Femoral Injury Over the Site of Spontaneous Regression of an Osteochondroma in a Teenage Athlete.

ABSTRACT: The spontaneous regression of an osteochondroma is extremely rare. We report a case of medial femoral condyle impaction fracture over the site of spontaneous regression of a pedunculated osteochondroma discovered on advanced imaging after an acute injury in a 16-year-old male American football athlete. Although spontaneous regression of an osteochondroma has been described, the case presented reveals questions regarding resultant architectural changes to the bone after resorption, leaving it prone to injury. This is the first case that describes increased injury risk potential at the site of osteochondral regression.

Comparing the Accuracy of Mass Casualty Triage Systems When Used in an Adult Population.

Objective: To use a previously published criterion standard to compare the accuracy of 4 different mass casualty triage systems (Sort, Assess, Lifesaving Interventions, Treatment/Transport [SALT], Simple Triage and Rapid Treatment [START], Triage Sieve, and CareFlight) when used in an emergency department-based adult population. Methods: We performed a prospective, observational study of a convenience sample of adults aged 18 years or older presenting to a single tertiary care hospital emergency department. A co-investigator with prior emergency medical services (EMS) experience observed each subject's initial triage in the emergency department and recorded all data points necessary to assign a triage category using each of the 4 mass casualty triage systems being studied. Subjects' medical records were reviewed after their discharge from the hospital to assign the "correct" triage category using the criterion standard. The 4 mass casualty triage system assignments were then compared to the "correct" assignment. Descriptive statistics were used to compare accuracy and over- and under-triage rates for each triage system. Results: A total of 125 subjects were included in the study. Of those, 53% were male and 59% were transported by private vehicle. When compared to the criterion standard definitions, SALT was found to have the highest accuracy rate (52%; 95% CI 43-60) compared to START (36%; 95% CI 28-44), CareFlight (36%; 95% CI 28-44), and TriageSieve (37%; 95% CI 28-45). SALT also had the lowest under-triage rate (26%; 95% CI 19-34) compared to START (57%; 95% CI 48-66), CareFlight (58%; 95% CI 49-66), and TriageSieve (58%; 95% CI 49-66). SALT had the highest over-triage rate (22%; 95% CI 14-29) compared to START (7%; 95% CI 3-12), CareFlight (6%; 95% CI 2-11) and TriageSieve (6%; 95% CI 2-11). Conclusion: We found that SALT triage most often correctly triaged adult emergency department patients when compared to a previously published criterion standard. While there are no target under- and over-triage rates that have been published for mass casualty triage, all 4 systems had relatively high rates of under-triage.

The Use of the Abdominal Aortic and Junctional Tourniquet Versus Combat Gauze in a Porcine Hemicorporectomy Model.

BACKGROUND: Junctional hemorrhage is a potentially preventable cause of death. The Abdominal Aortic and Junctional Tourniquet (AAJT) compresses major vascular structures and arrests blood flow in exsanguinating hemorrhage. In a human model, the AAJT was effective in stopping blood flow in the femoral arteries via compression of the distal aorta. This study compares the ability of AAJT and Combat Gauze (CG) to stop hemorrhagic bleeding from a hemicorporectomy in a swine model. METHOD: Six anesthetized swine were used. Carotid arterial catheters were placed for continuous mean arterial pressure (MAP) readings. A hemicorporectomy was accomplished with a blade lever device by cutting the animal through both femoral heads transecting the proximal iliac arteries and veins. Hemorrhage control was attempted with the AAJT and regular Kerlix gauze or CG packing and direct pressure followed by Kerlix gauze placed over the CG. The primary outcome measure was survival at 60 minutes. RESULTS: The 60-minute survival was 100% for the AAJT and 0% for the CG group. During the 60-minute monitoring period, only one CG animal achieved hemostasis. For the AAJT group, the mean time to hemostasis was 30 seconds. Initial MAP was higher in the AAJT group (mean, 87mmHg) than the CG group (mean, 70mmHg). The mean 60-minute MAP was 73mmHg for the AAJT group. Mean blood loss at 5 minutes and mean total blood loss were greater in the CG group than in the AAJT group. CONCLUSION: AAJT is superior to CG in controlling hemorrhage in a junctional wound in a swine model.

Early administration of Fab antivenom resulted in faster limb recovery in copperhead snake envenomation patients.

