Medic and Portable Pulse Oximeter Respiratory Rate Measurement Comparison to Waveform Capnography: A Prospective, Observational Study.

BACKGROUND: The second leading cause of preventable battlefield death involves airway management. Tactical combat casualty care (TCCC) guidelines emphasize combat casualty airway, breathing and respiratory evaluation, including respiratory rate (RR) measurement. The current standard of practice for the US Army medics is to measure the RR by manual counting. Manual counting methods are operator-dependent, and medics face situational stressors limiting accurate measurement of RR in combat settings. To date, no published studies evaluate alternate methods of RR measurement by medics. The purpose of this study is to compare RR assessment by medics against waveform capnography and commercial finger pulse oximeters with continuous plethysmography. MATERIALS AND METHODS: We conducted a prospective, observational study to compare Army medic RR assessments against plethysmography and waveform capnography RR. Assessments were performed prior to and following exertion at 30 and 60 seconds with both the pulse oximeter (NSN 6515-01-655-9412) and defibrillator monitor (NSN 6515-01-607-8629), followed by end-user surveys. RESULTS: Of the 40 medics enrolled over a 4-month period, most were male (85%), and reported between less than 5 years of military and medical experience. The mean manual RR reported by medics at rest did not significantly differ from waveform capnography (14.05 versus 13.98, p is equal to 0.523); however, mean manual RR reported by medics on post-exertional subjects was significantly lower than waveform capnography (25.62 versus 29.77, p is less than 0.001). Time to medic-obtained RR was slower than the pulse oximeter (NSN 6515-01-655-9412) both at rest (-7.37 seconds, p is less than 0.001) and at exertion (-6.50 seconds, p is less than 0.001). While the mean difference in RR between the pulse oximeter (NSN 6515-01-655-9412) and waveform capnography in models at rest at 30 seconds was statistically significant (-1.38, p is less than 0.001). There was no overall statistically significant differences in RR between the pulse oximeter (NSN 6515-01-655-9412) and waveform capnography in models at exertion at 30 seconds and at rest and exertion at 60 seconds. CONCLUSION: Resting RR measurement did not differ significantly; however, medic-obtained RR considerably deviated from both pulse oximeters and waveform capnography at elevated rates. Existing commercial pulse oximeters with RR plethysmography do not differ significantly from waveform capnography and should be investigated further for consideration in fielding across the force for RR assessment.

Glenohumeral joint effusion assessment with point-of-care ultrasound.

ABSTRACT: Ultrasound has favorable diagnostic accuracy for detecting glenohumeral joint effusions. This article describes an easy-to-learn and interpret limited glenohumeral joint ultrasound examination that can help guide further evaluation and treatment. We report on a patient ultimately diagnosed with septic arthritis of the glenohumeral joint, the associated joint effusion having been detected on bedside ultrasound. This ultrasound examination is applicable to generalist PAs and those working in orthopedics and acute care settings.

Hypertriglyceridemia-Induced Pancreatitis and a Lipemic Blood Sample: A Case Report and Brief Clinical Review.

Hypertriglyceridemia is the third most common cause of acute pancreatitis after gallstones and long-term alcohol use. There are specific therapeutic options unique to hyperglyceridemia-induced pancreatitis, such as continuous insulin therapy and plasmapheresis, emphasizing the importance of identifying hypertriglyceridemia as the cause. Triglyceride levels > 1000 mg/dL may result in a visibly lipemic blood sample. Lipemic samples may interfere with laboratory equipment, resulting in erroneous levels or the inability to measure several serum blood tests. Consider hypertriglyceridemia as a cause for acute pancreatitis in the setting of a lipemic blood sample or when gallstones have been excluded.

A lethargic child with COVID-19 infection.

ABSTRACT: COVID-19 infection in children is less understood than COVID-19 infection in adults, and although it is believed to cause mild or asymptomatic infections, several cases of severe or atypical presentations have been reported. Children presenting with gastrointestinal symptoms, even those without respiratory symptoms, should raise the suspicion for possible COVID-19 infection. This case report describes a 20-month-old girl with a clear history of COVID-19 exposure whose acute abdomen and lethargy were diagnosed as COVID-19 infection complicated by intussusception.

Comparing two doses of intramuscular ketorolac for treatment of acute musculoskeletal pain in a military emergency department.

