National community disparities in prehospital penetrating trauma adjusted for income, 2020-2021.

INTRODUCTION: While Black individuals experienced disproportionately increased firearm violence and deaths during the COVID-19 pandemic, less is known about community level disparities. We sought to evaluate national community race and ethnicity differences in 2020 and 2021 rates of penetrating trauma. METHODS: We linked the 2018-2021 National Emergency Medical Services Information System databases to ZIP Code demographics. We stratified encounters into majority race/ethnicity communities (>50% White, Black, or Hispanic/Latino). We used logistic regression to compare penetrating trauma for each community in 2020 and 2021 to a combined 2018-2019 historical baseline. Majority Black and majority Hispanic/Latino communities were compared to majority White communities for each year. Analyses were adjusted for household income. RESULTS: We included 87,504,097 encounters (259,449 penetrating traumas). All communities had increased odds of trauma in 2020 when compared to 2018-2019, but this increase was largest for Black communities (aOR 1.4, [1.3-1.4]; White communities - aOR 1.2, [1.2-1.3]; Hispanic/Latino communities - aOR 1.1. [1.1-1.2]). There was a similar trend of increased penetrating trauma in 2021 for Black (aOR 1.2, [1.2-1.3]); White (aOR 1.2, [1.1-1.2]); Hispanic/Latino (aOR 1.1, [1.1-1.1]). Comparing penetrating trauma in each year to White communities, Black communities had higher odds of trauma in all years (2018/2019 - aOR 3.0, [3.0-3.1]; 2020 - aOR 3.3, [3.3-3.4]; 2021 - aOR 3.3, [3.2-3.2]). Hispanic/Latino also had more trauma each year but to a lesser degree (2018/2019 - aOR 2.0, [2.0-2.0]; 2020 - aOR 1.8, [1.8-1.9]; 2021 - aOR 1.9, [1.8-1.9]). CONCLUSION: Black communities were most impacted by increased penetrating trauma rates in 2020 and 2021 even after adjusting for income.

Prehospital Validation of the Assessment of Blood Consumption (ABC) Score.

INTRODUCTION: The Assessment of Blood Consumption (ABC) score is a previously validated scoring system designed to predict which severely injured trauma patients will require massive transfusion. When the ABC score is used in the prehospital setting to activate massive transfusion at the receiving hospital, a 23% decrease in mortality has been demonstrated. However, the ABC score was developed and validated using hospital data from the emergency department (ED). The sensitivity and specificity of the ABC score when calculated using data from the prehospital setting are unknown. We hypothesized that the sensitivity and specificity of the prehospital ABC score will be similar to the sensitivity and specificity of the ED ABC score. METHODS: A 5-year retrospective analysis (2015-2019) of highest-activation adult trauma patients arriving to a quaternary Level I trauma center by hospital-based helicopter air medical service (HEMS) was performed. Demographic, prehospital, ED triage, and blood product utilization data were collected. Prehospital ABC score was calculated using the highest heart rate, lowest systolic blood pressure, and focused assessment with sonography for trauma (FAST) exam results obtained prior to arrival at the trauma center. ED ABC score was calculated using ED triage vital signs and ED FAST results. Sensitivity, specificity, positive predictive value, negative predictive value, and the area under the receiver operating characteristics (AUROC) curve were calculated for each ABC score. RESULTS: 2,067 patients met inclusion criteria. Mean age 39 (±17) years, 76% male, 22% penetrating mechanism. Of these, 128 patients (6%) received massive transfusion using the definition from the original study. Prehospital ABC score at a cutoff of 2 was 51% sensitive and 85% specific for predicting massive transfusion, with 83% correctly classified and an AUROC = 0.73. ED ABC score at the same cutoff was 60% sensitive and 84% specific, with 83% correctly classified and an AUROC = 0.81. By logistic regression, the odds of massive transfusion increased by 2.76 for every 1-point increase in prehospital ABC score (95%CI 2.25-3.37, p < 0.001). CONCLUSIONS: The ABC score is a useful prehospital tool for identifying who will require massive transfusion. Future studies to evaluate the effect of the prehospital ABC score on clinical care and mortality are necessary.

