95% CI [.03, .73]), or in those who received bilateral NT treatment (OR = 0.13; p < .01; 95% CI [.05, .37]). A pretreatment BP < 90 mmHg was predictive of a positive clinical response to initial NT (OR = 3.33; p = .04; 95% CI [1.09, 10.20]).

Conclusions: Only a small portion of patients in the setting of a Canadian HEMS service were treated with NT. Patients most likely to receive NT were males who had suffered blunt trauma. NT may have questionable benefit for patients presenting with blunt trauma, in cardiac arrest, or requiring bilateral NT.

Assessing Baseline Proficiency of National Guard Combat Medics Due for Recertification: A Pilot Study

Ryoma Nichols, Luke Noury

Mil Med. 2021 Dec 22; Online ahead of print

 

Introduction: Combat medics, or 68W Healthcare Specialists in the Army, are an early part of a combat casualty's chain of survival. Their job requires a high degree of competency in emergency medical guidelines established by the Committee of Tactical Combat Casualty Care (CoTCCC) as well as basic bleeding control skills. The American Warfighting Experience for the last two decades highlights just how important these skills are in preventing death on the battlefield. A recent Government Office of Accountability suggests sustainment for critical wartime skills is lacking. This is especially concerning for National Guard Soldiers who must juggle their military obligations with their civilian ones. It is unknown how well-prepared National Guard combat medics are in fulfilling their most critical combat care responsibilities. The current study attempts to address this gap in knowledge by assessing National Guard Soldiers due for their annual recertification.

Materials and methods: Nine medics due for their annual recertification were recruited for the study. First, they were given a questionnaire intended to gather basic demographic information about their experience and a six-question quiz on current CoTCCC guidelines. The medics were then evaluated on their ability to place a Combat Application Tourniquet on a live person, which was verified by a Doppler microphone. The medics were finally evaluated on their ability to pack a wound with a hemostatic dressing. Statistical analysis was used to determine if experience or frequency of practice over the previous year could predict success.

Results: Medics, on average, were only able to answer an average of 2.2 questions on the quiz correctly. The overall success rate for tourniquet application was 44.4%, and the overall success rate for wound packing was 22.2%. Statistical analysis showed that experience or frequency of practice could not adequately explain the success rates.

Conclusions: A soldier's experience alone could not predict if the soldier will be successful in performing bleeding control tasks or if they will demonstrate higher levels of casualty care knowledge. Future research is needed in this area to better define recertification and refresher training issues.

 

Recommendations for Improving Stop the Bleed: A Systematic Review

Ryoma Nichols, Jordan Horstman

Mil Med. 2022 Jan 27; Online ahead of print

 

Introduction: In response to mass casualty events, The Hartford Consensus brought together subject matter experts across multiple disciplines in health care and public safety to create guidelines and publications intended to improve survivability in active shooter events. Among the recommendations was the earlier recognition and treatment application of life-threatening hemorrhage control. These recommendations culminated in efforts to create the Stop the Bleed Campaign, which aims to empower the layperson to render aid in a life-threatening bleeding emergency. As of February 2020, the program has held over 86,000 courses, trained over 1.4 million attendees, and over 77,000 instructors since its inception. In addition to spreading within the United States, American College of Surgeons (ACS) Stop the Bleed (StB) classes have been held in 118 different countries. This systematic narrative review aims to answer the following research question: What does the ACS StB Initiative do well, and where can it improve?

Materials and methods: The following search terms were utilized: "Stop the Bleed," "American College of Surgeons," "bleeding control," "first-aid," tourniquet, "wound pack," "direct pressure" hemorrhage, and bystander. The inclusion criteria were that the article needed to speak to the program or some aspect of bystander first aid, the article needed to be in a civilian setting, the article needed to be more than a case study or overview, and the first aid tools needed to be in the StB curriculum. 4 databases were searched, which produced 138 articles for screening. One hundred four full-text articles were able to be retrieved, and 56 articles were determined to meet the inclusion criteria once the full text was reviewed.

Results: Fifty-six articles were included in the final review and were placed into the following categories: Needs Within the Community, Confidence and Knowledge, Training Modalities, Barriers and Gaps in Training, Instructor Selection, Skill Retention, and Patient Outcomes. The articles were then organized into each outcome for synthesis and reporting of the results. The program overwhelmingly improves short-term confidence, but gaps in skill retention, data collection on patient outcomes, and settings that would benefit were identified.

Conclusion: StB is an effective tool in building confidence in laypersons, which is its biggest strength. A review of the literature shows several areas where the curriculum and materials could be better developed. Research can also be further refined to better quantify the program's impact.

 

Extraglottic Airway Device Misplacement: A Novel Classification System and Findings in Postmortem Computed Tomography

Tatsuya Norii, Yohsuke Makino, Kana Unuma, Gary M Hatch, Natalie L Adolphi, Sarah Dallo, Danielle Albright, David P Sklar, Darren Braude

Ann Emerg Med. 2021 Mar;77(3):285-295

 

Study objective: Extraglottic airway devices are frequently used during cardiac arrest resuscitations and for failed intubation attempts. Recent literature suggests that many extraglottic airway devices are misplaced. The aim of this study is to create a classification system for extraglottic airway device misplacement and describe its frequency in a cohort of decedents who died with an extraglottic airway device in situ.

Methods: We assembled a cohort of all decedents who died with an extraglottic airway device in situ and underwent postmortem computed tomographic (CT) imaging at the state medical examiner's office during a 6-year period, using retrospective data. An expert panel developed a novel extraglottic airway device misplacement classification system. We then applied the schema in reviewing postmortem CT for extraglottic airway device position and potential complications.

Results: We identified 341 eligible decedents. The median age was 47.0 years (interquartile range 32 to 59 years). Out-of-hospital personnel placed extraglottic airway devices in 265 patients (77.7%) who subsequently died out of hospital; the remainder died inhospital. The classification system consisted of 6 components: depth, size, rotation, device kinking, mechanical blockage of ventilation opening, and injury. Under the system, extraglottic airway devices were found to be misplaced in 49 cases (14.4%), including 5 (1.5%) that resulted in severe injuries.

