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.
Abstract
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.
Stewardship of Prehospital Low Titer O-Positive Whole Blood in a Large Urban Fire-Based EMS System
William Bullock, Randall Schaefer, David Wampler, Michael Stringfellow, Mark Dieterle, Christopher Cj Winckler
Prehosp Emerg Care. 2021 Nov 22;1-7
Abstract
Introduction: Trauma is the leading cause of death for those aged 1 to 46 years with most fatalities resulting from hemorrhage prior to arrival to hospital. Hemorrhagic shock patients receiving transfusion with 15 minutes experience lower mortality. Prehospital blood transfusion has many legal, fiduciary, and logistical issues. The San Antonio Fire Department participates in a consortium designed to enhance the stewardship of prehospital whole blood. This study aimed to stratify blood usage amongst the field supervisors and special operations units that carry whole blood. Methods: This was a 12-month retrospective analysis of blood usage. Blood tracking forms (used for either blood exchange of transfusion) were cross referenced with city financial records to determine blood usage patterns in the 7th Largest City in the US. We used descriptive statistics, compared usage ratios, and chi-square to compare dichotomized data. Results: A total of 363 whole blood units were obtained and 248 (68.3%) units of whole blood were transfused. EMS field supervisors transfused 74% of whole blood vs. 44% for special operations ambulances (p= <0.001). Response vehicles located in densely populated areas had the highest usage rates. All blood units were either transfused or returned for a zero blood unit wastage for expiration. Conclusion: The information contained within this work can provide other EMS agencies with a basic framework for comparison. The data from the SAFD's whole blood transfusion rate coupled with the clinical transfusion guideline has provided some insight for prospective agencies considering adopting a whole blood program. EMS systems and municipalities with similar characteristics can project their own whole blood needs and make informed decisions regarding program feasibility and design.
Luca Carenzo, Adam McDonald, Gareth Grier
Br J Anaesth. 2022 Feb;128(2):e206-e208
No abstract available
The Story of Blood for Shock Resuscitation: How the Pendulum Swings
Samuel P Carmichael 2nd, Nicholas Lin, Meagan E Evangelista, John B Holcomb
J Am Coll Surg. 2021 Nov;233(5):644-653
Abstract
Whole blood transfusion (WBT) began in 1667 as a treatment for mental illness, with predictably poor results. Its therapeutic utility and widespread use were initially limited by deficiencies in transfusion science and antisepsis. James Blundell, a British obstetrician, was recognized for the first allotransfusion in 1825. However, WBT did not become safe and therapeutic until the early 20th century, with the advent of reliable equipment, sterilization, and blood typing. The discovery of citrate preservation in World War I allowed a separation of donor from recipient and introduced the practice of blood banking. During World War II, Elliott and Strumia were the first to separate whole blood into blood component therapy (BCT), producing dried plasma as a resuscitative product for "traumatic shock." During the 1970s, infectious disease, blood fractionation, and financial opportunities further drove the change from WBT to BCT, with few supporting data. Following a period of high-volume crystalloid and BCT resuscitation well into the early 2000s, measures to avoid the resulting iatrogenic resuscitation injury were developed under the concept of damage control resuscitation. Modern transfusion strategies for hemorrhagic shock target balanced BCT to reapproximate whole blood. Contemporary research has expanded the role of WBT to therapy for the acute coagulopathy of trauma and the damaged endothelium. Many US trauma centers are now using WBT as a front-line treatment in tandem with BCT for patients suffering hemorrhagic shock. Looking ahead, it is likely that WBT will once again be the resuscitative fluid of choice for patients in hemorrhagic shock.
Jee-Eun Chang, Hyerim Kim, Dongwook Won, Jung-Man Lee, Tae Kyong Kim, Seong-Won Min, Jin-Young Hwang
Anesth Analg. 2021 Nov 1;133(5):1288-1295
Abstract
Background: Accurate identification of the cricothyroid membrane is crucial for successful cricothyroidotomy. The aim of this study was to compare the conventional downward and modified upward laryngeal handshake techniques in terms of accuracy to identify the cricothyroid membrane in nonobese female patients.
Methods: In 198 anesthetized female patients, the cricothyroid membrane was identified by either the conventional downward laryngeal handshake technique (n = 99) or the modified upward laryngeal handshake technique (n = 99). According to the conventional downward laryngeal handshake technique, the cricothyroid membrane was identified by palpating the neck downward from the greater cornu of the hyoid bone, thyroid laminae, and cricoid cartilage. According to the modified upward laryngeal handshake technique, the cricothyroid membrane was located by moving up from the sternal notch. The primary outcome was the accuracy of identifying the cricothyroid membrane. Secondary outcomes included the accuracy of midline identification and time taken to locate what participants believed to be the cricothyroid membrane. The primary and secondary outcomes according to the technique were analyzed using generalized estimating equations.
Results: The cricothyroid membrane could be identified more accurately by the modified upward laryngeal handshake technique than by the conventional downward technique (84% vs 56%, respectively; odds ratio [OR], 4.36; 95% confidence interval [CI], 2.13-8.93; P < .001). Identification of the midline was also more accurate by the modified laryngeal handshake than by the conventional technique (96% vs 83%, respectively; OR, 4.98; 95% CI, 1.65-15.01; P = .004). The time taken to identify the cricothyroid membrane was not different between the conventional and modified techniques (20.2 [16.2-26.6] seconds vs 19.0 [14.5-26.4] seconds, respectively; P = .83).
Conclusions: The modified upward laryngeal handshake technique that involved tracing the trachea and laryngeal structures upward from the sternal notch was more accurate in identifying the cricothyroid membrane than the conventional downward technique in anesthetized female patients.
Shaila K Coffey, J Priyanka Vakkalanka, Haley Egan, Kelli Wallace, Karisa K Harland, Nicholas M Mohr, Azeemuddin Ahmed
West J Emerg Med. 2021 Aug 30;22(5):1183-1189
Introduction: Ketamine is commonly used to treat profound agitation in the prehospital setting. Early in ketamine's prehospital use, intubation after arrival in the emergency department (ED) was frequent. We sought to measure the frequency of ED intubation at a Midwest academic medical center after prehospital ketamine use for profound agitation, hypothesizing that intubation has become less frequent as prehospital ketamine has become more common and prehospital dosing has improved.
Methods: We conducted a retrospective cohort study of adult patients receiving ketamine in the prehospital setting for profound agitation and transported to a midwestern, 60,000-visit, Level 1 trauma center between January 1, 2017-March 1, 2021. We report descriptive analyses of patient-level prehospital clinical data and ED outcomes. The primary outcome was proportion of patients intubated in the ED.
Results: A total of 78 patients received ketamine in the prehospital setting (69% male, mean age 36 years). Of the 42 (54%) admitted patients, 15 (36% of admissions) were admissions to the intensive care unit. Overall, 12% (95% confidence interval [CI]), 4.5-18.6%)] of patients were intubated, and indications included agitation (n = 4), airway protection not otherwise specified (n = 4), and respiratory failure (n = 1).
Conclusion: Endotracheal intubation in the ED after prehospital ketamine use for profound agitation in our study sample was found to be less than previously reported.
Clinical use of tranexamic acid: evidences and controversies
Maria J Colomina, Laura Contreras, Patricia Guilabert, Maylin Koo, Esther Méndez, Antoni Sabate
Braz J Anesthesiol. 2021 Oct 7;S0104-0014(21)00369-9
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.
Jack Louro, Christian Diez, Albert J Varon
J Trauma Acute Care Surg. 2021 Dec 1;91(6):e146.
No abstract available
Robust hemostatic bandages based on nanoclay electrospun membranes
Yan Cui, Zongwang Huang, Li Lei, Qinglin Li, Jinlong Jiang, Qinghai Zeng, Aidong Tang, Huaming Yang, Yi Zhang
Nat Commun. 2021 Oct 11;12(1):5922
Abstract
Death from acute hemorrhage is a major problem in military conflicts, traffic accidents, and surgical procedures, et al. Achieving rapid effective hemostasis for pre-hospital care is essential to save lives in massive bleeding. An ideal hemostasis material should have those features such as safe, efficient, convenient, economical, which remains challenging and most of them cannot be achieved at the same time. In this work, we report a rapid effective nanoclay-based hemostatic membranes with nanoclay particles incorporate into polyvinylpyrrolidone (PVP) electrospun fibers. The nanoclay electrospun membrane (NEM) with 60 wt% kaolinite (KEM1.5) shows better and faster hemostatic performance in vitro and in vivo with good biocompatibility compared with most other NEMs and clay-based hemostats, benefiting from its enriched hemostatic functional sites, robust fluffy framework, and hydrophilic surface. The robust hemostatic bandages based on nanoclay electrospun membrane is an effective candidate hemostat in practical application.
Tracheal Transection from Gunshot Wound to the Neck
Sahil Dayal, Patrick Dugom, Alexandra Kharazi, Mark Iannettoni, Carlos Anciano, Aundrea Oliver, James Speicher
Ann Thorac Surg. 2021 Oct 8;S0003-4975(21)01696-9
Abstract
A male patient presented with a gunshot wound superior to his left scapula and difficulty breathing. En route to the emergency department, he rapidly became unresponsive, culminating in a cricothyroidotomy by paramedics. Oxygen saturation was 70% on arrival, and a tracheobronchial injury was suspected. In the operating room, a complete transection of the mid-trachea was found and repaired. Postoperatively, the patient developed acute respiratory distress syndrome. The patient was placed on extracorporeal membrane oxygenation and was eventually decannulated on postoperative day 12. The need for immediate identification of airway inadequacy, despite appropriate interventions, is underscored by this case report.
Devin Dishong, Andrew P Cap, John B Holcomb, Darrell J Triulzi, Mark H Yazer
Hematology. 2021 Dec;26(1):601-611
Abstract
There has been renewed interest in the use of low titer group O whole blood (LTOWB) for the resuscitation of civilian casualties. LTOWB offers several advantages over conventional components such as providing balanced resuscitation in one bag that contains less additive/preservative solution than an equivalent volume of conventional components, is easier and faster to transfuse than multiple components, avoids blood product ratio confusion, contains cold stored platelets, and reduces donor exposures. The resurgence in its use in the resuscitation of civilian trauma patients has led to the publication of an increasing number of studies on its use, primarily amongst adult recipients but also in pediatric patients. These studies have indicated that hemolysis does not occur amongst adult and pediatric non-group O recipients of a modest quantity of LTOWB. The published studies to date on mortality have shown conflicting results with some demonstrating a reduction following LTOWB transfusion while most others have not shown a reduction; there have not been any studies to date that have found significantly increased overall mortality amongst LTOWB recipients. Similarly, when other clinical outcomes, such as venous thromboembolism, sepsis, hospital or intensive care unit lengths of stay are evaluated, LTOWB recipients have not demonstrated worse outcomes compared to conventional component recipients. While definitive proof of the trends in these morbidity and mortality outcomes awaits confirmation in randomized controlled trials, the evidence to date indicates the safety of transfusing LTOWB to injured civilians.
The long and short of it: Nonstandardised length of nasopharyngeal airways
Neeti Dogra, Sumit Dhanda
Eur J Anaesthesiol. 2021 Nov 1;38(11):1202-1204
No abstract available
Erez Dvir, Danny Epstein, Baruch Berzon, Aeyal Raz, Amit Lehavi
Emerg Med J. 2021 Nov 5;emermed-2020-211057
Background: Preventing and treating hypothermia in prehospital settings is crucial. Several products have been developed to prevent heat loss and actively warm patients in prehospital settings. We compared the efficacy and the surface temperature of different antihypothermia products, using a fluid-based model at two ambient temperatures.
Methods: We tested five active (Blizzard Heat with active pads, Ready-Heat, Ready-Heat-II, Hypothermia Prevention and Management Kit (HPMK), Bair Hugger) and five passive (Blizzard Heat, Heat Reflective Shell, sleeping bag, 'space blanket', wool blanket) antihypothermia products. A torso model consisting of four 8 L bags of fluid preheated to 36°C±0.5°C (97±0.5°F) was used to compare the devices' performances at 20°C (68°F) and 8°C (46°F). Inner and surface temperatures were recorded for up to 480 min.
Results: We found significant differences in heat loss in fluid bags among the tested devices at both temperatures (p<0.001). At 20°C, only HPMK and Ready-Heat-II increased the inner temperature for 480 min while Blizzard Heat with active pads prevented heat loss. Ready-Heat prevented heat loss for 90 min. All the other devices did not prevent heat loss beyond 30 min. At 8°C, none of the products heated the model. Bair Hugger, HPMK, Ready-Heat II and sleeping bag prevented heat loss for 30 min. At 60, 90 and 120 min HPMK, Ready-Heat II and Bair Hugger were the most effective. Over 480 min, Bair Hugger was most effective, with a heat loss of 2.3°C±0.4°C. The surface temperature exceeded 44°C (111°F) for all the exothermic warming devices when used for a prolonged period of time.
Conclusion: At 20°C, HPMK and Ready-Heat-II increased fluid temperature in the model, while the other devices decreased heat loss. At 8°C, none of the tested devices increased the temperature. However, active heating devices prevented heat loss slightly better than passive methods. A protective insulation layer should be used with all active heating blankets.
Andrew D Fisher, Michael D April, Jason F Naylor, Russ S Kotwal, Steven G Schauer
Mil Med. 2021 Oct 15; Online ahead of print.
Background: The battalion aid station (BAS) has historically served as the first stop during which combat casualties would receive care beyond a combat medic. Since the conflicts in Iraq and Afghanistan, many combat casualties have bypassed the BAS for treatment facilities capable of surgery. We describe the care provided at these treatment facilities during 2007-2020.
Methods: This is a secondary analysis of previously described data from the Department of Defense Trauma Registry. We included encounters with the documentation of an assessment or intervention at a BAS or forward operating base from January 1, 2007 to March 17, 2020. We utilized descriptive statistics to characterize these encounters.
Results: There were 28,950 encounters in our original dataset, of which 3.1% (884) had the documentation of a prehospital visit to a BAS. The BAS cohort was older (25 vs. 24, P < .001) The non-BAS cohort saw a larger portion of pediatric (<18 years) patients (10.7% vs. 5.7%, P < .001). A higher proportion of BAS patients had nonbattle injuries (40% vs. 20.7%, P < .001). The mean injury severity score was higher in the non-BAS cohort (9 vs. 5, P < .001). A higher proportion of the non-BAS cohort had more serious extremity injuries (25.1% vs. 18.4%, P < .001), although the non-BAS cohort had a trend toward serious injuries to the abdomen (P = .051) and thorax (P = .069). There was no difference in survival.
Conclusions: The BAS was once a critical point in casualty evacuation and treatment. Within our dataset, the overall number of encounters that involved a stop at a BAS facility was low. For both the asymmetric battlefield and multidomain operations/large-scale combat operations, the current model would benefit from a more robust capability to include storage of blood, ventilators, and monitoring and hold patients for an undetermined amount of time.
Louise J Geneen, Susan J Brunskill, Carolyn Doree, Lise J Estcourt, Laura Green
Transfus Med Rev. 2022 Jan;36(1):7-15
Abstract
Our aim was to assess whether there is a difference in outcomes of potential "all-cause" harm in the transfusion of whole blood (WB) compared to blood components (BC) for any bleeding patient regardless of age or clinical condition. We searched multiple electronic databases using a pre-defined search strategy from inception to 2nd March 2021. 1 reviewer screened, extracted, and analysed data, with verification by a second reviewer of all decisions. We used Cochrane ROB1 and GRADE to assess the quality of the evidence. We used predefined subgroups of trauma and non-trauma studies in the analysis. We included six RCTs (618 participants) which compared WB and BC transfusion therapy in major bleeding, one trauma trial (n = 107), and 5 surgical trials (non-trauma) (n = 511). We GRADED evidence as very-low for all outcomes (downgraded for high and unclear risk of bias, small sample size, and wide confidence intervals around the estimate). Our primary outcome (all-cause mortality at 24-hours and 30-days) was reported in 3 out of 6 included trials. There was no evidence of a difference in mortality of WB compared to BC therapy (very-low certainty evidence). There may be a benefit of WB therapy compared to BC therapy in the non-trauma subgroup, with a reduction in the duration of oxygen dependence (1 study; n = 60; mean difference 5.9 fewer hours [95% Confidence Interval [CI] -10.83, -0.99] in WB group), and a reduction in hospital stay (1 study, n = 64, median difference 6 fewer days in WB group) (very-low certainty evidence). For the remaining outcomes (organ injury, mechanical ventilation and intensive care unit requirement, infection, arterial/venous thrombotic events, and haemolytic transfusion reaction) there was no difference between WB and BC therapy (wide CI, crossing line of no effect), though many of these outcomes were based on small single studies (very-low certainty evidence). In conclusion, there appears to be little to no difference in harms between WB and BC therapy, based on small studies with very low certainty of the evidence. Further large trials are required to establish the overall safety of WB compared to BC, and to assess differences between trauma and non-trauma patients.
Characteristics of Prehospital Death in Trauma Victims
Jan Gewiess, Christoph Emanuel Albers, Hans-Christoph Pape, Hannes Bangerter, Wolf-Dieter Zech, Marius Johann Baptist Keel, Johannes Dominik Bastian
J Clin Med. 2021 Oct 18;10(20):4765
Background: Using Injury Severity Score (ISS) data, this study aimed to give an overview of trauma mechanisms, causes of death, injury patterns, and potential survivability in prehospital trauma victims.
Methods: Age, gender, trauma mechanism, cause of death, and ISS data were recorded regarding forensic autopsies and whole-body postmortem CT. Characteristics were analyzed for injuries considered potentially survivable at cutoffs of (I) ISS ≤ 75 vs. ISS = 75, (II) ISS ≤ 49 vs. ISS ≥ 50, and (III) ISS < lethal dose 50% (LD50) vs. ISS > LD50 according to Bull's probit model.
Results: In n = 130 prehospital trauma victims (45.3 ± 19.5 years), median ISS was 66. Severity of injuries to the head/neck and chest was greater compared to other regions (p < 0.001). 52% died from central nervous system (CNS) injury. Increasing injury severity in head/neck region was associated with CNS-injury related death (odds ratio (OR) 2.7, confidence interval (CI) 1.8-4.4). Potentially survivable trauma was identified in (I) 56%, (II) 22%, and (III) 9%. Victims with ISS ≤ 75, ISS ≤ 49, and ISS < LD50 had lower injury severity across most ISS body regions compared to their respective counterparts (p < 0.05).
Conclusion: In prehospital trauma victims, injury severity is high. Lethal injuries predominate in the head/neck and chest regions and are associated with CNS-related death. The appreciable amount (9-56%) of victims dying at presumably survivable injury severity encourages perpetual efforts for improvement in the rescue of highly traumatized patients.
Preventable death in trauma: A systematic review on definition and classification
N A G Hakkenbrak, S Y Mikdad, W P Zuidema, J A Halm, L J Schoonmade, U J L Reijnders, F W Bloemers, G F Giannakopoulos
Injury. 2021 Oct;52(10):2768-2777
Abstract
Purpose: Trauma-related preventable death (TRPD) has been used to assess the management and quality of trauma care worldwide. However, due to differences in terminology and application, the definition of TRPD lacks validity. The aim of this systematic review is to present an overview of current literature and establish a designated definition of TRPD to improve the assessment of quality of trauma care.
Methods: A search was conducted in PubMed, Embase, the Cochrane Library and the Web of Science Core Collection. Including studies regarding TRPD, published between January 1, 1990, and April 6, 2021. Studies were assessed on the use of a definition of TRPD, injury severity scoring tool and panel review.
Results: In total, 3,614 articles were identified, 68 were selected for analysis. The definition of TRPD was divided in four categories: I. Clinical definition based on panel review or expert opinion (TRPD, trauma-related potentially preventable death, trauma-related non-preventable death), II. An algorithm (injury severity score (ISS), trauma and injury severity score (TRISS), probability of survival (Ps)), III. Clinical definition completed with an algorithm, IV. Other. Almost 85% of the articles used a clinical definition in some extend; solely clinical up to an additional algorithm. A total of 27 studies used injury severity scoring tools of which the ISS and TRISS were the most frequently reported algorithms. Over 77% of the panels included trauma surgeons, 90% included other specialist; 61% emergency medicine physicians, 46% forensic pathologists and 43% nurses.
Conclusion: The definition of TRPD is not unambiguous in literature and should be based on a clinical definition completed with a trauma prediction algorithm such as the TRISS. TRPD panels should include a trauma surgeon, anesthesiologist, emergency physician, neurologist, and forensic pathologist.
Prehospital Emergency Cricothyrotomy in Dogs Part 1: Experiences With Commercial Cricothyrotomy Kits
Sureiyan Hardjo, Lee Palmer, Mark David Haworth
Front Vet Sci. 2021 Sep 16;8:705695
Abstract
The surgical cricothyrotomy (CTT) has been recommended for emergency front of neck airway access (eFONA) during a cannot intubate, cannot oxygenate scenario for military working dogs (MWD) and civilian law enforcement working dogs (operational K9s). In prehospital and austere environments, combat medics and emergency medical service providers are expected to administer emergency medical care to working dogs and may only have emergency airway kits designed for humans at their disposal. The objective of this article is to provide a detailed description of the application of such devices in cadaver dogs and highlight potential alterations to manufacturer guidelines required for successful tube placement. The kits evaluated included the Portex® PCK, Melker universal cricothyrotomy kit and H&H® emergency cricothyrotomy kit. A novel technique for awake cricothyrotomy in the dog is also described, which can also be considered for in-hospital use, together with the open surgical method described for the H&H® kit. To the authors' knowledge, this is the first publication documenting and providing instruction on the application of commercial cricothyrotomy kits in dogs.
Preventable death in trauma: A systematic review on definition and classification
N A G Hakkenbrak, S Y Mikdad, W P Zuidema, J A Halm, L J Schoonmade, U J L Reijnders, F W Bloemers, G F Giannakopoulos
Injury. 2021 Oct;52(10):2768-2777
Purpose: Trauma-related preventable death (TRPD) has been used to assess the management and quality of trauma care worldwide. However, due to differences in terminology and application, the definition of TRPD lacks validity. The aim of this systematic review is to present an overview of current literature and establish a designated definition of TRPD to improve the assessment of quality of trauma care.
Methods: A search was conducted in PubMed, Embase, the Cochrane Library and the Web of Science Core Collection. Including studies regarding TRPD, published between January 1, 1990, and April 6, 2021. Studies were assessed on the use of a definition of TRPD, injury severity scoring tool and panel review.
Results: In total, 3,614 articles were identified, 68 were selected for analysis. The definition of TRPD was divided in four categories: I. Clinical definition based on panel review or expert opinion (TRPD, trauma-related potentially preventable death, trauma-related non-preventable death), II. An algorithm (injury severity score (ISS), trauma and injury severity score (TRISS), probability of survival (Ps)), III. Clinical definition completed with an algorithm, IV. Other. Almost 85% of the articles used a clinical definition in some extend; solely clinical up to an additional algorithm. A total of 27 studies used injury severity scoring tools of which the ISS and TRISS were the most frequently reported algorithms. Over 77% of the panels included trauma surgeons, 90% included other specialist; 61% emergency medicine physicians, 46% forensic pathologists and 43% nurses.
Conclusion: The definition of TRPD is not unambiguous in literature and should be based on a clinical definition completed with a trauma prediction algorithm such as the TRISS. TRPD panels should include a trauma surgeon, anesthesiologist, emergency physician, neurologist, and forensic pathologist.
A Novel Approach to Emergency Airway Simulation Using a 3D-printed Cricothyrotomy Task Trainer
Jeffrey Huang, Lauren K Licatino, Santiago Ocariz, Paul A Warner, Charles R Sims 3rd
J Educ Perioper Med. 2021 Jul 1;23(3):E670
Abstract
Background: Cricothyrotomy is a final recourse for salvaging a difficult airway, yet most anesthesiology providers have little training, exposure, or comfort with the procedure. Pig tracheas are frequently used for training, but are single use and require special handling and storage. Other simulation models, such as mannequins and cadavers, are costly. Advances in 3dimensional (3D) printing have improved accessibility and decreased costs. This research project sought to determine whether an inexpensive 3D-printed task trainer was noninferior to pig tracheas for teaching surgical cricothyrotomy skills.
Methods: Anesthesiology residents were enrolled in an institutional review board-exempted, unblinded, randomized, controlled, single-institution, noninferiority trial. Participants were trained in the scalpel-finger-bougie technique for surgical cricothyrotomy. Participants were randomized to practice 5 repetitions on either a pig trachea or the 3D model and were assessed on time to cricothyrotomy completion on a pig trachea before and after practice.
Results: Demographic characteristics of the 25 workshop attendees were similar between study arms. Overall mean (SD) improvement in speed was 9 (12) seconds (P = .001). Postpractice times were similar between groups (analysis of covariance estimated difference of -0.1 seconds [95% confidence interval, -9.4 to 9.2]; P = .55). The 3D model was noninferior to the pig trachea at the prespecified noninferiority margin of 10 seconds (P = .017).
Conclusions: The 3D model was noninferior to pig tracheas for improving the time to completion of a surgical cricothyrotomy. A 3D-printed model offers a viable alternative to pig tracheas for emergency airway simulation that is inexpensive, reusable, and readily modified to simulate challenging airway anatomy.
A Novel Approach to Emergency Airway Simulation Using a 3D-printed Cricothyrotomy Task Trainer
Jeffrey Huang, Lauren K Licatino, Santiago Ocariz, Paul A Warner, Charles R Sims 3rd
J Educ Perioper Med. 2021 Jul 1;23(3):E670
Background: Cricothyrotomy is a final recourse for salvaging a difficult airway, yet most anesthesiology providers have little training, exposure, or comfort with the procedure. Pig tracheas are frequently used for training, but are single use and require special handling and storage. Other simulation models, such as mannequins and cadavers, are costly. Advances in 3dimensional (3D) printing have improved accessibility and decreased costs. This research project sought to determine whether an inexpensive 3D-printed task trainer was noninferior to pig tracheas for teaching surgical cricothyrotomy skills.
Methods: Anesthesiology residents were enrolled in an institutional review board-exempted, unblinded, randomized, controlled, single-institution, noninferiority trial. Participants were trained in the scalpel-finger-bougie technique for surgical cricothyrotomy. Participants were randomized to practice 5 repetitions on either a pig trachea or the 3D model and were assessed on time to cricothyrotomy completion on a pig trachea before and after practice.
Results: Demographic characteristics of the 25 workshop attendees were similar between study arms. Overall mean (SD) improvement in speed was 9 (12) seconds (P = .001). Postpractice times were similar between groups (analysis of covariance estimated difference of -0.1 seconds [95% confidence interval, -9.4 to 9.2]; P = .55). The 3D model was noninferior to the pig trachea at the prespecified noninferiority margin of 10 seconds (P = .017).
Conclusions: The 3D model was noninferior to pig tracheas for improving the time to completion of a surgical cricothyrotomy. A 3D-printed model offers a viable alternative to pig tracheas for emergency airway simulation that is inexpensive, reusable, and readily modified to simulate challenging airway anatomy.
Sophie Hugger, Robert Greif, Nils Corson, Sabine Nabecker
Eur J Anaesthesiol. 2021 Nov 1;38(11):1204-1207
No abstract available
Nabil Issa, Whitney E Liddy, Sandeep Samant, David B Conley, Robert C Kern, Eric S Hungness, Elaine R Cohen, Jeffrey H Barsuk
BMJ Open. 2021 Nov 19;11(11):e054746
Abstract
Objectives: To develop and evaluate a simulation-based mastery learning (SBML) curriculum for cricothyrotomy using wet towels to suppress aerosolisation during a pandemic.
Design: Quasi-experimental, pre-post study.
Setting: Tertiary care, academic medical centre in Chicago.
Participants: Ear, nose and throat and general surgery residents, fellows and attendings.
Intervention: Cricothyroidotomy simulation-based mastery learning curriculum.
Outcomes measure: Pretest to posttest simulated cricothyrotomy skills checklist performance.
Results: 37 of 41 eligible surgeons participated in the curriculum. Median pretest score was 72.5 (IQR 55.0-80.0) and 100.0 (IQR 98.8-100.0) for the posttest p<0.001. All participants scored at or above a minimum passing standard (93% checklist items correct) at posttest.
Conclusions: Using SBML is effective to quickly train clinicians to competently perform simulated cricothyrotomy during a pandemic.
Lessons Learned From a Traumatic Brain Injury Mass Casualty Incident
Brendan Killian, Roman Clark, Collin Hu
J Spec Oper Med. Fall 2021;21(3):123-125.
Abstract
In January 2020, an American base was attacked by the largest theater ballistic missile strike in history. This case report covers the resulting mass casualty (MASCAL) incident. In this case, we defined this incident as a MASCAL due to a lack of medical personnel available to properly and timely evaluate the patients. There was no loss of life during the attack but there were > 80 traumatic brain injuries (TBIs). This article focuses on lessons learned from diagnosing and treating Soldiers during a TBI MASCAL event.
Sharon Y Kim, Chester C Buckenmaier, Edmund G Howe, Kwang H Choi
Mil Med. 2021 Sep 29; Online ahead of print.
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.
Myeong-Sik Kim, Heejun Shin, Giwoon Kim, Jae Hyuk Kim, Sori Kang, Tai Been Kang, Jeong Gyun Kim
Cureus. 2021 Sep 14;13(9):e17980.
Abstract
Background With the occurrence of a number of major disasters around the world, there is growing interest in chemical disaster medicine. In South Korea, there is a training program for mass casualty incidents (MCI) and backup by legal regulations by the Framework Act on the Management of Disasters and Safety. However, there is no program focusing on chemical disasters. Thus, the authors newly created a program, the Chemical-Mass Casualty Incident Response Education Module (C-MCIREM) in September 2019. This was a pilot study to verify the educational effect of the program. Method A pre/post study was conducted of a chemical MCI training program based on simulation. A total of 25 representative and qualified participants were recruited from fire departments, administrative staff of public health centers, and healthcare workers of hospitals in the Gyeonggi-do province of South Korea. They participated in a one-day training program. A knowledge test and confidence survey were provided to participants just before training, and again immediately following the training online. The authors compared improvements of pre/post-test results. In the tabletop drill exercise, quantified qualitative analyses were used to measure the educational effect on the participants. Results In the knowledge test, the mean (standard deviation) scores for all 25 participants at baseline and after training were 41.72 (15.186) and 77.96 (11.227), respectively (p < 0.001). In the confidence survey for chemical MCI response for all 25 participants, all the sub-items concerning personal protective equipment selection, antidote selection, antidote stockpiling and passing on knowledge to colleagues, zone setup and decontamination, and chemical triage were improved compared to the baseline score (p < 0.001). The tabletop exercise represented a prehospital setting and had 11 participants. The self-efficacy qualitative survey showed pre- and post-exercise scores of 64/100 and 84/100 respectively. For a hospital setting exercise, it had 14 participants. The survey showed pre/post-exercise scores of 26/100 and 73/100 respectively. Twenty-two (88%) participants responded to the final satisfaction survey, and their overall mean scores regarding willingness to recommend this training program to others, overall satisfaction with theoretical education, overall satisfaction with tabletop drill simulation, and opinion about whether policymakers need this training were all over 8 out of 10 respectively. Conclusion C-MCIREM, the newly created chemical MCI program, provided effective education to the selected 25 participants among Korean chemical MCI responders in terms of both knowledge and practice at a single pilot trial. Participants were highly satisfied with the educational material and their confidence in disaster preparedness was clearly improved. In order to prove the universal educational effect of this C-MCIREM in the future, more education is needed.
Cutaneous Cold Weather Injuries in the US Military
Robert A Kowtoniuk, Yinzhen E Liu, Jonathan P Jeter
Cutis. 2021 Oct;108(4):181-184
Abstract
Service members of the US Military are at risk for cutaneous cold weather injuries due to the demands of military training, combat operations, and peacekeeping missions. In this article, we review common cutaneous cold weather injuries likely to be encountered in the military, including frostbite, immersion foot, pernio, Raynaud phenomenon (RP), and cold urticaria. We aim to bring awareness to these specific injuries to improve diagnostic and treatment outcomes, both in service members and civilians.
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):12861
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.
Joseph J Lee, Andrew B Hall, Matthew J Carr, Austin G MacDonald, Theodore D Edson, Matthew D Tadlock
J Trauma Acute Care Surg. 2022 Apr 1;92(4):e57-e76
No abstract available
A simple improvised prehospital method to warm intravenous fluid
John W Lyng, Michael C Perlmutter, Michaela A West
J Am Coll Emerg Physicians Open. 2021 Oct 4;2(5):e12536
Study objective: Use of warmed intravenous fluid by emergency medical services (EMS) for prehospital injured patients is recommended to avoid iatrogenic hypothermia. We hypothesized that an improvised heating method would significantly increase the temperature of an intravenous fluid bag in a simulated prehospital environment.
Methods: The change from baseline in the temperature of a 1-L intravenous fluid bag positioned above the vehicle windshield defroster vent was measured for 30 minutes using a thermocouple probe. Temperature changes were compared with a control fluid bag positioned on the vehicle console armrest. A total of 10 independent experiments were performed.
Results: The defroster vent method increased intravenous fluid bag temperature from a mean starting temperature of 19.4°C (95% confidence interval [CI], 17.4°C-21.4°C) to a mean end temperature of 32.6°C (95% CI, 30.6°C-34.6°C) after 30 minutes. The temperature of a control intravenous fluid bag (mean starting temperature of 20.1°C; 95% CI, 19.0°C-21.2°C) exposed to a warmed (mean 33.2°C) passenger compartment changed little during the same time period (mean end temperature of 22.3°C; 95% CI, 19.4°C-25.2°C).
Conclusions: Convective warming of an intravenous fluid bag using the dashboard defroster vent significantly raised the fluid temperature. Such a method should be readily available to EMS or first responders.
Joseph K Maddry, Alejandra G Mora, Crystal A Perez, Allyson A Arana, Kimberly L Medellin, Joni A Paciocco, Patrick C Ng, William T Davis, John C Hunninghake, Vikhyat S Bebarta
Mil Med. 2021 Dec 4; Online ahead of print.
Background: Critical Care Air Transport Teams (CCATTs) play a vital role in the transport and care of critically ill and injured patients in the combat theater to include mechanically ventilated patients. Previous research has demonstrated improved morbidity and mortality when lung protective ventilation strategies are used. Our previous study of CCATT trauma patients demonstrated frequent non-adherence to the Acute Respiratory Distress Syndrome Network (ARDSNet) protocol and a corresponding association with increased mortality. The goals of our study were to examine CCATT adherence with ARDSNet guidelines in non-trauma patients, compare the findings to our previous publication of CCATT trauma patients, and evaluate adherence before and after the publication of the CCATT Ventilator Management Clinical Practice Guideline (CPG).
Methods: We performed a retrospective chart review of ventilated non-trauma patients who were evacuated out of theater by Critical Care Air Transport Teams (CCATT) between January 2007 and April 2015. Data abstractors collected flight information, oxygenation status, ventilator settings, procedures, and in-flight assessments. We calculated descriptive statistics to determine the frequency of compliance with the ARDSNet protocol before and after the CCATT Ventilator CPG publication and the association between ARDSNet protocol adherence and in-flight events.
Results: We reviewed the charts of 124 mechanically ventilated patients transported out of theater via CCATT on volume control settings. Seventy percent (n = 87/124) of records were determined to be Non-Adherent to ARDSNet recommendations predominately due to excessive tidal volume settings and/or high FiO2 settings relative to the patient's positive end-expiratory pressure setting. The Non-Adherent group had a higher proportion of in-flight respiratory events. Compared to our previous study of ventilation guideline adherence in the trauma population, the Non-Trauma population had a higher rate of non-adherence to tidal volume and ARDSNet table recommendations (75.6% vs. 61.5%). After the CPG was rolled out, adherence improved from 24% to 41% (P = 0.0496).
Conclusions: CCATTs had low adherence with the ARDSNet guidelines in non-trauma patients transported out of the combat theater, but implementation of a Ventilator Management CPG was associated with improved adherence.
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.
Yaar Betelman Mahalo, Guy Avital, Irina Radomislensky, Moshe Vysokovsky, Rotem Avital-Cohen, Shaul Gelikas, Avishai M Tsur, Roy Nadler, Moran Bodas, Jacob Chen, Elon Glassberg, Avi Benov, Israel Trauma Group
J Trauma Acute Care Surg. 2021 Aug 1;91(2S Suppl 2):S201-S205
Background: Lifesaving interventions (LSIs) are the hallmark of medical care in trauma casualties, reducing mortality and morbidity. Analgesia is another essential treatment, which has been shown to improve outcomes and decrease long-term complications. However, oligoanalgesia is common, and information regarding its relation to the performance of LSIs is scarce. The purpose of this study was to assess the relation between the performance of LSIs and analgesia administration in the prehospital environment.
Methods: A retrospective database-based study was performed, including all trauma casualties treated by Israeli Defense Forces physicians and paramedics during 2006 to 2017 and admitted to hospitals participating in the Israeli National Trauma Registry. Included LSIs were tourniquet application, administration of tranexamic acid and freeze-dried plasma, and administration of chest decompression. Casualties treated with endotracheal intubation or cricothyroidotomy were excluded.
Results: In the multivariable logistic regression analysis, LSIs were associated with prehospital analgesia administration (odds ratio [OR], 3.59; confidence interval [CI], 2.56-5.08; p < 0.001). When assessing for the different LSIs, tourniquet application (OR, 2.83; CI, 1.89-4.27; p < 0.001) and tranexamic acid administration (OR, 4.307; CI, 2.42-8.04; p < 0.001) were associated with prehospital analgesia administration.
Conclusion: A positive association exists between performance of LSIs and administration of analgesia in the prehospital environment. Possible explanations may include cognitive and emotional biases affecting casualty care providers.
Cleared for takeoff: The effects of hypobaric conditions on traumatic pneumothoraces
Sarah Majercik, Thomas W White, Don H Van Boerum, Steven Granger, Joseph Bledsoe, Karen Conner, Emily Wilson, Lindell K Weaver
J Trauma Acute Care Surg. 2014 Nov;77(5):729-733
Background: Current guidelines suggest that traumatic pneumothorax (tPTX) is a contraindication to commercial airline travel, and patients should wait at least 2 weeks after radiographic resolution of tPTX to fly. This recommendation is not based on prospective, physiologic study. We hypothesized that despite having a radiographic increase in pneumothorax size while at simulated altitude, patients with a recently treated tPTX would not exhibit any adverse physiologic changes and would not report any symptoms of cardiorespiratory compromise.
Methods: This is a prospective, observational study of 20 patients (10 in Phase 1, 10 in Phase 2) with tPTX that has been treated by chest tube (CT) or high flow oxygen therapy. CT must have been removed within 48 hours of entering the study. Subjects were exposed to 2 hours of hypobaria (554 mm Hg in Phase 1, 471 mm Hg in Phase 2) in a chamber in Salt Lake City, Utah. Vital signs and subjective symptoms were recorded during the "flight." After 2 hours, while still at simulated altitude, a portable chest radiograph (CXR) was obtained. tPTX sizes on preflight, inflight, and postflight CXR were compared.
Results: Sixteen subjects (80%) were male. Mean (SD) age and ISS were 49 (5) years and 10.5 (4.6), respectively. Fourteen (70%) had a CT to treat tPTX, which had been removed 19 hours (range, 4-43 hours) before the study. No subject complained of any cardiorespiratory symptoms while at altitude. Radiographic increase in tPTX size at altitude was 5.6 (0.61) mm from preflight CXR. No subject developed a tension tPTX. No subject required procedural intervention during the flight. Four hours after the study, all tPTX had returned to baseline size.
Conclusion: Patients with recently treated tPTX have a small increase in the size of tPTX when subjected to simulated altitude. This is clinically well tolerated. Current prohibitions regarding air travel following traumatic tPTX should be reconsidered and further studied.
Conan L McCaul, Edward Bick, Richard Vanner
Br J Anaesth. 2021 Dec;127(6):e191-e192
No abstract available
Back to the Future: Whole Blood Resuscitation of the Severely Injured Trauma Patient
Christopher Cameron McCoy, Megan Brenner, Juan Duchesne, Derek Roberts, Paula Ferrada, Tal Horer, David Kauvar, Mansoor Khan, Andrew Kirkpatrick, Carlos Ordonez, Bruno Perreira, Artai Priouzram, Bryan A Cotton
Shock. 2021 Dec 1;56(1S):9-15
Abstract
Following advances in blood typing and storage, whole blood transfusion became available for the treatment of casualties during World War I. While substantially utilized during World War II and the Korean War, whole blood transfusion declined during the Vietnam War as civilian centers transitioned to blood component therapies. Little evidence supported this shift, and recent conflicts in Iraq and Afghanistan have renewed interest in military and civilian applications of whole blood transfusion. Within the past two decades, civilian trauma centers have begun to study transfusion protocols based upon cold-stored, low anti-A/B titer type O whole blood for the treatment of severely injured civilian trauma patients. Early data suggests equivalent or improved resuscitation and hemostatic markers with whole blood transfusion when compared to balanced blood component therapy. Additional studies are taking place to define the optimal way to utilize low-titer type O whole blood in both prehospital and trauma center resuscitation of bleeding patients.
Is It Time to Abandon Routine Mask Ventilation Before Intubation?
Kevin J Min, Anna L Rabinowitz, Cary J Hess
Anesth Analg. 2021 Nov 1;133(5):1353-1357
No abstract available
Eran Beit Ner, Avishai M Tsur, Roy Nadler, Elon Glassberg, Avi Benov, Jacob Chen
Prehosp Disaster Med. 2021 Dec;36(6):713-718
Introduction: Securing the airway is a crucial stage of trauma care. Cricothyroidotomy (CRIC) is often addressed as a salvage procedure in complicated cases or following a failed endotracheal intubation (ETI). Nevertheless, it is a very important skill in prehospital settings, such as on the battlefield.
Hypothesis/problem: This study aimed to review the Israel Defense Forces (IDF) experience with CRIC over the past two decades.
Methods: The IDF Trauma Registry (IDF-TR) holds data on all trauma casualties (civilian and military) cared for by military medical teams since 1997. Data of all casualties treated by IDF from 1998 through 2018 were extracted and analyzed to identify all patients who underwent CRIC procedures.Variables describing the incident scenario, patient's characteristics, injury pattern, treatment, and outcome were extracted. The success rate of the procedure was described, and selected variables were further analyzed and compared using the Fisher's-exact test to identify their effect on the success and failure rates. Odds Ratio (OR) was further calculated for the effect of different body part involvement on success and for the mortality after failed ETI.
Results: One hundred fifty-three casualties on which a CRIC attempt was made were identified from the IDF-TR records. The overall success rate of CRIC was reported at 88%. In patients who underwent one or two attempts, the success rate was 86%. No difference was found across providers (physician versus paramedic). The CRIC success rates for casualties with and without head trauma were 80% and 92%, respectively (P = .06). Overall mortality was 33%.
Conclusions: This study shows that CRIC is of merit in airway management as it has shown to have consistently high success rates throughout different levels of training, injuries, and previous attempts with ETI. Care providers should be encouraged to retain and develop this skill as part of their tool box.
Roland Paquette, Meredith Quinene, Lorne H Blackbourne, Paul B Allen
J Spec Oper Med. Fall 2021;21(3):78-85.
Background: Penetrating thoracic injuries account for an essential subset of battlefield and civilian injuries that result in death. Current recommendations are to use commercially available nonocclusive chest seals. We review current evidence for which chest seal(s) is likely to be the most effective in treating open pneumothoraces.
Methods: A systematic review was conducted in accordance with the PRIMSA 2009 standard systematic review methodology, except where noted. The databases Pubmed, MEDLINE, CINAHL, Scopus, and gray sources were searched for all English-language, full-manuscript, experimental, quantitative studies of humans and animals concerning seal adherence or their efficacy at preventing tension pneumothoraces published between 1990 and 2020. A numerical analysis was used to provide the consensus recommendation.
Results: Of 683 eligible identified articles [PubMed 528 (77.3%), Scopus 87 (12.7%), CINAHL 67 (9.8%), one (0.1%) unpublished], six (0.9%) articles were included. Synthesis of all studies' results suggests a consensus recommendation for the Hyfin Vent Chest Seal and Russell Chest Seal. These two were the most effective chest seals, as previously investigated in a quantifiable, experimental study.
Conclusion: While chest seals are recommended in civilian and military prehospital medicine to improve patient survival, current evidence concerning the individual device's efficacy is limited. Further scientific, quantitative research is needed to clarify which commercially available chest seals are most effective and provide patients with penetrating chest trauma the best possible method for preventing or mitigating tension pneumothoraces.
Jason D Pasley, William A Teeter, William B Gamble, Philip Wasick, Anna N Romagnoli, Amelia M Pasley, Thomas M Scalea, Megan L Brenner
J Spec Oper Med. Spring 2018;18(1):33-36
Background: The management of noncompressible torso hemorrhage remains a significant issue at the point of injury. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used in the hospital to control bleeding and bridge patients to definitive surgery. Smaller delivery systems and wirefree devices may be used more easily at the point of injury by nonphysician providers. We investigated whether independent duty military medical technicians (IDMTs) could learn and perform REBOA correctly and rapidly as assessed by simulation.
Methods: US Air Force IDMTs without prior endovascular experience were included. All participants received didactic instruction and evaluation of technical skills. Procedural times and pretest/posttest examinations were administered after completion of all trials. The Likert scale was used to subjectively assess confidence before and after instruction.
Results: Eleven IDMTs were enrolled. There was a significant decrease in procedural times from trials 1 to 6. Overall procedural time (± standard deviation) decreased from 147.7 ± 27.4 seconds to 64 ± 8.9 seconds (ρ < .001). There was a mean improvement of 83.7 ± 24.6 seconds from the first to sixth trial (ρ < .001). All participants demonstrated correct placement of the sheath, measurement and placement of the catheter, and inflation of the balloon throughout all trials (100%). There was significant improvement in comprehension and knowledge between the pretest and posttest; average performance improved significantly from 36.4.6% ± 12.3% to 71.1% ± 8.5% (ρ < .001). Subjectively, all 11 participants noted significant improvement in confidence from 1.2 to 4.1 out of 5 on the Likert scale (ρ < .001).
Conclusion: Technology for aortic occlusion has advanced to provide smaller, wirefree devices, making field deployment more feasible. IDMTs can learn the steps required for REBOA and perform the procedure accurately and rapidly, as assessed by simulation. Arterial access is a challenge in the ability to perform REBOA and should be a focus of further training to promote this procedure closer to the point of injury.
Ketamine Should be the Preferred Agent for Rapid Sequence Intubation
Gary D Peksa, Michael Gottlieb
Ann Emerg Med. 2021 Dec;78(6):722-723
No abstract available
Needle Decompression of Tension Pneumoperitoneum: A Case Report
Joseph Ray, Nadin Exantus
Clin Pract Cases Emerg Med. 2021 Nov;5(4):511-514
Introduction: Tension pneumoperitoneum is rarely encountered in the emergency department but can have disastrous effects on the body when it is. However, an emergency physician has skills that can be readily applied to needle decompress the abdomen for rapid stabilization.
Case report: A 42-year-old male arrived via ambulance after a likely overdose with mental status improvement following naloxone administration. He was found to be in respiratory distress due to a rigid, distended abdomen that required intubation for stabilization. Computed tomography imaging showed significant pneumoperitoneum with tension physiology. Surgery consultation was unable to intervene immediately, and needle decompression with an angiocatheter was performed at the bedside with immediate ventilatory improvement.
Conclusion: Tension pneumoperitoneum is a rare but potentially disastrous consequence of overdose secondary to emesis and rupture of the gastric wall. Needle decompression is a skillset already in the emergency physician's toolbox and can be applied for emergency stabilization of a tension pneumoperitoneum with proper forethought and technique.
Providing whole blood for an urban paramedical ambulance system
Michael R Sayre, Betty Y Yang, David L Murphy, Catherine R Counts, Maika Dang, Peter Ubaldi, Erin E Tuott, John R Hess
Transfusion. 2022 Jan;62(1):82-86
Introduction: Hemorrhage is the second leading cause of death among urban trauma patients, and the provision of prehospital blood-based resuscitation can be lifesaving. We developed an efficient system to support blood-based resuscitation by an urban advanced life support ambulance system.
Methods: We worked with our state health department for permission for fire department paramedics to initiate blood transfusion and built protocols for field whole blood resuscitation. Our regional trauma center transfusion service provided 2 units of O positive, low-titer, leukoreduced whole blood in an internally monitored and sealed ice box weighing 10 pounds to the fire department paramedic supervisor. When notified, the supervisor transported the blood to the sites of anticipated need. Total blood use and wastage were recorded.
Results: Following two public hearings, we obtained state-wide approval for the initiation of emergency uncrossmatched blood transfusion by paramedics. Over a 1-year period beginning August 27, 2019, 160 units of whole blood were made available for use, and 51 units were transfused to 39 patients, 30 of whom were trauma patients. Other recipients include patients in shock from massive gastrointestinal, peripartum, or other suspected bleeding. Unused units were returned to the providing transfusion service after 1 week and used for hospital patient care without loss. The estimated cost of providing blood per mission was $0.28 and per patient transfused was $1138.
Conclusions: With appropriate attention to detail, it is possible to provide whole blood to an urban paramedical ambulance system with efficient blood component usage, minimal blood wastage, and low cost.
Rescue Blanket as a Provisional Seal for Penetrating Chest Wounds in a New Ex Vivo Porcine Model
Thomas Schachner, Markus Isser, Matthias Haselbacher, Philipp Schröcker, Manuel Winkler, Florian Augustin, Wolfgang Lederer
Ann Thorac Surg. 2021 Aug 8;S0003-4975(21)01379-5
Background: Open pneumothorax after a penetrating thorax trauma is a life-threatening disease with high mortality. An emergency application of a chest seal (CS) allowing the release of trapped air is the optimum initial therapy until surgical chest drainage is available.
Methods: In a newly developed experimental porcine model of open pneumothorax, we tested 3 different materials regarding their applicability for acute treatment of sucking chest wounds in prehospital emergency care, namely a commonly used rescue blanket (RB), plastic foil from a gauze package (packing material), and a commercial CS.
Results: An ex vivo open pneumothorax model using a porcine chest wall and a vacuum-assisted drainage system was successfully established. RB segments sized 70 × 100 mm achieved significantly higher rates of successful sealing than plastic foils from a gauze package sized 100 × 100 mm when the devices were applied to the moistened chest wall and fixed on 3 sides (5/5 [100%] vs 0/5 [0%], respectively; P = .002). Loosely fixed RBs efficiently released injected air (10/10 [100%]) and consequently sealed the wound in all cases (10/10).
Conclusions: RBs, applied wet, are appropriate CSs with good occlusive and adherence properties. Fixation on 2 sides of the dressing is sufficient to allow trapped air to exit while providing appropriate sealing of the chest wound. RBs were superior to plastic foils from a gauze package and were seen to function as a potent makeshift CS when no commercial CS is available.
Studies on the Correct Length of Nasopharyngeal Airways in Adults: A Literature Review
Catharina Scheuermann-Poley, Andre Lieber
J Spec Oper Med. Fall 2021;21(3):45-50
Abstract
The use of a nasopharyngeal airway (NPA) as an adjunct airway device can be critically important in emergency medicine. When placed correctly, the device can prevent upper airway obstruction. The goal of our review was to learn whether there is scientific evidence about the correct length and the insertion depth, and also possible facial landmarks, that can predict the appropriate length of the NPA. There has been no real consensus on how to measure the appropriate tube length for the NPA. Several studies have been able to demonstrate correlations between facial landmarks and body dimensions; however, we did not find any scientific evidence on this matter. The reviewed studies do not indicate evidence to support current recommended guidelines. This could potentially lead to both military and civilian emergency training programs not having the most accurate scientific information for training on anatomic structures and also not having a better overall understanding of intraoral dimensions. Emergency personnel should be taught validated scientific knowledge of NPAs so as to quickly determine the correct tube length and how to use anatomic correlations. This might require further studies on the correlations and perhaps radiographic measurements. A further approach includes adjusting the tube to its correct length according to the sufficient assessment and management of the airway problem.
Implementation and Evaluation of Tactical Combat Casualty Care for Army Aviators
Stephen M Scott, Margaret J Carman, Michael E Zychowicz, Mark L Shapiro, Nicholas A True
Mil Med. 2020 Aug 14;185(7-8):e1271-e1276
Introduction: The importance of developing military strategies to decrease preventable death by mitigating hemorrhage and reducing time between the point of injury and surgical intervention on the battlefield is highlighted in previous studies. Successful implementation of Tactical Combat Casualty Care (TCCC) throughout elements of the USA and allied militaries begins to address this need. However, TCCC implementation is neither even nor complete in the larger, conventional force. Army Aviators are at risk for preventable death as they do not receive prehospital care training and are challenged to render prehospital care in the austere environment of helicopter operations. Army aviators are at risk for preventable death due to the challenges to render prehospital care in the austere environment of helicopter operations. Helicopters often fly at low altitudes, engage in direct action in support of ground troops, operate at a great distance from medical facilities, typically do not have medical personnel onboard, and can have long wait times for medical evacuation services due to the far forward nature of helicopter operations.
Materials and methods: This is a quality improvement pre-post-intervention design study evaluating the implementation of a combat casualty care training program for Army aviators using well-established evidence-based guidelines for providing care to casualties on the battlefield. The evaluation consisted of participants' self-perceived confidence in providing care to a casualty and change in knowledge level in combat casualty care in a pre/post-intervention design. Clinical skills of tourniquet application, nasopharyngeal airway placement, and needle chest decompression were assessed on a pass/fail grading standard.
Results: A total of 18 participants completed the pre- and post-education surveys. A paired t-test showed a statistically significant increase in total composite scores from pre (M = 24.67, SD = 5.06) to post-education self-efficacy (M = 37.94, SD = 2.10), t (17) = -11.29, p < 0.001. A paired t-test revealed a significant increase in exam scores from pre (M = 70.22, SD = 9.43) to post (M = 87.78, SD = 7.19), t (17) = -7.31, p < 0.001. There was no pre-intervention skills assessment, however, all participants (n = 18, 100%) passed the tourniquet application, needle chest compression, and insertion of nasopharyngeal airway.
Conclusion: TCCC for Army Aviators is easily implemented, demonstrates an increase in knowledge and confidence in providing prehospital care, and provides effective scenario-based training of necessary psychomotor skills needed to reduce preventable death on the battlefield. TCCC for Army Aviators effectively takes the TCCC for All Combatants curriculum and modifies it to address the unique considerations in treating wounded aviators and passengers, both in flight and after crashes. This project demonstrates on a small scale how TCCC can be tailored to specific military jobs in order to successfully meet the intent of the upcoming All Service Member TCCC course mandated in DoD 1322.24. Beyond Army aviation, this program is easily modifiable for aviators throughout the military and civilian sector.
Prehospital paramedic pleural decompression: A systematic review
Ms Kelsey Sharrock, Brendan Shannon, Carlos Garcia Gonzalez, Toby St Clair, Biswadev Mitra, Michael Noonan, Prof Mark Fitzgerald, Alexander Olaussen
Injury. 2021 Oct;52(10):2778-2786
Background: Tension pneumothorax (TPT) is a frequent life-threat following thoracic injury. Time-critical decompression of the pleural cavity improves survival. However, whilst paramedics utilise needle thoracostomy (NT) and/or finger thoracostomy (FT) in the prehospital setting, the superiority of one technique over the other remains unknown.
Aim: To determine and compare procedural success, complications and mortality between NT and FT for treatment of a suspected TPT when performed by paramedics.
Methods: We searched four databases (Ovid Medline, PubMed, CINAHL and Embase) from their commencement until 25th August 2020. Studies were included if they analysed patients suffering from a suspected TPT who were treated in the prehospital setting with a NT or FT by paramedics (or local equivalent nonphysicians).
Results: The search yielded 293 articles after duplicates were removed of which 19 were included for final analysis. Seventeen studies were retrospective (8 cohort; 7 case series; 2 case control) and two were prospective cohort studies. Only one study was comparative, and none were randomised controlled trials. Most studies were conducted in the USA (n=13) and the remaining in Australia (n=4), Switzerland (n=1) and Canada (n=1). Mortality ranged from 12.5% to 79% for NT and 64.7% to 92.9% for FT patients. A higher proportion of complications were reported among patients managed with NT (13.7%) compared to FT (4.8%). We extracted three common themes from the papers of what constituted as a successful pleural decompression; vital signs improvement, successful pleural cavity access and absence of TPT at hospital arrival.
Conclusion: Evidence surrounding prehospital pleural decompression of a TPT by paramedics is limited. Available literature suggests that both FT and NT are safe for pleural decompression, however both procedures have associated complications. Additional high-quality evidence and comparative studies investigating the outcomes of interest is necessary to determine if and which procedure is superior in the prehospital setting.
Natalia Stathakarou, Linda Sonesson, Lars Lundberg, Kenneth D Boffard, Andrzej A Kononowicz, Klas Karlgren
Health Informatics J. Oct-Dec 2021;27(4):14604582211052253
Abstract
Surgical training in civilian hospitals may not be sufficient for managing complex trauma in a setting where such care is not commonly practiced. Understanding the challenges that civilian teams face when moving to austere environments can inform the competencies that need to be trained. The aim of this study was to explore the competencies required in austere environments for teams managing complex trauma, and how they can be trained with simulation technologies. Ethnographic field observations were conducted, and field notes were synthesized. The field notes were structured with the elements of Activity Theory to generate the teams' competencies that need to be trained. A literature review was conducted to verify the results and identify examples of relevant simulation modalities. The analysis resulted in a structured list of competencies for civilian teams to manage complex trauma in an austere environment and recommendations which simulation technologies could be used in training of those competencies based on published studies. Our study contributes to understanding the challenges that civilian teams face when operating in an austere environment. A systematized list of competencies with suggested simulation technologies directs future research to improve quality of complex trauma training in civilian and military collaboration.
Rachel Strauss, Isabella Menchetti, Laure Perrier, Erik Blondal, Henry Peng, Wendy Sullivan-Kwantes, Homer Tien 1, Avery Nathens, Andrew Beckett, Jeannie Callum, Luis Teodoro da Luz
Trauma Surg Acute Care Open. 2021 Oct 19;6(1):e000773
Objectives: The Tactical Combat Casualty Care (TCCC) guidelines detail resuscitation practices in prehospital and austere environments. We sought to review the content and quality of the current TCCC and civilian prehospital literature and characterize knowledge gaps to offer recommendations for future research.
Methods: MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials were searched for studies assessing intervention techniques and devices used in civilian and military prehospital settings that could be applied to TCCC guidelines. Screening and data extraction were performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Quality appraisal was conducted using appropriate tools.
Results: Ninety-two percent (n=57) of studies were observational. Most randomized trials had low risk of bias, whereas observational studies had higher risk of bias. Interventions of massive hemorrhage control (n=17) were wound dressings and tourniquets, suggesting effective hemodynamic control. Airway management interventions (n=7) had high success rates with improved outcomes. Interventions of respiratory management (n=12) reported low success with needle decompression. Studies assessing circulation (n=18) had higher quality of evidence and suggested improved outcomes with component hemostatic therapy. Hypothermia prevention interventions (n=2) were generally effective. Other studies identified assessed the use of extended focused assessment with sonography in trauma (n=3) and mixed interventions (n=2).
Conclusions: The evidence was largely non-randomized with heterogeneous populations, interventions, and outcomes, precluding robust conclusions in most subjects addressed in the review. Knowledge gaps identified included the use of blood products and concentrate of clotting factors in the prehospital setting.
The Tight Rope Act: A Multicenter Regional Experience Of Tourniquets In Acute Trauma Resuscitation
Leah C Tatebe, 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.
The Role of Plasma Transfusion in Pre-Hospital Haemostatic Resuscitation
Harriet Tucker, Ross Davenport, Laura Green
Transfus Med Rev. 2021 Oct;35(4):91-95
Abstract
Traumatic haemorrhage remains a major cause of preventable death and early haemostatic resuscitation is now a mainstay of treatment internationally. Recently, 2 randomized control trials (RCTs) - PAMPer (Prehospital Air Medical Plasma) and COMBAT (Control of Major Bleeding After Trauma), evaluating the effect of pre-hospital use of plasma on mortality provided conflicting results, raising important questions on the role of plasma resuscitation in pre-hospital environment. Both PAMPer (n = 501 patients) and COMBAT (n = 144 patients) trials were pragmatic RCTs that evaluated the effect of pre-hospital plasma transfusion (two units) versus standard of care on 28/30 days mortality in trauma patients who presented with clinical signs of haemorrhagic shock (defined as hypotension or tachycardia). The PAMPer trial showed that plasma transfusion reduced 30-day mortality compared with standard of care (23% vs 33%, 95% confidence interval -18.6; -1.0%; P = 0.03), while COMBAT trial showed no difference in 28-day survival. The post-hoc analyses of the 2 trials have suggested that the benefit of pre-hospital plasma transfusion may be greater for patients who are coagulopathic, have blunt injury and have a transport time from the scene of injury to the hospital of >20 minutes. In this review we evaluate strengths and limitations of the two trials and their differences and similarities, which may explain the conflicting results, as well as provide directions for future trials to better define the target population that would most benefit from pre-hospital plasma resuscitation. Further, considering the logistical challenges of carrying any blood components on an aircraft, cost/safety of plasma, and the scarcity of universal blood group donors, there is a need for a health economic evaluation of pre-hospital plasma transfusion in trauma patients, prior to this intervention becoming universal.
Karlijn J P van Wessem, Denise Jochems, Luke P H Leenen
Eur J Trauma Emerg Surg. 2021 Nov 14;1-11
Abstract
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.
