Blood consumption in the Role 2 setting: A Department of Defense Trauma Registry analysis.

BACKGROUND: The Role 2 setting represents the most far-forward military treatment facility with limited surgical and holding capabilities. There are limited data to guide recommendations on blood product utilization at the Role 2. We describe the consumption of blood products in this setting. STUDY DESIGN AND METHODS: We analyzed data from 2007 to 2023 from the Department of Defense Trauma Registry (DODTR) that received care at a Role 2. We used descriptive and inferential statistics to characterize the volumes of blood products consumed in this setting. We also performed a secondary analysis of US military, Coalition, and US contractor personnel. RESULTS: Within our initial cohort analysis of 15,581 encounters, 17% (2636) received at least one unit of PRBCs or whole blood, of which 11% received a submassive transfusion, 4% received a massive transfusion, and 1% received a supermassive transfusion. There were 6402 encounters that met inclusion for our secondary analysis. With this group, 5% received a submassive transfusion, 2% received a massive transfusion, and 1% received a supermassive transfusion. CONCLUSIONS: We described volumes of blood products consumed at the Role 2 during recent conflicts. The maximum number of units consumed among survivors exceeds currently recommended available blood supply. Our findings suggest that rapid resupply and cold-stored chain demands may be higher than anticipated in future conflicts.

A prospective, pragmatic non-inferiority study of emergency intubation success with the single-use i-view versus standard reusable video laryngoscope.

INTRODUCTION: Video laryngoscope (VL) technology improves first-pass success. The novel i-view VL device is inexpensive and disposable. We sought to determine the first-pass intubation success with the i-view VL device versus the standard reusable VL systems in routine use at each site. METHODS: We performed a prospective, pragmatic study at two major emergency departments (EDs) when VL was used. We rotated i-view versus reusable VL as the preferred device of the month based on an a priori schedule. An investigator-initiated interim analysis was performed. Our primary outcome was a first-pass success with a non-inferiority margin of 10% based on the per-protocol analysis. RESULTS: There were 93 intubations using the reusable VL devices and 81 intubations using the i-view. Our study was stopped early due to futility in reaching our predetermined non-inferiority margin. Operator and patient characteristics were similar between the two groups. The first-pass success rate for the i-view group was 69.1% compared to 84.3% for the reusable VL group. A non-inferiority analysis indicated that the difference (-15.1%) and corresponding 90% confidence limits (-25.3% to -5.0%) did not fall within the predetermined 10% non-inferiority margin. CONCLUSIONS: The i-view device failed to meet our predetermined non-inferiority margin when compared to the reusable VL systems with the study stopping early due to futility. Significant crossover occurred at the discretion of the intubating operator during the i-view month.

A survey of low titer O whole blood use within the trauma quality improvement program registry.

INTRODUCTION: The use of low titer O whole blood (LTOWB) has expanded although it remains unclear how many civilian trauma centers are using LTOWB. METHODS: We analyzed data on civilian LTOWB recipients in the American College of Surgeons Trauma Quality Improvement Program (TQIP) database 2020-2021. Unique facility keys were used to determine the number of centers that used LTOWB in that period. RESULTS: A total of 16,603 patients received LTOWB in the TQIP database between 2020 and 2021; 6600 in 2020, and 10,003 in 2021. The total number of facilities that reported LTOWB use went from 287/779 (37%) in 2020 to 302/795 (38%) in 2021. Between 2020 and 2021, among all level 1-3 designated trauma facilities that report to TQIP LTOWB use increased at level-1 centers (118 to 129), and level-2 centers (81 to 86), but decreased in level-3 facilities (9 to 4). Among pediatric and dual pediatric-adult designated hospitals there was a decrease in the number of pediatric level-1 centers (29 to 28) capable of administering LTOWB. Among centers with either single or dual level-1 trauma center designation with adult centers, the number that administered LTOWB to injured pediatric patients also decreased from 17 to 10, respectively. CONCLUSIONS: There was an increase in the number of facilities transfusing LTOWB between 2020 and 2021. The use of LTOWB is underutilized in children at centers that have it available. These findings inform the expansion of LTOWB use in trauma.

