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.

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.

Establishment of the Clinician-Scientist Investigator Opportunity Network to Develop Military Medical Research Leaders.

INTRODUCTION: The ability of military clinicians to conduct military medical research is often limited because of competing priorities and a lack of research mentorship. The Clinician-Scientist Investigator Opportunity Network (CSION) was developed with the intent of training clinicians how to engage in requirements-driven research within the DoD. MATERIALS AND METHODS: Three to five academic medical faculties were selected from a pool of applicants each year to participate in a 2-year research fellowship. To be eligible for the CSION program, applicants had to meet the following criteria: (1) Completed residency graduate medical education training, (2) not be currently enrolled as a graduate medical education trainee, and (3) obtained permission from their department leadership to focus 25% of their duty hours on CSION participation to include didactic and research efforts. The remaining 75% of fellows' time was dedicated to clinical duties. Monthly didactics, intensive mentorship, and consistent support were offered to each fellow by the CSION leadership team. Metrics were recorded to include both research and clinical productivity. RESULTS: Between January 2019 and December 2022, 12 CSION fellows graduated from the program (four in the class of 2020, three in 2021, and five in 2022). From 2019 to 2021, the 12 CSION fellows initiated 204 research protocols, generated 489 publications/presentations, and secured 33 research grants. All graduates of the program remain active in clinical research with multiple graduates currently assigned to research positions. CONCLUSIONS: The CSION research education program is a 2-year additional duty research fellowship producing clinician-scientists conducting military-relevant medical research and publications and may be considered a low-cost/highly efficient alternative to achieve the reported benefits of the MD-PhD tract. The expansion of the CSION program may improve the quality of military medical research and health care.

Utilization of the En Route Aeromedical Patient Movement Form by Critical Care Air Transport Teams.

INTRODUCTION: Understanding usage patterns of current paper-based documentation can inform the development of electronic documentation forms for en route care. The primary objective was to analyze the frequency of use of each field within the 3899 L Patient Movement Record documented by en route Critical Care Air Transport Teams. Secondary objectives were to identify rarely utilized form fields and to analyze the proportion of verifiable major events documented within the 3899 L form. MATERIALS AND METHODS: We performed a retrospective review of 3899 L patient movement records for patients transported via Critical Care Air Transport Teams from January 2019 to December 2019. Scanned 3899 L forms were manually transcribed into a Microsoft Access database for evaluation and analysis. Proportions were calculated for completed fields. Major vital sign event frequency was compared for checkbox fields versus the vital sign flow sheet for each patient. We performed descriptive analyses for the proportion of charts with completed documentation in each evaluated field and the proportion of flow sheet events documented in major event fields. RESULTS: We analyzed 130 records. Fourteen of 18 (77.8%) demographic fields had a 75% or greater completion ratio. Sections with the largest proportion of rarely or never utilized fields (<1.5% completed) were procedures (77.8% of fields) and major events (63.9% of fields). Major event checkboxes had low sensitivity for documented events in the flow sheet: Change in heart rate greater than 20% (1 of 28 patients); increase in the fraction of inspired oxygen requirement of greater than 10% (6 of 23 patients); decrease in mean arterial pressure of greater than 20% (1 in 12 patients); and temperature less than 35.6°C (1 in 13 patients). CONCLUSIONS: Many of the current 3899 L fields are highly utilized, but some 3899 L sections contain high proportions of rarely utilized fields. Major event checkboxes did not consistently capture events documented within the in-flight vital sign flow sheet.

Management of Combat Casualties during Aeromedical Evacuation from a Role 2 to a Role 3 Medical Facility.