BACKGROUND: No previous research has studied whether early snake antivenom administration leads to better clinical outcomes than late antivenom administration in North American pit viper envenomation. METHODS: A secondary analysis of data from a clinical trial of Fab antivenom (FabAV) versus placebo for copperhead snake envenomation was conducted. Patients treated before the median time to FabAV administration were classified as receiving early treatment and those treated after the median time were defined as the late treatment group. A Cox proportional hazards model was used to compare time to full recovery on the Patient-Specific Functional Scale (PSFS) instrument between groups. Secondary analyses compared estimated mean PSFS scores using a generalized linear model and the estimated proportion of patients with full recovery at each time point using logistic regression. To evaluate for confounding, the main analysis was repeated using data from placebo-treated subjects. RESULTS: Forty-five subjects were treated with FabAV at a median of 5.47 h after envenomation. Patients in the early treatment group had a significantly shorter time to full recovery than those treated late (median time: 17 versus 28 days, p = .025). Model-estimated PSFS scores were numerically higher at each time point in the early group. No difference was found between patients treated early versus late with placebo. CONCLUSIONS: In this secondary analysis of trial data, recovery of limb function was faster when Fab antivenom was administered soon after envenomation, as opposed to late administration.

Comparing the Accuracy of Mass Casualty Triage Systems in a Pediatric Population.

INTRODUCTION: It was previously difficult to compare the accuracy of different mass casualty triage systems to one another. This pilot study is one of the first attempts to operationalize an expert panel's criterion standard definitions of triage categories in a pediatric population in order to compare accuracy between different systems. OBJECTIVE: To compare the accuracy of 4 different mass casualty triage systems (SALT, JumpSTART, Triage Sieve, and CareFlight) when used for children. METHODS: We observed the emergency department triage of patients less than 18 years old presenting to the only pediatric specialty hospital/Level 1 trauma center in Milwaukee County, Wisconsin. A single, certified EMS provider observed each patient's initial triage in the emergency department and recorded all findings that were necessary to categorize the patient using each of the 4 mass casualty triage systems being studied. Hospital medical records were then reviewed for each patient and assigned a criterion standard triage category based on the treatments received and final disposition. Descriptive statistics were used to compare accuracy, over-, and under-triage rates for each of the triage systems. RESULTS: A total of 115 subjects were enrolled. Of those, 51% were male and 57% were transported by ambulance. When compared to the criterion standard definitions, SALT was found to have the highest accuracy rate (59%; 95% CI 50-68) compared to JumpSTART (57%; 95% CI 48-66), CareFlight (56%; 95% CI 47-65), and TriageSieve (56%; 95% CI 46-65). SALT also had the lowest under-triage rate (33%; 95% CI 24-42) compared to JumpSTART (39%; 95% CI 30-48), CareFlight (39%; 95% CI 30-48), and TriageSieve (39%; 95% CI 30-48). SALT had the highest over-triage rate (6%; 95% CI 2-11) compared to JumpSTART (4%; 95% CI 1-8), CareFlight (5%; 95% CI 1-9), and TriageSieve (5%; 95% CI 1-9). However, the confidence intervals for both the accuracy and under-triage rates overlapped between all triage systems. For each triage system, the most common error was designating a patient as "minimal" that, according to the criterion standard, should have been triaged as "delayed." CONCLUSION: We found that the 4 most popular mass casualty triage systems preformed similarly in an emergency department-based pediatric population. None of the systems were extremely accurate, and each demonstrated an unacceptable amount of under-triage. Better differentiating between patients categorized as "minimal" and "delayed" may improve the accuracy of mass casualty triage systems.

Integration of Tactical Emergency Casualty Care Into the National Tactical Emergency Medical Support Competency Domains.

Tactical emergency medical support (TEMS) is a critical component of the out-of-hospital response to domestic high-threat incidents such as hostage scenarios, warrant service, active shooter or violent incidents, terrorist attacks, and other intentional mass casualty-producing acts. From its grass-roots inception in the form of medical support of select law enforcement special weapons and tactics (SWAT) units in the 1980s, the TEMS subspecialty of prehospital care has rapidly grown and evolved over the past 40 years. The National TEMS Initiative and Council (NTIC) competencies and training objectives are the only published recommendations of their kind and offer the opportunity for national standardization of TEMS training programs and a future accreditation process. Building on the previous work of the NTIC and the creation of acknowledged competency domains for TEMS and the acknowledged civilian translation of TCCC by the Committee for Tactical Emergency Casualty Care (C-TECC), the Joint Review Committee (JRC) has created an opportunity to bring forward the work in a form that could be operationally useful in an all-hazards and whole of community format.

Evaluation of NuStatr, a Novel Nonimpregnated Hemostatic Dressing, Compared With Combat Gauze in Severe Traumatic Porcine Hemorrhage Model.

