RESUMO
Major trauma frequently occurs in the deployed, combat setting and is especially applicable in the recent conflicts with explosives dominating the combat wounded. In future near-peer conflicts, we will likely face even more profound weapons including mortars and artillery. As such, the number of severely wounded will likely increase. Hypocalcemia frequently occurs after blood transfusions, secondary to the preservatives in the blood products; however, recent data suggests major trauma in and of itself is a risk factor for hypocalcemia. Calcium is a major ion involved in heart contractility; thus, hypocalcemia can lead to poor contractility. Smaller studies have linked hypocalcemia to worse outcomes, but it remains unclear what causes hypocalcemia and if intervening could potentially save lives. The objective of this study is to determine the incidence of hypocalcemia on hospital arrival and the association with survival. We are seeking to address the following scientific questions, (1) Is hypocalcemia present following traumatic injury prior to transfusion during resuscitation? (2) Does hypocalcemia influence the amount of blood products transfused? (3) To what extent is hypocalcemia further exacerbated by transfusion? (4) What is the relationship between hypocalcemia following traumatic injury and mortality? We will conduct a multicenter, prospective, observational study. We will gather ionized calcium levels at 0, 3, 6, 12, 18, and 24 hours as part of scheduled calcium measurements. This will ensure we have accurate data to assess the early and late effects of hypocalcemia throughout the course of resuscitation and hemorrhage control. These data will be captured by a trained study team at every site. Our findings will inform clinical practice guidelines and optimize the care delivered in the combat and civilian trauma setting. We are seeking 391 patients with complete data to meet our a priori inclusion criteria. Our study will have major immediate short-term findings including risk prediction modeling to assess who is at risk for hypocalcemia, data assessing interventions associated with the incidence of hypocalcemia, and outcome data including mortality and its link to early hypocalcemia.
Assuntos
Cálcio , Hipocalcemia , Humanos , Hipocalcemia/diagnóstico , Hipocalcemia/epidemiologia , Hipocalcemia/etiologia , Estudos Prospectivos , Hemorragia/complicações , Transfusão de Sangue , Cálcio da DietaRESUMO
INTRODUCTION: Within the Military Health System, the process of transporting patients from an initial point of injury and throughout the entire continuum of care is called "en route care." A Committee on En Route Combat Casualty Care was established in 2016 as part of the DoD Joint Trauma System to create practice guidelines, recommend training standards, and identify research priorities within the military en route care system. MATERIALS AND METHODS: Following an analysis of currently funded research, future capabilities, and findings from a comprehensive scoping study, members of a sub-working group for research identified the top research priorities that were needed to better guide evidence-based decisions for practice and policy, as well as the future state of en route care. RESULTS: Based on the input from the entire committee, 10 en route care research topics were rank-ordered in the following manner: (1) medical documentation, (2) clinical decision support, (3) patient monitoring, (4) transport physiology, (5) transfer of care, (6) maintaining normothermia, (7) transport timing following damage control resuscitation or surgery, (8) intelligent tasking, (9) commander's risk assessment, and (10) unmanned transport. Specific research questions and technological development needs were further developed by committee members in an effort to guide future research and development initiatives that can directly support operational en route care needs. The research priorities reflect three common themes, which include efforts to enhance or increase care provider capability and capacity; understand the impact of transportation on patient physiology; and increase the ability to coordinate, communicate, and facilitate patient movement. Technology needs for en route care must support interoperability of medical information, equipment, and supplies across the global military health system in addition to adjusting to a dynamic transport environment with the smallest possible weight, space, and power requirements. CONCLUSIONS: To ensure an evidence-based approach to future military conflicts and other medical challenges, focused research and technological development to address these 10 en route care research gaps are urgently needed.