Trends in prehospital pain management following the introduction of new clinical practice guidelines
Moshe Vysokovsky, Guy Avital, Yaar Betelman-Mahalo, Shaul Gelikas, Lidar Fridrich, Irina Radomislensky, Avishai M Tsur, Elon Glassberg, Avi Benov
J Trauma Acute Care Surg. 2021 Aug 1;91(2S Suppl 2):S206-S212
Background: Early pain treatment following injury has been shown to improve long-term outcomes, while untreated pain can facilitate higher posttraumatic stress disorder rates and worsen outcomes. Nonetheless, trauma casualties frequently receive inadequate analgesia. In June 2013, a new clinical practice guideline (CPG) regarding pain management was introduced in the Israel Defense Forces (IDF) Medical Corps, recommending oral transmucosal fentanyl citrate (OTFC) and low-dose intravenous (IV)/intramuscular ketamine. The purpose of this study was to examine trends in prehospital pain management in the IDF.
Methods: All cases documented in the IDF trauma registry between 2008 and 2020 were examined. This study compared casualty parameters before and after the introduction of analgesia CPG in 2013. Parameters compared included demographics, injury parameters, treatment modalities, and types of analgesia provided.
Result: Overall, 5,653 casualties were included in our study. During the 6 years before the introduction of the CPG, 289 (26.7%) of 1,084 casualties received an analgesic treatment, compared with 1,578 (34.5%) of 4,569 casualties during the 7 years following (p < 0.001). Since its introduction, OTFC was administered to 41.8% of all casualties who received analgesia and became the most used analgesic drug in 2020 (61.1% of casualties receiving analgesia). The rate of IV morphine significantly decreased after 2013 (22.6-16%, p < 0.001).
Conclusion: Pain management has become more common in trauma patients' prehospital care in the IDF in recent years. There has been a significant increase in analgesia administration, with the increased use of OTFC, along with a significant reduction in the use of IV morphine. These results may be attributed to introducing a pain management CPG and implementing OTFC among medical teams. The perception of OTFC as a safe user-friendly analgesic may have contributed to its use by medical providers, increasing analgesia rates overall.
Tyler Webb, Daniel Lynch, James Lin, Adam Groth, Thuan Ly, Kevin D Martin
Mil Med. 2021 Dec 4; Online ahead of print
Introduction: Splinting is an essential component of treating many lower extremity musculoskeletal injuries; however, little development has been made in splinting technology. The purpose of this study is to evaluate the efficacy of current immobilization equipment for lower extremity fractures by testing a novel one-step spray-on foam splint (Fast Cast) against structural aluminum malleable (SAM) lower extremity musculoskeletal injuries and 6-inch ACE (3M Corp., Minneapolis, MN, USA) bandage splints.
Materials and methods: Six orthopedic surgical residents and two medical students participated in a prospective analysis of austere splinting techniques and equipment that utilized a cadaveric model with a distal third tibia-fibula shaft fracture. Each participant was observed and scored by three fellowship trained attending orthopedic surgeons. All scoring was independent using a 5-point Likert scale based on 10 splinting criteria (50 total points possible), including quality of radiographic reduction, time to completion, safety, and sustain longitudinal traction. The Likert scale is a set of questions that reflects the respondent's degree of agreement or disagreement with a statement. Each of the 10 questions has a range of 1-5. A score of 50 means the splint performed perfectly. The lowest possible score is a 10. The participants utilized standard equipment that included SAM splints and 6-inch ACE wraps (3M Corp., Minneapolis, MN, USA) in their first attempt. A second immobilization attempt was done with a one-step spray-on foam splint (Fast Cast). After each splinting attempt, the reduction was verified with radiographic imaging. Data analysis was performed using standard descriptive statistics, Student's t-tests, and inter-rater reliability was calculated using Cronbach's alpha scores. This project is Institutional Review Board (IRB) exempt.
Results: The one-step spray-on foam splinting technique was superior (P < .05) in all parameters of the Likert scale, yielding a mean overall score of 45.1 points (±3.8), safety 4.7 points, longitudinal traction 4.5 points, and time 136 seconds (±23). The SAM resulted in a mean overall score of 33.8 points (±7.3), safety 2.8 points, longitudinal traction 4.1 points, and time 170 seconds (±52). Radiographic rating was 4.1 points (±0.7) for the SAM splint and 4.5 (±0.6) for Fast Cast. The differences in time to completion and radiograph rating did not reach statistical significance (P = .12 and P = .07, respectively).
Conclusion: A one-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.
Nawaf Yassi, Henry Zhao, Leonid Churilov, Bruce C V Campbell, Teddy Wu, Henry Ma, Andrew Cheung, Timothy Kleinig, Helen Brown, Philip Choi, Jiann-Shing Jeng, Annemarei Ranta, Hao-Kuang Wang, Geoffrey C Cloud, Rohan Grimley, Darshan Shah, Neil Spratt, Der-Yang Cho, Karim Mahawish, Lauren Sanders, John Worthington, Ben Clissold, Atte Meretoja, Vignan Yogendrakumar, Mai Duy Ton, Duc Phuc Dang, Nguyen Thai My Phuong, Huy-Thang Nguyen, Chung Y Hsu, Gagan Sharma, Peter J Mitchell, Bernard Yan, Mark W Parsons, Christopher Levi, Geoffrey A Donnan, Stephen M Davis
Stroke Vasc Neurol. 2021 Nov 30;svn-2021-001070
Rationale: Haematoma growth is common early after intracerebral haemorrhage (ICH), and is a key determinant of outcome. Tranexamic acid, a widely available antifibrinolytic agent with an excellent safety profile, may reduce haematoma growth.
Methods and design: Stopping intracerebral haemorrhage with tranexamic acid for hyperacute onset presentation including mobile stroke units (STOP-MSU) is a phase II double-blind, randomised, placebo-controlled, multicentre, international investigator-led clinical trial, conducted within the estimand statistical framework.
Hypothesis: In patients with spontaneous ICH, treatment with tranexamic acid within 2 hours of onset will reduce haematoma expansion compared with placebo.
Sample size estimates: A sample size of 180 patients (90 in each arm) would be required to detect an absolute difference in the primary outcome of 20% (placebo 39% vs treatment 19%) under a two-tailed significance level of 0.05. An adaptive sample size re-estimation based on the outcomes of 144 patients will allow a possible increase to a prespecified maximum of 326 patients.
Intervention: Participants will receive 1 g intravenous tranexamic acid over 10 min, followed by 1 g intravenous tranexamic acid over 8 hours; or matching placebo.
Primary efficacy measure: The primary efficacy measure is the proportion of patients with haematoma growth by 24±6 hours, defined as either ≥33% relative increase or ≥6 mL absolute increase in haematoma volume between baseline and follow-up CT scan.
Discussion: We describe the rationale and protocol of STOP-MSU, a phase II trial of tranexamic acid in patients with ICH within 2 hours from onset, based in participating mobile stroke units and emergency departments.
THOR-AABB Working Party Recommendations for a Prehospital Blood Product Transfusion Program
Mark H Yazer, Philip C Spinella, Eric A Bank, Jeremy W Cannon, Nancy M Dunbar, John B Holcomb, Bryon P Jackson, Donald Jenkins, Michael Levy, Paul E Pepe, Jason L Sperry, James R Stubbs, Christopher J Winckler
Prehosp Emerg Care. 2021 Nov 19;1-13
Abstract
The evidence for the lifesaving benefits of prehospital transfusions is increasing. As such, emergency medical services (EMS) might increasingly become interested in providing this important intervention. While a few EMS and air medical agencies have been providing exclusively red blood cell (RBC) transfusions to their patients for many years, transfusing plasma in addition to the RBCs, or simply using low titer group O whole blood (LTOWB) in place of two separate components, will be a novel experience for many services. The recommendations presented in this document were created by the Trauma, Hemostasis and Oxygenation Research (THOR)-AABB (formerly known as the American Association of Blood Banks) Working Party, and they are intended to provide a framework for implementing prehospital blood transfusion programs in line with the best available evidence. These recommendations cover all aspects of such a program including storing, transporting, and transfusing blood products in the prehospital phase of hemorrhagic resuscitation.
Hemostatic materials in wound care
Peiyu Yu, Wen Zhong
Burns Trauma. 2021 Sep 15;9:tkab019.
Abstract
Blood plays an essential role in the human body. Hemorrhage is a critical cause of both military and civilian casualties. The human body has its own hemostatic mechanism that involves complex processes and has limited capacity. However, in emergency situations such as battlefields and hospitals, when the hemostatic mechanism of the human body itself cannot stop bleeding effectively, hemostatic materials are needed for saving lives. In this review, the hemostatic mechanisms and performance of the most commonly used hemostatic materials, (including fibrin, collagen, zeolite, gelatin, alginate, chitosan, cellulose and cyanoacrylate) and the commercial wound dressings based on these materials, will be discussed. These materials may have limitations, such as poor tissue adhesion, risk of infection and exothermic reactions, that may lessen their hemostatic efficacy and cause secondary injuries. High-performance hemostatic materials, therefore, have been designed and developed to improve hemostatic efficiency in clinical use. In this review, hemostatic materials with advanced performances, such as antibacterial capacity, superhydrophobicity/superhydrophilicity, superelasticity, high porosity and/or biomimicry, will be introduced. Future prospects of hemostatic materials will also be discussed in this review.
European Resuscitation Council Guidelines 2021: First aid
David A Zideman, Eunice M Singletary, Vere Borra, Pascal Cassan, Carmen D Cimpoesu, Emmy De Buck, Therese Djärv, Anthony J Handley, Barry Klaassen, Daniel Meyran, Emily Oliver, Kurtis Poole
Resuscitation. 2021 Apr;161:270-290
Abstract
The European Resuscitation Council has produced these first aid guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics include the first aid management of emergency medicine and trauma. For medical emergencies the following content is covered: recovery position, optimal positioning for shock, bronchodilator administration for asthma, recognition of stroke, early aspirin for chest pain, second dose of adrenaline for anaphylaxis, management of hypoglycaemia, oral rehydration solutions for treating exertion-related dehydration, management of heat stroke by cooling, supplemental oxygen in acute stroke, and presyncope. For trauma related emergencies the following topics are covered: control of life-threatening bleeding, management of open chest wounds, cervical spine motion restriction and stabilisation, recognition of concussion, cooling of thermal burns, dental avulsion, compression wrap for closed extremity joint injuries, straightening an angulated fracture, and eye injury from chemical exposure.
Advances in Hemostatic Wound Dressings: Clinical Implications and Insight
Roopali Agarwal, Jonathan Niezgoda, Jeffrey Niezgoda, Nethaji Madetipati, Sandeep Gopalakrishnan
Adv Skin Wound Care. 2022 Feb 1;35(2):113-121
Abstract
Hemorrhagic shock is one of the leading causes of prehospital death in the armed forces. In this state, the body begins to shut down because of blood volume depletion. In both civilian and military trauma, a significant number of hemorrhage deaths occur in the first several hours after injury. Researchers all over the globe are working to develop relatively inexpensive and easy-to-transport products to prevent soldiers from going into hemorrhagic shock. For example, many advances have been made during the last several years toward the development of ideal hemostatic dressings. No current hemostatic agents meet all of the requirements, but the ideal dressing would fulfill many important measures: minimizes or stops blood flow within minutes, contains hemostatic agents to enhance blood clotting, is easy to apply, does not need preapplication preparation, has a reasonably long shelf life, is safe to use, prevents bacterial or viral transmission, is stable at extreme temperatures, and is inexpensive. For this literature review, the authors conducted an extensive search of academic scientific databases for relevant keywords and assessed and summarized the results. This review aimed to identify recent advances in hemostatic wound dressings; summarize the currently available dressings and their supporting literature; and discuss the compositions, mechanisms of action, and clinical relevance of each category of dressing. In addition, case studies and suggestions for future research into hemorrhage control with new hemostatic agents are provided.
A prehospital scoring system for predicting the need for emergent blood product transfusion
Guy Avital, Shaul Gelikas, Irina Radomislensky, Avishai M Tsur, Alex Sorkin, Eilat Shinar, Moran Bodas, Mark H Yazer, Andrew P Cap, Jacob Chen, Elon Glassberg, Avi Benov.
Transfusion. 2021 Jul;61 Suppl 1:S195-S205
Background: Several tools have been proven to predict the need for massive transfusion in trauma casualties, yet tools that are easily applicable in the prehospital setting for predicting the need for any blood product transfusion in the emergency department (ED) are lacking.
Methods: A retrospective analysis of the cross-referenced Israeli Defense Forces Trauma Registry and the Israeli National Trauma Registry databases was performed to identify predictors for any blood product transfusion in the ED. A scoring system was developed after internally validating the prediction model. Division to risk groups was performed.
Results: Seven variables (systolic blood pressure, heart rate, arterial oxygen saturation, trunk involvement, mechanism of injury, chest decompression, and tourniquet application) were included in the scoring system, ranging from 0 to 11.5. Risk groups for ED transfusion included very low (0.8%), low (3.2%), intermediate (8.5%), and high (31.2%) risk.
Conclusion: A scoring system for predicting the need for any blood product transfusion in the ED was developed, based on information readily available in the early stages of prehospital resuscitation, allowing the receiving medical facility to prepare for that need.
Mark Bates, Sarah Watts, Heidi Doughty, Tom Woolley, Andrew Miles, Liam Barry, Dominic Jenner, Andrew Sedman, Robert Purcell, Emrys Kirkman
Transfusion. 2021 Jul;61 Suppl 1:S223-S233
Background: Parachute airdrop offers a rapid transfusion supply option for humanitarian aid and military support. However, its impact on longer-term RBC survival is undocumented. This study aimed to determine post-drop quality of RBCs in concentrates (RCC), and both RBCs and plasma in whole blood (WB) during subsequent storage.
Study design and methods: Twenty-two units of leucodepleted RCC in saline, adenine, glucose, mannitol (SAGM) and 22 units of nonclinical issue WB were randomly allocated for air transportation, parachute drop, and subsequent storage (parachute), or simply storage under identical conventional conditions (4 ± 2°C) (control). All blood products were 6-8 days post-donation. Parachute units were packed into Credo Cubes, (Series 4, 16 L) inside a PeliCase (Peli 0350) and rigged as parachute delivery packs. Packs underwent a 4-h tactical flight (C130 aircraft), then parachuted from 250 to 400 ft before ground recovery. The units were sampled aseptically before and after airdrop at weekly intervals. A range of assays quantified the RBC storage lesion and coagulation parameters.
Results: Blood units were maintained at 2-6°C and recovered intact after recorded ground impacts of 341-1038 m s-2 . All units showed a classical RBC storage lesion and increased RBC microparticles during 42 days of storage. Fibrinogen and clotting factors decreased in WB during storage. Nevertheless, no significant difference was observed between Control and Parachute groups. Air transportation and parachute delivery onto land did not adversely affect, or shorten, the shelf life of fresh RBCs or WB.
Discussion: Appropriately packaged aerial delivery by parachute can be successfully used for blood supply.
Submarine medicine: An overview of the unique challenges, medical concerns, and gaps
Luke A Beardslee, Erica T Casper, Ben D Lawson
Undersea Hyperb Med. Third-Quarter 2021;48(3):263-278
Abstract
Submariners face many challenges. For example, they "live where they work" and can be called to duty anytime. They have limited access to open space, natural settings, fresh air, fresh food, sunlight, privacy, exercise, and outside communication. They support a wider range of missions than occur aboard most other Navy vessels. At sea or on shore, submariners work long hours under conditions with little margin for error. They may traverse remote or disputed areas of the ocean far from rescue assets, and must remain vigilant for potential encounters with hostile forces, onboard fires, anomalies in the breathing atmosphere, leaks, undersea collisions, or radiation exposures. If any of these factors cause casualties, the Independent Duty Corpsman (with intermittent advice from shore-based medical personnel), must be ready to provide aid as long as necessary. The challenges of submarine service led to the growth of the unique field of submarine medicine, which has maintained an excellent record of health and safety. This review introduces the field of submarine medicine as practiced in the U.S. Navy, describing its major concerns, giving an overview of the operation of a submarine medical department, and identifying several medical gaps that researchers are working to fill. Submarine medicine already has a stellar record in terms of radiation and atmospheric safety and has made strides in fatigue management. Ongoing work will deliver improved psychological screening and support tools. This report summarizes developments in these and other areas of submarine medicine.
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.
Adam T Biggs, Sarah M Henry, Scott L Johnston, David R Whittaker, Lanny F Littlejohn
J Spec Oper Med. Summer 2021;21(2):43-48
Abstract
Special Operations Forces have made brain health a medical priority in recent years, and new guidance identified a new challenge-unconventionally acquired brain injury (UBI). Although this emerging condition is described as a cluster of neurosensory and cognitive symptoms with unknown etiology/ origin, there remain critical questions about how this diagnosis differs from other brain injuries. More importantly, there are limited recommendations about how medical personnel should approach the problem. The current discussion will provide context and information about UBI based on higher guidance and will also review the scant literature to provide context. Foremost, UBI can be distinguished from traumatic brain injury (TBI) largely due to an unknown point of injury. The described symptoms otherwise appear to be largely the same as TBI. Likewise, the recommended course of treatment is to follow the Clinical Practice Guidelines for mild TBI/TBI even if the injury is an actual or suspected UBI. Personnel must be careful to avoid entering sensitive information into the medical record, which may be particularly challenging if identifying the cause involves classified information about an unconventional weapon. Finally, we briefly discuss the literature about several suspected incidents fitting UBI diagnostic criteria, and we conclude with five primary takeaways for medical personnel to follow.
Novel use of XSTAT 30 for mitigation of lethal non-compressible torso hemorrhage in swine
Alicia M Bonanno, Todd L Graham, Lauren N Wilson, James D Ross
PLoS One. 2020 Nov 18;15(11):e0241906
Background: Management of Non-Compressible Torso Hemorrhage (NCTH) consists primarily of aortic occlusion which has significant adverse outcomes, including ischemia-reperfusion injury, in prolonged field care paradigms. One promising avenue for treatment is through use of RevMedx XSTAT 30™ (an FDA approved sponge-based dressing utilized for extremity wounds). We hypothesized that XSTAT 30™ would effectively mitigate NCTH during a prolonged pre-hospital period with correctable metabolic and physiologic derangements.
Methods and findings: Twenty-four male swine (53±2kg) were anesthetized, underwent line placement, and splenectomy. Animals then underwent laparoscopic transection of 70% of the left lobe of the liver with hemorrhage for a period of 10min. They were randomized into three groups: No intevention (CON), XSTAT 30™-Free Pellets (FP), and XSTAT 30™-Bagged Pellets (BP). Animals were observed for a pre-hospital period of 180min. At 180min, animals underwent damage control surgery (DCS), balanced blood product resuscitation and removal of pellets followed by an ICU period of 5 hours. Postoperative fluoroscopy was performed to identify remaining pellets or bags. Baseline physiologic and injury characteristics were similar. Survival rates were significantly higher in FP and BP (p<0.01) vs CON. DCS was significantly longer in FP in comparison to BP (p = 0.001). Two animals in the FP group had pellets discovered on fluoroscopy following DCS. There was no significant difference in blood product or pressor requirements between groups. End-ICU lactates trended to baseline in both FP and BP groups.
Conclusions: While these results are promising, further study will be required to better understand the role for XSTAT in the management of NCTH.
Brief Research Report: Prehospital Rapid Sequence Airway
Darren Braude, Douglas Dixon, Michael Torres, John P Martinez, Sean O'Brien, Timothy Bajema
Prehosp Emerg Care. Jul-Aug 2021;25(4):583-587
Background: Rapid Sequence Airway (RSA) describes the administration of an induction agent and paralytic followed by the intended primary placement of an extraglottic airway device rather than an endotracheal tube. The purpose of this study was to determine the success rates for prehospital RSA. The secondary goal was to determine aspiration rates among patients managed with RSA.
Methods: Adult and pediatric prehospital RSA cases between 2005 and 2017 reported to an airway quality assurance registry from one ground and one air agency were reviewed. Success was defined as the ability to adequately ventilate patients after extraglottic device placement. Aspiration was defined as radiologic evidence (chest x-ray or CT scan) within 48 hours of hospital presentation.
Results: 68 patients underwent RSA with a King LTS-D (n = 24), LMA-Supreme (n = 28), Combitube (n = 2), LMA-Unique (n = 8) and iGel (n = 6). Age ranged from 1 year to 73 years with 10 patients less than 18. RSA was successful in 64 (94%) cases; 56 (88%) were successful on first pass and 63 (98%) within 2 attempts. The RSA procedure occurred in an aircraft in 14 (21%) of cases and 71% of patients were in cervical precautions. Duration of EGD insertion prior to hospital arrival ranged from 5 to 102 minutes with an average of 34.5 minutes. Aspiration data was available for 46 patients of whom 4 (8.7%) were found to have evidence of aspiration.
Conclusion: Overall and first pass RSA success rates were high and aspiration rates were low in this quality assurance registry despite predictors of airway difficulty. RSA may be a reasonable alternative to RSI for prehospital airway management that merits further research.
Prehospital whole blood reduces early mortality in patients with hemorrhagic shock
Maxwell A Braverman, Alison Smith, Douglas Pokorny, Benjamin Axtman, Charles Patrick Shahan, Lauran Barry, Hannah Corral, Rachelle Babbitt Jonas, Michael Shiels, Randall Schaefer, Eric Epley, Christopher Winckler, Elizabeth Waltman, Brian J Eastridge, Susannah E Nicholson, Ronald M Stewart, Donald H Jenkins
Transfusion. 2021 Jul;61 Suppl 1:S15-S21
Background: Low titer O+ whole blood (LTOWB) is being increasingly used for resuscitation of hemorrhagic shock in military and civilian settings. The objective of this study was to identify the impact of prehospital LTOWB on survival for patients in shock receiving prehospital LTOWB transfusion.
Study design and methods: A single institutional trauma registry was queried for patients undergoing prehospital transfusion between 2015 and 2019. Patients were stratified based on prehospital LTOWB transfusion (PHT) or no prehospital transfusion (NT). Outcomes measured included emergency department (ED), 6-h and hospital mortality, change in shock index (SI), and incidence of massive transfusion. Statistical analyses were performed.
Results: A total of 538 patients met inclusion criteria. Patients undergoing PHT had worse shock physiology (median SI 1.25 vs. 0.95, p < .001) with greater reversal of shock upon arrival (-0.28 vs. -0.002, p < .001). In a propensity-matched group of 214 patients with prehospital shock, 58 patients underwent PHT and 156 did not. Demographics were similar between the groups. Mean improvement in SI between scene and ED was greatest for patients in the PHT group with a lower trauma bay mortality (0% vs. 7%, p = .04). No survival benefit for patients in prehospital cardiac arrest receiving LTOWB was found (p > .05).
Discussion: This study demonstrated that trauma patients who received prehospital LTOWB transfusion had a greater improvement in SI and a reduction in early mortality. Patient with prehospital cardiac arrest did not have an improvement in survival. These findings support LTOWB use in the prehospital setting. Further multi-institutional prospective studies are needed.
Prehospital end-tidal carbon dioxide predicts hemorrhagic shock upon emergency department arrival
Natalie Bulger, Brenna Harrington, Josh Krieger, Andrew Latimer, Saman Arbabi, Catherine R Counts, Michael Sayre, Charles Maynard, Eileen M Bulger
J Trauma Acute Care Surg. 2021 Sep 1;91(3):457-464
Background: In addition to reflecting gas exchange within the lungs, end-tidal carbon dioxide (ETCO2) also reflects cardiac output based on CO2 delivery to the pulmonary parenchyma. We hypothesized that low prehospital ETCO2 values would be predictive of hemorrhagic shock in intubated trauma patients.
Methods: A retrospective observational study of adult trauma patients intubated in the prehospital setting and transported to a single Level I trauma center from 2016 to 2019. Continuous prehospital ETCO2 data were linked with patient care registries. We developed a novel analytic approach that allows for reflection of prehospital ETCO2 over the entire prehospital course of care. The primary outcome was hemorrhagic shock on emergency department (ED) presentation, defined as either initial ED systolic blood pressure of 90 mm Hg or less or initial Shock Index (SI) > 0.9, and transfusion of at least one unit of blood product during their ED stay. Prehospital ETCO2 less than 25 mm Hg was evaluated for predictive value of hemorrhagic shock.
Results: Three hundred and seven patients (82% men, 34% penetrating injury, 42% in hemorrhagic shock on ED arrival, 27% mortality) were included in the study. Patients in hemorrhagic shock had lower median ETCO2 values (26.5 mm Hg vs. 32.5 mm Hg; p < 0.001) than those not in hemorrhagic shock. Patients with prehospital ETCO2 less than 25 mm Hg were 3.0 times (adjusted odds ratio = 3.0; 95% confidence interval, 1.1-7.9) more likely to be in hemorrhagic shock upon ED arrival than patients with ETCO2 ≥ 25 mm Hg.
Conclusion: Intubated patients with hemorrhagic shock upon ED arrival had significantly lower prehospital ETCO2 values. Incorporating ETCO2 assessment into prehospital care for trauma patients could support decisions regarding prehospital blood transfusion, and triage to higher-level trauma centers, and trauma team activation.
Methoxyflurane May Be a Suitable Analgesic for Extreme Prehospital Conditions
Frédéric Bussienne, Thomas Reynaud
Wilderness Environ Med. 2021 Jun;32(2):261-264
No abstract available
Lactate as a mediator of prehospital plasma mortality reduction in hemorrhagic shock
Stephen P Canton, Waseem Lutfi, Brian J Daley, Richard S Miller, Brian G Harbrecht, Jeffrey A Claridge, Herb A Phelan, Francis X Guyette, Jason L Sperry, Joshua B Brown
J Trauma Acute Care Surg. 2021 Jul 1;91(1):186-191
Background: Prehospital plasma transfusion in trauma reduces mortality. However, the underlying mechanism remains unclear. Reduction in shock severity may play a role. Lactate correlates with physiologic shock severity and mortality after injury. Our objective was to determine if prehospital plasma reduces lactate and if this contributes to the mortality benefit of plasma.
Methods: Patients in the Prehospital Air Medical Plasma trial in the upper quartile of injury severity (Injury Severity Score, >30) were included to capture severe shock. Trial patients were randomized to prehospital plasma or standard care resuscitation (crystalloid ± packed red blood cells). Regression determined the associations between admission lactate, 30-day mortality, and plasma while adjusting for demographics, prehospital crystalloid, time, mechanism, and injury characteristics. Causal mediation analysis determined what proportion of the effect of plasma on mortality is mediated by lactate reduction.
Results: A total of 125 patients were included. The plasma group had a lower adjusted admission lactate than standard of care group (coefficient, -1.64; 95% confidence interval [CI], -2.96 to -0.31; p = 0.02). Plasma was associated with lower odds of 30-day mortality (odds ratio [OR], 0.27; 95% CI, 0.08-0.90; p = 0.03). When adding lactate to this model, the effect of plasma on 30-day mortality was no longer significant (OR, 0.36; 95% CI, 0.07-1.88; p = 0.23), while lactate was associated with mortality (OR, 1.74 per 1 mmol/L increase; 95% CI, 1.10-2.73; p = 0.01). Causal mediation demonstrated 35.1% of the total effect of plasma on 30-day mortality was mediated by the reduction in lactate among plasma patients.
Conclusion: Prehospital plasma is associated with reduced 30-day mortality and lactate in severely injured patients. More than one third of the effect of plasma on mortality is mediated by a reduction in lactate. Thus, reducing the severity of hemorrhagic shock appears to be one mechanism of prehospital plasma benefit. Further study should elucidate other mechanisms and if a dose response exists.
J Trauma Acute Care Surg. 2021 Aug 1;91(2S Suppl 2):S26-S32
Synthetic blood and blood products for combat casualty care and beyond
Andrew P Cap, Jeremy W Cannon, Michael C Reade
Abstract
Synthetic biology adopts an engineering design approach to create innovative treatments that are reliable, scalable, and customizable to individual patients. Interest in substitutes for allogenic blood components, primarily red blood cells and platelets, increased in the 1980s because of concerns over infectious disease transmission. However, only now, with emerging synthetic approaches, are such substitutes showing genuine promise. Affordable alternatives to donated blood would be of enormous benefit worldwide. Several approaches to replacing the oxygen-carrying function of red cells are under advanced investigation. Hemoglobin-based oxygen carriers incorporate modifications to reduce the renal toxicity and nitric oxide scavenging of free hemoglobin. While use of earlier-generation hemoglobin-based oxygen carriers may be limited to circumstances in which blood transfusion is not an option, recent advances in chemical modification of hemoglobin may eventually overcome such problems. Another approach encases hemoglobin molecules in biocompatible synthetic nanoparticles. An alternative is the ex vivo production of red cells in bioreactors, with or without genetic manipulation, that offers the potential of a universal donor product. Various strategies to manufacture synthetic platelets are also underway, ranging from simple phospholipid liposomes encapsulating adenosine diphosphate and decorated with fibrinogen fragments, to more complex capsules with multiple receptor peptide sequences. Ex vivo production of platelets in bioreactors is also possible including, for example, platelets derived from induced pluripotent stem cells that are differentiated into a megakaryocytic lineage. Prior to clinical use, trials assessing synthetic blood components must evaluate meaningful safety and effectiveness outcomes in relatively large numbers of critically ill patients. Overcoming these challenges may be as much a hurdle as product design. This article reviews the state of the science of the synthetic biology approach to developing blood component substitutes.
An Analysis of Prehospital Trauma Registry After-Action Reviews in Afghanistan
Brandon M Carius, Peter M Dodge, Andrew D Fisher, Paul E Loos, Dominic Thompson, Steven G Schauer
J Spec Oper Med. Summer 2021;21(2):49-53.
Background: After-action reviews (AARs) in the Prehospital Trauma Registry (PHTR) enable performance improvements and provide commanders feedback on care delivered at Role 1. No published data exist exploring overall trends of end-user performance-improvement feedback.
Methods: We performed an expert panel review of AARs within the PHTR in Afghanistan from January 2013 to September 2014. When possible, we categorized our findings and selected relevant medical provider comments.
Results: Of 737 registered patient encounters found, 592 (80%) had AAR documentation. Most AAR patients were male (98%, n = 578), injured by explosion (48%, n = 283), and categorized for urgent evacuation (64%, n = 377). Nearly two thirds of AARs stated areas needing improvement (64%, n = 376), while the remainder left the improvement section blank (23%, n = 139) or specified no improvements (13%, n = 76). The most frequently cited areas for improvement were medical knowledge (23%, n = 136), evacuation coordination (19%, n = 115), and first responder training (16%, n = 95).
Conclusions: Our expert panel reviewed AARs within the PHTR and found substantial numbers of AARs without improvements recommended, which limits quality improvement capabilities. Our analysis supports previous calls for better documentation of medical care in the prehospital combat setting.
Critical traumatic brain injury is associated with worse coagulopathy
Daniel Cucher, Laura Harmon, Brian Myer, Andrew Ngyuen, Timothy Rankin, Alan Cook, Charles Hu, Ronald Tesoriero, Thomas Scalea, Deborah Stein
J Trauma Acute Care Surg. 2021 Aug 1;91(2):331-335
Objectives: As thromboelastography (TEG) becomes the standard of care in patients with hemorrhagic shock (HS), an association between concomitant traumatic brain injury (TBI) and coagulopathy by TEG parameters is not well understood and is thus investigated.
Methods: Retrospective analysis of trauma registry data at a single level 1 trauma center of 772 patients admitted with head Abbreviated Injury Scale (AIS) score of 3 and TEG studies between 2014 and 2017. Patients were stratified to moderate-severe TBI by head AIS scores of 3 and 4 (435 patients) and critical TBI by head AIS score of 5 (328 patients). Hemorrhagic shock was defined by base deficit of 4 or shock index of 0.9. Statistical analysis with unpaired t tests compared patients with critical TBI with patients with moderate-severe TBI, and patients were grouped by presence or absence of HS. A comparison of TBI data with conventional coagulation studies was also evaluated.
Results: In the setting of HS, critical TBI versus moderate-severe TBI was associated with longer R time (p = 0.004), longer K time (p < 0.05), less acute angle (p = 0.001), and lower clot strength and stability (maximum amplitude [MA]) (p = 0.01). Worse TBI did not correlate with increased fibrinolysis by clot lysis measured by the percentage decrease in amplitude at 30 minutes after MA (p = 0.3). Prothrombin time and international normalized ratio failed to demonstrate more severe coagulopathy, while partial thromboplastin time was found to correlate with severity of TBI (p = 0.01). In patients with critical TBI, the presence of HS correlated with a statistically significant worsening of all parameters (p < 0.05) except for clot lysis measured by the percentage decrease in amplitude at 30 minutes after MA (LY-30).
Conclusion: Thromboelastography demonstrates that, with and without hemorrhagic shock, critical TBI correlates with a significant worsening of traumatic coagulopathy in comparison with moderate/severe TBI. In HS, critical TBI correlates with impaired clot initiation, impaired clot kinetics, and impaired platelet-associated clot strength and stability versus parameters found in moderate-severe TBI. Hemorrhagic shock correlates with worse traumatic coagulopathy in all evaluated patient groups with TBI. Conventional coagulation studies underestimate TBI-associated coagulopathy. Traumatic brain injury-associated coagulopathy is not associated with fibrinolysis.
Cassidy Cunningham, Karen Gross, John P Broach, Laurel O'Connor
Prehosp Disaster Med. 2021 Jun;36(3):276-282
Background: Agitated behaviors are frequently encountered in the prehospital setting and require emergent treatment to prevent harm to patients and prehospital personnel. Chemical sedation with ketamine works faster than traditional pharmacologic agents, though it has a higher incidence of adverse events, including intubation. Outcomes following varying initial doses of prehospital intramuscular (IM) ketamine use have been incompletely described.
Objective: To determine whether using a lower dose IM ketamine protocol for agitation is associated with more favorable outcomes.
Methods: This study was a pre-/post-intervention retrospective chart review of prehospital care reports (PCRs). Adult patients who received chemical sedation in the form of IM ketamine for agitated behaviors were included. Patients were divided into two cohorts based on the standard IM ketamine dose of 4mg/kg and the lower IM dose of 3mg/kg with the option for an additional 1mg/kg if required. Primary outcomes included intubation and hospital admission. Secondary outcomes included emergency department (ED) length of stay, additional chemical or physical restraints, assaults on prehospital or ED employees, and documented adverse events.
Results: The standard dose cohort consisted of 211 patients. The lower dose cohort consisted of 81 patients, 17 of whom received supplemental ketamine administration. Demographics did not significantly differ between the cohorts (mean age 35.14 versus 35.65 years; P = .484; and 67.8% versus 65.4% male; P = .89). Lower dose subjects were administered a lower ketamine dose (mean 3.24mg/kg) compared to the standard dose cohort (mean 3.51mg/kg). There was no statistically significant difference between the cohorts in intubation rate (14.2% versus 18.5%; P = .455), ED length of stay (14.31 versus 14.88 hours; P = .118), need for additional restraint and sedation (P = .787), or admission rate (26.1% versus 25.9%; P = .677). In the lower dose cohort, 41.2% (7/17) of patients who received supplemental ketamine doses were intubated, a higher rate than the patients in this cohort who did not receive supplemental ketamine (8/64, 12.5%; P <.01).
Conclusion: Access to effective, fast-acting chemical sedation is paramount for prehospital providers. No significant outcomes differences existed when a lower dose IM ketamine protocol was implemented for prehospital chemical sedation. Patients who received a second dose of ketamine had a significant increase in intubation rate. A lower dose protocol may be considered for an agitation protocol to limit the amount of medication administered to a population of high-risk patients.
Julie Degueldre, Emilie Dessy, France T'Sas, Véronique Deneys, Nathalie Pattyn
Transfusion. 2021 Jul;61 Suppl 1:S32-S42
Background: The major causes of death of combat casualties in austere environments are related to hemorrhage and occur early after injury. The implementation of a walking blood bank may overcome the logistical issues raised using blood component therapy. Nonetheless, it is important to ensure that this buddy transfusion is not going to compromise the mission success by altering the donor's performance. The results available so far cannot rule out this issue with certainty. Therefore, this study aimed at investigating the immediate effect of a 450-ml blood donation on the performances of elite soldiers in laboratory and field environments.
Study design and methods: This double-blind, randomized controlled study included two experiments. For both experiments, subjects were randomly assigned either to a control group (n1 = n2 = 7) or to a 450-ml-blood-bag donation group (n1 = 7 and n2 = 8). All participants underwent before and after a potential blood donation a multifactorial assessment including adapted physical tasks, hematological variables, vigilance parameters, and subjective assessments.
Results: No significant results were evidenced in this study. There was no impact of blood donation on the participants' performances in both the hospital and the combat-like environments.
Conclusion: From a donor's point of view, a 450-ml blood donation has no impact on the required abilities of our elite soldiers to fulfill a demanding tactical mission. Thus, the results of this study support the fact that buddy transfusions could be part of the operational clinical armamentarium in austere environments for elite soldiers when no blood components are available.
Ashleigh Delorenzo, Matthew Shepherd, Emily Andrew, Paul Jennings, Stephen Bernard, Karen Smith
Air Med J. Jul-Aug 2021;40(4):216-219
Objective: The pressure within an endotracheal tube cuff is of particular importance in helicopter emergency medical services (HEMS) transport because the unpressurized cabin is subjected to decreases in atmospheric pressure. This can cause the cuff to overinflate and may be associated with clinical complications. We sought to evaluate endotracheal tube cuff pressure changes among intubated patients during HEMS transport.
Methods: A prospective observational study was performed including adult patients who were intubated and transported by helicopter between April 2017 and October 2018. Cuff pressures were measured before, during, and after HEMS transport with a commercial manometer.
Results: A total of 208 patients were included. The median maximum flight altitude was 3,000 (interquartile range [IQR], 2,000-5,000) ft. The median initial cuff pressure before takeoff was 35 (IQR, 24-50) cm H2O, which increased to 50 (IQR, 35-70) cm H2O at maximum altitude. A total of 169 (81.3%) patients had a cuff pressure > 30 cm H2O at maximum altitude. There was a moderate correlation between altitude and cuff pressure (r = 0.532, P < .001).
Conclusions: Cuff pressure increased during HEMS transport, demonstrating the need for routine cuff pressure monitoring during flight. Further research is required to determine if exposure to transient increases in cuff pressure for short durations is clinically significant.
Erik Scott DeSoucy, Kelsey Cacic, Brian P Staak, Christopher D Petersen, David van Wyck, Venkatakrishna Rajajee, John Dorsch, Stephen C Rush
J Spec Oper Med. Summer 2021;21(2):25-28.
Abstract
There are limited options available to the combat medic for management of traumatic brain injury (TBI) with impending or ongoing herniation. Current pararescue and Tactical Combat Casualty Care (TCCC) guidelines prescribe a bolus of 3% or 5% hypertonic saline. However, this fluid bears a tactical burden of weight (~570g) and pack volume (~500cm3). Thus, 23.4% hypertonic saline is an attractive option, because it has a lighter weight (80g) and pack volume (55cm3), and it provides a similar osmotic load per dose. Current literature supports the use of 23.4% hypertonic saline in the management of acute TBI, and evidence indicates that it is safe to administer via peripheral and intraosseous cannulas. Current combat medic TBI treatment algorithms should be updated to include the use of 23.4% hypertonic saline as an alternative to 3% and 5% solutions, given its effectiveness and tactical advantages.
Prehospital Hemorrhage Assessment Criteria: A Concise Review
Sara Di Carlo, Giuseppe Cavallaro, Kenia Palomeque, Maurizio Cardi, Giuseppe Sica, Piero Rossi, Simone Sibio
J Trauma Nurs. 2021 Sep-Oct 01;28(5):332-338
Objective: Early assessment of the clinical status of trauma patients is crucial for guiding the treatment strategy, and it requires a rapid and systematic approach. The aim of this report is to critically review the assessment parameters currently used in the prehospital setting to quantify blood loss in trauma.
Data sources: Studies regarding hemorrhagic shock in trauma were pooled from PubMed, EMBASE, and Cochrane databases using key words such as "hemorrhagic shock," "vital signs evaluation," "trauma," "blood loss," and "emergency medical service," alone or combined.
Study selection: Articles published since 2009 in English and Italian were considered eligible if containing data on assessment parameters in blood loss in adults.
Data extraction: Sixteen articles matching the inclusion criteria were considered in our study.
Data synthesis: Current prehospital assessment measures lack precise correlation with blood loss.
Conclusions: Traditional assessment parameters such as heart rate, systolic blood pressure, shock index, and Glasgow Coma Scale score often lag in providing accurate blood loss assessment. The current literature supports the need for a noninvasive, continuously monitored assessment parameter to identify early shock in the prehospital setting.
Point-of-care ultrasound for treatment and triage in austere military environments
Christophe Dubecq, Olivier Dubourg, Gabriel Morand, Romain Montagnon, Stéphane Travers, Pierre Mahe
J Trauma Acute Care Surg. 2021 Aug 1;91(2S Suppl 2):S124-S129
Background: Assessment and triage in an austere environment represent a major challenge in casualty care. Modern conflicts involve a significant proportion of multiple wounds, either superficial or penetrating, which complicate clinical evaluation. Furthermore, there is often poor accessibility to computed tomography scans and a limited number of surgical teams. Therefore, ultrasound (US) represents a potentially valuable tool for distinguishing superficial fragments or shrapnels from penetrating trauma requiring immediate damage-control surgery.
Methods: This retrospective observational multicenter study assessed casualties treated for 8 months by five medical teams deployed in Africa and Middle East. Two experts, who were experienced in military emergency medicine but did not take part in the missions, carried out an independent analysis for each case, evaluating the contribution of US to the following five items: triage categorization, diagnosis, clinical severity, prehospital therapeutic choices, and priority to operation room. Consensus was obtained using the Delphi method with three rounds.
Results: Of 325 casualties, 189 underwent US examination. The mean injury severity scale score was 25.6, and 76% were wounded by an improvised explosive device. Ultrasound was useful for confirming (23%) or excluding (63%) the suspected diagnosis made in the clinical assessment. It also helped obtain a diagnosis that had not been considered for 3% of casualties and was responsible for a major change in procedure or therapy in 4%. Ultrasound altered the surgical priority in 43% of cases. For 30% of cases, US permitted surgery to be temporarily delayed to prioritize another more urgent casualty.
Conclusion: Ultrasound is a valuable tool for the management of mass casualties by improving treatment and triage, especially when surgical resources are limited. In some situations, US can also correct a diagnosis or improve prehospital therapeutic choices. Field medical teams should be trained to integrate US into their prehospital protocols.
A Case Study of Long-Range Rotary Wing Critical Care Transport in the Battlefield Environment
Jamie Eastman, Jennifer Dumont, Kelly Green
J Spec Oper Med. Summer 2021;21(2):77-79.
Abstract
Military medical evacuation continues to grow both in distance and transport times. With the need for long-range transport of greater than 2 hours, crews are having to manage critical care patients for longer trips. This case study evaluates one specific event in which long-range transport of a sick noncombat patient required an enroute critical care team. Medical electronics and other equipment require special attention. Oxygen bottles and batteries for medical devices become the limiting factor in transport from point to point. Having to juggle multiple data streams requires prioritization and reassessment of interventions. Using the mnemonic "bottles, bags, batteries, battlefield environment" keeps the transport paramedic and enroute care nurse on track to effectively deliver the patient to the next level of care. Consideration should be given to such mnemonics for long critical care transports.
Jonathan L Eliason, Daniel D Myers, Abhijit Ghosh, Jonathan J Morrison, Angela R Mathues, Laura Durham, Veronica Dunivant, Andrew A Gonzalez, Todd E Rasmussen
Ann Surg. 2021 Jul 1;274(1):e54-e61
Objectives: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has been used clinically to limit torso bleeding and restore central perfusion. The objective of this study was to determine the sequelae of prolonged REBOA in a nonhuman primate animal model.
Summary background data: Prolonged duration of REBOA is associated with adverse clinical outcomes. Threshold occlusion values tied to relative risk have yet to be determined.
Methods: Juvenile baboons were subjected to 40% to 55% total blood volume hemorrhage to achieve profound hypotension and shock. Zone I REBOA was performed for 60 minutes to assess acute injury and survival at 4 hours (group 1; n = 7). Post-REBOA 10-day survival and complications were then compared between 60 minutes (group 2; n = 8) and 30 minutes (group 3; n = 6) REBOA animals.
Results: Overall survival was 20/21 (95%). IL-6 and IL-8 were elevated at 1 and 4 hours in group 1 (P = 0.005; P = 0.001). Comparing 60-minute REBOA with 30-minute REBOA, there was (1) hypertension compared with normotension (P = 0.005), (2) increased base deficit (P = 0.003), (3) elevated Troponin I (P = 0.04), and histological evidence of kidney injury (P = 0.004). In addition, group 2 demonstrated paralysis with histopathologic changes of spinal cord ischemia (SCI) in 4/8 (50%), with no SCI in group 3 (P = 0.033).
Conclusions: REBOA limits mortality in the primate model of severe hemorrhagic shock. However, unopposed balloon inflation in the distal thoracic aorta for 60 minutes results in high rates of spinal cord ischemia, an effect mitigated by limiting balloon inflation to 30 minutes.
The Association of Body Mass Index and Outcomes in Adult Patients with Chest Wall Injuries
Adel Elkbuli, Brad Boserup, Amy Liu, Scott Rowe, Mark McKenney
J Surg Res. 2021 Nov;267:544-555
Background: Thoracic injury secondary to rib fractures following motor vehicle collisions (MVCs) significantly contribute to morbidity and mortality. While obesity has reached epidemic proportions, little is known regarding how BMI impacts outcomes in MVCs. The aim of this study was to examine how BMI impacts outcomes in MVC patients with rib fractures.
Methods: The ACS-TQIP Database was utilized to evaluate adult MVC patients with ≥3 rib fractures. Patients with a non-thoracic AIS ≥3 were excluded, to focus on chest injuries. Patients were sorted according to the presence or absence of flail chest injuries and BMI into groups with a low (<15), intermediate (15-24), or severe (≥25) ISS.
Results: Overweight and obese patients in the non-flail cohort had decreased odds of pneumothorax in all ISS groups (P < 0.05). Overweight (P = 0.049) and obese (P = 0.011) patients in the low ISS non-flail cohort had decreased odds of splenic laceration. In the non-flail cohort, obese patients with a low and intermediate ISS had decreased odds of pulmonary contusion (P < 0.01). Obese patients in the low and intermediate ISS non-flail cohorts had increased odds of PE (P < 0.05). In both the flail and non-flail cohorts, obese patients with an intermediate ISS had decreased odds of liver laceration (P < 0.05), as well as a longer HLOS, ICU-LOS, and mechanical ventilation time (P < 0.01).
Conclusion: Obesity affects associated injuries, complications, and hospital outcomes in a complex way after MVC related chest wall trauma. Thus, the effect of BMI should be taken into consideration when assessing and treating obese MVC trauma patients.
Analysis of patients requiring urgent thoracotomy
A Ertekin, D Öcalan, K Öcalan, A Gencer
Eur Rev Med Pharmacol Sci. 2021 Jun;25(12):4345-4350
Objective: We aimed at investigating the effects of clinical data, urgent thoracotomy (UT) indications and results on prognosis and mortality in traumatic and non-traumatic patients who were and underwent UT in the operating room.
Patients and methods: Patients (17-90 years old) who were admitted to the Emergency Department of Afyonkarahisar State Hospital between 01.01.2012 and 31.06.2020 with traumatic and non-traumatic reasons requiring UT were retrospectively conducted from the archive. The patients' age, gender, complaints during admission, trauma classification, reports of thorax images, injury sites accompanying trauma, hospitalization and mortality rates were examined. IBM SPSS 22.0 program was used to compare all the data obtained.
Results: During the 90-month study period, a total of 40 patients who were admitted for traumatic and non-traumatic reasons were applied UT. The mean age of all patients (77.5% male, 22.5% female) was 33.35±14.1 years. There were 55% penetrating injuries, 32.5% blunt injuries and 12.5% non-traumatic causes. Indications for UT in the study were; massive hemothorax (25%), diaphragmatic rupture (22.5 %), hypovolemic shock (25%), heart or great vessel injuries (15%), massive air leak despite thoracostomy (10%), rupture of the pulmonary hydatid cyst into the bronchus and accompanying hemoptysis (2.5%). The time to surgical procedure in patients who underwent thoracotomy was shorter in patients with death. Mean time to thoracotomy was 4.5±6.5 hours. Mortality of UT was 20% with survival of 80%.
Conclusions: In the context of indications, urgent thoracotomy reduces mortality. The cooperation between the emergency physician and the thoracic surgeon is important during the decision phase.
Hooman Esfahani, Zahra Khazaeipour, Arash Safaie, Seyed Mojtaba Aghili
Bull Emerg Trauma. 2021 Apr;9(2):73-79
Objective: To compare the ketamine efficacy at a sub-dissociative morphine dose to reduce pain in isolated limb traumatic injuries.
Methods: A double-blind randomized clinical trial study was carried out on patients referred to emergency departments (EDs) due to isolated limb traumatic injuries. Eligible patients were divided into two groups which one group received 0.1 mg/kg ketamine and the other group received 0.05 mg/kg morphine, intravenously. An observed side effect includes pain scores and vital signs were recorded at baseline of every 5 minutes for 30 minutes.
Results: Totally, 73 patients with the mean age of 32.9±10.4 were enrolled of whom 59 (80.8%) individuals were men. The baseline characteristics difference of the two study groups was not statistically significant. The results showed that the change of mean pain score was -6.2 (95% CI: -5.72 to -6.69) points in the group receiving ketamine compared to -5.8 (95%CI: -5.15 to - 6.48) in the group who were administered morphine. At all assessed checkpoints, the pain mean score was lower in the ketamine group than in the morphine group (p<0.05); the mean of total pain reduction was greater in the ketamine group during the observation period compared with patients who received morphine (p=0.002).
Conclusion: The study findings suggest that the sub-dissociative ketamine efficacy in controlling of the acute pain is not lower than morphine sulfate in patients with isolated limb trauma in ED's. Thus, it can be considered as a safe and effective alternative approach.
Laura Faiver, David Hensler, Stephen C Rush, Osama Kashlan, Craig A Williamson, Venkatakrishna Rajajee
Neurocrit Care. 2021 Dec;35(3):845-852
Background: Sodium chloride (NaCl) 23.4% solution has been shown to reduce intracranial pressure (ICP) and reverse transtentorial herniation. A limitation of 23.4% NaCl is its high osmolarity (8008 mOsm/l) and the concern for tissue injury or necrosis following extravasation when administered via peripheral venous access. The use of this agent is therefore often limited to central venous or intraosseous routes of administration. Our objective was to evaluate the safety and efficacy of administration of 23.4% NaCl via peripheral venous access compared with administration via central venous access.
Methods: We reviewed pharmacy records to identify all administrations of 23.4% NaCl at our institution between December 2017 and February 2020. Medical records were then reviewed to identify complications, such as extravasation, soft tissue injury or necrosis, hypotension (mean arterial pressure less than 65 mm Hg), pulmonary edema, hemolysis, and osmotic demyelination. We also compared the change in physiological variables, such as ICP, mean arterial pressure, cerebral perfusion pressure, and heart rate, as well as laboratory values, such as sodium, chloride, bicarbonate, creatinine, and hemoglobin, following administration of 23.4% NaCl via the peripheral and central venous routes.
Results: We identified 299 administrations of 23.4% NaCl (242 central and 57 peripheral) in 141 patients during the study period. There was no documented occurrence of soft tissue injury or necrosis in any patient. One patient developed hypotension following central administration. Among the 38 patients with ICP monitoring at the time of drug administration, there was no significant difference in median ICP reduction (- 13 mm Hg [central] vs. - 24 mm Hg [peripheral], p = 0.21) or cerebral perfusion pressure augmentation (16 mm Hg [central] vs. 15 mm Hg [peripheral], p = 0.87) based on route of administration.
Conclusions: Peripheral venous administration of 23.4% NaCl is safe and achieves a reduction in ICP equivalent to that achieved by administration via central venous access.
Paul Fennessy, Eugene Greco, Nicholas Gelber, David J Brewster, John H Reeves
Anesth Analg. 2021 Jul 1;133(1):187-195
Background: Emergency front-of-neck airway rescue is recommended in a can't intubate, can't oxygenate clinical scenario. Cannula cricothyroidotomy has been reported as having a high failure rate. Our primary aim was to estimate the angle of the trachea in relation to the horizontal axis in a simulated emergency front-of-neck airway rescue position. Our secondary aims were to estimate the optimal cannula angle of approach and evaluate the anatomical relationship of the cricothyroid membrane (CTM) to adjacent structures. We also assessed whether the CTM lies above or below the neck midpoint, a point equidistant from the suprasternal notch (SSN), and the chin surface landmarks. All measurements were compared between the male and female subjects.
Methods: Subjects having elective computed tomography of their thorax were consented to have extension of the computed tomography to include their neck. A preliminary radiation dose and risk assessment deemed the additional radiation to be of very low risk (level IIa). Subjects were positioned supinely on the computed tomography table. Standard neck extension was achieved by placing a pillow under the scapulae and a rolled towel under the neck to simulate emergency front-of-neck airway rescue positioning.
Results: Fifty-two subjects were included in this study: 31 men and 21 women. The mean angle of the trachea in relation to the horizontal axis was 25.5° (95% confidence interval [CI], 21.8-29.1) in men and 14.0° (95% CI, 11.5-16.5) in women. The mean minimum angles required for hypothetical cannula cricothyroidotomy for men and women were 55.2° (95% CI, 51.8-58.7) and 50.5° (95% CI, 45.4-55.6), respectively. The CTM was located lower in the neck in men compared to women. The CTM was located below the neck midpoint in 30 of 30 (100%) male subjects and 11 of 20 (55%) female subjects (P < .001).
Conclusions: The trachea angulates posteriorly in a simulated emergency front-of-neck airway rescue position in supine subjects and to a greater degree in men compared to women (P < .001). The minimum angle required for hypothetical cannula cricothyroidotomy was >45° in the majority (75%) of subjects studied. A steeper cannula angle of approach may be more reliable and warrants further clinical study. If airway anatomy is indistinct and performing a vertical scalpel cricothyroidotomy, consideration should be given to performing this incision lower in the neck in men compared to women.
Out-of-Hospital Ketamine: Indications for Use, Patient Outcomes, and Associated Mortality
Antonio R Fernandez, Scott S Bourn, Remle P Crowe, E Stein Bronsky, Kenneth A Scheppke, Peter Antevy, J Brent Myers
Study objective: To describe out-of-hospital ketamine use, patient outcomes, and the potential contribution of ketamine to patient death.
Ann Emerg Med. 2021 Jul;78(1):123-131
Methods: We retrospectively evaluated consecutive occurrences of out-of-hospital ketamine administration from January 1, 2019 to December 31, 2019 reported to the national ESO Data Collaborative (Austin, TX), a consortium of 1,322 emergency medical service agencies distributed throughout the United States. We descriptively assessed indications for ketamine administration, dosing, route, transport disposition, hypoxia, hypercapnia, and mortality. We reviewed cases involving patient death to determine whether ketamine could be excluded as a potential contributing factor.
Results: Indications for out-of-hospital ketamine administrations in our 11,291 patients were trauma/pain (49%; n=5,575), altered mental status/behavioral indications (34%; n=3,795), cardiovascular/pulmonary indications (13%; n=1,454), seizure (2%; n=248), and other (2%; n=219). The highest median dose was for altered mental status/behavioral indications at 3.7 mg/kg (interquartile range, 2.2 to 4.4 mg/kg). Over 99% of patients (n=11,274) were transported to a hospital. Following ketamine administration, hypoxia and hypercapnia were documented in 8.4% (n=897) and 17.2% (n=1,311) of patients, respectively. Eight on-scene and 120 in-hospital deaths were reviewed. Ketamine could not be excluded as a contributing factor in 2 on-scene deaths, representing 0.02% (95% confidence interval 0.00% to 0.07%) of those who received out-of-hospital ketamine. Among those with in-hospital data, ketamine could not be excluded as a contributing factor in 6 deaths (0.3%; 95% confidence interval 0.1% to 0.7%).
Conclusion: In this large sample, out-of-hospital ketamine was administered for a variety of indications. Patient mortality was rare. Ketamine could not be ruled out as a contributing factor in 8 deaths, representing 0.07% of those who received ketamine.
William A Florez-Perdomo, Ezequiel García-Ballestas, Rafael Martinez-Perez, Amit Agrawal, Harsh Deora, Andrei F Joaquim, Gabriel A Quiñones-Ossa, Luis Rafael Moscote-Salazar
Br J Neurosurg. 2021 Jun 21;1-7
Background: Several factors can influence the outcome of severe head injuries including the patient's hemoglobin levels. There has often been a dilemma regarding levels of hemoglobin at which red cell blood transfusion (RCBT) should be performed.
Objective: To systematically review the literature to determine the usefulness of management protocols that have hemoglobin levels <10 g/dL vs <7 g/dL as an RCBT criterion.
Methods: Following the PRISMA statement, the search was constructed using terms and descriptors of the Medical Subject Heading (MeSH), combined with Boolean operators. Full text of these articles was studied, and outcome measures at 3-6 months were considered for patients who were given a RCBT at <10 g/dL or at 7 g/dL hemoglobin levels.
Results: A total of 4 articles were found suitable for inclusion in the meta-analysis. RCBT below 7 g/dL was not associated with an increased risk of mortality as compared to RCBT using the value of less than 10 g/dL. RCBT at lower levels of hemoglobin was also not associated with a poor neurological outcome (GOS 4-5) but rather RCBT at lower levels lead to better outcomes (GOS 1-3) and the association was significant.
Conclusion: Allogenic RCBT was associated with poorer neurological outcomes, within a wide range of reported differences in the hemoglobin threshold to decide for RCBT in TBI patients. Restrictive RCBT strategy may be useful in moderate to severe TBI cases although the risk of anemia-induced cerebral injury needs further investigation regarding the risks and complications inherent to RCBT.
Saving lives and limbs: Challenges for the REBOA aficionado
Charles J Fox
J Vasc Surg. 2021 Aug;74(2):477
No abstract available
Prehospital evaluation and detection of induced coagulopathy in trauma: The PREDICT study
Holger Gaessler, Matthias Helm, Martin Kulla, Bjoern Hossfeld, Uta Schmid, Juergen Kerschowski, Ingeborg Bretschneider
J Trauma Acute Care Surg. 2021 Aug 1;91(2):344-351
Background: Hemorrhage with trauma-induced coagulopathy (TIC) and hyperfibrinolysis (HF) increases the mortality risk after severe trauma. While TIC at hospital admission is well studied, little is known about coagulopathy at the incident site. The aim of the study was to investigate coagulation disorders already present on scene.
Methods: In a prospective single-center observational study, blood samples of trauma patients obtained before and at hospital admission were analyzed. Data on rotational thromboelastometry, blood gas analysis, prehospital treatment, injury severity, in-hospital blood transfusions, and mortality were investigated according to the presence of coagulation disorders at the incident site. The patients were divided into three groups according to the presence of coagulation disorders (no coagulopathy, TIC, TIC with HF). In a subgroup analysis, patients with a Trauma-Induced Coagulopathy Clinical Score (TICCS) of ≥10 were investigated.
Results: Between August 2015 and February 2018, 148 patients were enrolled in the study. The mean Injury Severity Score was 22.1, and overall mortality was 7.4%. Trauma-induced coagulopathy and HF were already detectable at the incident site in 18.2% and 6.1%, respectively. Patients with HF had significantly altered circulation parameters with significant changes in pH, hemoglobin, lactate, and base excess at the incident site. In patients with TICCS of ≥10 (14.2%), TIC was detected in 47.6% of the cases and HF in 28.6%. Furthermore, in these patients, blood gas parameters significantly changed and the need for blood transfusion and mortality.
Conclusion: Trauma-induced coagulopathy and HF can be detected in severely injured patients even before medical treatment is started. Furthermore, in patients with HF and TICCS of ≥10, blood gas parameters were significantly changed at the incident site.
Francisco José Garcés Garcés, Ervigio Corral Torres, Edite Joao Simoes da Silva Pereira, Alberto Hernández-Tejedor
Eur J Emerg Med. 2021 Aug 1;28(4):326-327
No abstract available
Tourniquet Use on a Pediatric Patient
Marco Gattere, Niccolo Scaffei, Luca Gozzetti, Maverick Alessandrini
J Spec Oper Med. Spring 2021;21(1):120-123
Abstract
As a result of the increasing use and application of military tourniquets in civilian settings, it is necessary to evaluate the size and effectiveness of the equipment on patients that differ from the military-aged population for whom the devices have been primarily created. This case report describes the application of a tourniquet on a pediatric patient while also profiling a common situation in which the Combat Application Tourniquet GEN 7 (C-A-T Resources) might be used in civilian care systems. The case is that of a 14-month-old child who suffered a limb amputation secondary to a road accident in Italy and the ensuing life-saving treatment. The intervening nurse at the scene had been trained on the use of hemorrhage-control devices through the American College of Surgeons "Stop the Bleed" campaign.
Guillaume Giral, Antoine Grosset, Pauline Podeur, Frédérik Bélot-de Saint Leger
Mil Med. 2022 Jan 4;187(1-2):40-41
No abstract available
Christopher J Groombridge, Amit Maini, Joseph Mathew, Yesul Kim, Mark Fitzgerald, De Villiers Smit, Gerard O'Reilly
Scand J Trauma Resusc Emerg Med. 2021 Jul 28;29(1):104
Objective: In the 'can't intubate can't oxygenate' scenario, techniques to achieve front of neck access to the airway have been described in the literature but there is a lack of guidance on the optimal method for securing the tracheal tube (TT) placed during this procedure. The aim of this study was to compare three different methods of securing a TT to prevent extubation following a surgical cricothyroidotomy.
