A novel melanocortin fusion protein inhibits fibrinogen oxidation and degradation during trauma-induced coagulopathy.

Immune cell inflammation is implicated in the pathophysiology of acute trauma-induced coagulopathy (TIC). We hypothesized that leukocyte inflammation contributes to TIC through the oxidation and proteolysis of fibrinogen. To test this hypothesis, antioxidants and a novel anti-inflammatory melanocortin fusion protein (AQB-565) were used to study the effects of interleukin-6 (IL-6)-stimulated human leukocytes on fibrinogen using single-cell imaging flow cytometry and multiplex fluorescent western blotting. We also studied the effects of AQB-565 on fibrinogen using an in vivo rat trauma model of native TIC. IL-6 induced cellular inflammation and mitochondrial superoxide production in human monocytes, causing fibrinogen oxidation and degradation in vitro. Antioxidants suppressing mitochondrial superoxide reduced oxidative stress and inflammation and protected fibrinogen. AQB-565 decreased inflammation, inhibited mitochondrial superoxide, and protected fibrinogen in vitro. Trauma with hemorrhagic shock increased IL-6 and other proinflammatory cytokines and chemokines, selectively oxidized and degraded fibrinogen, and induced TIC in rats in vivo. AQB-565, given at the onset of hemorrhage, blocked inflammation, protected fibrinogen from oxidation and degradation, and prevented TIC. Leukocyte activation contributes to TIC through the oxidation and degradation of fibrinogen, which involves mitochondrial superoxide and cellular inflammation. Suppression of inflammation by activation of melanocortin pathways may be a novel approach for the prevention and treatment of TIC.

Slow Intravenous Infusion of a Novel Damage Control Cocktail Decreases Blood Loss in a Pig Polytrauma Model.

BACKGROUND: Our objective was to optimize a novel damage control resuscitation (DCR) cocktail composed of hydroxyethyl starch, vasopressin, and fibrinogen concentrate for the polytraumatized casualty. We hypothesized that slow intravenous infusion of the DCR cocktail in a pig polytrauma model would decrease internal hemorrhage and improve survival compared with bolus administration. METHODS: We induced polytrauma, including traumatic brain injury (TBI), femoral fracture, hemorrhagic shock, and free bleeding from aortic tear injury, in 18 farm pigs. The DCR cocktail consisted of 6% hydroxyethyl starch in Ringer's lactate solution (14mL/kg), vasopressin (0.8U/kg), and fibrinogen concentrate (100mg/kg) in a total fluid volume of 20mL/kg that was either divided in half and given as two boluses separated by 30 minutes as control or given as a continuous slow infusion over 60 minutes. Nine animals were studied per group and monitored for up to 3 hours. Outcomes included internal blood loss, survival, hemodynamics, lactate concentration, and organ blood flow obtained by colored microsphere injection. RESULTS: Mean internal blood loss was significantly decreased by 11.1mL/kg with infusion compared with the bolus group (p = .038). Survival to 3 hours was 80% with infusion and 40% with bolus, which was not statistically different (Kaplan Meier log-rank test, p = .17). Overall blood pressure was increased (p < .001), and blood lactate concentration was decreased (p < .001) with infusion compared with bolus. There were no differences in organ blood flow (p > .09). CONCLUSION: Controlled infusion of a novel DCR cocktail decreased hemorrhage and improved resuscitation in this polytrauma model compared with bolus. The rate of infusion of intravenous fluids should be considered as an important aspect of DCR.

Leukocyte activation primes fibrinogen for proteolysis by mitochondrial oxidative stress.

