Validation of Air Medical Prehospital Triage Score in Determining Resource Utilization at Level 1 Trauma Centers.

OBJECTIVE: Overtriage (ie, delivering less severely injured patients via helicopter) is costly, raises safety concerns, and reduces efficiency of the trauma system. The Air Medical Prehospital Triage (AMPT) scoring system was developed to determine which trauma patients would gain a survival benefit by air transport. The objective of this study was to evaluate the AMPT scoring system as a method of reducing trauma overtriage when helicopter emergency medical services were used. METHODS: A retrospective study of all scene trauma transports delivered by helicopter to 1 of 2 level 1 trauma centers was evaluated for 1) hospital stay less than 1 day and 2) failure to meet 1 of the following criteria for resource utilization: intensive care unit admission, an operative procedure within the first 24 hours, the need for blood products, Injury Severity Score ≥ 16, or death during hospitalization. Helicopter emergency medical services personnel recorded specific criteria from the Centers for Disease Control and Prevention (CDC) field trauma triage guidelines and AMPT that were met by transported trauma patients. RESULTS: There were 244 patients in the study population. Eighty-one (33.2%) patients were discharged within 24 hours; 11 (13.5%) of these patients were positive using AMPT scoring, whereas 44 (54.3%) patients met 1 of the CDC criteria. Similarly, 141 (57.8%) patients failed to meet 1 of the level 1 resource criteria; 19 (13.5%) met the AMPT criteria for air medical transport, whereas 84 (59.6%) met 1 of the CDC criteria. Undertriage was 63.5% for AMPT and 20.2% for CDC based on resource utilization criteria. CONCLUSION: The AMPT score reduced the number of patients who were inappropriately transported to a trauma center. However, this appeared to be at the expense of undertriage. Future studies should focus on developing a refined air medical-specific triage tool that has both low overtriage rates as well as lower undertriage rates.

Correlation of Preflight Risk Assessment Scores With First-Pass Intubation Success in a Critical Care Transport Environment.

OBJECTIVE: The purpose of this study was to examine the impact of crew fatigue on the performance of a high-risk clinical skill in a clinical setting. METHODS: This was a retrospective analysis of first-pass intubation success comparing critical care providers with self-reported fatigue and those without fatigue in a transport environment. RESULTS: No statistical difference was found in first-pass intubation between fatigued and nonfatigued practitioners. CONCLUSION: Future studies should determine the impact of fatigue on psychomotor and cognitive skills using validated methods of assessing the level of fatigue at the time of skill performance.

Prehospital Ketamine Use for Rapid Sequence Intubation: Are Higher Doses Associated With Adverse Events?

OBJECTIVE: Ketamine for rapid sequence intubation (RSI) is typically dosed at 1 to 2 mg/kg intravenously. The need to ensure dissociation during RSI led some to administer ketamine at doses greater than 2 mg/kg. This study assessed associations between ketamine dose and adverse events. METHODS: This multisite, retrospective study included adult subjects undergoing RSI with intravenous ketamine. Subjects were categorized into 2 groups: a standard ketamine dose (≤ 2 mg/kg intravenously) or a high dose (> 2 mg/kg intravenously). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for adverse events. RESULTS: Eighty subjects received standard-dose ketamine, and 50 received high-dose ketamine. The high-dose group had a significantly (P < .05) higher proportion of trauma patients, were younger, and had higher predose blood pressure compared with the standard-dose group. High-dose ketamine was associated with greater odds of adverse events including hypotension (OR = 7.0; 95% CI, 3.0-16.6), laryngospasm (OR = 10.8; 95% CI, 1.3-93.4), bradycardia (OR = 7.5; 95% CI, 1.5-36.6), repeat medications (OR = 12.9; 95% CI, 1.5-107.9), oxygen desaturation (OR = 6.0; 95% CI, 1.8-19.9), multiple attempts (OR = 3.2; 95% CI, 1.5-6.8%), and failed airway (OR = 3.6; 95% CI, 1.0-12.7). CONCLUSION: Ketamine at higher doses was associated with increased odds of adverse events. Studies assessing adverse events of ketamine at lower than standard doses in shock patients are needed.

Characteristics of scene trauma patients discharged within 24-hours of air medical transport.

