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.

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.

Short-term Complications for Proximal Humerus Fracture Surgery Have Decreased: An Analysis of the National Surgical Quality Improvement Program Database.

BACKGROUND: Multiple surgical treatments exist for proximal humerus fractures (PHFs), but current practice patterns and short-term complication profiles remain poorly understood. This is in part due to changes in treatment paradigms over the past decade. A more thorough understanding of the evolution in management over this time as well as an appreciation of the preoperative factors associated with both the chosen surgical modality and short-term complications will help inform future surgical considerations. QUESTIONS/PURPOSES: In this study, we sought to: (1) characterize trends in the surgical management of PHFs over time, including usage rates of various surgical modalities and changes in complication rates; (2) identify preoperative variables associated with the selection of surgical modality; and (3) assess the independent covariates of acute 30-day complications, including demographic variables, injury characteristics, and treatment type. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried using Current Procedural Terminology and ICD-9 and ICD-10 codes to identify individuals with PHF undergoing open reduction and internal fixation (ORIF), hemiarthroplasty (HA), or reverse total shoulder arthroplasty (RTSA) from 2007 to 2018. The NSQIP database was utilized because of its collection of detailed preoperative demographic information and large repository of clinically derived data, which is felt to be more accurate than claims or administrative data. In total, 5889 patients with PHFs met the inclusion criteria. Patients 17 years or older were included. Patients with isolated greater tuberosity, humeral shaft, and distal humerus fractures; nonunions; malunions; and those undergoing revision procedures were excluded. A Cochran-Armitage test was used to evaluate surgical trends over time. Multivariable logistic regression models were created to identify covariates associated with surgical modality and complications. Although complications were either classified as major or minor, specific complications were also individually analyzed to avoid potentially misleading conclusions associated with pooling. RESULTS: The proportion of patients with PHFs undergoing RTSA (4% in 2007 and 34% in 2018; p < 0.001) and ORIF (46% in 2007 and 57% in 2018; p < 0.001) increased over time, and the proportion of those undergoing HA (50% in 2007 and 9% in 2018; p < 0.001) decreased. Across each surgical modality, minor complication rates decreased over time (RTSA: 10% in 2018; p < 0.001; ORIF: 5% in 2018; p = 0.01; and HA: 6% in 2018; p = 0.01). After controlling for confounding variables like diabetes, chronic obstructive pulmonary disease, congestive heart failure, dialysis, and preoperative blood transfusion, the following factors were independently associated with an increased odds of a patient undergoing RTSA rather than HA: older age, higher BMI, independent functional status, and smoking. The following factors were independently associated with a decreased odds of a patient undergoing ORIF rather than RTSA and HA: older age, higher BMI, higher American Society of Anesthesiologists (ASA) classification, smoking, steroid/immunosuppressant use, as well as three- and four-part fractures. After controlling for age, ASA classification, functional status, and preoperative blood transfusion, we also found that in the latter part of the study period, arthroplasty (RTSA and HA) was no longer independently associated with 30-day major or minor complications compared with ORIF. CONCLUSION: The increasing utilization of RTSA and decreasing short-term complication rates for fixation and arthroplasty alike represent a substantial change compared even with recent historic norms in the management of proximal humerus fractures. Quantifying demographics, injury characteristics, and comorbidities associated with both the choice of surgical modality and complications serves as the groundwork for decision support tools, which can inform patients and surgeons of the probability of a particular surgical modality being chosen and the risk of complications, based on national benchmarks. Future studies should investigate longer term complication rates, as many differences between the approaches being compared might occur beyond the perioperative period and our study had no means to address questions about complications beyond that period, but obviously those must be considered when choosing a treatment for patients with these injuries. Future work might also investigate the mechanisms behind the decreasing rates of short-term complications. LEVEL OF EVIDENCE: Level III, therapeutic study.

Comparison Between a Color-only Method and a Food and Drug Administration-approved Validation Method for a Pediatric Color-coded Syringe Using Midazolam: A Randomized Crossover Trial.