Use of Low-Titer O-Positive Whole Blood in Female Trauma Patients: A Literature Review, Qualitative Multidisciplinary Analysis of Risk/Benefit, and Guidelines for Its Use as a Universal Product in Hemorrhagic Shock.

BACKGROUND: Whole blood transfusion is associated with benefits including improved survival, coagulopathy, and decreased transfusion requirements. The majority of whole blood transfusion is in the form of low-titer O-positive whole blood (LTOWB). Practice at many trauma centers withholds the use of LTOWB in women of childbearing potential due to concerns of alloimmunization. The purpose of this article is to review the evidence for LTOWB transfusion in female trauma patients and generate guidelines for its application. STUDY DESIGN: Literature and evidence for LTOWB transfusion in hemorrhagic shock are reviewed. The rates of alloimmunization and subsequent obstetrical outcomes are compared to the reported outcomes of LTOWB vs other resuscitation media. Literature regarding patient experiences and preferences in regards to the risk of alloimmunization is compared to current trauma practices. RESULTS: LTOWB has shown improved outcomes in both military and civilian settings. The overall risk of alloimmunization for Rhesus factor (Rh) - female patients in hemorrhagic shock exposed to Rh + blood is low (3% to 20%). Fetal outcomes in Rh-sensitized patients are excellent compared to historical standards, and treatment options continue to expand. The majority of female patients surveyed on the risk of alloimmunization favor receiving Rh + blood products to improve trauma outcomes. Obstetrical transfusion practices have incorporated LTOWB with excellent results. CONCLUSIONS: The use of whole blood resuscitation in trauma is associated with benefits in the resuscitation of severely injured patients. The rate at which severely injured, Rh-negative patients develop anti-D antibodies is low. Treatments for alloimmunized pregnancies have advanced, with excellent results. Fears of alloimmunization in female patients are likely overstated and may not warrant the withholding of whole blood resuscitation. The benefits of whole blood resuscitation likely outweigh the risks of alloimmunization.

National trends in prehospital penetrating trauma in 2020 and 2021.

OBJECTIVE: Prior studies identified increased penetrating trauma rates during the earlier phase of the COVID-19 pandemic, but there is limited study of penetrating trauma rates in 2021 or at a national level. We evaluated trends in prehospital encounters for penetrating trauma in 2020 and 2021 using a national database. METHODS: We conducted a retrospective analysis of the National Emergency Medicinal Services (EMS) Information System (NEMSIS) combined 2018-2021 databases of prehospital encounters. We calculated penetrating trauma yearly and monthly rates with 95% confidence; both overall and for each census region. We compared trauma rates in 2020 and 2021 to combined 2018/2019. RESULTS: There were 67,457 (rate of 0.30%) penetrating traumas in 2018, 86,054 (0.30%) in 2019, 95,750 (0.37%) in 2020, and 98,040 (0.34%) in 2021. Nationally, trauma rates were higher from March 2020 to July 2021 than baseline. Penetrating trauma rates from May-December 2021 were lower than May-December of 2020. All census regions similarly had increased trauma rates during from March 2020 to July 2021. CONCLUSION: We identified elevated rates of trauma on 2020 that lasted until July of 2021 that was present in all US census regions.

Continuum of Care: A Multiagency Approach to Seamless Warmed Prehospital Whole Blood Resuscitation of a Patient with Noncompressible Truncal Hemorrhage.