INTRODUCTION: Helicopters play an important role in trauma; however, this service comes with safety risks, high transport costs, and downstream care charges. OBJECTIVE: Our objective was to determine the characteristics of early discharged trauma patients (<24 h length of stay) in order to reduce overtriage. METHODOLOGY: Data were obtained from the trauma registries at one of two Level 1 trauma centers. Eligible patients included all scene trauma patients transported by helicopter to the Level 1 trauma centers from January 1, 2016, to December 31, 2017, who had a length of stay of 24 h or less. Patient factors such as age, gender, scene location, loaded miles, and transportation costs were collected. Trauma type, mechanism of injury, Abbreviated Injury Scale (AIS), Injury Severity Score, Revised Trauma Score, and prehospital vital signs were documented. Driving distances between the accident scene to local hospital, home of record to local hospital, and home of record to the Level I trauma center were also calculated for patients transported to Level 1 trauma center. RESULTS: Two hundred and twenty-six of 1042 total patients (21.7%) were discharged within 24 h of helicopter transport from the accident scene to trauma center. Less than 2% of patients were in the age group of 70 years or older. Only 2 (0.88%) patients discharged within 24 h had a prehospital systolic blood pressure <90 mmHg. For patients transported to Level 1 trauma center, the average loaded miles were 50.51 ± 14.99, with average transport charges being $27,921.19± $3536.61. Twenty-one percent of Level 1 trauma center patients were self-pay, and families typically drove 71.7 ± 123.23 miles to Level 1 trauma center versus 28.74 ± 40.62 to their local emergency department. CONCLUSIONS: A significant number of patients transported from the scene are discharged within 24 h of admission to a trauma center. These patients rarely have prehospital hypotension, do not receive significant volumes of crystalloid resuscitation, and are infrequently over 70 years of age. One in five patients has no third-party coverage and assumes $27,921.19 in average transport charges.

Are there Field Triage Criteria that Can Predict Low-Yield Air Medical Transports?

INTRODUCTION: Air medical transport of trauma patients from the scene of injury plays a critical role in the delivery of severely injured patients to trauma centers. Over-triage of patients to trauma centers reduces the system efficiency and jeopardizes safety of air medical crews. HYPOTHESIS: The objective of this study was to determine which triage factors utilized by Emergency Medical Services (EMS) providers are strong predictors of early discharge for trauma patients transported by helicopter to a trauma center. METHODS: A retrospective chart review over a two-year period was performed for trauma patients flown from the injury site into a Level I trauma center by an air medical transport program. Demographic and clinical data were collected on each patient. Prehospital factors such as Glasgow Coma Score (GCS), Revised Trauma Score (RTS), intubation status, mechanism of injury, anatomic injuries, physiologic parameters, and any combinations of these factors were investigated to determine which triage criteria accurately predicted early discharge. Hospital factors such as Injury Severity Score (ISS), length-of-stay (LOS), survival, and emergency department disposition were also collected. Early discharge was defined as a hospital stay of less than 24 hours in a patient who survives their injuries. A more stringent definition of appropriate triage was defined as a patient with in-hospital death, an ISS >15, those taken to the operating room (OR) or intensive care unit (ICU), or those receiving blood products. Those patients who failed to meet these criteria were also used to determine over-triage rates. RESULTS: An overall early discharge rate of 35% was found among the study population. Furthermore, when the more stringent definition was applied, over-triage rates were as high as 85%. Positive predictive values indicated that patients who met at least one anatomic and physiologic criteria were appropriately transported by helicopter as 94% of these patients had stays longer than 24 hours. No other criteria or combination of criteria had a high predictive value for early discharge. CONCLUSIONS: No individual triage criteria or combination of criteria examined demonstrated the ability to uniformly predict an early discharge. Although helicopter transport and subsequent hospital care is costly and resource consuming, it appears that a significant number of patients will be discharged within 24 hours of their transport to a trauma center. Future studies must determine the impact of eliminating "low-yield" triage criteria on under-triage of scene trauma patients.

Impact of Paralytic Agent on Postintubation Sedation.

OBJECTIVE: The aim of this study was to evaluate the difference in the time to postintubation sedation between patients receiving etomidate and either succinylcholine or rocuronium in the prehospital setting. SETTING: Patients who received rapid sequence intubation medications from transport service personnel and were subsequently intubated were included. The critical care transport agency operates 8 helicopter- and 3 ground-based emergency medical service units. METHODS: This retrospective cohort study compared the time to the first sedative in patients intubated with etomidate and succinylcholine versus etomidate and rocuronium. Enrollment of 64 patients per arm was needed to achieve 80% power with a 2-tailed alpha of 0.05. RESULTS: Sixty-four and 38 patients received succinylcholine or rocuronium, respectively. The median time to postetomidate sedation was 10 (range, 5.0-16.0) and 13.5 (range, 7.0-20.8) minutes for succinylcholine and rocuronium patients, respectively (P = .13). Given the average duration of effect of etomidate, succinylcholine, and rocuronium, 0 (0%) succinylcholine versus 33 (86.8%) rocuronium patients were found to be at risk of wakeful paralysis. CONCLUSIONS: This study suggests rocuronium's long duration of effect puts patients at risk for wakeful paralysis once the short effects of etomidate have subsided.