The employment of resuscitative endovascular balloon occlusion of the aorta in deployed settings.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been often used in place of open aortic occlusion for management of hemorrhagic shock in trauma. There is a paucity of data evaluating REBOA usage in military settings. STUDY DESIGN AND METHODS: We queried the Department of Defense Trauma Registry (DODTR) for all cases with at least one intervention or assessment available within the first 72 h after injury between 2007 and 2023. We used relevant procedural codes to identify the use of REBOA within the DODTR, and we used descriptive statistics to characterize its use. RESULTS: We identified 17 cases of REBOA placed in combat settings from 2017 to 2019. The majority of these were placed in the operating room (76%) and in civilian patients (70%). A penetrating mechanism caused the injury in 94% of cases with predominantly the abdomen and extremities having serious injuries. All patients subsequently underwent an exploratory laparotomy after REBOA placement, with moderate numbers of patients having spleen, liver, and small bowel injuries. The majority (82%) of included patients survived to hospital discharge. DISCUSSION: We describe 17 cases of REBOA within the DODTR from 2007 to 2023, adding to the limited documentation of patients undergoing REBOA in military settings. We identified patterns of injury in line with previous studies of patients undergoing REBOA in military settings. In this small sample of military casualties, we observed a high survival rate.

Emergency Medicine Postgraduate Year, Laryngoscopic View, and Endotracheal Tube Placement Success.

STUDY OBJECTIVE: Prior work has found first-attempt success improves with emergency medicine (EM) postgraduate year (PGY). However, the association between PGY and laryngoscopic view - a key step in successful intubation - is unknown. We examined the relationship among PGY, laryngoscopic view (ie, Cormack-Lehane view), and first-attempt success. METHODS: We performed a retrospective analysis of the National Emergency Airway Registry, including adult intubations by EM PGY 1 to 4 resident physicians. We used inverse probability weighting with propensity scores to balance confounders. We used weighted regression and model comparison to estimate adjusted odds ratios (aOR) with 95% confidence intervals (CIs) between PGY and Cormack-Lehane view, tested the interaction between PGY and Cormack-Lehane view on first-attempt success, and examined the effect modification of Cormack-Lehane view on the association between PGY and first-attempt success. RESULTS: After exclusions, we included 15,453 first attempts. Compared to PGY 1, the aORs for a higher Cormack-Lehane grade did not differ from PGY 2 (1.01; 95% CI 0.49 to 2.07), PGY 3 (0.92; 0.31 to 2.73), or PGY 4 (0.80; 0.31 to 2.04) groups. The interaction between PGY and Cormack-Lehane view was significant (P-interaction<0.001). In patients with Cormack-Lehane grade 3 or 4, the aORs for first-attempt success were higher for PGY 2 (1.80; 95% CI 1.17 to 2.77), PGY 3 (2.96; 1.66 to 5.27) and PGY 4 (3.10; 1.60 to 6.00) groups relative to PGY 1. CONCLUSION: Compared with PGY 1, PGY 2, 3, and 4 resident physicians obtained similar Cormack-Lehane views but had higher first-attempt success when obtaining a grade 3 or 4 view.

Trauma in pregnancy: A narrative review of the current literature.

INTRODUCTION: Trauma accounts for nearly half of all deaths of pregnant women. Pregnant women have distinct physiologic and anatomic characteristics which complicate their management following major trauma. OBJECTIVE: This paper comprises a narrative review of the most recent literature informing the management of pregnant trauma patients. DISCUSSION: The incidence of trauma during pregnancy is 6-8%. The focus of clinical assessment must be on the mother, starting with the primary survey. During airway management, clinicians should consider early intubation if necessary and utilize gastric tubes to minimize the risk of aspiration. Pregnant women experience progesterone-mediated hyperventilation, and normal PaCO2 levels may portend imminent respiratory failure. Clinicians should utilize left lateral tilt in hypotensive pregnant women to displace the uterus off the inferior vena cava. Ultrasonography is an attractive imaging modality for pregnant women which is specific for ruling in intraabdominal hemorrhage but not sufficiently sensitive to exclude this diagnosis. Clinicians should not hesitate to order computed tomography imaging in unstable patients if there is diagnostic ambiguity. Cardiotocographic monitoring simultaneously assesses uterine contractions and fetal heart rate and should last at least 4 h for pregnant women following even minor abdominal trauma if their fetus has achieved viable gestational age (approximately 24 weeks). In the event of cardiac arrest, peri-mortem cesarean section may improve outcomes for the mother and fetus alike. Unique specific complications include uterine rupture and placental abruption, which require emergent resuscitation and obstetrics consultation for definitive management. Emergency clinicians should maintain a low threshold for transfer to a tertiary care center given correlations between even isolated and relatively minor traumatic injuries with adverse fetal and maternal outcomes. CONCLUSIONS: Trauma is a common cause of morbidity and mortality in pregnant women. Emergency clinicians must understand the evaluation and management of pregnant trauma patients.