OBJECTIVE: The objective of this study was to assess the use of a color-only method syringe for accuracy and timeliness when administrating midazolam. This method was compared with a U.S. Food and Drug Administration (FDA)-approved validation method. METHODS: A prospective, randomized, crossover trial was conducted to compare the dosing accuracy and timeliness of the color-only syringe method versus the validation method. Twenty-five participants prepared pediatric midazolam doses according to their preferred method, a FDA-approved validation method, and a color-only method. Primary endpoints included dosing accuracy and time to medication administration. RESULTS: The preferred 3-kg calculations had a median margin of error of 5.6% and a median time to completion of 55.6 seconds. The color-only method took less time to complete than the validation method (median time: 29.5 seconds vs 58.2 seconds). There was no statistically significant difference in errors between the color-only method and the validation method. None of the participants reported a mistake using the color-only method, whereas 25% (5/20) reported a mistake using the validation method. Only 20% (4/20) of participants believed that the validation method found or eliminated any mistakes. There were 8 medication errors identified when participants used the method of choice, 4 with the validation method, and 1 with the color-only method. CONCLUSIONS: There was no significant difference in dosing errors between the FDA-approved validation method and the color-only method. Use of a color-only method did reduced time to medication administration when compared with a preferred method and an FDA-approved validation method.

Descriptive Analysis of Coronavirus Disease 2019 Air Medical Evacuations by Critical Care Air Transport Teams.

OBJECTIVE: Preserving air medical evacuation capabilities for critically ill patients with coronavirus disease 2019 (COVID-19) required innovation for en route care logistics, training, and equipment. The aim of this study was to describe characteristics and in-flight interventions for patients with suspected COVID-19 requiring air medical evacuation by US Air Force critical care air transport teams (CCATTs). METHODS: We performed a retrospective chart review of patients with suspected COVID-19 requiring air medical evacuation by CCATT from April 2020 to February 2021. We included patients with an available CCATT medical record and transport with COVID-19 infection isolation precautions. CCATT medical records were the data source, and we performed descriptive analyses of patient characteristics and in-flight interventions. RESULTS: We reviewed 460 records and identified 16 patients for inclusion. The Transport Isolation System (50%) and Negatively Pressurized Conex (31%) were commonly used portable biocontainment units. The median patient age was 48.5 years, and 94% were male. All patients required oxygen supplementation, with 8 (50%) receiving mechanical ventilation. In-flight interventions among intubated patients (n = 8) included vasopressors (50%), paralytics (25%), and patient-ventilator asynchrony management (63%). CONCLUSION: Patients with COVID-19 requiring CCATT transport were older than prior military en route care cohorts, and in-flight interventions for patient-ventilator asynchrony were commonly required during mechanical ventilation.

Efficacy of the compensatory reserve measurement in an emergency department trauma population.

BACKGROUND: The Compensatory Reserve Measurement (CRM) is a novel method used to provide early assessment of shock based on arterial wave form morphology changes. We hypothesized that (1) CRM would be significantly lower in those trauma patients who received life-saving interventions compared with those not receiving interventions, and (2) CRM in patients who received interventions would recover after the intervention was performed. STUDY DESIGN AND 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 throughout their emergency department stay. RESULTS: Ninety subjects met inclusion with 13 receiving a blood product and 10 a major airway intervention. Most trauma was blunt (69%) with motor vehicle collisions making up the largest proportion (37%) of injury mechanism. Patients receiving blood products had lower CRM values just prior to administration versus those who did not (50% versus 58%, p = .045), and lower systolic pressure (SBP; 95 versus 123 mmHg, p = .005), diastolic (DBP; 62 versus 79, p = .007), and mean arterial pressure (MAP; 75 versus 95, p = .006), and a higher pulse rate (HR; 101 versus 89 bpm, p = .039). Patients receiving an airway intervention had lower CRM values just prior to administration versus those who did not (48% versus 58%, p = .062); however, SBP, DBP, MAP, and HR were not statistically distinguishable (p ≥ .645). CONCLUSIONS: Our results support our hypotheses that the CRM distinguished those patients who received blood or an airway intervention from those who did not, and increased appropriately after interventions were performed.

Prospective Randomized Trial of Standard Left Anterolateral Thoracotomy Versus Modified Bilateral Clamshell Thoracotomy Performed by Emergency Physicians.