Conclusion: We created a novel extraglottic airway device misplacement classification system. Misplacement occurred in greater than 14% of cases. Severe traumatic complications occurred rarely. Quality improvement activities should include review of extraglottic airway device placement when CT images are available and use the classification system to describe misplacements.

Provision of pre-hospital medical care for terrorist attacks

Claire L Park, Gareth R Grier

Br J Anaesth. 2022 Feb;128(2):e85-e89

 

Abstract

The delivery of medical care to the severely injured during major incidents and mass casualty events has been a recurring challenge for decades across the world. From events in resource-poor developing countries, through richly funded military conflicts, to the most equipped of developed nations, the provision of rapid medical care to the severely injured during major incidents and mass casualty events has been a priority for healthcare providers. This is often under the most difficult of circumstances. Whilst mass casualty events are a persistent global challenge, it is clear in developed countries that patients and their families demand and expect a high standard of care from their rescuers, that this care should be delivered rapidly, and this should be of the highest quality possible.3 Whilst there is respect afforded to those who 'run towards danger' during a high-threat situation, first responders are subjected to a high degree of scrutiny for their actions, even when the circumstances they are presented with are considered to be extraordinary.4 Likewise, even for those who are catastrophically injured beyond salvage, society expects the response to be dignified, calculated, and thorough.

 

Prehospital Airway Management for Trauma Patients by First Responders in Six Sub-Saharan African Countries and Five Other Low- and Middle-Income Countries: A Scoping Review

Haleigh Pine, Zachary J Eisner, Peter G Delaney, Simon Ochieng Ogana, Dinnah Akosa Okwiri, Krishnan Raghavendran

World J Surg. 2022 Feb 25. Online ahead of print

 

Abstract

The global injury burden disproportionately affecting low- and middle-income countries (LMICs) is exacerbated by a lack of robust emergency medical services. Though airway management (AM) is an essential component of prehospital emergency care, the current standard of prehospital AM training and resources for first responders in LMICs is unknown. This scoping review includes articles published between January 2000 and June 2021, identified using PMC, MEDLINE, and SCOPUS databases, following PRISMA-ScR guidelines. Inclusion criteria spanned programs training formal or informal prehospital first responders. Included articles were assessed for quality using the Newcastle-Ottawa scale. Relevant characteristics were extracted by multiple authors to assess prehospital AM training. Of the initial 713 articles, 17 met inclusion criteria, representing 11 countries. Basic AM curricula were found in 11 studies and advanced AM curricula were found in nine studies. 35.3% (n = 6) of first responder programs provided no equipment to basic life support (BLS) AM training participants, reporting a median cost of $7.00USD per responder trained. Median frequency of prehospital AM intervention was reported in 31.0% (IQR: 6.0, 50.0) of patient encounters (advanced life support trainees: 12.1%, BLS trainees: 32.0%). In three studies, adverse event frequencies during intubation occurred with a median frequency of 22.0% (IQR: 21.0, 22.0). The training deficit in advanced AM interventions in LMICs suggests BLS AM courses should be prioritized, especially in sub-Saharan Africa. Prehospital AM resources are sparse and should be a priority for future development.

Whole blood use in trauma resuscitation: targeting prehospital transfusion

Govind Rangrass

Curr Opin Anaesthesiol. 2022 Apr 1;35(2):146-149

Purpose of review: Trauma resuscitation management has evolved over the years with a more nuanced understanding of the injured patient's physiologic state of shock. The purpose of this review is to discuss the role of whole blood administration in the prehospital setting in the resuscitation of the trauma patient.

Recent findings: In traumatically injured patients, whole blood administration initiated in the prehospital setting may improve early shock severity, coagulopathy, and survival when used over traditional resuscitation fluids such as crystalloid administration or component therapy.

Summary: The timing of resuscitation and its components deserve special attention when improving outcomes for trauma patients requiring massive transfusion.

Prehospital Surgical Airway Management: An NAEMSP Position Statement and Resource Document

Robert F Reardon, Aaron E Robinson, Rebecca Kornas, Jeffrey D Ho, Brendan Anzalone, Jestin Carlson, Michael Levy, Brian Driver

Prehosp Emerg Care. 2022;26(sup1):96-101

 

Bag-valve-mask ventilation and endotracheal intubation have been the mainstay of prehospital airway management for over four decades. Recently, supraglottic device use has risen due to various factors. The combination of bag-valve-mask ventilation, endotracheal intubation, and supraglottic devices allows for successful airway management in a majority of patients. However, there exists a small portion of patients who are unable to be intubated and cannot be adequately ventilated with either a facemask or a supraglottic airway. These patients require an emergent surgical airway. A surgical airway is an important component of all airway algorithms, and in some cases may be the only viable approach; therefore, it is imperative that EMS agencies that are credentialed to manage airways have the capability to perform surgical airways when appropriate. The National Association of Emergency Medical Services Physicians (NAEMSP) recommends the following for emergency medical services (EMS) agencies that provide advanced airway management.A surgical airway is reasonable in the prehospital setting when the airway cannot be secured by less invasive means.When indicated, a surgical airway should be performed without delay.A surgical airway is not a substitute for other airway management tools and techniques. It should not be the only rescue option available.Success of an open surgical approach using a scalpel is higher than that of percutaneous Seldinger techniques or needle-jet ventilation in the emergency setting.