Impact of shift duration on alertness among air-medical emergency care clinician shift workers.

BACKGROUND: Greater than half of Emergency Medical Services (EMS) shift workers report fatigue at work and most work long duration shifts. We sought to compare the alertness level of EMS shift workers by shift duration. METHODS: We used a multi-site, 14-day prospective observational cohort study design of EMS clinician shift workers at four air-medical EMS organizations. The primary outcome was behavioral alertness as measured by psychomotor vigilance tests (PVT) at the start and end of shifts. We stratified shifts by duration (< 24 h and 24 h), night versus day, and examined the impact of intra-shift napping on PVT performance. RESULTS: One hundred and twelve individuals participated. The distribution of shifts <24 h and 24 h with complete data were 54% and 46%, respectively. We detected no differences in PVT performance measures stratified by shift duration (P > 0.05). Performance for selected PVT measures (lapses and false starts) was worse on night shifts compared to day shifts (P < 0.05). Performance also worsened with decreasing time between waking from a nap and the end of shift PVT assessment. CONCLUSIONS: Deficits in performance in the air-medical setting may be greatest during night shifts and proximal to waking from an intra-shift nap. Future research should examine alertness and performance throughout air-medical shifts, as well as investigate the timing and duration of intra-shift naps on outcomes.

Botulism Outbreak in a Regional Community Hospital: Lessons Learned in Transfer and Transport Considerations.

Botulism is a potentially lethal disease caused by a toxin released by Clostridium botulinum. Outbreaks of botulism from food sources can lead to a Mass Casualty Incident (MCI) involving sometimes hundreds of individuals. We report on a recent outbreak of botulism treated at a regional community hospital with a focus on emergency medical services (EMS) response and transport considerations. Case Presentation: There were 53 patient evaluated for botulism at the sending facility. In total, 11 botulism exposures required intubation at the sending facility. Twenty-four patients were ultimately transported by critical care capable ALS crews with the majority (16) of these transports occurred in the first 24 hours. There was one fatality in the first days of the outbreak and a second death that occurred in a patient who died after long-term acute care (LTAC) placement several months after hospital discharge. Conclusion: Local EMS providers and public safety officers have a critical role in identifying and following up on potentially exposed botulism cases. The organization of transporting agencies and the logistics of transfer turned out to be 2 opportunities for improvement in response to this mass casualty incident.

Real-Time Fatigue Mitigation with Air-Medical Personnel: The SleepTrackTXT2 Randomized Trial.

Objective: The aims of this study were: 1) to determine the short-term impact of the SleepTrackTXT2 intervention on air-medical clinician fatigue during work shifts and 2) determine the longer-term impact on sleep quality over 120 days. Methods: We used a multi-site randomized controlled trial study design with a targeted enrollment of 100 (ClinicalTrials.gov NCT02783027). The intervention was behavioral (non-pharmacological) and participation was scheduled for 120 days. Participation was voluntary. All consented participants answered baseline as well as follow-up surveys. All participants answered text message queries, which assessed self-rated fatigue, sleepiness, concentration, recovery, and hours of sleep. Intervention participants received additional text messages with recommendations for behaviors that can mitigate fatigue. Intervention participants received weekly text messages that promoted sleep. Our analysis was guided by the intent-to-treat principle. For the long-term outcome of interest (sleep quality at 120 days), we used a two-sample t-test on the change in sleep quality to determine the intervention effect. Results: Eighty-three individuals were randomized and 2,828 shifts documented (median shifts per participant =37, IQR 23-49). Seventy-one percent of individuals randomized (n = 59) participated up to the 120-day study period and 52% (n = 43) completed the follow-up survey. Of the 69,530 text messages distributed, participants responded to 61,571 (88.6%). Mean sleep quality at 120 days did not differ from baseline for intervention (p > 0.05) or control group participants (p > 0.05), and did not differ between groups (p > 0.05). There was no change from baseline to 120 days in the proportion with poor sleep quality in either group. Intra-shift fatigue increased (worsened) over the course of 12-hour shifts for participants in both study arms. Fatigue at the end of 12-hour shifts was higher among control group participants than participants in the intervention group (p < 0.05). Pre-shift hours of sleep were often less than 7 hours and did not differ between the groups over time. Conclusions: The SleepTrackTXT2 behavioral intervention showed a positive short-term impact on self-rated fatigue during 12-hour shifts, but did not impact longer duration shifts or have a longer-term impact on sleep quality among air-medical EMS clinicians.