STUDY OBJECTIVE: Resuscitative thoracotomy is a time-sensitive, lifesaving procedure that may be performed by emergency physicians. The left anterolateral thoracotomy (LAT) is the standard technique commonly used in the United States to gain rapid access to critical intrathoracic structures. However, the smaller incision and subsequent limited exposure may not be optimal for the nonsurgical specialist to complete time-sensitive interventions. The modified bilateral anterior clamshell thoracotomy (MCT) developed by Barts Health NHS Trust clinicians at London's Air Ambulance overcomes these inherent difficulties, maximizes thoracic cavity visualization, and may be the ideal technique for the nonsurgical specialist. The aim of this study is to identify the optimal technique for the nonsurgical-specialist-performed resuscitative thoracotomy. Secondary aims of the study are to identify technical difficulties, procedural concerns, and physician preferences. METHODS: Emergency medicine staff and senior resident physicians were recruited from an academic Level I trauma center. Subjects underwent novel standardized didactic and skills-specific training on both the MCT and LAT techniques. Later, subjects were randomized to the order of intervention and performed both techniques on separate fresh, nonfrozen human cadaver specimens. Success was determined by a board-certified surgeon and defined as complete delivery of the heart from the pericardial sac and subsequent 100% occlusion of the descending thoracic aorta with a vascular clamp. The primary outcome was time to successful completion of the resuscitative thoracotomy technique. Secondary outcomes included successful exposure of the heart, successful descending thoracic aortic cross clamping, successful procedural completion, time to exposure of the heart, time to descending thoracic aortic cross-clamp placement, number and type of iatrogenic injuries, correct anatomic structure identification, and poststudy participant questionnaire. RESULTS: Sixteen emergency physicians were recruited; 15 met inclusion criteria. All participants were either emergency medicine resident (47%) or emergency medicine staff (53%). The median number of previously performed training LATs was 12 (interquartile range 6 to 15) and the median number of previously performed MCTs was 1 (interquartile range 1 to 1). The success rates of our study population for the MCT and LAT techniques were not statistically different (67% versus 40%; difference 27%; 95% confidence interval -61% to 8%). However, staff emergency physicians were significantly more successful with the MCT compared with the LAT (88% versus 25%; difference 63%; 95% CI 9% to 92%). Overall, the MCT also had a significantly higher proportion of injury-free trials compared with the LAT technique (33% versus 0%; difference 33%; 95% CI 57% to 9%). Physician procedure preference favored the MCT over the LAT (87% versus 13%; difference 74%; 95% CI 23% to 97%). CONCLUSION: Resuscitative thoracotomy success rates were lower than expected in this capable subject population. Success rates and procedural time for the MCT and LAT were similar. However, the MCT had a higher success rate when performed by staff emergency physicians, resulted in less periprocedural iatrogenic injuries, and was the preferred technique by most subjects. The MCT is a potentially feasible alternative resuscitative thoracotomy technique that requires further investigation.

Impact of a Standardized EMS Handoff Tool on Inpatient Medical Record Documentation at a Level I Trauma Center.

BACKGROUND: The emergency department (ED) poses challenges to effective handoff from emergency medical services (EMS) personnel to ED staff. Despite the importance of a complete and accurate patient handoff report between EMS and trauma staff, communication is often interrupted, incomplete, or otherwise ineffective. The Mechanism of injury/Medical Complaint, Injuries or Inspections head to toe, vital Signs, and Treatments (MIST) report initiative was implemented to standardize the handoff process. The objective of this study was to evaluate whether documentation of prehospital care in the inpatient medical record improved after MIST implementation. METHODS: Research staff abstracted data from the EMS and inpatient medical records of trauma patients transported by EMS and treated at a Level I trauma center from January 2015 through June 2017. Data included patient demographics, mechanism and location of injury, vital signs, treatments, and period of data collection (pre-MIST and post-MIST). We summarized the MIST elements in EMS and inpatient medical records and assessed the presence or absence of data elements in the inpatient record from the EMS record and the agreement between the two sets of records over time to determine if implementation of MIST improved documentation. RESULTS: We analyzed data from 533 trauma patients transported by EMS and treated in a Level I trauma center (pre-MIST: n = 281; post-MIST: n = 252). For mechanism of injury, agreement between the two records was ≥96% before and after MIST implementation. Cardiac arrest and location of injury were under-reported in the inpatient record before MIST; post-MIST, there were no significant discrepancies, indicating an improvement in reporting. Reporting of prehospital hypotension improved from 76.5% pre-MIST to 83.3% post-MIST. After MIST implementation, agreement between the EMS and inpatient records increased for the reporting of fluid administration (45.6% to 62.7%) and decreased for reporting of pain medications (72.2% to 61.9%). CONCLUSIONS: The use of the standardized MIST tool for EMS to hospital patient handoff was associated with a mixed value on inpatient documentation of prehospital events. After MIST implementation, agreement was higher for mechanism and location of injury and lower for vital signs and treatments. Further research can advance the prehospital to treatment facility handoff process.

