Veterinary Education's Role in the Opioid Epidemic: Integration of an Online Safe Opioid Prescribing Course into the Core Curriculum.

As the COVID-19 pandemic continues, the opioid epidemic has worsened. Opioid-related deaths continue to rise, and many of these deaths can be traced to a prescription opioid. Because veterinarians prescribe opioids, many organizations and federal agencies have called for increased veterinary education on the topic. In this teaching tip, we review the current literature surrounding the veterinary profession's link to the opioid epidemic and one potential way that educational institutions can successfully and efficiently incorporate safe opioid prescribing training into the curriculum using an online course.

Interfacility Transport of Critically Ill Patients.

OBJECTIVES: To assess recent advances in interfacility critical care transport. DATA SOURCES: PubMed English language publications plus chapters and professional organization publications. STUDY SELECTION: Manuscripts including practice manuals and standard (1990-2021) focused on interfacility transport of critically ill patients. DATA EXTRACTION: Review of society guidelines, legislative requirements, objective measures of outcomes, and transport practice standards occurred in work groups assessing definitions and foundations of interfacility transport, transport team composition, and transport specific considerations. Qualitative analysis was performed to characterize current science regarding interfacility transport. DATA SYNTHESIS: The Task Force conducted an integrative review of 496 manuscripts combined with 120 from the authors' collections including nonpeer reviewed publications. After title and abstract screening, 40 underwent full-text review, of which 21 remained for qualitative synthesis. CONCLUSIONS: Since 2004, there have been numerous advances in critical care interfacility transport. Clinical deterioration may be mitigated by appropriate patient selection, pretransport optimization, and transport by a well-resourced team and vehicle. There remains a dearth of high-quality controlled studies, but notable advances in monitoring, en route management, transport modality (air vs ground), as well as team composition and training serve as foundations for future inquiry. Guidance from professional organizations remains uncoupled from enforceable regulations, impeding standardization of transport program quality assessment and verification.

Prehospital Mechanical Ventilation: An NAEMSP Position Statement and Resource Document.

Airway emergencies and respiratory failure frequently occur in the prehospital setting. Patients undergoing advanced airway management customarily receive manual ventilations. However, manual ventilation is associated with hypo- and hyperventilation, variable tidal volumes, and barotrauma, among other potential complications. Portable mechanical ventilators offer an important strategy for optimizing ventilation and mitigating ventilatory complications.EMS clinicians, including those performing emergency response as well as interfacility transports, should consider using mechanical ventilation after advanced airway insertion.Prehospital mechanical ventilation techniques, strategies, and parameters should be disease-specific and should mirror in-hospital best practices.EMS clinicians must receive training in the general principles of mechanical ventilation as well as detailed training in the operation of the specific system(s) used by the EMS agency.Patients undergoing mechanical ventilation must receive appropriate sedation and analgesia.

Compliance and Attitudes of Critical Care Transport Providers Regarding a Prehospital Rapid Sequence Intubation Checklist.

Human factors engineering innovations, such as checklists, have been adopted in various acute care settings to improve safety with reasonable compliance and acceptance. In the air medical industry, checklists have been implemented by different teams for critical clinical procedures such as rapid sequence intubation. However, compliance and attitudes toward these human factors engineering innovations in the critical care transport setting are not well described. In this institutional review board-exempt, retrospective review of checklist usage, we assessed rapid sequence intubation checklist compliance and surveyed providers with 5 questions based on Rogers' theory of diffusion of innovation to examine why or why not there was compliance. Our results indicated that compliance with checklist implementation was excellent. The survey questions were consistent with process improvement factors that enhance the spread and acceptance of innovation.

Analytic Morphomics Are Related to Outcomes After Lung Volume Reduction Surgery.