Fatigue mitigation with SleepTrackTXT2 in air medical emergency care systems: study protocol for a randomized controlled trial.

BACKGROUND: Most air medical Emergency Medical Services (EMS) clinicians work extended duration shifts, and more than 50% report inadequate sleep, poor sleep quality, and/or poor recovery between shifts. The SleepTrackTXT pilot trial (ClinicalTrials.gov, NCT02063737) showed that use of mobile phone text messages could impact EMS clinician self-reported fatigue and sleepiness during long duration shifts. The purpose of the SleepTrackTXT2 trial is to leverage lessons learned from the first SleepTrackTXT study and test an enhanced intervention targeting air medical EMS clinicians. METHODS/DESIGN: We will conduct a multi-site randomized trial with a sample of adult EMS clinicians recruited from four air medical EMS systems located in the midwest, northeastern, and southern USA. Participants will be allocated to one of two possible arms for a 4-month (120-day) study period. The intervention arm will involve text-message assessments of sleepiness, fatigue, and difficulty concentrating at the beginning, every 4 hours during, and at the end of scheduled shifts. Participants reporting high levels of sleepiness, fatigue, or difficulty with concentration will receive one of nine randomly selected intervention messages to promote behavior change during shift work to improve alertness. Intervention participants will receive a text-message report on Friday of each week that shows their sleep debt over the previous 7 days followed by a text message to promote paying back sleep debt recovery when feasible. Participants in the control group receive text messages that only include assessments. Both arms will receive text-message assessments of perceived recovery since last shift, sleepiness, fatigue, or difficulty with concentration at noon (1200 hours) on days between scheduled shifts (off-duty days). We have two aims for this study: (1) to determine the short-term impact of the enhanced SleepTrackTXT2 intervention on air medical clinician fatigue reported in real time during and at the end of shift work, and (2) to determine the long-term impact of the SleepTrackTXT2 intervention on sleep quality and sleep health indicators including hours of sleep and recovery between shift work. DISCUSSION: The SleepTrackTXT2 trial may provide evidence of real-world effectiveness that would support widespread expansion of fatigue mitigation interventions in emergency care clinician shift workers. The trial may specifically support use of real-time assessments and interventions delivered via mobile technology such as text messaging. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02783027 . Registered on 23 May 2016.

Do Trauma Patients Aged 55 and Older Benefit from Air Medical Transport?

INTRODUCTION: A recent analysis of the National Sample Project demonstrated that the mortality benefits of air medical transport do not extend to patients age 55 or older. The purpose of the current investigation was to evaluate mortality benefits of air transport in adult trauma patients ≥ 55 years of age. METHODS: A retrospective analysis of all adult patients greater than age 55 years directly transported from a trauma scene to a Level I or II facility was conducted. The primary outcome variable was in-hospital mortality. Using the imputed dataset we then performed multivariable logistic regression with mortality as the dependent variable to determine if mode of transport had a significant impact on mortality for patients older than 55 years of age. RESULTS: There were 7,739 (90.9%) patients transported by ground and 682 (9.1%) transported by air in our dataset. There were 3,556 between the ages of 55 to 69 years and an additional 4865 over the age of 69 years. In the multivariable model of all patients ≥ 55, air transport was associated with lower mortality (adjusted odds ratio [aOR] = 0.60; 95% confidence interval [CI] = 0.39--0.91; p = 0.017) when compared to those transported by ground. CONCLUSION: Our study was able to demonstrate a survival benefit for the cohort of patients age greater than 55 years of age. Key words: air medical transport; trauma; geriatric.

Limb Replantation in Air-Transported Patients: A 4-Year Study.