STUDY OBJECTIVE: The goal of the study was to assess a low-dose versus a high-dose of intramuscular (IM) ketorolac for non-inferiority in adults with acute MSK pain in an emergency department (ED). METHODS: This was a single-blinded, randomized controlled, non-inferiority trial of adults presenting to an ED with a chief complaint of acute MSK pain. Patients were randomized to either a 15 mg or a 60 mg IM ketorolac dose. The primary outcome was the mean difference of change in pain from baseline to 60-min between the two groups as reported on a 100-mm (mm) visual analog scale (VAS). Secondary outcomes included the mean difference of change in VAS scores at 30-min and the incidence of reported adverse effects associated with the administration of ketorolac. RESULTS: One hundred ten patients were randomized with 55 in each group. The mean difference in pain between groups at 60-min (0.2 mm [95% CI -8.5-8.7]; p = .98) and 30 min (-1.7 mm [95% CI -8.5-5.1; p = .63) was less than the predetermined non-inferiority margin of 13 mm. There were no major adverse effects reported. Minor adverse effects were more frequent in the 60 mg group (n = 9; 16.4% vs. n = 1; 1.8%; p = .016) with burning at the injection site being the most commonly reported. CONCLUSIONS: A 15 mg dose of IM ketorolac was found to be non-inferior to a 60 mg dose for acute MSK pain in adults presenting to the ED. Discontinuing the practice of ordering 60 mg doses of IM ketorolac in place of a lower dose for acute MSK pain should be considered.

Combat Medic eFAST with Novel and Conventional Portable Ultrasound Devices: A Prospective, Randomized, Crossover Trial.

BACKGROUND: Extended Focused Assessment with Ultrasonography in Trauma (eFAST) reliably identifies noncompressible torso hemorrhage (NCTH), a major cause of battlefield death. Increased portability of ultrasound enables eFAST far forward on the battlefield, and published data demonstrate combat medics can learn and reliably perform ultrasound exams. One medical company developed an ultrasound device with an intuitive graphical user interface (GUI) and novel, finger-worn transducer with built-in linear and phased arrays, referred to as the novel device. We evaluated combat medic eFAST performance between the novel and conventional device. METHODS: This was a prospective, randomized, crossover trial completed at a single US military installation. Subjects were US Army combat medics with no previous ultrasound experience. Subjects performed an eFAST on a live human and a simulation model with both devices after a brief training intervention. Our primary outcome was time in seconds for eFAST completion, limited to 600 seconds. Secondary outcomes included diagnostic accuracy, technical adequacy using a validated task-specific checklist, and end-user appraisal of device ease-of-use with 5-point Likert items. This study was approved by the local institutional review board. RESULTS: Forty subjects volunteered, most were male (67.5%), less than 36 years old (95.0%), and grade E-4 or below (75.0%). Subjects performed a total of 160 eFAST scans (80 novel, 80 conventional). We found no significant difference in time for eFAST completion between the novel and conventional devices (391 seconds [95% CI 364, 417] versus 352 seconds [95% CI 325, 379]; p = 0.71). We also found no significant differences between the novel and conventional devices with respect to diagnostic accuracy (91.5% versus 89.2%; p = 0.28) and technical adequacy (75.0% versus 72.5%; p = 0.28). However, we did find that subjects favored the image quality of the novel device (4.3 versus 3.6; p is less than 0.01), while favoring the conventional transducer (3.8 versus 4.3; p = 0.04). CONCLUSION: Combat medic eFAST performance utilizing both devices did not differ with respect to time to completion, diagnostic accuracy, and technical adequacy. Medics with limited ultrasound experience performed diagnostically accurate eFAST after a brief training intervention. Future research should assess learning gaps and skill retention in order to guide development of US military ultrasound training programs for combat medics.

FAST Performance in a Stationary versus In-Motion Military Ambulance Utilizing Handheld Ultrasound: A Randomized Controlled Study.

