Risk Factors for Gastrointestinal Leak after Perforated Peptic Ulcer Disease Operative Repair.

BACKGROUND: There are limited studies regarding the impact of post-operative leak on perforated peptic ulcer disease (PPUD) and conflicting results regarding routine drain placement in operative repair of PPUD. This study aims to identify risk factors for gastrointestinal leak after operative repair of PPUD to better guide intra-operative decisions about drain placement. METHODS: We performed a retrospective cohort study at a tertiary care center from 2008 to 2019, identifying 175 patients who underwent operative repair of PPUD. RESULTS: Patients who developed a leak (17%) were compared to patients who did not. Both hypoalbuminemia (albumin < 3.5 g/dL) (P = .03) and duodenal ulcers (P < .01) were identified as significant risk factors for leak. No significant difference was found between leak and no leak groups for AAST disease severity grade, repair technique, or pre-operative use of tobacco, alcohol, or steroids. Post-operative leaks were associated with prolonged hospital stay (29 days compared to 10, P < .01), increased complication rates (77% compared to 48%, P < .01), and increased re-operation rates (73% compared to 26%, <0.01). No difference was identified in patient characteristics or operative leak rates between patients who had drains placed at the index operation and those that did not. DISCUSSION: Leak after operative PPUD repair is associated with significant post-operative morbidity. Hypoalbuminemia and duodenal perforations are significant risk factors for post-operative leaks.

Validation of a Point-of-Care Analyzer for Determining Anticoagulation Status During Air Transport.

OBJECTIVE: We evaluated a point-of-care prothrombin time (PT)/international normalized ratio (INR) cartridge-based analyzer for its feasibility, accuracy, and value in critical care air transport. METHODS: In this prospective study, blood samples from 10 randomly selected adult patients were tested with the cartridge during transport to determine feasibility. The cartridge results were compared with the laboratory results for the same samples. Similarly, blood samples from an additional 20 randomly selected adult patients were tested to determine test accuracy. A chart review identified 110 adult patients with PT/INR cartridge results to determine the clinical value of those results. RESULTS: Data from the first group of 10 patients showed that vibration did not affect use of the cartridge. The average bias between the 2 testing methods was 0.0 INR units. A comparison of the PT/INR cartridge results and the laboratory results from the group of 20 patients showed that 73% of the cartridge values were within 0.2 of the laboratory values, 83% were within 0.4, and 93% were within 0.6. Of the 110 patients whose charts showed PT/INR cartridge results, 23% received blood products (45 trauma patients and 65 medical patients). CONCLUSION: The PT/INR cartridge withstands the rigors of rotor wing transport and provides accurate, valuable results for making clinical decisions.

Early Hospital Discharge After Helicopter Transport of Pediatric Trauma Patients: Analysis of Rates of Over and Undertriage.

OBJECTIVES: Helicopter air ambulance (HAA) of pediatric trauma patients is a life-saving intervention. Triage remains a challenge for both scene transport and interhospital transfer of injured children. We aimed to understand whether overtriage or undertriage was a feature of scene or interhospital transfer and how in or out of state transfers affected these rates. METHODS: Children (<18 years) who underwent trauma activation at a level I trauma center between 2011 and 2013 were identified and reviewed. Patients transported by HAA were compared with those transported by ground ambulance (GA). RESULTS: Of 399 pediatric patients (median age, 10.4 years; range, 0.1-17 years; 264 male [66%]), 71 (18%) were transported by HAA. Seventy-two percent of HAA patients went to the intensive care unit or the operating room from the trauma bay or suffered in-hospital mortality (vs 42% GA, P < 0.001). More patients were overtriaged (HAA with injury severity score [ISS] of <15) from interhospital transfers than from the scene (25% vs 3%, P = 0.002). Undertriage (GA with ISS >15) was acceptable at 5% from the scene and 14% from interhospital transfers (P = 0.08). Overtriage of patients with ISS less than 15 to HAA was significantly lower from in-state hospitals (22%) than out-of-state hospitals (45%) (P = 0.02). Undertriage of patients with ISS greater than 15 to GA was also lower from in-state hospitals (20%) versus out-of-state hospitals (38%) (P = 0.03). CONCLUSIONS: Triage of pediatric trauma patients to HAA remains difficult. There remains potential for improvement, particularly as regards interhospital HAA overtriage, but well developed transfer protocols (such in-state protocols) may help.