OBJECTIVE: Patients who require extremity reimplantation represent a population in whom rapid transport could provide potential benefit. Only 1 previous report has described the use of air transport in patients with these injuries. We describe our experience in air medical transport of limb reimplantation candidates. METHODS: A retrospective chart review for all patients with amputation or near-amputation extremity injuries who were transported by helicopter to a regional reimplantation center over a 4-year period was conducted. The primary outcome measure was patients who were taken to the operating room (OR) for a definitive repair attempt by the surgical team. RESULTS: Of the 115 patients, 104 were taken to the OR (90%), and 84 (80%) had a repair attempted. Similar results were found between those patients who were transported from the scene or another hospital with regard to the number of candidates taken to the OR and the number of patients in who definitive repair was attempted. CONCLUSION: Air medical transport can play an important role in a regional reimplantation program.

Ambulance Diversion: Ethical Dilema and Necessary Evil.

Ambulance diversion presents a dilemma pitting the ethical principles of patient autonomy and beneficence against the principles of justice and nonmaleficence. The guiding priority in requesting ambulance diversion is to maintain the safety of all patients in the emergency department as well as those waiting to be seen. Policies and procedures can be developed that maintain the best possible outcome for patients transported by ambulance during periods of diversion. More importantly, the discussion must focus on addressing the operational inefficiencies within our health systems that lead to conditions such as patient boarding, high waiting room congestion, and ambulance diversion. Addressing these inefficiencies has a greater potential impact on ambulance diversion than simply banning or restricting the practice for practical or ethical considerations.

Survivors Perceptions of Recovery following Air Medical Transport Accidents.

Abstract Objective: Air medical transport (AMT) teams play an essential role in the care of the critically ill and injured. Their work, however, is not without risk. Since the inception of the industry numerous AMT accidents have been reported. The objective of this research is to gain a better understanding of the post-accident sequelae for professionals who have survived AMT accidents. The hope is that this understanding will empower the industry to better support survivors and plan for the contingencies of post-accident recovery. Methods: Qualitative methods were used to explore the experience of flight crew members who have survived an AMT accident. "Accident" was defined using criteria established by the National Transportation Safety Board. Traditional focus group methodology explored the survivors' experiences following the accident. Results: Seven survivors participated in the focus group. Content analysis revealed themes in four major domains that described the experience of survivors: Physical, Psychological, Relational and Financial. Across the themes survivors reported that industry and company response varied greatly, ranging from generous support, understanding and action to make safety improvements, to little response or action and lack of attention to survivor needs. Conclusion: Planning for AMT post-accident response was identified to be lacking in scope and quality. More focused efforts are needed to assist and support the survivors as they regain both their personal and professional lives following the accident. This planning should include all stakeholders in safe transport; the individual crewmember, air medical transport companies, and the industry at large.

Characteristics of nontrauma scene flights for air medical transport.

INTRODUCTION: Little is known about the use of air medical transport for patients with medical, rather than traumatic, emergencies. This study describes the practices of air transport programs, with respect to nontrauma scene responses, in several areas throughout the United States and Canada. METHODS: A descriptive, retrospective study was conducted of all nontrauma scene flights from 2008 and 2009. Flight information and patient demographic data were collected from 5 air transport programs. Descriptive statistics were used to examine indications for transport, Glasgow Coma Scale Scores, and loaded miles traveled. RESULTS: A total of 1,785 nontrauma scene flights were evaluated. The percentage of scene flights contributed by nontraumatic emergencies varied between programs, ranging from 0% to 44.3%. The most common indication for transport was cardiac, nonST-segment elevation myocardial infarction (22.9%). Cardiac arrest was the indication for transport in 2.5% of flights. One air transport program reported a high percentage (49.4) of neurologic, stroke, flights. CONCLUSION: The use of air transport for nontraumatic emergencies varied considerably between various air transport programs and regions. More research is needed to evaluate which nontraumatic emergencies benefit from air transport. National guidelines regarding the use of air transport for nontraumatic emergencies are needed.

Assessing satisfaction and quality in the EMS/HEMS working relationship.