BACKGROUND: Prehospital transfusion capabilities vary widely in the United States. Here we describe a case of prehospital resuscitation using warmed, whole blood in a patient with penetrating torso trauma and associated hemorrhagic shock. CASE REPORT: A 68-year-old man sustained a single gunshot wound to the left chest and was found to have a shock index of 1.5 at the time of emergency medical services (EMS) arrival. Rapid peripheral intravenous and central venous access enabled the infusion of warmed low-titer O-positive whole blood. The EMS crew intentionally resuscitated the patient before managing the airway by means of rapid sequence intubation. An air medical services helicopter crew assumed patient care from the ground EMS crew and continued the warmed, whole blood transfusion during the flight to a regional Level I trauma center. The patient went directly to the operating room from the helipad, underwent definitive operative management, and was ultimately discharged home on hospital day nine. CONCLUSION: Early recognition of hemorrhagic shock, implementation of prehospital transfusion protocols that emphasize transfusion of warmed blood without interruption, and an organized, regional approach to trauma care are critical for improving patient survival.

A Case Report of Anesthesia-induced Diffuse Alveolar Hemorrhage Presenting to the Emergency Department.

Introduction: The inhaled anesthetic sevoflurane is an uncommon etiology of diffuse alveolar hemorrhage (DAH). As DAH typically presents in the inpatient, postoperative setting, it has been infrequently reported in the anesthesiology literature and, to our knowledge, has not been reported in the emergency medicine literature to date. Case Report: We describe the presentation of a young, healthy male in respiratory distress to a busy urban emergency department (ED) after an outpatient surgical procedure. We highlight the etiology of post-anesthesia DAH and the acute management of this rare diagnosis in the ED. Conclusion: With outpatient surgical centers becoming an increasingly popular option for lower risk procedures, emergency physicians would benefit from understanding this presentation and its pathophysiology.

Expanding Our Reach: Development of a Civilian Helicopter Air Ambulance K9 Response Program.

This short communication highlights the development and implementation of the first civilian helicopter air ambulance canine response program in the United States.

Out-of-hospital, non-invasive, positive-pressure ventilation for acute dyspnea.

BACKGROUND: Emergency medical services (EMS) patients with acute dyspnea require prompt treatment. Limited data describe out-of-hospital dyspnea treatment with non-invasive, positive-pressure ventilation (NIPPV), including continuous positive airway pressure (CPAP) or bi-level positive air pressure (BPAP). We sought to determine the course and outcomes of out-of-hospital acute dyspnea patients treated with NIPPV. METHODS: We analyzed retrospective data on 1289 EMS agencies from the ESO Data Collaborative (ESO, Inc., Austin, TX) between January and December 2018. We defined acute dyspnea as adults with an initial respiratory rate ≥ 30 breaths/min (bpm), with a primary or secondary EMS subjective impression of a respiratory condition, who received oxygen and/or a respiratory medication and had 2 or more recordings of respiratory rate (RR). We excluded patients with trauma and those with altered mental status. We identified cases receiving care with and without NIPPV. The primary outcome was change in respiratory rate (RR), censored at 90 minutes of treatment. We compared baseline characteristics between NIPPV and non-NIPPV patients. We compared RR changes between NIPPV and non-NIPPV patients at 20 and 40 minutes of treatment. Using mixed linear, fractional polynomial, and multiple spline models, we examined the association of out-of-hospital NIPPV with overall change in RR. Secondary outcomes included whether the patient received advanced airway treatment (intubation, supraglottic airway device, and/or cricothyroidotomy). RESULTS: We analyzed 33,585 EMS encounters for patients with acute dyspnea, including 8,750 (26.1%) NIPPV and 24,835 (73.9%) non-NIPPV encounters. Median treatment duration was similar between NIPPV and non-NIPPV (23.3 minutes vs 23.6 minutes, rank-sum P = 0.266). Common concurrent treatments included albuterol (NIPPV, 48.8%; non-NIPPV, 46.2%), ipratropium bromide (27.9%, 24.8%), and methylprednisolone (24.9%, 18.5%). At 20 minutes, mean RR change was slightly lower for the NIPPV group than non-NIPPV; -6.0 versus -6.8 breaths/min. At 40 minutes, mean RR change was similar between NIPPV and non-NIPPV groups; -7.7 versus -7.9 breaths/min. On linear mixed modeling adjusted for age, sex, incident location, race, ethnicity, agency type, initial RR, and medication use, NIPPV was associated with a smaller RR decrease across time than NIPPV; [NIPPV × time] interaction P < 0.001. Out-of-hospital advanced airway placement (endotracheal intubation or supraglottic airway insertion) was higher for NIPPV than non-NIPPV group (2.3% vs 1.3%, odds ratio = 2.23, 95% confidence interval = 2.01-2.47). CONCLUSIONS: NIPPV has been proven to be an effective treatment for out-of-hospital patients experiencing acute dyspnea through prior studies. Our findings provide detailed insight into characteristics and use of NIPPV and highlight the commonality of this treatment modality with use in over 1 in 4 patients in respiratory distress.