Prehospital Use of Ketamine: Effectiveness in Critically Ill and Injured Patients.

BACKGROUND: The military use of ketamine is well established. The benefits of prehospital civilian use have not been extensively reported. METHODS: A retrospective review was performed of patients with prehospital ketamine use in Mayo One's air and critical care ground transport. RESULTS: The medical records were reviewed from 2014 to 2016 to assess the efficacy of Ketamine. During this time frame, 158 (167 instances) patients were treated with ketamine for analgesia (38%), sedation (44%), or procedural (18%) use. The patient population had a mean age of 49 (range: 1-100), with 105 (67%) male patients. Indications included trauma (69%), which was further broken down into blunt (57%), penetrating (4%), and miscellaneous (8%), and medical illness (31%). The mean ketamine dose was 52.6 mg (range: 5-200 mg) via intravenous route. Ketamine was utilized in 61% of patients after other medications were ineffective. Overall success rate was 98%. Mean pain scale before and after ketamine use was 9/10 and 3/10, respectively. Ketamine use increased yearly from 21 (13%) in 2014, 56 (36%) in 2015, and 81 (51%) in 2016. CONCLUSION: Prehospital ketamine use is effective alone or in conjunction with other medications for analgesia, sedation, and procedural use in trauma and critically ill patients with minimal hemodynamic and respiratory consequences.

Management of Suspected Tension Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 17-02.

This change to the Tactical Combat Casualty Care (TCCC) Guidelines that updates the recommendations for management of suspected tension pneumothorax for combat casualties in the prehospital setting does the following things: (1) Continues the aggressive approach to suspecting and treating tension pneumothorax based on mechanism of injury and respiratory distress that TCCC has advocated for in the past, as opposed to waiting until shock develops as a result of the tension pneumothorax before treating. The new wording does, however, emphasize that shock and cardiac arrest may ensue if the tension pneumothorax is not treated promptly. (2) Adds additional emphasis to the importance of the current TCCC recommendation to perform needle decompression (NDC) on both sides of the chest on a combat casualty with torso trauma who suffers a traumatic cardiac arrest before reaching a medical treatment facility. (3) Adds a 10-gauge, 3.25-in needle/ catheter unit as an alternative to the previously recommended 14-gauge, 3.25-in needle/catheter unit as recommended devices for needle decompression. (4) Designates the location at which NDC should be performed as either the lateral site (fifth intercostal space [ICS] at the anterior axillary line [AAL]) or the anterior site (second ICS at the midclavicular line [MCL]). For the reasons enumerated in the body of the change report, participants on the 14 December 2017 TCCC Working Group teleconference favored including both potential sites for NDC without specifying a preferred site. (5) Adds two key elements to the description of the NDC procedure: insert the needle/ catheter unit at a perpendicular angle to the chest wall all the way to the hub, then hold the needle/catheter unit in place for 5 to 10 seconds before removing the needle in order to allow for full decompression of the pleural space to occur. (6) Defines what constitutes a successful NDC, using specific metrics such as: an observed hiss of air escaping from the chest during the NDC procedure; a decrease in respiratory distress; an increase in hemoglobin oxygen saturation; and/or an improvement in signs of shock that may be present. (7) Recommends that only two needle decompressions be attempted before continuing on to the "Circulation" portion of the TCCC Guidelines. After two NDCs have been performed, the combat medical provider should proceed to the fourth element in the "MARCH" algorithm and evaluate/treat the casualty for shock as outlined in the Circulation section of the TCCC Guidelines. Eastridge's landmark 2012 report documented that noncompressible hemorrhage caused many more combat fatalities than tension pneumothorax.1 Since the manifestations of hemorrhagic shock and shock from tension pneumothorax may be similar, the TCCC Guidelines now recommend proceeding to treatment for hemorrhagic shock (when present) after two NDCs have been performed. (8) Adds a paragraph to the end of the Circulation section of the TCCC Guidelines that calls for consideration of untreated tension pneumothorax as a potential cause for shock that has not responded to fluid resuscitation. This is an important aspect of treating shock in combat casualties that was not presently addressed in the TCCC Guidelines. (9) Adds finger thoracostomy (simple thoracostomy) and chest tubes as additional treatment options to treat suspected tension pneumothorax when further treatment is deemed necessary after two unsuccessful NDC attempts-if the combat medical provider has the skills, experience, and authorizations to perform these advanced interventions and the casualty is in shock. These two more invasive procedures are recommended only when the casualty is in refractory shock, not as the initial treatment.

