En Route Use of Analgesics in Nonintubated, Critically Ill Patients Transported by U.S. Air Force Critical Care Air Transport Teams.

INTRODUCTION: U.S. Critical Care Air Transport Teams (CCATTs) evacuate critically ill patients with acute pain in the combat setting. Limited data have been reported on analgesic administration en route, and no study has reported analgesic use by CCATTs. Our objective was to describe analgesics used by CCATTs for nonintubated, critically ill patients during evacuation from a combat setting. METHODS: We conducted an institutional review board-approved, retrospective review of CCATT records. We included nonintubated, critically ill patients who were administered analgesics in flight and were evacuated out of theater (2007-2012). Demographics, injury description, analgesics and anesthetics, and predefined clinical adverse events were recorded. Data were presented as mean ± standard deviation or percentage (%). RESULTS: Of 1,128 records, we analyzed 381 subjects with the following characteristics: age 26 ± 7.0 years; 98% male; and 97% trauma (70% blast, 17% penetrating, 11% blunt, and 3% burn). The injury severity score was 19 ± 9. Fifty-one percent received morphine, 39% hydromorphone, 15% fentanyl, and 5% ketamine. Routes of delivery were 63% patient-controlled analgesia (PCA), 32% bolus intravenous (IV) administration, 24% epidural delivery, 21% continuous IV infusions, and 9% oral opioids. Patients that were administered local anesthetics (nerve block or epidural delivery) with IV opioids received a lower total dose of opioids than those who received opioids alone. No differences were associated between analgesics and frequency of complications in flight or postflight. CONCLUSION: About half of nonintubated, critically ill subjects evacuated out of combat by CCATT received morphine and more than half had a PCA. In our study, ketamine was not frequently used and pain scores were rarely recorded. However, we detected an opioid-sparing effect associated with local anesthetics (regional nerve blocks and epidural delivery).

Aeromedical evacuation of combat patients by military critical care air transport teams with a lower hemoglobin threshold approach is safe.

BACKGROUND: Military critical care air transport teams (CCATT) evacuate critically ill and injured patients out of theater for tertiary treatment. Teams are led by a physician, nurse, and respiratory technician. Current aeromedical guidelines require a hemoglobin (Hgb) of 9 g/dL or greater to evacuate; however, civilians report that an Hgb of 8 g/dL or less is safe in critically ill patients. This study aimed to compare postflight short-term and 30-day patient outcomes for CCATT patients evacuated out of theater with an Hgb of 8 g/dL or less with those with an Hgb of greater than 8 g/dL. METHODS: We conducted a retrospective record review of all traumatically injured patients evacuated from theater by CCATT between March 2007 and December 2011. We recorded demographics, injury descriptions, vital signs, laboratory values, adverse events, and disposition at 30 days. Patients were separated into those with a preflight Hgb of 8 g/dL or less versus those with greater than 8 g/dL. Continuous data were analyzed using Student's t tests or Wilcoxon tests and reported as mean ± SD. χ or Fisher's exact tests were performed. Stepwise, multifactorial logistic regression models were used. Statistical significance was considered with p < 0.05. RESULTS: Of 1,252 patients, 1,033 had a preflight Hgb of greater than 8 and 219 had an Hgb of 8 or less. Age, sex proportions, vitals, laboratory values, and Injury Severity Score (ISS; 24±13) were similar. The group with 8 or less had more blast injuries (68% vs. 76%, p = 0.01). No associations were identified between preflight Hgb levels and adverse outcomes. Disposition at 30 days was similar. We also compared preflight Hgb greater than 7 versus 7 or less (n = 1,212 vs. 45). Those with an Hgb greater than 7 had a greater incidence of hospitalization at 30 days (77% vs. 67%, p = 0.04). The group with an Hgb of 7 or less had more subjects discharged home or returning to duty (10% vs. 21%, p = 0.04). CONCLUSION: Evacuating CCATT patients with an Hgb of 8 or less had similar adverse outcomes and mortality at 30 days compared with those with an Hgb greater than 8. Patients with an Hgb of 7 or less had higher rates of hospital discharge and decreased incidence of hospitalization at 30 days. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Prehospital and en route cricothyrotomy performed in the combat setting: a prospective, multicenter, observational study.

INTRODUCTION: Airway compromise is the third most common cause of potentially preventable combat death. Surgical cricothyrotomy is an infrequently performed but lifesaving airway intervention. There are limited published data on prehospital cricothyrotomy in civilian or military settings. Our aim was to prospectively describe the survival rate and complications associated with cricothyrotomy performed in the military prehospital and en route setting. METHODS: The Life-Saving Intervention (LSI) study is a prospective, institutional review board-approved, multicenter trial examining LSIs performed in the prehospital combat setting. We prospectively recorded LSIs performed on patients in theater who were transported to six combat hospitals. Trained site investigators evaluated patients on arrival and recorded demographics, vital signs, and LSIs performed. LSIs were predefined and include cricothyrotomies, chest tubes, intubations, tourniquets, and other procedures. From the large dataset, we analyzed patients who had a cricothyrotomy performed. Hospital outcomes were cross-referenced from the Department of Defense Trauma Registry. Descriptive statistics or Wilcoxon test (nonparametric) were used for data comparisons; statistical significance was set at p<.05. The primary outcome was success of prehospital and en route cricothyrotomy. RESULTS: Of the 1,927 patients enrolled, 34 patients had a cricothyrotomy performed (1.8%). Median age was 24 years (interquartile range [IQR]: 22.5-25 years), 97% were men. Mechanisms of injury were blast (79%), penetrating (18%), and blunt force (3%), and 83% had major head, face, or neck injuries. Median Glasgow Coma Scale score (GCS) was 3 (IQR: 3-7.5) and four patients had GCS higher than 8. Cricothyrotomy was successful in 82% of cases. Reasons for failure included left main stem intubation (n=1), subcutaneous passage (n=1), and unsuccessful attempt (n=4). Five patients had a prehospital basic airway intervention. Unsuccessful endotracheal intubation preceded 15% of cricothyrotomies. Of the 24 patients who had the provider type recorded, six had a cricothyrotomy by a combat medic (pre-evacuation), and 18 by an evacuation helicopter medic. Combat-hospital outcome data were available for 26 patients, 13 (50%) of whom survived to discharge. The cricothyrotomy patients had more LSIs than noncricothyrotomy patients (four versus two LSIs per patient; p<.0011). CONCLUSION: In our prospective, multicenter study evaluating cricothyrotomy in combat, procedural success was higher than previously reported. In addition, the majority of cricothyrotomies were performed by the evacuation helicopter medic rather than the prehospital combat medic. Prehospital military medics should receive training in decision making and be provided with adjuncts to facilitate this lifesaving procedure.