Community disparities in out of hospital cardiac arrest care and outcomes in Texas.

BACKGROUND: Large racial and socioeconomic inequalities exist for out-of-hospital cardiac arrest (OHCA) care and outcomes. We sought to characterize racial, ethnic, and socioeconomic disparities in OHCA care and outcomes in Texas. METHODS: We analyzed 2014-2018 Texas-Cardiac Arrest Registry to Enhance Survival (CARES) data. Using census tracts, we defined race/ethnicity neighborhoods based on majority race/ethnicity composition: non-Hispanic/Latino white, non-Hispanic/Latino black, and Hispanic/Latino. We also stratified neighborhoods into socioeconomic categories: above and below the median for household income, employment rate, and high school graduation. We defined outcomes as bystander CPR rates, public bystander AED use, and survival to hospital discharge. Using mixed models, we analyzed the associations between outcomes and neighborhood (1) racial/ethnic categories and (2) socioeconomic categories. RESULTS: We included data on 18,488 OHCAs. Relative to white neighborhoods, black neighborhoods had lower rates of AED use (OR 0.3, CI 0.2-0.4), and Hispanic/Latino neighborhoods had lower rates of bystander CPR (OR 0.7, CI 0.6-0.8), AED use (OR 0.4, CI 0.3-0.6), and survival (OR 0.8, CI 0.7-0.8). Lower income was associated with a lower rates of bystander CPR (OR 0.8, CI 0.7-0.8), AED use (OR 0.5, CI 0.4-0.8), and survival (OR 0.9, CI 0.9-0.98). Lower high school graduation was associated with a lower rate of bystander CPR (OR 0.8, CI 0.7-0.9) and AED use (OR 0.6, CI 0.4-0.9). Higher unemployment was associated with lower rates of bystander CPR (OR 0.9, CI 0.8-0.94) and AED use (OR 0.7, CI 0.5-0.99). CONCLUSION: Minority and poor neighborhoods in Texas experience large and unacceptable disparities in OHCA bystander response and outcomes.

Monocled Cobra (Naja kaouthia) Envenomations Requiring Mechanical Ventilation.

BACKGROUND: Bites from nonnative snakes are uncommon, accounting for 1.1% of envenomations reported to poison centers between 2015 and 2018. Here we discuss two monocled cobra (Naja kaouthia) envenomations resulting in respiratory failure. CASE REPORTS: A 30-year-old man and a 40-year-old man were bitten by their captive monocled cobras. At the first hospital, the first patient was mildly hypotensive, transiently bradycardic, and confused. He was intubated for respiratory distress. He was hypertensive to 211/119 mm Hg upon arrival to the second hospital. In the Emergency Department, cobra antivenom was administered. He was admitted to the medical intensive care unit (MICU) and had an additional bradycardic episode that corrected with atropine. He was extubated after 35 h. He was observed for an additional 9 h prior to going home, where he recovered without incident. The second patient developed abdominal pain, blurry vision, and dyspnea within 90 min of the bite. He was intubated at the first hospital. At the second hospital he received cobra antivenom and was admitted to the MICU. He was extubated after 9 h and discharged the following day with no further symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Envenomations after N. kaouthia bites are characterized by local tissue injury and various neurotoxic effects. Nonspecific signs and symptoms are common. Hematologic toxicity and cardiovascular manifestations are uncommon. Antivenom is the specific treatment for snake envenomation, but only certain antivenoms are indicated for N. kaouthia. Cholinesterase inhibitors may reduce toxicity from postsynaptic alpha toxins by increasing acetylcholine concentrations.