Methods: A randomised controlled trial was undertaken. The population studied were emergency physicians (EPs) attending a cadaveric airway course. The intervention was securing a TT placed via a surgical cricothyroidotomy by suture. The comparison was securing the TT using fabric tape with two different tying techniques. The primary outcome was the force required to extubate the trachea. The trial was registered with ANZCTR.org.au (ACTRN12621000320853).
Results: 17 emergency physicians completed intubations using all three of the securing methods on 12 cadavers for a total of 51 experiments. The mean extubation force was 6.54 KG (95 % CI 5.54-7.55) in the suture group compared with 2.28 KG (95 % CI 1.91-2.64) in the 'Wilko tie' group and 2.12 KG (95 % CI 1.63-2.60) in the 'Lark's foot tie' group; The mean difference between the suture and fabric tie techniques was significant (p < 0.001).
Conclusions: Following a surgical cricothyroidotomy in cadavers, EPs were able to effectively secure a TT using a suture technique, and this method was superior to tying the TT using fabric tape.
Ali Gur, Erdal Tekin
Am J Emerg Med. 2021 Nov;49:89-93
Aim: Radial artery blood gas sampling is a very common procedure undertaken in the emergency department to evaluate respiratory and metabolic parameters. This intervention causes both anxiety and pain for the patient. Therefore, the current study aimed to examine the analgesic efficacy of lidocaine spray compared to a placebo during radial artery blood gas sampling.
Methods: This study was conducted in the emergency department of a tertiary hospital with a randomized, double-blind, placebo-controlled design. A total of 144 patients were randomly divided into two groups: One group (n = 72) received 10% lidocaine spray and the other (n = 72) was the placebo group. The analgesic efficacy of the 10% lidocaine spray was compared with the placebo group using the Visual Analog Scale (VAS).
Results: In the evaluation of the analgesic efficacy of the 10% lidocaine spray, the VAS score was 1.5 [interquartile range (IQR): 2.0] for the lidocaine group and 5 (IQR: 2.0) for the placebo group. The role of lidocaine spray in reducing pain was statistically significant compared to the placebo (p = 0.000).
Conclusion: In blood gas sampling, 10% lidocaine spray has analgesic efficacy. Therefore, we recommend the use of lidocaine spray while performing arterial blood gas sampling in emergency departments.
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.
Mohamed Serhan Hamam, Howard A Klausner, John France, Amy Tang, Robert A Swor, James H Paxton, Brian J O'Neil, Christine Brent, Robert W Neumar, Robert B Dunne, Swetha Reddi, Joseph B Miller
Resuscitation. 2021 Oct;167:261-266
Background: Recent reports have questioned the efficacy of intraosseous (IO) drug administration for out-of-hospital cardiac arrest (OHCA) resuscitation. Our aim was to determine whether prehospital administration of resuscitative medications via the IO route was associated with lower rates of return of spontaneous circulation (ROSC) and survival to hospital discharge than peripheral intravenous (IV) infusion in the setting of OHCA.
Methods: We obtained data on all OHCA patients receiving prehospital IV or IO drug administration from the three most populous counties in Michigan over three years. Data was from the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) database. The association between route of drug administration and outcomes was tested using a matched propensity score analysis.
Results: From a total of 10,626 OHCA patients, 6869 received parenteral drugs during their prehospital resuscitation (37.8% by IO) and were included in analysis. Unadjusted outcomes were lower in patients with IO vs. IV access: 18.3% vs. 23.8% for ROSC (p < 0.001), 3.2% vs. 7.6% for survival to hospital discharge (p < 0.001), and 2.0% vs. 5.8% for favorable neurological function (p < 0.001). After adjustment, IO route remained associated with lower odds of sustained ROSC (OR 0.72, 95% CI 0.63-0.81, p < 0.001), hospital survival (OR 0.48, 95% CI 0.37-0.62, p < 0.001), and favorable neurological outcomes (OR 0.42, 95% CI 0.30-0.57, p < 0.001).
Conclusion: In this cohort of OHCA patients, the use of prehospital IO drug administration was associated with unfavorable clinical outcomes.
Zain G Hashmi, Mohamad Chehab, Avery B Nathens, Bellal Joseph, Eric A Bank, Jan O Jansen, John B Holcomb
Transfusion. 2021 Jul;61 Suppl 1:S348-S353
Background: In recent years, several studies have demonstrated the efficacy of using pre-hospital blood product and in-hospital whole blood for trauma resuscitation. While some observations suggest an encouraging uptake of this evidence by emergency medical service (EMS) agencies and trauma centers, a nationwide characterization of blood product utilization for bleeding trauma patients remains unknown. The objective of this study is to determine nationwide estimates of pre-hospital blood product and in-hospital whole blood utilization for trauma resuscitation.
Study design and methods: All adult trauma patients reported to the National Emergency Medical Services Information System (NEMSIS) dataset 2019 were included. Proportions of patients who received any pre-hospital blood product were calculated. The American College of Surgeons (ACS) Trauma Quality Programs (TQP) databases 2015-2017 and first quarter of 2020 were used to calculate the proportion of ACS-verified trauma centers that transfused whole blood.
Results: Among a total of 3,058,804 pre-hospital trauma patients, only 313 (0.01%) received any blood transfusion; 208 (0.21%) patients with systolic blood pressure (SBP) ≤90 mmHg and 121 (0.67%) patients with SBP ≤90 mmHg and heart rate ≥120 beats per minute received any blood product. The proportion of ACS-verified trauma centers transfusing whole blood increased from 16.7% (45/269) in 2015 to 24.5% (123/502) in first quarter of 2020.
Discussion: Despite strong evidence and recommendations, pre-hospital utilization of blood products for trauma resuscitation remains low. Additionally, while the overall in-hospital whole blood use also remains low, its use has increased at ACS-verified trauma centers over the past 5 years.
Pre-Hospital Pain Management in Children with Injuries: A Retrospective Cohort Study
Ada Holak, Michał Czapla, Marzena Zielińska
J Clin Med. 2021 Jul 9;10(14):3056
Background: The all-too-frequent failure to rate pain intensity, resulting in the lack of or inadequacy of pain management, has long ceased to be an exclusive problem of the young patient, becoming a major public health concern. This study aimed to evaluate the methods used for reducing post-traumatic pain in children and the frequency of use of such methods. Additionally, the methods of pain assessment and the frequency of their application in this age group were analysed.
Methods: A retrospective analysis of 2452 medical records of emergency medical teams dispatched to injured children aged 0-18 years in the area around Warsaw (Poland).
Results: Of all injured children, 1% (20 out of 2432) had their pain intensity rated, and the only tool used for this assessment was the numeric rating scale (NRS). Children with burns most frequently received a single analgesic drug or cooling (56.2%), whereas the least frequently used method was multimodal treatment combining pharmacotherapy and cooling (13.5%). Toddlers constituted the largest percentage of patients who were provided with cooling (12%). Immobilisation was most commonly used in adolescents (29%) and school-age children (n = 186; 24%).
Conclusions: Low frequency of pain assessment emphasises the need to provide better training in the use of various pain rating scales and protocols. What is more, non-pharmacological methods (cooling and immobilisation) used for reducing pain in injured children still remain underutilized.
Sebastian Imach, Arasch Wafaisade, Rolf Lefering, Andreas Böhmer, Mark Schieren, Victor Suárez, Matthias Fröhlich, TraumaRegister DGU®
Crit Care. 2021 Aug 4;25(1):277
Background: Outcome data about the use of tranexamic acid (TXA) in civilian patients in mature trauma systems are scarce. The aim of this study was to determine how severely injured patients are affected by the widespread prehospital use of TXA in Germany.
Methods: The international TraumaRegister DGU® was retrospectively analyzed for severely injured patients with risk of bleeding (2015 until 2019) treated with at least one dose of TXA in the prehospital phase (TXA group). These were matched with patients who had not received prehospital TXA (control group), applying propensity score-based matching. Adult patients (≥ 16) admitted to a trauma center in Germany with an Injury Severity Score (ISS) ≥ 9 points were included.
Results: The matching yielded two comparable cohorts (n = 2275 in each group), and the mean ISS was 32.4 ± 14.7 in TXA group vs. 32.0 ± 14.5 in control group (p = 0.378). Around a third in both groups received one dose of TXA after hospital admission. TXA patients were significantly more transfused (p = 0.022), but needed significantly less packed red blood cells (p ≤ 0.001) and fresh frozen plasma (p = 0.023), when transfused. Massive transfusion rate was significantly lower in the TXA group (5.5% versus 7.2%, p = 0.015). Mortality was similar except for early mortality after 6 h (p = 0.004) and 12 h (p = 0.045). Among non-survivors hemorrhage as leading cause of death was less in the TXA group (3.0% vs. 4.3%, p = 0.021). Thromboembolic events were not significantly different between both groups (TXA 6.1%, control 4.9%, p = 0.080).
Conclusion: This is the largest civilian study in which the effect of prehospital TXA use in a mature trauma system has been examined. TXA use in severely injured patients was associated with a significantly lower risk of massive transfusion and lower mortality in the early in-hospital treatment period. Due to repetitive administration, a dose-dependent effect of TXA must be discussed.
Battlefield Medicine: Anesthesia and Critical Care in the Combat Zone
J Michael Jaeger, Darian C Rice, Brooke Albright-Trainer
Anesthesiol Clin. 2021 Jun;39(2):321-336
Abstract
The US Military Joint Trauma System has been developed to mitigate the harsh conditions under which medical providers care for combat casualties and provide continuity of care from the battlefield to US medical centers. We review the components of this system with emphasis on combat trauma care under fire and the role of the anesthesiologist and intensivist in this continuum of care. An important link in the chain of survival is the Air Force Critical Care Aeromedical Transport Team, which provides critical care while transporting casualties from the theater to higher levels of care outside the war zone and home.
Emerging approaches to pre-hospital hemorrhage control: a narrative review
Leila Jamal, Aman Saini, Keith Quencer, Izzet Altun, Hassan Albadawi, Aditya Khurana, Sailendra Naidu, Indravadan Patel, Sadeer Alzubaidi, Rahmi Oklu
Ann Transl Med. 2021 Jul;9(14):1192
Abstract
In the United States, trauma claims the lives of over 150,000 civilians each year. In military settings, trauma and exsanguination result in 50% of combat related deaths. The majority of these deaths result from uncontrolled non-compressible hemorrhage. Non-compressible hemorrhage often results from deep vascular injuries within the torso, however can also occur secondary to penetrating injuries that involve the extremities. Given the high mortality rates for non-compressible hemorrhage, rapid and effective management of patients suffering from hemorrhage is essential to good patient outcomes. Consequently, there has been increasing interest in solutions for point-of-injury hemorrhage control in trauma and military medicine. Undoubtedly there is a great need for prehospital hemostatic interventions that can be deployed by trained and untrained personnel. Since 2001, various hemostatic agents have been developed, each with its advantages based upon the type and severity of injury, wound size, wound location, accessibility to injury site, and the coagulation status of the patient. These agents are often used in the military setting as a temporizing measure prior to definitive therapy and include techniques such as resuscitative endovascular balloon occlusion of the aorta (REBOA) and bioengineered agents including ResQFoam, RevMedx's XSTAT, Tranexamic acid (TXA), and QuikClot Combat Gauze (QCG). Here, we review the indications, composition, technique, efficacy, and outcomes of these hemostatic agents.
New and Off-Label Uses of Tranexamic Acid
Stephanie M Johnson, Dawn Tsang, Mary Dansby, Christopher Allen
AACN Adv Crit Care. 2021 Sep 15;32(3):237-242
No abstract available
Romain Jouffroy, Benoît Vivien
Am J Emerg Med. 2021 Oct;48:328-329
No abstract available
Awake intubations in the emergency department: A report from the National Emergency Airway Registry
Maria C Kaisler, Robert J Hyde, Benjamin J Sandefur, Amy H Kaji, Ronna L Campbell, Brian E Driver, Calvin A Brown 3rd
Am J Emerg Med. 2021 Nov;49:48-51
Objective: To describe awake intubation practices in the emergency department (ED) and report success, complications, devices used, and rescue techniques using multicenter surveillance.
Methods: We analyzed data from the National Emergency Airway Registry (NEAR). Patients with an awake intubation attempt between January 1, 2016 and December 31, 2018 were included. We report univariate descriptive data as proportions with cluster-adjusted 95% confidence intervals (CIs).
Results: Of 19,071 discrete patient encounters, an awake technique was used on the first attempt in 82 (0.4%) patients. The majority (91%) of first attempts were performed by emergency medicine physicians. Angioedema (32%) and non-angioedema airway obstruction (31%) were the most common indications for an awake intubation attempt. The most common initial device used was a flexible endoscope (78%). Among all awake intubations first-attempt success was achieved in 85% (95% CI [76%-95%]), and peri-intubation complications occurred in 16% (95% CI [9%-26%]).
Conclusion: Awake intubation in this multicenter cohort of emergency department patients was rare and was performed most often in patients with airway edema or obstruction. Emergency physicians performed the majority of first intubation attempts with high first-attempt success. Further studies are needed to determine optimal emergency airway management in this patient population.
Incidence and factors influencing tourniquet pain
Krithika Kamath, Surendra Umesh Kamath, Purnachandra Tejaswi
Chin J Traumatol. 2021 Sep;24(5):291-294
Purpose: The use of tourniquet in orthopedic surgery facilitates operation by establishing a bloodless surgical field. However, many complications following the use of tourniquets have been reported. Tourniquet pain is the most common complication. This study aimed to find the actual incidence of pain associated with tourniquet use in orthopedic surgery and the various factors.
Methods: It is a prospective observational study conducted on 132 consecutive cases. Patients aged 18-70 years with musculoskeletal problems of the forearm and leg requiring surgery were included in the study. Patients with open injuries or contraindications such as diabetes mellitus, compromised circulatory states, neurological deficit, compartment syndrome and unable to give informed consent were excluded. The parameters assessed included duration of tourniquet use, tourniquet pressure, type of anesthesia, any interval release of the tourniquet and reapplication after a reperfusion period, whether upper or lower limb surgery, severity of tourniquet pain, timing of tourniquet release and complications. Chi-square and non-parametric Mann-Whitney U test were used for data analysis.
Results: In upper limb surgeries, if duration of surgery was less than 60 min, 14 (51.8%) cases experienced tourniquet pain and 13 (48.1%) had no pain, and if duration of surgery was more than 60 min, 24 (60.0%) had pain and 16 (40.0%) experienced no pain. In lower limb surgeries if duration of surgery was less than 60 min, 2 (7.7%) experienced pain and 24 (92.3%) had no pain, and if duration of surgery was more than 60 min, 14 (35.8%) experienced pain and 25 (64.8%) had no pain. Degree of tourniquet pain increases with the duration of surgery. Statistically, there was significant association between tourniquet inflation time and tourniquet pain in both upper and lower limbs (p = 0.034 and 0.024, respectively) CONCLUSION: Incidence of tourniquet pain was in direct proportion to the duration of tourniquet use and was higher in cases with regional anesthesia. Other risk factors assessed including tourniquet pressure, upper or lower limb surgery, tourniquet release time and interval had no significant contribution to the incidence or severity of tourniquet pain.
Fresh Whole Blood Transfusion: Perspectives From a Federal Law Enforcement Agency Tactical Program
Stephanie J Kemp, Matthew J Levy, Joshua G Knapp, Lisa A Steiner, Nelson Tang
J Spec Oper Med. Summer 2021;21(2):108-111
No abstract available
Amir Khorram-Manesh, Johan Nordling, Eric Carlström, Krzysztof Goniewicz, Roberto Faccincani, Frederick M Burkle
Scand J Trauma Resusc Emerg Med. 2021 Aug 17;29(1):119
Background: There is no global consensus on the use of prehospital triage system in mass casualty incidents. The purpose of this study was to evaluate the most commonly used pre-existing prehospital triage systems for the possibility of creating one universal translational triage tool.
Methods: The Rapid Evidence Review consisted of (1) a systematic literature review (2) merging and content analysis of the studies focusing on similarities and differences between systems and (3) development of a universal system.
Results: There were 17 triage systems described in 31 eligible articles out of 797 identified initially. Seven of the systems met the predesignated criteria and were selected for further analysis. The criteria from the final seven systems were compiled, translated and counted for in means of 1/7's. As a product, a universal system was created of the majority criteria.
Conclusions: This study does not create a new triage system itself but rather identifies the possibility to convert various prehospital triage systems into one by using a triage translational tool. Future research should examine the tool and its different decision-making steps either by using simulations or by experts' evaluation to ensure its feasibility in terms of speed, continuity, simplicity, sensitivity and specificity, before final evaluation at prehospital level.
The effects of prehospital plasma on patients with injury: a prehospital plasma resuscitation
Brian D Kim, Martin D Zielinski, Donald H Jenkins, Henry J Schiller, Kathleen S Berns, Scott P Zietlow
J Trauma Acute Care Surg. 2012 Aug;73(2 Suppl 1):S49-53
Background: The prehospital resuscitation of the exsanguinating patient with trauma is time and resource dependent. Rural trauma care magnifies these factors because transportation time to definitive care is increased. To address the early resuscitation needs and trauma-induced coagulopathy in the exsanguinating patient with trauma an aeromedical prehospital thawed plasma-first transfusion protocol was used.
Methods: Retrospective review of trauma and flight registries between February 1, 2009, and May 31, 2011, was performed. The study population included all patients with traumatic injury transported by rotary wing aircraft who met criteria for massive transfusion protocol
Results: A total of 59 patients identified over 28 months met criteria for initiation of aeromedical initiation of prehospital blood product resuscitation. Nine patients received thawed plasma-first protocol compared with 50 controls. The prehospital plasma group was more commonly on warfarin (22 vs. 2%, p = 0.036) and had a greater degree of coagulopathy measured by international normalized ratio at baseline (2.6 vs. 1.5, p = 0.004) and trauma center arrival (1.6 vs. 1.3, p < 0.001). The prehospital plasma group had a predicted mortality nearly three times greater than controls based on Trauma and Injury Severity Score (0.24 vs. 0.66, p = 0.005). The use of prehospital plasma resuscitation led to a plasma-red blood cell ratio that more closely approximated a 1:1 resuscitation en route (1.3:1.0 vs. not applicable, p < 0.001), at 30 minutes (1.3:1.0 vs. 0.14:1.0, p < 0.001), at 6 hours (0.95:1.0 vs. 0.42:1.0, p < 0.001), and at 24 hours (1.0:1.0 vs. 0.45:1.0, p < 0.001). An equivalent amount of packed red blood cells were transfused between the groups. Despite more significant hypotension, less crystalloid was used in the prehospital thawed plasma group, through 24 hours after injury (6.3 vs. 16.4 L, p = 0.001).
Conclusion: Use of plasma-first resuscitation in the helicopter system creates a field ready, mobile blood bank, allowing early resuscitation of the patient demonstrating need for massive transfusion. There was early treatment of trauma-induced coagulopathy. Although there was not a survival benefit demonstrated, there was resultant damage control resuscitation extending to 24 hours in the plasma-first cohort.
Ketamine: Focusing on the Facts and Forgetting the Fiction
Lauren R Klein, Jon B Cole
Ann Emerg Med. 2021 Jul;78(1):132-139
No abstract available.
Cutaneous Complications Associated With Intraosseous Access Placement
Emily Konopka, Kirsten Webb, Jeave Reserva, Lauren Moy, Hieu Ton-That, Jodi Speiser, Rebecca Tung
Cutis. 2021 Jun;107(6):E31-E33
Abstract
Intraosseous (IO) access provides a potentially lifesaving means of vascular access in settings of trauma and advanced cardiovascular life support in which patients often require prompt and large volumes of fluid resuscitation, blood products, and medications. An additional benefit of IO access is the rare incidence of complications, with many studies reporting rates of less than 1%. The most commonly cited complications include compartment syndrome, osteomyelitis, traumatic bone fracture, and epiphyseal plate damage. To evaluate the dermatologic sequelae, we performed a retrospective chart review spanning 18 consecutive months to identify patients who underwent IO line placement, either at or en route to a large metropolitan level I trauma center in the Midwestern United States. Our review identified a complication rate of 2.7%, with complications including compartment syndrome, needle breakage, and a previously unreported cutaneous complication of traumatic bullae.
Exploring Tourniquet Conversion in Simulation to Develop Concepts and Hypotheses
John F Kragh Jr, Tuan D Le, Michael A Dubick
J Spec Oper Med. Fall 2021;21(3):23-29.
Background: Compared with those of tourniquet application, tourniquet conversion concepts are underdeveloped. The purpose of this project was to develop tourniquet conversion concepts and generate hypotheses.
Methods: One person performed 100 tests of tourniquet application and conversion. Testing varied by conversion types, materials, and assessments. Conversions were from improvised or Combat Application Tourniquets (C-A-T) to another C-A-T, a new site (with initial C-A-T only), a pneumatic Emergency and Military Tourniquet (EMT), or a pressure dressing (compression bandage or a roll gauze and an elastic wrap). Simulated limbs were created using plastic bottle-based manikins, pool noodle-based manikins, plastic pipes, glass bottles, a rain downspout, and a cardboard poster tube.
Results: Tourniquet application, conversion, and total times averaged 105, 132, and 237 seconds, respectively. Improvised tourniquet time was longer than that of C-A-T (p ≤ .05, all three). By initial tourniquet site, the 2-3 inches site had longer conversion and total time (p ≤ .02, both) compared with highest site. By whether initial tourniquets placed were also used in conversion, total time was shorter if yes (p = .05). Conversion to a pressure dressing was longer in conversion and total time (p ≤ .02, both) compared with conversion to a tourniquet. One wrap was short; we switched to those longer to cover limbs better. Limb types varied for indentation. Conversion communications improved when we used abbreviations and symbols.
Conclusions: This preliminary project simulated tourniquet conversion to develop clinical concepts and research hypotheses to build a better basis for later research.
Valentin Kuhlwilm
J Spec Oper Med. Spring 2021;21(1):94-101
Introduction: Sucking chest wounds occur when injuries penetrate the thorax and inhalation results in air entering the pleural cavity. Well documented in the prehospital environment, treatment should be chest seal application to attempt prevention of an expanding pneumothorax. However, a seal might occlude the pathway for the escape of air and lead to a worsening tension pneumothorax.
Methods: The author conducted a literature search of studies reporting the efficacy of various chest seals for treating sucking chest wounds and the prevention of a tension pneumothorax. Study results were compared to current international guidelines.
Results/discussion: Included were four studies testing chest seals in a swine model of hemopneumothorax. Vented and unvented chest seals stabilized cardiorespiratory parameters after an open pneumothorax, but only vented chest seals showed more success at preventing a tension pneumothorax. Chest seals with flutter valves seemed to be inferior. An additional study showed that vertical movements and soiled skin were more stressful on the applied chest seals. Eight international guidelines were identified: four focused on the tactical environment, and four appeared to be more civilian-oriented. Only two of the civilian-oriented guidelines did not prefer vented chest seals.
Conclusion: Vented chest seals seem to be superior to unvented chest seals, and most international guidelines have updated their recommendations for the use of vented chest seals. However, frequent physical examinations for early signs of a developing or worsening tension pneumothorax are the best medical care.
Hyuksool Kwon, Jin Hee Lee, Yoo Jin Choi, Jae Yun Jung
Am J Emerg Med. 2021 Jun;44:208-212
Purpose: The objective of this study was to evaluate whether sedation with ketamine without local anesthesia was sufficient in children undergoing primary repair.
Methods: Randomized, double-blind trial conducted between December 2013 and October 2016 in a tertiary care pediatric emergency department in Korea. Children aged 1 to 10 years requiring sedation for primary repair were randomly assigned to receive local lidocaine anesthesia with ketamine sedation or local saline injection with ketamine sedation. Children's Hospital of Eastern Ontario Pain Scale scores was recorded during the procedures. The pain scales were recorded by nurses who were blinded to the study drugs, before ketamine sedation, after sedation, during the first injection of the study drugs for wound repair, during the first stitch, and after the procedure.
Results: Twenty-five were randomized to receive ketamine sedation with local anesthesia and twenty-two to receive ketamine sedation without local anesthesia. There was no significant difference in pain scale before ketamine sedation (difference (mean): -1.11, CI: -2.78-0.55, P value: 0.18), after sedation (difference (mean): -0.60, CI: -2.20-1.01, P = 0.46), during the first injection of the study drugs for wound repair (difference (mean): -0.03, CI: -0.31-0.25, P = 0.84), during the first stitch (difference (mean): -0.15, CI: 6.19-6.79, P = 0.62), during the primary repair (difference (mean): 0.20, CI: -55-0.95, P = 0.59), and after the procedure (difference (mean): 0.17, CI: -0.48-0.82, P = 0.59).
Conclusion: Sedating with ketamine for primary wound repair, there was no difference in pain and sedation scales between the patients treated with or without lidocaine local anesthesia, and local anesthesia was not needed.
Pascal Lange, Mohamad Umar, Jerimiah D Walker, Mark Riddle, Paul Mochmer
Mil Med. 2021 Jul 30; Online ahead of print
No abstract available
Analysis of Nonbattle Deaths Among U.S. Service Members in the Deployed Environment
Tuan D Le, Jennifer M Gurney, Kevin S Akers, Kevin K Chung, Karan P Singh, Heuy-Ching Wang, Mark E Stackle, Anthony E Pusateri
Ann Surg. 2021 Nov 1;274(5):e445-e451
Objective: Describe etiologies and trends in non-battle deaths (NBD) among deployed U.S. service members to identify areas for prevention.
Background: Injuries in combat are categorized as battle (result of hostile action) or nonbattle related. Previous work found that one-third of injured US military personnel in Iraq and Afghanistan had nonbattle injuries and emphasized prevention. NBD have not yet been characterized.
Methods: U.S. military casualty data for Iraq and Afghanistan from 2001 to 2014 were obtained from the Defense Casualty Analysis System (DCAS) and the Department of Defense Trauma Registry (DoDTR). Two databases were used because DoDTR does not capture prehospital deaths, while DCAS does not contain clinical details. Nonbattle injuries and NBD were identified, etiologies classified, and NBD trends were assessed using a weighted moving average and time-series analysis with autoregressive integrated moving average. Future NBD rates were forecast.
Results: DCAS recorded 59,799 casualties; 21.0% (n = 1431) of all deaths (n = 6745) were NBD. DoDTR recorded 29,958 casualties; 11.5% (n = 206) of all deaths (n = 1788) were NBD. After early fluctuations, NBD rates for both Iraq and Afghanistan stabilized at approximately 21%. Leading causes of NBD were gunshot wounds and vehicle accidents, accounting for 66%. Approximately 25% was self-inflicted. A 24% NBD rate was forecasted from 2015 through 2025.
Conclusions: Approximately 1 in 5 deaths were NBD. The majority were potentially preventable, including a significant proportion of self-inflicted injuries. A single comprehensive data repository would facilitate future mortality monitoring and performance improvement. These data may assist military leaders with implementing targeted safety strategies.
Determining a Need for Point-of-Care Ultrasound in Helicopter Emergency Medical Services Transport
Timothy J Lenz, Mary Beth Phelan, Tom Grawey
Air Med J. May-Jun 2021;40(3):175-178
Objective: Point-of care-ultrasound (PoCUS) is useful in evaluating unstable emergency department patients. The portability of this technology increases its potential use in prehospital settings, including helicopter emergency medical services (HEMS) programs. Identifying useful applications may support implementing a PoCUS program that develops sonography skills for prehospital providers. The aim of this study was to determine the HEMS patient population that would benefit from prehospital PoCUS for hypotension and how commonly the extended focused assessment with sonography in trauma (E-FAST) for trauma patients or the rapid ultrasound in shock (RUSH) for medical patients could be used by HEMS.
Methods: A retrospective chart review was performed over a 1-year period of adult patients transported by a midwestern HEMS system. Charts were reviewed for episodes of hypotension.
Results: The chart review included 216 charts, of which 3 were excluded. Of the 213 cases, 100 were trauma patients, and 113 were medical patients. Of the trauma patients, 51% experienced hypotension, as did 73 of 113 medical patients.
Conclusion: Fifty percent of HEMS patients may benefit from PoCUS to evaluate for hypotension in flight.
Ketamine Use in Operation Enduring Freedom
Eric Leslie, Eric Pittman, Brendon Drew, Benjamin Walrath
Mil Med. 2021 Jul 1;186(7-8):e720-e725
Introduction: Ketamine is a dissociative anesthetic increasingly used in the prehospital and battlefield environment. As an analgesic, it has been shown to have comparable effects to opioids. In 2012, the Defense Health Board advised the Joint Trauma System to update the Tactical Combat Casualty Care Guidelines to include ketamine as an acceptable first line agent for pain control on the battlefield. The goal of this study was to investigate trends in the use of ketamine during Operation Enduring Freedom (OEF) and Operation Freedom's Sentinel (OFS) during the years 2011-2016.
Materials and methods: A retrospective review of Department of Defense Trauma Registry (DoDTR) data was performed for all patients receiving ketamine during OEF/OFS in 2011-2016. Prevalence of ketamine use, absolute use, mechanism of injury, demographics, injury severity score, provider type, and co-administration rates of various medications and blood products were evaluated.
Results: Total number of administrations during the study period was 866. Ketamine administration during OEF/OFS increased during the years 2011-2013 (28 patient administrations in 2011, 264 administrations in 2012, and 389 administrations in 2013). A decline in absolute use was noted from 2014 to 2016 (98 administrations in 2014, 41 administrations in 2015, and 46 administrations in 2016). The frequency of battlefield ketamine use increased from 0.4% to 11.3% for combat injuries sustained in OEF/OFS from 2011 to 2016. Explosives (51%) and penetrating trauma (39%) were the most common pattern of injury in which ketamine was administered. Ketamine was co-administered with fentanyl (34.4%), morphine (26.2%), midazolam (23.1%), tranexamic acid (12.3%), plasma (10.3%), and packed red blood cells (18.5%).
Conclusions: This study demonstrates increasing use of ketamine by the U.S. Military on the battlefield and effectiveness of clinical practice guidelines in influencing practice patterns.
Lessons Learned During Prolonged Care of Combat Casualties by a Minimally Manned Surgical Team
Richard N Lesperance, Steven Adamson, Jennifer M Gurney
Mil Med. 2021 Jul 17;Online ahead of print.
Abstract
In the current deployed environment, small teams are dispersed to provide damage control surgical capabilities within an hour of injury. Given the well-developed evacuation system, these teams do not typically have a significant patient hold capability. Improved understanding of the shortfalls and problems encountered when caring for combat casualties in prolonged care situations will facilitate improved manning, training, and equipping of these resource-limited teams. We present the case of two critically injured soldiers who were evacuated to a 10-person split Forward Surgical Team (FST) during a weather system that precluded further evacuation. The casualties underwent damage control procedures necessitating temporary abdominal closures. The FST had to organize itself to provide intensive care significantly longer than traditional timelines for this role of care. Additionally, most team members had scarce critical care experience. An after-action review confirmed that most team members felt that they had not received adequate pre-mission training in postoperative intensive care and were not comfortable managing ventilated patients. In the current mature theaters of operations, there are robust evacuation capabilities, and presentations of scenarios like that are rare. However, as combat casualty care becomes increasingly austere and remote, small surgical teams need to train and be equipped to provide care outside of normal operation and doctrinal limits, including robust team cross-training. Incorporating principles of the prolonged care of combat casualties into the training of military surgeons will improve preparedness for these challenging situations.
Shimena R Li, Francis Guyette, Joshua Brown, Mazen Zenati, Katherine M Reitz, Brian Eastridge, Raminder Nirula, Gary A Vercruysse, Terence O'Keeffe, Bellal Joseph, 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.
Justin Lin, Yelena Figuerado, Adrienne Montgomery, Jonathan Lee, Mark Cannis, Valerie C Norton, Richard Calvo, Harminder Sikand
Am J Emerg Med. 2021 Jun;44:306-311
Background: Clinicians often encounter agitated patients, and current treatment options include benzodiazepines and antipsychotics. Ketamine rapidly induces dissociation, maintains cardiovascular stability, spontaneous respirations, and airway reflexes. There are no prospective, randomized studies comparing ketamine to other agents in the initial management of acute agitation in the Emergency Department (ED).
Objective: Determine the efficacy and safety of ketamine compared to parenteral haloperidol plus lorazepam for initial control of acute agitation.
Methods: This study was a prospective, single-institution, randomized, open-label, real world, standard of care pilot study. Adult patients with combative agitation were randomized to ketamine (4 mg/kg IM or 1 mg/kg IV) or haloperidol/lorazepam (haloperidol 5-10 mg IM or IV + lorazepam 1-2 mg IM or IV). The primary outcome was sedation within 5 min, and secondary outcomes included sedation within 15 min, time to sedation, and safety.
Results: Ninety three patients were enrolled from January 15, 2018 to October 10, 2018. Significantly more patients who received ketamine compared to haloperidol/lorazepam were sedated within 5 min (22% vs 0%, p = 0.001) and 15 min (66% vs 7%, p < 0.001). The median time to sedation in patients who received ketamine compared to haloperidol/lorazepam was 15 vs 36 min respectively (p < 0.001). Patients who received ketamine experienced a significant, but transient tachycardia (p = 0.01) and hypertension (p = 0.01).
Conclusion: In patients with combative agitation, ketamine was significantly more effective than haloperidol/lorazepam for initial control of acute agitation, and was not associated with any significant adverse effects.
Sublingual Sufentanil in Pain Management After Pulmonary Resection: A Randomized Prospective Study
Ivan Lomangino, Alessandro Berni, Andrea Lloret Madrid, Stefano Terzi, Luca Melan, Giorgio Cannone, Alessandro Rebusso, Andrea Zuin, Andrea Dell'Amore, Federico Rea
Ann Thorac Surg. 2021 Jul 29;S0003-4975(21)01294-7
Background: Successful postoperative pain management after major lung resection surgery is mostly achieved through intravenous administration of analgesic drugs. This study explored the use of sublingual sufentanil cartridges (Zalviso) as a noninvasive alternative to postoperative analgesia.
Methods: From July 2019 to April 2020, patients who underwent major thoracoscopic lung resection surgery were randomly allocated to receive either intravenous pain management, or patient-controlled analgesia by the Zalviso system. Pain assessment scores were collected for a 72-hour time window, and requests for additional medication due to insufficient pain control were recorded.
Results: Of the 80 patients enlisted, 40 were assigned to the Zalviso group and 40 to the control group. The groups were not statistically different from each other. The difference in the mean pain scores reported was statistically significant in the first 24 hours in favor of the Zalviso group (P = .046), and the need for additional pain medication was significantly higher in the control group (P = .004).
Conclusions: Patient-controlled analgesia using sublingual sufentanil cartridges can provide effective pain relief for patients undergoing video-assisted thoracic surgery and can reduce the need for additional medication, offering a noninvasive alternative to traditional intravenous therapy.
Shannon Lovett, Trent Reed, Robert Riggs, George Lew, Erica Koch, Ramon A Durazo-Arvizu, Megan A Rech
Acad Emerg Med. 2021 Jun;28(6):647-654
Objective: This study aimed to determine if 0.15 mg/kg intravenous (IV) subdissociative ketamine is noninferior to 0.3 mg/kg in emergency department (ED) patients with acute pain.
Methods: This randomized, prospective, double-blinded, noninferiority trial included patients' age 18 to 59 years presenting to the ED with acute moderate to severe pain. Subjects were randomized to IV subdissociative ketamine, 0.15 mg/kg ("low" dose) or 0.30 mg/kg ("high" dose), over 15 minutes. The primary endpoint was the 11-point numeric rating scale (NRS) pain score between groups at 30 minutes. Secondary endpoints included NRS pain scores at 15 and 60 minutes; change in NRS at 15, 30, and 60 minutes; rescue analgesia; and adverse effects. The noninferiority limit, δ0 , was set to 1.3.
Results: Forty-nine patients were included in each group. After the differences in the baseline NRS score were adjusted for, the mean NRS score at 30 minutes was 4.7 (95% confidence interval [CI] = 3.8 to 5.5) in the low-dose group and 5.0 (95% CI = 4.2 to 5.8) in the high-dose group (mean difference = 0.4, 95% CI = -0.8 to 1.5), indicating that the low-dose subdissociative ketamine was noninferior to the high dose (lower limit of 95% CI = -0.8 to ≥1.3 = -δ0 ). Adverse effects were similar at 30 minutes. At 15 minutes, the high-dose group experienced greater change in NRS; however, more adverse effects occurred.
Conclusion: Our data did not detect a large difference in analgesia or adverse effect profile between 0.15 mg/kg IV ketamine and 0.30 mg/kg in the short-term treatment of acute pain in the ED.
Minrui Lv, Yijun Jia, Zhaowen Zong, Renqing Jiang, Wenqiong Du, Lin Zhang, Zhao Ye, Xin Zhong
Mil Med. 2021 Jul 17;Online ahead of print.
Introduction: Training combat personnel in combat first-aid skills has faced many challenges over time, such as the need to combine tactics with medicine and to overcome combat personnel's lack of medical background knowledge. Therefore, many simulation methods are currently being developed, each of which has its advantages and disadvantages. In this study, a combined simulation method involving live-actor patients using a wearable training apparatus was developed, and the effects of this method were observed.
Materials and methods: Focusing on the major causes of preventable deaths among victims killed in action, wearable training apparatuses simulating massive hemorrhage, airway obstruction, and tension pneumothorax were designed and produced. Methods of simulating these three injury types using live-actor patients with these training apparatuses were developed, and medical teachers evaluated the simulation effects. The live-actor patients were incorporated into a tactical scenario to train and test nonmedical and medical students in year 3, respectively. High-fidelity simulator-based training and traditional training without simulation served as the control. A post-training survey using a 7-point Likert scale evaluated the trainees' feelings toward these training approaches.
Results: Three types of training apparatuses were developed to simulate three life-threatening injuries, and the simulation effects of the live-actor patients using these apparatuses were highly recognized by medical teachers. Both live-actor patients and high-fidelity simulator-based training improved performance significantly more than traditional training. However, the improvement due to training with live-actor patients was greater than that due to high-fidelity simulator-based training for nonmedical students, whereas there was no difference between these two simulation methods for medical students. A post-training survey revealed that all the trainees were confident in practicing first-aid skills after training, and they all agreed that live-actor patients could combine tactical situations with first aid better than high-fidelity simulators. The nonmedical students strongly agreed that live-actor patients were more helpful in the training of injury evaluation than high-fidelity simulators.
Conclusions: The method using wearable training apparatus-based live-actor patients was satisfying and effective for teaching life-saving combat first-aid skills, especially for nonmedical students.
C Cameron McCoy, Kelsey Montgomery, Madeline E Cotton, David E Meyer, Charles E Wade, Bryan A Cotton
J Trauma Acute Care Surg. 2021 Oct 1;91(4):627-633
Background: Low-titer group O whole blood (LTO-WB) has recently gained popularity in trauma centers for the acute resuscitation of hemorrhagic shock. However, limited supplies of Rh- product prevent implementation and strain sustainability at many trauma centers. We set out to identify whether Rh+ LTO-WB could be safely substituted for RH- product, regardless of patient's Rh status.
Methods: Following Institutional Review Board approval, information on all trauma patients receiving prehospital or emergency department transfusion of uncrossed, emergency release LTO-WB (11/17-10/19) were evaluated. Patients were first divided into those who received Rh- versus Rh+ product, the assessed by Rh of the recipient. Serial hemolysis panels, transfusion reactions, and outcomes were compared.
Results: Six hundred thirty-seven consecutive trauma patients received emergency release LTO-WB. Of these, 448 received Rh+ product, while 189 received Rh- LTO-WB. Patients receiving Rh+ product were more likely to be men (81 vs. 70%) and have lower field blood pressure (median 99 vs. 109) and GCS (median 7 vs. 12); all p < 0.05. There were no differences in blood product volume, hemolysis laboratories, transfusion reactions, complications, or survival. We then separated patients by Rh status (577 were Rh+, 70 were Rh-). Rh- patients were older (median age 54 vs. 39), more likely to be women (57 vs. 26%), and more likely to have sustained blunt trauma than their Rh+ counterparts (92 vs. 70%); all p < 0.05. There were no differences in hemolysis laboratories, transfusion reactions, complications, or survival between Rh+ and Rh- patients, regardless of Rh product received.
Conclusion: When Rh- whole blood is unavailable or in short supply, Rh+ LTO-WB appears to be a safe alternative for the resuscitation of hemorrhagic shock in both Rh+ and Rh- patients. Use of Rh+ product may help trauma centers incorporate LTO-WB into their hospital and improve sustainability of such programs.
A Survey of Tranexamic Acid Use by US Tactical Emergency Medical Support Providers
Sarayna S McGuire, Aaron B Klassen, Aidan F Mullan, Matthew D Sztajnkrycer
J Spec Oper Med. Summer 2021;21(2):72-76
Background: Tactical Emergency Medical Support (TEMS) providers may encounter severe traumatic injuries, with associated hemorrhagic shock, coagulopathy, and hyperfibrinolysis. Tranexamic acid (TXA) administration represents a potential intervention in this operational environment. This study evaluated TXA availability and use among US tactical medical personnel supporting law enforcement tactical teams.
Methods: An anonymous on-line survey of the American College of Emergency Physicians (ACEP) Tactical Emergency Medicine (TEM) section was administered.
Results: Fifty respondents were included in the final study. Fifty-four percent reported TXA availability, with 14% reporting its use at least once in the past year. Additional available resuscitative products included crystalloids (88%) and packed red blood cells (6%). Twenty-five respondents reported managing ≥ 1 patient(s) with hemorrhagic shock in the past year. Resuscitative measures included crystalloids (96%), TXA (68%), and blood products (16%). Overall, 88% of respondents were supportive of TXA use. Full-time teams, those with = 3 monthly callouts, and teams that carried blood products were more likely to have TXA.
Conclusions: Half of respondents reported managing a patient with hemorrhagic shock in the past year. Although 88% were supportive of TXA use, only 54% reported availability. Tactical teams with higher call volume and more resources were more likely to carry TXA. Further studies evaluating TEMS patient wounding patterns and barriers to TXA utilization are required.
A Rapid Review of Burns First Aid Guidelines: Is There Consistency Across International Guidelines?
Michael McLure, Finlay Macneil, Fiona M Wood, Leila Cuttle, Kathryn Eastwood, Janet Bray, Lincoln M Tracy
Cureus. 2021 Jun 20;13(6):e15779
Abstract
We conducted a rapid review of current international and Australian/New Zealand guidelines on first aid for burns to identify any critical variation and any recent major changes in the literature that would warrant a significant change to current recommendations. A search was conducted to identify Australian/New Zealand and international first aid guidelines for burn care using guideline databases, and we compared key recommendations from each guideline relating to burns first aid. A literature search of relevant databases (Medline, Embase, Cochrane Database of Systematic Reviews, PROSPERO international register of systematic reviews, and ClinicalTrials.gov databases) was conducted to identify existing and in-progress research published on the topic of first aid for burn injuries. Seven guidelines were identified from the Australia/New Zealand region, and 11 international guidelines were identified from the United States of America and Europe. All Australian and New Zealand guidelines recommended a cooling duration of 20 minutes and made some mention of when to refer a burn for medical evaluation, while international guidelines saw cooling duration variation, a number of guidelines failed to mention referral criteria. The review of published systematic reviews and clinical trials revealed a lack of new evidence in the last six years. Our rapid review identified key variation between first aid guidelines for burns that would benefit from the development of an international consensus on management. We identified no new significant evidence that would alter guideline recommendations and did not identify any upcoming reviews or clinical trials on this subject.
Margaret M Morgan, Debra G Perina, Nicole M Acquisto, Mary E Fallat, John M Gallagher, Kathleen M Brown, Jeffrey Ho, Aaron Burnett, Julio Lairet, Dennis Rowe, Mark L Gestring
Prehosp Emerg Care. Jul-Aug 2021;25(4):588-592
Abstract
The American College of Surgeons Committee on Trauma (ACS-COT), the American College of Emergency Physicians (ACEP), the National Association of State EMS Officials (NASEMSO), the National Association of EMS Physicians (NAEMSP) and the National Association of EMTs (NAEMT) have previously offered varied guidance on the use of ketamine in trauma patients. The following consensus statement represents the collective positions of the ACS-COT, ACEP, NASEMSO, NAEMSP and NAEMT. This updated uniform guidance is intended for use by emergency medical services (EMS) personnel, EMS medical directors, emergency physicians, trauma surgeons, nurses and pharmacists in their treatment of the trauma patient in both the prehospital and hospital setting.
Emergency Cricothyrotomy: A 10-Year Single Institution Experience
Annie E Moroco, Scott B Armen, David Goldenberg
Am Surg. 2021 Feb 10; Online ahead of print
Background: With recent technological advances reducing the demand for emergent surgical airway placement, surgeons are less often performing this life-saving procedure. We sought to assess the characteristics and outcomes surrounding patients undergoing modern emergent cricothyrotomy.
Methods: A retrospective case series was performed between January 2010 and January 2020 at a single tertiary academic level 1 trauma center. Patients who underwent tracheostomy (CPT 31600, 31601) within 48 hours of admission or listed in the trauma registry were queried. Charts were individually reviewed to identify patients with cricothyrotomy. Demographic, operative and relevant hospital course data were collected.
Results: A total of 1642 patients were identified with 12 of those found to have met inclusion criteria. The population was mostly male (91.7%) with an average age of 43 years and average body mass index of 30. Survival rate of patients was 75%. A total of 7 patients (58%) had appropriate anatomical placement of cricothyrotomy. Of those patients, 75% were performed by Trauma Surgery. Of the 5 patients with misplaced cricothyrotomy, all were male, with an average age and body mass index of 36 years and 25, respectively. Procedures were performed by prehospital personnel (20%), referring hospital (20%), and Trauma Surgery (60%).
Discussion: Cricothyrotomy remains a vital tool in the successful management of emergent airway access. The most common complication observed was improper anatomical placement, which occurred in nearly half of patients. Trauma surgeons perform 75% of cricothyrotomies, with an anatomical accuracy rate of 66.7%.
The effect of prehospital intravenous access in traumatic shock: a Japanese nationwide cohort study
Hiroki Nagasawa 1, Keita Shibahashi 2, Kazuhiko Omori 1, Youichi Yanagawa 1
Acute Med Surg. 2021 Jul 18;8(1):e681
Aim: We aimed to evaluate effect of prehospital intravenous (IV) access on mortality in traumatic shock using a large nationwide dataset.
Methods: We used the Japan Trauma Data Bank to identify adults (≥18 years) with a systolic blood pressure <90 mm Hg at the trauma scene and were directly transported to the hospital between 2010 and 2019. We compared patients who had prehospital IV access (IV (+)) or not (IV (-)), using propensity score-matched analysis, and 1:1 nearest-neighbor matching without replacement. Standardized mean difference was used to evaluate the match balance between the two matched groups; a standardized mean difference >0.1 was considered a significant imbalance. Primary outcome was 72-h mortality.
Results: Propensity scores matching generated 479 pairs from 5,857 patients. No significant between group differences occurred in 72-h mortality (7.8 versus 8.8%; difference, -1.0%; 95% confidence interval [CI]: -2.5-4.5%), 28-day mortality (11.8 versus 11.3%; 95% CI: -4.6-3.6%), blood transfusion administration within 24 h (55.3 versus 49.1%; 95% CI: -0.1-12.6%), prehospital time (56.3 versus 53.0 min; 95% CI: -1.8-8.4 min), and cardiopulmonary arrest on hospital arrival (1.3 versus 1.3%; 95% CI: -1.4-1.4%). However, significantly higher systolic blood pressure on hospital arrival was found in the IV (+) than in the IV (-) group (104.6 versus 100.1 mm Hg; 95% CI: 0.3-8.7 mm Hg).
Conclusion: We found no significant effect of establishing IV access in the prehospital setting on survival outcomes of patients with traumatic shock.
The multiple faces of ketamine in anaesthesia and analgesia
Silvia Natoli
Drugs Context. 2021 Apr 23;10:2020-12-8
Objective: Ketamine is an anaesthetic agent with a unique dissociative profile and pharmacological effects ranging from the induction and maintenance of anaesthesia to analgesia and sedation, depending on the dose. This article provides information for the clinical use of ketamine in anaesthesia, in both conventional and special circumstances.
Methods: This is a non-systematic review of the literature, through a PubMed search up to February 2021.
Results: With a favourable pharmacokinetic profile, ketamine is used in hospital and prehospital settings for emergency situations. It is suitable for patients with many heart conditions and, unlike other anaesthetics, its potential for cardiorespiratory depression is low. Furthermore, it may be used when venous access is difficult as it may be administered through various routes. Ketamine is the anaesthetic of choice for patients with bronchospasm thanks to its bronchodilatory and anti-inflammatory properties.
Conclusion: With a favourable pharmacokinetic profile, ketamine is used in hospital and prehospital settings for emergency situations and is suitable for patients with many cardiac and respiratory conditions.
Michael M Neeki, Christina Cheung, Fanglong Dong, Nam Pham, Dylan Shafer, Arianna Neeki, Keeyon Hajjafar, Rodney Borger, Brandon Woodward, Louis Tran
Trauma Surg Acute Care Open. 2021 Aug 27;6(1)
Background: Traumatic tension pneumothoraces (TPT) are among the most serious causes of death in traumatic injuries, requiring immediate treatment with a needle thoracostomy (NT). Improperly placed NT insertion into the pleural cavity may fail to treat a life-threatening TPT. This study aimed to assess the accuracy of prehospital NT placements by paramedics in adult trauma patients.
Methods: A retrospective chart review was performed on 84 consecutive trauma patients who had received NT by prehospital personnel. The primary outcome was the accuracy of NT placement by prehospital personnel. Comparisons of various variables were conducted between those who survived and those who died, and proper versus improper needle insertion separately.
Results: Proper NT placement into the pleural cavity was noted in 27.4% of adult trauma patients. In addition, more than 19% of the procedures performed by the prehospital providers appeared to have not been medically indicated.
Discussion: Long-term strategies may be needed to improve the capabilities and performance of prehospital providers' capabilities in this delicate life-saving procedure.
Matthew R Neth, Mohamud R Daya
Resuscitation. 2021 Oct;167:387-389
No abstract available
Red-Green Tactical Lighting Is Preferred for Suturing Wounds in a Simulated Night Environment
Brandon P Noyes, Julie B Mclean, Alexandra C Walchak, Gregory J Zarow, Micah J Gaspary, Kevin J Knoop, Paul J D Roszko
J Spec Oper Med. Spring 2021;21(1):65-69.
Background: Delivering medical care in nighttime conditions is challenging, as 25% of Special Operations medical Operators have reported that problems with lighting contributed to poor casualty outcomes. Red light is often used in nighttime operations but makes blood detection difficult and diminishes depth perception and visual acuity. Red-green combination lighting may be superior for differentiating blood from tissue and other fluids but had not been tested versus red-only or green-only lighting for combat-related medical procedures, such as wound suturing.
Methods: Dark-adapted medical resident physicians (N = 24) sutured 6cm long, 3cm deep, full-thickness lacerations in deceased swine under red-only, green-only, and red-green lighting provided by a tactical flashlight using a randomized within-subjects design. Time to suture completion, suture quality, user ratings, and user preference data were contrasted at p < .05. This study was approved by Naval Medical Center Portsmouth IRB.
Results: Suture completion time and suture quality were similar across all lighting conditions. Participants rated red-green lighting as significantly easier for identifying blood, identifying instruments, and performing suturing (p < .01). Red-green lighting was preferred by 83% of participants compared to 8% each for red-only and green-only (p < .001).
Conclusions: Pending further study under tactical conditions, red-green lighting is tentatively recommended for treating battlefield wounds in low-light environments.
The Efficacy and Safety of Tranexamic Acid Treatment in Orthopaedic Trauma Surgery
Cody R Perskin, Connor P Littlefield, Charles Wang, Uchenna Umeh, Kenneth A Egol
JBJS Rev. 2021 Jul 16;9(7)
Abstract
»: Tranexamic acid (TXA) is a drug used to control hemorrhage by preventing the breakdown of fibrin.
»: TXA is a cost-effective treatment for trauma patients across a variety of economic settings.
»: Concerns of TXA causing thromboembolic events (TEEs) in orthopaedic trauma patients are not supported by evidence.
»: TXA has been shown to reduce blood loss in hip fracture surgery.
Spray-dried plasma: A post-traumatic blood "bridge" for life-saving resuscitation
Mark A Popovsky, Nathan White
Transfusion. 2021 Jul;61 Suppl 1:S294-S300
Abstract
Massive bleeding remains a major source of morbidity and mortality worldwide. Recent studies have shed light on the pathophysiology of traumatic-induced coagulopathy and the central role of endotheliopathy. Transfusion therapy has changed dramatically in the last decade with use of red cells and plasma in a 1:1 ratio. The use of early transfusion increases the likelihood of a favorable outcome. Early intervention-preferably less than 60 min of injury-is a major factor in improved survival. Experience with dried plasma products-lyophilized or freeze-dried-in Europe and South Africa has demonstrated both safety and efficacy. Dry plasma products are not available in the United States but several products are in development. Spray-dried plasma contains clinically meaningful levels of coagulation activity and in vitro data suggest robust ability to generate thrombus. The decentralized, blood-center based manufacturing model of spray-dried plasma offers advantages for availability to meet routine and extraordinary demands.
Erik Prytz, Rachel Phillips, Susanna Lönnqvist, Marc Friberg, Carl-Oscar Jonson
BMC Emerg Med. 2021 Sep 4;21(1):100
Introduction: First aid performed by immediate responders can be the difference between life and death in the case of trauma with massive bleeding. To develop effective training programs to teach bleeding control to laypersons, it is important to be aware of beliefs and misconceptions people hold on bleeding and severity of bleeding situations.
Method: A controlled study was conducted in which 175 American college students viewed 78 video clips of simulated bleeding injuries. The volume of blood present (between 0 and 1900 ml), rate of blood flow, and victim gender were systematically varied within participants. Participants were asked to rate injury severity, indicate the appropriate first aid action, and estimate the amount of time until death for the victim.
Results: Though the Stop the Bleed® campaign recommends training laypeople to treat 165 ml of blood loss as life threatening, participants largely rated this volume of blood loss as minimal, mild, or moderate and estimated that the victim had just under one hour to live. Increased blood loss was associated with increased recommendations to use a tourniquet. However, in the 1900 ml conditions, participants still estimated that victims had around 22 minutes to live and approximately 15% recommended direct pressure as the intervention. Severity ratings and recommendations to use a tourniquet were also higher for the male victim than the female victim.
Conclusions: Injury classification, intervention selection, and time to death-estimations revealed that training interventions should connect classifications of blood loss to appropriate action and focus on perceptions of how much time one has to respond to a bleeding. The study also revealed a gender related bias in terms of injury classification and first aid recommendations. Bleeding control training programs can be designed to address identified biases and misconceptions while building on existing knowledge and commonly used terminology.
Patrick Richard, Nilam Patel, Daniel Gedeon, Regine Hyppolite, Mustafa Younis
Int J Environ Res Public Health. 2021 Jul 30;18(15):8079
Abstract
This study used data from the Military Health System Data Repository to examine the association between mild traumatic brain injuries (mTBI) and work functioning such as work duty limitations, hospital emergency room visits and inpatient admissions for active-duty service members (ADSMs). Further, this study assessed the role that common symptoms of mTBI play in work functioning. Multivariate results showed that having a mTBI diagnosis is not a major factor that results in being "released with work duty limitations". However, findings from these regression models also showed that the interaction of mTBI with cognitive and linguistic symptoms resulted in odds of 3.63 (CI: 1.40-9.36, p < 0.01) for being "released with work duty limitations" and odds of 4.98 (CI: 1.16-21.39, p < 0.05) for having any emergency department visits compared to those with no diagnosis of mTBI and none of these symptoms. Additionally, the interaction of mTBI with sleep disturbance and chronic pain showed odds of 2.72 (CI: 1.31-5.65, p < 0.01) and odds of 11.56 (CI: 2.65-50.44, p < 0.01) for being "released with work duty limitations" compared to those with no diagnosis of TBI and none of these symptoms, respectively. Further research is needed to investigate the association between mTBI and duration of time off work to provide a comprehensive understanding of the effect of mTBI on work functioning in the Military Health System.
Acting on the potentially reversible causes of traumatic cardiac arrest: Possible but not sufficient
Dominique Savary, Delphine Douillet, François Morin, Adrien Drouet, Thomas Moumned, Pierre Metton, Bruno Carneiro, Marc Fadel, Alexis Descatha
Resuscitation. 2021 Aug;165:8-13
Introduction: Traumatic cardiac arrest (TCA) guidelines emphasize specific actions that aim to treat the potential reversible causes of the arrest. The aim of this study was to measure the impact of these recommendations on specific rescue measures carried out in the field, and their influence on short-term outcomes in the resuscitation of TCA patients.
Methods: We conducted a retrospective study of all TCA patients treated in two emergency medical units, which are part of the Northern Alps Emergency Network, from January 2004 to December 2017. We categorised cases into three periods: pre-guidelines (from January 2004 to December 2007), during guidelines (from January 2008 to December 2011), and post-guidelines (from January 2012 to December 2017). Local guidelines, a physician education programme, and specific training were set up during the post-guidelines period to increase adherence to recommendations. Utstein variables, and specific rescue measures were collected: advanced airway management, fluid administration, pelvic stabilisation or tourniquet application, bilateral thoracostomy, and thoracotomy procedures. The primary endpoint was survival rate at day 30 with good neurological status (cerebral performance category scores 1 & 2) in each period, considering the pre-guidelines period as the reference.
Results: There were 287 resuscitation attempts in the TCA cases included, and 279 specific interventions were identified with a significant increase in the number of fluid expansions (+16%), bilateral thoracostomies (+75%), and pelvic stabilisations (+25%) from the pre- to post-guidelines periods. However, no improvement in survival over time was found.
Blood Product Administration During Transport Throughout the US Africa Command Theater of Operation
Steven G Schauer, Jason F Naylor, Andrew D Fisher, Darren G Hyams, Brandon M Carius, Mireya A Escandon, Carlissa D Linscomb, Harry McDonald, Andrew P Cap, James Bynum
J Spec Oper Med. Fall 2021;21(3):66-70.
Background: United States Africa Command (US AFRICOM) is one of six US Defense Department's geographic combatant commands and is responsible to the Secretary of Defense for military relations with African nations, the African Union, and African regional security organizations. A full-spectrum combatant command, US AFRICOM is responsible for all US Department of Defense operations, exercises, and security cooperation on the African continent, its island nations, and surrounding waters. We seek to characterize blood product administration within AFRICOM using the in-transit visibility tracking tool known as TRAC2ES (TRANSCOM Regulating and Command & Control Evacuation System).
Methods: We performed a retrospective review of TRAC2ES medical evacuations from the AFRICOM theater of operations conducted between 1 January 2008 and 31 December 2018.
Results: During this time, there were 963 cases recorded in TRAC2ES originating within AFRICOM, of which 10 (1%) cases received blood products. All patients were males. One was a Department of State employee, one was a military working dog, and the remainder were military personnel. Of the ten humans, seven were the result of trauma, most by way of gunshot wound, and three were due to medical causes. Among human subjects receiving blood products for traumatic injuries, a total of 5 units of type O negative whole blood, 29 units of packed red blood cells (pRBCs), and 9 units of fresh frozen plasma (FFP) were transfused. No subjects underwent massive transfusion of blood products, and only one subject received pRBCs and FFP in 1:1 fashion. All subjects survived until evacuation.
Conclusions: Within the TRAC2ES database, blood product administration within AFRICOM was infrequent, with some cases highlighting lack of access to adequate blood products. Furthermore, the limitations within this database highlight the need for systems designed to capture medical care performance improvement, as this database is not designed to support such analyses. A mandate for performance improvement within AFRICOM that is similar to that of the US Central Command would be beneficial if major improvements are to occur.
Conclusion: Reversible measures were applied but to a varying degree, and may not adequately capture pre-hospital performance on overall TCA survival.
Something Old Becomes Something New: Ketamine
Bruce A Schoneboom
Mil Med. 2021 Jul 1;186(7-8):207-208
No abstract available
Stacy A Shackelford, Deborah J Del Junco, Jamie C Riesberg, Douglas Powell, Edward L Mazuchowski, Russ S Kotwal, Paul E Loos, Harold R Montgomery, Michael A Remley, Jennifer M Gurney, Sean Keenan
J Trauma Acute Care Surg. 2021 Aug 1;91(2S Suppl 2):S186-S193
Background: Quantification of medical interventions administered during prolonged field care (PFC) is necessary to inform training and planning.
Materials and methods: Retrospective cohort study of Department of Defense Trauma Registry casualties with maximum Abbreviated Injury Scale (MAIS) score of 2 or greater and prehospital records during combat operations 2007 to 2015; US military nonsurvivors were linked to Armed Forces Medical Examiner System data. Medical interventions administered to survivors of 4 hours to 72 hours of PFC and nonsurvivors who died prehospital were compared by frequency-matching on mechanism (explosive, firearm, other), injury type (penetrating, blunt) and injured body regions with MAIS score of 3 or greater. Covariates for adjustment included age, sex, military Service, shock, Glasgow Coma Scale, transport team, MAIS and Injury Severity Score (ISS). Sensitivity analysis focused on US military subgroup with AIS/ISS assigned to nonsurvivors after autopsy.
Results: The total inception cohort included 16,202 casualties (5,269 US military, 10,809 non-US military), 64% Afghanistan, 36% Iraq. Of US military, 734 deaths occurred within 30 days, nearly 90% occurred within 4 hours of injury. There were 3,222 casualties (1,111 US military, 2,111 non-US military) documented for prehospital care and died prehospital (691) or survived 4 hours to 72 hours of PFC (2,531). Twenty-five percent (815/3,222) received advanced airway, 18% (583) ventilatory support, 9% (281) tourniquet. Twenty-three percent (725) received blood transfusions within 24 hours. Of the matched cohort (1,233 survivors, 490 nonsurvivors), differences were observed in care (survivors received more warming, intravenous fluids, sedation, mechanical ventilation, narcotics, antibiotics; nonsurvivors received more intubations, tourniquets, intraosseous fluids, cardiopulmonary resuscitation). Sensitivity analysis focused on US military (732 survivors, 379 nonsurvivors) showed no significant differences in prehospital interventions. Without autopsy information, the ISS of nonsurvivors significantly underestimated injury severity.