:Lung volume reduction surgery continues to have a high morbidity despite National Emphysema Treatment Trial selection criteria. This study evaluated the association between analytic morphomics on chest computed tomography scans and outcomes after lung volume reduction surgery. In a retrospective review of 85 lung volume reduction surgery patients from 1998-2013, dorsal muscle group area, subcutaneous and visceral fat area, and bone mineral density were assessed using analytic morphomics. Lung density was divided into five levels of increasing density (Lung density 1, emphysema; 2, normal lung; 4-5, scarring). Outcomes including survival, hospital length of stay, readmission at 30 days, and pulmonary complications were analyzed using univariate and multivariable techniques. Pulmonary complications developed in 27.1% (23/85). Mortality at 90 days was 9.4% (8/85). On multivariable analysis, lower bone mineral density (Odds ratio 0.61; 95% confidence interval 0.39-0.95) was associated with decreased survival, longer length of stay (0.83; 0.77-0.89), and readmissions (0.39; 0.15-1.00). Higher lung density 5:lung density 2 volume (1.84; 1.05-3.23), possibly due to scarring, was associated with pulmonary complications and longer length of stay (1.32; 1.23-1.41) while lower subcutaneous fat area:height was associated with readmissions which may reflect decreased metabolic reserve (0.35; 0.13-0.93). Patients with signs of frailty including lower bone mineral density may be at increased risk of adverse outcomes including decreased survival after lung volume reduction surgery. The results of this hypothesis-generating study will need to be confirmed in larger, multicenter trials to determine whether analytic morphomics can improve risk stratification and patient selection.

The Carle-Illinois (Urbana, Illinois USA) Transport Protocol for LEK9s: Guidelines for Emergency Medical Service Providers.

Three states and one county now allow Emergency Medical Services (EMS) providers to transport injured law enforcement K9s (LEK9s) as long as no human needs the ambulance at the time. Several other states either have pending legislation or are in discussions about this topic. As additional states ponder these laws, it is likely that the EMS transport of LEK9s will become legal in many states. In the wake of this legislation, a significant void was created. Currently, there are no published protocols for the safe transport of LEK9s by EMS providers. Additionally, the transport destination for these LEK9s is unlikely to be programmed into vehicle Global Positioning Systems. The authors of this report convened a Joint Task Force on Working Dog Care, consisting of veterinarians, EMS directors, EMS physicians, and LEK9 handlers, who met to develop a protocol for LEK9s being transported to a veterinary facility. The protocol covers the logistics of getting the LEK9 into the ambulance (eg, when the handler is or is not available), appropriate restraint, and the importance of prior arrangements with a veterinary emergency facility. A LEK9 hand-off form and a Transport Policy Form are provided, downloadable, and customizable for each EMS provider. This protocol provides essential information on safety and transport logistics for injured LEK9s. The hope is that this protocol will assist EMS providers to streamline the transport of an injured LEK9 to an appropriate veterinary facility.

The Carle-Illinois (Urbana, Illinois USA) Treatment Protocol for Law Enforcement K9s: Guidelines for Emergency Medical Services.

This document is a resource for Emergency Medical Services (EMS) treating an injured law enforcement K9 (LEK9) in the field and/or during transport by ambulance to a veterinary hospital. A Joint Task Force on Working Dog Care was created, which included veterinarians, EMS directors, EMS physicians, and canine handlers, who met to develop a treatment protocol for injured LEK9s. The protocol covers many major life-threatening injuries that LEK9s may sustain in the line of duty, and also discusses personnel safety and necessary equipment. This protocol may help train EMS providers to save the life of an injured LEK9.

Analytic Morphomics Predict Outcomes After Lung Transplantation.