Interventions associated with survival after prehospital intubation in the deployed combat setting.

INTRODUCTION: Airway compromise is the second leading cause of potentially preventable death on the battlefield. Prehospital airway management is often unavoidable in a kinetic combat environment and expected to increase in future wars where timely evacuation will be unreliable and air superiority not guaranteed. We compared characteristics of survivors to non-survivors among combat casualties undergoing prehospital airway intubation. MATERIALS AND METHODS: We requested all Department of Defense Trauma Registry (DODTR) encounters during 2007-2023 with documentation of any airway intervention or assessment within the first 72-h after injury. We conducted a retrospective cohort study of all casualties with intubation documented in the prehospital setting. We used descriptive and inferential statistical analysis to compare survivors through 7 days post injury versus non-survivors. We constructed 3 multivariable logistic regression models to test for associations between interventions and 7-day survival after adjusting for injury severity score, mechanism of injury, and receipt of sedatives, paralytics, and blood products. RESULTS: There were 1377 of 48,301 patients with documentation of prehospital intubation in a combat setting. Of these, 1028 (75%) survived through 7 days post injury. Higher proportions of survivors received ketamine, paralytic agents, parenteral opioids, and parenteral benzodiazepines; there was no difference in the proportions of survivors versus non-survivors receiving etomidate. The multivariable models consistently demonstrated positive associations between 7-day survival and receipt of non-depolarizing paralytics and opioid analgesics. CONCLUSIONS: We found an association between non-depolarizing paralytic and opioid receipt with 7-day survival among patients undergoing prehospital intubation. The literature would benefit from future multi-center randomized controlled trials to establish optimal pharmacologic strategies for trauma patients undergoing prehospital intubation.

A Contemporary Analysis of Combat-related Urological Injuries: Data From the Department of Defense Trauma Registry.

PURPOSE: There has been little to no literature published on combat-related genitourinary injuries beyond 2013. With the goal of enhancing medical readiness prior to deployment and making recommendations to improve the long-term rehabilitation of service members as they become civilians, we sought to describe the incidence of combat-related genitourinary injuries and interventions from January 1, 2007, to March 17, 2020. MATERIALS AND METHODS: We conducted a retrospective analysis of the Department of Defense Trauma Registry, which is a prospectively maintained database, for the time between 2007 and 2020. We used predefined search criteria to primarily identify any casualties that arrived at a military treatment facility with urological-based injuries. RESULTS: The registry contained 25,897 adult casualties, of which 7.2% sustained urological injuries. The median age was 25. Explosive injuries (64%) and firearms (27%) predominated. The median injury severity score was 18 (IQR 10-29). Most patients survived until hospital discharge (94%). The most frequently injured organs were the scrotum (60%), testes (53%), penis (30%), and kidneys (30%). Massive transfusion protocols were activated in 35% of all patients who sustained a urological injury and accounted for 28% of all protocols between 2007 and 2020. CONCLUSIONS: The incidence of genitourinary trauma persistently increased for both military and civilian personnel as the U.S. remained actively engaged in major military conflicts during this period. Patients with genitourinary trauma in this data set were often associated with high injury severity scores and required an increased number of immediate and long-term resources for survival and rehabilitation.

A prospective assessment of the time required to obtain one unit of fresh whole blood by civilian phlebotomists and Army laboratory technicians (68 K).