Prehospital Blood Product Administration Opportunities in Ground Transport ALS EMS - A Descriptive Study.

IntroductionHemorrhage remains the major cause of preventable death after trauma. Recent data suggest that earlier blood product administration may improve outcomes. The purpose of this study was to determine whether opportunities exist for blood product transfusion by ground Emergency Medical Services (EMS). METHODS: This was a single EMS agency retrospective study of ground and helicopter responses from January 1, 2011 through December 31, 2015 for adult trauma patients transported from the scene of injury who met predetermined hemodynamic (HD) parameters for potential transfusion (heart rate [HR]≥120 and/or systolic blood pressure [SBP]≤90). RESULTS: A total of 7,900 scene trauma ground transports occurred during the study period. Of 420 patients meeting HD criteria for transfusion, 53 (12.6%) had a significant mechanism of injury (MOI). Outcome data were available for 51 patients; 17 received blood products during their emergency department (ED) resuscitation. The percentage of patients receiving blood products based upon HD criteria ranged from 1.0% (HR) to 5.9% (SBP) to 38.1% (HR+SBP). In all, 74 Helicopter EMS (HEMS) transports met HD criteria for blood transfusion, of which, 28 patients received prehospital blood transfusion. Statistically significant total patient care time differences were noted for both the HR and the SBP cohorts, with HEMS having longer time intervals; no statistically significant difference in mean total patient care time was noted in the HR+SBP cohort. CONCLUSIONS: In this study population, HD parameters alone did not predict need for ED blood product administration. Despite longer transport times, only one-third of HEMS patients meeting HD criteria for blood administration received prehospital transfusion. While one-third of ground Advanced Life Support (ALS) transport patients manifesting HD compromise received blood products in the ED, this represented 0.2% of total trauma transports over the study period. Given complex logistical issues involved in prehospital blood product administration, opportunities for ground administration appear limited within the described system. MixFM, ZielinskiMD, MyersLA, BernsKS, LukeA, StubbsJR, ZietlowSP, JenkinsDH, SztajnkrycerMD. Prehospital blood product administration opportunities in ground transport ALS EMS - a descriptive study. Prehosp Disaster Med. 2018;33(3):230-236.

Definitive airway management after pre-hospital supraglottic airway insertion: Outcomes and a management algorithm for trauma patients.

BACKGROUND: Prehospital airway management increasingly involves supraglottic airway insertion and a paucity of data evaluates outcomes in trauma populations. We aim to describe definitive airway management in traumatically injured patients who necessitated prehospital supraglottic airway insertion. METHODS: We performed a single institution retrospective review of multisystem injured patients (≥15years) that received prehospital supraglottic airway insertion during 2009 to 2016. Baseline demographics, number and type of: supraglottic airway insertion attempts, definitive airway and complications were recorded. Primary outcome was need for tracheostomy. Univariate and multivariable statistics were performed. RESULTS: 56 patients met inclusion criteria and were reviewed, 78% were male. Median age [IQR] was 36 [24-56] years. Injuries comprised blunt (94%), penetrating (4%) and burns (2%). Median ISS was 26 [22-41]. Median number of prehospital endotracheal intubation (PETI) attempts was 2 [1-3]. Definitive airway management included: (n=20, 36%, tracheostomy), (n=10, 18%, direct laryngoscopy), (n=6, 11%, bougie), (n=9, 15%, Glidescope), (n=11, 20%, bronchoscopic assistance). 24-hour mortality was 41%. Increasing number of PETI was associated with increasing facial injury. On regression, increasing cervical and facial injury patterns as well as number of PETI were associated with definitive airway control via surgical tracheostomy. CONCLUSIONS: After supraglottic airway insertion, operative or non-operative approaches can be utilized to obtain a definitive airway. Patients with increased craniofacial injuries have an increased risk for airway complications and need for tracheostomy. We used these factors to generate an evidence based algorithm that requires prospective validation. LEVEL OF EVIDENCE: Level IV - Retrospective study. STUDY TYPE: Retrospective single institution study.