INTRODUCTION: Emergent clinical care and patient movements through the military evacuation system improves survival. Patient management differs when transporting from the point-of-injury (POI) to the first medical treatment facility (MTF) versus transporting from the Role 2 to the Role 3 MTF secondary to care rendered within the MTF, including surgery and advanced resuscitation. The objective of this study was to describe care provided to patients during theater inter-facility transports and compare with pre-hospital transports (POI to first MTF). MATERIALS AND METHODS: We performed a retrospective chart review of patients with the Role 2 to the Role 3 transports in Afghanistan and Iraq from 2007 to 2016. Data collected included procedures and events at the MTF and during transport. We compared the intra-theater transport data (Role 2 to Role 3) to data from a previous study evaluating pre-hospiital transports (POI to first MTF). RESULTS: We reviewed the records of 869 Role 2 to Role 3 transport patients. Role 2 to Role 3 transports were longer in duration compared to POI transports (39 minutes vs. 23 minutes) and were more likely to be staffed by advanced personnel (nurses, physician assistants, and physicians) (57% vs. 3%). The sample primarily consisted of military-aged males (mean age 27 years) who suffered from explosive or blunt force injuries. Procedures performed during each phase of care reflected the capabilities of the teams and locations. Pain and cardiac events were more common in POI evacuations compared to the Role 2 to Role 3 transports, but documentation of respiratory events, hemodynamic events, neurologic events, and equipment failure was more common during the Role 2 to Role 3 transports. Survival rates were slightly higher among the Role 2 to Role 3 cohort (98% vs. 95%, difference 3% [95% confidence interval of the difference 1-5%]). CONCLUSIONS: Inter-facility transports (Role 2 to Role 3) are longer in duration, transport more complex patients, and are staffed by more advanced level provider types compared to transports from POI.

A Descriptive Study of Casualties Evacuated Out of Afghanistan by Critical Care Air Transport Teams During the Withdrawal of U.S. Troops.

INTRODUCTION: The War in Afghanistan ended in August 2021. Evacuation from the country was a large effort during the last days of the conflict. During evacuation efforts at Kabul Hamid Karzai International Airport, a suicide bombing occurred necessitating emergent medical care for many injured troops and civilians. The U.S. Air Force Critical Care Air Transport Teams (CCATTs) played a role in the medical care provided during the operations in Afghanistan. We report on in-flight events and interventions that took place during the final days of the Afghanistan withdrawal. MATERIALS AND METHODS: We performed a retrospective chart review of patients requiring aeromedical evacuation from the Afghanistan theater of operations by CCATT from July 1 to August 30, 2021. From the CCATT patient care record, data abstractors collected patient characteristics, flight information, vital signs, laboratory values, in-flight interventions, and in-flight events in a study-specific electronic database. We performed descriptive analyses of patient characteristics and in-flight interventions. This study was approved by the San Antonio Institutional Review Board. RESULTS: Nine patients were included in this analysis. Seven out of nine patients were foreign nationals; the remaining two were U.S. Marines. Five patients suffered penetrating injuries from gunshot wounds and four suffered blast injuries. Six received intravenous narcotic analgesia. Four received intravenous sedatives, and four received antibiotics in flight. Two patients required chest tube management. One patient received blood. Three patients were in acute respiratory distress. CONCLUSIONS: Severe injuries were sustained during the withdrawal efforts at the end of the War in Afghanistan. Critical Care Air Transport Teams played a role in the care and evacuation of patients out of theater during this unique and unprecedented time. Even given the limitations associated with retrospective studies and a small sample size, information reported in this study can help inform future decisions, and aid in preparatory efforts for future operations, that may require medical care by CCATT.

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.

Improved Adherence to Best Practice Ventilation Management After Implementation of Clinical Practice Guideline (CPG) for United States Military Critical Care Air Transport Teams (CCATTs).