BACKGROUND: Resuscitation with blood products improves survival after major hemorrhage. Blood product administration at or near the point-of-injury (POI) amplifies this benefit. Size, weight, and cold-chain management challenges all limit the amount of blood medics can carry. Warm fresh whole blood (WFWB) transfusions from a pre-screened donor within the unit represent an alternative source of blood at the POI. We measured the time required for civilian and Army technicians performing phlebotomy frequently to obtain one unit of blood to serve as a goal metric for combat medics being trained in this skill. METHODS: We gathered demographic and experience data along with proportion of first intravenous cannulation attempt success, time to blood flow initiated, and time to unit draw complete. RESULTS: We prospectively enrolled 12 civilian phlebotomy technicians and 10 Army laboratory technicians performing whole blood collections on 50 and 68 donors respectively. The mean time from setup to needle insertion was 3.7 min for civilians versus 4.2 min for Army technicians. The mean time from blood flowing to the bag being full was 10.7 min versus 8.4 min for civilians versus Army technicians respectively. The mean bag weights were 514 g versus 522 g. First-pass intravenous cannulation success was 96% versus 98% respectively. CONCLUSIONS: We found a high first intravenous cannulation attempt success among both the civilian and Army technicians. Medians times were <5 min to obtain venipuncture and <11 min to obtain one unit. These findings provide time-based benchmarks for potential use during transfusion training among military medics.

A prospective assessment of the medic autologous blood transfusion skills for field transfusion preparation.

BACKGROUND: Data demonstrate the benefit of blood product administration near point-of-injury (POI). Fresh whole blood transfusion from a pre-screened donor provides a source of blood at the POI when resources are constrained. We captured transfusion skills data for medics performing autologous blood transfusion training. METHODS: We conducted a prospective, observational study of medics with varying levels of experience. Inexperienced medics were those with minimal or no reported experience learning the autologous transfusion procedures, versus reported experience among special operations medics. When available, medics were debriefed after the procedure for qualitative feedback. We followed them for up to 7 days for adverse events. RESULTS: The median number of attempts for inexperienced and experienced medics was 1 versus 1 (interquartile range 1-1 for both, p = .260). The inexperienced medics had a slower median time to needle venipuncture access for the donation of 7.3 versus 1.5 min, needle removal after clamping time of 0.3 versus 0.2 min, time to bag preparation of 1.9 versus 1.0 min, time to IV access for reinfusion of 6.0 versus 3.0 min, time to transfusion completion of 17.3 versus 11.0 min, and time to IV removal of 0.9 versus 0.3 min (all p < .05). We noted one administrative safety event in which an allogeneic transfusion occurred. No major adverse events occurred. Qualitative data saturated around the need for quarterly training. CONCLUSIONS: Inexperienced medics have longer procedure times when training autologous whole blood transfusion skills. This data will help establish training measures of performance for skills optimization when learning this procedure.

First-Attempt Intubation Success Among Emergency Medicine Trainees by Laryngoscopic Device and Training Year: A National Emergency Airway Registry Study.