BACKGROUND: Uncontrolled hemorrhage remains one of the most challenging problems facing emergency medical professionals and a leading cause of traumatic death in both battlefield and civilian environments. Survival is determined by the ability to rapidly control hemorrhage. Several commercially available topical adjunct agents have been shown to be effective in controlling hemorrhage, and one, Combat Gauze (CG), is used regularly on the battlefield and for civilian applications. However, recent literature reviews have concluded that no ideal topical agent exists for all injuries and scenarios. The authors compared a novel nonimpregnated dressing composed of cellulose and silica, NuStat (NS), to CG in a lethal hemorrhagic groin injury. These dressings were selected for their commercial availability and design intended for control of massive hemorrhage. METHODS: A complex penetrating femoral artery groin injury was made using a 5.5mm vascular punch followed by 45 seconds of uncontrolled hemorrhage in 15 swine. The hemostatic dressings were randomized using a random sequence generator and then assigned to the animals. Three minutes of manual pressure was applied with each agent after the free bleed. Hextend bolus (500 mL) was subsequently rapidly infused using a standard pressure bag along with the addition of maintenance fluids to maintain blood pressure. Hemodynamic parameters were recorded every 10 minutes and additionally at critical time points defined in the protocol. Primary end points included immediate hemostasis upon release of manual pressure (T0), hemostasis at 60 minutes, and rebleeding during the 60-minute observation period. RESULTS: NS was statistically superior to CG in a 5.5 mm traumatic hemorrhage model at T0 for immediate hemostasis (p=.0475), duration of application time (p=.0093), use of resuscitative fluids (p=.0042) and additional blood loss after application (p=.0385). NS and CG were statistically equivalent for hemostasis at 60 minutes, rebleeding during the study, and the additional secondary metrics, although the trend indicated that in a larger sample size, NS could prove statistical superiority in selected categories. CONCLUSIONS: In this porcine model of uncontrolled hemorrhage, NS improved immediate hemorrhage control, stability, and use of fluid in a 60-minute severe porcine hemorrhage model. In this study, NS demonstrated equivalence to CG at achieving long-term hemostasis and the prevention of rebleed after application. NS was shown to be an efficacious choice for hemorrhage control in combat and civilian emergency medical service environments.

Development of a National Consensus for Tactical Emergency Medical Support (TEMS) Training Programs--Operators and Medical Providers.

INTRODUCTION: Tactical teams are at high risk of sustaining injuries. Caring for these casualties in the field involves unique requirements beyond what is provided by traditional civilian emergency medical services (EMS) systems. Despite this need, the training objectives and competencies are not uniformly agreed to or taught. METHODS: An expert panel was convened that included members from the Departments of Defense, Homeland Security, Justice, and Health and Human Services, as well as federal, state, and local law-enforcement officers who were recruited through requests to stakeholder agencies and open invitations to individuals involved in Tactical Emergency Medical Services (TEMS) or its oversight. Two face-to-face meetings took place. Using a modified Delphi technique, previously published TEMS competencies were reviewed and updated. RESULTS: The original 17 competency domains were modified and the most significant changes were the addition of Tactical Emergency Casualty Care (TECC), Tactical Familiarization, Legal Aspects of TEMS, and Mass Casualty Triage to the competency domains. Additionally, enabling and terminal learning objectives were developed for each competency domain. CONCLUSION: This project has developed a minimum set of medical competencies and learning objectives for both tactical medical providers and operators. This work should serve as a platform for ensuring minimum knowledge among providers, which will serve enhance team interoperability and improve the health and safety of tactical teams and the public.

Use of a novel abdominal aortic tourniquet to reduce or eliminate flow in the common femoral artery in human subjects.

BACKGROUND: Penetrating injuries of proximal femoral and iliac vessels are a common cause of death on the battlefield. Previous studies have shown that by applying 80 lb to 140 lb of pressure externally over the distal abdominal aorta, flow can be ceased in the common femoral artery (CFA). It has also been demonstrated that in a porcine model, an externally applied pneumatic abdominal aortic tourniquet (AAT) can occlude the aorta and inferior vena cava for 60 minutes without bowel injury or significant potassium elevations.The objectives of this study were (1) determine if AAT use in humans results in flow cessation in the CFA, (2) measure the pressure required to cease flow in the CFA, and (3) measure discomfort associated with application of the AAT. METHODS: Pulse wave Doppler measurements were taken in supine volunteers at the right CFA. The AAT was placed just above the iliac crests over the anterior abdomen. The AAT was inflated using a hand pump with an integrated manometer. Measurements were taken every 30 mm Hg. Discomfort was measured using a 10-point pain scale. RESULTS: In all subjects, flow was reduced in the CFA. Flow ceased in seven of nine subjects at a median pressure of 180 mm Hg (150-230 mm Hg). Median discomfort at ceasing of flow was 7 (3-10), returning to 0 after device removal. CONCLUSION: The AAT device was effective at reducing flow in the CFA and ceased flow in most of the subjects. Application of the device was associated with discomfort varying from moderate to severe and resolving with device removal.