Conclusion: Tourniquets, blood transfusion, airway, and ventilatory support are frequently required interventions for the seriously injured. Prolonged field care should direct resources, technology, and training to field technology for sustained resuscitation, airway, and breathing support in the austere environment.
Stacy A Shackelford, Jennifer M Gurney, Audra L Taylor, Sean Keenan, Jason B Corley, Cord W Cunningham, Brendon G Drew, Shane D Jensen, Russ S Kotwal, Harold R Montgomery, Erika T Nance, Michael A Remley, Andrew P Cap, Joint Trauma System Defense Committee on Trauma; Armed Services Blood Program
Transfusion. 2021 Jul;61 Suppl 1:S333-S335
Abstract
Hemorrhage is the most common mechanism of death in battlefield casualties with potentially survivable injuries. There is evidence that early blood product transfusion saves lives among combat casualties. When compared to component therapy, fresh whole blood transfusion improves outcomes in military settings. Cold-stored whole blood also improves outcomes in trauma patients. Whole blood has the advantage of providing red cells, plasma, and platelets together in a single unit, which simplifies and speeds the process of resuscitation, particularly in austere environments. The Joint Trauma System, the Defense Committee on Trauma, and the Armed Services Blood Program endorse the following: (1) whole blood should be used to treat hemorrhagic shock; (2) low-titer group O whole blood is the resuscitation product of choice for the treatment of hemorrhagic shock for all casualties at all roles of care; (3) whole blood should be available within 30 min of casualty wounding, on all medical evacuation platforms, and at all resuscitation and surgical team locations; (4) when whole blood is not available, component therapy should be available within 30 min of casualty wounding; (5) all prehospital medical providers should be trained and logistically supported to screen donors, collect fresh whole blood from designated donors, transfuse blood products, recognize and treat transfusion reactions, and complete the minimum documentation requirements; (6) all deploying military personnel should undergo walking blood bank prescreen laboratory testing for transfusion transmitted disease immediately prior to deployment. Those who are blood group O should undergo anti-A/anti-B antibody titer testing.
Combat-related ocular injuries in the Israel Defense Forces during the years 2013 to 2019
Nitzan Shakarchy-Kaminsky, Jacob Megreli, Dan Kaminsky, Avishai M Tsur, Roy Nadler, Irina Radomislensky, Shaul Gelikas, Elon Glassberg, Avi Benov, Ariel Furer
J Trauma Acute Care Surg. 2021 Aug 1;91(2S Suppl 2):S241-S246
Background: Ocular injuries account for up to 13% of battle injuries, despite the implementation of advanced protective eyewear (PE). The aim of this study was to describe the extent of ocular injuries over the last years among Israel Defense Forces soldiers and to examine the change in PE policy introduced in 2013 and the effect of a high-intensity conflict on ocular injury characteristics.
Methods: This retrospective registry-based analysis derived data from the Israel Defense Forces Trauma Registry and included soldiers who sustained combat-related ocular injuries between the years 2013 and 2019. Demographic data and injury characteristics of casualties, as well as information regarding the use of PE, were collected and analyzed.
Results: A total of 2,312 military casualties were available for this study; the incidence of combat-related ocular injuries was 8.9% (n = 113). Ocular injuries occurred among male soldiers (98.2%) with a mean ± SD age of 22.7 ± 4.6 years; mechanism of injury was penetrating in 59.3% of the casualties and blunt in 22.1% of the casualties, ocular injury was isolated in 51.3% of the casualties, and others sustained concomitant injuries including head (32.7%), upper extremity injury (17.7%), lower extremity (15.9%), torso (8.0%), neck (6.2%), and other (5.9%) injuries. Ocular injuries rate was similar among casualties who used PE (11.2%) and those who did not use PE (13.0%) while injured (p = 0.596). Rate of open globe injuries was 9.1% in casualties who used PE and 39.5% (p = 0.002) in casualties who did not.
Conclusion: Eye protection may significantly reduce ocular injuries severity. Education of the combatants on the use of PE and guidance of medical teams on proper assessment, initial treatment, and rapid evacuation of casualties are needed to improve visual outcomes of the casualties further.
Prehospital paramedic pleural decompression: A systematic review
Ms Kelsey Sharrock, Brendan Shannon, Carlos Garcia Gonzalez, Toby St Clair, Biswadev Mitra, Michael Noonan, Prof Mark Fitzgerald, Alexander Olaussen
Injury. 2021 Oct;52(10):2778-2786
Background: Tension pneumothorax (TPT) is a frequent life-threat following thoracic injury. Time-critical decompression of the pleural cavity improves survival. However, whilst paramedics utilise needle thoracostomy (NT) and/or finger thoracostomy (FT) in the prehospital setting, the superiority of one technique over the other remains unknown.
Aim: To determine and compare procedural success, complications and mortality between NT and FT for treatment of a suspected TPT when performed by paramedics.
Methods: We searched four databases (Ovid Medline, PubMed, CINAHL and Embase) from their commencement until 25th August 2020. Studies were included if they analysed patients suffering from a suspected TPT who were treated in the prehospital setting with a NT or FT by paramedics (or local equivalent nonphysicians).
Results: The search yielded 293 articles after duplicates were removed of which 19 were included for final analysis. Seventeen studies were retrospective (8 cohort; 7 case series; 2 case control) and two were prospective cohort studies. Only one study was comparative, and none were randomised controlled trials. Most studies were conducted in the USA (n=13) and the remaining in Australia (n=4), Switzerland (n=1) and Canada (n=1). Mortality ranged from 12.5% to 79% for NT and 64.7% to 92.9% for FT patients. A higher proportion of complications were reported among patients managed with NT (13.7%) compared to FT (4.8%). We extracted three common themes from the papers of what constituted as a successful pleural decompression; vital signs improvement, successful pleural cavity access and absence of TPT at hospital arrival.
Conclusion: Evidence surrounding prehospital pleural decompression of a TPT by paramedics is limited. Available literature suggests that both FT and NT are safe for pleural decompression, however both procedures have associated complications. Additional high-quality evidence and comparative studies investigating the outcomes of interest is necessary to determine if and which procedure is superior in the prehospital setting.
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.
A quantitative evaluation of aerosol generation during supraglottic airway insertion and removal
A J Shrimpton, J M Brown, T M Cook, A E Pickering
Anaesthesia. 2022 Feb;77(2):230-231
No abstract available
Christopher Simpson, Harriet Tucker, Anthony Hudson
Scand J Trauma Resusc Emerg Med. 2021 Sep 16;29(1):137
Abstract
Penetrating injuries to the neck pose a unique challenge to clinicians due to the proximity of multiple significant anatomical structures with little protective soft tissue coverage. Injuries to this area, whilst low in incidence, are potentially devastating. Respiratory, vascular, gastro-oesophageal and neurological structures may all be involved, either in isolation or combination. These injuries are particularly difficult to manage in the resource poor, often austere and/or remote, pre-hospital environment. A systematic scoping review of the literature was conducted to evaluate the current available research pertaining to managing this injury profile, prior to the patient arriving in the emergency department. The available research is discussed in sections based on the commonly used trauma management acronym 'cABCD' (catastrophic haemorrhage, Airway, Breathing, Circulation, Disability) to facilitate a systematic approach and clinical evaluation familiar to clinicians. Based on the available reviewed evidence, we have proposed a management algorithm for this cohort of patients. From this we plan to instigate a Delphi process to develop a consensus statement on the pre-hospital management of this challenging presentation.
Kathleen E Singer, Taylor E Wallen, Mackenzie C Morris, Emily McGlone, Sabre Stevens-Topie, Ryan Earnest, Michael D Goodman
J Trauma Acute Care Surg. 2021 Aug 1;91(2S Suppl 2):S89-S98
Background: Traumatic brain injury (TBI) is common in civilians and military personnel. No potential therapeutics have been evaluated to prevent secondary injury induced by the hypobaric hypoxia (HH) environment integral to postinjury aeromedical evacuation (AE). We examined the role of allopurinol, propranolol, adenosine/lidocaine/magnesium (ALM), or amitriptyline administration prior to simulated flight following murine TBI.
Methods: Mice underwent TBI and were given allopurinol, propranolol, amitriptyline, or ALM prior to simulated AE or normobaric normoxia (NN) control. Heart rate (HR), respiratory rate, and oxygen saturation (Spo2) were recorded throughout simulated AE. Mice were sacrificed at 24 hours, 7 days, or 30 days. Serum and cerebral cytokines were assessed by enzyme-linked immunosorbent assay. Motor function testing was performed with Rotarod ambulation. Immunohistochemistry was conducted to examine phosphorylated tau (p-tau) accumulation in the hippocampus at 30 days.
Results: While all treatments improved oxygen saturation, propranolol, amitriptyline, and allopurinol improved AE-induced tachycardia. At 24 hours, both propranolol and amitriptyline reduced tumor necrosis factor alpha levels while allopurinol and ALM reduced tumor necrosis factor alpha levels only in NN mice. Propranolol, amitriptyline, and ALM demonstrated lower serum monocyte chemoattractant protein-1 7 days after AE. Both amitriptyline and allopurinol improved Rotarod times for AE mice while only allopurinol improved Rotarod times for NN mice. Propranolol was able to reduce p-tau accumulation under both HH and NN conditions while ALM only reduced p-tau in hypobaric hypoxic conditions.
Conclusion: Propranolol lowered post-TBI HR with reduced proinflammatory effects, including p-tau reduction. Amitriptyline-induced lower post-TBI HR and improved functional outcomes without affecting inflammatory response. Allopurinol did not affect vital signs but improved late post-TBI systemic inflammation and functional outcomes. Adenosine/lidocaine/magnesium provided no short-term improvements but reduced p-tau accumulation at 30 days in the HH cohort. Allopurinol may be the best of the four treatments to help prevent short-term functional deficits while propranolol may address long-term effects.
Benzodiazepines increase the likelihood of both infectious and thrombotic complications
Edward Skicki, Madison Morgan, Catherine Brown, Eric Bradburn, Frederick Rogers
J Trauma Acute Care Surg. 2021 Jul 1;91(1):206-211
Introduction: Benzodiazepines (BZDs) modulate peripheral γ-amino-butyric acid type A on macrophages causing immunomodulation. They inhibit proinflammatory cytokines increasing infections. Prior studies have also shown that infections can increase thrombotic complications. We sought to examine this relationship in trauma patients. We hypothesized that the presence of BZDs on admission urine drug screen (UDS) would increase rates of both complications.
Methods: All patients submitted to the Pennsylvania Trauma Outcome Study database from 2003 to 2018 were queried. Those with a positive UDS for BZDs were analyzed. Infectious complications were defined as pneumonia, urinary tract infection, sepsis, wound, and soft tissue infection, and thrombotic complications were defined as presence of pulmonary embolism or deep vein thrombosis. Logistic regressions controlling for demographic and injury covariates assessed the adjusted impact of BZDs on infectious and thrombotic complications.
Results: A total of 3,393 patients (2.08%) had infectious complications, and 3,048 (1.87%) had thrombotic complications. Furthermore, 33,260 patients (20.4%) had a positive UDS for BZDs on admission. Univariate analysis showed that those positive for BZDs had higher rates of infectious (3.33% vs. 1.76%, p < 0.001) and thrombotic (2.84% vs. 1.62%, p < 0.001) complications. Multivariate analysis revealed that BZDs significantly increased the odds of infectious and thrombotic complications. Patients who tested positive for BZDs and subsequently developed infection had increased odds (adjusted odds ratio, 1.65; p < 0.001) of developing thrombotic complications.
Conclusion: Trauma patients with a positive UDS for BZDs had higher odds of both infectious and thrombotic complications. Moreover, odds of thrombotic complications were higher in those with infections.
Cardiopulmonary resuscitation in special circumstances
Jasmeet Soar, Lance B Becker, Katherine M Berg, Sharon Einav, Qingbian Ma, Theresa M Olasveengen, Peter Paal, Michael J A Parr
Lancet. 2021 Oct 2;398(10307):1257-1268
Abstract
Cardiopulmonary resuscitation prioritises treatment for cardiac arrests from a primary cardiac cause, which make up the majority of treated cardiac arrests. Early chest compressions and, when indicated, a defibrillation shock from a bystander give the best chance of survival with a good neurological status. Cardiac arrest can also be caused by special circumstances, such as asphyxia, trauma, pulmonary embolism, accidental hypothermia, anaphylaxis, or COVID-19, and during pregnancy or perioperatively. Cardiac arrests in these circumstances represent an increasing proportion of all treated cardiac arrests, often have a preventable cause, and require additional interventions to correct a reversible cause during resuscitation. The evidence for treating these conditions is mostly of low or very low certainty and further studies are needed. Irrespective of the cause, treatments for cardiac arrest are time sensitive and most effective when given early-every minute counts.
Elizabeth A Stokes, Michelle J Lazaroo, Madeleine Clout, Stephen J Brett, Sarah Black, Kim Kirby, Jerry P Nolan, Barnaby C Reeves, Maria Robinson, Chris A Rogers, Lauren J Scott, Helena Smartt, Adrian South, Jodi Taylor, Matthew Thomas, Sarah Voss, Jonathan R Benger, Sarah Wordsworth
Resuscitation. 2021 Oct;167:1-9
Aim: Optimal airway management during out-of-hospital cardiac arrest (OHCA) is uncertain. Complications from tracheal intubation (TI) may be avoided with supraglottic airway (SGA) devices. The AIRWAYS-2 cluster randomised controlled trial (ISRCTN08256118) compared the i-gel SGA with TI as the initial advanced airway management (AAM) strategy by paramedics treating adults with non-traumatic OHCA. This paper reports the trial cost-effectiveness analysis.
Methods: A within-trial cost-effectiveness analysis of the i-gel compared with TI was conducted, with a six-month time horizon, from the perspective of the UK National Health Service (NHS) and personal social services. The primary outcome measure was quality-adjusted life years (QALYs), estimated using the EQ-5D-5L questionnaire. Multilevel linear regression modelling was used to account for clustering by paramedic when combining costs and outcomes.
Results: 9296 eligible patients were attended by 1382 trial paramedics and enrolled in the AIRWAYS-2 trial (4410 TI, 4886 i-gel). Mean QALYs to six months were 0.03 in both groups (i-gel minus TI difference -0.0015, 95% CI -0.0059 to 0.0028). Total costs per participant up to six months post-OHCA were £3570 and £3413 in the i-gel and TI groups respectively (mean difference £157, 95% CI -£270 to £583). Based on mean difference point estimates, TI was more effective and less costly than i-gel; however differences were small and there was great uncertainty around these results.
Conclusion: The small differences between groups in QALYs and costs shows no difference in the cost-effectiveness of the i-gel and TI when used as the initial AAM strategy in adults with non-traumatic OHCA.
Eric Sulava, William Bianchi, Christian S McEvoy, Paul J Roszko, Gregory J Zarow, Micah J Gaspary, Ramesh Natarajan, Jonathan D Auten
J Surg Res. 2021 Nov;267:172-181
Background: Blood transfusion via single site intraosseous access is a critical modality when caring for a trauma victim that lacks intravascular access. Flow rates and potential clinical complications when utilizing two sites of intraosseous access are not well known.
Materials and methods: Anesthetized adult female Yorkshire swine (Sus scrofa; n = 48; 76.7 ± 1.75kg; range 66-90kg) were cannulated and then bled approximately 30% total blood volume. Swine were randomly assigned to treatment groups: single sited humerus, single sited sternum, dual sited humerus or dual sited humerus and sternum. Flow rates, hemolysis, physiologic measurements, biochemical variables, and pulmonary histologic inflammation and occlusion were contrasted between groups.
Results: Dual sited intraosseous transfusion flow rates (128ml/min, 95% CI 123-132) were double the flow rates of single sites (65ml/min, 95% CI 60-70), P < .0001.Single sited humeral flow rates were greater than sternal flow rates, with respective averages of 74ml/min and 55ml/min, though not reaching statistical significance (P < 0.17). There was no significant elevation of plasma free hemoglobin in any group after transfusion as compared to baseline (P = 0.7). Groups did not significantly differ in vitals or biochemical variables. Most pulmonary specimens had some intraparenchymal fat embolism, however no animals had evidence of occlusive intra-arterial fat embolism.
Conclusions: Dual anatomic site, pressure bag driven, intraosseous blood transfusion approximately doubles flow rates without evidence of clinical complications or hemolysis. Further research using a survivability model is needed to characterize long-term complications from pressurized IO transfusions.
Characteristics of burn casualties treated at role 2 in Afghanistan
Mithun R Suresh, Amanda M Staudt, Jennifer D Trevino, Krystal K Valdez-Delgado, Christopher A VanFosson, Julie A Rizzo
J Trauma Acute Care Surg. 2021 Aug 1;91(2S Suppl 2):S233-S240
Background: Role 2 medical treatment facilities (MTFs) are frequently located in austere settings and have limited resources. A dedicated assessment of burn casualties treated at this level of care has not been performed. Therefore, the objective of this study was to characterize burn casualties presenting to role 2 MTFs in Afghanistan, along with the procedures they required, complications, and mortality to begin understanding the resources consumed by their care.
Methods: We identified burn casualties from the Department of Defense Trauma Registry (DODTR). The inclusion criteria were (1) experienced burn injuries in Afghanistan between October 2005 and April 2018 and (2) had documentation of treatment at role 2 in the DODTR. We excluded casualties with only first-degree burns, not otherwise specified burns, or only corneal burns. Casualty demographics, injury characteristics, procedures, and outcomes were reported.
Results: We identified 453 burn casualties with a median (interquartile range) Injury Severity Score of 10 (4-22) and percent total body surface area burned of 11 (5-30). There were 123 casualties (27.2%) with inhalation injury, and the casualties experienced 3,343 additional traumatic injuries and needed 2,530 procedures. Casualties with documentation of resuscitation information received a median (interquartile range) of 1.9 (0.7-3.7) L of crystalloid fluids. Complications were documented in 53 casualties (11.7%). Final mortality was reported in 36 casualties (8.0%), and mortality at role 2 MTFs was reported in 7 casualties (1.5%).
Conclusion: Burn casualties had many injuries and needed many procedures, including those related to airway management, resuscitation, and wound care. Given the urgency of these procedures, ensuring that there is enough equipment and supplies will be important in the future. Although infrequent, some casualties experienced complications. Factors that may influence resuscitation include injury severity, concomitant traumatic injuries, and available supplies. Obtaining more contextual information on the patient care environment will be useful going forward.
Penetrating abdominal trauma - selected case reports
P Svoboda, R Doležel, P Kupka, J Rudiš, R Pohnán
Rozhl Chir. Summer 2021;100(5):246-251
Abstract
We present 3 case-reports with penetrating abdominal injury from our practice in this article. An urgent laparotomy was performed in all cases because of haemodynamic instability or the mechanism of injury. Penetrative abdominal traumas are associated with a high risk of life-threatening intra-abdominal injuries, require urgent revision and are often accompanied by postoperative infections of the peritoneal cavity. In recent years, there has been a growing tendency towards mini-invasive approaches or even non-operative treatment. This trend is particularly evident in the United States of America, where doctors experience a higher number of penetrating injuries compared to the prevalent blunt force trauma in Europe. The authors describe the need to follow all recommended procedures in the pre-hospital and hospital phases of treatment of these patients and compare them with recent literature. Key words: penetrating abdominal trauma.
Matthew D Tadlock, Jennifer Gurney, Michael S Tripp, Leopoldo C Cancio, Michael J Sise, Jesse Bandle, Miguel Cubano, Joseph Lee, Matthew Vasquez, José A Acosta
J Trauma Acute Care Surg. 2021 Aug 1;91(2S Suppl 2):S46-S55
Abstract: In the future, United States Navy Role 1 and Role 2 shipboard medical departments will be caring for patients during Distributed Maritime Operations in both contested and noncontested austere environments; likely for prolonged periods of time. This literature review examines 25 modern naval mass casualty incidents over a 40-year period representative of naval warfare, routine naval operations, and ship-based health service support of air and land operations. Challenges, lessons learned, and injury patterns are identified to prepare afloat medical departments for the future fight.
Head Impact Modeling to Support a Rotational Combat Helmet Drop Test
Ryan Terpsma, Rika Wright Carlsen, Ron Szalkowski, Sushant Malave, Alice Lux Fawzi, Christian Franck, Chad Hovey
Mil Med. 2021 Sep 11; Online ahead of print.
Introduction: The Advanced Combat Helmet (ACH) military specification (mil-spec) provides blunt impact acceleration criteria that must be met before use by the U.S. warfighter. The specification, which requires a helmeted magnesium Department of Transportation (DOT) headform to be dropped onto a steel hemispherical target, results in a translational headform impact response. Relative to translations, rotations of the head generate higher brain tissue strains. Excessive strain has been implicated as a mechanical stimulus leading to traumatic brain injury (TBI). We hypothesized that the linear constrained drop test method of the ACH specification underreports the potential for TBI.
Materials and methods: To establish a baseline of translational acceleration time histories, we conducted linear constrained drop tests based on the ACH specification and then performed simulations of the same to verify agreement between experiment and simulation. We then produced a high-fidelity human head digital twin and verified that biological tissue responses matched experimental results. Next, we altered the ACH experimental configuration to use a helmeted Hybrid III headform, a freefall cradle, and an inclined anvil target. This new, modified configuration allowed both a translational and a rotational headform response. We applied this experimental rotation response to the skull of our human digital twin and compared brain deformation relative to the translational baseline.
Results: The modified configuration produced brain strains that were 4.3 times the brain strains from the linear constrained configuration.
Conclusions: We provide a scientific basis to motivate revision of the ACH mil-spec to include a rotational component, which would enhance the test's relevance to TBI arising from severe head impacts.
Operation Blood Rain: The Effect of Airdrop on Fresh Whole Blood
Robert L Tong, Cody W Bohlke, Roselyn W Clemente Fuentes, Manuel Moncada, Alexander D Schloe, Robert L Ashley
J Spec Oper Med. Summer 2021;21(2):29-33
Background: Administration of fresh whole blood (FWB) is a life-saving treatment that prolongs life until definitive surgical intervention can be performed; however, collecting FWB is a time-consuming and resource-intensive process. Furthermore, it may be difficult to collect sufficient FWB to treat critically wounded patients or multiple-hemorrhaging casualties. This study describes the effect of airdrop on FWB and explores the possibility of using airdrop to deliver FWB to combat medics treating casualties in the prehospital setting when FDA-approved, cold-stored blood products are not readily available and timely casualty evacuation (CASEVAC) is not feasible.
Methods: Four units of FWB were collected from volunteer donors and loaded into a blood cooler that was dropped from a fixed-wing aircraft under a standard airdrop training bundle (SATB) parachute. A control group of 4 units of FWB was stored in a blood cooler that was not dropped. Baseline and postintervention laboratory samples were measured in both airdropped and control units, including full blood counts, prothrombin time/partial thromboplastin time/international normalized ratio (PT/PTT/INR), pH, lactate, potassium, indirect bilirubin, glucose, fibrinogen, lactate dehydrogenase, and peripheral blood smears.
Results: The blood cooler, cooling bags, and all 4 FWB units did not sustain any damage from the airdrop. There was no evidence of hemolysis. All airdropped blood met parameters for transfusion per the Whole Blood Transfusion Clinical Practice Guideline of the Joint Trauma System (JTS).
Conclusions: Airdrop of FWB in a blood cooler with a SATB parachute may be a viable way of delivering blood products to combat medics treating hemorrhaging patients in the prehospital setting, although further research is needed to fully validate the safety of this method of FWB delivery.
A comparison of efficacy, efficiency, and durability in novel tourniquet designs
Christopher Treager, Tyler Lopachin, Sally Mandichak, Bradley Kinney, Megan Bohan, Michael Boboc, Christian Go, Emily Friedrich, Sean Stuart
J Trauma Acute Care Surg. 2021 Aug 1;91(2S Suppl 2):S139-S145
Background: Exsanguination due to extremity hemorrhage is a major cause of preventable traumatic deaths. Extremity tourniquet use has been shown to be safe and improve survival. The purpose of this study was to compare the efficacy, efficiency, and durability of the Generation 7 Combat Application Tourniquet (CAT; North American Rescue, Greer, SC), the Tactical Mechanical Tourniquet (TMT; Combat Medical Systems, Harrisburg, NC), and the SOF Tactical Tourniquet-Wide (SOFTT-W; Tactical Medical Solutions, Anderson, SC).
Methods: This study was a three-phase randomized, cross-over trial. In successive trials, subjects were timed during the application of each tourniquet to the upper and lower extremity. Following successful lower extremity application, subjects low crawled 25 ft and then were dragged 25 ft, after which effectiveness was reassessed, as defined by the cessation of distal pulses by Doppler ultrasound.
Results: In arm application, both the CAT and TMT had significantly less failure rates than the SOFTT-W (5.56%, 19.44%, 58.33%), with the CAT being the fastest tourniquet when compared with TMT and SOFTT-W (37.8 seconds, 65.01 seconds, 63.07 seconds). In leg application, the CAT had significantly less rates of failure when compared with the SOFTT-W, but there was no other significant difference between the tourniquets (27.78%, 44.44%, 61.11%). In addition, the CAT was significantly faster than both the TMT and SOFTT-W when applied to the leg (8.33 seconds, 40.96 seconds, 34.5 seconds). There was no significant difference in tourniquet failure rates between the three tourniquets after subject maneuvers in phase 3 (34.29%, 42.86%, 45.45%).
Discussion: The CAT is as effective as the TMT and significantly more effective than the SOFTT-W. In addition, the CAT demonstrated shorter application times than either the TMT or SOFTT-W. However, there was no significant difference between the three tourniquets in their ability to maintain pulselessness after subject maneuvers.
Glenn K Wakam, Ben E Biesterveld, Manjunath P Pai, Michael T Kemp, Rachel L O'Connell, Krishani K Rajanayake, Kiril Chtraklin, Claire A Vercruysse, Hasan B Alam
J Trauma Acute Care Surg. 2021 Nov 1;91(5):867-871
Background: We lack specific treatments for traumatic brain injury (TBI), which remains the leading cause of trauma-related morbidity and mortality. Treatment with valproic acid (VPA) improves outcomes in models of severe TBI with concurrent hemorrhage. However, it is unknown if VPA will have similar benefits after isolated nonlethal TBI, which is the more common clinical scenario. The goal of this study was to evaluate the effect of VPA treatment in a preclinical isolated TBI swine model on neurologic outcomes and brain lesion size and to perform detailed pharmacokinetic analyses for a future clinical trial.
Methods: Yorkshire swine (n = 10; 5/cohort) were subjected to TBI (8-mm controlled cortical impact). An hour later, we randomized them to receive VPA (150 mg/kg) or saline placebo (control). Neuroseverity scores were assessed daily (0 [normal] to 36 [comatose]), brain lesion size was measured on postinjury 3, and serial blood samples were collected for pharmacokinetic studies.
Results: Physiologic parameters and laboratory values were similar in both groups. Valproic acid-treated animals demonstrated significantly better neuroseverity scores on postinjury 1 (control, 9.2 ± 4.4; VPA, 0 ± 0; p = 0.001). Valproic acid-treated animals had significantly smaller brain lesion sizes (mean volume in microliter: control, 3,130 ± 2,166; VPA, 764 ± 208; p = 0.02). Pharmacokinetic data confirmed adequate plasma and tissue levels of VPA.
Conclusion: In this clinically relevant model of isolated TBI, a single dose of VPA attenuates neurological impairment and decreases brain lesion size.
Limb Tourniquet Holding Location: Model Results Fail to Translate to Human Results
Piper L Wall, Charisse M Buising
J Spec Oper Med. Fall 2021;21(3):30-35.
Background: During strap pulling, how limb tourniquet sliding is prevented affects secured pressure achievement. Data from model setups indicated moving the Tactical Ratcheting Medical Tourniquet (Tac RMT; m2 inc.) holding loop location could be advantageous regarding strap-pulling pressure achievement.
Methods: Self- and buddy-strap pull applications to the arm and mid-thigh were done with the commercially available Tac RMT with the holding loop adjacent to the strap redirect buckle (NEAR) and with a modified Tac RMT with the holding loop moved to the far end of the toothed ladder from the redirect (FAR). Arm applications had the strap redirect buckle on the lateral aspect of the arm. Thigh applications had the strap redirect buckle on the lateral aspect and included applications with the strap's free end pulled downward and applications with the strap free end pulled upward. Buddy- arm and thigh pull-upward applications with FAR allowed a nonstandard technique of including thumb assistance of the strap into the redirect.
Results: With standard technique, five of six pairs had lower FAR secured pressures (median difference, 16mmHg). When thumb assistance was used, four of five NEAR-FAR pairs had higher FAR secured pressures (median difference, 40mmHg). The thumb strap feeding technique was neither simple nor obvious.
Conclusions: Moving the holding loop location is unlikely to be advantageous for Tac RMT actual applications. Model setup findings need to be checked with applications by humans to humans.
Pressure Responses of Tourniquet Practice Models to Calibrated Force Applications
Piper L Wall, Emma Hingtgen, Charisse M Buising
J Spec Oper Med. Summer 2021;21(2):11-17.
Background: Tourniquet training sometimes involves models, and a certification process is expected to use something other than human limbs; therefore, investigating model- and limb-pressure responses to force application is important.
Methods: Pressure response to force was collected for a 3.8cm-wide nonelastic strap and a 10.1cm-wide elastic strap placed over 14 objects. Each object was suspended; an inflated neonatal blood pressure cuff was placed atop the object with the strap over the bladder; and strap ends were connected below with 4.54kg weights attached at 20-second intervals to 27.24kg.
Results: Pressure-response curves differed by strap, thigh aspect (medial, lateral, ventral, dorsal; n = 2 subjects; p < .0001); subject (medial thigh; n = 3 subjects; p < .0001); and object (thighs; small and large pool noodles ± central metal rod, foam yoga roller, coffee can, 20% ballistic gel cylinder [Gel; Clear Ballistics; clearballistics.com] with central metal tubing, rolled pair of 5mm yoga mats ± central metal rod, hemorrhage-control training thigh [Z-Medica], sand-filled training manikin limb [Drumm Emergency Solutions]; p < .0001). Compliance, circumference, support techniques, and surface interactions, especially with the 10.1cm-wide elastic strap, affected pressure responses: smaller circumference, lower compliance, and lower surface coefficient of friction were associated with higher pressure/force applied.
Conclusions: Different objects have different pressure-response curves. This may be important to acquisition and retention of limb tourniquet skills and is important for systems for certifying tourniquets.
Xuren Wang, Demeng Xia, Panyu Zhou, Li Gui, Yixin Wang
Am J Transl Res. 2021 Jun 15;13(6):6134-6141
Objectives: Combat Application Tourniquet (CAT) is generally applied by self-aid or buddy-aid for exsanguinating extremity hemorrhage. The purpose of this study was to compare the accuracy, time and effectiveness between self-aid and buddy aid in ordinary and simulated scenarios.
Methods: A total of 64 undergraduates from the Red Cross Commando of a military medical university participated in this study, which involved ordinary and simulated scenarios. In each scenario, every participant completed tourniquet application to upper and lower extremities by self-aid and buddy-aid, respectively. Measures of time, accuracy and effectiveness were assessed by an examiner identically after each application.
Results: Compared with the performance of CAT application by buddy-aid, the time of application to upper extremities by self-aid increased by 8.39 s (P<0.001) and 3.24 s to lower extremities (P<0.05), and the percentage of pulse elimination by self-aid declined by 13.29% and 10.93% to both upper and lower extremities, respectively (P<0.05). Simulated combat performance showed longer time and lower accuracy (P<0.05).
Conclusions: The hypothesized different performances between self-aid and buddy-aid, as well as between ordinary and simulated scenarios were verified in this study, indicating the need for superior tourniquet design for self-aid and rigorous deployment readiness training, especially for self-aid in tourniquet application.
Leah Woodward, Mohammed Alsabri
Cureus. 2021 Jul 19;13(7):e16487
Abstract
Trauma is one of the leading causes of death, with hemorrhage being one of the most preventable aspects. Aggressive fluid resuscitation protocols were implemented before their value was critically evaluated. Permissive hypotension limits blood loss while maintaining adequate perfusion and positively impacts outcomes in actively hemorrhaging trauma patients. Peer-reviewed articles pertaining to the use of hypotensive resuscitation were identified and selected from a search of the PubMed database. Based on this, seven primary research articles were selected for evaluation. The articles were grouped based on their approach to hypotensive resuscitation. We focused on the safety and viability of hypotensive resuscitation, compared it to normotensive resuscitation, and compared mortality rates. Our review shows that hypotensive resuscitation is safe and has a decreased mortality rate when compared to normotensive resuscitation in hemorrhagic shock patients. There is less blood loss, hemodilution, ischemia, and hypoxia in tissues. Additional research is required to determine the exact parameters that are most beneficial in different patient populations.
Benjamin E Zusman, Patrick M Kochanek, Zachary S Bailey, Lai Yee Leung, Vincent A Vagni, David O Okonkwo, Ava M Puccio, Lori A Shutter, Keri L Janesko-Feldman, Janice S Gilsdorf, Deborah A Shear, Ruchira M Jha
Neurocrit Care. 2021 Jun;34(3):781-794
Background: Despite increasing use in hemorrhagic shock (HS), whole blood (WB) resuscitation for polytrauma with traumatic brain injury (TBI) is largely unexplored. Current TBI guidelines recommend crystalloid for prehospital resuscitation. Although WB outperforms lactated Ringer's (LR) in increasing mean arterial pressure (MAP) in TBI + HS models, effects on brain tissue oxygenation (PbtO2), and optimal MAP remain undefined.
Methods: C57BL/6 mice (n = 72) underwent controlled cortical impact followed by HS (MAP = 25-27 mmHg). Ipsilateral hippocampal PbtO2 (n = 40) was measured by microelectrode. Mice were assigned to four groups (n = 18/group) for "prehospital" resuscitation (90 min) with LR or autologous WB, and target MAPs of 60 or 70 mmHg (LR60, WB60, LR70, WB70). Additional LR (10 ml/kg) was bolused every 5 min for MAP below target.
Results: LR requirements in WB60 (7.2 ± 5.0 mL/kg) and WB70 (28.3 ± 9.6 mL/kg) were markedly lower than in LR60 (132.8 ± 5.8 mL/kg) or LR70 (152.2 ± 4.8 mL/kg; all p < 0.001). WB70 MAP (72.5 ± 2.9 mmHg) was higher than LR70 (59.8 ± 4.0 mmHg, p < 0.001). WB60 MAP (68.7 ± 4.6 mmHg) was higher than LR60 (53.5 ± 3.2 mmHg, p < 0.001). PbtO2 was higher in WB60 (43.8 ± 11.6 mmHg) vs either LR60 (25.9 ± 13.0 mmHg, p = 0.04) or LR70 (24.1 ± 8.1 mmHg, p = 0.001). PbtO2 in WB70 (40.7 ± 8.8 mmHg) was higher than in LR70 (p = 0.007). Despite higher MAP in WB70 vs WB60 (p = .002), PbtO2 was similar.
Conclusion: WB resuscitation after TBI + HS results in robust improvements in brain oxygenation while minimizing fluid volume when compared to standard LR resuscitation. WB resuscitation may allow for a lower prehospital MAP without compromising brain oxygenation when compared to LR resuscitation. Further studies evaluating the effects of these physiologic benefits on outcome after TBI with HS are warranted, to eventually inform clinical trials.
Herman A Allison
Crit Care Nurs Q. Apr/Jun 2019;42(2):165-172
Abstract
Uncontrolled blood loss is a major cause of preventable death worldwide. A severe injury can occur anywhere at any time. Controlling blood loss is an important issue for patient care in the hospital setting. Through the casualties of war, the lifesaving value of quick interventions was developed. Since 2001, new hemostatic agents have advanced the benefits of controlling blood loss. There are unforgettable lessons learned in the preventable deaths of many soldiers and should be passed on to the next generation of health care providers, to include all hospitals up to level I trauma hospitals. This article covers the current hemostatic agents that have been used for more than 17 years on the battlefield and are slowly making their way into the hospital settings. The hemostatic agents covered include QuikClot Combat Gauze, QuikClot Control+, WoundClot Hemostatic Gauze, HemCon Nasal Plug, and RevMedx's XSTAT hemostatic device. The standard of care should not be affected by the location of a patient, whether that patient is in a remote village overseas, on the battlefield, a rural farm, or at a major metropolitan hospital here in the United States.
Ateeq Almuwallad, Elaine Cole, Jennifer Ross, Zane Perkins, Ross Davenport
J Trauma Acute Care Surg. 2021 May 1;90(5):901-907
Abstract
Background: Tranexamic acid (TXA) is an antifibrinolytic drug associated with improved survival among trauma patients with hemorrhage. Tranexamic acid is considered a primary hemostatic intervention in prehospital for treatment of bleeding alongside blood product transfusion.
Methods: A systematic review and meta-analysis was conducted to investigate the impact of prehospital TXA on mortality among trauma patients with bleeding. A systematic search was conducted using the National Institute for Health and Care Excellence Healthcare Databases Advanced Search library which contain the following of databases: EMBASE, Medline, PubMed, BNI, EMCARE, and HMIC. Other databases searched included SCOPUS and the Cochrane Central Register for Clinical Trials Library. Quality assessment tools were applied among included studies; Cochrane Risk of Bias for randomized control trials and Newcastle-Ottawa Scale for cohort observational studies.
Results: A total of 797 publications were identified from the initial database search. After removing duplicates and applying inclusion/exclusion criteria, four studies were included in the review and meta-analysis which identified a significant survival benefit in patients who received prehospital TXA versus no TXA. Three observational cohort and one randomized control trial were included into the review with a total of 2,347 patients (TXA, 1,169 vs. no TXA, 1,178). There was a significant reduction in 24 hours mortality; odds ratio (OR) of 0.60 (95% confidence interval [CI], 0.37-0.99). No statistical significant differences in 28 days to 30 days mortality; OR of 0.69 (95% CI, 0.47-1.02), or venous thromboembolism OR of 1.49 (95% CI, 0.90-2.46) were found.
Conclusion: This review demonstrates that prehospital TXA is associated with significant reductions in the early (24 hour) mortality of trauma patients with suspected or confirmed hemorrhage but no increase in the incidence of venous thromboembolism.
Adam H H Altman, Brandon M Carius, Grant A Justin, Steven G Schauer, Mireya A Escandon, Joseph K Maddry, Robert A Mazzoli, Gary L Legault
Mil Med. 2021 Apr 7;usab134. doi: 10.1093/milmed/usab134
Abstract
Introduction: American military personnel in U.S. Africa Command (AFRICOM) operate in a continent triple the size of the USA without mature medical facilities, requiring a substantial transportation network for medical evacuation. We describe medical transportation based on ophthalmic complaints analyzed from the U.S. Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES) database from 2008 to 2018.
Methods: We conducted a retrospective review of all TRAC2ES records for medical evacuations for ophthalmic complaints from the AFRICOM theater of operations conducted between January 1, 2008 and December 31, 2018. We analyzed free-text data in TRAC2ES for ophthalmic diagnostic and therapeutic interventions performed before established patient movement requests. An expert panel analyzed evacuations for their indications and interventions.
Results: Nine hundred and sixty-one total records originating within AFRICOM were identified in TRAC2ES. Forty-three cases (4%) had ophthalmic complaints. The majority of transports were routine (72%) and originated in Djibouti (83%), and all were transported to Landstuhl Regional Medical Center. The majority of patients were evacuated without a definitive diagnosis (60%). Leading ophthalmic diagnoses were chalazion (14%), corneal abrasion/ulcer (14%), and posterior vitreous detachment (12%). More than one-quarter of patients were transported without recorded evaluation and approximately half (51%) did not receive any intervention before evacuation. Consultation with an ophthalmologist occurred in only 16 (37%) cases. By majority, the expert panel deemed 12 evacuations (28%) potentially unnecessary.
Conclusion: Evacuations were primarily routine often for disease etiology and further diagnostic evaluation. These findings support opportunities for telemedicine consultation to avoid potentially unnecessary transportation. Increased ophthalmic care and enhanced data collection on transports would support process improvement, optimize ophthalmic care by ensuring proper disposition of patients thus limiting unnecessary evacuations, and ultimately strengthen the entire fighting force.
Whole blood hemostatic resuscitation in pediatric trauma: A nationwide propensity-matched analysis
Tanya Anand, Omar Obaid, Adam Nelson, Mohamad Chehab, Michael Ditillo, Ahmad Hammad, Molly Douglas, Letitia Bible, Bellal Joseph
J Trauma Acute Care Surg. 2021 Oct 1;91(4):573-578
Abstract
Background: Whole blood (WB) has shown promise in pediatric trauma resuscitation following its prominent role in the resuscitation of adult trauma patients. Although WB in children has been shown to be feasible, its effectiveness has yet to be explored. The aim of this study was to examine the outcomes of WB transfusion as an adjunct to component therapy (CT) compared with CT only as early resuscitation for pediatric trauma patients.
Methods: Children aged 1 to 17 years, who were transfused within 4 hours of presentation, were identified in the Trauma Quality Improvement Program 2017 database. Patients were stratified into those receiving WB-CT versus CT alone. Propensity score matching in a 1:2 ratio was performed based on patient demographics, injury characteristics, hemorrhage control interventions, and trauma center level. The primary outcome measure was patient transfusion requirement. Secondary outcome measures were mortality, hospital length of stay, ventilation days, and major complications.
Results: A total of 135 children receiving WB-CT were matched to 270 patients receiving CT only. Mean (SD) age was 12 (5) years, 66% were male, and the median Injury Severity Score was 32 (range, 20-43). A total of 51% of patients were in shock, 34% had penetrating injuries, and 41% required surgical intervention for hemorrhage control. Total blood products transfused were significantly decreased in children receiving WB, both at 4 hours (35 [22-73] vs. 48 [33-95] mL/kg; p = 0.013) and 24 hours (39 [24-97] vs. 53 [36-119] mL/kg; p < 0.001). Mortality rate at 24 hours (19.3% vs. 21.9%; p = 0.546) and in-hospital mortality (31.1% vs. 34.4%; p = 0.502) were not different. Similarly, no difference in hospital length of stay and rates of major complications was found. Patients in the WB group required significantly less ventilation days (2 [2-6] vs. 3 [2-8] days; p = 0.021).
Conclusion: Using WB as an adjunct to CT was associated with decreased transfusion requirements and ventilation days in pediatric trauma patients.
Susanne Ångerman, Hetti Kirves, Jouni Nurmi
Prehosp Emerg Care. 2021 Feb 24;1-9. Online ahead of print.
Abstract
Objective: While prehospital blood transfusion (PHBT) for trauma patients has been established in many services, the literature on PHBT use for nontrauma patients is limited. We aimed to describe and compare nontrauma and trauma patients receiving PHBT who had similar hemodynamic triggers.
Methods: We analyzed 3.5 years of registry data from a single prehospital critical care unit. The PHBT protocol included two packed red blood cell units and was later completed with two freeze-dried plasma units. The transfusion triggers were a strong clinical suspicion of massive hemorrhage and systolic blood pressure below 90 mmHg or absent radial pulse.
Results: Thirty-six nontrauma patients and 96 trauma patients received PHBT. The nontrauma group had elderly patients (median 65 [interquartile range, IQR, 56-73] vs 37 [IQR 25-57] years, p < 0.0001) and included patients with gastrointestinal bleeding (n = 15; 42%), vascular catastrophes (n = 9; 25%), postoperative bleeding (n = 6; 17%), obstetrical bleeding (n = 4; 11%) and other (n = 2; 6%). Cardiac arrest occurred in nine (25%) nontrauma and in 15 (16%) trauma patients. Of these, 5 (56%) and 10 (67%) survived to hospital admission and 3 (33%) and 2 (13%) to hospital discharge. On admission, the nontrauma patients had lower hemoglobin (median 95 [84-119] vs 124 [108-133], p < 0.0001), higher pH (median 7.40 [7.27-7.44] vs 7.30 [7.19-7.36], p = 0.0015) and lower plasma thromboplastin time (median 55 [45-81] vs 72 [58-86], p = 0.0261) than the trauma patients.
Conclusions: We identified four nontrauma patient groups in need of PHBT, and the patients appeared to be seriously ill. Efficacy of prehospital transfusion in nontrauma patients should be evaluated futher in becoming studies.
Rachel A Bailey, Erica M Simon, Aerial Kreiner, Dana Powers, Livia Baker, Connor Giles, Robert Sweet, Stephen C Rush.
J Spec Oper Med. Spring 2021;21(1):44-48.
Abstract
Uncontrolled hemorrhage secondary to unstable pelvic fractures is a preventable cause of prehospital death in the military and civilian sectors. Because the mortality rate associated with unstable pelvic ring injuries exceeds 50%, the use of external compression devices for associated hemorrhage control is paramount. During mass casualty incidents and in austere settings, the need for multiple external compression devices may arise. In assessing the efficacy of these devices, the magnitude of applied force has been offered as a surrogate measure of pubic symphysis diastasis reduction and subsequent hemostasis. This study offers a sensor-circuit assessment of applied force for a convenience sample of pelvic compression devices. The SAM® (structural aluminum malleable) Pelvic Sling II (SAM Medical) and improvised compression devices, including a SAM Splint tightened by a Combat Application Tourniquet® (C-A-T; North American Rescue) and a SAM® Splint tightened by a cravat, as well as two joined cravats and a standard-issue military belt, were assessed in male and female subjects. As hypothesized, compressive forces applied to the pelvis did not vary significantly based on device operator, subject sex, and subject body fat percentage. The use of the military belt as an improvised method to obtain pelvic stabilization is not advised.
Nathan Balzer, Shelley L McLeod, Chris Walsh, Keerat Grewal
Acad Emerg Med. 2021 Apr;28(4):444-454
Abstract
Objective: There has been increased interest in the use of low-dose ketamine (LDK) as an alternative analgesic for the management of acute pain in the emergency department (ED). The objective of this systematic review was to compare the analgesic effectiveness and safety profile of LDK and morphine for acute pain management in the ED.
Methods: Electronic searches of Medline and EMBASE were conducted and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing LDK to morphine for acute pain control in the ED were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Data were pooled using random-effects models and reported as mean differences and risk ratios (RRs) with 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty of the evidence.
Results: Eight RCTs were included with a total of 1,191 patients (LDK = 598, morphine = 593). There was no significant difference in reported mean pain scores between LDK and morphine within the first 60 minutes after analgesia administration and a slight difference in pain scores favoring morphine at 60 to 120 minutes. The need for rescue medication was also similar between groups (RR = 1.26, 95% CI = 0.50 to 3.16), as was the proportion of patients who experienced nausea (RR = 0.97, 95% CI = 0.63 to 1.49) and hypoxia (RR = 0.38, 95% CI = 0.10 to 1.41). All outcomes were judged to have low certainty in the evidence.
Conclusion: Low-dose ketamine and morphine had similar analgesic effectiveness within 60 minutes of administration with comparable safety profiles, suggesting that LDK is an effective alternative analgesic for acute pain control in the ED.
Prehospital tourniquet use: An evaluation of community application and outcome
Leslie M Barnard, Sally Guan, Lori Zarmer, Brianna Mills, Jennifer Blackwood, Eileen Bulger, Betty Y Yang, Peter Johnston, Monica S Vavilala, Michael R Sayre, Thomas D Rea, David L Murphy
J Trauma Acute Care Surg. 2021 Jun 1;90(6):1040-1047
Abstract
Background: There is substantial investment in layperson and first responder training involving tourniquet use for hemorrhage control. Little is known however about prehospital tourniquet application, field conversion, or outcomes in the civilian setting. We describe the experience of a metropolitan region with prehospital tourniquet application.
Methods: We conducted a retrospective cohort study characterizing prehospital tourniquet use treated by emergency medical services (EMS) in King County, Washington, from January 2018 to June 2019. Emergency medical services and hospital records were abstracted for demographics, injury mechanism, tourniquet details, clinical care, and outcomes. We evaluated the incidence of tourniquet application, who applied the device (EMS, law enforcement, or layperson), and subsequent course.
Results: A total of 168 patients received tourniquet application, an incidence of 5.1 per 100,000 person-years and 3.48 per 1,000 EMS responses for trauma. Tourniquets were applied for penetrating trauma (64%), blunt trauma (30%), and bleeding ateriovenous fistulas (7%). A subset was critically ill: 13% had systolic blood pressures of <90 mm Hg, 8% had Glasgow Coma Scale score of <13, and 3% had cardiac arrest. Among initial applications, 48% were placed by law enforcement, 33% by laypersons, and 18% by EMS. Among tourniquets applied by layperson or law enforcement (n = 137), EMS relied solely on the original tourniquet in 45% (n = 61), placed a second tourniquet in 20% (n = 28), and removed the tourniquet without replacement in 35% (n = 48). Overall, 24% required massive transfusion, 59% underwent urgent surgery, and 21% required vascular surgery. Mortality was 3% (n = 4). At hospital discharge, the tourniquet limb was fully functional in 81%, partially functional in 10%, and nonfunctional in 9%; decreased function was not attributed to tourniquet application.
Conclusion: The high rate of application, need for urgent hospital intervention in a subset, and low incidence of apparent complication suggest that efforts to increase access and early tourniquet use can provide public health benefit.
Sebastian Bergrath, Jörg Christian Brokmann, Stefan Beckers, Marc Felzen, Michael Czaplik, Rolf Rossaint
BMJ Open. 2021 Mar 24;11(3):e041942. doi: 10.1136/bmjopen-2020-041942.
Abstract
Objectives: To review the implementation strategy from a research project towards routine care of a comprehensive mobile physician-staffed prehospital telemedicine system. The objective is to evaluate the implementation process and systemic influences on emergency medical service (EMS) resource utilisation.
Design: Retrospective pre-post implementation study.
Setting: Two interdisciplinary projects and the EMS of a German urban region.
Interventions: Implementation of a full-scale prehospital telemedicine system.
Endpoints: Descriptive evaluation of the implementation strategy. Primary endpoint: ground-based and helicopter-based physician staffed emergency missions before and after implementation.
Results: The first research project revealed positive effects on guideline adherence and patient safety in two simulation studies, with feasibility demonstrated in a clinical study. After technical optimisation, safety and positive effects were demonstrated in a multicentre trial. Routine care in the city of Aachen, Germany was conducted stepwise from April 2014 to March 2015, including modified dispatch criteria. Systemic parameters of all EMS assignments between pre-implementation (April 2013 to March 2014) and post implementation (April 2015 to March 2016): on-scene EMS physician operations decreased from 7882/25 187 missions (31.3%) to 6360/26 462 (24.0%), p<0.0001. The need for neighbouring physician-staffed units dropped from 234/25 187 (0.93%) to 119/26 462 (0.45%), p<0.0001, and the need for helicopter EMS from 198/25 187 (0.79%) to 100/26 462 (0.38%), p<0.0001. In the post implementation period 2347 telemedical interventions were conducted, with 26 462 emergency missions (8.87%).
Conclusion: A stepwise implementation strategy allowed transfer from the project phase to routine care. We detected a reduced need for conventional on-scene physician care by ground-based and helicopter-based EMS, but cannot exclude unrecognised confounders, including modified dispatch criteria and possible learning effects. This creates the potential for increased availability of EMS physicians for life-threatening emergencies by shifting physician interventions from conventional to telemedical care.
Yaar Betelman Mahalo, Guy Avital, Irina Radomislensky, Moshe Vysokovsky, Rotem Avital-Cohen, Shaul Gelikas, Avishai M Tsur, Roy Nadler, Moran Bodas, Jacob Chen, Elon Glassberg, Avi Benov, Israel Trauma Group
J Trauma Acute Care Surg. 2021 Aug 1;91(2S Suppl 2):S201-S205
Abstract
Background: Lifesaving interventions (LSIs) are the hallmark of medical care in trauma casualties, reducing mortality and morbidity. Analgesia is another essential treatment, which has been shown to improve outcomes and decrease long-term complications. However, oligoanalgesia is common, and information regarding its relation to the performance of LSIs is scarce. The purpose of this study was to assess the relation between the performance of LSIs and analgesia administration in the prehospital environment.
Methods: A retrospective database-based study was performed, including all trauma casualties treated by Israeli Defense Forces physicians and paramedics during 2006 to 2017 and admitted to hospitals participating in the Israeli National Trauma Registry. Included LSIs were tourniquet application, administration of tranexamic acid and freeze-dried plasma, and administration of chest decompression. Casualties treated with endotracheal intubation or cricothyroidotomy were excluded.
Results: In the multivariable logistic regression analysis, LSIs were associated with prehospital analgesia administration (odds ratio [OR], 3.59; confidence interval [CI], 2.56-5.08; p < 0.001). When assessing for the different LSIs, tourniquet application (OR, 2.83; CI, 1.89-4.27; p < 0.001) and tranexamic acid administration (OR, 4.307; CI, 2.42-8.04; p < 0.001) were associated with prehospital analgesia administration.
Conclusion: A positive association exists between performance of LSIs and administration of analgesia in the prehospital environment. Possible explanations may include cognitive and emotional biases affecting casualty care provider.
Novel use of XSTAT 30 for mitigation of lethal non-compressible torso hemorrhage in swine
Alicia M Bonanno, Todd L Graham, Lauren N Wilson, James D Ross
PLoS One. 2020 Nov 18;15(11):e0241906
Abstract
Background: Management of Non-Compressible Torso Hemorrhage (NCTH) consists primarily of aortic occlusion which has significant adverse outcomes, including ischemia-reperfusion injury, in prolonged field care paradigms. One promising avenue for treatment is through use of RevMedx XSTAT 30™ (an FDA approved sponge-based dressing utilized for extremity wounds). We hypothesized that XSTAT 30™ would effectively mitigate NCTH during a prolonged pre-hospital period with correctable metabolic and physiologic derangements.
Methods and findings: Twenty-four male swine (53±2kg) were anesthetized, underwent line placement, and splenectomy. Animals then underwent laparoscopic transection of 70% of the left lobe of the liver with hemorrhage for a period of 10min. They were randomized into three groups: No intevention (CON), XSTAT 30™-Free Pellets (FP), and XSTAT 30™-Bagged Pellets (BP). Animals were observed for a pre-hospital period of 180min. At 180min, animals underwent damage control surgery (DCS), balanced blood product resuscitation and removal of pellets followed by an ICU period of 5 hours. Postoperative fluoroscopy was performed to identify remaining pellets or bags. Baseline physiologic and injury characteristics were similar. Survival rates were significantly higher in FP and BP (p<0.01) vs CON. DCS was significantly longer in FP in comparison to BP (p = 0.001). Two animals in the FP group had pellets discovered on fluoroscopy following DCS. There was no significant difference in blood product or pressor requirements between groups. End-ICU lactates trended to baseline in both FP and BP groups.
Conclusions: While these results are promising, further study will be required to better understand the role for XSTAT in the management of NCTH.
Binder use and early pelvic radiographs in the management of unstable patients with blunt trauma
Nori L Bradley, Michael J Kim, Matthew R Menon
CMAJ. 2021 May 3;193(18):E649
No abstract available
Alexandra M P Brito, Martin Schreiber
Trauma Surg Acute Care Open. 2021 May 10;6(1):e000729
Abstract
Traumatic injury is the leading cause of death in young people in the USA. Our knowledge of prehospital resuscitation is constantly evolving and is often informed by research based on military experience. A move toward balanced blood product resuscitation and away from excessive crystalloid use has led to improvements in outcomes for trauma patients. This has been facilitated by new technologies allowing more front-line use of blood products as well as use of tranexamic acid in the prehospital setting. In this article, we review current practices in prehospital resuscitation and the studies that have informed these practices.
Kimberly M Burbank, Steven G Schauer, Robert A De Lorenzo, Joseph C Wenke
OTA Int. 2020 Oct 12;3(4):e091. doi: 10.1097/OI9.0000000000000091. eCollection 2020 Dec.
Abstract
Despite meticulous surgical care and systemic antibiotics, open fracture wounds have high rates of infection leading to increased morbidity. To reduce infection rates, orthopaedic surgeons may administer local antibiotics using various carriers that may be ineffective due to poor antibiotic release from carriers, subsequent surgery to remove nondegradable carriers, and mismatch between release kinetics and material degradation. Biofilms form rapidly as bacteria that are within the wound multiply quickly and transform from the antibiotic-susceptible planktonic phenotype to the antibiotic-tolerant biofilm phenotype. This tolerance to antibiotics can occur within hours. Currently, local antibiotics are placed in the wounds using a carrier such as polymethylmethacrylate beads; however, this occurs after surgical debridement that can be hours to even a day after initial injury allowing bacteria enough time to form a biofilm that makes the antibiotic containing polymethylmethacrylate beads less effective. In contrast, emerging practices in elective surgical procedures, such as spine fusion, place antibiotic powder (e.g. vancomycin) in the wound at the time of closure. This has been shown to be extremely effective, presumably because of the very small-time period between potential contamination and local antibiotic application. There is evidence that suggests that the ineffectiveness of local antibiotic use in open fractures is primarily due to the delay in application of local antibiotics from the time of injury and propose a concept of topical antibiotic powder application in the prehospital or emergency department setting.
Tactical Medicine Training for SEAL Mission Commanders
Frank K Butler Jr
J Spec Oper Med. Spring 2021;21(1):127-133.
Abstract
The Tactical Combat Casualty Care (TCCC) project initiated by Naval Special Warfare and continued by the US Special Operations Command has developed a new set of combat trauma care guidelines that seek to combine good medical care with good small-unit tactics. The principles of care recommended in TCCC have gained increasing acceptance throughout the Department of Defense in the four years since their publication and increasing numbers of combat medical personnel and military physicians have been trained in this concept. Since casualty scenarios in small-unit operations typically present tactical as well as medical problems, however, it has become apparent that a customized version of this course suitable for small-unit mission commanders is a necessary addition to the program. This paper describes the development of a course in Tactical Medicine for SEAL Mission Commanders and its transition into use in the Naval Special Warfare community.
An Analysis of Prehospital Trauma Registry After-Action Reviews in Afghanistan
Brandon M Carius, Peter M Dodge, Andrew D Fisher, Paul E Loos, Dominic Thompson, Steven G Schauer
J Spec Oper Med. Summer 2021;21(2):49-53
Abstract
Background: After-action reviews (AARs) in the Prehospital Trauma Registry (PHTR) enable performance improvements and provide commanders feedback on care delivered at Role 1. No published data exist exploring overall trends of end-user performance-improvement feedback.
Methods: We performed an expert panel review of AARs within the PHTR in Afghanistan from January 2013 to September 2014. When possible, we categorized our findings and selected relevant medical provider comments.
Results: Of 737 registered patient encounters found, 592 (80%) had AAR documentation. Most AAR patients were male (98%, n = 578), injured by explosion (48%, n = 283), and categorized for urgent evacuation (64%, n = 377). Nearly two thirds of AARs stated areas needing improvement (64%, n = 376), while the remainder left the improvement section blank (23%, n = 139) or specified no improvements (13%, n = 76). The most frequently cited areas for improvement were medical knowledge (23%, n = 136), evacuation coordination (19%, n = 115), and first responder training (16%, n = 95).
Conclusions: Our expert panel reviewed AARs within the PHTR and found substantial numbers of AARs without improvements recommended, which limits quality improvement capabilities. Our analysis supports previous calls for better documentation of medical care in the prehospital combat 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. doi: 10.1080/10903127.2021.1940400. Online ahead of print.
Abstract
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.
Ketamine for Pain Management: A Review of Literature and Clinical Application
Kelsea Caruso, Dion Tyler, Abbie Lyden
Orthop Nurs. 2021 May-Jun 01;40(3):189-193
Abstract
Ketamine is a dissociative anesthetic used increasingly as analgesia for different manifestations of pain, including acute, chronic, cancer and perioperative pain as well as pain in the critically ill patient population. Its distinctive pharmacologic properties may provide benefits to individuals suffering from pain, including increased pain control and reduction in opioid consumption and tolerance. Despite wide variability in proposed dosing and method of administration when used for analgesia, it is important all clinicians be familiar with the pharmacodynamics of ketamine in order to appropriately anticipate its therapeutic and adverse effects.
Improving Emergency Cricothyroidotomies: Simulation-Based Training for Critical Care Providers
Clayton M Clark, Brett T Morgan, Daniel Schmitt, Robert J Harman, Victoria Goode
Crit Care Nurs Q. 2021 Apr-Jun 01;44(2):203-213
Abstract
This article discusses skill proficiency of providers related to emergency cricothyroidotomies. Various techniques to improve procedural skills were studied. Accurate identification of the cricothyroid membrane via palpation remained consistently inadequate. High-fidelity simulation including the use of human cadavers may be the preferred method of skill training for crisis management. The authors emphasize that additional research is needed regarding a method for rapid cricothyroid membrane identification as well as needle cricothyroidotomy versus surgical airway on cadavers. More consistent training will enable emergency care providers to perform this rare but lifesaving skill.
Thomas Clements, Cameron McCoy, Scott Assen, Jessica Cardenas, Charles Wade, David Meyer, Bryan A Cotton
J Trauma Acute Care Surg. 2021 Apr 1;90(4):607-614
Abstract
Introduction: Recent in vitro data have shown that the hemostatic profile of whole blood (WB) degrades significantly after 14 days, yet the optimal storage remains debated. We hypothesized that arrival coagulation studies would be improved in patients receiving younger WB in the prehospital setting.