BACKGROUND: The purpose of this study was to identify morphomic factors on standard, pretransplantation computed tomography (CT) scans associated with outcomes after lung transplantation. METHODS: A retrospective review of 200 patients undergoing lung transplantation at a single institution from 2003 to 2014 was performed. CT scans obtained within 1 year before transplantation underwent morphomic analysis. Morphomic characteristics included lung, dorsal muscle group, bone, and subcutaneous and visceral fat area and density. Patient data were gathered from institutional and United Network for Organ Sharing databases. Outcomes, including initial ventilator support greater than 48 hours, length of stay, and survival, were evaluated using univariate and multivariable analyses. RESULTS: On multivariable Cox regression, subcutaneous fat/total body area (hazard ratio [HR] 0.60, p = 0.001), lung density 3 volume (HR 0.67, p = 0.013), and creatinine (HR 4.37, p = 0.010) were independent predictors of survival. Initial ventilator support more than 48 hours was associated with decreased vertebral body to linea alba distance (odds ratio [OR] 0.49, p = 0.002) and Zubrod score 4 (OR 14.0, p < 0.001). Increased bone mineral density (p < 0.001) and increased cross-sectional body area (p < 0.001) were associated with decreased length of stay, whereas supplemental oxygen (p < 0.001), bilateral transplantation (p = 0.002), cardiopulmonary bypass (p < 0.001), and Zubrod score 3 (p < 0.001) or 4 (p = 0.040) were associated with increased length of stay. CONCLUSIONS: Morphomic factors associated with lower metabolic reserve and frailty, including decreased subcutaneous fat, bone density, and body dimensions were independent predictors of survival, prolonged ventilation, and increased length of stay. Analytic morphomics using pretransplantation CT scans may improve recipient selection and risk stratification.

Increased Variance in Oral and Gastric Microbiome Correlates With Esophagectomy Anastomotic Leak.

BACKGROUND: Anastomotic leak after esophagectomy remains a significant source of morbidity and mortality. The gastrointestinal (GI) microbiome has been found to play a significant role in tumor oncogenesis and postoperative bowel anastomotic leak. We hypothesized that the GI microbiome could differentiate between esophageal cancer histologies and predict postoperative anastomotic leak. METHODS: A prospective study of esophagectomy patients was performed from May 2013 to August 2014, with the collection of oral saliva, intraoperative esophageal and gastric mucosa, and samples of postoperative infections (neck swab or sputum). The presence and level for each bacterial probe as end points were used to analyze correlations with tumor histology, tumor stage, and presence of postoperative complications by unequal variances t tests for multiple comparisons and principal coordinate analysis. RESULTS: Esophagectomy was successful in 55 of 66 patients who were enrolled. Among those, the diagnosis was adenocarcinoma in 44 (80%) squamous cell carcinoma in (13%), and benign disease in 4 (7%). The 30-day mortality was 1.8% (1 of 55). Complications included anastomotic leak requiring local drainage in 18% (10 of 55) and postoperative pneumonia in 2% (1 of 55). No correlation was noted between GI microbiome flora and tumor histology or tumor stage. A significant difference (p = 0.015) was found when the variance in bacterial composition between the preoperative oral flora was compared with intraoperative gastric flora in patients who had a leak but not in patients with pneumonia. CONCLUSIONS: Patients with anastomotic leaks had increased variance in their preoperative oral and gastric flora. Microbiome analysis could help identify patients at higher risk for leak after esophagectomy.

Cocaine-induced chest pain.

Cocaine-associated chest pain is a clinical entity that crosses all socioeconomic groups and hence will be encountered by many physicians. The initial evaluation and treatment of cocaine-induced chest pain are similar to those of patients who have non-cocaine-induced chest pain, but there are several notable exceptions. This article reviews the pathophysiology, evaluation, management, and disposition decisions unique to patients presenting with cocaine-induced chest pain.

Prehospital Ketamine is a Safe and Effective Treatment for Excited Delirium in a Community Hospital Based EMS System.