STUDY OBJECTIVE: We compare intubation first-attempt success with the direct laryngoscope, hyperangulated video laryngoscope, and standard geometry video laryngoscope among emergency medicine residents at various postgraduate years (PGY) of training. METHODS: We analyzed prospective data from emergency department (ED) patients enrolled in the National Emergency Airway Registry from January 1, 2016 to December 31, 2018 using mixed-effects logistic regression to assess the association between PGY of training and first-attempt success by the device. RESULTS: Among 15,204 intubations performed by emergency medicine trainees, first-attempt success for PGY-1, PGY-2, and PGY3+ residents, respectively were: 78.8% (95% CI, 75.0 to 82.2%), 81.3% (79.4 to 83.0), and 83.6% (95% CI, 82.1 to 85.1) for direct laryngoscope; 87.2% (95% CI, 84.2 to 89.7), 90.4% (95% CI, 88.8 to 91.9%), and 91.2% (95% CI, 89.8 to 92.5%) for hyperangulated video laryngoscope; and 88.7% (95% CI, 86.1 to 90.9), 90.2% (95% CI, 88.7 to 91.5%), and 94.6% (95% CI 93.9 to 95.3%) for standard geometry video laryngoscope. Direct laryngoscope first-attempt success improved for PGY-2 (adjusted odds ratio [aOR],1.41; 95% CI, 1.09 to 1.82) and PGY-3+ (aOR, 1.76; 1.36 to 2.27) trainees compared to PGY-1. Hyperangulated video laryngoscope success also improved for PGY-2 (aOR, 1.51; 1.1 to 2.05) and PGY-3+ (aOR, 1.56; 1.15 to 2.13) trainees compared to PGY-1. For the standard geometry video laryngoscope, only PGY-3+ (aOR, 1.72; 1.25 to 2.36) was associated with improved first-attempt success compared to PGY-1. CONCLUSION: Each laryngoscopy device class was associated with improvement in first-attempt success as training progressed. The video laryngoscope outperformed the direct laryngoscope for all operator groups, and PGY-1 trainees achieved higher first-attempt success using a standard geometry video laryngoscope than PGY-3+ trainees using a direct laryngoscope. These findings support the conjecture that in adult patients, a direct laryngoscope should not be routinely used for the first intubation attempt unless clinical circumstances, such as the presence of a soiled airway, would favor its success. These findings need to be validated with prospective randomized clinical trials.

A Conceptual Framework for Non-Military Investigators to Understand the Joint Roles of Medical Care in the Setting of Future Large Scale Combat Operations.

As the wars in Iraq and Afghanistan end, the US military has begun to transition to the multi-domain operations concept with preparation for large scale combat operations against a near-peer adversary. In large scale combat operations, the deployed trauma system will likely see challenges not experienced during the Global War on Terrorism. The development of science and technology will be critical to close existing capability gaps and optimize casualty survival. This review comprises a framework of deployed trauma care to provide nonmilitary investigators a general understanding of our deployed trauma care system. Trauma care begins at the Role 1 which encompasses all care from the point of injury and the battalion aid station, through transport to the Role 2 or forward staged mobile surgical team such as a Forward Resuscitative Surgical Detachment. Role 1 point of injury care approximates the care delivered by Emergency Medical Services (EMS) personnel. The Battalion Aid Station approximates the care available at a freestanding emergency center with significant differences in training level of the providers, number of beds, and diagnostic capabilities. Role 2 medical care is part of an area support medical company with surgical capabilities. The Role 2 represents the first role of care which provides damage control surgery. This capability approximates a small community hospital with the primary difference being limited patient holding capacity and reduced diagnostic equipment. The Role 3 field hospital is the largest military treatment facility in the deployed setting. The Role 3 approximates a civilian level 2 trauma center with smaller holding capabilities and diagnostic abilities limited to that of a computed tomography (CT) scanner and less.

Hypothermia in the Combat Trauma Population.

BACKGROUND: The MARCH (Massive hemorrhage, Airway, Respirations, Circulation, and Hypothermia/Head injuries) algorithm taught to military medics includes interventions to prevent hypothermia. As possible sequelae from major trauma, hypothermia is associated with coagulopathy and lower survival. This paper sought to define hypothermia within our combat trauma population using an outcomes-based method, and determine clinical variables associated with hypothermia. METHODS: This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry focused on casualties who received prehospital care. A receiver operating curve was constructed and Youden's index was used to define hypothermia within the predetermined population based on mortality risk. A multivariable regression model was used to identify associations. RESULTS: There were 23,243 encounters that met the inclusion criteria for this study with patients having received prehospital care and documentation of at least one emergency department temperature. An optimal threshold of 36.2° C was found to predict mortality; 3,159 casualties had temperatures below this threshold (14%). Survival to discharge was lower among casualties with hypothermia (91% versus 98%). Hypothermic casualties were less likely to undergo blanket application (38% versus 40%). However, they had higher proportions with Hypothermia Prevention and Management Kit application (11% versus 7%) and radiant warming (2% versus 1%). On multivariable regression modeling, none of the hypothermia interventions were associated with a decreased likelihood of hypothermia. Non-hypothermia interventions associated with hypothermia included prehospital intubation (OR 1.57, 95% CI 1.45-1.69) and blood product administration. CONCLUSIONS: Hypothermia, including a single recorded low temperature in the patient care record, was associated with worse outcomes in this combat trauma population. Prehospital intubation was most strongly associated with developing hypothermia. Prehospital warming interventions were not associated with a reduction in hypothermia risk. Our dataset suggests that current methods for prehospital warming are inadequate.