Prolonged Casualty Care Guidelines 21 December 2021

J Spec Oper Med. Spring 2022;22(1):18-47

Michael A Remley, Paul E Loos, Jamie C Riesberg

 

No abstract available

The Management of Abdominal Evisceration in Tactical Combat Casualty Care: TCCC Guideline Change 20-02

Jamie C Riesberg, Jennifer M Gurney, Meg Morgan, D Marc Northern, Dana J Onifer, William J Gephart, Michael A Remley, Erin Eickhoff, Carl Miller, Brian J Eastridge, Harold R Montgomery, Frank K Butler Jr, Brendon Drew

J Spec Oper Med. Winter 2021;21(4):138-142

 

Abstract

Historically, about 20% of hospitalized combat injured patients have an abdominal injury. Abdominal evisceration may be expected to complicate as many as one-third of battle-related abdominal wounds. The outcomes for casualties with eviscerating injuries may be significantly improved with appropriate prehospital management. While not as extensively studied as other forms of combat injury, abdominal evisceration management recommendations extend back to at least World War I, when it was recognized as a significant cause of morbidity and was especially associated with bayonet injury. More recently, abdominal evisceration has been noted as a frequent result of penetrating, ballistic trauma. Initial management of abdominal evisceration for prehospital providers consists of assessing for and controlling associated hemorrhage, assessing for bowel content leakage, covering the eviscerated abdominal contents with a moist, sterile barrier, and carefully reassessing the patient. Mortality in abdominal evisceration is more likely to be secondary to associated injuries than to the evisceration itself. Attempting to establish education, training, and a standard of care for nonmedical and medical first responders and to leverage current wound management technologies, the Committee on Tactical Combat Casualty Care (CoTCCC) conducted a systematic review of historical Service guidelines and recent medical studies that include abdominal evisceration. For abdominal evisceration injuries, the following principles of management apply: (1) Control any associated bleeding visible in the wound. (2) If there is no evidence of spinal cord injury, allow the patient to take the position of most comfort. (3) Rinse the eviscerated bowel with clean fluid to reduce gross contamination. (4) Cover exposed bowel with a moist, sterile dressing or a sterile water-impermeable covering. It is important to keep the wound moist; irrigate the dressing with warm water if available. (4) For reduction in wounds that do not have a substantial loss of abdominal wall, a brief attempt may be made to replace/reduce the eviscerated abdominal contents. If the external contents do not easily go back into the abdominal cavity, do not force or spend more than 60 seconds attempting to reduce contents. If reduction of eviscerated contents is successful, reapproximate the skin using available material, preferably an adhesive dressing like a chest seal (other examples include safety pins, suture, staples, wound closure devices, etc.). Do not attempt to reduce bowel that is actively bleeding or leaking enteric contents. (6) If unable to reduce, cover the eviscerated organs with water-impermeable, nonadhesive material (transparent preferred to allow ability to reassess for ongoing bleeding; examples include a bowel bag, IV bag, clear food wrap, etc.), and then secure the impermeable dressing to the patient using an adhesive dressing (e.g., Ioban, chest seal). (7) Do NOT FORCE contents back into abdomen or actively bleeding viscera. (8) Death in the abdominally eviscerated patient is typically from associated injuries, such as concomitant solid organ or vascular injury, rather than from the evisceration itself. (9) Antibiotics should be administered for any open wounds, including abdominal eviscerating injuries. Parenteral ertapenem is the preferred antibiotic for these injuries.

Benefits of early application of pelvic circumferential compression device to reduce bleeding in pelvic fractures

Visit Rungsinaporn, Pawin Akkarawanit, Pinkawas Kongmalai

BMC Musculoskelet Disord. 2022 Mar 3;23(1):203

 

Background: To study of efficacy of early pelvic circumferential compression device using in patients with suspected pelvic trauma, compared with conventional stepwise approach.

Methods: Traumatic injury and at least one of the following criteria are required for inclusion: loss of consciousness or a Glasgow coma score (GCS) of less than 13; systolic blood pressure less than 90 mmHg; falling from more than 6 m; injury to several important organs; and a positive pelvic compression test. Patients who satisfied the inclusion criteria for the experimental group were given an early application of a commercial pelvic sling beginning in July 2019. The control group consisted of cases who got the device after clinical or radiological confirmation of a pelvic fracture in the previous year. Gender, age, mechanism of injury, GCS, hospital stay, amount of packed red blood cell transfusion, hematocrit in emergency room, and hematocrit 24 h after application of pelvic binder were all assessed and compared.

Results: The study had a total of 30 participants, with 15 in each group. The number of packed red blood cell transfusions in the early pelvic binder group (0.80 ± 1.42) is considerably lower than in the control group (2.4 ± 2.32) (P = 0.008), although the hematocrit change is not statistically different between the groups (2.1 VS 0.7) (P = 0.191). The time it took to install a pelvic binder was considerably shorter in the early pelvic binder group (16.40 ± 5.45) than in the control group (40.40 ± 13.64) (P = 0.001). There were no problems associated to soft tissue and skin necrosis in either group of patients.

Conclusions: The use of the PCCD for 24 h prior to clinical and radiographic confirmation has significantly reduced the rate of packed red blood cell transfusion in any pelvic fracture patient without device-related complications.

Not So FAST- Chest Ultrasound Underdiagnoses Traumatic Pneumothorax

Jarrett E Santorelli, Harrison Chau, Laura Godat, Giovanna Casola, Jay J Doucet, Todd W Costantini

J Trauma Acute Care Surg. 2022 Apr 1. Online ahead of print

 

No abstract available

A Prospective, Feasibility Assessment of a Novel, Disposable Video Laryngoscope With Special Operations Medical Personnel in a Mobile Helicopter Simulation Setting

Steven G Schauer, Jessica Mendez, Nguvan Uhaa, Ian L Hudson, Wells L Weymouth

J Spec Oper Med. Winter 2021;21(4):26-29

 

Background: Video laryngoscopy (VL) is shown to improve first-pass success rates and decrease complications in intubations, especially in novice proceduralists. However, the currently fielded VL devices are cost-prohibitive for dispersion across the battlespace. The novel i-view VL is a low-cost, disposable VL device that may serve as a potential solution. We sought to perform end-user performance testing and solicit feedback.

