Characteristics of victims of trauma requiring invasive mechanical ventilation with a short stay in critical care.

BACKGROUND: Many patients who are admitted to the intensive care unit (ICU) have needs which rapidly resolve and are discharged alive within 24 h. We sought to characterize the outcomes of critically ill trauma victims at our institution with a short stay in the ICU. METHODS: We conducted a retrospective cohort study of all critically ill adult trauma victims presenting to our ED between January 1st, 2011 and December 31st, 2019. We included patients who were endotracheally intubated in either the prehospital setting or the ED and were admitted either to the operating room (OR), angiography suite, or ICU. Our primary outcome was the proportion of patients who were discharged alive from the ICU within 24 h. RESULTS: We included 3869 patients meeting the criteria above who were alive at 24 h. This population was 78% male with a median age of 40 and 76% of patients suffered from blunt trauma. The median injury severity score (ISS) of the group was 21 [inter-quartile range (IQR) 11-30]. In-hospital mortality amongst the group was 12%. 17% of the group were discharged alive from the ICU within 24 h. Thirty-four percent of the group had an ISS ≤ 15. Of the group which left the ICU alive within 24 h, six patients (0.9%) died in the hospital, 2 % of patients were re-admitted to an ICU, and 0.6% of patients required re-intubation. CONCLUSIONS: We found that 17% of patients who were intubated in the prehospital setting or emergency department and subsequently hospitalized were discharged alive from the ICU within 24 h.

A Description of Mechanically Ventilated Patients Admitted From the Emergency Department With a Short Critical Care Stay.

BACKGROUND: Patients admitted to an intensive care unit (ICU) requiring invasive mechanical ventilation who are discharged alive from the ICU within 24 h are poorly characterized in the literature. OBJECTIVE: Our aim was to characterize a cohort of intubated emergency department (ED) patients who are extubated and discharged from the ICU within 24 h. METHODS: We conducted a retrospective, observational cohort study at a single level I trauma center from January 2017 to December 2019. We included adults who were admitted to an ICU from the ED requiring invasive mechanical ventilation. Our primary outcome was the proportion of patients who were discharged from the ICU alive within 24 h. RESULTS: Of 13,374 ED patients admitted to an ICU during the study period, 2871 patients were intubated and ventilated in the prehospital or ED settings. Of these, 14% were discharged alive from the ICU within 24 h of admission. Only 21% of these patients were intubated in the ED. We identified the following two distinct subpopulations comprising 62% of this short-stay group: patients with a primary discharge diagnosis of intoxication (47%) and minimally injured trauma patients (53%), with 4% of patients in both subgroups. CONCLUSIONS: A total of 14% of patients receiving intubation with mechanical ventilation in the prehospital environment or in the ED were discharged alive from the ICU within 24 h. We identified two distinct subgroups of patients with a short stay in intensive care who may be candidates for ED extubation, including patients with intoxication and minimally injured trauma patients.

Can Military Role 1 Practitioners Maintain Their Skills Working at Civilian Level 1 Trauma Centers: A Retrospective, Cross-Sectional Study.

BACKGROUND: Introduction: Military Role 1 practitioners have difficulty maintaining skill competency by working solely in military medical treatment facilities. Recognizing this, the Army Medical Department has renewed focus on physician specialty-specific Individual Critical Task Lists (ICTL) and is increasing the number of military-civilian partnerships, wherein small military treatment teams work full-time in civilian trauma centers. Yet, data to validate this approach is lacking. We hypothesize military Role 1 practitioners working full-time at a civilian Level 1 trauma center would attain similar resuscitation-specific procedural frequency to providers deployed to an active combat zone, and use the emergency medicine (EM) ICTL to compare select procedural frequency between a cohort of trauma patients from a civilian Level 1 trauma center and a cohort of combat casualties from the Department of Defense Trauma Registry (DODTR). METHODS: We compared a selected subset of critically-injured, military-aged (18-35 years) trauma patients who were seen in a Level I Trauma Center emergency department (ED) between January 1, 2016 and December 31, 2017 and dispositioned directly either to the operating room, intensive care unit, or morgue to a selected cohort from the Department of Defense Trauma Registry (DODTR) who were seen in EDs in Iraq and Afghanistan between January 2007 and August 2016 using descriptive statistics. The primary outcome was the frequency of ICTL procedures performed, and the secondary outcome was injury severity. RESULTS: We identified 843 civilian patients meeting inclusion criteria, of 1,719 military-aged patients captured by the trauma registry during the study. The selected cohort from the DODTR included 27,359 patients. Demographics were similar between the 2 groups, except the DODTR cohort included significantly more patients with blast trauma (55% versus 0.4%). We found similar ICTL procedural frequency (1 procedure for every 1.84 patients in the civilian cohort compared to one procedure/1.52 patients in the military cohort). CONCLUSION: Role-1 ICTL trauma procedures were performed at similar frequencies between civilian patients seen at a Level 1 trauma center and combat casualties. With proper practice implementation, the opportunity exists for Role 1 practitioners to maintain their trauma resuscitation skills at civilian trauma centers.

A 57-Year-Old Man With COVID-19 Pneumonia Who Required Venovenous Extracorporeal Life Support With a Rapidly Escalating WBC Count.

CASE PRESENTATION: A 57-year-old man who had been intubated and placed on venovenous extracorporeal membrane oxygenation for hypoxemic respiratory failure due to COVID-19 pneumonia was transferred to our facility. He underwent anticoagulation with IV heparin titrated to an anti-Factor Xa goal of 0.1 to 0.3 international unit/mL. Over extracorporeal membrane oxygenation days 13 to 17, his WBC count rose from 17,500 to 47,000 cells/µL. He simultaneously experienced the development of fluid-refractory shock that required multiple vasopressors and received stress-dose hydrocortisone when his WBC was 30,000 cells/µL. He remained afebrile and was started on broad-spectrum antimicrobials that included antifungal and anthelminthic therapy.

Trends in B-Vitamin Prescriptions From Military Treatment Facilities: 2007 to 2011.

INTRODUCTION: The use of B-vitamin supplements has increased over the last decade. Although use is widespread in both military and civilian populations, data on patterns of B-vitamin prescription rates are lacking. OBJECTIVE: This study examines trends in B-vitamin prescriptions dispensed by military treatment facilities. METHODS: We examined data from the Department of Defense Pharmacy Data Transaction Service to determine the nature of several B-vitamin prescriptions dispensed through military treatment facilities from 2007 through 2011. The eight B vitamins examined were B1 (thiamine), B2 (riboflavin), B3 (niacin), B5 (panthenol), B6 (pyridoxine), B7 (biotin), B9 (folic acid), and B12 (cobalamin). RESULTS: The number of B-vitamin prescriptions dispensed from military treatment facilities decreased 7% from 278,972 in 2007 to 260,472 in 2011. Individual vitamin prescription patterns varied widely. Vitamins B6, B9, and B12 were the most frequently prescribed in each year. Vitamin B2 prescriptions quadrupled between 2009 and 2011, and B12 prescriptions showed a steady increase over time. In contrast, vitamins B3, B6, and B9 prescriptions showed a steady decline, and vitamin B7 prescriptions decreased by 66% between 2008 and 2009. CONCLUSIONS: No single pattern in B-vitamin prescriptions was observed. The driving forces behind increases in prescribed and non-prescribed dietary supplement use remain speculative.