Methods: This study was approved by our institutional institutional review board. We evaluated all trauma patients who received prehospital blood products by our helicopter service between July 2017 and July 2019. "Young" WB was defined as 14 days or less. Patients who received at least 1 U of young WB were classified as YOUNG, while the remainder was classified as OLD. Continuous data are presented as medians (25th-75th interquartile range) with comparisons performed using Wilcoxon rank sum. Assessments of clinical hemostatic potential included arrival platelet cell count and rapid thrombelastography. Multivariate regression analysis was also performed (Stata 12.1; College Station, TX).
Results: A total of 220 patients received prehospital WB during the study period. Of these, 153 patients received YOUNG WB, while 67 were transfused only OLD WB units. There were no differences in demographics, prehospital or arrival physiology, or Injury Severity Score among the two groups. The measures of clot initiation (activated clotting time) and kinetics (k time) were improved, as were the measures of clot acceleration/fibrinogen function (angle) and platelet function (maximum amplitude). As well, arrival platelet count was higher in the YOUNG cohort. No significant differences in postarrival transfusion were noted (p = 0.220). Multivariate analysis showed the greatest differences in maximum amplitude and α angle but failed to reach significance.
Conclusion: Previous in vitro data have suggested deterioration of platelet function in cold-stored WB after 14 days. The current study demonstrated decreased global hemostasis by clinically available laboratory tests, especially related to fibrinogen and platelet interactions on univariate, but not multivariate analysis. This did not translate into increased transfusion requirements. Further studies are needed to determine the optimal storage duration for cold-stored WB for transfusion in the bleeding trauma patient, as well as rule out the presence of confounding variables.
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. Spring 2021;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.
A Retrospective Study of Transfusion Requirements in Trauma Patients Receiving Tranexamic Acid
Brian Cornelius, Kelsey Moody, Katelyn Hopper, Phillip Kilgore, Urska Cvek, Marjan Trutschl, Angela P Cornelius
J Trauma Nurs. May/Jun 2019;26(3):128-133
Abstract
The Military Application of Tranexamic Acid in Trauma Emergency Resuscitation Study (MATTERs) and Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage-2 (CRASH-2) studies demonstrate that tranexamic acid (TXA) reduces mortality in patients with traumatic hemorrhage. However, their results, conducted in foreign countries and U.S. military soldiers, provoke concerns over generalizability to civilian trauma patients in the United States. We report the evaluation of patient outcomes and transfusion requirements following treatment with TXA by a civilian air medical program. We conducted a retrospective chart review of trauma patients transported by air service to a Level 1 trauma center. For the purposes of intervention evaluation, patients meeting this criterion for the 2 years (2012-2014) prior to therapy implementation were compared with patients treated during the 2-year study period (2014-2016). Goals were to evaluate morbidity, mortality, transfusion requirements, and length of stay. During the review, 52 control (non-TXA) and 43 study (TXA) patients were identified as meeting inclusion criteria. Patients in the control group were found to be less acute, which correlated with shorter hospitals stays. There was reduced mortality for patients receiving TXA in spite of their increased acuity and decreased likelihood of survival. Trauma patients from this cohort study receiving TXA demonstrate decreased mortality in spite of increased acuity. This increased acuity is associated with increased transfusion requirements. Future research should evaluate patient selection with concern for fibrinolysis and provider bias. Randomized controlled trial is needed to evaluate the role of TXA administration in the United States.
Thomas H Edwards, Michael A Dubick, Lee Palmer, Anthony E Pusateri
Front Vet Sci. 2021 Jan 14;7:571368
Abstract
In humans, the leading cause of potentially preventable death on the modern battlefield is undoubtedly exsanguination from massive hemorrhage. The US military and allied nations have devoted enormous effort to combat hemorrhagic shock and massive hemorrhage. This has yielded numerous advances designed to stop bleeding and save lives. The development of extremity, junctional and truncal tourniquets applied by first responders have saved countless lives both on the battlefield and in civilian settings. Additional devices such as resuscitative endovascular balloon occlusion of the aorta (REBOA) and intraperitoneal hemostatic foams show great promise to address control the most difficult forms (non-compressible) of hemorrhage. The development of next generation hemostatic dressings has reduced bleeding both in the prehospital setting as well as in the operating room. Furthermore, the research and fielding of antifibrinolytics such as tranexamic acid have shown incredible promise to ameliorate the effects of acute traumatic coagulopathy which has led to significant morbidity and mortality in service members. Advances from lessons learned on the battlefield have numerous potential parallels in veterinary medicine and these lessons are ripe for translation to veterinary medicine.
Thomas H Edwards, Anthony E Pusateri, Erin Long Mays, James A Bynum, Andrew P Cap
Front Vet Sci. 2021 May 7;8:571370.
Abstract
Since the inception of recent conflicts in Afghanistan and Iraq, transfusion practices in human military medicine have advanced considerably. Today, US military physicians recognize the need to replace the functionality of lost blood in traumatic hemorrhagic shock and whole blood is now the trauma resuscitation product of choice on the battlefield. Building on wartime experiences, military medicine is now one of the country's strongest advocates for the principle of hemostatic resuscitation using whole blood or balanced blood components as the primary means of resuscitation as early as possibly following severe trauma. Based on strong evidence to support this practice in human combat casualties and in civilian trauma care, military veterinarians strive to practice similar hemostatic resuscitation for injured Military Working Dogs. To this end, canine whole blood has become increasingly available in forward environments, and non-traditional storage options for canine blood and blood components are being explored for use in canine trauma. Blood products with improved shelf-life and ease of use are not only useful for military applications, but may also enable civilian general and specialty practices to more easily incorporate hemostatic resuscitation approaches to canine trauma care.
Kalev Freeman, Zachary D Miller, Robert Ramsey Herrington, Nathan T Dreyfus, Philip Buttaravoli, Adam Burgess, Joshua P Nickerson, Nirav Daphtary, Jason H T Bates
J Am Coll Emerg Physicians Open. 2021 Apr 29;2(2):e12440
Abstract
Objective: No oropharyngeal devices exist for use in conscious and semiconscious trauma patients during emergency evacuation, transport, or resuscitation. We aimed to test the hypotheses that the ManMaxAirway (MMA) is better tolerated than the standard Guedel-style device in awake volunteers and that it produces a jaw thrust and improves air flow.
Methods: This was a randomized cross-over study of healthy volunteers with either the MMA or standard device. The primary outcome of tolerability was defined as maintaining the device in place for 60 seconds. Secondary outcomes included respiratory system function and jaw thrust. Resistance to airflow through the device lumen was measured in situ and when placed in subjects in the pulmonary laboratory alone. Jaw thrust was quantified as displacement between the mandibular condyle and condylar fossa apex relative to baseline visualized with magnetic resonance imaging (MRI).
Results: We enrolled 19 subjects. Of these, a convenience sample of 5 individuals was selected for MRI; the remaining individuals (n = 14) were randomized for the cross-over study. All 14 subjects were able to maintain the MMA for 60 seconds compared with 2/14 (14%) with the standard device (odds ratio, 145; 95% confidence interval, 6.3-3314). Subjects reported that the experimental device was more comfortable and its placement did not trigger the gag reflex. Airway resistance produced by the MMA in an oscillatory flow model was nearly an order of magnitude lower than that of the standard device (experimental vs standard, 8 Hz-0.092 vs 0.786 cmH20·s/L; 15 Hz-0.193 vs 1.321 cmH20·s/L). Rapid induction of the gag reflex precluded further measurements with the standard device. Forced oscillation pulmonary testing in conscious volunteers with and without the MMA demonstrated that the device decreased respiratory system resistance to airflow and reduced respiratory elastance (31% ± 8% and 44% ± 13.4%, respectively; P < 0.05). MRIs of the subjects (n = 5) with the MMA in place showed a significant jaw thrust compared with baseline (7 ± 1 mm).
Conclusions: The MMA proved well tolerated in conscious subjects, resulting in an opening of the anatomic airway and a decreased resistance to airflow.
Louis Gerber, Martin Botha, Abdullah E Laher
J Emerg Med. 2021 Sep;61(3):252-258
Abstract
Background: Bag-valve-mask (BVM) ventilation using a two-handed mask-face seal has been shown to be superior to a one-handed mask-face seal during cardiopulmonary resuscitation (CPR).
Objective: We aimed to compare CPR quality metrics during simulation-based two-rescuer CPR with a modified two-handed mask-face seal technique and two-rescuer CPR with the conventional one-handed mask-face seal technique.
Methods: Participants performed two-rescuer CPR on a simulation manakin and alternated between the modified and conventional CPR methods. For the modified method, the first rescuer performed chest compressions and thereafter squeezed the BVM resuscitator bag during the ventilatory pause, while the second rescuer created a two-handed mask-face seal. For the conventional method, the first rescuer performed chest compressions and the second rescuer thereafter delivered rescue breaths by creating a mask-face seal with one hand and squeezing the BVM resuscitator bag with the other hand.
Results: Among the 40 participants that were enrolled, the mean ± standard deviation (SD) delivered respiratory volume was significantly higher for the modified two-rescuer method (319.4 ± 71.4 mL vs. 190.2 ± 50.5 mL; p < 0.0001). There were no statistically significant differences between the two methods with regard to mean ± SD compression rate (117.05 ± 9.67 compressions/min vs. 118.08 ± 10.99 compressions/min; p = 0.477), compression depth (52.80 ± 5.57 mm vs. 52.77 ± 6.77 mm; p = 0.980), chest compression fraction (75.92% ± 2.14% vs. 76.57% ± 2.57%; p = 0.186), and ventilatory pause time (4.62 ± 0.64 s vs. 4.56 ± 0.43 s; p = 0.288).
Conclusions: With minor modifications to the conventional method of simulated two-rescuer CPR, rescuers can deliver significantly higher volumes of rescue breaths without compromising the quality of chest compressions.
Effect of Tourniquet Use During Surgical Treatment of Open Fractures
Ida Leah Gitajn, Paul M Werth, Sheila Sprague, Sofia Bzovsky, Brad A Petrisor, Kyle J Jeray, Nathan N O'Hara, Mohit Bhandari, Gerard Slobogean, FLOW Investigators
J Bone Joint Surg Am. 2021 May 19;103(10):860-868
Abstract
Background: We sought to evaluate whether tourniquet use, with the resultant ischemia and reperfusion, during surgical treatment of an open lower-extremity fracture was associated with an increased risk of complications.
Methods: This is a retrospective cohort study of 1,351 patients who had an open lower-extremity fracture at or distal to the proximal aspect of the tibia and who participated in the FLOW (Fluid Lavage of Open Wounds) trial. The independent variable was intraoperative tourniquet use, and the primary outcome measures were adjudicated unplanned reoperation within 1 year of the injury and adjudicated nonoperative wound complications.
Results: Unplanned reoperation and nonoperative wound complications were roughly even between the no-tourniquet (18.7% and 19.1%, respectively) and tourniquet groups (17.8% and 20.8%) (p = 0.78 and p = 0.52). Following matching, as determined by model interactions, tourniquet use was a significant predictor of unplanned reoperation in Gustilo Type-IIIA (odds ratio, 3.60; 95% confidence interval, 1.16 to 11.78) and IIIB fractures (odds ratio, 16.61; 95% confidence interval, 2.15 to 355.40).
Conclusions: The present study showed that tourniquet use did not influence the likelihood of complications following surgical treatment of an open lower-extremity fracture. However, in cases of severe open fractures, tourniquet use was associated with increased odds of unplanned reoperation; surgeons should be cautious with regard to tourniquet use in this setting.
Increased Use of Prehospital Tourniquet and Patient Survival: Los Angeles Countywide Study
Reynold Henry, Kazuhide Matsushima, Cameron Ghafil, Rachel N Henry, Hailey Theeuwen, Adam C Golden, Tiffany M Abramson, Kenji Inaba
J Am Coll Surg. 2021 Aug;233(2):233-239
Abstract
Background: Recent trends in prehospital tourniquet use remain underreported. In addition, the impact of prehospital tourniquet use on patient survival has not been evaluated in a population-level study. We hypothesized that prehospital tourniquets were used more frequently in Los Angeles County and their use was associated with improved patient survival.
Study design: This is a retrospective cohort study using a database maintained by the Los Angeles County Emergency Medical Services Agency. We included patients who sustained extremity vascular injuries between October 2015 and July 2019. Patients were divided into the following study groups: prehospital tourniquet and no-tourniquet group. Our primary end point was in-hospital mortality. The secondary outcomes included 4- and 24-hour transfusion requirements and delayed amputation.
Results: A total of 944 patients met our inclusion criteria. Of those, 97 patients (10.3%) had prehospital tourniquets placed. The rate of tourniquet use increased linearly throughout our study period (goodness of fit, p = 0.014). In multivariable analysis, prehospital tourniquet use was significantly associated with improved mortality (adjusted odds ratio 0.32; 95% CI, 0.16 to 0.85; p = 0.032). Similarly, transfusion requirements were significantly lower within 4 hours (regression coefficient -547.76; 95% CI, -762.73 to -283.49; p < 0.001) and 24 hours (regression coefficient -1,389.82; 95% CI, -1,824.88 to -920.97; p < 0.001). There was no significant difference in delayed amputation rates (adjusted odds ratio 1.07; 95% CI, 0.21 to 10.88; p < 0.097).
Conclusions: Prehospital tourniquet use has been on the rise in Los Angeles County. Our results suggest that the use of prehospital tourniquets for extremity vascular injuries is associated with improved patient survival and decreased blood transfusion requirements, without an increase in delayed amputations.
Influence of Celox Rapid's Mode of Action Under Normal and Compromised Blood Conditions
Andrew Hoggarth, Matthew Grist, Toni Murch
J Spec Oper Med. Summer 2020;20(2):154-155.
No abstract available
Nurudeen Hussain, I B J Okeke, A E Oyebanji, J I Akunne, O J Omoruyi
Afr J Emerg Med. 2021 Mar;11(1):196-201.
Abstract
Background: Understanding the epidemiology of battlefield casualties is required for plans and coordinated efforts towards improved combat trauma care (CTC) performance and outcome. The engagement of the Armed Forces of Nigeria (AFN) in containing Boko Haram Terrorism (BHT) and insurgency in Northeast Nigeria has increased the risk of combat injuries to the troops. This study determined the characteristics of combat injuries sustained by soldiers on counter terrorism and counter-insurgency operations to contain BHT.
Methods: A retrospective cross-sectional study of combat casualties managed in 7 Division (Field) Hospital, [an equivalent of UN Level 2 facility] Maiduguri, Northeast Nigeria between November 2013 and October 2014. Using data obtained from a designed Operational Casualty Card that contains their sociodemographic characteristics, categorization (as Combat Arm, Combat Support Service, Civ-JTF), nature, mechanism and sites of injury as well as inpatients records. The data were collated and analysed using SPSS version 20.
Results: A total of 209 casualties were treated. The age of the casualties ranged from 18 to 57 years with a mean of 30.6 ± 7.7 years and males constituting 99%. Over two-third (71.3%) casualties had gunshot injuries while 14.3% and 8.1% sustained improvised explosive device (IED) and fragments injuries respectively. Over three-quarter (77.5%) sustained injuries on the upper and lower extremities while 17 (7.7%) and 12 (5.7%) had injuries on thorax/abdomen and head/neck respectively. Nineteen (9.1%) casualties resulted from friendly forces/colleagues.
Conclusion: The study revealed that gunshot and IED/blasts on the extremities were the most frequent mechanism and pattern of injuries sustained with less than a tenth of the casualties resulting from friendly forces. Training health personnel on CTC, deployment of combat lifesavers to improve pre-hospital CTC, employment of skilled Orthopaedic Surgeon and other relevant surgical subspecialties and timely air evacuation of critical cases from the Field Hospital to the Base Hospital are recommended.
Evaluation of a Novel Three-Dimensional Emergency Cricothyrotomy Task Trainer
Tina T Jing, Sharan J Shah, Nicholas B Dadario, Farrukh N Jafri
Cureus. 2021 Apr 30;13(4):e14775
Abstract
Background Emergency cricothyrotomy is a critical, yet infrequently performed and time-sensitive procedure that requires practice in order to be reliably completed in emergent airway situations. Many physicians never have the opportunity to practice this rarely performed but highly impactful procedure during their training due to a lack of an affordable, high-fidelity training model. In this study, the educational impact and realism of a new synthetic cricothyrotomy training model (high-fidelity emergency cricothyrotomy, HiFEC) were compared with those of a standard porcine explant model.
Methodology A total of thirty-one attending physicians from four medical specialties were recruited on a volunteer basis to participate in a cricothyrotomy simulation workshop. Participants were randomly assigned to complete the initial workshop using one of the two models but had the opportunity to practice on both trainers. Pre- and post-workshop comfort level as well as the realism of the models were surveyed using questionnaires and evaluated using a five-point Likert scale.
Results Improvements in self-reported comfort levels were seen in both the porcine group (p = 0.0014) and HiFEC group (p = 0.0036) as well as overall (p < 0.001). The realism rating of both training models was similar with a median score of 4 on a five-point Likert scale. When comparing the cost of conducting our workshop using these models, the synthetic model saved over $650.
Conclusions Given the similar realism of the models and the improvement in participant comfort level, the synthetic HiFEC trainer is an effective and more affordable alternative training model for emergency cricothyrotomies.
Amir Khorram-Manesh, Krzysztof Goniewicz, Frederick M Burkle, Yohan Robinson
Mil Med. 2021 Mar 20;usab108. doi: 10.1093/milmed/usab108. Online ahead of print.
Abstract
Introduction: The re-emergence of armored warfare in modern conflicts has resulted in a higher number of extremity injuries, burns, and brain injuries. Despite this dramatic increase, little is reported on the type of injuries caused and their management. This review summarizes the publicly available literature and reports on the rate and type of injuries related to armored warfare, their medical outcomes, and management limitations.
Materials and methods: This rapid evidence review involves a systematic literature search, followed by a non-systematic literature review. The reason for choosing this approach was the inherent lack of quantitative outcome data in the literature to satisfy the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. The study also used content analysis to study all peer-reviewed articles, focusing on similarities and differences in the findings necessary to formulate tentative results. The electronic search included PubMed, Scopus, and Web of Science, using the following search string: "Armored; Injuries; Mechanized; Morbidity; Mortality; War; Warfare", alone or in combination.
Results: Modern conflicts are associated with higher number of extremity injuries, burns, and brain injuries among military casualties. Several publications claim that the characteristics of armored warfare and anticipated injuries in this type of warfare might require the far forward deployment of medical support supported by a reliable casualty evacuation chain. Still the quality of the available casualty data is low.
Conclusions: Because of the limited availability of reliable data or military trauma registries, up-to-date military casualty estimation remains a recognized knowledge gap, which needs to be addressed by armed forces worldwide. The future management of modern war casualties requires professional and well-trained staff in all levels, indicating a need for educational initiatives to provide both nurses and medics a greater proportion of medical care and management capabilities and responsibilities than in past conflicts.
A Cross-sectional Survey on the Use of Tranexamic Acid in the Pre-hospital Setting
Meagan Kozhimala 1, Nicholas Asselin 2, Mark R Zonfrillo 3
R I Med J (2013). 2021 Mar 1;104(2):71-75.
Abstract
Study objective: Tranexamic Acid (TXA), an anti- fibrinolytic, has been used in military trauma cases and civilian Emergency Departments for several years. This study aims to evaluate protocols for the administration of TXA across Emergency Medical Services (EMS) regions in the United States.
Methods: An anonymous survey was distributed by the National Association of Emergency Medical Technicians (NAEMT) to its members.
Results: A total of 264 eligible responses were received. Respondents included paramedics (62.5%), emergency medical technicians (EMTs) (9%), critical care paramedics (11%), and other health care professionals (19%). The majority of protocols included criteria for blood pressure (67%), heart rate (53%), and age (66%). Notable variations included TXA dilution and indications for traumatic brain injury.
Conclusion: TXA has been widely implemented in EMS protocols since the CRASH (Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage) trials. However, there remains significant variations in indications and dose concentrations.
Comeback of ketamine: resurfacing facts and dispelling myths
Abhijit Kumar, Amit Kohli
Korean J Anesthesiol. 2021 Apr;74(2):103-114.
Abstract
Initially known as CI-581, ketamine was first synthesized in 1962 as a replacement from phencyclidine. It has since been used as an anesthetic and analgesic. In addition, it has bronchodilating, sedative, and amnestic properties, preserving airway reflexes and sympathetic nervous system tone. Since the discovery of ketamine, it has been a major topic of discussion due to controversies regarding its usage in particular sets of patients. In the past 50 years, despite its potential benefits, it is not commonly used because of concerns of "emergence phenomenon," its use as a substance of abuse, and its systemic side effects. Since 2012, three World Health Organization reviews on ketamine have addressed its international control. Researchers have been studying this wonder drug for a decade worldwide. Many myths of ketamine regarding emergence phenomenon and its use in traumatic brain injury and open eye injury have been disproved in recent times. It is becoming popular in pre-hospital settings, critical care, emergency medicine, low-dose acute pain services, and adjuvant in regional anesthesia techniques. This review highlights the current consensus on the various applications of ketamine in the literature.
Ketamine Use in Operation Enduring Freedom
Eric Leslie 1, Eric Pittman 2, Brendon Drew 3, Benjamin Walrath 2
Mil Med. 2021 Jul 1;186(7-8):e720-e725
Abstract
Introduction: Ketamine is a dissociative anesthetic increasingly used in the prehospital and battlefield environment. As an analgesic, it has been shown to have comparable effects to opioids. In 2012, the Defense Health Board advised the Joint Trauma System to update the Tactical Combat Casualty Care Guidelines to include ketamine as an acceptable first line agent for pain control on the battlefield. The goal of this study was to investigate trends in the use of ketamine during Operation Enduring Freedom (OEF) and Operation Freedom's Sentinel (OFS) during the years 2011-2016.
Materials and methods: A retrospective review of Department of Defense Trauma Registry (DoDTR) data was performed for all patients receiving ketamine during OEF/OFS in 2011-2016. Prevalence of ketamine use, absolute use, mechanism of injury, demographics, injury severity score, provider type, and co-administration rates of various medications and blood products were evaluated.
Results: Total number of administrations during the study period was 866. Ketamine administration during OEF/OFS increased during the years 2011-2013 (28 patient administrations in 2011, 264 administrations in 2012, and 389 administrations in 2013). A decline in absolute use was noted from 2014 to 2016 (98 administrations in 2014, 41 administrations in 2015, and 46 administrations in 2016). The frequency of battlefield ketamine use increased from 0.4% to 11.3% for combat injuries sustained in OEF/OFS from 2011 to 2016. Explosives (51%) and penetrating trauma (39%) were the most common pattern of injury in which ketamine was administered. Ketamine was co-administered with fentanyl (34.4%), morphine (26.2%), midazolam (23.1%), tranexamic acid (12.3%), plasma (10.3%), and packed red blood cells (18.5%).
Conclusions: This study demonstrates increasing use of ketamine by the U.S. Military on the battlefield and effectiveness of clinical practice guidelines in influencing practice patterns.
Augmented reality visualization tool for the future of tactical combat casualty care
Christoph Leuze, Andreas Zoellner, Alexander R Schmidt, Robin E Cushing, Marc J Fischer, Kristin Joltes, Gary P Zientara
J Trauma Acute Care Surg. 2021 Aug 1;91(2S Suppl 2):S40-S45
Abstract
The objective of this project was to identify and develop software for an augmented reality application that runs on the US Army Integrated Visual Augmentation System (IVAS) to support a medical caregiver during tactical combat casualty care scenarios. In this augmented reality tactical combat casualty care application, human anatomy of individual soldiers obtained predeployment is superimposed on the view of an injured war fighter through the IVAS. This offers insight into the anatomy of the injured war fighter to advance treatment in austere environments.In this article, we describe various software components required for an augmented reality tactical combat casualty care tool. These include a body pose tracking system to track the patient's body pose, a virtual rendering of a human anatomy avatar, speech input to control the application and rendering techniques to visualize the virtual anatomy, and treatment information on the augmented reality display. We then implemented speech commands and visualization for four common medical scenarios including injury of a limb, a blast to the pelvis, cricothyrotomy, and a pneumothorax on the Microsoft HoloLens 1 (Microsoft, Redmond, WA).The software is designed for a forward surgical care tool on the US Army IVAS, with the intention to provide the medical caregiver with a unique ability to quickly assess affected internal anatomy. The current software components still had some limitations with respect to speech recognition reliability during noise and body pose tracking. These will likely be improved with the improved hardware of the IVAS, which is based on a modified HoloLens 2.
X Li 1, G-C Hua, F Peng
Eur Rev Med Pharmacol Sci. 2021 Apr;25(8):3286-3295.
Abstract
Objective: This study aimed to compare the efficacy of intranasal (IN) ketamine for pain control with placebo and other analgesics in an emergency setting.
Materials and methods: Electronic databases of PubMed, Embase, and CENTRAL were searched for randomized controlled trials (RCTs) comparing IN ketamine with placebo or other analgesics up to 1st January 2021. Studies were to be conducted on adults and in an emergency setting. Pain outcomes and adverse events were compared.
Results: Seven RCTs were included. Three compared IN ketamine with placebo while others with opioids. Comparing IN ketamine with opioids, the pooled analysis demonstrated no significant difference in pain scores between the two groups at 15 minutes but better pain reduction with opioids at 30 minutes. Comparing IN ketamine with placebo, our analysis demonstrated a non-significant difference but a tendency for better pain relief with IN ketamine at 15 minutes and 60 minutes. Pain scores at 30 minutes were, however, significantly lower with IN ketamine as compared to placebo. The need for rescue analgesics was significantly lower with IN ketamine as compared to placebo. There was no significant difference in the incidence of dizziness and nausea/vomiting between IN ketamine and opioids. As compared to placebo, IN ketamine was associated with an increased incidence of dizziness but not nausea/vomiting. Emergence reactions were significantly increased with IN ketamine as compared to opioids and placebo.
Conclusions: There may be a role of IN ketamine for acute pain management in adults in an emergency setting. There is a tendency for better pain control with IN ketamine as compared to control and the possibility of similar efficacy of IN ketamine as compared to opioids. However, the results are not unequivocal and are limited by the low number of studies in literature and limited pain indications studied. Further RCTs are required to strengthen the evidence.
Tranexamic Acid for Traumatic Brain Injury
Brit Long, Michael Gottlieb
Acad Emerg Med. 2021 May;28(5):595-597.
No abstract available
Maja Pålsdatter Lønvik, Odd Eirik Elden, Mats Joakimsen Lunde, Trond Nordseth, Karin Elvenes Bakkelund, Oddvar Uleberg
BMC Emerg Med. 2021 Apr 20;21(1):51
Abstract
Background: Airway management in patients with out of hospital cardiac arrest (OHCA) is important and several methods are used. The establishment of a supraglottic airway device (SAD) is a common technique used during OHCA. Two types of SAD are routinely used in Norway; the Kings LTS-D™ and the I-gel®. The aim of this study was to compare the clinical performance of these two devices in terms of difficulty, number of attempts before successful insertion and overall success rate of insertion.
Methods: All adult patients with OHCA, in whom ambulance personnel used a SAD over a one-year period in the ambulance services of Central Norway, were included. After the event, a questionnaire was completed and the personnel responsible for the airway management were interviewed. Primary outcomes were number of attempts until successful insertion, by either same or different ambulance personnel, and the difficulty of insertion graded by easy, medium or hard. Secondary outcomes were reported complications with inserting the SAD's.
Results: Two hundred and fifty patients were included, of whom 191 received I-gel and 59 received LTS-D. Overall success rate was significantly higher in I-gel (86%) compared to LTS-D (75%, p = 0.043). The rates of successful placements were higher when using I-gel compared to LTS-D, and there was a significant increased risk that the insertion of the LTS-D was unsuccessful compared to the I-gel (risk ratio 1.8, p = 0.04). I-gel was assessed to be easy to insert in 80% of the patients, as opposed to LTS-D which was easy to insert in 51% of the patients.
Conclusions: Overall success rate was significantly higher and the difficulty in insertion was significantly lower in the I-gel group compared to the LTS-D in patients with OHCA.
Sarah Mikdad, Ava K Mokhtari, Casey M Luckhurst, Kerry A Breen, Betty Liu, Haytham M A Kaafarani, George Velmahos, April E Mendoza, Frank W Bloemers, Noelle Saillant
J Trauma Acute Care Surg. 2021 Aug 1;91(2):352-360.
Abstract
Background: Prehospital tourniquet (PHT) utilization has increased in response to mass casualty events. We aimed to describe the incidence, therapeutic effectiveness, and morbidity associated with tourniquet placement in all patients treated with PHT application.
Methods: A retrospective observational cohort study was performed to evaluate all adults with a PHT who presented at two Level I trauma centers between January 2015 and December 2019. Medically trained abstractors determined if the PHT was clinically indicated (placed for limb amputation, vascular hard signs, injury requiring hemostasis procedure, or significant documented blood loss). Prehospital tourniquets were further designated as appropriately or inappropriately applied (based on PHT anatomic placement location, occurrence of a venous tourniquet, or ischemic time defined as >2 hours). Statistical analyses were performed to generate primary and secondary results.
Results: A total of 147 patients met study inclusion criteria, of which 70% met the criteria for trauma registry inclusion. Total incidence of PHT utilization increased from 2015 to 2019, with increasing proportions of PHTs placed by nonemergency medical service personnel. Improvised PHTs were frequently used. Prehospital tourniquets were clinically indicated in 51% of patients. Overall, 39 (27%) patients had a PHT that was inappropriately placed, five of which resulted in significant morbidity.
Conclusion: In summary, prehospital tourniquet application has become widely adopted in the civilian setting, frequently performed by civilian and nonemergency medical service personnel. Of PHTs placed, nearly half had no clear indication for placement and over a quarter of PHTs were misapplied with notable associated morbidity. Results suggest that the topics of clinical indication and appropriate application of tourniquets may be important areas for continued focus in future tourniquet educational programs, as well as future quality assessment efforts.
Nurudeen Hussain, I B J Okeke, A E Oyebanji, J I Akunne, O J Omoruyi
Afr J Emerg Med. 2021 Mar;11(1):196-201
Abstract
Background: Understanding the epidemiology of battlefield casualties is required for plans and coordinated efforts towards improved combat trauma care (CTC) performance and outcome. The engagement of the Armed Forces of Nigeria (AFN) in containing Boko Haram Terrorism (BHT) and insurgency in Northeast Nigeria has increased the risk of combat injuries to the troops. This study determined the characteristics of combat injuries sustained by soldiers on counter terrorism and counter-insurgency operations to contain BHT.
Methods: A retrospective cross-sectional study of combat casualties managed in 7 Division (Field) Hospital, [an equivalent of UN Level 2 facility] Maiduguri, Northeast Nigeria between November 2013 and October 2014. Using data obtained from a designed Operational Casualty Card that contains their sociodemographic characteristics, categorization (as Combat Arm, Combat Support Service, Civ-JTF), nature, mechanism and sites of injury as well as inpatients records. The data were collated and analysed using SPSS version 20.
Results: A total of 209 casualties were treated. The age of the casualties ranged from 18 to 57 years with a mean of 30.6 ± 7.7 years and males constituting 99%. Over two-third (71.3%) casualties had gunshot injuries while 14.3% and 8.1% sustained improvised explosive device (IED) and fragments injuries respectively. Over three-quarter (77.5%) sustained injuries on the upper and lower extremities while 17 (7.7%) and 12 (5.7%) had injuries on thorax/abdomen and head/neck respectively. Nineteen (9.1%) casualties resulted from friendly forces/colleagues.
Conclusion: The study revealed that gunshot and IED/blasts on the extremities were the most frequent mechanism and pattern of injuries sustained with less than a tenth of the casualties resulting from friendly forces. Training health personnel on CTC, deployment of combat lifesavers to improve pre-hospital CTC, employment of skilled Orthopaedic Surgeon and other relevant surgical subspecialties and timely air evacuation of critical cases from the Field Hospital to the Base Hospital are recommended.
Freeze-dried plasma for major trauma - Systematic review and meta-analysis
Garrick Mok, Richard Hoang, Montaha Wajid Khan, Dylan Pannell, Henry Peng, Homer Tien, Avery Nathens, Jeannie Callum, Keyvan Karkouti, Andrew Beckett, Luis Teodoro da Luz
J Trauma Acute Care Surg. 2021 Mar 1;90(3):589-602.
Abstract
Background: Treatment of acute trauma coagulopathy has shifted toward rapid replacement of coagulation factors with frozen plasma (FP). There are logistic difficulties in providing FP. Freeze-dried plasma (FDP) may have logistical advantages including easier storage and rapid preparation time. This review assesses the feasibility, efficacy, and safety of FDP in trauma.
Study design and methods: Studies were searched from Medline, Embase, Cochrane Controlled Trials Register, ClinicalTrials.gov, and Google Scholar. Observational and randomized controlled trials (RCTs) assessing FDP use in trauma were included. Trauma animal models addressing FDP use were also included. Bias was assessed using validated tools. Primary outcome was efficacy, and secondary outcomes were feasibility and safety. Meta-analyses were conducted using random-effect models. Evidence was graded using Grading of Recommendations Assessment, Development, and Evaluation profile.
Results: Twelve human studies (RCT, 1; observational, 11) and 15 animal studies were included. Overall, studies demonstrated moderate risk of bias. Data from two studies (n = 119) were combined for meta-analyses for mortality and transfusion of allogeneic blood products (ABPs). For both outcomes, no difference was identified. For mortality, pooled odds ratio was 0.66 (95% confidence interval, 0.29-1.49), with I2 = 0%. Use of FDP is feasible, and no adverse events were reported. Animal data suggest similar results for coagulation and anti-inflammatory profiles for FP and FDP.
Conclusion: Human data assessing FDP use in trauma report no difference in mortality and transfusion of ABPs in patients receiving FDP compared with FP. Data from animal trauma studies report no difference in coagulation factor and anti-inflammatory profiles between FP and FDP. Results should be interpreted with caution because most studies were observational and have heterogeneous population (military and civilian trauma) and a moderate risk of bias. Well-designed prospective observational studies or, preferentially, RCTs are warranted to answer FDP's effect on laboratory (coagulation factor levels), transfusion (number of ABPs), and clinical outcomes (organ dysfunction, length of stay, and mortality).
Trends in combat casualty care following the publication of clinical practice guidelines
Roy Nadler, Avishai M Tsur, Ari M Lipsky, Avi Benov, Alex Sorkin, Elon Glassberg, Jacob Chen
J Trauma Acute Care Surg. 2021 Aug 1;91(2S Suppl 2):S194-S200.
Abstract
Background: The current study explores the trends in the application of combat casualty care following the publication of clinical practice guidelines (CPGs) in five domains for 13 years.
Methods: The Israel Defense Forces Trauma Registry was used to assess practice and adherence to guidelines in five domains: (a) crystalloid transfusions, (b) tranexamic acid use, (c) freeze-dried plasma use, (d) chest decompression, and (e) airway management. All patients injured between January 2006 and December 2018 were included in the analysis. Trends were analyzed and presented monthly using linear regression and were compared using the Chow test.
Results: The mean ± SD crystalloid volume transfused decreased from 1,179 ± 653 mL in 2006 to 466 ± 202 mL in 2018 (B = 0.016, 0.006-0.044). The proportion of patients with an indication treated with tranexamic acid dropped from 8% (238 of 2,979 patients) to 2.5% (60 of 2,356 patients) following the stricter guideline's publication. Freeze-dried plasma administration in indicated casualties rose from 12.5% in 2013 to 48% in 2018 (B = 1.63, 1.3-2.05). The overall proportion of casualties undergoing chest decompression rose from 1% (61 of 6,036 casualties) to 1.5% (155 of 10,493 casualties) following the release of a new CPG in 2012 (p = 0.013). There were no significant trends in intubation ratios before (B = 0.987, 0.953-1.02) or after 2012 (B = 10.2, 0.996-1.05).
Conclusion: Some aspects demonstrate the desired trends in response to new CPGs; in others, initial improvement is achieved but followed by stagnation. In some medical care aspects, completely unexpected and undesirable trends are observed. Every change and update in CPGs should be based on reliable data. The effect of every change must be monitored carefully to ensure adequate adherence to lifesaving guidelines.
Prehospital tranexamic acid: READY for primetime?
Joe Nemeth, Alun Ackery, François de Champlain
CJEM. 2021 Mar;23(2):143-144.
No abstract available
A Focus on Non-Amputation Combat Extremity Injury: 2001-2018
Katheryne G Perez, Susan L Eskridge, Mary C Clouser, Cameron T McCabe, Michael R Galarneau
Mil Med. 2021 May 3;usab143. doi: 10.1093/milmed/usab143. Online ahead of print.
Abstract
Introduction: Extremity injuries have comprised the majority of battlefield injuries in modern U.S. conflicts since World War II. Most reports have focused on serious injuries only and, to date, no reports have described the full extent of combat extremity injuries, from mild to severe, resulting from post-9/11 conflicts. This study aims to identify and characterize the full spectrum of non-amputation combat-related extremity injury and extend the findings of previous reports.
Methods: The Expeditionary Medical Encounter Database was queried for all extremity injured service members (SMs) deployed in support of post-9/11 conflicts through July 2018. Only injuries incurred during combat operations were included in this report. Major amputations were excluded as well as SMs killed in action or who died of wounds. Extremity injuries were categorized by body region, nature of injury, and severity. Demographics and injury event characteristics are also presented.
Results: A total of 17,629 SMs sustained 42,740 extremity injuries during 18,004 separate injury events. The highest number of SMs were injured in 2004 (n = 3,553), 2007 (n = 2,244), and 2011 (n = 2,023). Injured SMs were mostly young (78% under 30 years), male (97%), junior- to mid-level enlisted (89%), in the Army (69%) or Marine Corps (28%), active duty (84%), serving as infantry and gun crew (59%), and injured in support of Operation Iraqi Freedom (60%). Blast weaponry was responsible for 75% of extremity injuries. Injuries were similarly distributed between the lower (52%) and upper (48%) extremities. The most common sites of lower extremity injury were the lower leg/ankle complex (40%) and thigh (26%). The most common upper extremities sites were the shoulder and upper arms (37%), and the hand, wrist, and fingers (33%). Nearly half (48%) of all extremity injuries were open wounds (48%), followed by fractures (20%) and contusions/superficial injuries (16%). SMs sustained an average of 2.4 extremity injuries per event and 56% of injuries were considered mild, with a median Injury Severity Score (ISS) of 3.
Conclusion: This study is the first publication to capture, review, and characterize the full range, from mild to severe, of non-amputation combat-related extremity injuries resulting from post-9/11 conflicts. The high prevalence of extremity injury, particularly in such a young population, and associated short- and long-term health outcomes, will impact military health care systems for decades to come.
Ian Roberts, Haleema Shakur-Still, Amy Aeron-Thomas, Danielle Beaumont, Antonio Belli, Amy Brenner, Madeleine Cargill, Rizwana Chaudhri, Nicolas Douglas, Lauren Frimley, Catherine Gilliam, Amber Geer, Zahra Jamal, Rashid Jooma, Raoul Mansukhani, Alec Miners, Jason Pott, Danielle Prowse, Temitayo Shokunbi, Jack Williams
Randomized Controlled Trial Health Technol Assess. 2021 Apr;25(26):1-76
Abstract
Background: Tranexamic acid safely reduces mortality in traumatic extracranial bleeding. Intracranial bleeding is common after traumatic brain injury and can cause brain herniation and death. We assessed the effects of tranexamic acid in traumatic brain injury patients.
Objective: To assess the effects of tranexamic acid on death, disability and vascular occlusive events in traumatic brain injury patients. We also assessed cost-effectiveness.
Design: Randomised trial and economic evaluation. Patients were assigned by selecting a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients, caregivers and those assessing outcomes were masked to allocation. All analyses were by intention to treat. We assessed the cost-effectiveness of tranexamic acid versus no treatment from a UK NHS perspective using the trial results and a Markov model.
Setting: 175 hospitals in 29 countries.
Participants: Adults with traumatic brain injury within 3 hours of injury with a Glasgow Coma Scale score of ≤ 12 or any intracranial bleeding on computerised tomography scan, and no major extracranial bleeding, were eligible.
Intervention: Tranexamic acid (loading dose 1 g over 10 minutes then infusion of 1 g over 8 hours) or matching placebo.
Main outcome measures: Head injury death in hospital within 28 days of injury in patients treated within 3 hours of injury. Secondary outcomes were early head injury deaths, all-cause and cause-specific mortality, disability, vascular occlusive events, seizures, complications and adverse events.
Results: Among patients treated within 3 hours of injury (n = 9127), the risk of head injury death was 18.5% in the tranexamic acid group versus 19.8% in the placebo group (855/4613 vs. 892/4514; risk ratio 0.94, 95% confidence interval 0.86 to 1.02). In a prespecified analysis excluding patients with a Glasgow Coma Scale score of 3 or bilateral unreactive pupils at baseline, the results were 12.5% in the tranexamic acid group versus 14.0% in the placebo group (485/3880 vs. 525/3757; risk ratio 0.89, 95% confidence interval 0.80 to 1.00). There was a reduction in the risk of head injury death with tranexamic acid in those with mild to moderate head injury (166/2846 vs. 207/2769; risk ratio 0.78, 95% confidence interval 0.64 to 0.95), but in those with severe head injury (689/1739 vs. 685/1710; risk ratio 0.99, 95% confidence interval 0.91 to 1.07) there was no apparent reduction (p-value for heterogeneity = 0.030). Early treatment was more effective in mild and moderate head injury (p = 0.005), but there was no obvious impact of time to treatment in cases of severe head injury (p = 0.73). The risk of disability, vascular occlusive events and seizures was similar in both groups. Tranexamic acid is highly cost-effective for mild and moderate traumatic brain injury (base case of £4288 per quality-adjusted life-year gained).
Conclusion: Early tranexamic acid treatment reduces head injury deaths. Treatment is cost-effective for patients with mild or moderate traumatic brain injury, or those with both pupils reactive.
Prehospital administration of blood and plasma products
Anna Roehl, Oliver Grottke
Curr Opin Anaesthesiol. 2021 Aug 1;34(4):507-513.
Abstract
Purpose of review: Posttraumatic bleeding following major trauma is life threatening for the patient and remains a major global health issue. Bleeding after major trauma is worsened by trauma-induced coagulopathy (TIC). TIC consists of acute trauma coagulopathy and resuscitation coagulopathy. The early diagnosis and management of prehospital TIC management are challenging.
Recent findings: Concepts for early diagnosis and management of civilian prehospital TIC management are evolving. The feasibility of prehospital blood component as well as coagulation factor transfusion has been proven.
Summary: Due to different national guidelines and regulations of blood component therapies there is a wide heterogeneity in concepts of prehospital damage control resuscitation. Tranexamic acid administration is widely accepted, whereas the transfusion of whole blood, blood components, or coagulations factors needs further examination in the civilian setting.
Operationalizing the Deployment of Low-Titer O-Positive Whole Blood Within a Regional Trauma System
Randall Schaefer, Tasia Long, David Wampler, Rena Summers, Eric Epley, Elizabeth Waltman, Brian Eastridge, Donald Jenkins
Mil Med. 2021 Jan 25;186(Suppl 1):391-399.
Introduction: The implementation of a low-titer O+ whole blood (LTOWB) resuscitation algorithm, particularly in the prehospital environment, has several inherent challenges, including cost, limited and inconsistent supply, and the logistics of cold-chain management. The Southwest Texas Regional Advisory Council has implemented the nation's first multidisciplinary, multi-institutional regional LTOWB program. This research effort was to illustrate the successful deployment of LTOWB within a regional trauma system.
Materials and methods: A deliberate systems approach to the deployment of LTOWB was used. Tenets of this program included the active management of blood donor sources and blood supply levels to minimize wastage as a result of expiration, maximize product utilization, the use of prehospital transfusion triggers, and efforts to decrease program costs prehospital agencies. A novel LTOWB rotation system was established using the concept of a "rotation site" and "rotation center." Standardized transfusion criteria, a regional approved equipment list, a regional Prehospital Blood Product Transfusion Record, and a robust multilevel communication plan serves as the framework for the program. The San Antonio Whole Blood Consortium was developed to create a consensus driven forum to manage and guide the program.
Results: From January 2018 to October 2019, LTOWB has been placed at 18 helicopter emergency medical services (HEMS) bases, 12 ground emergency medical service (EMS) agencies, 1 level I trauma center, and 1 level IV trauma center. A total of 450 patients have received a prehospital LTOWB transfusion. Program wide, the wastage rate of LTOWB due to expiration is between 1% and 2%. No complications related to prehospital LTOWB administration have been identified.
Discussion: This work demonstrates a novel model for the development of a trauma system LTOWB program. The program's implementation augments remote damage control resuscitation strategies and requires the integration and collaboration of a multidisciplinary stakeholder team to optimize efficiency, performance, and safety of the program.
An Analysis of Airway Interventions in the Setting of Smoke Inhalation Injury on the Battlefield
Steven G Schauer, Jason F Naylor, Gregory Dion, Michael D April, Kevin K Chung, Victor A Convertino
Mil Med. 2021 May 3;186(5-6):e474-e479
Abstract
Introduction: The Committee on Tactical Combat Casualty Care and Capabilities Development and Integration Directorate cite airway burn injuries as an indication for prehospital cricothyrotomy. We sought to build on previously published data by describing for the first time the incidence of prehospital airway interventions in combat casualties who received airway management in the setting of inhalational injuries.15,26 We hypothesized that (1) airway interventions in combat casualties who suffered inhalational injury would have a higher mortality rate than those without airway intervention and (2) prehospital cricothyrotomy was used with greater incidence than endotracheal intubation.
Materials and methods: Using a previously described Department of Defense Trauma Registry dataset from January 2007 to August 2016, unique casualties with documented inhalational injury were identified.
Results: Our predefined search codes captured 28,222 (72.8% of all encounters in the registry) of those subjects. A total of 347 (1.2%) casualties had a documented inhalational injury, 27 (7.8%) of those with at least 1 prehospital airway intervention inhalational injuries (0.09% of our dataset [n = 28,222]). Within the subset of patients with an inhalation injury, 23 underwent intubation, 2 underwent cricothyrotomy, 3 had placement of an airway adjunct not otherwise specifically listed, and 1 casualty had both a cricothyrotomy and intubation documented. No casualties had a supraglottic, nasopharyngeal, or oropharyngeal airway listed. Contrary to our hypotheses, of those with an airway intervention, 74.0% survived to hospital discharge. In multivariable regression models, when adjusting for confounders, there was no difference in survival to discharge in those with an airway intervention compared to those without.
Conclusions: Casualties undergoing airway intervention for inhalation injuries had similar survival adjusting for injury severity, supporting its role when indicated. Without case-specific data on airway status and interventions, it is challenging to determine if the low rate of cricothyrotomy in this population was a result of rapid transport to a more advanced provider capable of performing intubation or cricothyrotomy may not be meeting the needs of the medics.
Uwe Schweigkofler, Bernd Wohlrath, Heiko Trentzsch, Konstantin Horas, Reinhard Hoffmann, Dennis Wincheringer
Eur J Trauma Emerg Surg. 2021 Apr;47(2):493-498. 2019 Oct 14.
Abstract
Background: Massive hemorrhage is a common cause of death in patients sustaining instable pelvic ring fractures. Pelvic binders have been propagated for rapid, non-invasive pelvic ring stabilization and control of severe pelvic hemorrhage. There is a recommendation to applicate a pelvic binder due to the trauma mechanism alone. However, there is little evidence to support this advice. The aim of this study was to evaluate effects of an early pelvic binder application on transfusion requirements and hospital mortality.
Methods: This was a subgroup analysis of a study investigating clinical examination for pelvic stability. We included 64 patients who showed radiologically proven pelvic ring fracture (Tile type B or C). Study data were complemented by retrospective chart review to assess transfusion requirements. We used descriptive statistical analysis.
Results: 37 patients had a pelvic binder applied during prehospital treatment (pb), 27 received no binder (npb). Both showed no statistically significant difference in terms of injury severity or probability of survival. We found a trend towards higher ISS (29.7 vs. 24.4) and a lower probability of survival (RISC-II Prognosis 81% vs. 89%) in the pb group. Risk for massive transfusion according to TASH-Scores (10% vs. 6%), and average number of RPBC transfused (10.5 vs. 7.5) was higher in the pb group, without statistically significance. 20 patients (54%) in the pb group and 15 patients (55%) in the npb group showed a need of RPBC within the first 72 h. There was no significant difference in hospital mortality (20% vs. 13.3%).
Conclusion: We were unable to identify blood-saving effects with application of a pelvic binder to patients with instable pelvic ring fractures in terms of RPBC requirements. Nevertheless, some salutary effect of prehospital pb application may be assumed. Better studies are needed to elucidate the value of this intervention.
Combat-related ocular injuries in the Israel Defense Forces during the years 2013 to 2019
Nitzan Shakarchy-Kaminsky 1, Jacob Megreli, Dan Kaminsky, Avishai M Tsur, Roy Nadler, Irina Radomislensky, Shaul Gelikas, Elon Glassberg, Avi Benov, Ariel Furer
J Trauma Acute Care Surg. 2021 Aug 1;91(2S Suppl 2):S241-S246
Abstract
Background: Ocular injuries account for up to 13% of battle injuries, despite the implementation of advanced protective eyewear (PE). The aim of this study was to describe the extent of ocular injuries over the last years among Israel Defense Forces soldiers and to examine the change in PE policy introduced in 2013 and the effect of a high-intensity conflict on ocular injury characteristics.
Methods: This retrospective registry-based analysis derived data from the Israel Defense Forces Trauma Registry and included soldiers who sustained combat-related ocular injuries between the years 2013 and 2019. Demographic data and injury characteristics of casualties, as well as information regarding the use of PE, were collected and analyzed.
Results: A total of 2,312 military casualties were available for this study; the incidence of combat-related ocular injuries was 8.9% (n = 113). Ocular injuries occurred among male soldiers (98.2%) with a mean ± SD age of 22.7 ± 4.6 years; mechanism of injury was penetrating in 59.3% of the casualties and blunt in 22.1% of the casualties, ocular injury was isolated in 51.3% of the casualties, and others sustained concomitant injuries including head (32.7%), upper extremity injury (17.7%), lower extremity (15.9%), torso (8.0%), neck (6.2%), and other (5.9%) injuries. Ocular injuries rate was similar among casualties who used PE (11.2%) and those who did not use PE (13.0%) while injured (p = 0.596). Rate of open globe injuries was 9.1% in casualties who used PE and 39.5% (p = 0.002) in casualties who did not.
Conclusion: Eye protection may significantly reduce ocular injuries severity. Education of the combatants on the use of PE and guidance of medical teams on proper assessment, initial treatment, and rapid evacuation of casualties are needed to improve visual outcomes of the casualties further.
Keita Shibahashi, Hidenori Hoda, Yoshihiro Okura, Yuichi Hamabe
World Neurosurg. 2021 May;149:e504-e511.
Abstract
Background: Safe blood pressure levels in the prehospital setting for patients with traumatic brain injury (TBI) remain unclear. We aimed to investigate the association between prehospital blood pressure and the outcomes of patients with TBI to determine optimal threshold for hypotension that could be considered in the prehospital setting.
Methods: Using data from the Japan Trauma Data Bank, we identified adult patients (aged ≥18 years) who experienced severe TBI (maximum head Abbreviated Injury Severity score ≥3) and were transported directly from the scene of the blunt trauma occurrence to the hospital, between 2004 and 2019. We excluded patients with prehospital systolic blood pressure (SBP) levels of <60 and ≥160 mm Hg. Using mixed effects logistic regression models, we investigated the association between prehospital SBP and in-hospital mortality, considering the hospital ID as a random effect variable. In addition, we also conducted a stratified analysis based on age (<60 vs. ≥60 years).
Results: A total of 34,175 patients (16,114 aged <60 years and 18,061 aged ≥60 years) were eligible for the analyses. Plotting the adjusted odds ratios for in-hospital mortality as a function of SBP produced J-shaped curves. An SBP <110 mm Hg was significantly associated with in-hospital mortality, with an adjusted odds ratio of 1.52 (95% confidence interval: 1.39-1.65). Stratified analyses revealed that the threshold did not differ between the age groups.
Conclusions: An SBP <110 mm Hg in the prehospital setting is significantly associated with higher in-hospital mortality.
Sarah C Stokes, Christina M Theodorou, Scott A Zakaluzny, Joseph J DuBose, Rachel M Russo
J Trauma Acute Care Surg. 2021 Aug 1;91(2S Suppl 2):S56-S64
Abstract
Background: Noncompressible torso hemorrhage is a leading cause of preventable death on the battlefield. Intra-aortic balloon occlusion was first used in combat in the 1950s, but military use was rare before Operation Iraqi Freedom and Operation Enduring Freedom. During these wars, the combination of an increasing number of deployed vascular surgeons and a significant rise in deaths from hemorrhage resulted in novel adaptations of resuscitative endovascular balloon occlusion of the aorta (REBOA) technology, increasing its potential application in combat. We describe the background of REBOA development in response to a need for minimally invasive intervention for hemorrhage control and provide a detailed review of all published cases (n = 47) of REBOA use for combat casualties. The current limitations of REBOA are described, including distal ischemia and reperfusion injury, as well as ongoing research efforts to adapt REBOA for prolonged use in the austere setting
The Key to Combat Readiness Is a Strong Military-Civilian Partnership
Matthew S Sussman, Emily L Ryon, Eva M Urrechaga, Alessia C Cioci, Tyler J Herrington, Louis R Pizano, George D Garcia, Nicholas Namias, Paul J Wetstein, Mark D Buzzelli, Kirby R Gross, Kenneth G Proctor
Mil Med . 2021 May 3;186(5-6):571-576.
Abstract
Introduction: In peacetime, it is challenging for Army Forward Resuscitative Surgical Teams (FRST) to maintain combat readiness as trauma represents <0.5% of military hospital admissions and not all team members have daily clinical responsibilities. Military surgeon clinical experience has been described, but no data exist for other members of the FRST. We test the hypothesis that the clinical experience of non-physician FRST members varies between active duty (AD) and Army reservists (AR).
Methods: Over a 3-year period, all FRSTs were surveyed at one civilian center.
Results: Six hundred and thirteen FRST soldiers were provided surveys and 609 responded (99.3%), including 499 (81.9%) non-physicians and 110 (18.1%) physicians/physician assistants. The non-physician group included 69% male with an average age of 34 ± 11 years and consisted of 224 AR (45%) and 275 AD (55%). Rank ranged from Private to Colonel with officers accounting for 41%. For AD vs. AR, combat experience was similar: 50% vs. 52% had ≥1 combat deployment, 52% vs. 60% peri-deployment patient load was trauma-related, and 31% vs. 32% had ≥40 patient contacts during most recent deployment (all P > .15). However, medical experience differed for AD and AR: 18% vs. 29% had >15 years of experience in practice and 4% vs. 17% spent >50% of their time treating critically injured patients (all P < .001). These differences persisted across all specialties, including perioperative nurses, certified registered nurse anesthetists, operating room (OR) techs, critical-care nurses, emergency room (ER) nurses, licensed practical nurse (LPN), and combat medics.
Conclusions: This is the first study of clinical practice patterns in AD vs. AR, non-physician members of Army FRSTs. In concordance with previous studies of military surgeons, FRST non-physicians seem to be lacking clinical experience as well. To maintain readiness and to provide optimal care for our injured warriors, the entire FRST, not just individuals, should embed within civilian centers.
Operation Blood Rain: The Effect of Airdrop on Fresh Whole Blood
Robert L Tong, Cody W Bohlke, Roselyn W Clemente Fuentes, Manuel Moncada, Alexander D Schloe, Robert L Ashley
J Spec Oper Med. Summer 2021;21(2):29-33.
Abstract
Background: Administration of fresh whole blood (FWB) is a life-saving treatment that prolongs life until definitive surgical intervention can be performed; however, collecting FWB is a time-consuming and resource-intensive process. Furthermore, it may be difficult to collect sufficient FWB to treat critically wounded patients or multiple-hemorrhaging casualties. This study describes the effect of airdrop on FWB and explores the possibility of using airdrop to deliver FWB to combat medics treating casualties in the prehospital setting when FDA-approved, cold-stored blood products are not readily available and timely casualty evacuation (CASEVAC) is not feasible.
Methods: Four units of FWB were collected from volunteer donors and loaded into a blood cooler that was dropped from a fixed-wing aircraft under a standard airdrop training bundle (SATB) parachute. A control group of 4 units of FWB was stored in a blood cooler that was not dropped. Baseline and postintervention laboratory samples were measured in both airdropped and control units, including full blood counts, prothrombin time/partial thromboplastin time/international normalized ratio (PT/PTT/INR), pH, lactate, potassium, indirect bilirubin, glucose, fibrinogen, lactate dehydrogenase, and peripheral blood smears.
Results: The blood cooler, cooling bags, and all 4 FWB units did not sustain any damage from the airdrop. There was no evidence of hemolysis. All airdropped blood met parameters for transfusion per the Whole Blood Transfusion Clinical Practice Guideline of the Joint Trauma System (JTS).
Conclusions: Airdrop of FWB in a blood cooler with a SATB parachute may be a viable way of delivering blood products to combat medics treating hemorrhaging patients in the prehospital setting, although further research is needed to fully validate the safety of this method of FWB delivery.
A comparison of efficacy, efficiency, and durability in novel tourniquet designs
Christopher Treager, Tyler Lopachin, Sally Mandichak, Bradley Kinney, Megan Bohan, Michael Boboc, Christian Go, Emily Friedrich, Sean Stuart
Randomized Controlled Trial J Trauma Acute Care Surg. 2021 Aug 1;91(2S Suppl 2):S139-S145.
Abstract
Background: Exsanguination due to extremity hemorrhage is a major cause of preventable traumatic deaths. Extremity tourniquet use has been shown to be safe and improve survival. The purpose of this study was to compare the efficacy, efficiency, and durability of the Generation 7 Combat Application Tourniquet (CAT; North American Rescue, Greer, SC), the Tactical Mechanical Tourniquet (TMT; Combat Medical Systems, Harrisburg, NC), and the SOF Tactical Tourniquet-Wide (SOFTT-W; Tactical Medical Solutions, Anderson, SC).
Methods: This study was a three-phase randomized, cross-over trial. In successive trials, subjects were timed during the application of each tourniquet to the upper and lower extremity. Following successful lower extremity application, subjects low crawled 25 ft and then were dragged 25 ft, after which effectiveness was reassessed, as defined by the cessation of distal pulses by Doppler ultrasound.
Results: In arm application, both the CAT and TMT had significantly less failure rates than the SOFTT-W (5.56%, 19.44%, 58.33%), with the CAT being the fastest tourniquet when compared with TMT and SOFTT-W (37.8 seconds, 65.01 seconds, 63.07 seconds). In leg application, the CAT had significantly less rates of failure when compared with the SOFTT-W, but there was no other significant difference between the tourniquets (27.78%, 44.44%, 61.11%). In addition, the CAT was significantly faster than both the TMT and SOFTT-W when applied to the leg (8.33 seconds, 40.96 seconds, 34.5 seconds). There was no significant difference in tourniquet failure rates between the three tourniquets after subject maneuvers in phase 3 (34.29%, 42.86%, 45.45%).
Discussion: The CAT is as effective as the TMT and significantly more effective than the SOFTT-W. In addition, the CAT demonstrated shorter application times than either the TMT or SOFTT-W. However, there was no significant difference between the three tourniquets in their ability to maintain pulselessness after subject maneuvers.
James W Warwick, Daniel L Davenport, Amber Bettis, Andrew C Bernard
J Am Coll Surg. 2021 Apr;232(4):572-579.
Abstract
Background: This study analyzed data from the 2017 American College of Surgeons National Trauma Data Bank to examine the effects of pre-hospital Field Triage Decision Scheme Step 1 vital sign criteria (S1C) and vital sign decline on subsequent emergency department (ED) and hospital death in emergency medical services (EMS) transported trauma victims.
Study design: Patient and injury characteristics, transport time, and ED and hospital disposition were collected. S1C (respiratory rate [RR]<10, RR>29 breaths/min, systolic blood pressure [SBP]<90 mmHg, Glasgow Coma Scale [GCS]<14) were recorded at the injury scene and hospital arrival. Decline was defined as a change ≥ 1 standard deviation (SD) into or within an S1C range. S1C and decline were analyzed relative to ED and hospital death using logistic regression.
Results: Of 333,213 included patients, 54,849 (16.5%) met Step 1 criteria at the scene, and 21,566 (6.9%) declined en route. The ED death rate was 0.4% (n = 1,188), and the hospital death/hospice rate was 4.0% (11,624 of 287,675). Patients who met S1C at the scene or who declined were more likely to require longer hospital lengths of stay, ICU admission, and surgical intervention. S1C and decline patients had higher odds of death in both the ED (S1C odds ratio [OR] 15.1, decline OR 2.4, p values < 0.001) and hospital (S1C OR 4.8, decline OR 2.0, p values < 0.001) after adjusting for patient demographics, transport time and mode, injury severity, and injury mechanism. Each S1C and decline measure was independently predictive of death.
Conclusions: This study quantifies the mortality risks associated with individual S1C and validates their use as an indicator for injury severity and pre-hospital triage tool.
Systematic review of prehospital haemostatic dressings
Matthew Welch, J Barratt, A Peters, C Wright
BMJ Mil Health. 2020 Jun;166(3):194-200
Abstract
Introduction: Haemorrhage is one of the leading causes of battlefield and prehospital death. Haemostatic dressings are an effective method of limiting the extent of bleeding and are used by military forces extensively. A systematic review was conducted with the aim of collating the evidence on current haemostatic products and to assess whether one product was more effective than others.
Methods: A systematic search and assessment of the literature was conducted using 13 health research databases including MEDLINE and CINAHL, and a grey literature search. Two assessors independently screened the studies for eligibility and quality. English language studies using current-generation haemostatic dressings were included. Surgical studies, studies that did not include survival, initial haemostasis or rebleeding and those investigating products without prehospital potential were excluded.