Integration of aeromedicine in the response to the COVID-19 pandemic.

There is limited guidance on the use of helicopter medical personnel to facilitate care of critically ill COVID-19 patients. This manuscript describes the emergence of this novel virus, its mode of transmission, and the potential impacts on patient care in the unique environment of rotor wing aircraft. It details the development of clinical and operational guidelines for flight crew members. This allows other out-of-hospital clinicians to utilize our framework to augment or supplement their own for the current response effort to COVID-19. It further serves as a road map for future response to the care of high consequence infectious disease patients.

A Case Report of Angioedema and Anaphylactic Shock Induced by Ingestion of Polyethylene Glycol.

INTRODUCTION: We report one of few documented cases of a severe anaphylactic reaction with angioedema to polyethylene glycol (PEG). CASE REPORT: The patient presented 30 minutes after onset of his symptoms and quickly developed hypoxia and hypotension refractory to intramuscular epinephrine, intravenous fluids, methylprednisolone, and supplemental oxygen via non-rebreather mask. He ultimately required intubation, an epinephrine infusion, and admission to the medical intensive care unit. DISCUSSION: This case depicts a clinical reaction to PEG, a medication rarely implicated in severe anaphylaxis or angioedema. CONCLUSION: The allergenic potential of PEG-containing products should be raised, and providers should have a heightened awareness of these potential side effects.

Epidemiological and Accounting Analysis of Ground Ambulance Whole Blood Transfusion.

INTRODUCTION: In October 2017, the American Association of Blood Bankers (AABB; Bethesda, Maryland USA) approved a petition to allow low-titer group O whole blood as a standard product without the need for a waiver. Around that time, a few Texas, USA-based Emergency Medical Services (EMS) systems incorporated whole blood into their ground ambulances. The purpose of this project was to describe the epidemiology of ground ambulance patients that received a prehospital whole blood transfusion. The secondary aim of this project was to report an accounting analysis of these ground ambulance prehospital whole blood programs. METHODS: The dataset came from the Harris County Emergency Service District 48 Fire Department (HCESD 48; Harris County, Texas USA) and San Antonio Fire Department (SAFD; San Antonio, Texas USA) whole blood Quality Assurance/Quality Improvement (QA/QI) databases from September 2017 through December 2018. The primary outcome of this study was the prehospital transfusion indication. The secondary outcome was the projected cost per life saved during the first 10 years of the prehospital whole blood initiative. RESULTS: Of 58 consecutive prehospital whole blood administrations, the team included all 58 cases. Hemorrhagic shock from a non-traumatic etiology accounted for 46.5% (95% CI, 34.3%-59.2%) of prehospital whole blood recipients. In the non-traumatic hemorrhagic shock cohort, gastrointestinal hemorrhage was the underlying etiology of hemorrhagic shock in 66.7% (95% CI, 47.8%-81.4%) of prehospital whole blood transfusion recipients. The projected average cost to save a life in Year 10 was US$5,136.51 for the combined cohort, US$4,512.69 for HCESD 48, and US$5,243.72 for SAFD EMS. CONCLUSION: This retrospective analysis of ground ambulance patients that receive prehospital whole blood transfusion found that non-traumatic etiology accounted for 46.5% (95% CI, 34.3%-59.2%) of prehospital whole blood recipients. Additionally, the accounting analysis suggests that by Year 10 of a ground ambulance whole blood transfusion program, the average cost to save a life will be approximately US$5,136.51.

Resuscitative endovascular balloon occlusion of the aorta: current evidence.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has recently gained popularity as a minimally invasive alternative to open aortic cross-clamping in the management of patients with non-compressible hemorrhage arising below the diaphragm. The purpose of this review is to provide a description of the technical aspects of REBOA use along with an overview of the current animal and clinical data regarding its use.