Pediatric Prehospital Intraosseous Access During Combat Operations in Iraq and Afghanistan.

BACKGROUND: Vascular access in critically ill pediatric patients can be challenging with delays potentially leading to worse outcomes. Intraosseous (IO) access has a low rate of complications and can be utilized to administer lifesaving medications. Combat medics are trained to treat adults but may also be required to treat children in the deployed setting. Vascular access in children can be challenging, especially in a hypovolemic state. There are limited data on prehospital lifesaving interventions in children in the combat setting. We sought to characterize the use of IO access in pediatric patients who sustained trauma in the combat setting. METHODS: We queried the Department of Defense Trauma Registry for all pediatric patients admitted to fixed-facilities and forward surgical teams in Iraq and Afghanistan from January 2007 to January 2016. Within that population, we searched for all subjects with a documented prehospital IO or intravenous (IV) access obtained. Subjects with both an IO and IV documented were placed into the IO category. We separated subjects by age groupings: younger than 1, 1 to 4, 5 to 9, 10 to 14, and 15 to 17 years. RESULTS: During the study period, there were 3439 subjects 17 years or younger. There were 177 in the IO cohort and 803 in the IV cohort. Most subjects in the IO cohort were in the 10- to 14-year-old age group (35.6%), male (79.1%), located in Afghanistan (95.5%), and injured by explosive (52.0%), with lower survival rates than the IV cohort (68.9% vs 90.7%, P < 0.001). Hemostatic dressing application, tourniquet application, intubation, cardiopulmonary resuscitation, sedative administration, ketamine administration, and paralytic administration were all higher in the IO cohort. CONCLUSIONS: Pediatric IO placement in the prehospital setting occurred infrequently. Pediatric subjects receiving an IO had higher injury severity scores and higher mortality rates compared with those who received an IV only. Intraosseous use appears to be used more often in critically ill pediatric subjects.

The Effect of Chest Compression Location and Occlusion of the Aorta in a Traumatic Arrest Model.

BACKGROUND: Recent evidence demonstrates that closed chest compressions directly over the left ventricle (LV) in a traumatic cardiac arrest (TCA) model improve hemodynamics and return of spontaneous circulation (ROSC) when compared with traditional compressions. Resuscitative endovascular balloon occlusion of the aorta (REBOA) also improves hemodynamics and controls hemorrhage in TCA. We hypothesized that chest compressions located over the LV would result in improved hemodynamics and ROSC in a swine model of TCA using REBOA. MATERIALS AND METHODS: Transthoracic echo was used to mark the location of the aortic root (traditional location) and the center of the LV on animals (n = 26), which were randomized to receive chest compressions in one of the two locations. After hemorrhage, ventricular fibrillation was induced to simulate TCA. After a period of 10 min of ventricular fibrillation, basic life support (BLS) with mechanical cardiopulmonary resuscitation was initiated and performed for 10 min followed by advanced life support for an additional 10 min. REBOA balloons were inflated at 6 min into BLS. Hemodynamic variables were averaged during the final 2 min of the BLS and advanced life support periods. Survival was compared between this REBOA cohort and a control group without REBOA (no-REBOA cohort) (n = 26). RESULTS: There was no significant difference in ROSC between the two REBOA groups (P = 0.24). Survival was higher with REBOA group versus no-REBOA group (P = 0.02). CONCLUSIONS: There was no difference in ROSC between LV and traditional compressions when REBOA was used in this swine model of TCA. REBOA conferred a survival benefit regardless of compression location.

Prehospital Analgesia for Pediatric Trauma Patients in Iraq and Afghanistan.

