Comminuted Femur Fracture in a Free Fall Jump: A Case Report.

Military free fall or high-altitude low-opening parachute jumps play a key role in special operations tactics, though injury patterns in these operators are not well characterized. In contrast to lower-altitude static line paratroopers, free fall operators require precise parachute deployment after a prolonged descent, with the potential for high-velocity trauma. This report describes a 33-year-old Marine Corps Reconnaissance operator who sustained left comminuted basicervical femoral neck fracture requiring cephalomedullary nail internal fixation with a full recovery. This femoral neck fracture highlights the high-energy injuries experienced by these invaluable operators, especially when conducting combat or night jumps.

A Comparison of Prehospital Versus Emergency Department Intubations in Iraq and Afghanistan.

BACKGROUND: Airway obstruction is the second most common cause of potentially preventable death on the battlefield. We compared survival in the combat setting among patients undergoing prehospital versus emergency department (ED) intubation. METHODS: Patients were identified from the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. We defined the prehospital cohort as subjects undergoing intubation prior to arrival to a forward surgical team (FST) or combat support hospital (CSH), and the ED cohort as subjects undergoing intubation at an FST or CSH. We compared study variables between these cohorts; survival was our primary outcome. RESULTS: There were 4341 intubations documented in the DODTR during the study period: 1117 (25.7%) patients were intubated prehospital and 3224 (74.3%) were intubated in the ED. Patients intubated prehospital had a lower median age (24 versus 25 years, p < .001), composed a higher proportion of host nation forces (36.1% versus 29.1%, p < .001), had a lower proportion of injuries from explosives (57.6% versus 61.0%, p = .030), and had higher median injury severity scores (20 versus 18, p = .045). A lower proportion of the prehospital cohort survived to hospital discharge (76.4% versus 84.3%, p < .001). The prehospital cohort had lower odds of survival to hospital discharge in both univariable (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.51-0.71) and multivariable analyses controlling for confounders (OR 0.70, 95% CI 0.58-0.85). In a subgroup analysis of patients with a head injury, the lower odds of survival persisted in the multivariable analysis (OR 0.49, 95% CI 0.49-0.82). CONCLUSIONS: Patients intubated in the prehospital setting had a lower survival than those intubated in the ED. This finding persisted after controlling for measurable confounders.

Emergency department septic shock patient mortality with refractory hypotension vs hyperlactatemia: A retrospective cohort study.

BACKGROUND: Our objective was to compare in-hospital mortality among emergency department (ED) patients meeting trial-based criteria for septic shock based upon whether presenting with refractory hypotension (systolic blood pressure<90mmHg after 1L intravenous fluid bolus) versus hyperlactatemia (initial lactate≥4mmol/L). METHODS: We conducted a retrospective cohort analysis by chart review of ED patients admitted to an intensive care unit with suspected infection during 1 August 2012-28 February 2015. We included all patients with body fluid cultures sampled either during their ED stay without antibiotic administration or within 24h of antibiotic administration in the ED. We excluded patients not meeting criteria for either refractory hypotension or hyperlactatemia. Trained chart abstractors blinded to the study hypothesis double entered data from each patient's record including demographics, clinical data, treatments, and in-hospital mortality. We compared in-hospital mortality among patients with isolated refractory hypotension, isolated hyperlactatemia, or both. We also calculated odds ratios (ORs) via logistic regression for in-hospital mortality based on presence of refractory hypotension or hyperlactatemia. RESULTS: Of 202 patients included in the analysis, 38 (18.8%) died during hospitalization. Mortality was 10.9% among 101 patients with isolated refractory hypotension, 24.4% among 41 patients with isolated hyperlactatemia, and 28.3% among 60 patients with both (p=0.01). Logistic regression analyses yielded in-hospital mortality OR for refractory hypotension of 1.3 (95% CI 0.5-3.8) versus OR for hyperlactatemia of 2.9 (95% CI 1.2-7.4). CONCLUSIONS: Hyperlactatemia appears associated with higher in-hospital mortality compared to refractory hypotension among ED patients with septic shock.

Sepsis Clinical Criteria in Emergency Department Patients Admitted to an Intensive Care Unit: An External Validation Study of Quick Sequential Organ Failure Assessment.

BACKGROUND: Quick Sequential Organ Failure Assessment (qSOFA) is a prognostic score for patients with sepsis. OBJECTIVE: Our aim was to compare the area under the receiver operating curve (AUROC), sensitivity, specificity, and likelihood ratios of qSOFA vs. systemic inflammation response syndrome (SIRS) in predicting in-hospital mortality among emergency department (ED) patients with suspected infection admitted to intensive care units (ICUs). METHODS: We conducted a retrospective cohort chart review study of ED patients admitted to an ICU with suspected infection from August 1, 2012 to February 28, 2015. We included all patients with body fluid cultures sampled either during their ED stay without antibiotic administration or within 24 h of antibiotics administered in the ED. Trained chart abstractors blinded to the study hypothesis double-entered data from each patient's electronic medical record including demographic characteristics, vital signs, laboratory study results, physical examination findings, and in-hospital mortality. We then calculated the AUROC, sensitivity, specificity, and likelihood ratios for qSOFA and SIRS for predicting in-hospital mortality. RESULTS: Of 214 patients admitted to an ICU with presumed sepsis, 39 (18.2%) died during hospitalization. The AUROC value was 0.65 (95% confidence interval [CI] 0.56-0.74) for SIRS vs. 0.66 (95% CI 0.57-0.76) for qSOFA; 2+ qSOFA criteria predicted in-hospital mortality with 89.7% sensitivity, 27.4% specificity, 1.2 positive likelihood ratio, and 0.4 negative likelihood ratio. CONCLUSIONS: Among ED patients admitted to an ICU, the SIRS and qSOFA criteria had comparable prognostic value for predicting in-hospital mortality. These prognostic values are similar to those reported by the Sepsis-3 guidelines for ICU encounters.