Safety and efficacy of oral transmucosal fentanyl citrate for prehospital pain control on the battlefield.

BACKGROUND: Acute pain, resulting from trauma and other causes, is a common condition that imposes a need for prehospital analgesia on and off the battlefield. The narcotic most frequently used for prehospital analgesia on the battlefield during the past century has been morphine. Intramuscular morphine has a delayed onset of pain relief that is suboptimal and difficult to titrate. Although intravenously administered morphine can readily provide rapid and effective prehospital analgesia, oral transmucosal fentanyl citrate (OTFC) is a safe alternative that does not require intravenous access. This study evaluates the safety and efficacy of OTFC in the prehospital battlefield environment. METHODS: Data collected during combat deployments (Afghanistan and Iraq) from March 15, 2003, to March 31, 2010, were analyzed. Patients were US Army Special Operations Command casualties. Patients receiving OTFC for acute pain were evaluated. Pretreatment and posttreatment pain intensities were quantified by the verbal numeric rating scale (NRS) from 0 to 10. OTFC adverse effects and injuries treated were also evaluated. RESULTS: A total of 286 patients were administered OTFC, of whom 197 had NRS pain evaluations conducted before and approximately 15 minutes to 30 minutes following treatment. The difference between NRS pain scores at 0 minutes (NRS, 8.0 [1.4]) and 15 minutes to 30 minutes (NRS, 3.2 [2.1]) was significant (p < 0.001). Only 18.3% (36 of 197) of patients were also administered other types of analgesics. Nausea was the most common adverse effect as reported by 12.7% (25 of 197) of patients. The only major adverse effect occurred in the patient who received the largest opioid dose, 3,200-µg OTFC and 20-mg morphine. This patient exhibited hypoventilation and saturation of less than 90% requiring low-dose naloxone. CONCLUSION: OTFC is a rapid and noninvasive pain management strategy that provides safe and effective analgesia in the prehospital battlefield setting. OTFC has considerable implications for use in civilian prehospital and austere environments. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Event medicine: injury and illness during an expedition-length adventure race.

To describe the incidence and type of injury and illness occurring during an expedition-length adventure race and identify those resulting in withdrawal from the event, a prospective cohort study was conducted of the injuries and illness treated during the Subaru Primal Quest Expedition Adventure Race trade mark held in Colorado July 7-16, 2002. All racers, support crewmembers, and race staff were eligible to participate in the study. When a member of the study group received medical care due to an injury or illness, the encounter was recorded on a Medical Encounter Form. If an injury or illness resulted in withdrawal from the race, this was also recorded. Information from the Medical Encounter Forms was used to generate the Medical Log. There were 671 individuals eligible to participate in the study. A total of 243 medical encounters and 302 distinct injuries and illnesses were recorded. There were 179 (59%) injuries and 123 (41%) illnesses. Skin and soft tissue injuries and illness were the most frequent (48%), with blisters on the feet representing the single most common (32.8%). Second was respiratory illness (18.2%), including upper respiratory infection, bronchitis and reactive airway disease-asthma. Respiratory illness was the most common medical reason for withdrawal from the event. Injuries accounted for almost 60% of all injury and illness yet they contributed to less than 15% of the medical withdrawals from the race. Blisters accounted for almost one-third of all conditions treated. Providers of medical support for expedition-length adventure races should be prepared to treat a wide variety of injury and illness.

To air is human: altitude illness during an expedition length adventure race.

OBJECTIVE: To calculate the incidence and prevalence of altitude illness (acute mountain sickness [AMS], high altitude pulmonary edema, and high altitude cerebral edema) during an expedition length adventure race and to determine factors contributing to its development as well as identify cases requiring medical treatment, withdrawal from the event, or both. METHODS: The Primal Quest Expedition Length Adventure Race was held in Colorado in July 2002. Sixty-two coed teams of four participated in the event. It began at an altitude of over 9500 feet, ascended to an altitude over 13,500 feet with a cumulative elevation gain of 69,400 feet, of which 40,000 feet occurred in the first 12 hours of the event. There was 138,800 total feet of altitude change during the event. All racers underwent a prerace medical assessment 24 hours before the start of the race and completed an Environmental Systems Questionnaire version 3-R (ESQ 3-R). Onsite medical staff provided treatment during the event. A standard medical encounter form was used to record all patient encounters including a presumed diagnosis and disposition. RESULTS: At the start of the race, the prevalence of altitude illness was 4.5%. The incidence of altitude illness requiring medical treatment during the race was 14.1% (AMS, 33 [13.3%]; high altitude pulmonary edema, 2 [.81%]) resulting in 4 (14.3%) of the 28 medical withdrawals from the race. There was no correlation between home altitude, prerace ESQ scores, and successful completion of the race. CONCLUSIONS: Altitude illness occurs among participants in expedition length adventure races and contributes significantly to withdrawal from the event.

SARS and its impact on current and future Emergency Department operations.

A long-standing concern for international spread of new, virulent pathogens became a reality with the advent of Severe Acute Respiratory Syndrome (SARS). This respiratory syndrome, caused by a coronavirus, spread rapidly across 30 nations since its first recognition in late 2002. SARS has presented the greatest recent threat to U.S. public health, and has come at a time when purposeful introduction of pathogens by terrorists is also of heightened concern. SARS has forced the international medical establishment to reexamine how best to manage such incidents.