Critical illness leads to rapid fibrinogen consumption, hyperfibrinolysis, and coagulopathy that exacerbates bleeding and increases mortality. Immune cell activation and inflammation are associated with coagulopathy after injury but play an undetermined role. We performed high dimensional immunophenotyping and single-cell imaging flow cytometry to investigate for a pathophysiological mechanism governing the effects of leukocyte-associated inflammation on fibrinogen function. Fibrinogen was oxidized early, followed by its degradation after 3 hours of lipopolysaccharides (LPS)-induced sterile inflammation in a rat model in vivo. Fibrinogen incubated with human leukocytes activated by TNFα was similarly oxidized, and later proteolyzed after 3 hours in vitro. TNFα induced mitochondrial superoxide generation from neutrophils and monocytes, myeloperoxidase (MPO)-derived reactive oxygen species (ROS) from neutrophils, and nitric oxide from lymphocytes and monocytes. Inhibition of mitochondrial superoxide prevented oxidative modification and proteolysis of fibrinogen, whereas inhibition of MPO attenuated only fibrinogen proteolysis. Quenching of both mitochondrial superoxide and MPO-derived ROS prevented coagulopathy better than tranexamic acid. Collectively, these findings indicate that neutrophil and monocyte mitochondrial superoxide generation can rapidly oxidize fibrinogen as a priming step for fibrinogen proteolysis and coagulopathy during inflammation.

Therapeutic hypothermia cardioprotection in murine hemorrhagic shock/resuscitation differentially affects p38α/p38γ, Akt, and HspB1.

BACKGROUND: Therapeutic hypothermia (TH) has demonstrated great potential for forestalling cardiovascular collapse and improving outcomes in the setting of severe hemorrhagic shock (HS). We used an established mouse model of severe HS to study the response of interrelated cardiac-signaling proteins p38, HspB1, and Akt to shock, resuscitation, and cardioprotective TH. METHODS: Adult female C57BL6/J mice were bled and maintained at a mean arterial pressure of 35 mm Hg. After 30 minutes, mice were randomized to 120 minutes of TH (33°C ± 0.5°C) or continued normothermia at 37°C. After 90 minutes, animals were resuscitated and monitored for 180 minutes. Cardiac p38, Akt, and HspB1 phosphorylation (p-p38, p-Akt, and p-HspB1), expression, and Akt/HspB1 interactions were measured at serial time points during HS and resuscitation. Markers of mitochondrial damage (plasma cytochrome c), inflammation (myeloperoxidase), and apoptosis (terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling) were analyzed. RESULTS: By 15 minutes HS, p-p38 and p-HspB1 significantly increased while p-Akt(T308) decreased (p < 0.05). TH attenuated phosphorylation of the p38α isoform during HS and increased phosphorylation of the p38γ isoform during both HS and early resuscitation (p < 0.05). TH increased Akt/HspB1 coimmunoprecipitation during early resuscitation and increased p-Akt and HspB1 expression during late resuscitation (p < 0.05). Finally, TH attenuated the myocardial myeloperoxidase and terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling staining and plasma cytochrome c during late resuscitation. CONCLUSIONS: TH increases phosphorylation of p38γ during both HS and early resuscitation, but attenuates phosphorylation of p38α, increases Akt/HspB1 interaction, and modulates Akt phosphorylation during HS and resuscitation. Such TH-related signaling events are associated with reduced cardiac inflammation, apoptosis, and mitochondrial injury.

A Multifunctional, Low-Volume Resuscitation Cocktail Improves Vital Organ Blood Flow and Hemostasis in a Pig Model of Polytrauma with Traumatic Brain Injury.

The resuscitation of polytrauma with hemorrhagic shock and traumatic brain injury (TBI) is a balance between permissive hypotension and maintaining vital organ perfusion. There is no current optimal solution. This study tested whether a multifunctional resuscitation cocktail supporting hemostasis and perfusion could mitigate blood loss while improving vital organ blood flow during prolonged limited resuscitation. Anesthetized Yorkshire swine were subjected to fluid percussion TBI, femur fracture, catheter hemorrhage, and aortic tear. Fluid resuscitation was started when lactate concentration reached 3-4 mmol/L. Animals were randomized to one of five groups. All groups received hydroxyethyl starch solution and vasopressin. Low- and high-dose fibrinogen (FBG) groups additionally received 100 and 200 mg/kg FBG, respectively. A third group received TXA and low-dose FBG. Two control groups received albumin, with one also including TXA. Animals were monitored for up to 6 h. Blood loss was decreased and vital organ blood flow was improved with low- and high-dose fibrinogen compared to albumin controls, but survival was not improved. There was no additional benefit of high- vs. low-dose FBG on blood loss or survival. TXA alone decreased blood loss but had no effect on survival, and combining TXA with FBG provided no additional benefit. Pooled analysis of all groups containing fibrinogen vs. albumin controls found improved survival, decreased blood loss, and improved vital organ blood flow with fibrinogen delivery. In conclusion, a low-volume resuscitation cocktail consisting of hydroxyethyl starch, vasopressin, and fibrinogen concentrate improved outcomes compare to controls during limited resuscitation of polytrauma.