BACKGROUND: Critical Care Air Transport Teams (CCATTs) play a vital role in the transport and care of critically ill and injured patients in the combat theater to include mechanically ventilated patients. Previous research has demonstrated improved morbidity and mortality when lung protective ventilation strategies are used. Our previous study of CCATT trauma patients demonstrated frequent non-adherence to the Acute Respiratory Distress Syndrome Network (ARDSNet) protocol and a corresponding association with increased mortality. The goals of our study were to examine CCATT adherence with ARDSNet guidelines in non-trauma patients, compare the findings to our previous publication of CCATT trauma patients, and evaluate adherence before and after the publication of the CCATT Ventilator Management Clinical Practice Guideline (CPG). METHODS: We performed a retrospective chart review of ventilated non-trauma patients who were evacuated out of theater by Critical Care Air Transport Teams (CCATT) between January 2007 and April 2015. Data abstractors collected flight information, oxygenation status, ventilator settings, procedures, and in-flight assessments. We calculated descriptive statistics to determine the frequency of compliance with the ARDSNet protocol before and after the CCATT Ventilator CPG publication and the association between ARDSNet protocol adherence and in-flight events. RESULTS: We reviewed the charts of 124 mechanically ventilated patients transported out of theater via CCATT on volume control settings. Seventy percent (n = 87/124) of records were determined to be Non-Adherent to ARDSNet recommendations predominately due to excessive tidal volume settings and/or high FiO2 settings relative to the patient's positive end-expiratory pressure setting. The Non-Adherent group had a higher proportion of in-flight respiratory events. Compared to our previous study of ventilation guideline adherence in the trauma population, the Non-Trauma population had a higher rate of non-adherence to tidal volume and ARDSNet table recommendations (75.6% vs. 61.5%). After the CPG was rolled out, adherence improved from 24% to 41% (P = 0.0496). CONCLUSIONS: CCATTs had low adherence with the ARDSNet guidelines in non-trauma patients transported out of the combat theater, but implementation of a Ventilator Management CPG was associated with improved adherence.

Efficacy of a single-day task trainer-based extracorporeal membrane oxygenation training course.

Background: Extracorporeal membrane oxygenation (ECMO) is an advanced medical technology used to treat respiratory and heart failure. The coronavirus pandemic has resulted in significantly more ECMO patients worldwide. However, the number of hospitals with ECMO capabilities and ECMO-trained staff are limited. Training of personnel in ECMO could supplement this demand. Objective: To evaluate our previously developed ECMO course using a task trainer-based training, as opposed to an existing live tissue-training model, and determine if such a program was adequate and could be expanded to other facilities. Methods: Seventeen teams, each consisting of a physician and nurse, underwent a 5 hour accelerated ECMO course in which they watched prerecorded ECMO training lectures, primed circuit, cannulated, initiated ECMO, and corrected common complications. Training success was evaluated via knowledge and confidence assessments and observation of each team attempting to initiate ECMO while troubleshooting complications on a Yorkshire swine. Results: Seventeen teams successfully completed the course. Sixteen teams (94%, 95% CI = 71%-100%) successfully placed the swine on veno-arterial ECMO. Of those 16 teams, 15 successfully transitioned to veno-arterial-venous ECMO. The knowledge assessments and confidence levels of physicians and nurses increased by 24.3% from pretest (mean of 65.3%, SD 14.4%) to posttest (mean of 89.6%, SD 10.3%), p < 0.0001. Conclusions: An abbreviated one day lecture and hands-on task trainer-based ECMO course resulted in a high rate of successful skill demonstration and improvement of physicians' and nurses' knowledge assessments and confidence levels, similar to our previous live tissue training program.

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.

Hemodynamic events during en route critical care for patients with traumatic brain injury.

BACKGROUND: Exposure to stressors of flight may increase risk of secondary insults among critically injured combat casualties wounded with traumatic brain injury (TBI). The primary objective of this study was to describe the prevalence of hemodynamic events by phase of transport among patients with TBI transported by Critical Care Air Transport Teams (CCATT). METHODS: We performed a secondary analysis of a retrospective cohort of 477 adults with moderate to severe TBI, who required transport by CCATT to Germany from multiple hospitals in the Middle East between January 2007 and May 2014. We abstracted clinical data from handwritten CCATT medical records. Hemodynamic events included systolic blood pressure <100 mm Hg and cerebral perfusion pressure <60 mm Hg. We calculated the proportion of patients experiencing hemodynamic events for each phase of flight. RESULTS: We analyzed 404 subjects after exclusions for catastrophic brain injury (n = 39) and missing timestamps (n = 34). Subjects had high Injury Severity Scores (median, 29; interquartile range [IQR], 21-35) and a median flight time of 423 minutes (IQR, 392.5-442.5 minutes). The median of documented in-flight vital signs was 8 measurements (IQR, 6.5-8 measurements). Documented systolic blood pressure in-flight events occurred in 3% of subjects during ascent, 7.9% during early flight, 7.7% during late flight, and 2.2% during descent, with an overall in-flight prevalence of 13.9%. Among patients with intracranial pressure monitoring (n = 120), documented cerebral perfusion pressure events occurred in 5% of subjects during ascent, 23% during early flight, 17% during late flight, and 5.8% during descent, with an overall in-flight prevalence of 30.8%. CONCLUSION: Documented hemodynamic events occurred during each phase of flight in severely injured combat casualties wounded with TBI, and episodic documentation likely underestimated the actual in-flight frequency of secondary insults. LEVEL OF EVIDENCE: Prognostic and epidemiological; Level IV.