Mass casualty triage: an evaluation of the science and refinement of a national guideline.

Mass casualty triage is the process of prioritizing multiple victims when resources are not sufficient to treat everyone immediately. No national guideline for mass casualty triage exists in the United States. The lack of a national guideline has resulted in variability in triage processes, tags, and nomenclature. This variability has the potential to inject confusion and miscommunication into the disaster incident, particularly when multiple jurisdictions are involved. The Model Uniform Core Criteria for Mass Casualty Triage were developed to be a national guideline for mass casualty triage to ensure interoperability and standardization when responding to a mass casualty incident. The Core Criteria consist of 4 categories: general considerations, global sorting, lifesaving interventions, and individual assessment of triage category. The criteria within each of these categories were developed by a workgroup of experts representing national stakeholder organizations who used the best available science and, when necessary, consensus opinion. This article describes how the Model Uniform Core Criteria for Mass Casualty Triage were developed.

Paramedic accuracy using SALT triage after a brief initial training.

OBJECTIVE: To determine paramedics' understanding of and accuracy using SALT (sort-assess-lifesaving interventions-treatment/transport) triage, a proposed national guideline for primary triage during mass-casualty incidents, immediately and four months after training. METHODS: A 20-minute lecture on SALT triage was provided to all paramedics (n = 320) from a single county during mandatory continuing education. Triage concepts were reemphasized during a 10-minute small-group lecture throughout the study period as part of standard refresher training. After the initial training, all paramedics were asked to complete a posttest consisting of three general knowledge questions about SALT triage and 10 patient scenarios in which they had to assign a triage category. The same test was administered four months after the original educational session. Demographic and job experience information was also obtained. Responses were scored and matched for each paramedic and compared using paired t-test. RESULTS: A total of 290 (91%) paramedics completed the initial posttest. They correctly answered an average (± standard deviation) of 10.7 ± 2.3 of the 13 questions (82%). For the 10 patient scenarios, they correctly triaged an average of 8.1 ± 2.0 patients. A total of 159 paramedics completed both tests. Sixty-seven percent had more than 10 years of emergency medical services (EMS) experience; 72% had prior mass-casualty drill experience; 51% had prior actual mass-casualty experience; and 23% had heard of SALT triage prior to the training. There were no statistically significant differences in initial test scores for any of these demographic groups. For those subjects who completed both tests, the mean overall score for the initial test was 10.9 ± 1.9 (84%) and for the later test was 11.0 ± 1.9 (85%) (p < 0.770; 95% confidence interval [CI] -0.3 to 0.3). For the 10 patient scenarios, the paramedics correctly triaged an average of 8.3 ± 1.7 patients on the initial test and 8.3 ± 1.4 patients on the later test (p < 0.565; 95% CI -0.4 to 0.2). CONCLUSION: Following a short didactic course, paramedics were able to accurately perform SALT triage during a written scenario. Four months after the training, they had retained their understanding of and accuracy using SALT triage. It appears that a brief educational tool was effective for training EMS providers in SALT triage.

Use of SALT triage in a simulated mass-casualty incident.

OBJECTIVES: To determine the accuracy of SALT (sort-assess-lifesaving interventions-treatment/transport) triage during a simulated mass-casualty incident, the average time it takes to make triage designations, and providers' opinions of SALT triage. METHODS: Seventy-three trainees participating in one of two disaster courses were taught to use SALT triage during a 30-minute lecture. The following day they participated in teams, in one of eight simulated mass-casualty incidents. For each incident trainees were told to assess and prioritize all victims. Each scenario comprised 28 to 30 victims, including 10 to 11 moulaged manikins and 18 to 20 moulaged actors. Each victim had a card that stated the victim's respiratory effort, pulse quality, and ability to follow commands. Initial and final assigned triage categories were recorded and compared with the intended category. Ten of the victims were equipped with stopwatches to measure the triage time interval. Timing began when the trainee approached the victim and ended when the trainee verbalized his or her triage designation. The times were averaged and standard deviations were calculated. After the drill, trainees were asked to complete a survey regarding their experience. RESULTS: There were 217 victim observations. The initial triage was correct for 81% of the observations; 8% were overtriaged and 11% were undertriaged. The final triage was correct for 83% of the observations; 6% were overtriaged and 10% were undertriaged. The mean triage interval was 28 seconds (+/- 22; range: 4-94). Nine percent reported that prior to the drill they felt very confident using SALT triage and 33% were not confident. After the drill, no one reported not feeling confident using SALT triage, 26% were at the same level of confidence, 74% felt more confident, and none felt less confident. Before the drill, 53% of the respondents felt SALT triage was easier to use than their current disaster triage protocol, 44% felt it was similar, and 3% felt it was more difficult. After the drill, no one reported that SALT triage was more difficult to use. CONCLUSION: We found that assessments using SALT triage were accurate and made quickly during a simulated incident. The accuracy rate was higher than those published for other triage systems and of similar speed. Providers also felt confident using SALT triage and found it was similar or easier to use than their current triage protocol. Using SALT triage during a drill improved confidence.