Developing Emergency Medicine Leaders: The AACEM/SAEM Chair Development Program at 5 Years.

The Association of Academic Chairs of Emergency Medicine Chair Development Program (CDP) was started in 2014 to provide emergency medicine (EM) chairs and leaders who aspired to become academic chairs with EM-specific leadership training. Each class participated in a 1-year program, with five sessions taught primarily by EM leaders. Data from the first 5 years of the CDP are provided. A total of 81 participants completed the program (16% women). Twenty participants who were not chairs at entry have become EM chairs. Ratings of the CDP based on a survey of participants with a 94% response rate were very favorable. The CDP has been a popular and successful vehicle to increase leadership skills and prepare EM leaders for academic chair positions.

Lessons learned from COVID-19 outbreak in a skilled nursing facility, Washington State.

Long-term care facilities have been identified as a local epicenter of disease among populations vulnerable to coronavirus disease 2019 (COVID-19). A skilled nursing facility in Washington State was the first major site of COVID-19 infections in the United States. Many lessons were learned during the events surrounding this outbreak, including how to develop, and the importance of, a coordinated response between emergency medical services and local area hospitals. As these events came early in the U.S. pandemic, unfortunately, disease spread and mortality was high. However, these events also resulted in rapid mobilization of the regional response to the COVID-19 pandemic. Understanding the events surrounding this outbreak demonstrate some of the challenges involved in responding to acute infectious illnesses within these unique environments and associated vulnerable populations.

Damage Control Resuscitation Supplemented with Vasopressin in a Severe Polytrauma Model with Traumatic Brain Injury and Uncontrolled Internal Hemorrhage.

INTRODUCTION: Traumatic brain injury (TBI) and hemorrhagic shock (HS) are the leading causes of traumatic death worldwide and particularly on the battlefield. They are especially challenging when present simultaneously (polytrauma), and clear blood pressure end points during fluid resuscitation are not well described for this situation. The goal of this study is to evaluate for any benefit of increasing blood pressure using a vasopressor on brain blood flow during initial fluid resuscitation in a swine polytrauma model. MATERIALS AND METHODS: We used a swine polytrauma model with simultaneous TBI, femur fracture, and HS with uncontrolled noncompressible internal bleeding from an aortic tear injury. Five animals were assigned to each of three experimental groups (hydroxyethyl starch only [HES], HES + 0.4 U/kg vasopressin, and no fluid resuscitation [No Fluids]). Fluids were given as two 10 mL/kg boluses according to tactical field care guidelines. Primary outcomes were mean arterial blood pressure (MAP) and brain blood flow at 60 min. Secondary outcomes were blood flows in the heart, intestine, and kidney; arterial blood lactate level; and survival at 6 hr. Organ blood flow was measured using injection of colored microspheres. RESULTS: Five animals were tested in each of the three groups. There was a statistically significant increase in MAP with vasopressin compared with other experimental groups, but no significant increase in brain blood flow during the first 60 min of resuscitation. The vasopressin group also exhibited greater total internal hemorrhage volume and rate. There was no difference in survival at 6 hours. CONCLUSION: In this experimental swine polytrauma model, increasing blood pressure with vasopressin did not improve brain perfusion, likely due to increased internal hemorrhage. Effective hemostasis should remain the top priority for field treatment of the polytrauma casualty with TBI.

Effects of ethanol on limited resuscitation in a model of traumatic brain injury and hemorrhagic shock.