Prehospital Transfusion for Gastrointestinal Bleeding.

OBJECTIVE: Gastrointestinal (GI) bleeding is a common medical emergency with significant morbidity and mortality. Many patients are coagulopathic, which may perpetuate bleeding. Remote damage control resuscitation, including early correction of coagulopathy and anemia, may benefit exsanguinating patients with GI bleeding. METHODS: We conducted a retrospective review of patients with acute GI bleeding who received packed red blood cells (pRBC) and/or plasma during transportation to our institution between 2010 and 2014. A comparison group of patients who were not transfused en route was selected, and demographics, outcomes, and response to resuscitation were compared. RESULTS: A total of 112 patients with GI bleeding received pRBC (82%, n = 92 pRBC, mean 1.7 ± 0.9 units), plasma (62%, n = 69, mean 1.7 ± 0.8 units) or both (44%, n = 49) en-route. The comparison group comprised 49 patients transported by helicopter who were not transfused en-route. Demographics, crystalloid resuscitation, transfusion prior to transfer, rate of intervention, ICU days, length of stay, and mortality were similar between groups. Patients transfused en route had a significant increase in hemoglobin from 8.3 ± 2.2 to 8.9 ± 2.1 (P = .03) and decrease in INR from 2.0 ± 1.0 to 1.6 ± 1.4 (P = .01), whereas those not transfused en route experienced stable hemoglobin (8.7 ± 2.8 to 9.4 ± 2.5; P = .21) and INR values (1.9 ± 1.0 to 1.6 ± 1.4; P = .32). Both groups had a significant improvement in hemodynamic parameters with resuscitation. CONCLUSION: Prehospital damage control resuscitation with pRBC and/or plasma resulted in the improvement of hemodynamic instability, coagulopathy and anemia in patients with acute GI bleeding. Almost all patients required additional inpatient interventions and/or transfusions, suggesting that pre-hospital transfusion is being utilized for appropriately selected patients.

Cold platelets for trauma-associated bleeding: regulatory approval, accreditation approval, and practice implementation-just the "tip of the iceberg".

BACKGROUND: Laboratory and clinical evidence suggest that cold-stored platelets (CS-PLTs) might be preferable to room temperature platelets (RT-PLTs) for active bleeding. Ease of prehospital use plus potential hemostatic superiority led our facility to pursue approval of CS-PLTs for actively bleeding trauma patients. STUDY DESIGN AND METHODS: From November 18, 2013, through October 8, 2015, correspondence was exchanged between our facility, the AABB, and the US Food and Drug Administration (FDA). An initial AABB variance request was for 5-day CS-PLTs without agitation. The AABB deferred its decision pending FDA approval to use our platelet (PLT) bags for CS-PLTs. On March 27, 2015, the FDA approved 3-day CS-PLTs without agitation. On October 8, 2015, the AABB approved 3-day CS-PLTs without agitation and without bacterial testing for actively bleeding trauma patients. Our facility's goal is to carry CS-PLTs on air ambulances. RESULTS: CS-PLTs have been used for trauma patients at our facility since October 2015. As of August 2016, a total of 21 (19.1%) of 119 CS-PLTs have been transfused. The short 3-day storage period combined with the formation of clots in plasma-rich CS-PLTs during storage have been the major causes of a high (80.9%) discard rate. CONCLUSION: In the future, pathogen-reduced (PR), PLT additive solution (PAS) CS-PLTs seem more practical due to low risks of bacterial contamination and storage-related clotting. This should make longer storage of CS-PLTs feasible (e.g., 10 days or more). With a longer shelf life, PR PAS CS-PLTs could potentially be used in a wider range of patient populations.