A Retrospective Analysis of Combat Injury Patterns and Prehospital Interventions Associated with the Development of Sepsis.

BACKGROUND: Combat injury related wound infections are common. Untreated, these wound infections may progress to sepsis and septic shock leading to increased morbidity and mortality rates. Understanding infectious complications, patterns, progression, and correlated prehospital interventions are vital to understand the development of sepsis. We aim to analyze demographics, injury patterns, and interventions associated with sepsis in battlefield settings. MATERIALS AND METHODS: This is a secondary analysis of previously published data from the Department of Defense Trauma Registry (DoDTR) from 2007 to 2020. We searched for casualties diagnosed with sepsis (excluding line-sepsis) throughout their initial hospitalization. Regression models were used to seek associations. RESULTS: Our initial request yielded 28,950 encounters, of which 25,654 (88.6%) were adults that met inclusion, including 243 patients (0.9%) diagnosed with sepsis. Patients included US military (34%), non-North Atlantic Treaty Organization (NATO) military (33%) and humanitarian (30%) groups. Patients diagnosed with sepsis had a significantly lower survival rate than non-septic patients (78.1% vs. 95.7%, p < 0.001). There was no significant difference in administration of prehospital antibiotics between septic and the general populations (10.6% vs. 12.3%, p = 0.395). Prehospital intraosseous access (OR 1.56, 95% CI 1.27-1.91, p = 0.207) and packed red cell administration (1.63, 1.24-2.15, 0.029) were the interventions most associated with sepsis. CONCLUSIONS: Sepsis occurred infrequently in the DoDTR when evacuation from battlefield is not delayed, but despite increased intervention frequency, developing sepsis demonstrates a significant drop in survival rates. Future research would benefit from the development of risk mitigation measures.

Ketamine during resuscitation - Is it as hemodynamically perfect as we think?

INTRODUCTION: Ketamine administration in patients experiencing or at risk for hypotension is common based upon the presumption of this agent's favorable hemodynamic profile. The Compensatory Reserve Measurement (CRM) is a novel algorithm that accurately tracks systemic adequacy for delivery of oxygen (DO2) to the tissues. We present a case series of trauma patients receiving ketamine with CRM measurements to offer insight into the DO2 during resuscitation. METHODS: We captured vital signs along with analog arterial waveform data from trauma patients meeting major activation criteria using a prospective study design. Study team members tracked interventions and vital signs including systolic blood pressure (SBP), mean arterial pressure (MAP), and heart rate (HR) throughout their emergency department stay. RESULTS: Our study included 8 patients who received ketamine for intubation or analgesia (20-300 mg) and had adequate data for analysis. Most were male (88%) with a median age of 28. The most common mechanisms of injury were motor vehicle collisions (MVCs) (38%) and gunshot wounds (38%). After ketamine administration SBP, MAP, and HR all increased while the CRM exhibited minimal change. CONCLUSIONS: SBP, MAP, and HR generally appeared to increase while the CRM remained unchanged. Our findings suggest that while standard vital sign measurements appear to increase, ketamine may not improve delivery of oxygen to the tissues. This warrants further study to better understand the effects of ketamine on hemodynamics.

Extraglottic device use is rare during emergency airway management: A National Emergency Airway Registry (NEAR) study.