BACKGROUND: Previous studies have evaluated prehospital analgesia during combat operations in Iraq and Afghanistan, but were limited to the adult population. However, a significant portion of the casualties of those conflicts were children. We describe the prehospital analgesia administered to wartime pediatric trauma patients. METHODS: We queried the Department of Defense Trauma Registry (DODTR) for all pediatric patients (<18 years of age) admitted to United States and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. We divided pediatric patients into 2 groups: those that had documentation of receipt of analgesic drugs in the prehospital setting (n = 618) and those who had not received analgesia before reaching a fixed-facility (n = 2,821). For characterization of drug administration, we grouped patients into those receiving acetaminophen, NSAID, fentanyl, ketamine, morphine, or other analgesics (e.g., hydromorphone, tramadol, etc.). RESULTS: During the study period, there were 3,439 pediatric encounters with documentation of 703 instances of analgesia administrations to 618 patients (17.9% of total pediatric encounters). Of the subjects receiving analgesic agents, 46.2% (n = 325) received morphine, 30.4% (n = 214) received fentanyl, 17.4% (n = 122) received ketamine, 1.8% (n = 13) received acetaminophen, and 2.8% (n = 20) received a non-steroidal anti-inflammatory drug. The remaining 9 administrations consisted of methoxyflourane (1), nalbuphine (2), hydromorphone (3), and tramadol (3). An injury severity score (ISS) >15 increased the odds of receiving an analgesic agent (OR 1.26, 95% CI 1.02-1.56). Additionally, there was an association between analgesia administration and the following prehospital interventions: wound dressing, tourniquet, intravenous (IV) line placement, intraosseous line placement, IV fluids, intubation, and external warming. CONCLUSIONS: Overall, a low proportion of pediatric trauma subjects within this population received analgesia in the prehospital environment. The most common analgesic medication administered was morphine. Those receiving analgesic agents had more severe injuries and higher rates of concomitant interventions. These results highlight the potential need for Tactical Combat Casualty Care guidelines specifically providing recommendations for analgesia administration among pediatric patients.

Prehospital Application of Hemostatic Agents in Iraq and Afghanistan.

INTRODUCTION: Hemorrhage is the leading cause of death on the battlefield. Development of chitosan- and kaolin-based hemostatic agents has improved hemorrhage control options. Sparse data exists on the use of these agents in the prehospital, combat setting. We describe recent use of these agents and compare patients receiving hemostatic to the baseline population. METHODS: We used a series of emergency department (ED) procedure codes to identify patients within the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. We only included patients for whom the DODTR specified the hemostatic agent utilized (chitosan or kaolin). We defined a serious injury by body region as an Abbreviated Injury Score (AIS) of 3 or greater. RESULTS: Our predefined search codes captured 28,222 patients. Of those, 258 (0.9%) patients had documented hemostatic use: 58 chitosan, 201 kaolin, and one subject received both. Patients undergoing hemostatic agent application were more likely to be injured by gunshot wound or explosive. Patients with hemostatic application had higher median composite Injury Severity Scores (10 vs. 9, p < 0.001), and higher AIS for the abdomen, extremity and superficial body regions with higher rates of blood product utilization. Proportions of patients suffering traumatic amputations and undergoing tourniquet application were higher in the hemostatic agent group than the baseline population (11.6% vs. 6.7%, p = 0.002 and 43.4% vs. 13.8%, p < 0.001, respectively). CONCLUSIONS: Hemostatic agents were infrequently utilized to manage traumatic hemorrhage during the recent conflicts in Afghanistan and Iraq. Hemostatic agent use was more frequent in casualties with gunshot wounds, traumatic amputations, concomitant tourniquet application, and greater blood product administration."

Association of prehospital intubation with decreased survival among pediatric trauma patients in Iraq and Afghanistan.

INTRODUCTION: Airway compromise is the second leading cause of preventable death on the battlefield among US military casualties. Airway management is an important component of pediatric trauma care. Yet, intubation is a challenging skill with which many prehospital providers have limited pediatric experience. We compare mortality among pediatric trauma patients undergoing intubation in the prehospital setting versus a fixed-facility emergency department. METHODS: We queried the Department of Defense Trauma Registry (DODTR) for all pediatric encounters in Iraq and Afghanistan from January 2007 to January 2016. We compared outcomes of pediatric subjects undergoing intubation in the prehospital setting versus the emergency department (ED) setting. RESULTS: During this period, there were 3439 pediatric encounters (8.0% of DODTR encounters during this time). Of those, 802 (23.3%) underwent intubation (prehospital=211, ED=591). Compared to patients undergoing ED intubation, patients undergoing prehospital intubation had higher median composite injury severity scores (17 versus 16) and lower survival rates (66.8% versus 79.9%, p<0.001). On univariable logistic regression analysis, prehospital intubation increased mortality odds (OR 1.97, 95% CI 1.39-2.79). After adjusting for confounders, the association between prehospital intubation and death remained significant (OR 2.03, 95% CI 1.35-3.06). CONCLUSIONS: Pediatric trauma subjects intubated in the prehospital setting had worse outcomes than those intubated in the ED. This finding persisted after controlling for measurable confounders.