Assuntos
Militares , Humanos , Monitorização Fisiológica , Pesquisa , RessuscitaçãoRESUMO
BACKGROUND: Amid the ongoing U.S. opioid crisis, achieving safe and effective chronic pain management while reducing opioid-related morbidity and mortality is likely to require multi-level efforts across health systems, including the Military Health System (MHS), Department of Veterans Affairs (VA), and civilian sectors. OBJECTIVE: We conducted a series of qualitative panel discussions with national experts to identify core challenges and elicit recommendations toward improving the safety of opioid prescribing in the U.S. DESIGN: We invited national experts to participate in qualitative panel discussions regarding challenges in opioid risk mitigation and how best to support providers in delivery of safe and effective opioid prescribing across MHS, VA, and civilian health systems. PARTICIPANTS: Eighteen experts representing primary care, emergency medicine, psychology, pharmacy, and public health/policy participated. APPROACH: Six qualitative panel discussions were conducted via teleconference with experts. Transcripts were coded using team-based qualitative content analysis to identify key challenges and recommendations in opioid risk mitigation. KEY RESULTS: Panelists provided insight into challenges across multiple levels of the U.S. health system, including the technical complexity of treating chronic pain, the fraught national climate around opioids, the need to integrate surveillance data across a fragmented U.S. health system, a lack of access to non-pharmacological options for chronic pain care, and difficulties in provider and patient communication. Participating experts identified recommendations for multi-level change efforts spanning policy, research, education, and the organization of healthcare delivery. CONCLUSIONS: Reducing opioid risk while ensuring safe and effective pain management, according to participating experts, is likely to require multi-level efforts spanning military, veteran, and civilian health systems. Efforts to implement risk mitigation strategies at the patient level should be accompanied by efforts to increase education for patients and providers, increase access to non-pharmacological pain care, and support use of existing clinical decision support, including state-level prescription drug monitoring programs.
Assuntos
Analgésicos Opioides/efeitos adversos , Dor Crônica/terapia , Manejo da Dor/métodos , Padrões de Prática Médica/organização & administração , Programas de Monitoramento de Prescrição de Medicamentos/organização & administração , Analgésicos Opioides/normas , Sistemas de Apoio a Decisões Clínicas/organização & administração , Prescrições de Medicamentos/normas , Feminino , Humanos , Colaboração Intersetorial , Masculino , Serviços de Saúde Militar/normas , Epidemia de Opioides , Educação de Pacientes como Assunto/organização & administração , Padrões de Prática Médica/normas , Uso Indevido de Medicamentos sob Prescrição/prevenção & controle , Programas de Monitoramento de Prescrição de Medicamentos/normas , Atenção Primária à Saúde/organização & administração , Atenção Primária à Saúde/normas , Pesquisa Qualitativa , Estados Unidos/epidemiologia , United States Department of Veterans Affairs/organização & administração , United States Department of Veterans Affairs/normasRESUMO
INTRODUCTION: Non-medical use and abuse of prescription opioids is a growing problem in both the civilian and military communities, with minimal technologies for detecting hydrocodone use. This study explored the proteomic changes that occur in the oral fluid and blood plasma following controlled hydrocodone administration in 20 subjects. METHODS: The global proteomic profile was determined for samples taken at four time points per subject: pre-exposure and 4, 6, or 168 hours post-exposure. The oral fluid samples analyzed herein provided greater differentiation between baseline and response time points than was observed with blood plasma, at least partially due to significant person-to-person relative variability in the plasma proteome. RESULTS: A total of 399 proteins were identified from oral fluid samples, and the abundance of 118 of those proteins was determined to be significantly different upon metabolism of hydrocodone (4 and 6 hour time points) as compared to baseline levels in the oral fluid (pre-dose and 168 hours). CONCLUSIONS: We present an assessment of the oral fluid and plasma proteome following hydrocodone administration, which demonstrates the potential of oral fluid as a noninvasive sample that may reveal features of hydrocodone in opioid use, and with additional study, may be useful for other opioids and in settings of misuse.
Assuntos
Analgésicos Opioides/administração & dosagem , Proteínas Sanguíneas/metabolismo , Hidrocodona/administração & dosagem , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Proteoma , Proteômica , Saliva/metabolismo , Detecção do Abuso de Substâncias , Adulto , Cromatografia Líquida de Alta Pressão , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/sangue , Valor Preditivo dos Testes , Extração em Fase Sólida , Espectrometria de Massas por Ionização por Electrospray , Espectrometria de Massas em Tandem , Fatores de Tempo , Adulto JovemRESUMO
INTRODUCTION: Survival from traumatic cardiopulmonary arrest (TCA) has been reported at a rate as low as 0-2.6% in the civilian pre-hospital setting, and many consider resuscitation of this group to be futile. The aim of this investigation was to describe patients who received cardiac massage during TCA in a battlefield setting; we also aimed to identify predictors of survival. METHODS: We conducted a review of the Department of Defense Trauma Registry to identify patients who received cardiac massage in the battlefield between 2007 and 2014. Patients were also grouped according to location of cardiac arrest: pre-hospital (PH) and in-hospital (IH). The groups were compared and evaluated by injury, transport time, type of resuscitation, and pre-hospital procedures. Outcome variables included survival to discharge and 30-day survival. Categorical variables were analysed using chi-square or Fisher's exact tests. Wilcoxon tests were performed for continuous variables. Regression modelling was used to assess for predictors of survival. RESULTS: 75 of all 582 patients (13%, 95% CI 10-16) survived to 30 days, and all survivors were transported out of the battlefield; 23 PH (7.8%, 95% CI 5.2-12) and 52 IH (17%, 95% CI 13-22) patients survived to 30 days (p < 0.001). Closed-chest cardiac massage with the administration of intravenous medications was associated with 30-day survival among IH patients. CONCLUSIONS: We report a 13% survival to 30 days among all patients receiving cardiac massage in a battlefield setting. Closed-chest cardiac massage predicted survival among IH TCA victims who also received intravenous medications in this review of combat-related TCA.