Association of Hypocalcemia With Mortality of Combat Casualties With Brain Injury and Polytrauma Transported by Critical Care Air Transport Teams.

INTRODUCTION: Hypocalcemia at hospital presentation is associated with increased mortality in trauma patients with hemorrhagic shock. The 2019 updates to the Joint Trauma System Damage Control Resuscitation (DCR) Clinical Practice Guideline recommend calcium supplementation for ionized calcium (iCa) measurements <1.2 mmol/L. Ionized calcium goals for en route critical care (ERCC) following DCR are less defined, and the impact of in-flight hypocalcemia events among critically injured combat wounded is unknown. This study aimed to describe the association between hypocalcemia and mortality for combat-wounded with brain injury and polytrauma requiring transport by Critical Care Air Transport Teams (CCATT). METHODS: We performed a secondary analysis of a retrospective cohort of patients with moderate-to-severe traumatic brain injury transported by CCATT out of combat theater between January 2007 and May 2014. Additional inclusion criteria included polytrauma and at least one documented in-flight iCa measurement. We categorized exposures based on the minimum in-flight iCa measurement as severe hypocalcemia (iCa <0.9 mmol/L), hypocalcemia (iCa 0.9-1.11 mmol/L), and never hypocalcemic (iCa ≥1.12 mmol/L). The primary outcome measure was mortality. We calculated descriptive statistics and performed multivariate logistic regression to assess the association between hypocalcemia and mortality. RESULTS: We analyzed 190 subjects, with a median age of 24 years (interquartile range [IQR] 21 to 29 years) and 97.7% male gender. Explosive injuries (82.1%) and gunshot wounds (6.3%) were the most common mechanisms of injury. The median injury severity score was 34 (IQR 27 to 43). During the flight, 11.6% of patients had severe hypocalcemia, and 39.5% had hypocalcemia. Among patients with any hypocalcemia measurement in-flight (n = 97), 41.2% had hypocalcemia on pre-flight iCa, 28.9% received blood products in-flight, and 23.7% received in-flight calcium supplementation. Only 32.4% of patients with hypocalcemia or severe hypocalcemia in the setting of vasopressor administration received in-flight calcium supplementation. There was no significant difference in mortality between severe hypocalcemia (9.1%), hypocalcemia (5.3%), and never hypocalcemic (3.2%) patients even after controlling for pre-flight variables. CONCLUSION: In-flight hypocalcemia events were common among critically ill combat-wounded polytrauma patients transported by CCATT but were not associated with differences in mortality. Future training should emphasize the need for calcium correction among ERCC patients requiring vasopressors. Future studies with larger sample sizes of patients receiving ERCC are needed to assess the association between in-flight calcium supplementation with clinical outcomes.

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.

Evacuation Strategies for U.S. Casualties with Traumatic Brain Injury (TBI) with and without Polytrauma.