Methods: We prospectively enrolled Special Operations flight medics with the 160th Special Operations Aviation Regiment at Hunter Army Airfield, Savannah, Georgia. We asked them to perform an intubation using a synthetic cadaver model while in a mobile helicopter simulation setting. We surveyed their feedback afterward.

Results: The median age of participants was 30 and all were male. Of those, 60% reported previous combat deployments, with a median of 20 months of deployment time. Of the 10, 90% were successful with intubation, with 60% on first-pass success with an average of 83 seconds time to intubation. Most had a grade 1 view. Most agreed or strongly agreed that it was easy to use (70%), with half (50%) reporting they would use it in the deployed setting. Several made comments about the screen not being bright enough and would prefer one with a rotating display.

Conclusions: We found a high proportion of success for intubation in the mobile simulator and a high satisfaction rate for this device by Special Operations Forces medics.

Hydrogels in Burn Wound Management-A Review

Agnieszka Surowiecka, Jerzy Strużyna, Aleksandra Winiarska, Tomasz Korzeniowski

Gels. 2022 Feb 15;8(2):122

 

Abstract

Inert hydrogels are of a great importance in burn first aid. Hydrogel dressings may be an alternative to cooling burn wounds with streaming water, especially in cases of mass casualty events, lack of clean water, hypothermia, or large extent of burns. Hydrogels that contain mostly water evacuate the heat cumulating in the skin by evaporation. They not only cool the burn wound, but also reduce pain and protect the wound area from contamination and further injuries. Hydrogels are ideally used during the first hours after injury, but as they do not have antimicrobial properties per se, they might not prevent wound infection. The hydrogel matrix enables incorporating active substances into the dressing. The active forms may contain ammonium salts, nanocrystal silver, zinc, growth factor, cytokines, or cells, as well as natural agents, such as honey or herbs. Active dressings may have antimicrobial activity or stimulate wound healing. Numerous experiments on animal models proved their safety and efficiency. Hydrogels are a new dressing type that are still in development.

 

Refining mass casualty plans with simulation-based iterative learning

Rosel Tallach, Barry Schyma, Michael Robinson, Breda O'Neill, Naomi Edmonds, Ruth Bird, Matthew Sibley, Andrew Leitch, Susan Cross, Laura Green, Anne Weaver, Nina McLean, Rachel Cemlyn-Jones, Raj Menon, Dafydd Edwards, Elaine Cole

Br J Anaesth. 2022 Feb;128(2):e180-e189

 

Background: Preparatory, written plans for mass casualty incidents are designed to help hospitals deliver an effective response. However, addressing the frequently observed mismatch between planning and delivery of effective responses to mass casualty incidents is a key challenge. We aimed to use simulation-based iterative learning to bridge this gap.

Methods: We used Normalisation Process Theory as the framework for iterative learning from mass casualty incident simulations. Five small-scale 'focused response' simulations generated learning points that were fed into two large-scale whole-hospital response simulations. Debrief notes were used to improve the written plans iteratively. Anonymised individual online staff surveys tracked learning. The primary outcome was system safety and latent errors identified from group debriefs. The secondary outcomes were the proportion of completed surveys, confirmation of reporting location, and respective roles for mass casualty incidents.

Results: Seven simulation exercises involving more than 700 staff and multidisciplinary responses were completed with debriefs. Usual emergency care was not affected by simulations. Each simulation identified latent errors and system safety issues, including overly complex processes, utilisation of space, and the need for clarifying roles. After the second whole hospital simulation, participants were more likely to return completed surveys (odds ratio=2.7; 95% confidence interval [CI], 1.7-4.3). Repeated exercises resulted in respondents being more likely to know where to report (odds ratio=4.3; 95% CI, 2.5-7.3) and their respective roles (odds ratio=3.7; 95% CI, 2.2-6.1) after a simulated mass casualty incident was declared.

Conclusion: Simulation exercises are a useful tool to improve mass casualty incident plans iteratively and continuously through hospital-wide engagement of staff.

The Tight Rope Act: A Multicenter Regional Experience Of Tourniquets In Acute Trauma Resuscitation

Leah C Tatebe 1, Victoria Schlanser, David Hampton, Grace Chang, Isaac Hanson, James Doherty, Nabil Issa, Hani Ghandour, Samuel Kingsley, Amy Stewart, Michael Anstadt, Andrew Dennis

J Trauma Acute Care Surg. 2021 Dec 6. Online ahead of print.

 

Background: As tourniquets have become more prevalent, device use has been questioned. This study sought to characterize the incidence, indication, and efficacy of tourniquet placement in acute trauma resuscitation.

Methods: Nine regional Level 1 Trauma Centers prospectively enrolled for 12 months adult patients (≥18 yrs) who had a tourniquet placed. Age, gender, mechanism, tourniquet type, indication, applying personnel, location placed, level of occlusion, and degree of hemostasis were collected. Major vascular injury, imaging and operations performed, and outcomes were assessed. Analyses were performed with significance at p < 0.05.

Results: 216 tourniquet applications were reported on 209 patients. There were significantly more male patients (183, 88%) and penetrating injuries (186, 89%) with gunshots being most common (127, 61%). Commercial tourniquets were most often used (205, 95%). 92% were placed in the prehospital setting (by fire/paramedics 56%, police 33%, bystanders 2%). The most common indications were pooling (47%) and pulsatile (32%) hemorrhage. Only 2% were for amputation. The most frequent location was high proximal extremity (70%). 4% were placed over the wound and 0.5% were distal to the wound. Only 61% of applications were arterial occlusive. Median application time was 30 min (IQR 20-40 min). Imaging was performed in 54% of patients. Overall, 36% had a named arterial injury. Tourniquet application failed to achieve hemostasis in 22% of patients with a named vascular injury. There was no difference in hemostasis between those with and without vascular injury (p = 0.12) or between who placed the tourniquet (p = 0.07). 70 patients (34%) required vascular operations. 34% of patients were discharged home without admission.