Obturator externus bursa: prevalence of communication with the hip joint and associated intra-articular findings in 200 consecutive hip MR arthrograms.

The purpose of the study was to demonstrate the prevalence of communication between the hip joint and the obturator externus bursa on hip MR arthrography. Following institutional review board approval, 200 hip MR arthrograms in 196 subjects were independently reviewed by two musculoskeletal radiologists. Discrepancies were resolved by adjudication. The presence or absence of communication between the hip joint and the obturator externus bursa was recorded. Associated lesions involving the acetabular labrum and articular cartilage were recorded. The obturator externus bursa was shown to communicate with the hip joint in 11 of the 200 (5.5%) hip MR arthrograms. Of these, six were in men and five were in women. The age range was 15-63 years with a mean age of 34 years. All 11 patients had labral tears. Eight of the 11 had cartilage lesions. The obturator externus bursa can be seen to communicate with the hip joint in 5.5% of hip MR arthrograms. Associated labral and cartilage lesions are common.

The national disaster life support programs: a model for competency-based standardized and locally relevant training.

With grant funding from the Department of Health and Human Services under the Bioterrorism Training and Curriculum Development Program, the Medical College of Georgia Center of Operational Medicine (MCG-COM) provided an integrated disaster medicine continuing education program for the state of Georgia. This educational program was based on the American Medical Association (AMA) National Disaster Life Support (NDLS) curricula. With supplemental funding, the MCG-COM developed and piloted a national training strategy for all-hazards disaster preparedness education. This strategy built upon the existing 47 training centers delivering NDLS curricula. State advisory committees were established in four model states, developing state-specific modules based on a Hazard and Vulnerability Assessment. These modules were piloted as a model for the deployment of a national curriculum with state and local integration. In addition, the AMA established an educational consortium for the purpose of continual curriculum revision. This consortium, currently consisting of more than 75 participating organizations and federal liaisons, is responsible for all curriculum updates for the NDLS courses. Under this model, multidisciplinary crosscutting disaster medicine competencies and a proposed educational framework were developed. The resulting competencies and framework have been published in the peer-reviewed literature and are being integrated into the NDLS curricula.

Frequency of incomplete medication histories obtained at triage.

PURPOSE: The frequency of incomplete medication histories obtained at triage in an emergency department (ED) is described. METHODS: The survey of medication histories collected during ED triage was conducted during a 20-week period. Data collection occurred on weekdays during the dayshift for 15 hours per week for a total of 300 hours. Patients who bypassed triage or were unconscious, unable to communicate, uncooperative, or violent were excluded. Ten student pharmacists were trained on study procedures and collected data using a data collection tool which included patient's chief complaints, medications and dosages, and whether medications were identified at triage. Patients' medication-related ED visits were classified as being caused by adverse effects, medication errors, poor adherence, intentional overdose, or therapeutic failure. RESULTS: During the 300 hours of data collection, 2063 patients were admitted to the ED. Of these, 1465 (71%) were interviewed and evaluated for complete medication histories. Among 1172 (80%) patients identified as taking medications, the history obtained at triage failed to identify at least one medication in 707 (48%) patients. In cases where medications were not identified, a mixture of prescription (73%) and nonprescription (27%) medications were missed with a median of 2 drugs (range, 1-20 drugs). Drugs missed at triage were related to the patient's chief complaint in 27% of the cases. CONCLUSION: Medication histories collected at triage in the ED of an urban medical center were often incomplete, especially among patients taking multiple medications. Efforts should be taken to improve methods for obtaining more complete medication histories during triage and collecting supplemental medication histories to ensure appropriate emergency care.