OBJECTIVE: On-scene prehospital conditions and patient instability may warrant a during-transport ultrasound (US) exam. The objective of this study was to assess the effect of ambulance turbulence on the performance of the Focused Assessment with Sonography in Trauma (FAST) with a handheld US device. METHODS: This was a randomized controlled trial in which participants were randomized to perform a FAST in either a stationary or an in-motion military ambulance. Participants were physicians and physician assistants (PAs) with previous FAST training. All exams were performed on an US phantom model. The primary outcome was FAST completion time, reported as a mean, in seconds. Secondary outcomes included image acquisition score (range of 0-24, reported as a mean), diagnostic accuracy (reported as sensitivity and specificity), and a post-participation survey with five-item Likert-type scales. RESULTS: Twenty-seven participants performed 27 FASTs, 14 in the stationary ambulance and 13 in the in-motion ambulance. All participants obtained the four requisite views of the FAST. A significant difference was detected in image acquisition scores in favor of the stationary ambulance group (19.4 versus 16.7 [95% CI for difference, 0.9-4.4]; P <.01). Significant differences in survey items between groups were related to obtaining and maintaining US images and the exam conditions. There was not a difference in FAST completion time between groups (98.5 seconds versus 78.7 seconds [95% CI for difference, -13.5 seconds to 53.1 seconds]; P = .23). Sensitivity and specificity of FAST in the stationary ambulance was 85.7% (95% CI, 67.3%-96.0%) and 96.4% (95% CI, 81.7%-99.9%) versus 96.2% (95% CI, 80.4%-99.9%) and 100.0% (95% CI, 86.8%-100.0%) in the in-motion ambulance group (P = .21). CONCLUSION: Vehicular motion did not affect FAST completion time and diagnostic accuracy; however, it did reduce FAST image acquisition scores. The results suggest timely and diagnostically accurate FASTs may be completed by experienced sonographers during moderate levels of ambulance turbulence. Further investigation assessing the utility and limitations of newer handheld US devices in various prehospital conditions is warranted.

Effects of MOPP Gear on SAM Medical Junctional Tourniquet Application: A Prospective, Randomized Control Trial.

INTRODUCTION: Hemorrhage is the leading cause of preventable death on the battlefield, and hemostasis is particularly challenging to achieve at junctional sites such as the axillary or inguinal regions. Mission-oriented protective posture (MOPP) gear, as worn most recently in Syria to guard against chemical weapons, can make the performance of technical skills more challenging still. The objective of this study was to evaluate how wearing MOPP gear affects the application time of the SAM Medical Junctional Tourniquet (SJT) by U.S. Army combat medics. MATERIALS AND METHODS: We conducted a prospective, randomized control trial evaluating time for SJT application between participants wearing MOPP versus those not wearing MOPP. Secondary outcomes included SJT application success rate and participant appraisal of SJT application difficulty assessed with five-point Likert items, between groups. Participants placed SJTs on robotic simulation mannequins with a penetrating inguinal injury. RESULTS: In April 2019, we enrolled 49 combat medics. Most participants were male (77.5%), had a median age of 25 (interquartile range 23-28), and in the grade of E4 or less (63.3%). Mean SJT application times in seconds were higher among those wearing MOPP versus those who were not (223.1 versus 167.2; 95% confidence interval for difference in means 5.293, 106.374; P = 0.03). Participants wearing MOPP had a less successful application rate overall, but this difference was not statistically significant (64.3% versus 81.0%, P = 0.34). Compared to participants not wearing MOPP, those wearing MOPP agreed that SJT application was difficult (4 versus 3, P = 0.03), what they were wearing affected SJT application (4 versus 2, P = 0.01), and it was difficult to use their hands during SJT application (4 versus 1, P < 0.001). CONCLUSIONS: Wearing military MOPP gear significantly prolongs the amount of time required for combat medics to apply an SJT on a simulated casualty with a penetrating inguinal injury. This study highlights the importance of incorporating MOPP gear into medical training scenarios to improve skills competency while wearing these protective garments.

U.S. Army Combat Medic eFAST Performance with a Novel Versus Conventional Transducers: A Randomized, Crossover Trial.

BACKGROUND: Point-of-injury extended focused assessment with sonography in trauma (eFAST) may identify life-threatening torso hemorrhage and expedite casualty evacuation. The purpose of this study was to compare combat medic eFAST performance between the novel and conventional ultrasound (US) transducers. METHODS: We conducted a randomized crossover trial. Medic participants, previously naïve to US, were randomized to the type of transducer first utilized. The primary outcome was eFAST completion time in seconds. Secondary outcomes included diagnostic accuracy, technical adequacy, and transducer ease-of-use rating. RESULTS: Forty medics performed 160 eFASTs. We found a statistically significant difference in eFAST completion times in favor of conventional transducers (304 vs. 358 s; P = 0.03). There was no statistically significant difference between the conventional and novel transducers in terms of diagnostic accuracy (97.7% vs. 96.0%; P = 0.25) and technical adequacy (65% vs. 72.5%; P = 0.11). Median transducer ease-of-use rating (Likert 1-5 scale) was statistically significant in favor of the conventional transducers (5 vs. 4; P = < 0.001). CONCLUSIONS: Extended focused assessment with sonography in trauma exam times was faster with the conventional transducers. Combat medics performed diagnostically accurate eFASTs with both transducer types in a simulated aid station setting after a brief training intervention. Conventional transducers were rated higher for ease-of-use.