OBJECT: Limited resuscitation following uncontrolled hemorrhagic shock (HS) has been associated with improved outcomes in various animal models, although it has not been previously studied in the setting of traumatic brain injury (TBI) and ethanol intoxication. The aim of the present study was to determine the effects of ethanol intoxication in a model of experimental TBI and HS treated with limited resuscitation. METHODS: After induction of anesthesia and the placement of instruments, swine were subjected to a fluid-percussion injury of 3 atm. Simultaneously, hemorrhage was induced from an arterial catheter via a computerized roller pump to a mean arterial blood pressure (MABP) of 50 mm Hg, at which time uncontrolled hemorrhage was induced by the creation of an aortic tear. When the MABP decreased to 30 mm Hg, limited resuscitation to a MABP of 60 mm Hg was begun. After 60 minutes, animals were aggressively resuscitated to baseline MABP levels. Two groups of animals were studied: those receiving tap water by gastrostomy tube and those receiving ethanol (4 g/kg) by gastrostomy tube. Animals were monitored for 180 minutes after TBI. Hemorrhage volumes were significantly greater in ethanol-infused animals (mean +/- standard deviation, 41 +/- 34 mm Hg) compared with tap water-infused animals (17 +/- 18 mm Hg; p = 0.048). Resuscitation requirements were significantly higher and metabolic parameters significantly worse in the ethanol group. Survival time was also significantly decreased in the animals infused with ethanol (81 +/- 60 minutes) compared with those infused with tap water (130 +/- 51 minutes; p = 0.035). CONCLUSIONS: Ethanol intoxication led to increased hemorrhage volume and worsened hemodynamic and metabolic profiles in this model of limited resuscitation after TBI and HS. Ethanol-exposed animals had increased resuscitation requirements and decreased survival times.

Self-Propelled Dressings Containing Thrombin and Tranexamic Acid Improve Short-Term Survival in a Swine Model of Lethal Junctional Hemorrhage.

Hemorrhage is the leading cause of preventable death in trauma, and hemorrhage from noncompressible junctional anatomic sites is particularly difficult to control. The current standard is QuikClot Combat Gauze packing, which requires 3 min of compression. We have created a novel dressing with calcium carbonate microparticles that can disperse and self-propel upstream against flowing blood. We loaded these microparticles with thrombin and tranexamic acid and tested their efficacy in a swine arterial bleeding model without wound compression. Anesthetized immature female swine received 5 mm femoral arteriotomies to induce severe junctional hemorrhage. Wounds were packed with kaolin-based QuikClot Combat Gauze (KG), propelled thrombin-microparticles with protonated tranexamic acid (PTG), or a non-propelling formulation of the same thrombin-microparticles with non-protonated tranexamic acid (NPTG). Wounds were not compressed after packing. Each animal then received one 15 mL/kg bolus of hydroxyethyl starch solution followed by Lactated Ringer as needed for hypotension (maximum: 100 mL/kg) for up to 3 h. Survival was improved with PTG (3-h survival: 8/8, 100%) compared with KG (3/8, 37.5%) and NPTG (2/8, 25%) (P <0.01). PTG animals maintained lower serum lactate and higher hemoglobin concentrations than NPTG (P <0.05) suggesting PTG decreased severity of subsequent hemorrhagic shock. However, total blood loss, Lactated Ringer infusion volumes, and mean arterial pressures of surviving animals were not different between groups (P >0.05). Thus, in this swine model of junctional arterial hemorrhage, gauze with self-propelled, prothrombotic microparticles improved survival and 2 indicators of hemorrhagic shock when applied without compression, suggesting this capability may enable better treatment of non-compressible junctional wounds.

Post-translational oxidative modification of fibrinogen is associated with coagulopathy after traumatic injury.

Victims of trauma often develop impaired blood clot formation (coagulopathy) that contributes to bleeding and mortality. Fibrin polymerization is one critical component of clot formation that can be impacted by post-translational oxidative modifications of fibrinogen after exposure to oxidants. In vitro evidence suggests that Aα-C domain methionine sulfoxide formation, in particular, can induce conformational changes that prevent lateral aggregation of fibrin protofibrils during polymerization. We used mass spectrometry of plasma from trauma patients to find that fibrinogen Aα-C domain methionine sulfoxide content was selectively-increased in patients with coagulopathy vs. those without coagulopathy. This evidence supports a novel linkage between oxidative stress, coagulopathy, and bleeding after injury.

Effects of rapid wound sealing on survival and blood loss in a swine model of lethal junctional arterial hemorrhage.