Prehospital plasma resuscitation associated with improved neurologic outcomes after traumatic brain injury.

BACKGROUND: Trauma-related hypotension and coagulopathy worsen secondary brain injury in patients with traumatic brain injuries (TBIs). Early damage control resuscitation with blood products may mitigate hypotension and coagulopathy. Preliminary data suggest resuscitation with plasma in large animals improves neurologic function after TBI; however, data in humans are lacking. METHODS: We retrospectively identified all patients with multiple injuries age >15 years with head injuries undergoing prehospital resuscitation with blood products at a single Level I trauma center from January 2002 to December 2013. Inclusion criteria were prehospital resuscitation with either packed red blood cells (pRBCs) or thawed plasma as sole colloid resuscitation. Patients who died in hospital and those using anticoagulants were excluded. Primary outcomes were Glasgow Outcomes Score Extended (GOSE) and Disability Rating Score (DRS) at dismissal and during follow-up. RESULTS: Of 76 patients meeting inclusion criteria, 53% (n = 40) received prehospital pRBCs and 47% (n = 36) received thawed plasma. Age, gender, injury severity or TBI severity, arrival laboratory values, and number of prehospital units were similar (all p > 0.05). Patients who received thawed plasma had an improved neurologic outcome compared to those receiving pRBCs (median GOSE 7 [7-8] vs. 5.5 [3-7], p < 0.001). Additionally, patients who received thawed plasma had improved functionality compared to pRBCs (median DRS 2 [1-3.5] vs. 9 [3-13], p < 0.001). Calculated GOSE and DRS scores during follow-up, median 6 [5-7] months, demonstrated increased function in those resuscitated with thawed plasma compared to pRBCs by both median GOSE (8 [7-8] vs. 6 [6-7], p < 0.001) and DRS (0 [0-1] vs. 4 [2-8], p < 0.001). CONCLUSION: In critically injured trauma patients with TBI, early resuscitation with thawed plasma is associated with improved neurologic and functional outcomes at discharge and during follow-up compared to pRBCs alone. These preliminary data support the further investigation and use of plasma in the resuscitation of critically injured TBI patients. LEVEL OF EVIDENCE: Therapeutic, level V.

Prehospital blood transfusions in pediatric trauma and nontrauma patients: a single-center review of safety and outcomes.

PURPOSE: Prehospital transfusions are a novel yet increasingly accepted intervention in the adult population as part of remote damage control resuscitation, but prehospital transfusions remain controversial in children. Our purpose was to review our pediatric prehospital transfusion experience over 12 years to describe the safety of prehospital transfusion in appropriately triaged trauma and nontrauma patients. METHODS: Children (<18 years) transfused with packed red blood cells (pRBC) or plasma during transport to a single regional academic medical center between 2002 and 2014 were identified. Admission details, in-hospital clinical course, and outcomes were analyzed. RESULTS: 28 children were transfused during transport; median age was 8.9 ± 7 years and 15 patients were male (54%). Most patients required at least one additional unit of blood products during their hospitalization (79%), and/or required operative intervention (53%), endoscopy (7%), or died during their hospitalization (14%). Comparison of trauma patients (n = 16) and nontrauma patients (n = 12) revealed that nontrauma patients were younger, more anemic, more coagulopathy on admission, and required more ongoing transfusion in the hospital. Trauma patients were more likely to need operative intervention. No patient had a transfusion reaction. CONCLUSION: Remote damage control prehospital transfusions of blood products were safe in this small group of appropriately triaged pediatric patients. Further studies are needed to determine if outcomes are improved and to devise a rigorous protocol for this prehospital intervention for critically ill pediatric patients.

Thrombin generation profiles as predictors of symptomatic venous thromboembolism after trauma: A prospective cohort study.