Conclusion: Discerning which injuries require tourniquets over pressure dressings remains elusive. Trained responders had high rates of superfluous and inadequate deployments. As tourniquets continue to be disseminated, emphasis should be placed on improving education, device development, and quality control.

Efficacy of Vancomycin Powder in Mitigating Infection of Open Penetrating Trauma Wounds on the Battlefield: An Evidence-Based Review

Brett Ryan TerBeek, Paul E Loos, Timothy B Pekari, David J Tennent

J Spec Oper Med. Spring 2022;22(1):76-80

 

Background: Open penetrating trauma wounds to the extremities remain the most common injuries encountered in combat and are frequently complicated by bacterial infections. These infections place a heavy burden on the Servicemember and the healthcare system as they often require multiple additional procedures and can frequently cause substantial debility. Previous studies have shown that vancomycin powder has demonstrated efficacy in decreasing infection risks in clean and contaminated orthopedic surgical wounds.

Methods: This review evaluates the most prevalent organisms cultured post-trauma, the current Tactical Combat Casualty Care (TCCC) guidelines for antibiotic prophylaxis, and relevant research of vancomycin's prophylactic use.

Results: Results from previous studies have shown a time-dependent reduction in bacterial load when vancomycin powder is introduced early post injury in traumatic orthopedic wounds. Furthermore, perioperative application affords a cost-effective method to prevent infection with minimal adverse effects.

Discussion: The current TCCC guidelines advocate for the use of antibiotics at the point of injury. When vancomycin powder is used in synergy with these guidelines, it can contribute a timely and powerful antibiotic to prevent infection.

Conclusion: The prophylactic use of vancomycin powder is a promising adjunctive agent to current Clinical Practice Guidelines (CPG), but it cannot be conclusively determined to be effective without further research into its application in traumatic combat wounds.

 

 

Prehospital blood transfusion: who benefits?

Karl-Christian Thies, Kurt Ruetzler

Lancet Haematol. 2022 Apr;9(4):e238-e239

 

No abstract available

 

Characteristics and Demographics of Patients Requiring Emergent Air Medical

Anna Van Tuyl, Mark Quilon, Trevor Dudley, Olivia Grant, Neha Rao, Paul Barbara, David S Kugler, Kaitlin C McLoone-Cepin, Josh Greenstein, Barry Hahn

Emerg Med Int. 2022 Mar 1;2022:3044891

 

Background: As integrated health systems become more common, interfacility patient transfers will increase and air transport programs will be prioritized. Understanding characteristics of patients triaged to air medical transport will assist with resource allocation and needs assessment. The objective of this study was to investigate the demographics and clinical characteristics of patients that presented to the emergency department (ED) and subsequently required emergent air medical interfacility transport.

Methods: This was a retrospective, multicenter study conducted at eight hospitals within Northwell Health, the largest academic health system in New York state. The study was conducted between December 1, 2014, and July 31, 2020, and included patients who presented to an ED and subsequently required emergent air medical interfacility transport.

Results: Overall, the median age was 37 years (IQR 4-66), and 231 (54%) subjects were males. The majority of subjects (59%) had no reported comorbidities, arrived by ambulance (52%), and were emergency severity index triage 2 (48%). Frequent indications for transfer were nontraumatic neurologic (37%), pulmonary or respiratory (13%), trauma (12%), and cardiovascular (12%). Most patients were not ventilated before transport (71%). The median time to call for transport at the sending institution was 2:42 hours (IQR 1:14-6:54), and the median length of stay was 4:12 (IQR 2:31-8:48). Most patients were subsequently admitted (96%) at the receiving institution to an intensive care unit (72%).

Conclusions: This study describes patients' demographic and clinical characteristics who required emergent air medical transport. Helicopter transport is costly, and data from these patients may further help our understanding of who is transported by air and how important air transport is to the health system.

 

The effect of prehospital tranexamic acid on outcome in polytrauma patients with associated severe brain injury

Karlijn J P van Wessem, Denise Jochems, Luke P H Leenen

Eur J Trauma Emerg Surg. 2021 Nov 14;1-11

 

Introduction: Tranexamic acid (TXA) has shown to be beneficial in selected patients with hemorrhagic shock. Recently, TXA has gained interest in isolated traumatic brain injury (TBI) patients with variable results. There are limited data on TXA in polytrauma with associated TBI. This study investigated the role of TXA in severely injured patients with associated severe TBI.

Methods: A 7.5-year prospective cohort study was performed to investigate the relation between prehospital TXA and mortality in consecutive trauma patients with associated severe TBI (Abbreviated Injury Scale (AIS)head ≥ 3) admitted to a Level-1 Trauma Center ICU. Indication for prehospital TXA administration was (suspicion of) hemorrhagic shock, and/or systolic blood pressure (SBP) ≤ 90 mmHg. Demographics, data on physiology, resuscitation, and outcomes were prospectively collected.

Results: Two hundred thirty-four patients (67% males) with median age of 49 years and ISS 33 (98% blunt injuries) were included. Thirteen patients (6%) developed thromboembolic complications; mortality rate was 24%. Fifty-one percent of patients received prehospital TXA. TXA patients were younger, had more deranged physiology on arrival, and received more crystalloids and blood products ≤ 24 h. There was, however, no difference in overall outcome between TXA patients and no-TXA patients.

Conclusions: Despite having a more deranged physiology TXA patients had similar outcome compared to no-TXA patients who were much older. Thromboembolic complication rate was low. Prehospital tranexamic acid has no evident effect on outcome in polytrauma patients with associated critical brain injury.