BACKGROUND: Hemostatic gauzes, which must be packed into wounds and compressed for several minutes, may be of limited use for noncompressible wounds in junctional anatomic locations. Rapid mechanical wound sealing is an alternative approach that seals the wound at the skin, allowing internal clot formation. We evaluate wound sealing for junctional hemorrhage control using a hemostatic clamp (iTClamp). METHODS: Severe junctional hemorrhage was induced in anesthetized immature female swine using a 5-mm femoral arteriotomy. After 30 seconds of free bleeding, animals were randomized to one of seven hemostatic interventions: no intervention (control), direct compression for 3 minutes (compression), plain gauze packing (packing), mechanical wound seal (seal), plain gauze packing + wound seal (packing + seal), plain gauze packing + compression (packing + compression), or hemostatic gauze packing (Combat Gauze) + compression (HS-packing + compression). All animals then received one 15-mL/kg bolus of Hextend, followed by lactated Ringer's solution for hypotension up to 100 mL/kg. Animals were monitored for 3 hours. RESULTS: Survival was similar between control (3-hour survival, 0%) and compression (0%, Kaplan-Meier survival analysis and log-rank test [KM-LR], p = 1.0) but marginally improved with packing (12.5%, KM-LR, p < 0.001). Survival improved with seal (62.5%) versus control (KM-LR, p < 0.001) and with packing + seal (100%) versus packing alone (KM-LR, p < 0.001). Survival was similar between packing + compression (87.5%), HS-packing + compression (62.5%), and packing + seal (100%) (KM-LR, p ≥ 0.05). Total hemorrhage volume was decreased for seal versus control (p < 0.001) and for packing + seal versus packing (p < 0.001). Hemorrhage was similar among packing + compression, HS-packing + compression, seal, and packing + seal (analysis of variance p ≥ 0.05). Application times (mean [SD]) were significantly faster with packing + seal (125.8 [56.2] seconds) than packing + compression (236.6 [7.2] seconds) and HS-packing + compression (223.0 [6.8] seconds) (analysis of variance, all p < 0.001). CONCLUSION: In this preclinical junctional hemorrhage model, rapid wound sealing improved survival and decreased hemorrhage in both packed and unpacked wounds and performed comparably with standard-of-care hemostatic bandages. Rapidly sealing junctional wounds may be a viable alternative to wound compression.

Fluid resuscitation of uncontrolled hemorrhage using a hemoglobin-based oxygen carrier: effect of traumatic brain injury.

Animal models of combined traumatic brain injury (TBI) and hemorrhagic shock (HS) suggest a benefit of hemoglobin-based oxygen carrier (HBOC)-based resuscitation, but their use remains controversial, and little is known of the specific effects of TBI and high-pressure (large arterial injury) bleeding on resuscitation. We examine the effect of TBI and aortic tear injury on low-volume HBOC resuscitation in a swine polytrauma model and hypothesize that HBOC-based resuscitation will improve survival in the setting of aortic tear regardless of the presence of TBI. Anesthetized swine subjected to HS with aortic tear with or without fluid percussion TBI underwent equivalent limited resuscitation with HBOC, lactated Ringer's solution, or HBOC + nitroglycerine (vasoattenuated HBOC) and were observed for 6 h. There was no independent effect of TBI on survival time after adjustment for fluid type, and there was no interaction between TBI and resuscitation fluid type. However, total catheter hemorrhage volume required to reach target shock blood pressure was less with TBI (14.0 mL · kg(-1) [confidence interval, 12.4-15.6 mL · kg(-1)]) versus HS only (21.0 mL · kg(-1) [confidence interval, 19.5-22.5 mL · kg(-1)]), with equivalent lactate accumulation. Traumatic brain injury did not affect survival in this polytrauma model, but less hemorrhage was required in the presence of TBI to achieve an equivalent degree of shock suggesting globally impaired cardiovascular response to hemorrhage in the presence of TBI. There was also no benefit of HBOC-based fluid resuscitation over lactated Ringer's solution, contrary to models using liver injury as the source of hemorrhage, considering wound location is of paramount importance when choosing resuscitation strategy.