Assuntos
Fármacos Cardiovasculares/administração & dosagem , Serviços Médicos de Emergência/métodos , Parada Cardíaca , Massagem Cardíaca , Serviços de Saúde Militar/estatística & dados numéricos , Ferimentos e Lesões/complicações , Administração Intravenosa , Adulto , Reanimação Cardiopulmonar/métodos , Reanimação Cardiopulmonar/estatística & dados numéricos , Feminino , Parada Cardíaca/etiologia , Parada Cardíaca/mortalidade , Parada Cardíaca/terapia , Massagem Cardíaca/métodos , Massagem Cardíaca/mortalidade , Massagem Cardíaca/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Prognóstico , Sistema de Registros/estatística & dados numéricos , Análise de Sobrevida , Estados Unidos/epidemiologia , Ferimentos e Lesões/diagnósticoRESUMO
Operation Enduring Freedom (OEF-A) in Afghanistan and Operation Iraqi Freedom (OIF) represent the first major, sustained wars in which emergency physicians (EPs) fully participated as an integrated part of the military's health system. EPs proved invaluable in the deployments, and they frequently used the full spectrum of trauma and medical care skills. The roles EPs served expanded over the years of the conflicts and demonstrated the unique skill set of emergency medicine (EM) training. EPs supported elite special operations units, served in medical command positions, and developed and staffed flying intensive care units. EPs have brought their combat experience home to civilian practice. This narrative review summarizes the history, contributions, and lessons learned by EPs during OEF-A/OIF and describes changes to daily clinical practice of EM derived from the combat environment.
Assuntos
Medicina de Emergência/educação , Medicina de Emergência/métodos , Militares/estatística & dados numéricos , Médicos/estatística & dados numéricos , Guerra , Campanha Afegã de 2001- , Humanos , Guerra do Iraque 2003-2011 , Traumatismo Múltiplo , Alocação de RecursosRESUMO
Emergency department (ED) providers have limited time to evaluate patients at risk for opioid misuse. A validated tool to assess the risk for aberrant opioid behavior may mitigate adverse sequelae associated with prescription opioid misuse. We sought to determine if SOAPP-R, COMM, and provider gestalt were able to identify patients at risk for prescription opioid misuse as determined by pharmacy records at 12 months. We conducted a prospective observational study of adult patients in a high volume US ED. Patients completed the SOAPP-R and COMM, and treating EM providers evaluated patients' opioid misuse risk. We performed variable-centered, person-centered, and hierarchical cluster analyses to determine whether provider gestalt, SOAPP-R, or COMM, or a combination, predicted higher misuse risk. The primary outcome was the number of opioid prescriptions at 12 months according to pharmacy records. For 169 patients (mean age 43 years, 51% female, 73% white), correlation analysis showed a strong relationship between SOAPP-R and COMM with predicting the number of opioid prescriptions dispensed at 12 months. Provider scores estimating opioid misuse were not related to SOAPP-R and only weakly associated with COMM. In our adjusted regression models, provider gestalt and SOAPP-R uniquely predicted opioid prescriptions at 6 and 12 months. Using designated cutoff scores, only SOAPP-R detected a difference in the number of opioid prescriptions. Cluster analysis revealed that provider gestalt, SOAPP-R, and COMM scores jointly predicted opioid prescriptions. Provider gestalt and self-report instruments uniquely predicted the number of opioid prescriptions in ED patients. A combination of gestalt and self-assessment scores can be used to identify at-risk patients who otherwise miss the cutoff scores for SOAPP-R and COMM.