Results: 232 studies were initially found and, after applying exclusion criteria, 42 were included in the review. These studies included 31 animal studies and 11 clinical studies. The outcomes assessed were subject survival, initial haemostasis and rebleeding. A number of products were shown to be effective in stopping haemorrhage, with Celox, QuikClot Combat Gauze and HemCon being the most commonly used, and with no demonstrable difference in effectiveness.
Conclusions: There was a lack of high-quality clinical evidence with the majority of studies being conducted using a swine haemorrhage model. Iterations of three haemostatic dressings, Celox, HemCon and QuikClot, dominated the studies, probably because of their use by international military forces and all were shown to be effective in the arrest of haemorrhage.
Karlijn J P van Wessem, Luke P H Leenen
World J Surg. 2021 Aug;45(8):2398-2407
Abstract
Background: Early hemorrhage control is important in trauma-related death prevention. Tranexamic acid (TXA) has shown to be beneficial in patients in hemorrhagic shock, although widespread adoption might result in incorrect TXA administration leading to increased morbidity and mortality.
Methods: A 7-year prospective cohort study with consecutive trauma patients admitted to a Level-1 Trauma Center ICU was performed to investigate administration of both pre- and in-hospital TXA and its relation to morbidity and mortality. Indication for prehospital and in-hospital 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: Four hundred and twenty-two patients (71% males, median ISS 29, 95% blunt injuries) were included. Even though TXA patients were more severely injured with more deranged physiology, no differences in outcome were noted. Overall, thrombo-embolic complication rate was 8%. In half the patients, hemorrhagic shock was the indication for prehospital TXA, whereas 79% of in-hospital TXA was given based on suspicion of hemorrhagic shock. Thirteen percent of patients with SBP ≤ 90 mmHg in ED received no TXA at all. Based on SBP alone, 22% of prehospital TXA and 25% of in-hospital TXA were justified.
Conclusions: Despite being more severely injured, TXA patients had similar outcome compared to patients without TXA. Thrombo-embolic complication rate was low despite liberal use of both prehospital and in-hospital TXA. Caution should be exercised in selecting patients for TXA, although this might be challenging based on SBP alone in patients who do not yet show signs of deranged physiology on arrival in ED.
Prehospital Tranexamic Acid Administration in Injured Patients
Shaoyun Zhang, Cong Xiao, Zhixiang Gao
JAMA Surg. 2021 Jul 1;156(7):688.
No abstract available
Francois-Xavier Ageron, Timothy J Coats, Vincent Darioli, Ian Roberts
Scand J Trauma Resusc Emerg Med. 2021 Jan 6;29(1):6
Abstract
Background: Tranexamic acid reduces surgical blood loss and reduces deaths from bleeding in trauma patients. Tranexamic acid must be given urgently, preferably by paramedics at the scene of the injury or in the ambulance. We developed a simple score (Bleeding Audit Triage Trauma score) to predict death from bleeding.
Methods: We conducted an external validation of the BATT score using data from the UK Trauma Audit Research Network (TARN) from 1st January 2017 to 31st December 2018. We evaluated the impact of tranexamic acid treatment thresholds in trauma patients.
Results: We included 104,862 trauma patients with an injury severity score of 9 or above. Tranexamic acid was administered to 9915 (9%) patients. Of these 5185 (52%) received prehospital tranexamic acid. The BATT score had good accuracy (Brier score = 6%) and good discrimination (C-statistic 0.90; 95% CI 0.89-0.91). Calibration in the large showed no substantial difference between predicted and observed death due to bleeding (1.15% versus 1.16%, P = 0.81). Pre-hospital tranexamic acid treatment of trauma patients with a BATT score of 2 or more would avoid 210 bleeding deaths by treating 61,598 patients instead of avoiding 55 deaths by treating 9915 as currently.
Conclusion: The BATT score identifies trauma patient at risk of significant haemorrhage. A score of 2 or more would be an appropriate threshold for pre-hospital tranexamic acid treatment.
Ateeq Almuwallad, Elaine Cole, Jennifer Ross, Zane Perkins, Ross Davenport
J Trauma Acute Care Surg. 2021 May 1;90(5):901-907
Abstract
Background: Tranexamic acid (TXA) is an antifibrinolytic drug associated with improved survival among trauma patients with hemorrhage. Tranexamic acid is considered a primary hemostatic intervention in prehospital for treatment of bleeding alongside blood product transfusion.
Methods: A systematic review and meta-analysis was conducted to investigate the impact of prehospital TXA on mortality among trauma patients with bleeding. A systematic search was conducted using the National Institute for Health and Care Excellence Healthcare Databases Advanced Search library which contain the following of databases: EMBASE, Medline, PubMed, BNI, EMCARE, and HMIC. Other databases searched included SCOPUS and the Cochrane Central Register for Clinical Trials Library. Quality assessment tools were applied among included studies; Cochrane Risk of Bias for randomized control trials and Newcastle-Ottawa Scale for cohort observational studies.
Results: A total of 797 publications were identified from the initial database search. After removing duplicates and applying inclusion/exclusion criteria, four studies were included in the review and meta-analysis which identified a significant survival benefit in patients who received prehospital TXA versus no TXA. Three observational cohort and one randomized control trial were included into the review with a total of 2,347 patients (TXA, 1,169 vs. no TXA, 1,178). There was a significant reduction in 24 hours mortality; odds ratio (OR) of 0.60 (95% confidence interval [CI], 0.37-0.99). No statistical significant differences in 28 days to 30 days mortality; OR of 0.69 (95% CI, 0.47-1.02), or venous thromboembolism OR of 1.49 (95% CI, 0.90-2.46) were found.
Conclusion: This review demonstrates that prehospital TXA is associated with significant reductions in the early (24 hour) mortality of trauma patients with suspected or confirmed hemorrhage but no increase in the incidence of venous thromboembolism.
Long-term Health Outcomes Among Survivors Exposed to Sulfur Mustard in Iran
Hossein Amini, Masoud Solaymani-Dodaran, Batool Mousavi, Seyed Nooredin Alam Beladi, Mohammad Reza Soroush, Jamileh Abolghasemi, Amir Vahedian-Azimi, Mahmoud Salesi, Paul C Guest, Amirhossein Sahebkar, Mostafa Ghanei
JAMA Netw Open. 2020 Dec 1;3(12):e2028894
Abstract
Importance: The prevalence and severity of long-term health complications after exposure to sulfur mustard are unknown.
Objective: To investigate the long-term health outcomes among survivors exposed to sulfur mustard during the Iran-Iraq War.
Design, setting, and participants: In this retrospective cohort study, late-onset health complications of 64 190 Iranian survivors exposed to sulfur mustard during the Iran-Iraq War from 1980 to 1988 were investigated using descriptive statistics. Data involving affected organs and symptom severity were extracted from the Veterans and Martyr Affair Foundation (VMAF) database from 1980 to 2019. Assessments were conducted across 3 groups depending on whether survivors were (1) evacuated and admitted (EA) to a hospital; (2) not evacuated or admitted (NEA) to a hospital; or (3) evacuation or admission status was not documented.
Exposures: Analysis of chronic symptom severity following exposure to sulfur mustard.
Main outcomes and measures: Mild, moderate, or severe rankings of symptoms in lungs, eyes, and skin of survivors exposed to sulfur mustard using data from the VMAF database.
Results: Of 64 190 chemical survivors registered in the VMAF database, 60 861 met the inclusion criteria. Of the included survivors, 98.0% were male, and the mean (SD) age was 23.5 (7.7) years. Most survivors (53 675 [88.2%]) had no symptoms or mild lesions, and 7186 survivors (11.8%) had moderate or severe complications. Moderate to severe lung (6540 [10.7%]), eye (335 [0.6%]), or skin (725 [1.2%]) injuries were documented in the exposed population. The proportion of moderate plus severe late complications in eyes was 3 times as high in male survivors compared with female survivors (0.6% [95% CI, 0.53%-0.65%] vs 0.2% [95% CI, 0.09%-0.73%]; P < .001), whereas dermal complications were significantly more common in female survivors (3.9% [95% CI, 2.92%-5.11%] vs 1.14% [95% CI, 1.06%-1.23%]; P < .001). Mild lung lesions were more prevalent in the NEA group than in the EA group (73.9% [95% CI, 73.4%-74.4%] vs 11.0% [95% CI, 10.6%-11.3%]; P < .001). In the NEA group, 83.2% (n = 23 866) developed lung injuries that were mostly mild or moderate, whereas 77% (n = 24 766) of the EA group did not develop lung injuries (P < .001).
Conclusions and relevance: The present study found sex differences in the frequencies of eye and skin complications following sulfur mustard exposure, and lung complications were more prevalent years after sulfur mustard exposure than soon after exposure. Mild lung lesions were observed more frequently among sulfur mustard-exposed survivors who had not been evacuated or hospitalized than among those who had been evacuated or hospitalized. These differences may be due to physiological response or dose of exposure. Close monitoring over an extended period may be required for detection of late pulmonary complications in individuals exposed to sulfur mustard.
Case Series on 2g Tranexamic Acid Flush From the 75th Ranger Regiment Casualty Database
Christopher Patrick Androski Jr, William Bianchi, Douglas L Robinson, Gregory J Zarow, Charles H Moore, Travis G Deaton, Brendon Drew, Simon Gonzalez, Ryan M Knight
J Spec Oper Med. Winter 2020;20(4):85-91
Abstract
Early tranexamic acid (TXA) administration for resuscitation of critically injured warfighters provides a mortality benefit. The 2019 Tactical Combat Casualty Care (TCCC) recommendations of a 1g drip over 10 minutes, followed by 1g drip over 8 hours, is intended to limit potential TXA side effects, including hypotension, seizures, and anaphylaxis. However, this slow and cumbersome TXA infusion protocol is difficult to execute in the tactical care environment. Additionally, the side effect cautions derive from studies of elderly or cardiothoracic surgery patients, not young healthy warfighters. Therefore, the 75th Ranger Regiment developed and implemented a 2g intravenous or intraosseous (IV/IO) TXA flush protocol. We report on the first six cases of this protocol in the history of the Regiment. After-action reports (AARs) revealed no incidences of post-TXA hypotension, seizures, or anaphylaxis. Combined, the results of this case series are encouraging and provide a foundation for larger studies to fully determine the safety of the novel 2g IV/IO TXA flush protocol toward preserving the lives of traumatically injured warfighters.
Susanne Ångerman, Hetti Kirves, Jouni Nurmi
Prehosp Emerg Care . 2021 Feb 24;1-9
Abstract
Objective: While prehospital blood transfusion (PHBT) for trauma patients has been established in many services, the literature on PHBT use for nontrauma patients is limited. We aimed to describe and compare nontrauma and trauma patients receiving PHBT who had similar hemodynamic triggers.
Methods: We analyzed 3.5 years of registry data from a single prehospital critical care unit. The PHBT protocol included two packed red blood cell units and was later completed with two freeze-dried plasma units. The transfusion triggers were a strong clinical suspicion of massive hemorrhage and systolic blood pressure below 90 mmHg or absent radial pulse. Results: Thirty-six nontrauma patients and 96 trauma patients received PHBT. The nontrauma group had elderly patients (median 65 [interquartile range, IQR, 56-73] vs 37 [IQR 25-57] years, p < 0.0001) and included patients with gastrointestinal bleeding (n = 15; 42%), vascular catastrophes (n = 9; 25%), postoperative bleeding (n = 6; 17%), obstetrical bleeding (n = 4; 11%) and other (n = 2; 6%). Cardiac arrest occurred in nine (25%) nontrauma and in 15 (16%) trauma patients. Of these, 5 (56%) and 10 (67%) survived to hospital admission and 3 (33%) and 2 (13%) to hospital discharge. On admission, the nontrauma patients had lower hemoglobin (median 95 [84-119] vs 124 [108-133], p < 0.0001), higher pH (median 7.40 [7.27-7.44] vs 7.30 [7.19-7.36], p = 0.0015) and lower plasma thromboplastin time (median 55 [45-81] vs 72 [58-86], p = 0.0261) than the trauma patients.
Conclusions: We identified four nontrauma patient groups in need of PHBT, and the patients appeared to be seriously ill. Efficacy of prehospital transfusion in nontrauma patients should be evaluated futher in becoming studies.
The assessment and management of thermal burn injuries in a UK ambulance service: a clinical audit
Harriet Ashman, Dean Rigg, Fionna Moore
Br Paramed J. 2020 Dec 1;5(3):52-58
Abstract
Background: Although burn emergencies are infrequently encountered, the ambulance service is often the first point of contact for patients in these situations. It is therefore important that these potentially devastating injuries are managed in accordance with the evidence base. Appropriate assessment and management of these patients in the pre-hospital phase will have a significant impact upon their long-term outcomes, such as scarring cosmesis and functionality.
Aim and objectives: This audit was conducted to determine if patients presenting to one UK ambulance service with thermal burn injuries were managed safely, effectively and in a timely manner. Areas highlighted for improvement will assist in directing future pre-hospital research and educational requirements. Epidemiological data will also be provided.
Results: 278 thermal burn incidents occurring from June 2017 to May 2018 (inclusive) were included in this audit. A larger proportion of burn patients were paediatrics who fell into the 0-10 age category, most burn patients were injured at a home address and only nine of the overall sample were major burns. Only 35% of patients received adequate cooling of their burns, an essential first aid intervention. The assessment of pain (87%) and provision of analgesia (75%) showed a higher compliance rate. However, only 54% had pain reassessed after analgesia. There was a near 100% compliance rate for patients being managed without hydrogel dressings and topical medicines.
Conclusion: The results indicate several areas for improvement within the ambulance trust. Of importance is the application of basic first aid, such as cooling. It is important not only to improve education among staff but also to understand non-compliance. It should be acknowledged that assessment of pain and provision of analgesia demonstrated far higher compliance compared to current pre-hospital evidence. Several points for education and research have been identified.
Christof K Audretsch, Daniel Mader, Christian Bahrs, Alexander Trulson, Andreas Höch, Steven C Herath, Markus A Küper, Working Group on Pelvic Fractures of the German Trauma Society
Sci Rep. 2021 Jan 27;11(1):2338. doi: 10.1038/s41598-021-81745-z.
Abstract
Severe bleeding is the major cause of death in unstable pelvic ring fractures. Therefore, a quick and efficient emergency stabilization and bleeding control is inevitable. C-clamp and pelvic binder are efficient tools for temporary bleeding control, especially from the posterior pelvic ring. Yet the C-clamp requires more user knowledge, training and equipment. However, whether this makes up for a more efficient bleeding control, is still under debate. Patients with a type-C pelvic ring fracture were identified from the German Pelvic Registry (GPR) and divided into three groups of 40 patients (1. no emergency stabilization, 2. pelvic binder, 3. C-clamp). The matching occurred according to the parameters age, gender, initial RR and initial HB. Complication-and mortality rates were compared especially regarding bleeding control. Regarding ISS and fracture dislocation there was no difference. The use of the C-clamp resulted in more complications, a higher mortality rate due to severe bleeding and more blood transfusions were admitted. Moreover the pelvic binder was established noticeably faster. However, the C-clamp was more often rated as effective. There is no evidence of advantage comparing the C-clamp to the pelvic binder, regarding bleeding control in type-C pelvic ring fractures. In fact, using the pelvic binder even showed better results, as the time until established bleeding control was significantly shorter. Therefore, the pelvic binder should be the first choice. The C-clamp should remain a measure for selected cases only, if an adequate bleeding control cannot be achieved by the pelvic binder.
Use of Handheld Point-of-Care Ultrasound in Emergency Airway Management
Daniel R Austin, Marvin G Chang, Edward A Bittner
Chest. 2021 Mar;159(3):1155-1165
Abstract
Emergency airway management (EAM) is associated with a high rate of complications, morbidity, and mortality. Handheld point-of-care ultrasound shows promise as an emerging technology to facilitate rapid screening for difficult laryngoscopy, identify the cricothyroid membrane for potential cricothyroidotomy, and assess for increased aspiration risk, as well as provide confirmation of proper endotracheal tube positioning. This review summarizes the available evidence for the use of point-of-care ultrasound in EAM, provides an algorithm to facilitate its incorporation into existing EAM practice to improve patient safety, and serves as a framework for future validation studies.
Ewoud Ter Avest, Sam Taylor, Mark Wilson, Richard L Lyon
Emerg Med J. 2021 Jan;38(1):21-26
Abstract
Background: For the prehospital diagnosis of raised intracranial pressure (ICP), clinicians are reliant on clinical signs such as the Glasgow Coma Score (GCS), pupillary response and/or Cushing's triad (hypertension, bradycardia and an irregular breathing pattern). This study aimed to explore the diagnostic accuracy of these signs as indicators of a raised ICP.
Methods: We performed a retrospective cohort study of adult patients attended by a Helicopter Emergency Medical Service (Air Ambulance Kent, Surrey Sussex), who had sustained a traumatic brain injury (TBI), requiring prehospital anaesthesia between 1 January 2016 and 1 January 2018. We established optimal cut-off values for clinical signs to identify patients with a raised ICP and investigated diagnostic accuracy for combinations of these values.
Results: Outcome data for 249 patients with TBI were available, of which 87 (35%) had a raised ICP. Optimal cut-off points for systolic blood pressure (SBP), heart rate (HR) and pupil diameter to discriminate patients with a raised ICP were, respectively, >160 mm Hg,<60 bpm and >5 mm. Cushing criteria (SBP >160 mm Hg and HR <60 bpm) and pupillary response and size were complimentary in their ability to detect patients with a raised ICP. The presence of a fixed blown pupil or a Cushing's response had a specificity of 93.2 (88.2-96.6)%, and a positive likelihood ratio (LR+) of 5.4 (2.9-10.2), whereas sensitivity and LR- were only 36.8 (26.7-47.8)% and 0.7 (0.6-0.8), respectively, (Area Under the Curve (AUC) 0.65 (0.57-0.73)). Sensitivity analysis revealed that optimal cut-off values and resultant accuracy were dependent on injury pattern.
Conclusion: Traditional clinical signs of raised ICP may under triage patients to prehospital treatment with hyperosmolar drugs. Further research should identify more accurate clinical signs or alternative non-invasive diagnostic aids in the prehospital environment.
Josefine S Baekgaard, Paer-Selim Abback, Marouane Boubaya, Jean-Denis Moyer, Delphine Garrigue, Mathieu Raux, Benoit Champigneulle, Guillaume Dubreuil, Julien Pottecher, Philippe Laitselart, Fleur Laloum, Coralie Bloch-Queyrat, Frédéric Adnet, Catherine Paugam-Burtz, Traumabase® Study Group
Crit Care. 2020 Oct 12;24(1):604
Abstract
Background: Hyperoxemia has been associated with increased mortality in critically ill patients, but little is known about its effect in trauma patients. The objective of this study was to assess the association between early hyperoxemia and in-hospital mortality after severe trauma. We hypothesized that a PaO2 ≥ 150 mmHg on admission was associated with increased in-hospital mortality.
Methods: Using data issued from a multicenter prospective trauma registry in France, we included trauma patients managed by the emergency medical services between May 2016 and March 2019 and admitted to a level I trauma center. Early hyperoxemia was defined as an arterial oxygen tension (PaO2) above 150 mmHg measured on hospital admission. In-hospital mortality was compared between normoxemic (150 > PaO2 ≥ 60 mmHg) and hyperoxemic patients using a propensity-score model with predetermined variables (gender, age, prehospital heart rate and systolic blood pressure, temperature, hemoglobin and arterial lactate, use of mechanical ventilation, presence of traumatic brain injury (TBI), initial Glasgow Coma Scale score, Injury Severity Score (ISS), American Society of Anesthesiologists physical health class > I, and presence of hemorrhagic shock).
Results: A total of 5912 patients were analyzed. The median age was 39 [26-55] years and 78% were male. More than half (53%) of the patients had an ISS above 15, and 32% had traumatic brain injury. On univariate analysis, the in-hospital mortality was higher in hyperoxemic patients compared to normoxemic patients (12% versus 9%, p < 0.0001). However, after propensity score matching, we found a significantly lower in-hospital mortality in hyperoxemic patients compared to normoxemic patients (OR 0.59 [0.50-0.70], p < 0.0001).
Conclusion: In this large observational study, early hyperoxemia in trauma patients was associated with reduced adjusted in-hospital mortality. This result contrasts the unadjusted in-hospital mortality as well as numerous other findings reported in acutely and critically ill patients. The study calls for a randomized clinical trial to further investigate this association.
Alaa El Bashtaly, Elene Khalil, Francois Méthot, Lawrence Ledoux-Hutchinson, Jeffrey M Franc, Valérie Homier
J Trauma Acute Care Surg. 2021 Apr 1;90(4):666-672
Abstract
Background: Life-threatening hemorrhage is a major cause of preventable mortality in trauma. Studies have demonstrated the effectiveness and safety of commercial tourniquets when used by adult civilians. However, there are no data about tourniquet application by children.This study's goal is to determine which of three commercially available tourniquets is most effective when used by children.
Methods: A randomized crossover study was conducted in four elementary schools in Montreal to compare three commercially available tourniquets. The study population is primary school children aged 10 to 12 years (5th-6th grade). A total of 181 students were invited to participate; 96 obtained parental approval and were recruited. Participants underwent a short 7-minute video training on the use of three commercial tourniquets and were subsequently given a 2-minute practice period. Students were evaluated on their ability to successfully apply the tourniquet and the time to complete application. After applying all three tourniquets, the students selected their favorite model. The primary outcome is the proportion of successful applications per tourniquet model. Secondary outcomes include time to successful application for each tourniquet model and tourniquet model preference.
Results: The mechanical advantage tourniquet (MAT) outperformed the combat application tourniquet (CAT) and the stretch wrap and tuck tourniquet (SWATT) in terms of success rate (MAT, 67%; CAT, 44%; SWATT, 24%; p < 0.0001), time to application (MAT, 57 seconds; CAT, 80 seconds; SWATT, 90 seconds; p < 0.0001), and preference (MAT, 64%; CAT, 30%; SWATT, 6%; p < 0.0001).
Conclusion: In this study, the MAT performs better in terms of success rate, time to application, and preference when used by school-aged children. This study can be helpful when facilities are purchasing tourniquets for use by students.
Tourniquet use for civilian extremity hemorrhage: systematic review of the literature
Carlos YÁnez BenÍtez, Pablo Ottolino, Bruno M Pereira, Daniel Souza Lima, Antonio Guemes, Mansoor Khan, Marcelo Augusto Fontenelle Ribeiro Junior
Rev Col Bras Cir. 2021 Jan 13;48:e20202783. doi: 10.1590/0100-6991e-20202783
Abstract
Introduction: extremity tourniquet (TQ) use has increased in the civilian setting; the beneficial results observed in the military has influenced acceptance by EMS and bystanders. This review aimed to analyze extremity TQ types used in the civilian setting, injury site, indications, and complications.
Methods: a systematic review was conducted based on original articles published in PubMed, Embase, and Cochrane following PRISMA guidelines from 2010 to 2019. Data extraction focused on extremity TQ use for hemorrhage control in the civilian setting, demographic data, study type and duration, mechanism of injury, indications for use, injury site, TQ type, TQ time, and complications.
Results: of the 1384 articles identified, 14 were selected for review with a total of 3912 civilian victims with extremity hemorrhage and 3522 extremity TQ placements analyzed. The majority of TQs were applied to male (79%) patients, with blunt or penetrating trauma. Among the indications for TQ use were hemorrhagic shock, suspicion of vascular injuries, continued bleeding, and partial or complete traumatic amputations. Upper extremity application was the most common TQ application site (56%), nearly all applied to a single extremity (99%), and only 0,6% required both upper and lower extremity applications. 80% of the applied TQs were commercial devices, and 20% improvised.
Conclusions: TQ use in the civilian setting is associated with trauma-related injuries. Most are single-site TQs applied for the most part to male adults with upper extremity injury. Commercial TQs are more commonly employed, time in an urban setting is under 1 hour, with few complications described.
S F Bergmans, P Schober, L A Schwarte, S A Loer, S M Bossers
Injury. 2020 Nov;51(11):2356-2367
Abstract
Background: Prehospital management of severe traumatic brain injury (TBI) focuses on preventing secondary brain injury. Therefore, hypotension should be prevented, or if present, should be promptly treated in order to maintain optimal cerebral perfusion pressure. Fluid resuscitation is a traditional mainstay in the prehospital treatment of hypotension, however, the choice of fluid type that is to be administered in the prehospital setting is the subject of an on-going debate. This systematic review and meta-analysis was therefore performed to assess the effect of different fluid types on outcome in patients with severe TBI.
Methods: PubMed, Embase and Web of Science were searched for articles up to March 2020. Studies comparing two or more prehospital administered fluid types with suspected or confirmed severe TBI were deemed eligible for inclusion. Studied outcomes were mortality and (extended) Glasgow Outcome Scale (GOS). The meta-analysis tested for differences in survival between hypertonic saline (HTS) and normotonic crystalloids (i.e. normal saline or Lactated Ringer's) and between hypertonic saline with dextran (HSD) and normotonic crystalloids. The systematic review is registered in the PROSPERO register with number CRD42020140423.
Results: This literature search yielded a total of 519 articles, of which 12 were included in the systematic review and 6 were included in the meta-analysis. Eleven studies found no statistically significant difference in survival between patients treated with different fluid types (e.g. normal saline and hypertonic saline). All studies assessing neurological outcome, measured through (extended) GOS, found no statistically significant difference between different fluid types. Meta-analysis showed no better survival for patients treated with HSD, when compared to normotonic crystalloids (overall RR 0.99, 95% CI 0.93-1.06). Moreover, HTS compared to normotonic crystalloids does not result in a better survival (overall RR 1.04, 95% CI 0.97-1.12).
Conclusions: This systematic review and meta-analysis did not demonstrate a survival or neurological benefit for one specific fluid type administered in the prehospital setting.
Richard D Berkowitz, Richard Steinfeld, Alexander P Sah, Randall J Mack, Stewart W McCallum, Wei Du, Libby K Black, Alex Freyer, Erin Coyle
Pain Med. 2021 Jun 4;22(6):1261-1271
Abstract
Objective: To evaluate the effect of perioperative meloxicam IV 30 mg on opioid consumption in primary total knee arthroplasty (TKA).
Design: Multicenter, randomized, double-blind, placebo-controlled trial.
Subjects: In total, 181 adults undergoing elective primary TKA.
Methods: Subjects received meloxicam 30 mg or placebo via an IV bolus every 24 hours, the first dose administered prior to surgery as part of a multimodal pain management protocol. The primary efficacy parameter was total opioid use from end of surgery through 24 hours.
Results: Meloxicam IV was associated with less opioid use versus placebo during the 24 hours after surgery (18.9 ± 1.32 vs 27.7 ± 1.37 mg IV morphine equivalent dose; P < 0.001) and was superior to placebo on secondary endpoints, including summed pain intensity (first dose to 24 hours postdosing, first dose to first assisted ambulation, and first dose to discharge) and opioid use (48-72 hrs., 0-48 hrs., 0-72 hrs., hour 0 to end of treatment, and the first 24 hours after discharge). Adverse events (AEs) were reported for 69.9% and 92.0% of the meloxicam IV and placebo groups, respectively; the most common AEs were nausea (40% vs. 59%), vomiting (16% vs 22%), hypotension (14% vs 15%), pruritus (15% vs 11%), and constipation (11% vs 13%).
Conclusions: Perioperative meloxicam IV 30 mg as part of a multimodal analgesic regimen for elective primary TKA reduced opioid consumption in the 24-hour period after surgery versus placebo and was associated with a lower incidence of AEs typically associated with opioid use.
Ramesh Bhattarai, Pawan Kumar Hamal
J Nepal Health Res Counc. 2021 Jan 22;18(4):769-775
Abstract
Background: The aim of the study is to evaluate the efficacy of Ketamine-Propofol compared to Fentanyl-Propofol combination during induction and maintenance of total intravenous anesthesia for short surgical procedures at moderate elevation.
Methods: A prospective pilot study was done comparing between Fentanyl (1.2 mcg/kg)- Propofol and Ketamine (0.5mg/kg)-Propofol with 30 in each group at moderate altitude of approximately 2514 meters for the requirement of positive pressure ventilation, changes in heart rate and mean arterial pressure intraoperatively, total Propofol consumption and time to attain Modified Steward Score of 6.
Results: Requirement for positive pressure ventilation was significantly high in Fentanyl-Propofol group 18 (60%) compared to Ketamine-Propofol 1 (0.03%) [P = 0.00]. Fall in oxygen saturation was significant at 2 minute of Ketamine or Fentanyl [95% CI, 3.10-5.76, P = 0.00], after induction with Propofol [95% CI, 2.30-4.03, P = 0.00], 5 minute [95% CI, 1.66-3.54, P = 0.00], 10 minutes [95% CI, 0.55-2.32, P = 0.02], 15 minutes [95% CI, 0.50-2.09, P = 0.00] and 20 minutes [95% CI, 0.43-2.23, P = 0.00] respectively after study drug between the groups. Total Propofol consumption was significantly higher [95% CI, 0.19-0.43, P = 0.00] in KP (1.55±0.27mg/kg) compared to FP (1.23±0.16 mg/kg).
Conclusions: At moderate elevations of 2514 meters, during the induction and maintenance of intravenous anesthesia, Ketamine-Propofol causes significantly less fall in oxygen saturation in the first 20 minutes requiring lesser need of positive pressure ventilation with comparable least fall in heart rate and mean arterial pressure with higher total Propofol consumption when compared to Fentanyl-Propofol. It took a significantly longer time to recovery with Modified steward score of maximum 6 with Ketamine-Propofol.
Prehospital Plasma Resuscitation in Patients With Traumatic Brain Injury: PAMPering the Brain
Robert H Bonow
JAMA Netw Open. 2020 Oct 1;3(10):e2017590
No abstract available
Andreas Brännström, Albin Dahlquist, Jenny Gustavsson, Ulf P Arborelius, Mattias Günther
Eur J Trauma Emerg Surg. 2021 Jan 30;1-10
Abstract
Purpose: Pelvic and lower junctional hemorrhage result in a significant amount of trauma related deaths in military and rural civilian environments. The Abdominal Aortic and Junctional Tourniquet (AAJT) and infra-renal (zone 3) Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) are two options for resuscitation of patients with life threatening blood loss from and distal to the pelvis. Evidence suggest differences in the hemodynamic response between AAJT and zone 3 REBOA, but fluid management during resuscitation with the devices has not been fully elucidated. We compared crystalloid fluid requirements (Ringer's acetate) between these devices to maintain a carotid mean arterial pressure (MAP) > 60 mmHg.
Methods: 60 kg anesthetized and mechanically ventilated male pigs were subjected to a mean 1030 (range 900-1246) mL (25% of estimated total blood volume, class II) haemorrhage. AAJT (n = 6) or zone 3 REBOA (n = 6) were then applied for 240 min. Crystalloid fluids were administered to maintain carotid MAP. The animals were monitored for 30 min after reperfusion.
Results: Cumulative resuscitative fluid requirements increased 7.2 times (mean difference 2079 mL; 95% CI 627-3530 mL) in zone 3 REBOA (mean 2412; range 800-4871 mL) compared to AAJT (mean 333; range 0-1000 mL) to maintain target carotid MAP. Release of the AAJT required vasopressor support with norepinephrine infusion for a mean 9.6 min (0.1 µg/kg/min), while REBOA release required no vasopressor support.
Conclusion: Zone 3 REBOA required 7.2 times more crystalloids to maintain the targeted MAP. The AAJT may therefore be considered in a situation of hemorrhagic shock to limit the need for crystalloid infusions, although removal of the AAJT caused more severe hemodynamic and metabolic effects which required vasopressor support.
Johno Breeze, D M Bowley, D N Naumann, M E R Marsden, R N Fryer, D Keene, A Ramasamy, E A Lewis
BMJ Mil Health. 2020 Oct 27;bmjmilitary-2020-001582
Abstract
Developments in military personal armour have aimed to achieve a balance between anatomical coverage, protection and mobility. When death is likely to occur within 60 min of injury to anatomical structures without damage control surgery, then these anatomical structures are defined as 'essential'. However, the medical terminology used to describe coverage is challenging to convey in a Systems Requirements Document (SRD) for acquisition of new armour and to ultimately translate to the correct sizing and fitting of personal armour. Many of those with Ministry of Defence responsible for the procurement of personal armour and thereby using SRDs will likely have limited medical knowledge; therefore, the potentially complex medical terminology used to describe the anatomical boundaries must be translated into easily recognisable and measurable external landmarks. We now propose a complementary classification for ballistic protection coverage, termed threshold and objective, based on the feasibility of haemorrhage control within the prehospital environment.
Planning for UK terror attacks: Analysis of blast and ballistic injuries
C T Brewster, K Forbes, C Handford, N Scallan, M Eskell, S Hettiaratchy, J Baden
Injury. 2021 May;52(5):1221-1226
Abstract
Terrorist attacks have become more acute, less predictable and frequently involve use of explosives and gunfire to inflict mass casualty to civilians. Resource demand has been reported in Role 3 Medical Facilities but the continued resource required to manage blast and ballistic injuries has not been quantified. This study aimed to assess the resource required for blast and ballistic injuries at the United Kingdom's Role 4 Medical Facility. Military patients admitted to the Queen Elizabeth Hospital (Role 4 Medical Facility) from Afghanistan with blast or ballistic injuries during the 2012 calendar year were retrospectively reviewed. Injury pattern, theatre resource, length of stay and cost analysis were performed. This study included 99 blast and 53 gunshot wound (GSW) patients. Blast patients were more likely to suffer polytrauma than GSW (53% vs 23%), underwent more surgical procedures and utilized double the theatre time. Blast injury patients had a longer length of stay in hospital. The average cost per patient for blast patients was double that of the GSW injury cohort. The Queen Elizabeth experience represents a continuous flow of severely injured military casualties whilst managing concurrent civilian trauma over a long period. This workload has encouraged systematic advancements in managing high numbers of injured patients from point of wounding to rehabilitation. Distribution of resource, theatre planning and multi-disciplinary team working are critical in effectively managing Major Incidents such as terror attacks. Drawing on previous Role 4 Medical Facility experience can aid UK hospitals in terms of strategy and resource distribution.
Evolution of First Aid Training in the British Army
Martin C M Bricknell, Brigadier T J Hodgetts
Mil Med. 2021 Jan 25;186(Suppl 1):808-813
Abstract
Introduction: This article describes the evolution of first aid in the British Army from the Crimean War to the present day in order to interpret the processes of innovation, implementation, and diffusion of ideas to improve the clinical outcomes for military casualties.
Materials and methods: The article is an analysis of policy and practice for training in first aid published in King's/Queen's Regulations for the Army, the Field Service Pocket Book, or generic military training policy. This is complimented by a review of medical training manuals and a search of articles in the Journal of the Royal Army Medical Corps (RAMC). Most sources have been accessed from the Museum of Military of Medicine and the Wellcome RAMC Muniments Collection.
Results: The narrative summarizes the evolution of clinical concepts in first aid and their translation for Army personnel; starting with RAMC stretcher bearers, extended to soldiers assigned to medical duties at unit level, and finally simplified into first aid training to be taught to all soldiers. Alongside this story of training is a secondary story of the development of field first aid equipment, principally dressings, tourniquets, and analgesia. The final part of the story is the transfer of knowledge from military first aid training into the civilian, community setting. The following themes were identified: the reality of conflict wounds, battlefield first aid is different from civilian first aid, progressive transfer of training from medics to soldiers, transfer of knowledge to civilian sector and internationally, and specific clinical innovations: first field dressings, tourniquets, and prehospital analgesia.
Discussion: The current generation of soldiers are at the highest ever standard of first aid training and equipment. This must be maintained through gathering of evidence in effectiveness and outcomes in prehospital emergency care in both military and civilian settings.
Are mobile ECMO teams necessary to treat severe accidental hypothermia?
Hermann Brugger, Peter Paal, Ken Zafren, Giacomo Strapazzon, Martin E Musi
Resuscitation. 2021 Jan;158:301-302
No abstract available
Plasma flow distal to tourniquet placement provides a physiological mechanism for tissue salvage
Emily Busse, Cheryl Hickey, Nicole Vasilakos, Kennon Stewart, Fred O'Brien, Jessica Rivera, Luis Marrero, Michelle Lacey, Rebecca Schroll, Keith Van Meter, Mimi C Sammarco
PLoS One. 2020 Dec 21;15(12):e0244236
Abstract
Military literature has demonstrated the utility and safety of tourniquets in preventing mortality for some time, paving the way for increased use of tourniquets in civilian settings, including perioperatively to provide a bloodless surgical field. However, tourniquet use is not without risk and the subsequent effects of tissue ischemia can impede downstream rehabilitative efforts to regenerate and salvage nerve, muscle, tissue and bone in the limb. Limb ischemia studies in both the mouse and pig models have indicated not only that there is residual flow past the tourniquet by means of microcirculation, but also that recovery from tissue ischemia is dependent upon this microcirculation. Here we expand upon these previous studies using portable Near-Infrared Imaging to quantify residual plasma flow distal to the tourniquet in mice, pigs, and humans and leverage this flow to show that plasma can be supersaturated with oxygen to reduce intracellular hypoxia and promote tissue salvage following tourniquet placement. Our findings provide a mechanism of delivery for the application of oxygen, tissue preservation solutions, and anti-microbial agents prior to tourniquet release to improve postoperative recovery. In the current environment of increased tourniquet use, techniques which promote distal tissue preservation and limb salvage rates are crucial.
Strategic Orthopedic Evacuations to the Spanish Role 4 During a Decade (2009-2018)
Rafael García Cañas, Ricardo Navarro Suay, Carlos Rodríguez Moro, Daniel Aedo Martín, Rafael Tamburri Bariaín, Javier Areta Jiménez
Mil Med. 2020 Jun 8;185(5-6):e734-e741
Abstract
Introduction: Casualty evacuation is a key point in medical support to military operations, sometimes being necessary to transfer them to National Territory for a definitive diagnosis and treatment. The aim of this work is to analyze the patients evacuated from Areas of Operations to the Orthopedic Surgery and Traumatology Unit of the Spanish Role 4 Medical Treatment Facility in the last 10 years.
Material and methods: A cross-sectional, descriptive, and retrospective study carried out in the period between January 1, 2009 and December 31, 2018. The study population was all personnel evacuated from the Area of Operations to Spanish Role 4. For categorical variables, absolute and relative percent frequencies were used. Spanish military authorization was obtained to perform this study. This study has been approved by the Ethics and Clinical Research Committee of the Defense Central Hospital "Gómez Ulla" (code 12/17).
Results: A total of 520 medical evacuations have been performed on Role 4, of which 227 were on the Orthopedic Surgery and Traumatology Unit. Seven percent of the evacuees were categorized as "combat" casualties. The areas of operations from which more patients have been evacuated were Afghanistan and Lebanon, 30.39% and 19.38%, respectively. The most frequent lesion pattern was the fracture affecting the extremities. Accidents (n = 98, 43.17%) and sport (n = 57; 25.3%) were the main causes of injury. Sixty-seven (29.51%) patients were treated surgically in Role 4. No deaths were recorded among patients in this series.
Conclusion: Evacuations because of trauma cause more than half of the medical repatriations carried out on the National Territory, of which the majority are due to fractures affecting the limbs, especially the bones of the hand. Sport was the first preventable cause of injury among evacuated patients. Our results are similar to the experience obtained by other allied armed forces. It is a moral imperative and a fundamental necessity for the Spanish military medical services to promote and maintain the Spanish Role 4 Medical Treatment Facility as an indispensable element in medical support for international missions.
A Comparative Study Between Two Combat Injury Severity Scores
Rafael García Cañas, Ricardo Navarro Suay, Carlos Rodríguez Moro, Diana M Crego Vita, Javier Arias Díaz, Fco Javier Areta Jiménez
Mil Med. 2021 Feb 16;usab067. doi: 10.1093/milmed/usab067
Abstract
Introduction: In recent years, specific trauma scoring systems have been developed for military casualties. The objective of this study was to examine the discrepancies in severity scores of combat casualties between the Abbreviated Injury Scale 2005-Military (mAIS) and the Military Combat Injury Scale (MCIS) and a review of the current literature on the application of trauma scoring systems in the military setting.
Methods: A cross-sectional, descriptive, and retrospective study was conducted between May 1, 2005, and December 31, 2014. The study population consisted of all combat casualties attended in the Spanish Role 2 deployed in Herat (Afghanistan). We used the New Injury Severity Score (NISS) as reference score. Severity of each injury was calculated according to mAIS and MCIS, respectively. The severity of each casualty was calculated according to the NISS based on the mAIS (Military New Injury Severity Score-mNISS) and MCIS (Military Combat Injury Scale-New Injury Severity Score-MCIS-NISS). Casualty severity were grouped by severity levels (mild-scores: 1-8, moderate-scores: 9-15, severe-scores: 16-24, and critical-scores: 25-75).
Results: Nine hundred and eleven casualties were analyzed. Most were male (96.37%) with a median age of 27 years. Afghan patients comprised 71.13%. Air medevac was the main casualty transportation method (80.13). Explosion (64.76%) and gunshot wound (34.68%) mechanisms predominated. Overall mortality was 3.51%. Median mNISS and MCIS-NISS were similar in nonsurvivors (36 [IQR, 25-49] vs. [IQR, 25-48], respectively) but different in survivors, 9 (IQR, 4-17) vs. 5 (IQR, 2-13), respectively (P < .0001). The mNISS and MCIS-NISS were discordant in 34.35% (n = 313). Among cases with discordant severity scores, the median difference between mNISS and MCIS-NISS was 9 (IQR, 4-16); range, 1 to 57.
Conclusion: Our study findings suggest that discrepancies in injury severity levels may be observed in one in three of the casualties when using mNISS and MCIS-NISS.
Todd P Chang, Trevor Hollinger, Thomas Dolby, Joshua M Sherman
Simul Healthc. 2020 Dec 2. doi: 10.1097/SIH.0000000000000521. Online ahead of print.
Abstract
Introduction: Resuscitation simulations immerse learners into the complexity of emergency patient management. Head-Mounted Display Virtual Reality (VR) has been used for stress inoculation therapy for phobias and posttraumatic stress disorder. However, VR for stress inoculation in resuscitation leadership training has not been studied. We sought to develop VR simulation for stress inoculation, as exposure therapy training, for resuscitations.
Methods: We explain the conceptual design, development, production, and initial evaluation process for 2 VR simulations in infant status epilepticus and pediatric anaphylactic shock. We further describe deliberate game mechanic choices to maximize psychological fidelity. In-virtual reality performance data for time-to-critical actions and stress physiology markers (heart rate, salivary cortisol) were collected from expert pediatric emergency physicians and novice pediatric residents. Data were analyzed to examine differences between the 2 groups for both outcome types to determine the extent of stress response or performance deficit the VR induced.
Results: Multiple difficulties and distractions were designed for the 2 scenarios; we evaluated the highest difficulty and environmental distraction versions. Between 19 expert physicians and 15 novice physicians, no performance differences were found in typical airway, breathing, and circulation actions. Residents preferred more lorazepam first-line antiepileptics than attendings (P = 0.003) and performed a cricothyrotomy later than attendings (P = 0.02). Residents, however, manifested higher salivary cortisol levels than attendings (+0.07 μg/dL, 95% confidence interval = 0.03-0.12, P = 0.001).
Conclusions: A VR resuscitation simulation manifested expected stress physiology changes in physicians. Further evaluation is needed to determine the effect of VR simulation as longitudinal stress inoculation for healthcare providers.
Algorithm Directed Troop Medical Care Manual Application for Desktop and Smartphone
James Chrosniak, Christian Olsen, Andrew Galdi
Mil Med. 2021 Jan 25;186(Suppl 1):65-69
Abstract
Introduction: The U.S. Army medics are often the first responders in the care of sick and injured soldiers on the battlefield, sick call in a Role 2 aid station and garrison clinics. Sick call medics are required to utilize the Algorithm Directed Troop Medical Care (ADTMC) to care for and then render a disposition for these soldiers. The current ADTMC manual is a thick, heavy paper manual. A desktop and smartphone application has been developed that contains the entire ADTMC manual algorithm-based content. Our goal is to enhance the medics' clinical learning and critical thinking skills while improving their evaluation, disposition, and documentation during patient encounters.
Materials and methods: The application was field-tested with the 173rd IBCT (A) while attending a field exercise at Grafenwoehr, Germany. At the unit's Role 2 tent setup, the use of the paper manual to the utilization of the same material via the ADTMC application was compared by observing the medics' workflows directly while they were caring for ill and injured soldiers.
Results: Medics, while examining patients, would demonstrate 50% faster exam time using the application compared to medics using only the manual. Moreover, a 50% decrease in document processing time as a result of digitization of the paper documentation process was confirmed. The application ("app") enabled the medics to continue their screening assessments and patient disposition duties on a desktop computer or a smartphone without the need to refer to the paper manual.
Conclusion: Medics, by adopting this tool, will become quicker, more efficient, and develop critical thinking skills. In other words, the ability to objectively evaluate patients in order to form a proper disposition of sick and injured soldiers during training, in the field, as well as in garrison. When utilized properly, the ADTMC application ensures that soldiers reporting to sick call are expeditiously routed to the appropriate level of care, and is a vehicle for further training for medics in the care of soldiers.
Thomas Clements, Cameron McCoy, Scott Assen, Jessica Cardenas, Charles Wade, David Meyer, Bryan A Cotton
J Trauma Acute Care Surg. 2021 Apr 1;90(4):607-614
Abstract
Introduction: Recent in vitro data have shown that the hemostatic profile of whole blood (WB) degrades significantly after 14 days, yet the optimal storage remains debated. We hypothesized that arrival coagulation studies would be improved in patients receiving younger WB in the prehospital setting.
Methods: This study was approved by our institutional institutional review board. We evaluated all trauma patients who received prehospital blood products by our helicopter service between July 2017 and July 2019. "Young" WB was defined as 14 days or less. Patients who received at least 1 U of young WB were classified as YOUNG, while the remainder was classified as OLD. Continuous data are presented as medians (25th-75th interquartile range) with comparisons performed using Wilcoxon rank sum. Assessments of clinical hemostatic potential included arrival platelet cell count and rapid thrombelastography. Multivariate regression analysis was also performed (Stata 12.1; College Station, TX).
Results: A total of 220 patients received prehospital WB during the study period. Of these, 153 patients received YOUNG WB, while 67 were transfused only OLD WB units. There were no differences in demographics, prehospital or arrival physiology, or Injury Severity Score among the two groups. The measures of clot initiation (activated clotting time) and kinetics (k time) were improved, as were the measures of clot acceleration/fibrinogen function (angle) and platelet function (maximum amplitude). As well, arrival platelet count was higher in the YOUNG cohort. No significant differences in postarrival transfusion were noted (p = 0.220). Multivariate analysis showed the greatest differences in maximum amplitude and α angle but failed to reach significance.
Conclusion: Previous in vitro data have suggested deterioration of platelet function in cold-stored WB after 14 days. The current study demonstrated decreased global hemostasis by clinically available laboratory tests, especially related to fibrinogen and platelet interactions on univariate, but not multivariate analysis. This did not translate into increased transfusion requirements. Further studies are needed to determine the optimal storage duration for cold-stored WB for transfusion in the bleeding trauma patient, as well as rule out the presence of confounding variables.
Optimal Physical Space for En Route Care: Medic Posture and Injury Survey
Sandra M Conti, Laura R Kroening, Jeffrey J Molles, Matthew L Davenport, Rachel E Kinsler, Amy L Lloyd
Mil Med. 2021 Jan 25;186(Suppl 1):305-310
Abstract
Introduction: An anonymous online survey was presented to active duty U.S. Army, Reserve, and National Guard Soldiers with experience as en route care medical providers with the intent of identifying factors which contribute to musculoskeletal disorders in U.S. Army en route care medical providers. The survey looked at transport vehicle design, equipment, and awkward postures that could play a role in causing injuries.
Materials and methods: Survey responses were received from 60 en route care providers regarding postures assumed during administration of en route critical care tasks, routine medical transport scenarios, and patient loading. Care providers reported gender, height, weight, experience, tasks, and awkward postures experienced. They also reported occupational injuries that occurred as a result of performing job duties, such as back, neck, and joint pain, injuries, and discomfort.
Results: The survey was answered by 56 (93.3%) males and 4 females (6.7%) with an average of 7.34 years of experience as en route care personnel. Lower back injuries were suffered by 87% of respondents. The most common causes were awkward positions and lifting patients. There are statistically significant relationships between shoulder injuries and overextending, lower back injuries and overextending, and lower back injuries and reaching backwards, ankle injuries and care provider height, and knee injuries and the frequency at which care providers utilized the postures of kneeling, squatting, reaching behind themselves, and straining to lift a heavy weight. Loading and unloading patients from evacuation platforms was among the top causes of all awkward postures among respondents.
Conclusion: Results of this survey emphasize the need for injury mitigation and prevention strategies to reduce impacts on soldier health and readiness.
Brian Cornelius, Quinn Cummings, Mathieu Assercq, Erin Rizzo, Sonja Gennuso, Angela Cornelius
J Trauma Nurs. 2021 Jan-Mar 01;28(1):21-25
Abstract
Background: Although controversial, early administration of tranexamic acid (TXA) has been shown to reduce mortality in adult patients with major trauma. Tranexamic acid has also been successfully used in elective pediatric surgery, with significant reduction in blood loss and transfusion requirements. There are limited data to guide its use in pediatric trauma patients. We sought to determine the current practices for TXA administration in pediatric trauma patients in the United States.
Methods: A survey was conducted of all the American College of Surgeons-verified Level I and II trauma centers in the United States. The survey data underwent quantitative analysis.
Results: Of the 363 Level I and II qualifying centers, we received responses from 220 for an overall response rate of 61%. Eighty of 99 verified pediatric trauma centers responded for a pediatric trauma center response rate of 81%. Of all responding centers, 148 (67%) reported they care for pediatric trauma patients, with an average of 513 pediatric trauma patients annually. The pediatric trauma centers report caring for an average of 650 pediatric trauma patients annually. Of all centers caring for pediatric trauma, 52 (35%) report using TXA, with the most common initial dosing being 15 mg/kg (68%). A follow-up infusion was utilized by 45 (87%) of the programs, most commonly dosed at 2 mg/kg/hr × 8 hr utilized by 24 centers (54%).
Conclusion: Although the clinical evidence for TXA in pediatric trauma patients is limited, we believe that consideration should be given for use in major trauma with hemodynamic instability or significant risk for ongoing hemorrhage. If available, resuscitation should be guided by thromboelastography to identify candidates who would most benefit from antithrombolytic administration. This represents a low-cost/low-risk and high-yield therapy for pediatric trauma patients.
Camilla Cremonini, Nadya Nee, Matthew Demarest, Alice Piccinini, Michael Minneti, Catherine P Canamar, Elizabeth R Benjami, Demetrios Demetriades, Kenji Inaba
J Trauma Acute Care Surg. 2021 Mar 1;90(3):522-526
Abstract
Background: Tourniquets are a critical tool in the immediate response to life-threatening extremity hemorrhage; however, the optimal tourniquet type and effectiveness of noncommercial devices remain unclear. Our aim was to evaluate the efficacy of five tourniquets in a perfused-cadaver model.
Methods: This prospective study used a perfused-cadaver model with standardized superficial femoral artery injury bleeding at 700 mL/min. Five tourniquets were tested: combat application tourniquet; rapid application tourniquet system; Stretch, Wrap, And Tuck Tourniquet; an improvised triangle bandage windlass; and a leather belt. Forty-eight medical students underwent a practical hands-on demonstration of each tourniquet. Using a random number generator, they placed the tourniquets on the bleeding cadaver in random order. Time to hemostasis, time to secure devices, estimated blood loss, and difficulty rating were assessed. A one-way repeated measures analysis of variance was used to compare efficacy between the tourniquets in achieving the outcomes.
Results: The mean ± SD participant age was 25 ± 2.6 years, and 29 (60%) were male. All but one tourniquet was able to stop bleeding, but the rapid application tourniquet system had a 4% failure rate. Time to hemostasis and estimated blood loss did not differ significantly (p > 0.05). Stretch, Wrap, And Tuck Tourniquet required the longest time to be secured (47.8 ± 17.0 seconds), whereas the belt was the fastest (15.2 ± 6.5 seconds; p < 0.001). The improvised windlass was rated easiest to learn and apply, with 22 participants (46%) assigning a score of 1.
Conclusion: Four of five tourniquets evaluated, including both noncommercial devices, effectively achieved hemostasis. A standard leather belt was the fastest to place and was able to stop the bleeding. However, it required continuous pressure to maintain hemostasis. The improvised windlass was as effective as the commercial devices and was the easiest to apply. In an emergency setting where commercial devices are not available, improvised tourniquets may be an effective bridge to definitive care.
Mechanical Ventilation of Severe Traumatic Brain Injury Patients in the Prehospital Setting
Bentley Woods Curry, Steven Ward, Christopher J Lindsell, Kimberly W Hart, Jason T McMullan
Air Med J. Sep-Oct 2020;39(5):410-413
Abstract
Objective: Suboptimal ventilation may impact outcomes in patients with traumatic brain injury (TBI). This study compares the incidence of eucapnia between manually and mechanically ventilated patients with severe TBI during helicopter transport.
Methods: This retrospective chart review included consecutive intubated adults with severe TBI (Glasgow Coma Scale score < 9) transported by helicopter from the scene of injury to a level 1 trauma center between 2009 and 2015. The primary outcome was the first venous partial pressure of carbon dioxide obtained in the emergency department. Hypocapnia, eucapnia, and hypercapnia were defined based on the normal range for the testing instrument. The Fisher exact test was used to compare groups.
Results: Of 1,070 trauma patients intubated and transported, 93 met the inclusion criteria with full data. The mean age was 43 years, 81 of 93 were white, and 70 of 93 were men. The mean Injury Severity Score was 29, and 26 of 93 were mechanically ventilated. Hypocapnia occurred in 4 of 93 and hypercapnia in 56 of 93. There was no difference in the rate of eucapnia in manually ventilated compared with mechanically ventilated patients (36% vs. 35%, P = 1.00).
Conclusion: Eucapnia at emergency department arrival occurred in 36% of patients and was unaffected by whether ventilation was manually or mechanically controlled. Few patients were hypocapnic, indicating a low incidence of hyperventilation during helicopter transport.
Burn patient decontamination outside of mass casualties
Scott B Davidson, Nathan Brunken, Shannon Naughton, Sheri L VandenBerg
J Am Coll Emerg Physicians Open. 2020 Oct 17;1(6):1250-1254
Abstract
Objective: Decontamination protocols for victims of mass casualty events are well documented and emphasized to protect physicians, nurses and facilities. Decontamination practices outside of mass casualty events are unknown. This pilot study was undertaken to assess the current practices of burn patient decontamination outside of mass casualty events within level I and II trauma center emergency departments in the state of Michigan.
Methods: Using the Michigan Trauma Quality Improvement Project membership, a 10-question online survey was sent to trauma program managers at all level I and II trauma centers in Michigan. Survey questions focused on institutional decontamination protocols and consistency of use.
Results: Survey response was 50%. Of the responding facilities, 31% did not decontaminate burn patients. Of the centers who indicated that they did decontaminate burn patients, 31% did not follow a standardized protocol. Our survey revealed that 69% of facilities used a protocol for decontamination: 45% used the protocol consistently on all burns, and 55% at physician discretion. Products used most frequently to decontaminate burn patients included water (100%) followed by soap (44%).
Conclusion: This pilot survey of level I and II trauma centers in the state of Michigan revealed variability in the use of burn patient decontamination protocols and consistency of use. Additional research is warranted to determine if our results are reflective of trauma centers nationally.
Terrorist attacks: cutaneous patterns of gunshot and secondary blast injuries
Yann Delannoy, Isabelle Plu, Isabelle Sec, Tania Delabarde, Marc Taccoen, Antoine Tracqui, Bertrand Ludes
Forensic Sci Res. 2020 Jul 1;5(3):208-213
Abstract
Terrorist attacks have been on the rise. During the recent terrorist attacks in France, terrorists perpetrated their acts using weapons of war, as well as explosive charges. These two modes of action, when combined, can create skin lesions with similar macroscopic appearances, which can sometimes go unnoticed because of body fragmentation. A total of 68 autopsies, 83 external examinations, 140 standard radiographic examinations, and 49 computed tomography (CT) scans were performed over 7 days during the 2015 terrorist attacks in France. Bodies were injured by firearms and shrapnel-like projectiles. We analysed the clinical findings for the secondary blast cutaneous lesions from the explosive devices and compared these lesions with ballistic-related lesions to highlight that patterns can be macroscopically similar on external examination. Secondary blast injuries are characterised by penetrating trauma associated with materials added to explosive systems that are propelled by explosive air movement. These injuries are caused most often by small, shrapnel-like metallic objects, such as nails and bolts. Propulsion causes ballistic-type injuries that must be recognised and distinguished from those caused by firearm projectiles. Differentiating between these lesions is very difficult when using conventional criteria (size, shape, number and distribution on the body) with only external examination of corpses. This is why the particularities of these lesions must be further illustrated and then confirmed by complete autopsies and radiological and anatomopathological examinations.Key pointsWhen occurring simultaneously in terrorist attacks, injuries caused by secondary blasts appear as cutaneous wound patterns that can be macroscopically very similar to those caused by firearm projectiles.The criteria usually found in the literature for distinguishing these two types of projectiles may be difficult to use.It is important in these difficult situations to benefit from systematic postmortem imaging.Systematic autopsy and then anatomopathological analyses of the orifices also help determine the cause of the wounds.
Connor P Dolan, Michael S Valerio, W Lee Childers, Stephen M Goldman, Christopher L Dearth
NPJ Regen Med. 2021 Feb 4;6(1):6
Abstract
Extremity injuries occur frequently during warfare. While traditionally treated in definitive clinics, the future battlefield is projected to be different in a variety of ways, and there will likely be a shift towards prolonged field care (PFC) for treating extremity traumas. PFC is defined as field medical care that is applied beyond “doctrinal planning time-lines” by a tactical medical practitioner in order to decrease patient mortality and morbidity. At present, there is an urgent need to develop biologically focused technologies for treating extremity injuries in the PFC setting. Herein, the case is made for why rapid advancements in PFC is critical to achieve optimal care for injured Service members in the future, and important design criteria for developing next-generation biologically focused technologies. Finally, a case example—i.e., Gustilo Type III fracture—is presented to illustrate how these biologically focused technologies could be utilized to treat an extremity injury within a PFC environment.
Efficacy of a novel chest tube system in a swine model of hemothorax
Ross I Donaldson, Eric M Zimmermann, Oliver J Buchanan, Todd L Graham, James D Ross
J Thorac Dis. 2021 Jan;13;213-219
Abstract
Background: Tube thoracostomy is the definitive treatment for most significant chest trauma, including injuries resulting in pneumothorax, hemothorax, and hemopneumothorax. However, traditional chest tubes fail to sufficiently remove blood up to 20% of the time (i.e., retained hemothorax), which can lead to empyema and fibrothorax, as well as significant morbidity and mortality. Here we describe the use of a novel chest tube system in a swine model of hemothorax.
Methods: This was an intra-animal-paired, randomized-controlled study of hemothorax evacuation using the PleuraPath™ Thoracostomy System (PPTS) compared to a traditional chest tube in large Yorkshire-Landrace swine (75-85 kg). One liter of autologous whole blood was infused into each pleural cavity simultaneously with subsequent drainage from each device individually monitored for a total of 120 minutes, before the end of the experiment and necroscopy.
Results: Six animals completed the full protocol. On average, the PPTS removed 17% more blood (P=0.049) and left 19.1% less residual hemothorax (P=0.023) as compared to the standard of care during the first two hours of use. No complications or iatrogenic injury were identified in any animal for either device.
Conclusions: The novel PPTS device was superior to the traditional chest tube drainage system in this acute, large-animal model of retained hemothorax. While this study supports clinical translation, further research will be required to assess efficacy and optimize device use in humans.
Joseph J DuBose, Daniel J Stinner, Aric Baudek, Daniel Martens, Benjamin Donham, Matt Cuthrell, Tony Stephens, Jerry Schofield, Curtis C Conklin, Simon Telian
J Spec Oper Med. Winter 2020;20(4):47-52
Abstract
Background: Expedient resuscitation and emergent damage control interventions remain critical tools of modern combat casualty care. Although fortunately rare, the requirement for life and limb salvaging surgical intervention prior to arrival at traditional deployed medical treatment facilities may be required for the care of select casualties. The optimal employment of a surgical resuscitation team (SRT) may afford life and limb salvage in these unique situations.
Methods: Fifteen years of after-action reports (AARs) from a highly specialized SRTs were reviewed. Patient demographics, specific details of encounter, team role, advanced emergent life and limb interventions, and outcomes were analyzed.
Results: Data from 317 casualties (312 human, five canines) over 15 years were reviewed. Among human casualties, 20 had no signs of life at intercept, with only one (5%) surviving to reach a Military Treatment Facility (MTF). Among the 292 casualties with signs of life at intercept, SRTs were employed in a variety of roles, including MTF augmentation (48.6%), as a transport capability from other aeromedical platforms, critical care transport (CCT) between MTFs (27.7%), or as an in-flight damage control capability directly to point of injury (POI) (18.2%). In the context of these roles, the SRT performed in-flight life and limb preserving surgery for nine patients. Procedures performed included resuscitative thoracotomy (7/9; 77.8%), damage control laparotomy (1/9; 11.1%) and extremity fasciotomy for acute lower extremity compartment syndrome (1/11; 11%). Survival following in-flight resuscitative thoracotomy was 33% (1/3) when signs of life (SOL) were absent at intercept and 75% (3/4) among patients who lost SOL during transport.
Conclusion: In-flight surgery by a specifically trained and experienced SRT can salvage life and limb for casualties of major combat injury. Additional research is required to determine optimal SRT utilization in present and future conflicts.