Impact of prehospital airway management on combat mortality.

INTRODUCTION: Analysis of modern military conflicts suggests that airway compromise remains the second leading cause of preventable death of combat fatalities. This study compares outcomes of combat casualties that received prehospital airway interventions, specifically bag valve mask (BVM) ventilation, cricothyrotomy, and supraglottic airway (SGA) placement. The goal is to compare the effectiveness of airway management strategies used in the military pre-hospital setting. METHODS: This retrospective chart review of 1267 US Army medical evacuation patient care records, compared outcomes of casualties that received prehospital advanced airway interventions. The patients consisted of US military injured in Operation Enduring Freedom January 2011-March 2014. Compared outcomes consisted of vent-, ICU-, and hospital-free days. RESULTS: Those with SGA placement experienced fewer vent-free days, ICU-free days, and hospital-free days compared to BVM and cricothyrotomy patients. The groups did not significantly differ in rates of 30-day survival. The odds for survival were not significantly higher for BVM versus SGA patients (OR 1.5, 95% CI 0.2-9.8), cricothyrotomy versus SGA patients (OR 3.9, 95% CI 0.6-24.9), or cricothyrotomy versus BVM patients (OR 2.7, 95% CI 0.5-13.8) in a logistic regression model adjusting for GCS. CONCLUSION: This study supports prehospital BVM ventilation as a possible alternative to cricothyrotomy as there was no difference in measured outcomes between the groups. It further cautions against SGA use in the prehospital combat setting due to higher morbidity demonstrated by fewer ventilator, hospital, and ICU free days than those receiving cricothyrotomy or BVM ventilation. There was no difference in 30-day survival between the groups.

THAM Administration to Pediatric Trauma Patients in a Combat Zone.

OBJECTIVES: Pediatric casualties made up a significant proportion of patients during the recent military conflicts in Iraq and Afghanistan. Damage control resuscitation strategies used by military physicians included rapid reversal of metabolic acidosis to mitigate its pathophysiologic consequences, primarily through hemorrhage control and volume restoration. Alkalizing agents, including tris(hydroxymethyl)aminomethane (THAM), are potential therapeutic adjuncts to treat significant acidosis. There is, however, limited published data on THAM administration in the pediatric trauma population. We compared demographics and outcomes among pediatric trauma patients in Afghanistan and Iraq receiving THAM versus those not receiving THAM. METHODS: We queried the Department of Defense Trauma Registry for all of the pediatric patients admitted to US and Coalition fixed-facility hospitals in Afghanistan and Iraq from January 2007 to January 2016. We retrieved data on age, sex, location, mechanism of injury, Injury Severity Scores, ventilator days, days in the intensive care unit, days of total hospitalization, and survival to hospital discharge. We excluded subjects if they were dead on arrival to the emergency department. RESULTS: From January 2007 to January 2016, there were 3386 pediatric subjects that met our inclusion criteria. Of these, 15 received THAM. The youngest subject receiving THAM was a 2-month-old burn victim. Subjects receiving THAM were more likely to be injured by submersion or burn (P < 0.001), had higher composite Injury Severity Scores (17 vs 10; P < 0.001) and Abbreviated Injury Scores for the thorax and abdomen (P = 0.004 and P = 0.019, respectively), and longer ventilator days/intensive care unit stays/hospital lengths of stay (P < 0.001/P < 0.001/P = 0.013). In addition, subjects receiving THAM had a lower survival rate than subjects not receiving THAM (73.3% vs 91.7%; P = 0.011). CONCLUSIONS: THAM was administered rarely to pediatric trauma casualties during the conflicts in Afghanistan and Iraq. Subjects receiving THAM were more critically injured than the baseline population.

It's more than skin-deep: The relationship between social victimization and telomere length in adolescence.

This study examined the relationship between peer victimization and telomere length (TL), an indicator of biological aging that is associated with stressors (Epel, 2009). It was predicted that social victimization would have a greater impact upon TL, as well as the frequency and severity of health complaints than physical victimization. Adolescents (Mage = 15.91 years, SDage = 1.65) and their parents completed measures of peer victimization and physical health problems; adolescents also submitted a DNA sample for telomere analysis. Greater instances of being socially, but not physically, victimized were associated with shorter telomeres, as well as more frequent and severe health complaints. TL was also negatively related to both the frequency and severity of health problems, even after controlling for BMI, age, and sex of participant. The relationship between social victimization and health complaints via TL held only at higher levels of social victimization. These findings are the first to find an association between peer victimization and shortened telomeres.