Assuntos
Serviço Hospitalar de Emergência/tendências , Programas de Rastreamento/métodos , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Medição da Dor/normas , Adulto , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Distribuição de Qui-Quadrado , Serviço Hospitalar de Emergência/organização & administração , Feminino , Humanos , Masculino , Programas de Rastreamento/estatística & dados numéricos , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Dor/tratamento farmacológico , Medição da Dor/métodos , Estudos Prospectivos , Medição de Risco/métodos , Estatísticas não ParamétricasRESUMO
BACKGROUND: Drug overdose has become a leading cause of death in the United States and is a growing issue in civilian and military populations. Increasing prescription drug misuse and poisonings translate into greater utilization of medical resources. Our objective was to describe the incidences of overdoses and their associated events and outcomes following emergency department consult. METHODS: We performed a retrospective cohort study on cases evaluated in 2 military hospital emergency departments over 3 years. Subjects were identified using International Classification of Diseases, 9th Revision codes 960-970. Variables collected included demographics, military service, method of arrival, vital signs, clinical complications, and hospital admission, if overdose was documented as intentional or unintentional and drug ingested. RESULTS: Over 3 years, 342 overdoses were treated. Mean age was 35 ± 19 and gender was 53% female. 47% were active duty and 32% were dependents. 21% of overdoses involved benzodiazepines and 20% opioids. Active duty and benzodiazepine overdoses were more likely to arrive by ambulance (p = 0.0006, p = 0.03), were more likely to have overdosed intentionally (p = 0.02, p = 0.009), and were more likely to be admitted (p = 0.04, p = 0.007). Active duty had a longer length of stay (p = 0.02). CONCLUSION: Overdoses involving the active duty population and benzodiazepines consume greater military health care resources than other overdoses.
Assuntos
Overdose de Drogas/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Militares/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Benzodiazepinas/efeitos adversos , Benzodiazepinas/toxicidade , Overdose de Drogas/terapia , Serviço Hospitalar de Emergência/economia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/complicações , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES: Oseltamivir (Tamiflu) is approved by the Food and Drug Administration and is advertised for the treatment of influenza types A and B. Patient perceptions of its efficacy have not been adequately studied. Recent systematic reviews have called the benefits of this drug into question relative to the cost and adverse effect profile. We hypothesized that most people would be unaware of the efficacy, cost, or adverse effect profile of the drug. Our objective was to determine patient perceptions of efficacy, cost, and adverse effect profile of oseltamivir for the treatment of influenza. METHODS: This was a cross-sectional, multiple-choice, open-response survey of adult patients and adult caregivers of pediatric patients who presented to the emergency department (ED) with flu-like symptoms. Flu-like symptoms were defined as any respiratory symptom plus fever or body aches. The study took place during the 2014-2015 flu season at a rural ED. We analyzed the data, with descriptive statistics reported as frequencies/percentages for categorical data. Survey data collected as Likert scale data were summarized using mean, median, and mode. RESULTS: During the 4-month period, 70 surveys were completed. A total of 67% of the participants were women, with 84% younger than 40 years. Subjects younger than 40 years were more likely to have seen advertising for oseltamivir (31% vs 0%, P = 0.04). Less than half reported having received the flu vaccine that year. Most reported that oseltamivir was an effective treatment for the flu. Most overstated the perceived efficacy of oseltamivir. Most were not willing to take the medication if it had adverse effects, with the most deterring adverse effects being potential kidney and liver injury. CONCLUSIONS: In our study most patients reported overly positive expectations for the efficacy of oseltamivir for treating influenza. Most reported that commonly listed adverse effects would deter their use of the medication.
Assuntos
Antivirais/uso terapêutico , Conhecimentos, Atitudes e Prática em Saúde , Influenza Humana/tratamento farmacológico , Oseltamivir/uso terapêutico , Adolescente , Adulto , Antivirais/efeitos adversos , Antivirais/economia , Estudos Transversais , Custos de Medicamentos , Escolaridade , Feminino , Humanos , Masculino , Oseltamivir/efeitos adversos , Oseltamivir/economia , Resultado do Tratamento , Adulto JovemRESUMO
Cyanide toxicity is common after significant smoke inhalation. Two cases are presented that provide framework for the discussion of epidemiology, pathogenesis, presenting signs and symptoms, and treatment options of inhalational cyanide poisoning. An evidence-based algorithm is proposed that utilizes point-of-care testing to help physicians identify patients who benefit most from antidotal therapy.