There Is No Role for Damage Control Orthopedics Within the Golden Hour
John C Dunn, Eric A Elster, James A Blair, Kyle N Remick, Benjamin K Potter, Leon J Nesti
Mil Med. 2021 Jan 23;usaa379. doi: 10.1093/milmed/usaa379
Abstract
Introduction: Trauma systems within the United States have adapted the "golden hour" principle to guide prehospital planning with the goal to deliver the injured to the trauma facility in under 60 minutes. In an effort to reduce preventable prehospital death, in 2009, Secretary of Defense Robert M. Gates mandated that prehospital transport of injured combat casualties must be less than 60 minutes. The U.S. Military has implemented a 60-minute timeline for the transport of battlefield causalities to medical teams to include Forward Surgical Teams and Forward Resuscitative Surgical Teams. The inclusion of orthopedic surgeons on Forward Surgical Teams has been extrapolated from the concept of damage control orthopedics (DCO). However, it is not clear if orthopedic surgeons have yielded a demonstrable benefit in morbidity or mortality reduction. The purpose of this article is to investigate the function of orthopedic surgeons during the military "golden hour."
Materials and methods: The English literature was reviewed for evidence supporting the use of orthopedic surgeons within the golden hour. Literature was reviewed in light of the 2009 golden hour mandate by Secretary Gates as well as those papers which highlighted the utility of DCO within the golden hour.
Results: Evidence for orthopedic surgery within the "golden hour" or in the current conflicts when the United States enjoys air superiority was not identified.
Conclusions: Within the military context, DCO, specifically pertaining to fracture fixation, should not be considered an element of golden hour planning and thus orthopedic surgeons are best utilized at more centralized Role 3 facility locations. The focus within the first hour after injury on the battlefield should be maintained on rapid and effective prehospital care combined with timely evacuation, as these are the most critical factors to reducing mortality.
Sensors (Basel). 2021 Feb 10;21(4):1263
The Use of Pulse Oximetry in the Assessment of Acclimatization to High Altitude
Tobias Dünnwald, Roland Kienast, David Niederseer, Martin Burtscher
Abstract
Background: Finger pulse oximeters are widely used to monitor physiological responses to high-altitude exposure, the progress of acclimatization, and/or the potential development of high-altitude related diseases. Although there is increasing evidence for its invaluable support at high altitude, some controversy remains, largely due to differences in individual preconditions, evaluation purposes, measurement methods, the use of different devices, and the lacking ability to interpret data correctly. Therefore, this review is aimed at providing information on the functioning of pulse oximeters, appropriate measurement methods and published time courses of pulse oximetry data (peripheral oxygen saturation, (SpO2) and heart rate (HR), recorded at rest and submaximal exercise during exposure to various altitudes.
Results: The presented findings from the literature review confirm rather large variations of pulse oximetry measures (SpO2 and HR) during acute exposure and acclimatization to high altitude, related to the varying conditions between studies mentioned above. It turned out that particularly SpO2 levels decrease with acute altitude/hypoxia exposure and partly recover during acclimatization, with an opposite trend of HR. Moreover, the development of acute mountain sickness (AMS) was consistently associated with lower SpO2 values compared to individuals free from AMS.
Conclusions: The use of finger pulse oximetry at high altitude is considered as a valuable tool in the evaluation of individual acclimatization to high altitude but also to monitor AMS progression and treatment efficacy.
Point-of-Care Laboratory Data Collection During Critical Care Transport
Jamie Eastman, Deborah Allen, Kevin Mumma, Andrew Almond, Jason Theiling
Air Med J. Jan-Feb 2021;40(1):81-83
Abstract
Objective: Critical care transport involves a high level of intensive clinical care in a resource-limited environment. These patients require multiple assessments guiding specialty treatments, including blood product administration, intravenous electrolyte replacement, ventilator management, and extracorporeal membrane oxygenation. This study aims to measure the usage of point-of-care (POC) laboratory data during critical care transport.
Methods: Data were collected via electronic medical record review over 1 year of use in a hospital-based critical care rotor wing, fixed wing, and ground critical care transport team in the Southeastern United States.
Results: One hundred twenty POC tests were performed during 1,075 critical care transports over the 1-year period (8.9%). Patient transportations involved 35 extracorporeal membrane oxygenation, 21 medical, 17 cardiac, 13 neonatal, 11 respiratory failure, 8 gastrointestinal bleeding, 6 neurologic, 5 pediatrics, 3 trauma, and 1 organ donor. Seventy-eight POC laboratory tests (65%) required intervention, including ventilator changes (39.7%), electrolyte replacement (35.8%), blood products (7.6%), and other (12.8%). The remaining 42 (35%) POC laboratory tests confirmed no intervention was necessary (n = 35) and that ongoing treatments were effective (n = 7).
Conclusion: POC laboratory testing performed during critical care transport guides providers in performing essential emergent interventions in a timelier manner that may benefit critically ill patients.
Thomas H Edwards, Michael A Dubick, Lee Palmer, Anthony E Pusateri
Front Vet Sci. 2021 Jan 14;7:571368. doi: 10.3389/fvets.2020.571368
Abstract
In humans, the leading cause of potentially preventable death on the modern battlefield is undoubtedly exsanguination from massive hemorrhage. The US military and allied nations have devoted enormous effort to combat hemorrhagic shock and massive hemorrhage. This has yielded numerous advances designed to stop bleeding and save lives. The development of extremity, junctional and truncal tourniquets applied by first responders have saved countless lives both on the battlefield and in civilian settings. Additional devices such as resuscitative endovascular balloon occlusion of the aorta (REBOA) and intraperitoneal hemostatic foams show great promise to address control the most difficult forms (non-compressible) of hemorrhage. The development of next generation hemostatic dressings has reduced bleeding both in the prehospital setting as well as in the operating room. Furthermore, the research and fielding of antifibrinolytics such as tranexamic acid have shown incredible promise to ameliorate the effects of acute traumatic coagulopathy which has led to significant morbidity and mortality in service members. Advances from lessons learned on the battlefield have numerous potential parallels in veterinary medicine and these lessons are ripe for translation to veterinary medicine.
Mar Drugs. 2021 Jan 22;19(2):50
Design and Preclinical Evaluation of Chitosan/Kaolin Nanocomposites with Enhanced Hemostatic Efficiency
Mahmoud Elsabahy, Mostafa A Hamad
Abstract
In the current study, hemostatic compositions including a combination of chitosan and kaolin have been developed. Chitosan is a marine polysaccharide derived from chitins, a structural component in the shells of crustaceans. Both chitosan and kaolin have the ability to mediate a quick and efficient hemostatic effect following immediate application to injury sites, and thus they have been widely exploited in manufacturing of hemostatic composites. By combining more than one hemostatic agent (i.e., chitosan and kaolin) that act via more than one mechanism, and by utilizing different nanotechnology-based approaches to enhance the surface areas, the capability of the dressing to control bleeding was improved, in terms of amount of blood loss and time to hemostasis. The nanotechnology-based approaches utilized to enhance the effective surface area of the hemostatic agents included the use of Pluronic nanoparticles, and deposition of chitosan micro- and nano-fibers onto the carrier. The developed composites effectively controlled bleeding and significantly improved hemostasis and survival rates in two animal models, rats and rabbits, compared to conventional dressings and QuikClot® Combat Gauze. The composites were well-tolerated as demonstrated by their in vivo biocompatibility and absence of clinical and biochemical changes in the laboratory animals after application of the dressings.
Akira Endo, Mitsuaki Kojima, Saya Uchiyama, Atsushi Shiraishi, Yasuhiro Otomo
Scand J Trauma Resusc Emerg Med. 2021 Jan 6;29(1):9.
Abstract
Background: Although the results of previous studies suggested the effectiveness of physician-led prehospital trauma management, it has been uncertain because of the limited number of high-quality studies. Furthermore, the advantage of physician-led prehospital management might have been overestimated due to the shortened prehospital time by helicopter transportation in some studies. The present study aimed to evaluate the effect of physician-led prehospital management independent of prehospital time. Also, subgroup analysis was performed to explore the subpopulation that especially benefit from physician-led prehospital management.
Methods: This retrospective cohort study analyzed the data of Japan's nationwide trauma registry. Severe blunt trauma patients, defined by Injury Severity Score (ISS) ≥16, who were transported directly to a hospital between April 2009 and March 2019 were evaluated. In-hospital mortality was compared between groups dichotomized by the occupation of primary prehospital healthcare provider (i.e., physician or paramedic), using 1:4 propensity score-matched analysis. The propensity score was calculated using potential confounders including patient demographics, mechanism of injury, vital signs at the scene of injury, ISS, and total time from injury to hospital arrival. Subpopulations that especially benefit from physician-led prehospital management were explored by assessing interaction effects between physician-led prehospital management and patient characteristics.
Results: A total of 30,551 patients (physician-led: 2976, paramedic-led: 27,575) were eligible for analysis, of whom 2690 propensity score-matched pairs (physician-led: 2690, paramedic-led: 10,760) were generated and compared. Physician-led group showed significantly decreased in-hospital mortality than paramedic-led group (in-hospital mortality: 387 [14.4%] and 1718 [16.0%]; odds ratio [95% confidence interval] = 0.88 [0.78-1.00], p = 0.044). Patients with age < 65 years, ISS ≥25, Abbreviated Injury Scale in pelvis and lower extremities ≥3, and total prehospital time < 60 min were likely to benefit from physician-led prehospital management.
Conclusions: Physician-led prehospital trauma management was significantly associated with reduced in-hospital mortality independent of prehospital time. The findings of exploratory subgroup analysis would be useful for the future research to establish efficient dispatch system of physician team.
Gun-related eye injuries: A primer
Benjamin P Erickson, Paula W Feng, Marcus J Ko, Yasha S Modi, Thomas E Johnson
Surv Ophthalmol. Jan-Feb 2020;65(1):67-78
Abstract
Gun-related eye injuries are relatively common in the context of gunshot wounds to the head and neck. Many of the fundamental principles of gunshot wound management apply to the care of these patients, but the complex anatomy and functional relationships of the periocular region do pose special challenges. We provide a focused primer for physicians seeking a more in-depth understanding of gun-related eye injuries and present 3 representative cases outlining the spectrum of pathology, provide a focused review of the relevant ballistics concepts, and discuss the management of injuries to the periocular soft tissues, orbital structures, and globe. We found that good cosmetic and functional results can often be achieved with appropriate early intervention, but visual prognosis may remain guarded despite optimal treatment.
Nebulized Ketamine Used for Pain Management of Orthopedic Trauma
Catsim Fassassi, Daniel Dove, Ashley R Davis, Adam Ranginwala, Errol Khordipour, Sergey Motov
J Emerg Med. 2021 Mar;60(3):365-367
Abstract
Background: Ketamine is a noncompetitive N-methyl-D-aspartate/glutamate receptor complex antagonist that decreases pain by diminishing central sensitization and hyperalgesia. When administered via i.v. (push-dose, short infusion, or continuous infusion) or intranasal routes, ketamine has shown to be effective in patients with acute traumatic pain. However, when i.v. access is not attainable or readily available, the inhalation route of ketamine administration via breath-actuated nebulizer (BAN) provides a noninvasive and titratable method of analgesic delivery. The use of nebulized ketamine has been studied in areas of postoperative management of sore throat and acute traumatic musculoskeletal and abdominal pain. To our knowledge, this is the first case series describing the use of nebulized ketamine for analgesia and orthopedic reduction.
Case series: We describe 4 patients who presented to the emergency department with acute traumatic painful conditions (one patellar dislocation, one shoulder dislocation, and two forearm fractures) and received nebulized ketamine for management of their pain. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Administration of nebulized ketamine via BAN can be used as analgesic control for musculoskeletal trauma, as it can be administrated to patients with difficult i.v. access, has a rapid onset of analgesic effects with minimal side effects, and remains opioid-sparing.
Nonmissile penetrating spinal injuries: Mechanisms, expectations, and management
Brian Fiani, Ryan Arthur Figueras, Frank De Stefano, Neha Gautam, Asif Khan, Marisol Soula
Surg Neurol Int. 2020 Nov 25;11:406. doi: 10.25259/SNI_596_2020
Abstract
Background: Nonmissile penetrating spinal injury (NMPSI) is an uncommon form of traumatic injury to the spine. Here, we present a comprehensive and contemporary literature review that provides insight into NMPSI-type injuries, their mechanisms, clinical practice, management, and expectations.
Methods: An extensive review of the published literature was conducted in PubMed, OVID Medline, and EMBASE journals for studies of nonmissile penetrating spine injuries. Terms for search included NMPSI and nonmissile penetrating spinal cord injury. No date restrictions were used.
Results: The search yielded only 17 related articles. Cross-checking of articles was conducted to exclude duplicate articles. The 17 articles were screened for their full text and English language availability. We finalized those articles pertaining to the topic.
Conclusion: The mechanism of injury in NMPSI occurs in two different stages. Immediate injury is caused by direct damage to the neurological structures. The delayed injury response is caused by damage to the spinal vasculature and activated immune response pathways. Computed tomography (CT) angiograms or formal diagnostic angiograms are indicated to identify vascular injury or development of pseudoaneurysm and can be performed both preoperatively and postoperatively. Surgically, decompressive procedures include laminectomies and hemilaminectomies. Dural exploration may be indicated if a cerebrospinal fluid leak with fistula develops from dural puncture. Further research and technologies are being developed to provide patients who have suffered NMPSI with more resources for a better quality of life.
An Analysis and Comparison of Prehospital Trauma Care Provided by Medical Officers and Medics on the Battlefield
Andrew D Fisher, Jason F Naylor, Michael D April, Dominic Thompson, Russ S Kotwal, Steven G Schauer
Abstract
Background: Role 1 care represents all aspects of prehospital care on the battlefield. Recent conflicts and military operations conducted on behalf of the Global War on Terrorism have resulted in medical officers (MOs) being used nondoctrinally on combat missions. We are seeking to describe Role 1 trauma care provided by MOs and compare this care to that provided by medics.
Methods: This is a secondary analysis of previously described data from the Prehospital Trauma Registry and the Department of Defense Trauma Registry from April 2003 through May 2019. Encounters were categorized by type of care provider (MO or medic). If both were documented, they were categorized as MO; those without either were excluded. Descriptive statistics were used.
Results: A total of 826 casualty encounters met inclusion criteria. There were 418 encounters categorized as MO (57 with MO, 361 with MO and medic), and 408 encounters categorized as medic only. The composite injury severity score (median, interquartile range) was higher for casualties treated by the medic cohort (9, 3.5-17) than for the MO cohort (5, 2-9.5; P = .006). There was no difference in survival to discharge between the MO and medic groups (98.6% vs. 95.6%; P = .226). More life-saving interventions were performed by MOs compared to medics. MOs demonstrated a higher rate of vital sign documentation than medics.
Conclusion: More than half of casualty encounters in this study listed an MO in the chain of care. The difference in proportion of interventions highlights differences in provider skills, training and equipment, or that interventions were dictated by differences in mechanisms of injury.
Emergency Management of Pelvic Bleeding
Simone Frassini, Shailvi Gupta, Stefano Granieri, Stefania Cimbanassi, Fabrizio Sammartano, Thomas M Scalea, Osvaldo Chiara
J Clin Med. 2021 Jan 1;10(1):129
Abstract
Pelvic trauma continues to have a high mortality rate despite damage control techniques for bleeding control. The aim of our study was to evaluate how Extra-peritoneal Pelvic Packing (EPP) and Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) impact the efficacy on mortality and hemodynamic impact. We retrospectively evaluated patients who sustained blunt trauma, pelvic fracture and hemodynamic instability from 2002 to 2018. We excluded a concomitant severe brain injury, resuscitative thoracotomy, penetrating trauma and age below 14 years old. The study population was divided in EPP and REBOA Zone III group. Propensity score matching was used to adjust baseline differences and then a one-to-one matched analysis was performed. We selected 83 patients, 10 for group: survival rate was higher in EPP group, but not significantly in each outcome we analyzed (24 h, 7 day, overall). EPP had a significant increase in main arterial pressure after procedure (+20.13 mmHg, p < 0.001), but this was not as great as the improvement seen in the REBOA group (+45.10 mmHg, p < 0.001). EPP and REBOA are effective and improve hemodynamic status: both are reasonable first steps in a multidisciplinary management. Zone I REBOA may be useful in patients 'in extremis condition' with multiple sites of torso hemorrhage, particularly those in extremis.
An Analysis of Outcomes and Interventions for Female Pediatric Casualties in Iraq and Afghanistan
Hannah L Gale, Natalie J Koons, Matthew A Borgman, Michael D April, Steven G Schauer
Mil Med. 2021 Feb 6;Online ahead of print
Background: Traumatic injuries were the most common reason for admission of pediatric patients to military hospitals during the recent wars in Iraq and Afghanistan. We compare survival and interventions between female and male pediatric casualties.
Materials and methods: This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry. We requested pediatric encounters from January 2007 to January 2016 within Iraq and Afghanistan. We separated casualties by sex to compare injury and mortality patterns.
Results: Our initial dataset included 3439 pediatric encounters-784 (22.8%) females and 2655 (77.2%) males. Females were less likely to sustain injuries by explosive (38.0% versus 44.5%) but more likely to sustain injuries via alternative mechanisms of injury (28.9% versus 21.5%). Both sexes had similar ISS (females median 10 [5-17], males 10 [4-17]). Fewer females underwent tourniquet application (4.2% versus 7.2%; all findings were significant). In unadjusted and adjusted regression analyses, females under age 8 had lower odds of survival to hospital discharge (OR 0.67, 95% CI 0.51-0.89) compared to males.
Conclusions: Among pediatric patients treated by U.S. medical personnel in Iraq and Afghanistan, females had a lower survival to hospital discharge despite similar severity of injury. Further studies are necessary to elucidate causes for this finding.
Mass Casualty Management After a Boiling Liquid Expanding Vapor Explosion in an Urban Area
Lorenzo Gamberini, Guglielmo Imbriaco, Alfonso Flauto, Alessandro Monesi, Carlo Alberto Mazzoli, Cristian Lupi, Daniela Maria Roberta Costa, Fabio Mora, Oscar Dell'Arciprete, Fiorella Cordenons, Cosimo Picoco, Giovanni Gordini
J Emerg Med. 2021 Apr;60(4):471-477
Abstract
Background: The catastrophic fail of a container holding a pressure-liquified gas can generate a boiling liquid expanding vapor explosion (BLEVE) with a subsequent blast wave, flying fragments, and fire or toxic gas release.
Case report: This report describes the management of a mass casualty disaster related to a BLEVE in an urban area due to a highway accident involving a tanker carrying liquified petroleum gas and a truck transporting chemical solvents. The event resulted in 158 casualties that were triaged, stabilized, and transported into the "hub" and "spoke" hospitals of the regional trauma network within 3 h and 22 min from the event by the Emergency Medical Services. The logistic complications related to the partial collapse of the highway bridge on an underlying urban road and the relative solutions adopted, as well as the application and advantages of the use of the Simple Triage and Rapid Treatment (START) algorithm in the field and the criteria adopted for the distribution of patients within the trauma network, are discussed, along with the potential pitfalls observed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: BLEVE events are rare but can be complex in both logistical management and clinical presentation of the lesions related to the event. The START algorithm is a valuable tool for rapid triage in mass casualty incidents.
In vitro and in vivo assessment of the protective effect of sufentanil in acute lung injury
Qi Gao, Ningqing Chang, Donglian Liu
J Int Med Res. 2021 Feb;49(2):300060520986351. doi: 10.1177/0300060520986351.
Abstract
Objectives: To investigate the mechanisms underlying the protective effect of sufentanil against acute lung injury (ALI).
Material and methods: Rats were administered lipopolysaccharide (LPS) by endotracheal instillation to establish a model of ALI. LPS was used to stimulate BEAS-2B cells. The targets and promoter activities of IκB were assessed using a luciferase reporter assay. Apoptosis of BEAS-2B cells was evaluated by terminal deoxynucleotidyl transferase dUTP nick end labeling.
Results: Sufentanil treatment markedly reduced pathological changes in lung tissue, pulmonary edema and secretion of inflammatory factors associated with ALI in vivo and in vitro. In addition, sufentanil suppressed apoptosis induced by LPS and activated NF-κB both in vivo and in vitro. Furthermore, upregulation of high mobility group box protein 1 (HMGB1) protein levels and downregulation of miR-129-5p levels were observed in vivo and in vitro following sufentanil treatment. miR-129-5p targeted the 3' untranslated region and its inhibition decreased promoter activities of IκB-α. miR-129-5p inhibition significantly weakened the protective effect of sufentanil on LPS-treated BEAS-2B cells.
Conclusion: Sufentanil regulated the miR-129-5p/HMGB1 axis to enhance IκB-α expression, suggesting that sufentanil represents a candidate drug for ALI protection and providing avenues for clinical treatment.
Lilach Gavish, Mor Rittblat, S David Gertz, Ruth Shaylor, Charles Weissman, Arik Eisenkraft
Mil Med. 2020 Aug 14;185(7-8):e1300-e1308
Abstract
Introduction: Emergency field ventilation using bag-valve face mask devices can be difficult to perform, especially in bearded individuals. In view of the increasing numbers of servicemen and civilians sporting a beard or moustache, the issue of finding a technical solution for ventilation in this population has gained importance. We therefore developed a novel adaptor that enables the direct connection of a bag-valve device to a Guedel-type oropharyngeal airway device thereby directly connecting the oral airway to the bag valve, eliminating the need for a face mask. The objective of this study was to compare the efficacy of the bag-valve-Guedel adaptor (BVGA) to the common face mask in healthy bearded volunteers.
Methods: This study was a randomized-by-sequence, crossover-controlled trial (NCT02768246) approved by the local IRB (0051-16-HMO). All subjects signed an informed consent before participation. Twenty-five healthy bearded men (age 28 ± 7) were recruited. After randomization, the first group (mask then BVGA, n = 12) began breathing room air through the face mask, followed by 100% O2. After washout in room air, the procedure was repeated with the BVGA. The second group (BVGA then mask, n = 13) began with the BVGA followed by the face mask. Subjects were awake and breathed spontaneously throughout the experiment. Therefore, a Guedel was not used. Physiological and respiratory parameters were monitored continuously. The primary endpoint was the presence of suspected leak as determined by end-tidal-CO2 (EtCO2 < 20 mmHg). Secondary endpoints included tidal volume and safety.
Results: The order of device use did not affect the results significantly (p > 0.05 by Mann-Whitney-U test); therefore, the data were pooled. There were no cases of suspected leak while breathing through the BVGA. By contrast, while breathing through a face mask, there were 8 of 25 (32%) and 5 of 25 (20%) cases of suspected leak in air and 100% O2, respectively (air: p = 0.002; 100% O2: p = 0.014 by McNemar test). No adverse events were observed.
Conclusions: In bearded individuals, the BVGA provides significantly more efficient (less leak) ventilation compared to a face mask. This is also of particular importance in view of the increasing number of bearded individuals serving in the armed forces. Moreover, since effective ventilation with a mask requires experience, the relatively easy-to-apply BVGA will enable less experienced first responders to achieve higher success rates in this critical phase of treatment. Further studies are planned to evaluate the efficacy of the BVGA in the prehospital setting.
Novel Low-Cost, Low-Fidelity Hemorrhoidectomy Task Trainers
Alaina D Geary, Luise I M Pernar, Jason F Hall
J Surg Educ. Sep-Oct 2020;77(5):1285-1288
Abstract
Objective: Develop and describe a set of low-cost hemorrhoidectomy task trainer prototypes in the setting of inadequate junior resident surgical skill preparation for anorectal cases.
Design: This is a study comparing expert and novice performance and opinions. Three task trainers were developed to simulate dissecting, knot-tying, and suturing in a confined space, like the anus. Participants were asked to dissect the peel off of an orange, tie seven 2-handed knots on a weight, and close a defect in a piece of felt with a running stitch. An 8-oz mason jar was used to simulate the confined space. Participants were asked to fill out a 5-point Likert-based evaluation regarding the skills. The primary outcome was time to complete each task in seconds. Secondary outcome measures were number of errors associated with each task, subjective achievability of tasks, and utility of tasks for improving surgical skills.
Setting: General surgery residency program at a safety-net academic center.
Participants: Forty subjects participated in this study. There were 20 experts (7 attending surgeons, 13 PGY-1-PGY-5 surgical residents) and 20 novices (11 third- and 9 fourth-year medical students).
Results: Experts knot-tied (59s vs 140s, p < 0.001) and sutured (219s vs 295s, p < 0.001) faster than novices. Experts were able to tie 7 knots in fewer attempts than novices (p < 0.001). There was no significant difference in speed of orange dissection between groups. There were no significant differences in the number or frequency of other errors. All participants felt the tasks were achievable (4.90/5) and would be useful in improving skills (4.93/5).
Conclusions: This study demonstrated that a set of low-cost, low-fidelity prototypical hemorrhoidectomy task trainers can discriminate between experts and novices. Simulation models such as these can offer useful practice opportunities for junior general surgery trainees.
Ketamine in acute phase of severe traumatic brain injury "an old drug for new uses?"
Daniel Agustin Godoy, Rafael Badenes, Paolo Pelosi, Chiara Robba
Crit Care. 2021 Jan 6;25(1):19
Abstract
Maintaining an adequate level of sedation and analgesia plays a key role in the management of traumatic brain injury (TBI). To date, it is unclear which drug or combination of drugs is most effective in achieving these goals. Ketamine is an agent with attractive pharmacological and pharmacokinetics characteristics. Current evidence shows that ketamine does not increase and may instead decrease intracranial pressure, and its safety profile makes it a reliable tool in the prehospital environment. In this point of view, we discuss different aspects of the use of ketamine in the acute phase of TBI, with its potential benefits and pitfalls.
Potentially survivable fatal vascular access hemorrhage with tourniquet use: A post-mortem analysis
Craig Goolsby, Luis E Rojas, Michael Andersen, Nathan Charlton, Laura Tilley, Jason Pasley, Todd E Rasmussen, Matthew J Levy
J Am Coll Emerg Physicians Open. 2020 Aug 17;1(6):1224-1229
Abstract
Background: The US military has prioritized battlefield hemorrhage control. Researchers credit tourniquet use, and a novel trauma care training program, with saving 1000-2000 lives in Iraq and Afghanistan. The Stop the Bleed campaign translates these lessons learned to the public. This is the first analysis of the potential impact of this newfound knowledge about tourniquet use for extremity fatal vascular access hemorrhage in a civilian population. Fatal vascular access hemorrhage includes bleeding from arteriovenous fistulas and grafts used for hemodialysis and central venous catheters.
Methods: This is a retrospective study of decedent records. We selected Maryland death records from 2002-2017 using the following search terms: "graft," "shunt," "fistula," "dialysis," and "central venous catheter." The records were analyzed for potential survivability with a checklist of military criteria modified for a civilian population. Suicides were excluded. Two reviewers independently classified the deaths as either potentially survivable or non-survivable, and a third reviewer broke ties.
Results: There were 111 deaths included in the final analysis. Ninety-two of the 111 decedents had potentially survivable extremity fatal vascular access hemorrhage. The remaining 19 records were excluded, because they did not have extremity hemorrhage. Zero decedents had hemorrhage deemed to be non-survivable with prompt tourniquet application.
Conclusion: This study identified 92 Maryland extremity fatal vascular access hemorrhage decedents who potentially could have survived with tourniquet use-an average of 6 per year. These results suggest the need for further epidemiology investigation, as well as exploration of the risks and benefits of teaching and equipping vascular access patients and their caregivers to use tourniquets for life-threatening bleeding.
Nadav Haddad, Avishai M Tsur, Roy Nadler, Elon Glassberg, Avi Benov, Jacob Chen
Mil Med. 2021 Jan 25;186(Suppl 1):261-265
Abstract
Objective: The objective of this study was to assess the current experience of Israel Defense Forces' (IDF) advanced life support (ALS) providers in performing life-saving interventions (LSIs), the rate of doctors and paramedics achieving the Trauma and Combat Medicine Branch benchmarks, and the rate of providers feeling confident in performing the interventions although not achieving the benchmarks.
Methods: This study was based on an online survey delivered to IDF ALS providers. The survey investigated demographics; experience in performing endotracheal intubation, cricothyroidotomy, tube thoracostomy, and intraosseous access on human patients; and confidence in performing these LSIs. All benchmarks chosen referred to the number of times performed in the previous year. The benchmarks were 20 for intubation, 3 for cricothyroidotomy, 4 for tube thoracostomy, and 3 for intraosseous access.
Results: During the survey period, 175 IDF ALS providers started the survey, but only 138 (79%) completed it, 93 (67%) of them were paramedics. Doctors had higher rates than paramedics of failing to achieve the benchmarks for intubation (96 vs. 57%, P < .001) and intraosseous access (100 vs. 66%, P < .001). All respondents failed to achieve the benchmark for cricothyroidotomy, and all but one paramedic failed to achieve the tube thoracostomy benchmark. Doctors had lower rates of high confidence when failing to achieve the benchmark for intubation (35 vs. 64%, P = .008) and intraosseous access (7 vs. 31%, P = .005) compared to paramedics.
Conclusion: IDF ALS providers have alarmingly limited experience in performing LSIs. Many of them are confident in their ability despite not achieving evidence-based benchmarks. Additional training is required, maybe as a part of an annual medical fitness test.
Small-bore catheter is more than an alternative to the ordinary chest tube for pleural drainage
Abdel-Mohsen Mahmoud Hamad, Seham Ezzat Alfeky
Lung India. Jan-Feb 2021;38(1):31-35
Abstract
Background: Pleural collection is a common medical problem. For decades, the chest tube of different designs was the commonly used toll for pleural drainage. Over the past few years, small-bore catheter (SBC) has gained more popularity. We present our experience of using SBCs for the drainage of pleural collection of different etiologies.
Patients and methods: A total of 398 small-bore pleural catheters were inserted in 369 patients with pleural collection during the period from January 2013 to October 2019. Data were collected regarding the efficacy of drainage, experienced chest pain, duration of drainage, and the occurrence of complications.
Results: Malignant associated (59.24%) and parapneumonic (19.57%) effusions constituted the most common causes. The drainage was successful in 382/398 (95.98%) occasions; six cases had incomplete fluid evacuation that required decortications; five cases (1.26%) had nonexpendable lung. Catheter reinsertion was needed due to dislodgment in 2 (0.50%) cases and obstruction in 3 (0.75%) cases. Sixty-two cases (15.58%) experienced chest pain. No patient developed empyema or cellulites at the site of catheter insertion. The duration of drainage ranged from 2 to 7 days, with an average of 3.5 days.
Conclusions: SBC is equivalent to conventional chest tube for the drainage of pleural collection. Moreover, it has the advantages of less associated pain, versatility of insertion site, and relative safety of the technique in some risky and difficult situations.
Maximilian Hammer, Peter Santer, Maximilian S Schaefer, Friederike C Althoff, Karuna Wongtangman, Ulrich H Frey, Xinling Xu, Matthias Eikermann, Philipp Fassbender
Br J Anaesth. 2021 Mar;126(3):738-745
Abstract
Background: We examined the association between emergent postoperative tracheal intubation and the use of supraglottic airway devices (SGAs) vs tracheal tubes.
Methods: We included data from adult noncardiac surgical cases under general anaesthesia between 2008 and 2018. We only included cases (n=59 991) in which both airways were deemed to be feasible options. Multivariable logistic regression, instrumental variable analysis, propensity matching, and mediation analysis were used.
Results: Use of a tracheal tube was associated with a higher risk of emergent postoperative intubation (adjusted absolute risk difference [ARD]=0.80%; 95% confidence interval (CI), 0.64-0.97; P<0.001), and a higher risk of post-extubation hypoxaemia (ARD=3.9%; 95% CI, 3.4-4.4; P<0.001). The effect was modified by the use of non-depolarising neuromuscular blocking agents (NMBAs); mediation analyses revealed that 28.9% (95% CI, 14.4-43.4%; P<0.001) of the main effect was attributable to NMBA. Airway management modified the association of NMBA and risk of emergent postoperative intubation (Pinteraction=0.02). Patients managed with an SGA had higher odds of NMBA-associated reintubation compared to patients managed with a tracheal tube (adjusted odds ratio [aOR]=3.65, 95% CI, 1.99-6.67 vs aOR=1.68, 95% CI, 1.29-2.18 [P<0.001], respectively).
Conclusions: In patients undergoing procedures under general anaesthesia that could be managed with either SGA or tracheal tube, use of an SGA was associated with lower risk of emergent postoperative intubation. The effect can partly be explained by use of NMBAs. Use of NMBAs in patients with an SGA appears to increase the risk of emergent postoperative intubation.
Katherine Hawkridge, Ikhlaaq Ahmed, Zubair Ahmed
Eur J Trauma Emerg Surg. 2020 Dec 21 Online ahead of print.
Abstract
Purpose: Spinal collars were introduced in 1967 into the management of spinal trauma care as it was thought that this technique of immobilisation would prevent any further neurological or spinal damage in high-risk patients. The aim of this systematic review was to determine whether the use of spinal collars in the pre-hospital trauma patient was recommended by published literature.
Methods: A systematic search of the literature was conducted between 1990 and 2020, screening PubMed, Medline, Science Direct and Google Scholar. The consequent findings were then qualitatively synthesised with the aim of effectively evaluating the evidence to resolve the discrepancy between current practice and literature.
Results: Of the nine eligible studies, six deemed that spinal collars should not be used in pre-hospital trauma patients with the remaining three reporting uncertainty if spinal collars were best practice. Our results suggest that there is a discrepancy between current guidance and practice in that although the guidelines recommend the use of spinal collars in the pre-hospital setting the majority of the studies were against the use of spinal collars. Importantly, none of the studies reported any benefits of spinal collars.
Conclusion: Our study shows a disparity between current guidelines and the published literature and warrants further direct research to obtain a more comprehensive view of the use of spinal collars in a pre-hospital setting.
Peter Hilbert-Carius, Manuel F Struck Veronika Hofer, Jochen Hinkelbein, Leif Rognås, Jörn Adler, Michael D Christian, Thomas Wurmb, Michael Bernhard, Björn Hossfeld
Scand J Trauma Resusc Emerg Med. 2020 Nov 18;28(1):112
Abstract
Background: Mechanical ventilation in helicopter emergency medical service (HEMS) environments is a procedure which carries a significant risk of complications. Limited data on the quality and performance of mechanical ventilation in HEMS are available in the literature.
Method: We conducted an international survey to evaluate mechanical ventilation infrastructure in HEMS and collect data of transported ventilated patients. From June 20-22, 2019, the participating HEMS bases were asked to provide data via a web-based platform. Vital parameters and ventilation settings of the patients at first patient contact and at handover were compared using non-parametric statistical tests.
Results: Out of 215 invited HEMS bases, 53 responded. Respondents were from Germany, Denmark, United Kingdom, Luxembourg, Austria and Switzerland. Of the HEMS bases, all teams were physician staffed, mainly anesthesiologists (79%), the majority were board certified (92.5%) and trained in intensive care medicine (89%) and had a median (range) experience in HEMS of 9 (0-25) years. HEMS may provide a high level of expertise in mechanical ventilation whereas the majority of ventilators are able to provide pressure controlled ventilation and continuous positive airway pressure modes (77%). Data of 30 ventilated patients with a median (range) age of 54 (21-100) years and 53% male gender were analyzed. Of these, 24 were primary missions and 6 interfacility transports. At handover, oxygen saturation (p < 0.01) and positive end-expiratory pressure (p = 0.04) of the patients were significantly higher compared to first patient contact.
Conclusion: In this survey, the management of ventilated HEMS-patients was not associated with ventilation related serious adverse events. Patient conditions, training of medical crew and different technical and environmental resources are likely to influence management. Further studies are necessary to assess safety and process quality of mechanical ventilation in HEMS.
Maleea Denise Holbert, Roy M Kimble, Mark Chatfield, Bronwyn R Griffin
BMJ Open. 2021 Jan 5;11(1):e039981
Abstract
Objective: To compare the effectiveness of two acute burn dressings, Burnaid hydrogel dressing and plasticised polyvinylchloride film, on reducing acute pain scores in paediatric burn patients following appropriate first aid.
Design: Single-centre, superiority, two-arm, parallel-group, prospective randomised controlled trial.
Participants and setting: Paediatric patients (aged ≤16) presenting to the Emergency Department at the Queensland Children's Hospital, Brisbane, Australia, with an acute thermal burn were approached for participation in the trial from September 2017-September 2018.
Interventions: Patients were randomised to receive either (1) Burnaid hydrogel dressing (intervention) or (2) plasticised polyvinylchloride film (Control) as an acute burn dressing.
Primary and secondary outcomes: Observational pain scores from nursing staff assessed 5 min post application of the randomised dressing, measured using the Face Legs Activity Cry and Consolability Scale was the primary outcome. Repeated measures of pain, stress and re-epithelialisation were also collected at follow-up dressing changes until 95% wound re-epithelialisation occurred.
Results: Seventy-two children were recruited and randomised (n=37 intervention; n=35 control). No significant between-group differences in nursing (mean difference: -0.1, 95% CI -0.7 to 0.5, p=0.72) or caregiver (MD: 1, 95% CI -8 to 11, p=0.78) observational pain scores were identified. Moreover, no significant differences in child self-report pain (MD: 0.3, 95% CI -1.7 to 2.2, p=0.78), heart rate (MD: -3, 95% CI -11 to 5, p=0.41), temperature (MD: 0.6, 95% CI -0.13 to 0.24, p=0.53), stress (geometric mean ratio: 1.53, 95% CI 0.93 to 2.53, p=0.10), or re-epithelialisation rates (MD: -1, 95% CI -3 to 1, p=0.26) were identified between the two groups.
Conclusions: A clear benefit of Burnaid hydrogel dressing as an analgesic adjunct to first aid for the treatment of acute paediatric burns was not identified in this investigation.
Is massive hemothorax still an absolute indication for operation in blunt trauma?
Jen-Fu Huang, Chih-Po Hsu, Chih-Yuan Fu, Chun-Hsiang Ou Yang, Chi-Tung Cheng, Chien-Hung Liao, I-Ming Kuo, Chi-Hsun Hsieh
Injury. 2021 Feb;52(2):225-230
Abstract
Background: Surgery is usually suggested to treat massive haemothorax (MHT). The MHT criteria are based on penetrating trauma observations in military scenarios; the need for surgery in blunt trauma patients remains questionable. This study aimed to determine the characteristics of blunt trauma patients with MHT who required surgery.
Methods: Patients who presented to the emergency department (ED) with traumatic haemothorax or pneumothorax, heart and lung injuries, and thoracic blood vessel injuries from Jan 1, 2014, to Dec 31, 2018, were reviewed. The inclusion criterion was a chest tube drainage amount that met the MHT criteria. Therapeutic operations were defined as those involving surgical haemostasis; otherwise, operations were considered non-therapeutic. The non-therapeutic operation group included the patients who received nonoperative management. The characteristics of the therapeutic and non-therapeutic operation groups were compared.
Results: Forty-four patients were enroled in the study. Six patients received conservative treatment and were discharged uneventfully. Eleven patients underwent non-therapeutic operations. The patients with surgical bleeding had a high pulse rate (125.0 (111.0, 135.0) vs. 116.0 (84.0, 121.0) bpm, p = 0.013); low systolic blood pressure (SBP) after resuscitation (106.0 (84.0, 127.0) vs. 121.0 (116.0, 134.0) mmHg, p = 0.040); low pH (7.2 (7.2, 7.3) vs. 7.4 (7.3, 7.4), p = 0.002); and low bicarbonate (17.8 (14.6, 21.5) vs. 21.4 (17.0, 21.5) mEq/L, p = 0.038), low base excess (-9.1 (-13.4, -4.5) vs. -3.8 (-10.1, -0.7), p = 0.028), and high lactate (5.7 (3.3, 7.8) vs. 1.8 (1.7, 2.8) mmol/L, p = 0.002) levels.
Conclusion: Conservative treatment could be performed selectively in patients with MHT. Lactate could be a predictor of the need for surgical intervention in blunt trauma patients with MHT.
Cristos Ifantides, Karen L Christopher, Galia A Deitz, Jesse M Smith, Jennifer L Patnaik, Jeffrey R SooHoo, Prem S Subramanian
JAMA Ophthalmol. 2021 Feb 1;139(2):242-244
Abstract
This study investigates the experience of academic ophthalmology residency programs to assess less-lethal weapon eye trauma after the George Floyd protests in Denver, Colorado.
Farrukh N Jafri, Nicholas B Dadario, Anshul Kumar, Samantha R Silverstein, Frank Quintero, Erik A Larsen, Kimberly Fasciglione, Doreen Mirante, Kelly Ellsworth, Bernadette Amicucci, Joseph Ricca
Simul Healthc. 2021 Feb 16 Online ahead of print.
Abstract
Introduction: The Stop the Bleed (STB) program trains the general public on identifying and treating life-threatening bleeding. Data on efficacy and retention of skills taught through this program are limited, with the role of high-technology modalities to augment the program, such as simulation and feedback devices, untested.
Methods: A convenience sample of 66 school personnel participated in an open-label observational study from January to August 2019. The control group received the standard bleeding control course, while the intervention group received the bleeding control course with addition of a simulation and a feedback device for wound packing. Assessment was performed by STB instructors using performance metrics from prior studies as well as a feedback device. Retention testing was performed 2 to 8 months after intervention. The study was approved by the hospital's institutional review board.
Results: The intervention group performed better than the control group on correct tourniquet application [90.3% vs. 71.0%; odds ratio (OR) = 11.28; P = 0.015; 95% confidence interval (CI) = 1.86 to 104.67] wound packing scores (59.5% vs. 29.6%; OR = 0.33; P = 0.007; 95% CI = 9.36 to 56.00) and were more likely to assess their safety (OR = 5.49; P = 0.034; 95% CI = 1.28 to 27.66), and reported higher comfort scores on stepping into an emergency scenario (OR = 11.19; P = 0.004; 95% CI = 2.51 to 63.11), wound packing (OR = 5.16; P = 0.025; 95% CI = 1.35 to 22.46), and using a tourniquet (OR = 11.41; P = 0.003; 95% CI = 2.57 to 67.59). Thirty-one participants (46.9%) were assessed again at retention 2 to 8 months later where scores for tourniquet placement and wound packing were not significantly different in the two groups.
Conclusions: Augmenting STB with simulation and feedback improved both self-reported comfort level and skill set of participants, but the retention of skills was poor in both groups.
Michael T Kemp, Glenn K Wakam, Aaron M Williams, Ben E Biesterveld, Rachel L O'Connell, Claire A Vercruysse, Kiril Chtraklin, Rachel M Russo, Hasan B Alam
J Trauma Acute Care Surg. 2021 Mar 1;90(3):426-433
Abstract
Background: Hemorrhage is a leading cause of mortality in trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) can control hemorrhage, but distal ischemia, subsequent reperfusion injury, and the need for frequent balloon titration remain problems. Improved device design can allow for partial REBOA (pREBOA) that may provide hemorrhage control while also perfusing distally without need for significant provider titration.
Methods: Female Yorkshire swine (N = 10) were subjected to 40% hemorrhagic shock for 1 hour (mean arterial pressure [MAP], 28-32 mm Hg). Animals were then randomized to either complete aortic occlusion (ER-REBOA) or partial occlusion (novel pREBOA-PRO) without frequent provider titration or distal MAP targets. Detection of a trace distal waveform determined partial occlusion in the pREBOA-PRO arm. After 2 hours of zone 1 occlusion, the hemorrhaged whole blood was returned. After 50% autotransfusion, the balloon was deflated over a 10-minute period. Following transfusion, the animals were survived for 2 hours while receiving resuscitation based on objective targets: lactated Ringer's fluid boluses (goal central venous pressure, ≥ 6 mm Hg), a norepinephrine infusion (goal MAP, 55-60 mm Hg), and acid-base correction (goal pH, >7.2). Hemodynamic variables, arterial lactate, lactate dehydrogenase, aspartate aminotransferase, and creatinine levels were measured.
Results: All animals survived throughout the experiment, with similar increase in proximal MAPs in both groups. Animals that underwent partial occlusion had slightly higher distal MAPs. At the end of the experiment, the partial occlusion group had lower end levels of serum lactate (p = 0.006), lactate dehydrogenase (p = 0.0004) and aspartate aminotransferase (p = 0.004). Animals that underwent partial occlusion required less norepinephrine (p = 0.002), less bicarbonate administration (p = 0.006), and less fluid resuscitation (p = 0.042).
Conclusion: Improved design for pREBOA can decrease the degree of distal ischemia and reperfusion injury compared with complete aortic occlusion, while providing a similar increase in proximal MAPs. This can allow pREBOA zone-1 deployment for longer periods without the need for significant balloon titration.
Ryan J Keneally, Brittney A Meyers, Cynthia H Shields, Robert Ricca, Kevin M Creamer
Mil Med. 2021 Jan 28;usab020 Online ahead of print
Abstract
Introduction: The authors compared pediatric thoracic patients in the Joint Theatre Trauma Registry (JTTR) to those in the National Trauma Data Bank (NTDB) to assess differences in patient mortality rates and mortality risk accounting for age, injury patterns, and injury severity.
Materials and methods: Patients less than 19 years of age with thoracic trauma were identified in both the JTTR and NTDB. Multiple logistic regression, χ2, Student's t-test, or Mann-Whitney U test were used as indicated to compare the two groups.
Results: Pediatric thoracic trauma patients seen in Iraq and Afghanistan (n = 955) had a significantly higher mortality rate (15.1 vs. 6.0%, P <.01) than those in the NTDB (n = 9085). After controlling for covariates between the JTTR and the NTDB, there was no difference in mortality (odds ratio for mortality for U.S. patients was 0.74, 95% CI 0.52-1.06, P = .10). The patients seen in Iraq or Afghanistan were significantly younger (8 years old, interquartile ratio (IQR) 2-13 vs. 15, IQR 10-17, P <.01) had greater severity of injuries (injury severity score 17, IQR 12-26 vs. 12, IQR 8-22, P <.01), had significantly more head injuries (29 vs. 14%, P <.01), and over half were exposed to a blast.
Discussion: Pediatric patients with thoracic trauma in Iraq and Afghanistan in the JTTR had similar mortality rates compared to the civilian population in the NTDB after accounting for confounding covariates. These findings indicate that deployed military medical professionals are providing comparable quality of care in extremely challenging circumstances. This information has important implications for military preparedness, medical training, and casualty care.
Damage control strategy in bleeding trauma patients
Maru Kim, Hangjoo Cho
Acute Crit Care. 2020 Nov;35(4):237-241
Abstract
Hemorrhagic shock is a main cause of death in severe trauma patients. Bleeding trauma patients have coagulopathy on admission, which may even be aggravated by incorrectly directed resuscitation. The damage control strategy is a very urgent and essential aspect of management considering the acute coagulopathy of trauma and the physiological status of bleeding trauma patients. This strategy has gained popularity over the past several years. Patients in extremis cannot withstand prolonged definitive surgical repair. Therefore, an abbreviated operation, referred to as damage control surgery (DCS), is needed. In addition to DCS, the likelihood of survival should be maximized for patients in extremis by providing appropriate critical care, including permissive hypotension, hemostatic resuscitation, minimization of crystalloid use, early use of tranexamic acid, and avoidance of hypothermia and hypocalcemia. This review presents an overview of the evolving strategy of damage control in bleeding trauma patients.
Nicholas R Koreerat, Russell Giese
Mil Med. 2021 Jan 25;186(Suppl 1):579-583
Abstract
Introduction: Military units lack the ability to quickly, objectively, and accurately assess individuals that have suffered a closed head injury for structural brain injury and functional brain impairments in forward settings, where neurological assessment equipment and expertise may be lacking. With acute traumatic brain injury patients, detached medical providers are often faced with a decision to wait and observe or medically evacuate, both of which have cascading consequences. Structural brain injury assessment devices, when employed in forward environments, have the potential to reduce the risk of undiagnosed and/or mismanaged traumatic brain injuries given their high negative predictive value and suggested increased specificity compared to common subjective clinical decision rules. These handheld devices are portable and have an ease of use, from combat medic to physician, allowing for use in austere environments, safely keeping soldiers with their teams when able and suggesting further evaluation via computed tomography (CT) scan when warranted.
Methods: Data collected on 13 encounters at 5 locations were retrospectively analyzed using descriptive statistics.
Results: A total number of 13 examinations were performed using the BrainScope One device during the 9-month deployment. The Structural Injury Classification was negative for 11 of the patients. Two of the 11 patients underwent head CT scans, which confirmed the absence of intracranial hemorrhage. Of the two positive Structural Injury Classification exams, one was CT negative and no CT was performed for the other based on clinical judgment.
Conclusion: The data from this study suggest that structural brain injury devices may provide value by ruling out serious brain injury pathology while limiting excessive medical evacuations from austere settings, where neurological assessment equipment and expertise may be lacking, reducing unnecessary head CT scans.
Analgesic efficacy of sufentanil in dressings after surgical treatment of burn wounds
Grzegorz Kowalski, Marcin Zawadzki, Wojciech Leppert, Paweł Szpot, Marta Siczek, Krzysztof Słowiński, Małgorzata Sobieszczańska, Agata Gawłowska, Katarzyna Wieczorowska-Tobis
Burns. 2021 Jun;47(4):880-887
Abstract
Background: The aim of this study was to assess the analgesic efficacy of sufentanil in dressings after surgical treatment of burn wounds.
Patients and methods: Twenty adult patients, who underwent surgical treatment of third-degree burn wounds under general anesthesia, were included. Two of the patients underwent surgery twice. During surgery, patients received 50-100 μg fentanyl every 20-30 min and, after surgery, patients received 100 mg ketoprofen twice daily. Additionally, ten patients (group 1) received 50 μg sufentanil added to the burn wound dressings soaked in octenidine and phenoxyethanol while 10 patients (group 2) received 25 μg sufentanil added to the same dressings. The rescue analgesic, which was administered when pain intensified, was 5 mg subcutaneous morphine. Plasma sufentanil concentrations were assayed at 1, 2, 3, and 6 h after surgery completion and when pain was reported, along with pain intensity evaluation.
Results: Sufentanil was not detected in the serum of any patients. Rescue morphine was given during the postoperative period (24 h) in one patient in group 1 (who underwent surgery twice) and three patients in group 2. The mean sufentanil concentration in dressings was higher in group 1 (0.13 ± 0.03) than group 2 (0.06 ± 0.03 μg/mL; p < 0.001). The group 1 patient who received rescue morphine had a sufentanil concentration of 0.10 μg/mL, which was the lowest concentration in group 1. Group 2 patients who received rescue morphine had sufentanil concentrations of at least two-fold lower (0.03-0.05 μg/mL). No adverse effects were observed.
Conclusions: Sufentanil in dressings after burn wound surgery provides effective and safe analgesia and the sufentanil concentration in dressings should be ≥0.10 μg/mL in a solution of octenidine and phenoxyethanol.
Comeback of ketamine: resurfacing facts and dispelling myths
Abhijit Kumar, Amit Kohli
Korean J Anesthesiol. 2021 Apr;74(2):103-114
Abstract
Initially known as CI-581, ketamine was first synthesized in 1962 as a replacement from phencyclidine. It has since been used as an anesthetic and analgesic. In addition, it has bronchodilating, sedative, and amnestic properties, preserving airway reflexes and sympathetic nervous system tone. Since the discovery of ketamine, it has been a major topic of discussion due to controversies regarding its usage in particular sets of patients. In the past 50 years, despite its potential benefits, it is not commonly used because of concerns of "emergence phenomenon," its use as a substance of abuse, and its systemic side effects. Since 2012, three World Health Organization reviews on ketamine have addressed its international control. Researchers have been studying this wonder drug for a decade worldwide. Many myths of ketamine regarding emergence phenomenon and its use in traumatic brain injury and open eye injury have been disproved in recent times. It is becoming popular in pre-hospital settings, critical care, emergency medicine, low-dose acute pain services, and adjuvant in regional anesthesia techniques. This review highlights the current consensus on the various applications of ketamine in the literature.
Anna Kurek-Górecka, Katarzyna Komosinska-Vassev, Anna Rzepecka-Stojko, Paweł Olczyk
Molecules. 2020 Dec 31;26(1):148
Abstract
Bee venom (BV), also known as api-toxin, is widely used in the treatment of different inflammatory diseases such as rheumatoid arthritis or multiple sclerosis. It is also known that BV can improve the wound healing process. BV plays a crucial role in the modulation of the different phases of wound repair. It possesses anti-inflammatory, antioxidant, antifungal, antiviral, antimicrobial and analgesic properties, all of which have a positive impact on the wound healing process. The mentioned process consists of four phases, i.e., hemostasis, inflammation, proliferation and remodeling. The impaired wound healing process constitutes a significant problem especially in diabetic patients, due to hypoxia state. It had been found that BV accelerated the wound healing in diabetic patients as well as in laboratory animals by impairing the caspase-3, caspase-8 and caspase-9 activity. Moreover, the activity of BV in wound healing is associated with regulating the expression of transforming growth factor (TGF-β1), vascular endothelial growth factor and increased collagen type I. BV stimulates the proliferation and migration of human epidermal keratinocytes and fibroblasts. In combination with polyvinyl alcohol and chitosan, BV significantly accelerates the wound healing process, increasing the hydroxyproline and glutathione and lowering the IL-6 level in wound tissues. The effect of BV on the wounds has been proved by numerous studies, which revealed that BV in the wound healing process brings about a curative effect and could be applied as a new potential treatment for wound repair. However, therapy with bee venom may induce allergic reactions, so it is necessary to assess the existence of the patient's hypersensitivity to apitoxin before treatment.
Efficacy of Hemostatic Gauzes in a Swine Model of Prolonged Field Care with Limb Movement
Grace D Landers, Cassandra Townsend, Micah Gaspary, Ryan Kachur, Brian Thorne, Sean Stuart, Jose Henao, Gregory J Zarow, Ramesh Natarajan, Michael Boboc
Mil Med. 2021 Jan 25;186(Suppl 1):384-390
Abstract
Introduction: Prolonged field care for junctional wounds is challenging and involves limb movement to facilitate transport. No studies to date have explored the efficacy of gauze products to limit rebleeding in these scenarios.
Materials and methods: We randomly assigned 48 swine to QuikClot Combat Gauze, ChitoGauze, NuStat Tactical, or Kerlix treatment groups (12 each) and then inflicted a severe groin injury by utilizing a modified Kheirabadi model of a 6-mm femoral artery punch followed by unrestricted bleeding for 60 seconds. We reassessed rebleed following limb movement at 30 minutes of stabilization and 4 hours after stabilization.
Results: Swine treated with Combat Gauze proved to have the lowest incidence of rebleeding, and conversely, NuStat Tactical had the highest incidence of rebleeding at wounds after limb movement. Importantly, rebleeds occurred at a rate of 25%-58% across all swine treatment groups at 30 minutes postinjury and 0%-42% at 270 minutes postinjury demonstrating that limb movements universally challenge hemostatic junctional wounds.
Conclusions: Our findings highlight the difficulty of controlling hemorrhage from junctional wounds with hemostatic gauze in the context of prolonged field care and casualty transport. Our research can guide selection of hemorrhage control gauze when patients have prolonged field extraction or difficult transport. Our data demonstrates the frequency of junctional wound rebleeding after movement and thus the importance of frequent patient reassessment.
The Downrange Acoustic Toolbox: An Active Solution for Combat-Related Acute Acoustic Trauma
Jonathan Daw Ern Lee, Douglas M Bowley, J A Miles, J Muzaffar, R Poole, Linda E Orr
J Spec Oper Med. Winter 2020;20(4):104-111
Abstract
Frontline military personnel are at high risk of acute acoustic trauma (AAT) caused by impulse noise, such as weapon firing or blast. This can result in anatomic disruption of the tympanic membrane and damage to the middle and inner ear, leading to conductive, sensorineural, or mixed hearing loss that may be temporary or permanent. AAT reduces warfighters' operational effectiveness and has implications for future quality of life. Hearing protection devices can mitigate AAT but are not completely protective. Novel therapeutic options now exist; therefore, identification of AAT as soon as possible from point of injury is vital to ensure optimal treatment and fulfillment of the duty of care. Early recognition and treatment of frontline AAT can maintain the deployed team's capabilities, avoid unnecessary case evacuation (CASEVAC), and raise awareness of military occupational AAT. This will help prioritize hearing preservation, maintain the fighting force, and ultimately retain personnel in service. The UK Defence hearWELL research collaboration has developed a frontline protocol for the assessment of AAT utilizing future-facing technology developed by the US Department of Defense: the Downrange Acoustic Toolbox (DAT). The DAT has been operationally deployed since 2019 and has successfully identified AAT requiring treatment, thereby improving casualties' hearing and reducing unnecessary repatriation.
Removal of the Prehospital Tourniquet in the Emergency Department
Matthew J Levy, Jason Pasley, Kyle N Remick, Alexander L Eastman, Asa M Margolis Nelson Tang, Craig A Goolsby
J Emerg Med. 2021 Jan;60(1):98-102
Abstract
Background: Life-threatening hemorrhage from extremity injuries can be effectively controlled in the prehospital environment through direct pressure, wound packing, and the use of tourniquets. Early tourniquet application has been prioritized for rapid control of severe extremity hemorrhage and is a cornerstone of prehospital trauma resuscitation guidelines. Emergency physicians must be knowledgeable regarding the initial assessment and appropriate management of patients who present with a prehospital tourniquet in place.
Discussion: An interdisciplinary group of experts including emergency physicians, trauma surgeons, and tactical and Emergency Medical Services physicians collaborated to develop a stepwise approach to the assessment and removal (discontinuation) of an extremity tourniquet in the emergency department after being placed in the prehospital setting. We have developed a best-practices guideline to serve as a resource to aid the emergency physician in how to safely remove a tourniquet. The guideline contains five steps that include: 1) Determine how long the tourniquet has been in place; 2) Evaluate for contraindications to tourniquet removal; 3) Prepare for tourniquet removal; 4) Release the tourniquet; and 5) Monitor and reassess the patient.
Conclusion: These steps outlined will help emergency medicine clinicians appropriately evaluate and manage patients presenting with tourniquets in place. Tourniquet removal should be performed in a systematic manner with plans in place to immediately address complications.
Mark K Lukewich, Milad Modabber, Albert Hu, Steve A Arshinoff
Can J Ophthalmol. 2021 Jan 27; Online ahead of print.
Abstract
Objective: To determine how supplemental perioperative topical or oral moxifloxacin administration impacts anterior chamber (AC) antibiotic concentrations beyond those achieved by intracameral (IC) administration alone for postoperative endophthalmitis (POE) prophylaxis.
Design: Mathematical modeling.
Methods: The mathematical model developed by Arshinoff, Modabber, and Felfeli was adapted to calculate all reported data. A literature review of pharmacokinetic data for topical and oral moxifloxacin was used to inform the expansion of the model.
Results: Our previously constructed IC model yields a dose of moxifloxacin in the AC sufficient to confer bactericidal coverage against the most common POE pathogen, methicillin-sensitive Staphylococcus aureus (MSSA), for ∼40 hours postoperatively. Topical 0.5% moxifloxacin eye drops alone, administered every 4 or 6 hours, achieve an AC concentration just above or at the mutant prevention concentration (MPC) for MSSA, respectively, whereas 8-hour dosing produces levels generally below the MPC. Combining topical moxifloxacin with IC increases the AC concentration above IC alone only after 20 or more hours and maintains the AC concentration at, or just below, the MPC for MSSA for as long as the drops are continued. Combined perioperative oral moxifloxacin with IC increases AC levels over IC alone only after 16 hours and maintains the AC concentration above the MPC for MSSA for an additional 5 hours, owing to the systemic reservoir.
Conclusions: The addition of topical or oral moxifloxacin supplemental to IC can extend the duration of bactericidal coverage for the most common, but not the most resistant POE-causing pathogens.
Prehospital lactate levels in blood as a seizure biomarker: A multi-center observational study
Carl Magnusson, Johan Herlitz, Robert Höglind, Pär Wennberg, Anna Edelvik Tranberg, Christer Axelsson, Johan Zelano
Epilepsia. 2021 Feb;62(2):408-415
Abstract
Objective: The objective of this study was to assess the value of prehospital measurement of lactate level in blood for diagnosis of seizures in cases of transient loss of consciousness.
Methods: Between March 2018 and September 2019, prehospital lactate was measured with a point-of-care device by the emergency medical services in an area serving a population of 900 000. A total of 383 cases of transient loss of consciousness were identified and categorized as tonic-clonic seizure (TCS), other seizure, syncope, or other cause, according to the final diagnosis in the electronic medical records system. Receiver operating characteristic curve analyses were used to identify the optimal lactate cut-off.
Results: A total of 383 cases were included (135 TCS, 42 other seizure, 163 syncope, and 43 other causes). The median lactate level in TCS was 7.0 mmol/L, compared to a median of 2.0 mmol/L in all other cases (P < .001). The area under the curve (AUC) of TCS vs nonepileptic causes was 0.87 (95% confidence interval [CI] 0.83-0.91). The optimal cut-off (Youden index, 67.8%) was 4.75 mmol/L, with 79% sensitivity (95% CI 71-85) and 89% specificity (95% CI 85-93) for TCS.
Significance: Prehospital lactate can be a valuable tool for identifying seizures in transient loss of consciousness. For acceptable specificity, a higher cut-off than that previously demonstrated for hospital-based measurements must be used when values obtained close to the time of the event are interpreted.
Higher Crystalloid Volume During Initial Pediatric Trauma Resuscitation is Associated With Mortality
Nina Mbadiwe, Nathan Georgette, Mark B Slidell, Alisa McQueen
J Surg Res. 2021 Jun;262:93-100
Abstract
Background: Historically, aggressive fluid resuscitation has been a cornerstone of management of hemorrhagic shock in pediatrics. Adult data suggest this strategy may be harmful. We sought to determine whether aggressive fluid resuscitation within the first hour of presentation to the emergency department in pediatric patients with trauma is associated with worse clinical outcomes.