INTRODUCTION: Airway management is a critical component of the management of emergency department (ED) patients. The ED airway literature primarily focuses upon endotracheal intubation; relatively less is known about the ED use of extraglottic devices (EGDs). The goal of this study was to describe the frequency of use, success, and complications for EGDs among ED patients. METHODS: The National Emergency Airway Registry (NEAR) is a prospective, multi-center, observational registry. It captures data on all ED patients at participating sites requiring airway management. Intubating clinicians entered all data into an online system as soon as practical after each encounter. We conducted a secondary analysis of these data for all ED encounters in which EGD placement occurred. We used descriptive statistics to characterize these encounters. RESULTS: Of 19,071 patients undergoing intubation attempts, 56 (0.3%) underwent EGD placement. Of 25 participating sites, 13 reported no cases undergoing EGD placement; the median number of EGDs placed per site was 2 (interquartile range 1-2.5, range 1-31). Twenty-nine (54%) patients had either hypotension or hypoxia prior to the start of airway management. Clinicians reported anticipation of a difficult airway in 55% and at least one difficult airway characteristic in 93% of these patients. Forty-one encounters entailed placement of a laryngeal mask airway (LMA®) Fastrach™, 33 of whom underwent subsequent successful intubation through the EGD and 7 of whom underwent intubation by alternative methods. An additional 10 encounters utilized a standard LMA® device. Providers placed 34 (61%) EGDs during the first intubation attempt. Seventeen EGD patients (30%) experienced peri-procedure adverse events, including 14 (25%) experiencing hypoxemia. None of these patients expired due to failed airways. CONCLUSIONS: EGD use was rare in this multi-center ED registry. EGD occurred predominantly in patients with difficult airway characteristics with favorable airway management outcomes. Clinicians should consider this emergency airway device for patients with a suspected difficult airway.

An analysis of early volume resuscitation and the association with prolonged mechanical ventilation.

BACKGROUND: Previous studies have found that intravenous fluid administration within the first 24 h may be associated with prolonged mechanical ventilation (PMV). We examined the association between initial 24 h fluids and PMV in combat casualties. METHODS: This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry (DODTR). We included casualties with at least 24 h on the ventilator and no significant traumatic brain injury. The definition of PMV and associations were constructed using univariable and multivariable logistic regression models. RESULTS: We identified 1508 casualties available for analysis for this study - 1275 in the non-PMV cohort (<9 days on ventilator vs. 233 in the PMV cohort (≥9 days on ventilator). Explosives comprised the most common mechanism of injury for both groups (72% vs. 75%) followed by firearms (21% vs. 16%). The composite injury severity score (ISS) was lower in the non-PMV cohort (18 vs. 30, p < .001). There were lower volumes of all resuscitation fluid within the first 24 h in the non-PMV cohort. When adjusting for composite ISS and mechanism of injury in a multivariable logistic regression model with PMV as the outcome, crystalloid volume (unit odds ratio [UOR] 1.07) and colloid volume (UOR 1.03) were both associated with PMV. CONCLUSIONS: We found that volume of resuscitation fluids were substantially higher in the PMV cohort. Our findings suggest the need for caution with the routine use of crystalloid and colloid in the first 24 h of resuscitation.

An Analysis of 13 Years of Prehospital Combat Casualty Care: Implications for Maintaining a Ready Medical Force.

Background: Most potentially preventable deaths occur in the prehospital setting before reaching a military treatment facility with surgical capabilities. Thus, optimizing the care we deliver in the prehospital combat setting represents a ripe target for reducing mortality. We sought to analyze prehospital data within the Department of Defense Trauma Registry (DODTR). Materials and methods: We requested all encounters with any prehospital activity (e.g., interventions, transportation, vital signs) documented within the DODTR from January 2007 to March 2020 along with all hospital-based data that was available. We excluded from our search casualties that had no prehospital activity documented. Results: There were 28,950 encounters that met inclusion criteria. Of these, 25,897 (89.5%) were adults and 3053 were children (10.5%). There was a steady decline in the number of casualties encountered with the most notable decline occurring in 2014. U.S. military casualties comprised the largest proportion (n = 10,182) of subjects followed by host nation civilians (n = 9637). The median age was 24 years (interquartile range/IQR 21-29). Most were battle injuries (78.6%) and part of Operation ENDURING FREEDOM (61.8%) and Operation IRAQI FREEDOM (24.4%). Most sustained injuries from explosives (52.1%) followed by firearms (28.1%), with serious injury to the extremities (24.9%) occurring most frequently. The median injury severity score was 9 (IQR 4-16) with most surviving to discharge (95.0%). A minority had a documented medic or combat lifesaver (27.9%) in their chain of care, nor did they pass through an aid station (3.0%). Air evacuation predominated (77.9%). Conclusions: Within our dataset, the deployed U.S. military medical system provided prehospital medical care to at least 28,950 combat casualties consisting mostly of U.S. military personnel and host nation civilian care. There was a rapid decline in combat casualty volumes since 2014, however, on a per-encounter basis there was no apparent drop in procedural volume.