INTRODUCTION: According to the Military Health System Traumatic Brain Injury (TBI) Center of Excellence, 51,261 service members suffered moderate to severe TBI in the last 21 years. Moderate to severe TBI in service members is usually related to blast injury in combat operations, which necessitates medical evacuation to higher levels of care. Prevention of secondary insult, and mitigation of the unique challenges associated with the transport of TBI patients in a combat setting are important in reducing the morbidity and mortality associated with this injury. The primary goal of this study was a secondary analysis comparing the impact of time to transport on clinical outcomes for TBI patients without polytrauma versus TBI patients with polytrauma transported out of the combat theater via Critical Care Air Transport Teams (CCATT). Our secondary objective was to describe the occurrence of in-flight events and interventions for TBI patients without polytrauma versus TBI with polytrauma to assist with mission planning for future transports. MATERIALS AND METHODS: We performed a secondary analysis of a retrospective cohort of 438 patients with TBI who were evacuated out of theater by CCATT from January 2007 to May 2014. Polytrauma was defined as abbreviated injury scale (AIS) of at least three to another region in addition to head/neck. Time to transport was defined as the time (in days) from injury to CCATT evacuation out of combat theater. We calculated descriptive statistics and examined the associations between time to transport and preflight characteristics, in-flight interventions and events, and clinical outcomes for TBI patients with and without polytrauma. RESULTS: We categorized patients into two groups, those who had a TBI without polytrauma (n = 179) and those with polytrauma (n = 259). Within each group, we further divided those that were transported within 1 day of injury, in 2 days, and 3 or more days. Patients with TBI without polytrauma transported in 1 or 2 days were more likely to have a penetrating injury, an open head injury, a preflight Glascow Coma Score (GCS) of 8 or lower, and be mechanically ventilated compared to those transported later. Patients without polytrauma who were evacuated in 1 or 2 days required more in-flight interventions compared to patients without polytrauma evacuated later. Patients with polytrauma who were transported in 2 days were more likely to receive blood products, and patients with polytrauma who were evacuated within 1 day were more likely to have had at least one episode of hypotension en route. Polytrauma patients who were evacuated in 2-3 days had higher hospital days compared to polytrauma with earlier evacuations. There was no significant difference in mortality between any of the groups. CONCLUSIONS: In patients with moderate to severe TBI transported via CCATT, early evacuation was associated with a higher rate of in-flight hypotension in polytrauma patients. Furthermore, those who had TBI without polytrauma that were evacuated in 1-2 days received more in-flight supplementary oxygen, blood products, sedatives, and paralytics. Given the importance of minimizing secondary insults in patients with TBI, recognizing this in this subset of the population may help systematize ways to minimize such events. Traumatic Brain Injury patients with polytrauma may benefit from further treatment and stabilization in theater prior to CCATT evacuation.

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.

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.

The association of rocuronium dosing and first-attempt intubation success in adult emergency department patients.

BACKGROUND: The recommended rocuronium dose for rapid sequence intubation is 1.0 mg/kg; however, the optimal dose for emergency airway management is not clear. We assessed the relationship between rocuronium dose and first-attempt success among emergency department (ED) patients undergoing rapid sequence intubation. METHODS: This is a secondary analysis of the National Emergency Airway Registry (NEAR), an observational 25-center registry of ED intubations. Ninety percent recording compliance was required from each site for data inclusion. We included all patients > 14 years of age who received rocuronium for rapid sequence intubation from 1 Jan 2016 to 31 Dec 2018. We compared first-attempt success between encounters using alternative rocuronium doses (< 1.0, 1.0-1.1, 1.2-1.3 and ≥1.4 mg/kg). We performed logistic regressions to control for predictors of difficult airways, indication, pre-intubation hemodynamics, operator, body habitus and device. We also performed subgroup analyses stratified by device (direct vs. video laryngoscopy). We calculated univariate descriptive statistics and odds ratios (OR) from multivariable logistic regressions with cluster-adjusted 95% confidence intervals (CI). RESULTS: 19,071 encounters were recorded during the 3-year period. Of these, 8,034 utilized rocuronium for rapid sequence intubation. Overall, first attempt success was 88.4% for < 1.0 mg/kg, 88.1% for 1.0-1.1 mg/kg, 89.7% for 1.2-1.3 mg/kg, and 92.2% for ≥1.4 mg/kg. Logistic regression demonstrated that when direct laryngoscopy was used and when compared to the standard dosing range of 1.0-1.1 mg/kg, the adjusted odds of a first attempt success was significantly higher in ≥1.4 mg/kg group at 1.9 (95% CI 1.3-2.7) relative to the other dosing ranges, OR 0.9 (95% CI 0.7-1.2) for < 1.0 mg/kg and OR 1.2 (95% CI 0.9-1.7) for the 1.2-1.3 mg/kg group. First-attempt success was similar across all rocuronium doses among patients utilizing video laryngoscopy. Patients who were hypotensive (SBP < 100 mmHg) prior to intubation had higher first-attempt success 94.9% versus 88.6% when higher doses of rocuronium were used. The rates of all peri-intubation adverse events and desaturation were similar between dosing groups, laryngoscope type utilized and varying pre-intubation hemodynamics. CONCLUSIONS: Rocuronium dosed ≥1.4 mg/kg was associated with higher first attempt success when using direct laryngoscopy and among patients with pre-intubation hypotension with no increase in adverse events. We recommend further prospective evaluation of the dosing of rocuronium prior to offering definitive clinical guidance.