BACKGROUND: Reliable biomarkers predictive of venous thromboembolism (VTE) after acute trauma are uncertain. The objective of the study was to identify risk factors for symptomatic VTE after trauma, including individual plasma coagulome characteristics as reflected by thrombin generation. METHODS: In a prospective, case-cohort study, trauma patients were enrolled over the 4.5-year period, 2011 to 2015. Blood was collected by venipuncture into 3.2% trisodium citrate at 0, 6, 12, 24, and 72 hours after injury and at hospital discharge. Platelet poor plasma was stored at -80 °C until analysis. Thrombin generation, as determined by the calibrated automated thrombogram (CAT) using 5 pM tissue factor (TF)/4 µM phospholipid (PS), was reported as peak height (nM thrombin) and time to peak height (ttPeak [minutes]). Data are presented as median [IQR] or hazard ratio with 95% CI. RESULTS: Among 453 trauma patients (injury severity score = 13.0 [6.0, 22.0], hospital length of stay = 4.0 [2.0, 10.0] days, age = 49 [28, 64] years, 71% male, 96% with blunt mechanism, mortality 3.2%), 83 developed symptomatic VTE within 92 days after injury (35 [42%] after hospital discharge). In a weighted, multivariate Cox model that included clinical and CAT characteristics available within 24 hours of admission, increased patient age (1.35 [1.19,1.52] per 10 years, p < 0.0001), body mass index ≥30 kg/m (4.45 [2.13,9.31], p < 0.0001), any surgery requiring general anesthesia (2.53 [1.53,4.19], p = 0.0003) and first available ttPeak (1.67 [1.29, 2.15], p < 0.00001) were independent predictors of incident symptomatic VTE within 92 days after trauma (C-statistic = 0.799). CONCLUSION: The individual's plasma coagulome (as reflected by thrombin generation) is an independent predictor of VTE after trauma. Clinical characteristics and ttPeak can be used to stratify acute trauma patients into high and low risk for VTE. LEVEL OF EVIDENCE: Prognostic, level III.

Mortality following helicopter versus ground transport of injured children.

INTRODUCTION: Injured children may be transported to trauma centers by helicopter air ambulance (HAA); however, a benefit in outcomes to this expensive resource has not been consistently shown in the literature and there is concern that HAA is over-utilized. A study that adequately controls for selection biases in transport mode is needed to determine which injured children benefit from HAA. The purpose of this study was to determine if HAA impacts mortality differently in minimally and severely injured children and if there are predictors of over-triage of HAA in children that can be identified. METHODS: Children ≤18 years of age transported by HAA or ground ambulance (GA) from scene to a trauma center were identified from the 2010-2011 National Trauma Data Bank. Analysis was stratified by Injury Severity Score (ISS) into low ISS (≤15) and high ISS (>15) groups. Following propensity score matching of HAA to GA patients, conditional multivariable logistic regression was performed to determine if transport mode independently impacted mortality in each stratum. Rates and predictors of over-triage of HAA were also determined. RESULTS: Transport by HAA occurred in 8218 children (5574 low ISS, 2644 high ISS) and by GA in 35305 (30506 low ISS, 4799 high ISS). Overall mortality was greater in HAA patients (4.0 vs 1.4%, p<0.001). After propensity score matching, mortality was equivalent between HAA and GA for low ISS patients (0.2 vs 0.2%, p=0.82) but, for high ISS patients, mortality was lower in HAA (9.0 vs 11.1% p=0.014). On multivariable analysis, HAA was associated with decreased mortality in high ISS patients (OR=0.66, p=0.017) but not in low ISS patients (OR=1.13, p=0.73). Discharge within 24h of HAA transport occurred in 36.5% of low ISS patients versus 7.4% high ISS patients (p<0.001). CONCLUSIONS: Based on a national cohort adjusted for nonrandom assignment of transport mode, a survival benefit to HAA transport exists only for severely injured children with ISS >15. Many children with minor injuries are transported by helicopter despite frequent dismissal within 24h and no mortality benefit.

Medical malpractice in the management of small bowel obstruction: A 33-year review of case law.