 

Quality Management of Prehospital Airway Programs: An NAEMSP Position Statement and Resource Document

Veer Vithalani, Samuel Sondheim, Angela Cornelius, John Gonzales, Mary P Mercer, Brooke Burton, Michael Redlener

Prehosp Emerg Care. 2022;26(sup1):14-22

Abstract

Prehospital airway management encompasses a multitude of complex decision-making processes, techniques, and interventions. Quality management (encompassing quality assurance and quality improvement activities) in EMS is dynamic, evidence-based, and most of all, patient-centric. Long a mainstay of the EMS clinician skillset, airway management deserves specific focus and attention and dedicated quality management processes to ensure the delivery of high-quality clinical care.It is the position of NAEMSP that:All EMS agencies should dedicate sufficient resources to patient-centric, comprehensive prehospital airway quality management program. These quality management programs should consist of prospective, concurrent, and retrospective activities. Quality management programs should be developed and operated with the close involvement of the medical director.Quality improvement and quality assurance efforts should operate in an educational, non-disciplinary, non-punitive, evidence-based medicine culture focused on patient safety. The highest quality of care is only achieved when the quality management program rewards those who identify and seek to prevent errors before they occur.Information evaluated in prehospital airway quality management programs should include both subjective and objective data elements with uniform reporting and operational definitions.EMS systems should regularly measure and report process, outcome, and balancing airway management measures.Quality management activities require large-scale bidirectional information sharing between EMS agencies and receiving facilities. Hospital outcome information should be shared with agencies and the involved EMS clinicians.Findings from quality management programs should be used to guide and develop initial education and continued training.Quality improvement programs must continually undergo evaluation and assessment to identify strengths and shortcomings with a focus on continuous improvement.C:\Users\HRMon\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\NI3KP3I8\Quality Management of Prehospital Airway Programs: An NAEMSP Position Statement and Resource Document

Joint Trauma System Clinical Practice Guideline (JTS CPG): Prehospital Blood Transfusion. 30 October 2020

Jared Voller, Joshua M Tobin, Andrew P Cap, Cord W Cunningham, Michael Denoyer, Brendon Drew, Jay Johannigman, Elizabeth A Mann-Salinas, Benjamin Walrath, Jennifer M Gurney, Stacy A Shackelford

J Spec Oper Med. Winter 2021;21(4):11-21.

 

Abstract

This Clinical Practice Guideline (CPG) provides a brief summary of the scientific literature for prehospital blood use, with an emphasis on the en route care environment. Updates include the importance of calcium administration to counteract the deleterious effects of hypocalcemia, minimal to no use of crystalloid, and stresses the importance of involved and educated en route care medical directors alongside at a competent prehospital and en route care providers (see Table 1). With the paradigm shift to use FDA-approved cold stored low titer group O whole blood (CS-LTOWB) along with the operational need for continued use of walking blood banks (WBB) and point of injury (POI) transfusion, there must be focused, deliberate training incorporating the different whole blood options. Appropriate supervision of autologous blood transfusion training is important for execution of this task in support of deployed combat operations as well as other operations in which traumatic injuries will occur. Command emphasis on the importance of this effort as well as appropriate logistical support are essential elements of a prehospital blood program as part of a prehospital/en route combat casualty care system.

 

Advanced Bleeding Control in combat casualty care: an international, expert-based Delphi consensus

Suzanne M Vrancken,  Boudewijn L S Borger van der Burg, Joseph J DuBose, Jacob J Glaser, Tal M Hörer, Rigo Hoencamp

J Trauma Acute Care Surg. 2022 Jan 21.Online ahead of print.

 

Background: Hemorrhage from truncal and junctional injuries is responsible for the vast majority of potentially survivable deaths in combat casualties, causing most of its fatalities in the prehospital arena. Optimizing the deployment of the advanced bleeding control modalities required for the management of these injuries is essential to improve the survival of severely injured casualties. This study aimed to establish consensus on the optimal use and implementation of advanced bleeding control modalities in combat casualty care.

Methods: A Delphi method consisting of three rounds was used. An international expert panel of military physicians was selected by the researchers to complete the Delphi surveys. Consensus was reached if ≥70% of respondents agreed and if ≥70% responded.

Results: Thirty-two experts from 10 different nations commenced the process and reached consensus on which bleeding control modalities should be part of the standard equipment, that these modalities should be available at all levels of care, that only trained physicians should be allowed to apply invasive bleeding control modalities, but all medical and non-medical personnel should be allowed to apply non-invasive bleeding control modalities, and on the training requirements for providers. Consensus was also reached on the necessity of international registries and guidelines, and on certain indications and contraindications for resuscitative endovascular balloon occlusion of the aorta (REBOA) in military environments. No consensus was reached on the role of a wound clamp in military settings and the indications for REBOA in patients with chest trauma, penetrating axillary injury or penetrating neck injury in combination with thoraco-abdominal injuries.

Conclusions: Consensus was reached on the contents of a standard bleeding control toolbox, where it should be available, providers and training requirements, international registries and guidelines, and potential indications for REBOA in military environments.

Blood product resuscitation mitigates the effects of aeromedical evacuation after polytrauma

Taylor E Wallen, Kathleen E Singer, Mackenzie C Morris, Thomas Blakeman, Sabre M Stevens-Topie, Richard Strilka, Timothy A Pritts, Michael D Goodman

J Trauma Acute Care Surg. 2022 Jan 1;92(1):12-20

 

Background: The combined injury of traumatic brain injury and hemorrhagic shock has been shown to worsen coagulopathy and systemic inflammation, thereby increasing posttraumatic morbidity and mortality. Aeromedical evacuation to definitive care may exacerbate postinjury morbidity because of the inherent hypobaric hypoxic environment. We hypothesized that blood product resuscitation may mitigate the adverse physiologic effects of postinjury flight.