Assuntos
Antídotos/uso terapêutico , Medicina de Emergência Baseada em Evidências , Intoxicação por Gás/tratamento farmacológico , Cianeto de Hidrogênio/toxicidade , Lesão por Inalação de Fumaça/complicações , Centros Médicos Acadêmicos , Algoritmos , Antídotos/efeitos adversos , Biomarcadores/sangue , Terapia Combinada/efeitos adversos , Árvores de Decisões , Bolsas de Estudo , Feminino , Intoxicação por Gás/complicações , Intoxicação por Gás/diagnóstico , Intoxicação por Gás/terapia , Humanos , Cianeto de Hidrogênio/antagonistas & inibidores , Hidroxocobalamina/efeitos adversos , Hidroxocobalamina/uso terapêutico , Masculino , Massachusetts , Testes Imediatos , Lesão por Inalação de Fumaça/sangue , Lesão por Inalação de Fumaça/terapia , Toxicologia/educação , Recursos HumanosRESUMO
OBJECTIVES: The Review Committee for Emergency Medicine (RC-EM) requirement for scholarly activity, which programs may define as an original research project or some other form of scholarly activity, applies to all EM residents. The objectives of this study were to: 1) describe the percentage of residency programs that require an original research project to meet the RC-EM requirement for scholarly activity, 2) describe specific challenges and resources for residents completing the RC-EM scholarly activity requirement, and 3) identify associations between the interpretation of the requirement and early career outcomes. METHODS: This was a cross-sectional online survey of program or research directors from all U.S. allopathic EM residency programs. Respondents were queried about key demographics and domains relating to research curriculum, resources, expectations, outcomes, challenges, and future opportunities. Data were analyzed using descriptive statistics. RESULTS: The overall response rate was 113 of 156 (72%) EM residency programs. Respondents were more likely to represent university-based programs, but otherwise did not differ from nonrespondents across key demographic criteria. An original research project was required by 39% of responding programs, with a minimum deliverable in 93% of these programs. Program directors listed data collection and study design as the principle challenges residents face while completing their scholarly activities. Faculty mentorship, biostatistical support, and travel support were common resources reportedly available to residents. Comparison of programs with an original research requirement to those without revealed many differences in outcomes. Programs with a research requirement were more likely to have residents with oral or poster presentations (46% vs. 25%, mean difference = 21%, 95% confidence interval [CI] = 16% to 28%), published manuscripts (25% vs. 18%, mean difference = 7%, 95% CI = 2% to 10%), entering fellowship training after residency (27% vs. 20%, mean difference = 7%, 95% CI = 4% to 10%), and using a biostatistician (64% vs. 28%, median difference = 26%, 95% CI = 24% to 28%). There were no statistically significant differences in other evaluations of resources or outcome measures, including resident choice of academic career after leaving residency. CONCLUSIONS: There is no consistent interpretation and implementation of the RC-EM requirement for scholarly activity among EM residency programs. Residency programs requiring an original research project were more likely to have residents with accepted oral or poster presentations, published manuscripts, and entering fellowships after residency training.
Assuntos
Medicina de Emergência/educação , Internato e Residência/estatística & dados numéricos , Pesquisa/estatística & dados numéricos , Estudos Transversais , Currículo , Coleta de Dados , Bolsas de Estudo , Humanos , Mentores , Projetos de Pesquisa , Inquéritos e Questionários , Estados UnidosRESUMO
Poison centers save money and lives. Individual patients and their doctors benefit from local poison center availability, as do healthcare facilities and insurance companies. All have a stake in a stable poison control system. It is likely that the greatest contribution of poison control centers to society has yet to be realized. Poison control centers already possess an efficient, realtime surveillance mechanism (TESS). With increased funding, this can be expanded and made more available outside the poison control community. TESS can be used to detect chemical releases or attacks and environmental and infectious disease outbreaks as they occur - long before individual healthcare providers could connect the dots. In conclusion, while the value of a nationwide poison control system to society is well recognized, its future is not as clear. Establishing a stable system to monitor and treat poisonings in the US will take political will at the local, state, and federal levels to ensure full funding for years to come.