BACKGROUND: Annually, 15% of practicing general surgeons face a malpractice claim. Small bowel obstruction accounts for 12-16% of all surgical admissions. Our objective was to analyze malpractice related to small bowel obstruction. METHODS: Using the search terms "medical malpractice" and "small bowel obstruction," we searched through all jury verdicts and settlements for Westlaw. Information was collected on case demographics, alleged reasons for malpractice, and case outcomes. RESULTS: The search criteria yielded 359 initial case briefs; 156 met inclusion criteria. The most common reason for litigation was failure to diagnose and timely manage the small bowel obstruction (69%, n = 107). Overall, 54% (n = 84) of cases were decided in favor of the defendant (physician). Mortality was noted in 61% (n = 96) of cases. Eighty-six percent (42/49) of cases litigated as a result of failing to diagnose and manage the small bowel obstruction in a timely manner, resulting in patient mortality, had a verdict with an award payout for the plaintiff (patient). The median award payout was $1,136,220 (range, $29,575-$12,535,000). CONCLUSION: A majority of malpractice cases were decided in favor of the defendants; however, cases with an award payout were costly. Timely intervention may prevent a substantial number of medical malpractice lawsuits in small bowel obstruction, arguing in favor of small bowel obstruction management protocols.

A multi-institutional study of hemostatic gauze and tourniquets in rural civilian trauma.

BACKGROUND: Life-threatening hemorrhage is a leading cause of preventable mortality in trauma patients. Since publication of the Hartford Consensus statement, there has been intense interest in civilian use of commercial hemostatic gauze and tourniquets. Although the military has studied their use on soldiers with wartime injuries, there are limited data on patient outcomes following civilian prehospital use and no data on the use in rural trauma. METHODS: We performed a multi-institutional retrospective analysis of clinical outcomes following prehospital use of QuikClot combat gauze (QC) and combat application tourniquets (CATs) from 2009 to 2014. The primary outcome measured was effectiveness. Secondary outcomes included morbidity, mortality, patients' demographics, injury characteristics, and hospital outcomes. RESULTS: Between 2009 and 2014, 95 patients were managed by prehospital personnel with QC and/or CAT. Forty received QC, 61 received CAT, and 6 received both products. The median age was 40 years (6-91 years), 29% were female, and the median injury severity score was 7 (1-25). QuikClot combat gauze was 89% effective. Minimal morbidity was associated with QC use. Combat application tourniquet was 98% effective. Median tourniquet time was 21 minutes (6-142 minutes), the median injury severity score was 9 (1-50), and mortality was 9.8%. Morbidities observed with tourniquet use included amputation, fasciotomy, rhabdomyolysis, and acute kidney injury. Risk of amputation was associated with higher injury severity (p = 0.04) but not with elderly age, obesity, or the presence of medical comorbidities. No amputations resulted solely from the use of tourniquets. CONCLUSIONS: QuikClot combat gauze and CAT are safe and effective adjuncts for hemorrhage control in the rural civilian trauma across a wide range of injury patterns. In a rural civilian population including women, children, and elderly patients with medical comorbidities, these devices are associated with minimal morbidity beyond that of the original injury. LEVEL OF EVIDENCE: Therapeutic study, level V.

Prehospital Blood Transfusions in Non-Trauma Patients.

INTRODUCTION: Despite advances in trauma care, hemorrhage continues to be the leading cause of preventable mortality in trauma. The evidence to support its use in non-trauma patients is limited. We aim to report our experience with prehospital blood product transfusion. We hypothesize that it is safe, appropriately utilized, and that our protocol, which was designed for trauma patients, is adaptable to fit the needs of non-trauma patients. METHODS: Patients transfused with blood products, packed red blood cells (pRBCs) or plasma, in the prehospital environment between 2002 and 2014 were included. Trauma patients were compared to non-trauma patients using descriptive statistics. RESULTS: A total of 857 patients (n = 549 trauma and n = 308 non-trauma) were transfused with pRBCs (76 %, n = 654, mean 1.6 ± 1.1 units en route), plasma (53 %, n = 455, mean 1.7 ± 0.7 unit), or both (29 %, n = 252) during ground (12 %) or air (84 %) critical care transport. Mean age was 60.8 ± 21.6 years with 60.1 % (n = 515) males. Subsequently, in-hospital blood transfusions were performed in 80 % of patients, operations in 44 %, and endoscopy in 31 %. Five percent (n = 41) of patients did not require any of these interventions. Thirty-day mortality rate was 18 %, and one patient (<0.01 %) had a transfusion reaction. The majority of patients were non-trauma (n = 549, 64 %). Of the non-trauma patients, 219 (40 %) were surgical, 193 (35 %) gastrointestinal bleeds, and 137 (25 %) medical. CONCLUSION: Both non-trauma and trauma patients require blood products for life threatening hemorrhage and the majority required further interventions. Further research on the benefits of transfusion among non-trauma patients is warranted.