Imaging characteristics and CT sensitivity for pyogenic spinal infections.

BACKGROUND/OBJECTIVE: Contrast-enhanced magnetic resonance imaging (MRI) is the preferred imaging modality for diagnosing pyogenic spinal infection (PSI), but it is not always available. Our objective was to describe pyogenic spinal infection imaging characteristics in patients presenting to a community emergency department (ED) and estimate the computed tomography (CT) sensitivity for these infections. METHODS: We examined the MRI reports from a cohort of 88 PSI patients whom we enrolled in a prospective cohort study and report the prevalence of each PSI type (spinal epidural abscess/infection, vertebral osteomyelitis/discitis, septic facet, and paravertebral abscess/infection) according to contemporary nomenclature. In a 14 patient subcohort who underwent both CT and MRI studies, we report the sensitivity for each PSI from a post hoc blinded overread of the CT imaging by a single neuroradiologist. RESULTS: Of the 88 PSI patients, the median age was 55 years, and 31% were female. The PSI prevalence included: spinal epidural abscess/infection (SEA) in 61(69%), vertebral osteomyelitis/discitis (VO/D) in 54 (61%), septic facet (SF) in 15 (17%), and paravertebral abscess/infection (PVA) in 53 (60%). Of the SEAs, 82% (50/61) were associated with other spinal infections, while 18% (11/61) were isolated SEAs. The overall CT sensitivity in a masked overread was 79% (11/14) for any PSI, 83% (10/12) for any infection outside the spinal canal, and only 18% (2/11) for SEA. CONCLUSION: Patients found to have vertebral osteomyelitis/discitis, septic facet, and paravertebral infections frequently had a SEA coinfection. CT interpretation by a neuroradiologist had moderate sensitivity for infections outside the spinal canal but had low sensitivity for SEA.

Impact of video laryngoscope shape on first-attempt success during non-supine emergency department intubations.

INTRODUCTION: Laryngoscope blade shape may differentially facilitate first-attempt success in patients intubated in non-supine positions in the emergency department (ED). Therefore, we analyzed first-attempt success in ramped and upright positions stratified by hyperangulated or standard geometry video laryngoscopes (VL). METHODS: We performed a secondary analysis of the National Emergency Airway Registry (NEAR) on ED intubations from January 1, 2016 to December 31, 2018. Our primary outcome was first-attempt success, and secondary outcomes included first-attempt success without adverse events and glottic view. We included all VL intubation attempts in the ramped and upright positions on medical patients >17-years-old. We calculated adjusted odds ratios (aOR) using a multivariable logistic regression mixed-effects model with site as a random effect and blade type, obesity / morbid obesity, training level (i.e., post-graduate year), operator-perceived difficult airway, and presence of an objective difficult airway finding as fixed effects. RESULTS: Our analysis included 266 attempts with hyperangulated blades and 370 attempts with standard geometry blades in the ramped cohort, and 116 attempts with hyperangulated attempts and 55 attempts with standard geometry blades in the upright cohort. In the ramped cohort, 244 (91.7%) of hyperangulated first attempts were successful, and 341 (92.2%) of standard geometry first attempts were successful (aOR 1.02 [95% confidence interval 0.56, 1.84]). In the upright cohort, 107 (92.2%) of hyperangulated first attempts were successful, and 50 (90.9%) of standard geometry first attempts were successful (aOR 1.04 [0.28, 3.86]). There was no difference across the secondary outcomes, including first-attempt success without adverse events. CONCLUSION: Hyperangulated and standard geometry VL had similar first-attempt success in ramped and upright position intubations in the ED.