Materials and methods: We performed a retrospective cohort study from 2012 to 2017 at a single pediatric level 1 trauma center. We defined three patient cohorts: ≤ 20 cc/kg (reference), 20-40 (20.01 to 39.99) cc/kg, and ≥40 cc/kg of intravenous fluid (IVF) given in the first in-hospital hour. Covariates included age, injury severity score, shock index (adjusted for age), and mechanism of injury and were adjusted for with multivariable regression. The primary outcome was in-hospital mortality.
Results: A total of 1479 consecutive injured children were eligible for inclusion. One hundred ninety-four patients were excluded for missing IVF data, aged ≥16 y, having primary burns, or arriving pulseless. A total of 1285 patients met inclusion criteria (mean age 8.1 ± 5.5 y, male 64.5%). Higher rates of IVF administration were associated with mortality for both the 20-40 cc/kg (adjusted odds ratio (aOR) 2.96; 95% confidence interval (CI) 1.02-8.55; P = 0.045) and ≥40 cc/kg groups (aOR 6.26; 95% CI 1.79-21.83; P = 0.004). The ≥40 cc/kg group was associated with increased pediatric intensive care unit length of stay (aOR 2.20; 95% CI: 1.05-4.61; P = 0.036) and increased need for mechanical ventilation (aOR 3.79; 95% CI 1.62-8.87; P = 0.002).
Conclusions: Greater than one 20 cc/kg IVF bolus in the first emergency department hour was associated with mortality with a dose-response relationship, even after adjusting for injury severity and initial hemodynamics. These results encourage further investigation into initial resuscitation strategies for injured children.
Utilizing Drones to Restore and Maintain Radio Communication During Search and Rescue Operations
Jake N McRae, Brandon M Nielsen, Christopher J Gay, Andrew P Hunt, Andrew D Nigh
Wilderness Environ Med. 2021 Mar;32(1):41-46
Abstract
Introduction: The ability of rescuers to maintain contact with incident command (IC) and each other is a critical component of search and rescue (SAR) operations. When rescuers lose radio communication with operation leaders, the effectiveness of operations may be substantially affected. This often occurs owing to the limitations of standard communications equipment in difficult terrain or when victims are beyond line-of-sight. This study investigates the viability of using an aerial drone-repeater system configuration to restore and maintain radio communications between IC and deployed rescuers.
Methods: SAR operators in Southern Utah identified 10 areas where radio communication is compromised during live rescue operations. Trained SAR personnel were deployed to these areas in a mock exercise. After confirmed loss of communication, a repeater-equipped aerial drone was piloted 122 m above IC to restore communication. Once restored, communication was assessed at regular intervals for the duration of the mock deployment.
Results: In all 10 areas tested, communication was successfully restored. In all cases, once communication was restored, no additional loss of radio contact occurred. The time between communication loss and restoration across the 10 scenarios was 6.5±1.1 (4.4-9.3) min (mean±SD with range).
Conclusions: This method of restoring radio communication among SAR personnel could drastically improve the ability to assist victims and help mitigate the risks faced by rescuers. SAR leaders should be made aware of the useful applications of drones during SAR operations, especially in instances where communication is compromised.
Utilizing Drones to Restore and Maintain Radio Communication During Search and Rescue Operations
Jake N McRae, Brandon M Nielsen, Christopher J Gay, Andrew P Hunt, Andrew D Nigh
Wilderness Environ Med. 2021 Mar;32(1):41-46
Abstract
Introduction: The ability of rescuers to maintain contact with incident command (IC) and each other is a critical component of search and rescue (SAR) operations. When rescuers lose radio communication with operation leaders, the effectiveness of operations may be substantially affected. This often occurs owing to the limitations of standard communications equipment in difficult terrain or when victims are beyond line-of-sight. This study investigates the viability of using an aerial drone-repeater system configuration to restore and maintain radio communications between IC and deployed rescuers.
Methods: SAR operators in Southern Utah identified 10 areas where radio communication is compromised during live rescue operations. Trained SAR personnel were deployed to these areas in a mock exercise. After confirmed loss of communication, a repeater-equipped aerial drone was piloted 122 m above IC to restore communication. Once restored, communication was assessed at regular intervals for the duration of the mock deployment.
Results: In all 10 areas tested, communication was successfully restored. In all cases, once communication was restored, no additional loss of radio contact occurred. The time between communication loss and restoration across the 10 scenarios was 6.5±1.1 (4.4-9.3) min (mean±SD with range).
Conclusions: This method of restoring radio communication among SAR personnel could drastically improve the ability to assist victims and help mitigate the risks faced by rescuers. SAR leaders should be made aware of the useful applications of drones during SAR operations, especially in instances where communication is compromised.
Fatemeh Mojallal, Mehrnaz Nikooieh, Majid Hajimaghsoudi, Mehdi Baqherabadi, Mohammadali Jafari, Alireza Esmaeili, Naser Mohammad Karimi, Ehsan Zarepur
Med J Islam Repub Iran. 2020 Aug 27;34:107
Abstract
Background: Head trauma is one of the common reasons for patient attendance in the emergency ward. This study investigated the effect of tranexamic acid as a cheap, easily available antifibrinolytic drug on reducing the progress of cerebral hemorrhage compared to placebo.
Methods: This double-blind controlled clinical trial was performed on 120 traumatized patients presenting to the emergency room of Shahid Rahnemoon hospital during 2014-2015, Yazd, Iran. Those patients who met the inclusion criteria were randomly allocated into 2 groups. Group A received tranexamic acid, while group B received placebo parenterally. Finally, 56 patients in Group A and 44 in Group B were analyzed. The patients underwent brain CT scan and were followed up for ICU stay in days. Also, the number of patients who died during the first 7 days of hospitalization was recorded. The data were analyzed with SPSS20 using independent samples t test and chi-square test.
Results: The mean age of the patients was 41±20.27 years. Also, 20 patients (20%) were female and 80 were male (80%). There was no significant difference between the drug group and placebo group in the rate of hemorrhage volume progress (p=0.824). Regarding patients' ICU stay, the ICU stay of the tranexamic acid group decreased significantly compared to the placebo group (p=0.001). No significant difference was found between the intervention group and placebo group in the mortality rate of patients during the first 7 days of hospitalization (p=0.236).
Conclusion: Tranexamic acid has no effect on reducing cerebral hemorrhage volume in patients. Although this drug was not effective in reducing mortality rate in patients, it decreased their ICU stay.
Freeze-dried plasma for major trauma - Systematic review and meta-analysis
Garrick Mok, Richard Hoang, Montaha Wajid Khan, Dylan Pannell, Henry Peng, Homer Tien, Avery Nathens, Jeannie Callum, Keyvan Karkouti, Andrew Beckett, Luis Teodoro da Luz
J Trauma Acute Care Surg. 2021 Mar 1;90(3):589-602
Abstract
Background: Treatment of acute trauma coagulopathy has shifted toward rapid replacement of coagulation factors with frozen plasma (FP). There are logistic difficulties in providing FP. Freeze-dried plasma (FDP) may have logistical advantages including easier storage and rapid preparation time. This review assesses the feasibility, efficacy, and safety of FDP in trauma.
Study design and methods: Studies were searched from Medline, Embase, Cochrane Controlled Trials Register, ClinicalTrials.gov, and Google Scholar. Observational and randomized controlled trials (RCTs) assessing FDP use in trauma were included. Trauma animal models addressing FDP use were also included. Bias was assessed using validated tools. Primary outcome was efficacy, and secondary outcomes were feasibility and safety. Meta-analyses were conducted using random-effect models. Evidence was graded using Grading of Recommendations Assessment, Development, and Evaluation profile.
Results: Twelve human studies (RCT, 1; observational, 11) and 15 animal studies were included. Overall, studies demonstrated moderate risk of bias. Data from two studies (n = 119) were combined for meta-analyses for mortality and transfusion of allogeneic blood products (ABPs). For both outcomes, no difference was identified. For mortality, pooled odds ratio was 0.66 (95% confidence interval, 0.29-1.49), with I2 = 0%. Use of FDP is feasible, and no adverse events were reported. Animal data suggest similar results for coagulation and anti-inflammatory profiles for FP and FDP.
Conclusion: Human data assessing FDP use in trauma report no difference in mortality and transfusion of ABPs in patients receiving FDP compared with FP. Data from animal trauma studies report no difference in coagulation factor and anti-inflammatory profiles between FP and FDP. Results should be interpreted with caution because most studies were observational and have heterogeneous population (military and civilian trauma) and a moderate risk of bias. Well-designed prospective observational studies or, preferentially, RCTs are warranted to answer FDP's effect on laboratory (coagulation factor levels), transfusion (number of ABPs), and clinical outcomes (organ dysfunction, length of stay, and mortality).
Giulia Mormando, Matteo Paganini, Chiara Alexopoulos, Sandro Savino, Nicola Bortoli, Daniele Pomiato, Alessandro Graziano, Paolo Navalesi, Fabrizio Fabris
Simul Healthc. 2021 Jan 8; Online ahead of print.
Abstract
Introduction: Chemical-biological-radiological-nuclear-explosive (CBRNe) are complex events. Decontamination is mandatory to avoid harm and contain hazardous materials, but can delay care. Therefore, the stabilization of patients in the warm zone seems reasonable, but research is limited. Moreover, subjects involved in biological events are considered infectious even after decontamination and need to be managed while wearing personal protective equipment (PPE), as seen with Ebola and COVID-19 pandemic. With this simulation mannequin trial, we assessed the impact of CBRNe PPE on cardiopulmonary resuscitation and combat casualty care procedures.
Methods: We compared procedures performed by emergency medicine and anesthesiology senior residents, randomized in 2 groups (CBRNe PPE vs. no PPE). Chest compression (CC) depth was defined as the primary outcome. Time to completion was calculated for the following: tourniquet application; tension pneumothorax needle decompression; peripheral venous access (PVA) and intraosseous access positioning; and drug preparation and administration. A questionnaire was delivered to evaluate participants' perception.
Results: Thirty-six residents participated. No significant difference between the groups in CC depth (mean difference = 0.26 cm [95% confidence interval = -0.26 to 0.77 cm, P = 0.318]), as well as for CC rate, CC complete release, and time for drugs preparation and administration was detected. The PPE contributed to significantly higher times for tourniquet application, tension pneumothorax decompression, peripheral venous access, and intraosseous access positioning. The residents found simulation relevant to the residencies' core curriculum.
Conclusions: This study suggests that cardiopulmonary resuscitation can be performed while wearing PPE without impacting quality, whereas other tasks requiring higher dexterity can be significantly impaired by PPE.Trial Registration Number: NCT04367454, April 29, 2020 (retrospectively registered).
Sabine Nabecker, Tobias Alexander Hornshaw, Robert Greif, Carl Conrad, Mara Rohrer, Lorenz Theiler, Thomas Riva
Eur J Anaesthesiol. 2021 Mar 1;38(3):302-308
Abstract
Background: International guidelines recommend cricothyroidotomy as a life-saving procedure for 'cannot intubate, cannot ventilate' situations. Although commercially available sets facilitate surgical cricothyroidotomy, regular training seems to be the key to success.
Objectives: The goal was to investigate if trained anaesthetists are able to transfer their skill in one surgical cricothyroidotomy technique to another. The primary hypothesis postulated that trained anaesthetists could perform an emergency cricothyroidotomy equally fast and successfully with a pocketknife compared with a surgical cricothyroidotomy set.
Design: Crossover noninferiority randomised controlled trial.
Setting: After written informed consent and ethics committee approval, this single-centre study was performed at the University Hospital of Bern, Bern, Switzerland.
Participants: Altogether, 61 study participants already familiar with surgical cricothyroidotomy were included.
Intervention: The use of a commercially available cricothyroidotomy set was compared with a short-bladed pocketknife and ballpoint pen barrel. A pig-larynx cadaver model including trachea, with pig skin overlaid, was used. Participants underwent additional training sessions in both procedures.
Main outcome measures: The primary outcome was the time necessary to position the tracheal tube or pen barrel in the trachea. Other outcome parameters were success rate, tracheal and laryngeal injuries and preferred device.
Results: Cricothyroidotomy with the pocketknife was performed significantly faster and equally successfully as compared with the cricothyroidotomy sets. Tracheal and laryngeal injuries were similar in both groups. Paratracheal or submucosal placement of the pen barrel occurred in 32%, compared with 29% for the tracheal tube. Sixty-six per cent of participants preferred the cricothyroidotomy set.
Conclusion: Regularly trained anaesthetists are able to accomplish cricothyroidotomy irrespective of the equipment used. A pocketknife with a ballpoint pen barrel was just as effective as a commercially available surgical set.
Decision Support for Tactical Combat Casualty Care Using Machine Learning to Detect Shock
Christopher Nemeth, Adam Amos-Binks, Christie Burris, Natalie Keeney, Yuliya Pinevich, Brian W Pickering, Gregory Rule, Dawn Laufersweiler, Vitaly Herasevich, Mei G Sun
Mil Med. 2021 Jan 25;186(Suppl 1):273-280
Abstract
Introduction: The emergence of more complex Prolonged Field Care in austere settings and the need to assist inexperienced providers' ability to treat patients create an urgent need for effective tools to support care. We report on a project to develop a phone-/tablet-based decision support system for prehospital tactical combat casualty care that collects physiologic and other clinical data and uses machine learning to detect and differentiate shock manifestation.
Materials and methods: Software interface development methods included literature review, rapid prototyping, and subject matter expert design requirements reviews. Machine learning algorithm methods included development of a model trained on publicly available Medical Information Mart for Intensive Care data, then on de-identified data from Mayo Clinic Intensive Care Unit.
Results: The project team interviewed 17 Army, Air Force, and Navy medical subject matter experts during design requirements review sessions. They had an average of 17 years of service in military medicine and an average of 4 deployments apiece and all had performed tactical combat casualty care on live patients during deployment. Comments provided requirements for shock identification and management in prehospital settings, including support for indication of shock probability and shock differentiation. The machine learning algorithm based on logistic regression performed best among other algorithms we tested and was able to predict shock onset 90 minutes before it occurred with better than 75% accuracy in the test dataset.
Conclusions: We expect the Trauma Triage, Treatment, and Training Decision Support system will augment a medic's ability to make informed decisions based on salient patient data and to diagnose multiple types of shock through remotely trained, field deployed ML models.
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
Abstract
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.
Sarah N Pierrie, Rachel B Seymour, Meghan K Wally, Jon Studnek, Allison Infinger, Joseph R Hsu, Evidence-based Musculoskeletal Injury and Trauma Collaborative (EMIT).
Am J Emerg Med. 2021 Apr;42:43-48
Abstract
Background: Pelvic fractures represent a small percent of all skeletal injuries but are associated with significant morbidity and mortality secondary to hemodynamic instability from bleeding bone surfaces and disrupted pelvic vasculature. Stabilization of the pelvis prior to arrival at a treatment facility may mitigate the hemodynamic consequences of pelvic ring injuries and improve morbidity and mortality. Whether pelvic compression devices such as pelvic binders or sheets can be safely applied in the prehospital setting has not been well-studied. This study aims to evaluate the safety of applying a pelvic binder to at-risk patients in the field after scalable training and the feasibility of conducting a randomized trial evaluating this practice in the prehospital setting.
Methods: A pilot study (prospective randomized trial design) was conducted in the pre-hospital environment in an urban area surrounding a level-one trauma center. Pre-hospital emergency medical (EMS) personnel were trained to identify patients at high-risk for pelvic fracture and properly apply a commercial pelvic binder. Adult patients with a high-energy mechanism, suspected pelvic fracture, and "Priority 1" criteria were prospectively identified by paramedics and randomized to pelvic binder placement or usual care. Medical records were reviewed for safety outcomes. Secondary outcomes were parameters of efficacy including interventions needed to control hemorrhage (such as angioembolization and surgical control of bleeding) and mortality.
Results: Forty-three patients were randomized to treatment (binder: N=20; nonbinder: N=23). No complications of binder placement were identified. Eight patients (40%) had binders placed correctly at the level of the greater trochanter. Two binders (10%) were placed too proximally and 10 (50%) binders were not visualized on x-ray. Two binder group patients and three nonbinder group patients required angioembolization. None required surgical control of pelvic bleeding. Two nonbinder group patients and one binder group patient were readmitted within 30 days and one nonbinder group patient died within 30 days.
Conclusion: Identification of pelvic fractures in the field remains a challenge. However, a scalable training model for appropriate binder placement was successful without secondary injury to patients. The model for conducting prospective, randomized trials in the prehospital setting was successful.
The basics of trauma needs-based training in asymmetric warfare
Mohammad Raeeszadeh, Abolfazl Khoshi, Ataallah Rezaieh Azadi
J Family Med Prim Care. 2020 Oct 30;9(10):5193-5199
Abstract
Introduction: Trauma is the leading cause of mortality and one of the main causes of disability among the active populations in the battlefields. Therefore, trauma education is an important need for asymmetric warfare, which is met through training based on existing needs and possibilities.
Methods: In this qualitative study, validated using Delphi technique in Tehran in 2019, the participants were selected from the experts and activities in the field of trauma in asymmetric warfare. Inclusion criteria included willingness to participate in the research, history of treatment activity, and trauma training in asymmetric warfare. This study is based on the two axes: (1) Investigating existing upstream documents and resources on trauma in asymmetric warfare. (2) Conducting structured interviews (based on training elements and trauma experiences in asymmetric warfare) with trauma experts and professors in asymmetric warfare.
Results: The results obtained from the above resources, are defined and classified as 10 element training model (Akker). These results and related tables have also been reviewed and validated by trauma experts.
Conclusion: The achievements of the present research explained the dimensions and indicators of trauma needs based training in asymmetric warfare that is an effective approach to increase the effectiveness of trauma learning and training in asymmetric warfare and increase the cost effectiveness. It is also an effective approach to organize trauma preparedness for all troops present in asymmetric warfare and can be presented as an operational protocol in terms of methodology and roadmap.
Sepsis Management in Prolonged Field Care: 28 October 2020
Justin Rapp, Sean Keenan, Daniel Taylor, Andrea Rapp, Michael Turconi, Ryan Maves, Michael Kavanaugh, Devan Makati, Douglas Powell, Paul E Loos, Simon Sarkisian, Ankit Sakhuja, Dan S Mosely, Stacy A Shackelford
J Spec Oper Med. Winter 2020;20(4):27-39
Abstract
This Role 1 prolonged field care (PFC) guideline is intended for use in the austere environment when evacuation to higher level of care is not immediately possible. A provider must first be an expert in Tactical Combat Casualty Care (TCCC). The intent of this guideline is to provide a functional, evidence-based and experience-based solution to those individuals who must manage patients suspected of having or diagnosed with sepsis in an austere environment. Emphasis is placed on the basics of diagnosis and treatment using the tools most familiar to a Role 1 provider. Ideal hospital techniques are adapted to meet the limitations of austere environments while still maintaining the highest standards of care possible. Sepsis and septic shock are medical emergencies. Patients suspected of having either of these conditions should be immediately evacuated out of the austere environment to higher echelons of care. These patients are often complex, requiring 24-hour monitoring, critical care skills, and a great deal of resources to treat. Obtaining evacuation is the highest treatment priority for these patients. This Clinical Practice Guideline (CPG) uses the minimum, better, best paradigm familiar to PFC and gives medics of varying capabilities and resources options for treatment.
Shreyasi Ray, Jyotirmay Kirtania
Anesth Essays Res. Apr-Jun 2020;14(2):305-311
Abstract
Background: Passive movements of head and neck are sometimes unavoidable during surgery under general anesthesia due to patient positioning according to the needs of the surgery or transmitted movements from surgical manipulations.
Aims: This prospective crossover randomized study evaluates the effects of passive movements of the head and neck on the performance of i-gel® supraglottic airway device in spontaneously breathing patients under general anesthesia.
Materials and methods: Sixty spontaneously breathing patients on pressure support ventilation with positive end-expiratory pressure (PEEP) under general anesthesia were randomized to seven sequences of passive head-and-neck movements with i-gel® in situ. After steady state of general anesthesia was achieved and maintenance with sevoflurane in N2O and O2 was reached, the passive head-and-neck movements were done. Peak airway pressure, exhaled minute volume, end-tidal carbon dioxide (ETCO2), oxygen saturation, audible leak of airway gases, and visible outward displacement of the i-gel® were recorded in the neutral position and with each passive head-and-neck movement. Paired continuous data were analyzed by Friedman rank sum test with paired Wilcoxon signed-rank test. Paired nominal data were analyzed by Cochran's Q test with pair-wise McNemar test.
Results: Extension, right or left lateral flexion, and right or left rotation of the head and neck resulted in significant reduction in the exhaled minute ventilation, rise in ETCO2, and leak of airway gases compared to the neutral position (P < 0.05). Flexion movement did not cause significant changes in the exhaled minute ventilation, rise in ETCO2, and audible leak of airway gases as compared to the neutral position.
Conclusions: Ventilatory performance of the i-gel® deteriorates upon extension, right or left lateral flexion, and right or left rotation of the head and neck in spontaneously breathing patients under general anesthesia on pressure support ventilation with PEEP.
Sustaining Clinical Readiness for Combat Casualty Care
Kyle N Remick, Pamela B Andreatta, Mark W Bowyer
Mil Med. 2021 May 3;186(5-6):152-154
No abstract available
Is Tranexamic Acid Associated With Mortality or Multiple Organ Failure Following Severe Injury?
Justin E Richards, Benjamin T Fedeles, Jonathan H Chow, Jonathan J Morrison, Corinne Renner, Anthony T Trinh, Caroline S Schlee, Ken Koerner, Thomas E Grissom, Richard D Betzold, Thomas M Scalea, Rosemary A Kozar
Shock. 2021 Jan 1;55(1):55-60
Abstract
Background: Tranexamic acid (TXA) administration is recommended in severely injured trauma patients. We examined TXA administration, admission fibrinolysis phenotypes, and clinical outcomes following traumatic injury and hypothesized that TXA was associated with increased multiple organ failure (MOF).
Methods: Two-year, single-center, retrospective investigation. Inclusion criteria were age ≥ 18 years, Injury Severity Score (ISS) >16, admitted from scene of injury, thromboelastography within 30 min of arrival. Fibrinolysis was evaluated by lysis at 30 min (LY30) and fibrinolysis phenotypes were defined as: Shutdown: LY30 ≤ 0.8%, Physiologic: LY30 0.81-2.9%, Hyperfibrinolysis: LY30 ≥ 3.0%. Primary outcomes were 28-day mortality and MOF. The association of TXA with mortality and MOF was assessed among the entire study population and in each of the fibrinolysis phenotypes.
Results: Four hundred twenty patients: 144/420 Shutdown (34.2%), 96/420 Physiologic (22.9%), and 180/410 Hyperfibrinolysis (42.9%). There was no difference in 28-day mortality by TXA administration among the entire study population (P = 0.52). However, there was a significant increase in MOF in patients who received TXA (11/46, 23.9% vs 16/374, 4.3%; P < 0.001). TXA was associated MOF (OR: 3.2, 95% CI 1.2-8.9), after adjusting for confounding variables. There was no difference in MOF in patients who received TXA in the Physiologic (1/5, 20.0% vs 7/91, 7.7%; P = 0.33) group. There was a significant increase in MOF among patients who received TXA in the Shutdown (3/11, 27.3% vs 5/133, 3.8%; P = 0.001) and Hyperfibrinolysis (7/30, 23.3% vs 5/150, 3.3%; P = 0.001) groups.
Conclusions: Administration of TXA following traumatic injury was associated with MOF in the fibrinolysis shutdown and hyperfibrinolysis phenotypes and warrants continued evaluation.
Intranasal Ketamine for Acute Pain
Robert J Rocchio, Kristina E Ward
Clin J Pain. 2021 Apr 1;37(4):295-300
Abstract
Objectives: The aim was to review current evidence regarding the off-label use of intranasal ketamine for acute pain presenting in the setting of the emergency department, and secondary to pediatric limb injuries, renal colic, digital nerve block, and migraines.
Results: In all 5 indications reviewed, ketamine demonstrated efficacy in reducing pain. However, when compared with other agents, ketamine did not demonstrate superiority over opioids in pediatric limb injuries or renal colic and was not as efficacious as standard therapy for migraine relief. Ketamine was also associated with a greater incidence of transient adverse reactions, such as dizziness, bitter aftertaste, fatigue, and vomiting than opioid therapies.
Discussion: The current body of evidence is insufficient to support the use of intranasal ketamine over other standard therapies for acute pain. However, current evidence can be used when developing dosing strategies, preparing for adverse reactions, and generating hypotheses for future, more robust research.
Heating Intravenous Fluid Tubing in an Experimental Setting for Prehospital Hypothermia
Adriana Rodriguez, Isabel Algaze, Roy Almog, Robert J Katzer
Air Med J. Jan-Feb 2021;40(1):41-44
Abstract
Objective: Hypothermia secondary to environmental exposure is a serious condition. Active external warming measures to treat it may prove challenging in the prehospital setting. We conducted an experimental study to measure the ability of commercially available heating elements to warm intravenous (IV) fluids during infusion.
Methods: 250-milliliter bags of dextrose 10% solution were suspended inside a refrigerator. IV tubing was coiled, and the tubing output was placed inside a thermally insulated cup. The tubing was heated directly with a hand warmer, a meals ready-to-eat heater, or a heating blanket. Fluids were run through the IV line. The temperature of the fluid at the tubing output was measured. The initial and final infusion temperatures for the methods were compared.
Results: The use of hand warmers, meals ready-to-eat heaters, and heating blankets to warm IV tubing did increase the temperature of the fluids but was ineffective at achieving the desired mean infusion temperature of 35°C to 42°C.
Conclusion: Although the mean temperature increase did not meet the established experimental threshold, further research is needed to determine whether the fluid warming effect of these commercial heating elements used in the prehospital environment is significant enough to limit heat loss while repleting the dextrose of a hypothermic, hypoglycemic patient.
Does Blast Exposure to the Torso Cause a Blood Surge to the Brain?
Jose E Rubio, Maciej Skotak, Eren Alay, Aravind Sundaramurthy, Dhananjay Radhakrishnan Subramaniam, Vivek Bhaskar Kote, Stewart Yeoh, Kenneth Monson, Namas Chandra, Ginu Unnikrishnan, Jaques Reifman
Front Bioeng Biotechnol. 2020 Dec 17;8:573647. doi: 10.3389/fbioe.2020.573647
Abstract
The interaction of explosion-induced blast waves with the torso is suspected to contribute to brain injury. In this indirect mechanism, the wave-torso interaction is assumed to generate a blood surge, which ultimately reaches and damages the brain. However, this hypothesis has not been comprehensively and systematically investigated, and the potential role, if any, of the indirect mechanism in causing brain injury remains unclear. In this interdisciplinary study, we performed experiments and developed mathematical models to address this knowledge gap. First, we conducted blast-wave exposures of Sprague-Dawley rats in a shock tube at incident overpressures of 70 and 130 kPa, where we measured carotid-artery and brain pressures while limiting exposure to the torso. Then, we developed three-dimensional (3-D) fluid-structure interaction (FSI) models of the neck and cerebral vasculature and, using the measured carotid-artery pressures, performed simulations to predict mass flow rates and wall shear stresses in the cerebral vasculature. Finally, we developed a 3-D finite element (FE) model of the brain and used the FSI-computed vasculature pressures to drive the FE model to quantify the blast-exposure effects in the brain tissue. The measurements from the torso-only exposure experiments revealed marginal increases in the peak carotid-artery overpressures (from 13.1 to 28.9 kPa). Yet, relative to the blast-free, normotensive condition, the FSI simulations for the blast exposures predicted increases in the peak mass flow rate of up to 255% at the base of the brain and increases in the wall shear stress of up to 289% on the cerebral vasculature. In contrast, our simulations suggest that the effect of the indirect mechanism on the brain-tissue-strain response is negligible (<1%). In summary, our analyses show that the indirect mechanism causes a sudden and abundant stream of blood to rapidly propagate from the torso through the neck to the cerebral vasculature. This blood surge causes a considerable increase in the wall shear stresses in the brain vasculature network, which may lead to functional and structural effects on the cerebral veins and arteries, ultimately leading to vascular pathology. In contrast, our findings do not support the notion of strain-induced brain-tissue damage due to the indirect mechanism.
Christopher Rugg, Simon Woyke, Wolfgang Voelckel, Peter Paal, Mathias Ströhle
Scand J Trauma Resusc Emerg Med. 2021 Feb 1;29(1):28
Abstract
Background: Sufficient analgesia is an obligation, but oligoanalgesia (NRS> 3) is frequently observed prehospitally. Potent analgesics may cause severe adverse events. Thus, analgesia in the helicopter emergency medical service (HEMS) setting is challenging. Adequacy, efficacy and administration safety of potent analgesics pertaining to injured patients in HEMS were analysed.
Methods: Observational study evaluating data from 14 year-round physician-staffed helicopter bases in Austria in a 12-year timeframe.
Results: Overall, 47,985 (34.3%) patients received analgesics, 26,059 of whom were adult patients, injured and not mechanically ventilated on site. Main drugs administered were opioids (n=20,051; 76.9%), esketamine (n=9082; 34.9%), metamizole (n=798; 3.1%) and NSAIDs (n=483; 1.9%). Monotherapy with opioids or esketamine was the most common regimen (n=21,743; 83.4%), while opioids together with esketamine (n= 3591; 13.8%) or metamizole (n=369; 1.4%) were the most common combinations. Females received opioids less frequently than did males (n=6038; 74.5% vs. n=14,013; 78.1%; p< 0.001). Pain relief was often sufficient (> 95%), but females more often had moderate to severe pain on arrival in hospital (n=34; 5.0% vs. n=59; 3.2%; p=0.043). Administration of potent analgesics was safe, as indicated by MEES, SpO2 and respiratory rates. On 10% of all missions, clinical patient assessment was deemed sufficient by HEMS physicians and monitoring was spared.
Conclusions: Opioids and esketamine alone or in combination were the analgesics of choice in physician-staffed HEMS in Austria. Analgesia was often sufficient, but females more than males suffered from oligoanalgesia on hospital arrival. Administration safety was high, justifying liberal use of potent analgesics in physician-staffed HEMS.
Effect of Intravenous Tranexamic Acid on Intracerebral Brain Hemorrhage in Traumatic Brain Injury
Hosein Safari, Parnian Farrahi, Saleh Rasras, Hosein Jafari Marandi, Masoud Zeinali
Turk Neurosurg. 2021;31(2):223-227
Abstract
Aim: To determine the effect of Intravenous Tranexamic Acid (TXA) on traumatic intracerebral hemorrhage.
Material and methods: A total of 94 cases of TBI with intracerebral hemorrhage, admitted to the emergency department who did not need surgical intervention based on a primary brain spiral computed tomography (CT) scan, were randomly assigned into two groups of 47 patients. In the intervention group, intravenous TXA was administered as one gram of bolus and one gram every 6 hours for 48 hours, and in the control group, the placebo was administered in the same way. After 6, 24, and 48 hours all the cases underwent a brain CT scan. Scans were examined for the size and diameter of hematoma and the midline shift. The information regarding the level of consciousness, hematoma volume, and diameter on CT scan were recorded on arrival and 48 hours later.
Results: Statistical results depict that while there was no considerable difference in the demographic aspect of the two groups, the volume and diameter of hematoma and the midline shift in the first CT scans and also their level of consciousness, the diameter and volume of hematoma and also the amount of hematoma expansion in follow up are significantly different in the two groups.
Conclusion: The present study showed that the prescription of TXA would reduce the amount of hematoma expansion in traumatic intracerebral hemorrhage, and that medication can be introduced to reduce morbidity and complications.
Babak Sarani, E Reed Smith, Geoff Shapiro, Jeffry Nahmias, Lisbi Rivas, Robert McIntyre Jr, Bryce R H Robinson, Paul J Chestovich, Richard Amdur, Eric Campion, Shane Urban, Ilya Shnaydman, Bellal Joseph, Jonathan Gates, John Berne, Jordan M Estroff
J Trauma Acute Care Surg. 2021 Apr 1;90(4):652-658
Abstract
Background: Firearm injury remains a public health crisis. Whereas there have been studies evaluating causes of death in victims of civilian public mass shootings (CPMSs), there are no large studies evaluating injuries sustained and treatments rendered in survivors. The purpose of this study was to describe these characteristics to inform ideal preparation for these events.
Methods: A multicenter, retrospective study of CPMS survivors who were treated at designated trauma centers from July 1, 1999 to December 31, 2017, was performed. Prehospital and hospital variables were collected. Data are reported as median (25th percentile, 75th percentile interquartile range), and statistical analyses were carried out using Mann-Whitney U, χ2, and Kruskal-Wallis tests. Patients who died before discharge from the hospital were excluded.
Results: Thirty-one events involving 191 patients were studied. The median number of patients seen per event was 20 (5, 106), distance to each hospital was 6 (6, 10) miles, time to arrival was 56 (37, 90) minutes, number of wounds per patient was 1 (1, 2), and Injury Severity Score was 5 (1, 17). The most common injuries were extremity fracture (37%) and lung parenchyma (14%). Twenty-nine percent of patients did not receive paramedic-level prehospital treatment. Following arrival to the hospital, 27% were discharged from the emergency department, 32% were taken directly to the operating room/interventional radiology, 16% were admitted to the intensive care unit, and 25% were admitted to the ward. Forty percent did not require advanced treatment within 12 hours. The most common operations performed within 12 hours of arrival were orthopedic (15%) and laparotomy (15%). The most common specialties consulted were orthopedics (38%) and mental health (17%).
Conclusion: Few CPMS survivors are critically injured. There is significant delay between shooting and transport. Revised triage criteria and a focus on rapid transport of the few severely injured patients are needed.
Level of evidence: Therapeutic/care management, level IV.
Dominique Savary, Arnaud Lesimple, François Beloncle, François Morin, François Templier, Alexandre Broc, Laurent Brochard, Jean-Christophe Richard, Alain Mercat
Ann Intensive Care. 2020 Dec 9;10(1):166
Abstract
Background: Intensive Care Units (ICU) have sometimes been overwhelmed by the surge of COVID-19 patients. Extending ICU capacity can be limited by the lack of air and oxygen pressure sources available. Transport ventilators requiring only one O2 source may be used in such places.
Objective: To evaluate the performances of four transport ventilators and an ICU ventilator in simulated severe respiratory conditions.
Materials and methods: Two pneumatic transport ventilators, (Oxylog 3000, Draeger; Osiris 3, Air Liquide Medical Systems), two turbine transport ventilators (Elisee 350, ResMed; Monnal T60, Air Liquide Medical Systems) and an ICU ventilator (Engström Carestation-GE Healthcare) were evaluated on a Michigan test lung. We tested each ventilator with different set volumes (Vtset = 350, 450, 550 ml) and compliances (20 or 50 ml/cmH2O) and a resistance of 15 cmH2O/l/s based on values described in COVID-19 Acute Respiratory Distress Syndrome. Volume error (percentage of Vtset) with P0.1 of 4 cmH2O and trigger delay during assist-control ventilation simulating spontaneous breathing activity with P0.1 of 4 cmH2O and 8 cmH2O were measured.
Results: Grouping all conditions, the volume error was 2.9 ± 2.2% for Engström Carestation; 3.6 ± 3.9% for Osiris 3; 2.5 ± 2.1% for Oxylog 3000; 5.4 ± 2.7% for Monnal T60 and 8.8 ± 4.8% for Elisee 350. Grouping all conditions (P0.1 of 4 cmH2O and 8 cmH2O), trigger delay was 50 ± 11 ms, 71 ± 8 ms, 132 ± 22 ms, 60 ± 12 and 67 ± 6 ms for Engström Carestation, Osiris 3, Oxylog 3000, Monnal T60 and Elisee 350, respectively.
Conclusions: In surge situations such as COVID-19 pandemic, transport ventilators may be used to accurately control delivered volumes in locations, where only oxygen pressure supply is available. Performances regarding triggering function are acceptable for three out of the four transport ventilators tested.
Operationalizing the Deployment of Low-Titer O-Positive Whole Blood Within a Regional Trauma System
Randall Schaefer, Tasia Long, David Wampler, Rena Summers, Eric Epley, Elizabeth Waltman, Brian Eastridge, Donald Jenkins
Mil Med. 2021 Jan 25;186(Suppl 1):391-399
Abstract
Introduction: The implementation of a low-titer O+ whole blood (LTOWB) resuscitation algorithm, particularly in the prehospital environment, has several inherent challenges, including cost, limited and inconsistent supply, and the logistics of cold-chain management. The Southwest Texas Regional Advisory Council has implemented the nation's first multidisciplinary, multi-institutional regional LTOWB program. This research effort was to illustrate the successful deployment of LTOWB within a regional trauma system.
Materials and methods: A deliberate systems approach to the deployment of LTOWB was used. Tenets of this program included the active management of blood donor sources and blood supply levels to minimize wastage as a result of expiration, maximize product utilization, the use of prehospital transfusion triggers, and efforts to decrease program costs prehospital agencies. A novel LTOWB rotation system was established using the concept of a "rotation site" and "rotation center." Standardized transfusion criteria, a regional approved equipment list, a regional Prehospital Blood Product Transfusion Record, and a robust multilevel communication plan serves as the framework for the program. The San Antonio Whole Blood Consortium was developed to create a consensus driven forum to manage and guide the program.
Results: From January 2018 to October 2019, LTOWB has been placed at 18 helicopter emergency medical services (HEMS) bases, 12 ground emergency medical service (EMS) agencies, 1 level I trauma center, and 1 level IV trauma center. A total of 450 patients have received a prehospital LTOWB transfusion. Program wide, the wastage rate of LTOWB due to expiration is between 1% and 2%. No complications related to prehospital LTOWB administration have been identified.
Discussion: This work demonstrates a novel model for the development of a trauma system LTOWB program. The program's implementation augments remote damage control resuscitation strategies and requires the integration and collaboration of a multidisciplinary stakeholder team to optimize efficiency, performance, and safety of the program.
Steven G Schauer, Michael D April, Romeo Fairley, Nguvan Uhaa, Ian L Hudson, Michelle D Johnson, Donald E Keen, Robert A De Lorenzo
J Spec Oper Med. Winter 2020;20(4):68-72.
Abstract
Background: Airway obstruction is the second leading cause of potentially preventable death on the battlefield. Prior to 2017, the Committee on Tactical Combat Casualty Care (CoTCCC) recommended the surgical cricothyrotomy as the definitive airway of choice. More recently, the CoTCCC has recommended the iGel™ as the supraglottic airway (SGA) of choice. Data comparing these methods in medics are limited. We compared first-pass placement success among combat medics using a synthetic cadaver model.
Methods: We conducted a randomized cross-over study of United States Army combat medics using a synthetic cadaver model. Participants performed a surgical cricothyrotomy using a method of their choosing versus placement of the SGA iGel in random order. The primary outcome was first-pass success. Secondary outcomes included time-to-placement, complications, placement failures, and self-reported participant preferences. Results: Of the 68 medics recruited, 63 had sufficient data for inclusion. Most were noncommissioned officers in rank (54%, E6-E7), with 51% reporting previous deployment experience. There was no significant difference in first-pass success (P = .847) or successful cannulation with regard to the two devices. Time-to-placement was faster with the iGel (21.8 seconds vs. 63.8 seconds). Of the 59 medics who finished the survey, we found that 35 (59%) preferred the iGel and 24 (41%) preferred the cricothyrotomy.
Conclusions: In our study of active duty Army combat medics, we found no significant difference with regard to first-pass success or overall successful placement between the iGel and cricothyrotomy. Time-to-placement was significantly lower with the iGel. Participants reported preferring the iGel versus the cricothyrotomy on survey. Further research is needed, as limitations in our study highlighted many shortcomings in airway research involving combat medics.
An Analysis of Prolonged, Continuous Ketamine Infusions
Steven G Schauer, Jason F Naylor, William T Davis, Matthew A Borgman, Michael D Apri
Mil Med. 2021 Jan 25; Online ahead of print.
Abstract
Introduction: Opioids carry high risk of dependence, and patients can rapidly build tolerance after repetitive dosing. Low-dose ketamine is an analgesic agent alternative that provides more hemodynamic stability. We sought to describe the effects of prolonged ketamine use in non-burn patients.
Materials and methods: We queried the electronic health system at the Brooke Army Medical Center for patient encounters with ketamine infusions lasting >72 hours. We abstracted data describing demographics, vital signs, ketamine infusion dose and duration, and discharge diagnoses potentially relevant to ketamine side effects.
Results: We identified 194 subjects who met the study inclusion criteria. The median age was 39 years, most were male (67.0%), and most were primarily admitted for a non-trauma reason (59.2%). The mean ketamine drip strength was 43.9 mg/h (95% CI, 36.7-51.1; range 0.1-341.6) and the mean drip length was 130.8 hours (95% CI, 120.3-141.2; range 71-493). Most subjects underwent mechanical ventilation (56.1%) at some point during the infusion and most survived to hospital discharge (83.5%). On a per-day basis, the average heart rate was 93 beats per minute, systolic blood pressure was 128 mmHg, diastolic blood pressure was 71 mmHg, oxygen saturation was 96%, and respiratory rate was 22 respirations per minute.
Conclusions: We demonstrate that continuous ketamine infusions provide a useful adjunct for analgesia and/or sedation. Further development of this adjunct modality may serve as an alternative agent to opioids.
Binder use obscures traumatic pelvic injury in a 29-year-old man
K T Matthew Seah, James W MacKay
CMAJ. 2021 Feb 8;193(6):E216
No abstract available
Ahmed Shabhay, Zarina Shabhay, Kondo Chilonga, David Msuya, Theresia Mwakyembe, Samwel Chugulu
Case Rep Surg. 2021 Jan 29;2021:6689000. doi: 10.1155/2021/6689000
Abstract
Primary abdominal wall closure post laparotomy is not always possible. Certain surgical pathologies such as degloving anterior abdominal wall trauma injuries and peritoneal visceral volume and cavity disproportion render it nearly impossible for the attending surgeon to close the abdomen in the first initial laparotomy. In such surgical clinical scenarios leaving the abdomen open might be lifesaving. Forceful closure might lead to abdominal compartment syndrome and impair respiratory status of the patient. Open abdomen closure techniques have evolved over time from protection of abdominal viscera to complex fascia retraction prevention techniques. Silo bags, i.e., (Bogotá Bags), are relatively cheap, available materials used as a temporary abdominal closure method in limited resources settings. Despite its limitations of not preventing fascia retraction and draining of peritoneal fluid, it protects the abdominal viscera. We report a case of a 29-year-old male who developed incisional anterior abdominal wall wound dehiscence. He was scheduled for emergency explorative laparotomy. Intraoperatively, multiple attempts to reduce grossly dilated edematous bowels into the peritoneal cavity and fascia approximation into the midline were not possible. A urinary collection bag was sutured on the skin edges as a temporary abdominal closure method in prevention of abdominal compartment syndrome. He fared well postoperatively and eventually underwent abdominal incisional wound closure. In emergency abdominal surgeries done in limited surgical material resource settings were primary abdominal closure is not possible at initial laparotomy, sterile urine collection bags as alternatives to the standard Bogota bags as temporary abdominal closure materials can be safely used. These are relatively easily available and can be safely used until definite surgical intervention is achieved with relatively fewer complications.
Matthew R Shaw, Kate E Hughes
Air Med J. Sep-Oct 2020;39(5):380-382
Abstract
Objective: Cricothyrotomy is rarely performed by prehospital providers. Developing this low-frequency, high-acuity skill and maintaining competence is difficult; thus, using a realistic training model is paramount to successful training. The aim of this study was to evaluate a 3-dimensional-printed bleeding cricothyrotomy trainer in increasing paramedic comfort level and procedural competence as defined by completing the procedure unassisted without error.
Methods: Model implementation took place during mandatory biannual difficult airway training courses for all paramedics employed by a hospital-based ambulance agency. Participating paramedics performed 3 surgical cricothyrotomies using the bleeding trainer and subsequently completed an anonymous written survey that evaluated the comfort level of providers in performing a surgical cricothyrotomy both before and after training using a 10-point visual analog scale.
Results: Forty-four paramedics participated in the difficult airway training course. All (44/44) completed the postsurvey. Participants noted that their procedural skill comfort level improved after the training took place (average improvement of 3 ± 1.93). Participants also indicated that the high-fidelity trainer played a significant role in their increased comfort after skills training.
Conclusion: The bleeding cricothyrotomy model evaluated provides a high-fidelity, cost-effective means of teaching and maintaining a rare, lifesaving skill that is rarely performed in the field.
Keita Shibahashi, Hidenori Hoda, Yoshihiro Okura, Yuichi Hamabe
World Neurosurg. 2021 May;149:e504-e511
Abstract
Background: Safe blood pressure levels in the prehospital setting for patients with traumatic brain injury (TBI) remain unclear. We aimed to investigate the association between prehospital blood pressure and the outcomes of patients with TBI to determine optimal threshold for hypotension that could be considered in the prehospital setting.
Methods: Using data from the Japan Trauma Data Bank, we identified adult patients (aged ≥18 years) who experienced severe TBI (maximum head Abbreviated Injury Severity score ≥3) and were transported directly from the scene of the blunt trauma occurrence to the hospital, between 2004 and 2019. We excluded patients with prehospital systolic blood pressure (SBP) levels of <60 and ≥160 mm Hg. Using mixed effects logistic regression models, we investigated the association between prehospital SBP and in-hospital mortality, considering the hospital ID as a random effect variable. In addition, we also conducted a stratified analysis based on age (<60 vs. ≥60 years).
Results: A total of 34,175 patients (16,114 aged <60 years and 18,061 aged ≥60 years) were eligible for the analyses. Plotting the adjusted odds ratios for in-hospital mortality as a function of SBP produced J-shaped curves. An SBP <110 mm Hg was significantly associated with in-hospital mortality, with an adjusted odds ratio of 1.52 (95% confidence interval: 1.39-1.65). Stratified analyses revealed that the threshold did not differ between the age groups.
Conclusions: An SBP <110 mm Hg in the prehospital setting is significantly associated with higher in-hospital mortality.
Burns in the Military Setting-Analyzing 12,799 Routine and Combat Cases
Dafna Yaacobi Shilo, Alex Lvovsky, Nitay Ad-El, Diana Levi, Eyal Yaacobi, Asaf Olshinka, Yuval Glick, Ariel Furer, Dean D Ad-El
J Burn Care Res. 2021 Feb 3;42(1):67-70
Abstract
Burns are a major trauma source in civilian and military settings, with a huge impact on patient's well-being, health system, and operation status of the force in the military setting. The purpose of our study was to summarize characteristics of all burn cases seen by the Israel Defense Forces primary care physicians during the years 2008 to 2016. This can help understand what causes most burns, in what units, at which stages and settings and consequently will allow commanders to make decisions regarding safety rules, protective equipment and uniforms, medical education for soldiers, etc. Data were collected from the military database system. All burn-related visits were analyzed using a designated big data computerized algorithm that used keywords and phrases to retrieve data from the database. 12,799 burn injuries were found presented in 65,536 burn-related visits which were analyzed according to the demographics, burn mechanism, and military unit. It was observed that most of the burns (70.7%) occurred during routine noncombat setting and there was a gradual decrease in burn injuries during the investigated period, from 17.6% of the cases in 2008 to 2.3% in 2016. Most of the burns occurred in the Air Force (19.4%), and the leading etiology was chemical (35%). The average TBSA was 7.5%. Since most of the burns occurred in a routine setting and were occupational-related, investment in education and improving fire protection has proven itself, leading to the decrease in burn prevalence, we recommend that more emphasis should be given on proper handling of chemicals.
Mostafa Somri, Luis Gaitini, Dario Galante, Mhfod Sanallah, Jalaa Hossein, Manuel Ángel Gómez-Ríos
Resuscitation. 2021 Feb;159:35-37
No abstract available
Medical Challenges in Underground Warfare
Alex Sorkin, Roy Nadler, Adir Sommer, Avishai M Tsur, Jacob Chen, Tarif Bader, Avi Benov
Mil Med. 2021 Jan 25;186(Suppl 1):839-844
Abstract
Introduction: Throughout history, underground systems have served military purposes in both offensive and defensive tactical settings. With the advance of underground mining, combat tactics, and weapon systems, providing medical support in the subterranean battlefield is a constantly growing challenge. This retrospective cohort study describes the Israeli Defense Force (IDF) Medical Corps experience with treating casualties from underground warfare, as recorded in the IDF Trauma Registry.
Methods: A retrospective cohort study of all casualties engaged in underground warfare, between the years 2004-2018. Medical data were extracted from the IDF Trauma Registry and tactical data were obtained from operational reports. An expert committee characterized the most prevalent challenges. Recommendations were based on a literature review and the lessons learned by the IDF experience.
Results: During the study period, 26 casualties were injured in the underground terrain. Of casualties, 12 (46%) due to blast injuries, 9 (35%) were due to smoke inhalation, and 5 (19%) due to crushing injuries. All were males, and the average age was 21.6 years. Ten (38%) were killed in action (died before reaching a medical facility). All 16 casualties reaching the hospital survived (Table I). The expert committee divided the most common challenges into three categories-tactical, environmental, and medical. An overview of medical response planning, common injuries, and designated combat casualty care are discussed below. As in all combat casualty care, the focus should be on safety, bleeding control, and rapid evacuation.
Conclusion: To plan and provide medical support, a thorough understanding of operational planning is essential. This manuscript presents the evolution of underground warfare, tactical and medical implications, environmental hazards, and common casualty care challenges.
Human performance research for military operations in extreme cold environments
Wendy Sullivan-Kwantes, Francois Haman, Boris R M Kingma, Svein Martini, Emilie Gautier-Wong, Kong Y Chen, Karl E Friedl
J Sci Med Sport. 2020 Dec 15; Online ahead of print
Abstract
Objectives: Soldier performance in the Arctic depends on planning and training, protective equipment, and human physiological limits. The purpose of this review was to highlight the span of current research on enhancing soldier effectiveness in extreme cold and austere environments.
Methods: The practices of seasoned soldiers who train in the Arctic and cold-dwelling natives inform performance strategies. We provide examples of research and technology that build on these concepts.
Results: Examples of current performance research include evaluation of equipment and tactics such as the bioenergetics of load carriage over snow in Norwegian exercises; Canadian field monitoring of hand temperatures and freezing cold injuries for better protection of manual dexterity; and Dutch predictive modeling of cold-wet work tolerances. Healthy young men can respond to cold with a substantial thermogenic response based on US and Canadian studies on brown adipose tissue and other mechanisms of non-shivering thermogenesis; the potential advantage of greater fat insulation is offset in obese unfit subjects by a smaller thermogenic response. Current physiological studies are addressing previously unanswered problems of cold acclimation procedures, thermogenic enhancement and regulation, and modulation of sympathetic activation, all of which may further enhance cold survival and expand the performance envelope.
Conclusion: There is an inseparable behavioral component to soldier performance in the Arctic, and even the best equipment does not benefit soldiers who have not trained in the actual environment. Training inexperienced soldiers to performance limits may be helped with personal monitoring technologies and predictive models.
Keywords: Arctic; cold; human performance; load carriage, metabolic regulation; military personnel; personal equipment – cold weather; thermogenesis.
Preliminary Data on Trauma Knowledge, Confidence, and Stress During Navy Trauma Training
Tony Torres, Jami A Stakley, Elizabeth Garcia, Sorana Raiciulescu, Travis M Polk, Nancy A Stotts, Virginia Schmied Blackman
Mil Med. 2021 Jan 25;186(Suppl 1):266-272
Abstract
Introduction: The Navy Trauma Training Center (NTTC) is a military-civilian partnership that provides advanced trauma training for application across the range of military operations while exposing military medical personnel to high-volume and high-acuity trauma. Few published data evaluate the outcomes of military-civilian partnerships, including NTTC. The purpose of this study is to evaluate the knowledge, confidence, and stress of NTTC participants before, at mid-point, and after completion of the program. Participants include corpsmen (HM), nurses (RNs), physician assistants (PAs), and physicians (MDs).
Materials and methods: These are preliminary data from an ongoing prospective, observational study with repeated measures. Included are participants that complete NTTC training. Pre-training measures include a demographic questionnaire, trauma knowledge test, Confidence survey, and the Perceived Stress Scale. These same instruments are completed at mid-training and at the conclusion of the NTTC curriculum. Data were analyzed using paired t-tests and linear mixed models.
Results: The sample was composed of 83 participants (49 HM, 18 RNs, 4 PAs, and 12 MDs. Knowledge and confidence increased from baseline to post-NTTC for each clinical role (P < .05). Stress for all roles was low and stable over time (P > .05).
Conclusions: These preliminary data suggest that, as expected, trauma-related knowledge and confidence increase significantly with training at NTTC. Stress was low and stable over time. These data from a small sample of participants indicate NTTC training is increasing participants' trauma knowledge and confidence to care for trauma casualties. Continued collection of data in the ongoing study will allow us to determine whether these early findings persist in the overall study sample and may help inform the optimal length of training needed.
R N Verma, Navdeep Sethi, M S Honwad, S K Singh
Med J Armed Forces India. 2021 Jan;77(1):86-91
Abstract
Background: Prehospital emergency airway management challenges every paramedic. Emergencies evacuated from difficult areas by armed forces need airway maintenance throughout evacuation. Effective use of supraglottic airway (SGA) devices during prehospital transfer is life saving. This study compared use of four commonly available SGAs by Armed Forces paramedics in simulated emergency situations.
Methods: This prospective observational study conducted in a tertiary care institution, included 58 volunteer paramedics. They were trained on manikins before the study in basic airway skills and insertion of the four SGA devices under study viz. Classic laryngeal mask airway (cLMA), laryngeal tube (LT), I-gel, and Combitube. SGA device insertions were performed on 474 patients scheduled for short elective surgical procedures under general anesthesia. All volunteers inserted and assessed the four SGA devices equal number of times in different patients. Overall success rate, time for successful insertion, first attempt success rate, number of attempts for successful insertion, oro-pharyngeal leak pressures, ease of insertion, durability of device, and complications were recorded.
Results: Differences among the four groups were statistically significant in all parameters. Intergroup comparison revealed that both I-gel and LT were comparable to each other, however superior to cLMA and Combitube in all outcome measures except ease of insertion and durability of device where I-gel was better and oro-pharyngeal seal pressures where Combitube was better.
Conclusion: Considering all parameters, I-gel proved superior with minimal complications compared with other SGA devices tested. I-gel may be recommended for emergency airway rescue use in patients by military paramedics.
Mark Walsh, Ernest E Moore, Hunter B Moore, Scott Thomas, Hau C Kwaan, Jacob Speybroeck, Mathew Marsee, Connor M Bunch, John Stillson, Anthony V Thomas, Annie Grisoli, John Aversa, Daniel Fulkerson, Stefani Vande Lune, Lucas Sjeklocha, Quincy K Tran
J Clin Med. 2021 Jan 17;10(2):320
Abstract
This narrative review explores the pathophysiology, geographic variation, and historical developments underlying the selection of fixed ratio versus whole blood resuscitation for hemorrhaging trauma patients. We also detail a physiologically driven and goal-directed alternative to fixed ratio and whole blood, whereby viscoelastic testing guides the administration of blood components and factor concentrates to the severely bleeding trauma patient. The major studies of each resuscitation method are highlighted, and upcoming comparative trials are detailed.
James W Warwick, Daniel L Davenport, Amber Bettis, Andrew C Bernard
J Am Coll Surg. 2021 Apr;232(4):572-579
Abstract
Background: This study analyzed data from the 2017 American College of Surgeons National Trauma Data Bank to examine the effects of pre-hospital Field Triage Decision Scheme Step 1 vital sign criteria (S1C) and vital sign decline on subsequent emergency department (ED) and hospital death in emergency medical services (EMS) transported trauma victims.
Study design: Patient and injury characteristics, transport time, and ED and hospital disposition were collected. S1C (respiratory rate [RR]<10, RR>29 breaths/min, systolic blood pressure [SBP]<90 mmHg, Glasgow Coma Scale [GCS]<14) were recorded at the injury scene and hospital arrival. Decline was defined as a change ≥ 1 standard deviation (SD) into or within an S1C range. S1C and decline were analyzed relative to ED and hospital death using logistic regression.
Results: Of 333,213 included patients, 54,849 (16.5%) met Step 1 criteria at the scene, and 21,566 (6.9%) declined en route. The ED death rate was 0.4% (n = 1,188), and the hospital death/hospice rate was 4.0% (11,624 of 287,675). Patients who met S1C at the scene or who declined were more likely to require longer hospital lengths of stay, ICU admission, and surgical intervention. S1C and decline patients had higher odds of death in both the ED (S1C odds ratio [OR] 15.1, decline OR 2.4, p values < 0.001) and hospital (S1C OR 4.8, decline OR 2.0, p values < 0.001) after adjusting for patient demographics, transport time and mode, injury severity, and injury mechanism. Each S1C and decline measure was independently predictive of death.
Conclusions: This study quantifies the mortality risks associated with individual S1C and validates their use as an indicator for injury severity and pre-hospital triage tool.
The diamond of death: Hypocalcemia in trauma and resuscitation
Jesse P Wray, Rachel E Bridwell, Steven G Schauer, Stacy A Shackelford, Vikhyat S Bebarta, Franklin L Wright, James Bynum, Brit Long
Am J Emerg Med . 2021 Mar;41:104-109
Abstract
Introduction: Early recognition and management of hemorrhage, damage control resuscitation, and blood product administration have optimized management of severe trauma. Recent data suggest hypocalcemia exacerbates the ensuing effects of coagulopathy in trauma.
Objective: This narrative review of available literature describes the physiology and role of calcium in trauma resuscitation. Authors did not perform a systematic review or meta-analysis.
Discussion: Calcium is a divalent cation found in various physiologic forms, specifically the bound, inactive state and the unbound, physiologically active state. While calcium plays several important physiologic roles in multiple organ systems, the negative hemodynamic effects of hypocalcemia are crucial to address in trauma patients. The negative ramifications of hypocalcemia are intrinsically linked to components of the lethal triad of acidosis, coagulopathy, and hypothermia. Hypocalcemia has direct and indirect effects on each portion of the lethal triad, supporting calcium's potential position as a fourth component in this proposed lethal diamond. Trauma patients often present hypocalcemic in the setting of severe hemorrhage secondary to trauma, which can be worsened by necessary transfusion and resuscitation. The critical consequences of hypocalcemia in the trauma patient have been repeatedly demonstrated with the associated morbidity and mortality. It remains poorly defined when to administer calcium, though current data suggest that earlier administration may be advantageous.
Conclusions: Calcium is a key component of trauma resuscitation and the coagulation cascade. Recent data portray the intricate physiologic reverberations of hypocalcemia in the traumatically injured patient; however, future research is needed to further guide the management of these patients.
Satoshi Yamaga, Ayaka Kawabata, Koji Hosokawa, Nobuaki Shime
J Infect Chemother. 2021 Mar;27(3):540-543
Abstract
We investigated the relationship between the presence of hypothermia in infection and mortality in 233 infectious critically ill patients. The adjusted hazard ratio for death at 28 days in the low body temperature group was 3.30 compared with the high body temperature group. The proportion of appropriate antimicrobial therapy significantly decreased with decreasing body temperature. The proportion of medical records that documented body temperature abnormality in the low body temperature group (33%) was significantly lower than that in the high body temperature group (69%). Delayed antimicrobial therapy in patients with hypothermia, which may be due to poor recognition by physicians, could result in mortality.
Hypothermia rewarming does not cause cell injury
Ken Zafren, Gordon G Giesbrecht, Beat H Walpoth, Daniel F Danzl, Hermann Brugger
Med Hypotheses. Epub 2020 Aug 9.
No abstract available
Hemothorax: A Review of the Literature
Jacob Zeiler, Steven Idell, Scott Norwood, Alan Cook
Clin Pulm Med. 2020 Jan;27(1):1-12
Abstract
Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.
Building confidence to perform cricothyroidotomy: A task trainer-based training programme
Jinbin Zhang, Shimin Ong, Han Toh
Eur J Anaesthesiol. 2021 Mar 1;38(3):322-324
No abstract available
Tony Zitek, Ramsey Ataya, Lian Farino, Salman Mohammed, Glenn Miller
Am J Emerg Med. 2021 Feb;40:32-36
Abstract
Objective: Advanced Trauma Life Support guidelines recommend only 1 L of intravenous (IV) crystalloid before transitioning to blood products. We sought to determine if receiving >1 L of IV crystalloid during the initial resuscitation is associated with worse outcomes. We also sought to determine if receiving no crystalloids is associated with better outcomes.
Methods: We performed a single center retrospective study using trauma registry data, which was supplemented by manual chart review. We only included patients who had an initial heart rate ≥ 100 beats/min or a systolic blood pressure ≤ 90 mmHg. For each patient, we determined the total amount of IV crystalloid administered in the first 3 h after arrival to the hospital plus prehospital crystalloid. We performed multivariate regression analyses to determine if there is an association between the administration of >1 L of crystalloids or no crystalloids with in-hospital mortality, hospital length of stay (LOS), or packed red blood cells (PRBCs) transfused.
Results: Between January 1, 2018 and September 30, 2019, there were 878 who met criteria for enrollment. Among those, 55.0% received ≤1 L of IV crystalloids, and 45.0% received >1 L. Multivariate analyses showed no significant association between receiving >1 L and mortality (p = 0.61) or PRBCs transfused (p = 0.29), but patients who received >1 L had longer hospital LOS (p = 0.04). We found no association between receiving no crystalloids and mortality, PRBCs transfused, or LOS.
Conclusion: On a multivariate analysis of trauma patients, we did not find an association between the administration of >1 L of IV crystalloid and in-hospital mortality or the volume of PRBCs transfused. However, receiving >1 L of crystalloids was associated with a longer hospital LOS. We found no benefit to completely withholding crystalloids.