Excited delirium syndrome (ExDS) is defined by marked agitation and confusion with sympathomimetic surge and incessant physical struggle, despite futility, which may lead to profound pathophysiologic changes and sudden death. Severe metabolic derangements, including lactic acidosis, rhabdomyolysis, and hyperthermia, occur. The pathophysiology of excited delirium is a subject of ongoing basic science and clinical research. Positive associations with ExDS include male gender, mental health disorders, and substance abuse (especially sympathomimetics). Excited delirium syndrome patients often exhibit violent, psychotic behavior and have "superhuman" strength which can result in the patient fighting with police and first responders. Continued struggle can cause a patient with ExDS to experience elevated temperature (T) and acidosis which causes enzymes to fail, leading to sudden death from cardiovascular collapse and multi-system organ failure. Therefore, effective early sedation is optimal to stop this fulminant process. Treatment of ExDS must be focused on rapidly, safely, and effectively sedating the patient and providing intensive, supportive care. Benzodiazepines, like midazolam, may not be ideal to sedate ExDS patients since their onset takes several minutes, and their side effects include loss of airway control and respiratory depression. Injectable antipsychotic medications have a relatively slow onset and may cause prolongation of the QTc interval. Ketamine is the ideal medication to sedate patients with ExDS. Ketamine has a rapid, predictable onset within three to four minutes when given by intramuscular (IM) injection. It does not adversely affect airway control, breathing, heart rate, or blood pressure (BP). In this retrospective case series, prehospital scenarios in which ExDS patients received ketamine by paramedics for sedation, and their subsequent treatment in the emergency department (ED) and hospital, are described. It is demonstrated that ketamine administered by paramedics in the prehospital setting of a community hospital based Emergency Medical Services (EMS) system is a safe and effective treatment for ExDS. Scaggs TR , Glass DM , Hutchcraft MG , Weir WB . Prehospital ketamine is a safe and effective treatment for excited delirium in a community hospital based EMS system. Prehosp Disaster Med. 2016;31(5):563-569.

Cocaine-associated chest pain.

The pathophysiology of cocaine leading to myocardial ischemia is multifactorial. Given the paucity of well-designed clinical studies, treatment is directed toward the potential mechanisms involved in the development of myocardial ischemia. Fortunately, morbidity and mortality in this patient population are low, and the vast majority of patients will not suffer AMI or other cardiac complications. Long-term prognosis is excellent for those who abstain from continued cocaine use.

Shock index and prediction of traumatic hemorrhagic shock 28-day mortality: data from the DCLHb resuscitation clinical trials.

INTRODUCTION: To assess the ability of the shock index (SI) to predict 28-day mortality in traumatic hemorrhagic shock patients treated in the diaspirin cross-linked hemoglobin (DCLHb) resuscitation clinical trials. METHODS: We used data from two parallel DCLHb traumatic hemorrhagic shock efficacy trials, one in U.S. emergency departments, and one in the European Union prehospital setting to assess the relationship between SI values and 28-day mortality. RESULTS: In the 219 patients, the mean age was 37 years, 64% sustained a blunt injury, 48% received DCLHb, 36% died, and 88% had an SI≥1.0 at study entry. The percentage of patients with an SI≥1.0 dropped by 57% (88 to 38%) from the time of study entry to 120 minutes after study resuscitation (p<0.001). Patients with a SI≥1.0, 1.4, and 1.8 at any time point were 2.3, 2.7, and 3.1 times, respectively, more likely to die by 28 days than were patients with SI values below these cutoffs (p<0.001). Similarly, after 120 minutes of resuscitation, patients with a SI≥1.0 were 3.9× times more likely to die by 28 days (40 vs. 15%, p<0.001). Although the distribution of SI values differed based on treatment group, the receiver operator characeristics data showed no difference in SI predictive ability for 28-day mortality in patients treated with DCLHb. CONCLUSION: In these traumatic hemorrhagic shock patients, the shock index correlates with 28-day mortality, with higher SI values indicating greater mortality risk. Although DCLHb treatment did alter the distribution of SI values, it did not influence the ability of the SI to predict 28-day mortality.