Military suicide coverage: AP news wire & suicide guidelines.

The authors evaluated how well Associated Press News Wire stories adhered to the Recommendations for Reporting on Suicide™ during 2012, a peak year of military suicide. They included individual suicide stories (N = 167) from randomly selected days. They also evaluated differences in the military versus civilian coverage. Military and civilian stories typically had about five negative practices, and less than one positive practice, with military stories significantly more likely to miss valuable opportunities to promote help-seeking. The findings, combined with previous evidence, suggest the need for the development of specific military suicide reporting guidelines.

Comparative Analysis of Whole Blood Infusion Effects: Assessing LifeFlow Versus Pressure Bag in a Sus scrofa Model.

BACKGROUND: To improve survival for hemorrhagic shock treatment, guidelines emphasize two patient care priorities: (1) immediate hemorrhage control and (2) early resuscitation with whole blood or blood products. The LifeFlow device is designed to rapidly infuse blood products. However, the effects of using this device compared to pressure-bag systems remain unclear. We hypothesize that there will be no laboratory-measured difference with the blood when infused through the LifeFlow versus the current standard pressure bag system. METHODS: Two units of fresh whole blood were obtained from a sus scrofa model. One unit was "infused" using the LifeFlow with the other unit used as a control through a standard pressure bag system into an empty bag. The "before" measurements were obtained from blood samples from a standard fresh whole blood collection bag. The blood was "infused" into a whole blood bag devoid of storage solution from which the "after" measurements were obtained. RESULTS: This study utilized 22 clinically healthy sus scrofa. Blood units were primarily obtained from a left subclavian central line (50.0%). The median time to acquire and administer a unit of blood was similar for both the LifeFlow device (8.4 min and 8.1 min) and the pressure bag (8.7 min and 7.4 min). No significant differences were found in the total time to acquire or administer blood between the two devices. The median volume of blood acquired was 500 mL for both groups. While no significant differences in blood parameters were observed between the two devices, significant differences were noted when comparing pre- and post-transfusion values within each device. For the LifeFlow device, an increase in hemoglobin and chloride levels and a decrease in thromboplastin time and glucose levels were observed. With the pressure bag, only a decrease in blood urea nitrogen was observed. CONCLUSIONS: In comparing the LifeFlow to the pressure bag, there were no significant differences noted in the total time to acquire or administer a whole unit of blood. However, there were differences with several laboratory parameters of unclear clinical significance.

The Efficacy of Whole Blood Resuscitation During Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to Mitigate Post-occlusion Circulatory Collapse: A Translational Model in Large Swine.

INTRODUCTION: Uncontrolled torso hemorrhage is the primary cause of potentially survivable deaths on the battlefield. Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), in conjunction with damage control resuscitation, may be an effective management strategy for these patients in the prehospital or austere phase of their care. However, the effect of whole blood (WB) transfusion during REBOA on post-occlusion circulatory collapse is not fully understood. MATERIALS AND METHODS: Yorkshire male swine (n = 6 per group, 70-90 kg) underwent a 40% volume-controlled hemorrhage. After a 10-minute hemorrhagic shock period, a REBOA balloon was inflated in Zone 1. Fifteen minutes after inflation, 0, 1, or 3 units (450 mL/unit) of autologous WB was infused through the left jugular vein. Thirty minutes after initial balloon inflation, the balloon was deflated slowly over 3 minutes. Following deflation, normal saline was administered (up to 3,000 mL) and swine were observed for 2 hours. Survival (primary outcome), hemodynamics, and blood gas values were compared among groups. Statistical significance was determined by log-rank test, one-way ANOVA, and repeated measures ANOVA. RESULTS: Survival rates were comparable between groups (P = .345) with 66% of control, 33% of the one-unit animals, and 50% of the 3-unit animals survived until the end of the study. Following WB infusion, both the 1-unit and the 3-unit groups had significantly higher blood pressure (P < .01), pulmonary artery pressure (P < .01), and carotid artery flow (P < .01) compared to the control group. CONCLUSIONS: WB transfusion during Zone 1 REBOA was not associated with increased short-term survival in this large animal model of severe hemorrhage. We observed no signal that WB transfusion may mitigate post-occlusion circulatory collapse. However, there was evidence of supra-normal blood pressures during WB transfusion.