Guidance Document for the Prehospital Use of Tranexamic Acid in Injured Patients.

Tranexamic acid (TXA) is being administered already in many prehospital air and ground systems. Insufficient evidence exists to support or refute the prehospital administration of TXA, and results are pending from several prehospital studies currently in progress. We have created this document to aid agencies and systems in best practices for TXA administration based on currently available best evidence. This document has been endorsed by the American College of Surgeons-Committee on Trauma, the American College of Emergency Physicians, and the National Association of EMS Physicians.

Needle thoracostomy: Clinical effectiveness is improved using a longer angiocatheter.

BACKGROUND: Decompression of tension physiology may be lifesaving, but significant doubts remain regarding ideal needle thoracostomy (NT) catheter length in the treatment of tension physiology. We aimed to demonstrate increased clinical effectiveness of longer NT angiocatheter (8 cm) compared with current Advanced Trauma Life Support recommendations of 5-cm NT length. METHODS: This is a retrospective review of all adult trauma patients from 2003 to 2013 (age > 15 years) transported to a Level I trauma center. Patients underwent NT at the second intercostal space midclavicular line, either at the scene of injury, during transport (prehospital), or during initial hospital trauma resuscitation. Before March 2011, both prehospital and hospital trauma team NT equipment routinely had a 5-cm angiocatheter available. After March 2011, prehospital providers were provided an 8-cm angiocatheter. Effectiveness was defined as documented clinical improvement in respiratory, cardiovascular, or general clinical condition. RESULTS: There were 91 NTs performed on 70 patients (21 bilateral placements) either in the field (prehospital, n = 41) or as part of resuscitation in the hospital (hospital, n = 29). Effectiveness of NT was 48% until March 2011 (n = 24). NT effectiveness was significantly higher in the prehospital setting than in the hospital (68.3% success rate vs. 20.7%, p < 0.01). Patients who underwent NT using 8 cm compared with 5 cm were significantly more effective (83% vs. 41%, respectively, p = 0.01). No complications of NT were identified in either group. CONCLUSION: Eight-centimeter angiocatheters are more effective at chest decompression compared with currently recommended 5 cm at the second intercostal space midclavicular line. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Prehospital Use of Hemostatic Bandages and Tourniquets: Translation From Military Experience to Implementation in Civilian Trauma Care.

BACKGROUND: While the military use of tourniquets and hemostatic gauze is well established, few data exist regarding civilian emergency medical services (EMS) systems experience. METHODS: A retrospective review was performed of consecutive patients with prehospital tourniquet and hemostatic gauze application in a single ground and rotor-wing rural medical transport service. Standard EMS registry data were reviewed for each case. RESULTS: During the study period, which included 203,301 Gold Cross Ambulance and 8,987 Mayo One Transport records, 125 patients were treated with tourniquets and/or hemostatic gauze in the prehospital setting. Specifically, 77 tourniquets were used for 73 patients and 62 hemostatic dressings were applied to 52 patients. Seven patients required both interventions. Mechanisms of injury (MOIs) for tourniquet use were blunt trauma (50%), penetrating wounds (43%), and uncontrolled hemodialysis fistula bleeding (7%). Tourniquet placement was equitably distributed between upper and lower extremities, as well as proximal and distal locations. Mean tourniquet time was 27 minutes, with 98.7% success. Hemostatic bandage MOIs were blunt trauma (50%), penetrating wounds (35%), and other MOIs (15%). Hemostatic bandage application was head and neck (50%), extremities (36%), and torso (14%), with a 95% success rate. Training for both interventions was computer-based and hands-on, with maintained proficiency of %gt;95% after 2 years. CONCLUSION: Civilian prehospital use of tourniquets and hemostatic gauze is feasible and effective at achieving hemostasis. Online and practical training programs result in proficiency of skills, which can be maintained despite infrequent use.