Plasma and myocardial visfatin expression changes are associated with therapeutic hypothermia protection during murine hemorrhagic shock/resuscitation.

AIM: Cytokine production during hemorrhagic shock (HS) could affect cardiac function during the hours after resuscitation. Visfatin is a recently described protein that functions both as a proinflammatory plasma cytokine and an intracellular enzyme within the nicotinamide adenine dinucleotide (NAD(+)) salvage pathway. We developed a mouse model of HS to study the effect of therapeutic hypothermia (TH) on hemodynamic outcomes and associated plasma and tissue visfatin content. METHODS: Mice were bled and maintained at a mean arterial pressure (MAP) of 35 mmHg. After 30 min, animals (n=52) were randomized to normothermia (NT, 37+/-0.5 degrees C) or TH (33+/-0.5 degrees C) followed by rewarming at 60 min following resuscitation. After 90 min of HS (S90), mice were resuscitated and monitored for 180 min (R180). Visfatin, interleukin 6 (IL-6), keratinocyte-derived chemokine (KC), tumor necrosis factor-alpha (TNF-alpha), and myoglobin were measured by ELISA. RESULTS: Compared to NT, TH animals exhibited improved R180 survival (23/26 [88.5%] vs. 13/26 [50%]; p=0.001). Plasma visfatin, IL-6, KC, and TNF-alpha increased by S90 in both groups (p<0.05). TH attenuated S90 plasma visfatin and, after rewarming, decreased R180 plasma IL-6, KC, and myoglobin (p<0.05) relative to NT. Heart and gut KC increased at S90 while IL-6 increases were delayed until R180 (p<0.05). NT produced sustained elevations of myocardial KC but decreased visfatin by R180, effects abrogated by TH (p<0.05). CONCLUSIONS: In a mouse model of HS, TH improves hemodynamics and alters plasma and tissue proinflammatory cytokines including the novel cytokine visfatin. TH modulation of cytokines may attenuate cardiac dysfunction following HS.

Antibacterial properties of an iron-based hemostatic agent in vitro and in a rat wound model.

OBJECTIVES: Topical hemostatic agents are currently employed on the battlefield for control of major hemorrhage and have potential for use in civilian settings. Some of these compounds may also be antibacterial. Given the behavior of these compounds, the purpose of this study was to assess the potential antibacterial properties of an iron oxyacid-based topical hemostatic agent against three problematic species of wound-contaminating microorganisms: Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, and methicillin-resistant Staphylococcus epidermidis. METHODS: Bacteria were treated in vitro with the test powder for 30 minutes and then assessed for viability. Long-term (8-hour) inhibition of bacterial growth was also examined. In vivo, a rat full-thickness 1-cm(2) skin wound was studied. Wounds were contaminated, treated, and then quantitatively cultured 24 hours later. RESULTS: The lethal dose for 99% of the organisms (LD(99)) for the compound against each organism ranged from 0.89 (+/-0.28) to 4.77 (+/-0.66) mg/mL (p < 0.05). The compound produced sustained inhibition over 8 hours at both 1 and 5 mg/mL (p < 0.05 for each), for P. aeruginosa, S. epidermidis, and S. aureus. In vivo, activity was noted against only P. aeruginosa, with the largest magnitude reduction being on the order of 3-log colony-forming units (CFU; p < 0.01). CONCLUSIONS: The iron-based agent studied possesses significant in vitro and lesser in vivo antibacterial effects. Further optimization of the delivery, dosing, and evaluation of this agent in a larger animal model with more humanlike skin structures may reveal important wound effects beyond control of bleeding.

Emergency medicine research directors and research programs: characteristics and factors associated with productivity.