RéSUMé: CONTEXTE: La dose de rocuronium recommandée pour l'intubation à séquence rapide est de 1,0 mg / kg, mais la dose optimale pour la prise en charge des voies respiratoires d'urgence n'est pas claire. Nous avons évalué la relation entre la dose de rocuronium et la réussite de la première tentative chez les patients des services d'urgence soumis à une intubation à séquence rapide. MéTHODES : Il s'agit d'une analyse secondaire du National Emergency Airway Registry (NEAR), un registre d'observation des intubations aux urgences dans 25 centres. Pour que les données soient prises en compte, chaque site devait respecter 90 % des enregistrements. Nous avons inclus tous les patients âgés de plus de 14 ans qui ont reçu du rocuronium pour une intubation à séquence rapide du 1er janvier 2016 au 31 décembre 2018. Nous avons comparé le succès de la première tentative entre les rencontres utilisant des doses alternatives de rocuronium (<1,0 mg/kg, 1,0-1,1 mg/kg, 1,2-1,3 mg/kg et 1,4mg/kg). Nous avons effectué des régressions logistiques pour contrôler les facteurs prédictifs des voies aériennes difficiles, l'indication, l'hémodynamique pré-intubation, l'opérateur, l'habitus corporel et le dispositif. Nous avons également effectué des analyses de sous-groupes stratifiées par dispositif (laryngoscopie directe contre vidéo-laryngoscopie). Nous avons calculé des statistiques descriptives univariées et des rapports des cotes (RC) à partir de régressions logistiques multivariables avec des intervalles de confiance (IC) à 95 % ajustés par groupe RéSULTATS: 19 071 consultations ont été enregistrées au cours de la période de trois ans. Parmi celles-ci, 8 034 ont utilisé du rocuronium pour une intubation à séquence rapide. Dans l'ensemble, le succès de la première tentative était de 88,4 % pour <1,0 mg/kg, 88,1 % pour 1,0 à 1,1 mg/kg, 89,7 % pour 1,2 à 1,3 mg/kg et 92,2 % pour ≥1,4 mg/kg. La régression logistique a démontré que lorsque la laryngoscopie directe était utilisée et comparée à la gamme de dosage standard de 1,0-1,1 mg/kg, la probabilité ajustée de réussite de la première tentative était significativement plus élevée dans le groupe ≥ 1,4mg/kg à 1,9 (IC 95 % 1,3-2,7) par rapport aux autres gammes de dosage, RC 0,9 (IC 95 % 0,7-1,2) pour < 1,0 mg/kg et RC 1,2 (IC 95 % 0,9-1,7) pour le groupe 1,2-1,3 mg/kg. La réussite de la première tentative était similaire pour toutes les doses de rocuronium chez les patients utilisant la vidéo-laryngoscopie. Les patients qui étaient hypotendus (SBP <100 mmHg) avant l'intubation avaient un taux de réussite de la première tentative plus élevé 94,9% contre 88,6% lorsque des doses plus élevées de rocuronium étaient utilisées. Les taux de tous les effets indésirables péri-intubation et de désaturation étaient similaires entre les groupes de dosage, le type de laryngoscope utilisé et les différentes hémodynamiques pré-intubation CONCLUSIONS: Le rocuronium dosé à ≥1,4mg/kg a été associé à une meilleure réussite de la première tentative lors de l'utilisation de la laryngoscopie directe et chez les patients présentant une hypotension avant intubation, sans augmentation des effets indésirables. Nous recommandons une évaluation prospective plus poussée du dosage du rocuronium avant de proposer une orientation clinique définitive.

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.

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.

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.