Methods: An established porcine model of controlled cortical injury was used to induce traumatic brain injury. Intracerebral monitors were placed to record intracranial pressure, brain tissue oxygenation, and cerebral perfusion. Each of the 42 pigs was hemorrhaged to a goal mean arterial pressure of 40 ± 5 mm Hg for 1 hour. Pigs were grouped according to resuscitation strategy used-Lactated Ringer's (LR) or shed whole blood (WB)-then placed in an altitude chamber for 2 hours at ground, 8,000 ft, or 22,000 ft, and then observed for 4 hours. Hourly blood samples were analyzed for proinflammatory cytokines and lactate. Internal jugular vein blood flow was monitored continuously for microbubble formation with altitude changes.

Results: Cerebral perfusion, tissue oxygenation, and intracranial pressure were unchanged among the six study groups. Venous microbubbles were not observed even with differing altitude or resuscitation strategy. Serum lactate levels from hour 2 of flight to the end of observation were significantly elevated in 22,000 + LR compared with 8,000 + LR and 22,000 + WB. Serum IL-6 levels were significantly elevated in 22,000 + LR compared with 22,000 + WB, 8,000 + LR and ground+LR at hour 1 of observation. Serum tumor necrosis factor-α was significantly elevated at hour 2 of flight in 8,000 + LR versus ground+LR, and in 22,000 + LR vs. 22,000 + WB at hour 1 of observation. Serum IL-1β was significantly elevated hour 1 of flight between 8,000 + LR and ground+LR.

Conclusion: Crystalloid resuscitation during aeromedical transport may cause a prolonged lactic acidosis and proinflammatory response that can predispose multiple-injury patients to secondary cellular injury. This physiologic insult may be prevented by using blood product resuscitation strategies.

 

Rescue blankets as multifunctional rescue equipment in alpine and wilderness emergencies: a commentary

Bernd Wallner, Hannah Salchner, Markus Isser, Thomas Schachner, Franz J Wiedermann, Wolfgang Lederer

Scand J Trauma Resusc Emerg Med. 2022 Mar 10;30(1):17

 

Abstract

Emergency applications of rescue blankets go far beyond protection from hypothermia. In this review alternative applicabilities of these remarkable multifunctional tools were highlighted. Newly fabricated rescue blankets prove impressive robustness. The high tensile strength along with its low weight enable further applications, e.g. immobilization of injured extremities, splinting, wound dressing, a makeshift chest seal in sucking chest wounds, amongst others. Furthermore, the foil can be used as a vapour barrier, as eye protection and it can even be used to construct a stopgap bivouac sack, as alternative tool for transportation in the remote area and a wind shield or a water reservoir in the wilderness. During search-and-rescue missions the light reflection from the gold surface enhances visibility and increases the chance to be found. Rescue blankets are essential parts of first aid kits and backpacks in alpine and wilderness environment with multifunctional applicabilities. In this commentary to a review we want to evaluate the numerous applicabilities of rescue blankets in the treatment of emergencies by wilderness medicine and pre-hospital EMS.

Use of Topical Hemostatic Dressings in an Extended Field Care Model

Matthew Welch, Jon Barratt, Alethea Peters, Chris Wright

J Spec Oper Med. Winter 2021;21(4):63-65

 

Background: We sought to test whether Celox topical hemostatic dressing (Medtrade Products) would maintain hemostasis in extended use.

Methods: An anesthetized swine underwent bilateral arteriotomies and treatment with topical hemostatic dressings in line with the Kheirabadi method. The dressings were covered with standard field dressings, and these were visually inspected for bleeding every 2 hours until 8 hours, when the swine was euthanized.

Results: There was no evidence of rebleeding at any point up to and including 8 hours. The Celox dressings maintained hemostasis in extended use.

Conclusion: Celox topical hemostatic dressing is effective for extended use and maintains hemostasis. It should be considered for use in situations in which evacuation and definitive care may be delayed.

Low-dose ketamine in the prehospital setting

Alvin Yuhalogarasan, Chris Barclay, P Richard Verbeek

CMAJ. 2022 Feb 7;194(5):E171

 

No abstract available

 

Drone versus ambulance for blood products transportation: an economic evaluation study

M A Zailani, R Z Azma, I Aniza, A R Rahana, M S Ismail, I S Shahnaz, K S Chan, M Jamaludin, Z A Mahdy

BMC Health Serv Res. 2021 Dec 5;21(1):1308

 

Background: Medical transportation is an essential step in health care services, and includes ground, air and water transportation. Among the important uses of medical transportation is the delivery of blood products in the event of a clinical emergency. Drone technology is the latest technological advancement that may revolutionize medical transportation globally. Nonetheless, its economic evaluation is scant and insufficient, whilst its cost-effectiveness remains controversial. The aim of this study was to compare the cost-effectiveness of drone transportation versus the ambulance.

Methods: The setting of the study was within a developing nation. An economic evaluation study of drone versus ambulance for emergency blood products transportation between the Sabah Women and Children Hospital (SWACH) and the Queen Elizabeth II Hospital (QEH2) on Borneo Island was conducted using the Cost-Effectiveness Analysis (CEA) technique. The total cost of each mode of transportation was calculated using the Activity Based Costing (ABC) method. Travel time was used as a denominator to estimate the Incremental Cost Effectiveness Ratio (ICER).

Results: For one clinical emergency in SWACH, a round trip of blood products transportation from SWACH to QEH2 costs RM1,266.02 (USD307.09) when using the ambulance, while the drone costs RM1,313.28 (USD319.36). The travel time for the drone was much shorter (18 min) compared to the ambulance (34 min). The Cost-Effectiveness Ratio (CER) of ambulance transportation was RM37.23 (USD9.05) per minute whilst the CER of drone transportation was RM72.96 (USD17.74) per minute. The ICER of drone versus ambulance was - 2.95, implying an increase of RM2.95 in cost for every minute saved using a drone instead of an ambulance.

Conclusion: Although drone transportation of blood products costs more per minute compared to the ambulance, the significantly shorter transport time of the drone offset its cost. Thus, we believe there is good economic potential for drone usage for blood products transportation in developing nations particularly if the drone price decreases and its operational lifespan increases. Our limitation of a non-clinical denominator used in this study leads to the recommendation for use of clinical outcomes in future studies.