BACKGROUND/OBJECTIVE: Treatment provided to critically ill and injured patients during air medical transport bridges initial local emergency medical service (EMS) treatment and the care provided upon arrival to the emergency department. Transition of care from EMS to air medical service includes multiple elements, many of which have been previously undefined. These include operational details surrounding the handoff and attention to issues of continuity in patient care. The purpose of this study is to pilot the development of survey instrumentation to measure key elements of quality in the interaction between EMS and air medical crews. METHODS: A focus group of 12 individuals, including rural and urban EMS providers, medical directors, administrators, and air medical transport providers, defined the activities involved in the working relationship between EMS and air medical transport. Ideas were refined into statements and placed into a 16-item Likert scale questionnaire distributed to EMS agencies throughout Ohio. Exploratory factor analysis was performed to identify subscales within the questionnaire. RESULTS: 380 questionnaires were returned over 2009, 2010, and 2011. Factor analysis of the initial responses from 2009 revealed themes similar to those identified by the focus group: patient care, user-friendly helicopter EMS (HEMS) operations, response time accuracy, operational feedback, and general system issues. The measure had good internal reliability, with alphas for subscales in the 0.85-0.88 range. A modified questionnaire used in 2010 and 2011 actually performed as a single scale. CONCLUSION: Using qualitative and quantitative approaches, a survey instrument was developed to assess satisfaction with HEMS care from the EMS provider's perspective. Evaluating the EMS perspective on the working relationship with HEMS is a new field of discovery for the air medical transport industry and process improvement activities.

A framework for analysis of sentinel events in medical student education.

PROBLEM: Although previous studies have addressed student factors contributing to dismissal or withdrawal from medical school for academic reasons, little information is available regarding institutional factors that may hinder student progress. APPROACH: The authors describe the development and application of a framework for sentinel event (SE) root cause analysis to evaluate cases in which students are dismissed or withdraw because of failure to progress in the medical school curriculum. The SE in medical student education (MSE) framework was piloted at the Ohio State University College of Medicine (OSUCOM) during 2010-2012. Faculty presented cases using the framework during academic oversight committee discussions. OUTCOMES: Nine SEs in MSE were presented using the framework. Major institution-level findings included the need for improved communication, documentation of cognitive and noncognitive (e.g., mental health) issues, clarification of requirements for remediation and fitness for duty, and additional psychological services. Challenges related to alternative and combined programs were identified as well. The OSUCOM undertook system changes based on the action plans developed through the discussions of these SEs. NEXT STEPS: An SE analysis process appears to be a useful method for making system changes in response to institutional issues identified in evaluation of cases in which students fail to progress in the medical school curriculum. The authors plan to continue to refine the SE in MSE framework and analysis process. Next steps include assessing whether analysis using this framework yields improved student outcomes with universal applications for other institutions.

A blueprint for critical care transport research.

INTRODUCTION: An estimated 500,000 critical care patient transports occur annually in the United States. Little research exists to inform optimal practices, promote safety, or encourage responsible, cost-effective use of this resource. Previous efforts to develop a research agenda have not yielded significant progress in producing much-needed scientific study. PURPOSE: Identify and characterize areas of research needed to direct the development of evidence-based guidelines METHODS: The study used a modified Delphi technique to develop a concept map of the research domains in critical care transport. Proprietary, internet-based software was used for both data collection and analysis. The study was conducted in 3 phases: brainstorming, categorizing, and prioritizing, using experts from all aspects of critical care transport. RESULTS: A total of 101 research questions were developed and ranked by 27 participants representing the transport community and stakeholders. An 8-cluster solution was developed with multidimensional scaling and hierarchical cluster analysis to identify the following research areas: clinical care, education/training, finance, human factors, patient outcomes, safety, team configuration, and utilization. A plot characterized each domain by urgency and feasibility. CONCLUSION: The content and concepts represented by the cluster map can help direct research planning in the critical care transport industry and prioritize funding decisions.

Two cases of thenar compartment syndrome from blunt trauma.

BACKGROUND: Compartment syndrome is a limb-threatening complication associated with extremity trauma. The existence of compartment syndrome involving the thenar space is considered controversial and has not been reported in association with blunt traumatic injury of the hand. OBJECTIVE: We report two cases involving compartment syndrome of the thenar space in association with blunt trauma to the hand. CASE REPORT: Patient A was a young man who suffered a fracture/dislocation of the right thumb after a fall. Compartment pressures were measured at 70 mm Hg in the thenar space. The patient underwent successful fasciotomy and K-wire stabilization of the thumb and was ultimately discharged with good function on day 4. Patient B suffered a crush injury of the right hand and presented with diffuse swelling associated with median nerve paresthesia. Radiographs revealed a fracture of the triquetrum and of the base of the third metacarpal bone. The patient underwent multiple fasciotomies of the hand, including a release of the thenar space. He was discharged on day 2 with improving function of his thumb. CONCLUSION: Compartment syndrome of the thenar space may be more common than previously reported. Given the limited time frame after which permanent damage occurs, clinicians should consider measurement of thenar compartment pressures in high-risk injuries.