BACKGROUND: Periodic surveys of research directors (RDs) in emergency medicine (EM) are useful to assess the specialty's development and evolution of the RD role. OBJECTIVES: To assess associations between characteristics and research productivity of RDs and EM programs. METHODS: A survey of EM RDs was developed using the nominal group technique and pilot tested. RDs or surrogate respondents at programs certified by the Accreditation Council for Graduate Medical Education were contacted by e-mail in early 2005. The survey assessed programs' research infrastructure and productivity, as well as RD characteristics, responsibilities, and career satisfaction. Three measures of research productivity were empirically defined: research publications, grant awards, and grant revenue. RESULTS: Responses were received from 86% of 123 EM programs. Productivity was associated with the presence of nonclinical faculty, dedicated research coordinators, and reduced clinical hours for research faculty. Programs with an RD did not have greater research productivity, using any measure, than those without an RD. The majority of RDs cited pursuing their own studies, obtaining funding, research mentoring, and research administration to be major responsibilities. The majority characterized internal research funding, grant development support, and support from other faculty as inadequate. Most RDs are satisfied with their careers and expect to remain in the position for three or more years. CONCLUSIONS: Research productivity of EM residency programs is associated with the presence of dedicated research faculty and staff and with reduced clinical demands for research faculty. Despite perceiving deficiencies in important resources, most RDs are professionally satisfied.

Effects of cocaine in an experimental model of traumatic brain injury.

BACKGROUND: Cocaine intoxication is found in a significant subset of emergency department (ED) patients presenting with traumatic brain injury (TBI). OBJECTIVES: To investigate the effects of acute cocaine intoxication on physiologic and metabolic parameters in a model of experimental TBI. METHODS: Under inhalational anesthesia, swine were instrumented and subjected to fluid percussion TBI of 3 atm. Two groups were studied: TBI and cocaine (n = 7) and TBI only (n = 7). Two sequential doses of cocaine hydrochloride were administered intravenously to the animals receiving cocaine: 4 mg/kg 10 minutes prior to injury and 2 mg/kg 1 minute prior to injury. Control animals received normal saline. Cardiorespiratory and cerebral physiologic data were monitored for 180 minutes following injury. Cerebral blood flow (CBF) was measured using dye-labeled microspheres. Serum cocaine levels were measured by gas chromatography/mass spectrometry. RESULTS: Mean (+/- SD) cocaine levels at the time of injury were 1,771 (+/- 403) ng/mL. All animals survived the 180-minute observation period. There was a trend toward higher intracranial pressure (ICP) in the control (15.4 +/- 8.2) vs. cocaine-treated (11.1 +/- 5.8) animals, although this did not reach statistical significance (p = 0.18). Cerebral venous lactate (CVL) levels also trended higher in the control (1.14 +/- 0.22) vs. cocaine-treated (0.91 +/- 0.19) groups (p = 0.06). Cerebral perfusion pressures (CPPs), however, did not differ between groups. The CBF values decreased significantly from baseline in both groups but were not different between groups. CONCLUSIONS: Cocaine-intoxicated animals subjected to TBI showed no significant difference in primary outcome measures of CPP or CBF, although a nonsignificant trend toward lower ICP was noted. Overall, acute cocaine intoxication did not adversely affect the physiologic parameters examined in this TBI model.

Effect of hair and clothing on neck immobilization using a cervical collar.

An important step during spine immobilization is application of a cervical collar. Clothing or hair covering the neck may impinge on this process. The purpose of this study was to evaluate the effect of clothing and hair covering the neck on immobilization using a cervical collar. Study participants were 18 female volunteers with long hair aged 20 to 28 years. Cervical range of motion (ROM) was tested in 6 directions (flexion, extension, right and left lateral bending, right and left axial rotation) using a cervical ROM (CROM) device. After measuring unrestricted ROM (no cervical collar), a 1-piece rigid cervical collar was placed the neck (1) covered by hair and clothing; (2) covered by clothing; (3) covered by hair; or (4) uncovered. Range of motion was retested under all 4 conditions. Data were compared using crossover-design analysis of variance (P<.05 statistically significant). Range of motion in all directions was significantly restricted by cervical collar placement under all conditions. Unrestricted ROM in all directions ranged from 41.50 degrees (7.25 degrees) to 70.76 degrees (15.4 degrees). In contrast, ROM with a cervical collar under the 4 conditions in all directions ranged from 10.80 degrees (5.10 degrees) to 18.81 degrees (7.37 degrees). We were unable to detect any significant differences in ROM between the 4 conditions. Our data suggest that long hair and clothing, which cover the neck, do not alter the effectiveness of cervical collar immobilization as measured by the cervical ROM device.