Blood Transfus. 2022 Feb 28. Online ahead of print.

Stored whole blood transfusion initiates serum amyloid A activation monitored by real-time dynamic imaging

Yulong Zhang, Zhengjun Wang, Xinghuan Ma, Yuxuan Li, Qianqian Zhou, Sujing Sun, Ping Ma, Liping Lv, Linsheng Zhan, Xiaohui Wang

 

Background: Transfusion of stored whole blood (SWB) to resuscitate severe traumatic haemorrhage patients in military operations and civilian emergency centres is being increasingly used in routine practice. It has been well established that transfusion of red blood cells (RBCs) after prolonged storage has harmful effects, mainly mediated by inflammation. Whether the side effects of inflammation are brought about by SWB transfusion remains unclear.

Materials and methods: A hepatocyte SAA (serum amyloid A) specific reporter mouse that facilitated non-invasive imaging of hepatocyte SAA expression was used to evaluate acute inflammation and acute-phase reaction after the transfusion of SWB or components separated from end-storage whole blood. The whole blood of C57BL/6 donor mouse was used to model an allogeneic transfusion to BALB/c recipient mouse.

Results: End-storage whole blood (14 days of storage) transfusion induced the most significant SAA expression, while 10-day storage resulted in a much weaker signal compared to their fresh and 5-day storage counterparts. RBCs rather than white blood cells and plasma-containing platelets are thought to be responsible for the systemic inflammatory and SAA activation during end-storage whole blood transfusion. Circulatory and hepatic pro-inflammatory cytokines secreted by M1-polarised macrophage initiated the SAA expression in hepatocytes through nuclear transcription factor NF-κB.

Discussion: Storage lesions will also occur during the storage of whole blood, which is related to the change in RBCs with prolonged storage. The side effect induced by systemic inflammation and acute-phase reaction should be considered before resuscitation with long-term storage whole blood transfusion.

User Needs and Challenges in Information Sharing between Pre-Hospital and Hospital Emergency Care Providers

Zhan Zhang, Aleksandra Sarcevic, Karen Joy, Mustafa Ozkaynak, Kathleen Adelgais

AMIA Annu Symp Proc. 2022 Feb 21;2021:1254-1263

 

Abstract

Effective communication between pre-hospital and hospital providers is a critical first step towards ensuring efficient patient care. Despite many efforts in improving the communication process, inefficiencies persist. It is critical to understand user needs, work practices, and existing barriers to inform technology design for supporting pre-hospital communication. However, existing research examining the ways in which patient information is collected and shared by pre-hospital providers in the field has been limited. We conducted a series of ethnographic studies with both prehospital and hospital care providers to examine 1) the types of information that are commonly collected and shared by the pre-hospital providers in the field; 2) the types of pre-hospital information that are needed by hospital-based teams for ensuring appropriate preparation; and 3) the challenges in the pre-hospital communication process. We conclude by discussing technology opportunities for facilitating real-time information sharing in the field.

 

Success and Time to Oxygen Delivery for Scalpel-Finger-Cannula and Scalpel-Finger-Bougie Front-of-Neck Access: A Randomized Crossover Study With a Simulated "Can't Intubate, Can't Oxygenate" Scenario in a Manikin Model With Impalpable Neck Anatomy

Jinbin Zhang, Shimin Ong, Han Toh, Meifang Chew, Hope Ang, Stacey Goh

Anesth Analg. 2022 Mar 3. Online ahead of print

 

Background: Emergency front-of-neck access (FONA) is particularly challenging with impalpable neck anatomy. We compared 2 techniques that are based on a vertical midline neck incision, followed by finger dissection and then either a cannula or scalpel puncture to the cricothyroid membrane.

Methods: A manikin simulation scenario of impalpable neck anatomy and bleeding was created. Sixty-five anesthesiologists undergoing cricothyrotomy training performed scalpel-finger-cannula (SFC) and scalpel-finger-bougie (SFB) cricothyrotomy in random order. Primary outcomes were time to oxygen delivery and first-attempt success; data were analyzed using multilevel mixed-effects models.

Results: SFC was associated with a shorter time to oxygen delivery on univariate (median time difference, -61.5 s; 95% confidence interval [CI], -84.7 to -38.3; P < .001) and multivariable (mean time difference, -62.1 s; 95% CI, -83.2 to -41.0; P < .001) analyses. Higher first-attempt success was reported with SFC than SFB (47 of 65 [72.3%] vs 18 of 65 [27.7%]). Participants also had higher odds at achieving first-attempt success with SFC than SFB (odds ratio [OR], 10.7; 95% CI, 3.3-35.0; P < .001). Successful delivery of oxygen after the "can't intubate, can't oxygenate" (CICO) declaration within 3 attempts and 180 seconds was higher (84.6% vs 63.1%) and more likely with SFC (OR, 5.59; 95% CI, 1.7-18.9; P = .006). Analyzing successful cases only, SFC achieved a shorter time to oxygen delivery (mean time difference, -24.9 s; 95% CI, -37.8 to -12.0; P < .001), but a longer time to cuffed tube insertion (mean time difference, +56.0 s; 95% CI, 39.0-73.0; P < .001). After simulation training, most participants preferred SFC in patients with impalpable neck anatomy (75.3% vs 24.6%).

Conclusions: In a manikin simulation of impalpable neck anatomy and bleeding, the SFC approach demonstrated superior performance in oxygen delivery and was also the preferred technique of the majority of study participants. Our study findings support the use of a cannula-based FONA technique for achieving oxygenation in a CICO situation, with the prerequisite that appropriate training and equipment are available.

The use of supraglottic airways in the prone position is useful in specific situations

Paul Norbert Zilberman, Jochen Hinkelbein

Eur J Anaesthesiol. 2022 Feb 1;39(2):177

 

No abstract available