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1.
Am J Emerg Med ; 51: 139-143, 2021 Oct 24.
Artigo em Inglês | MEDLINE | ID: mdl-34739866

RESUMO

BACKGROUND: Trauma is the leading cause of pediatric mortality in the United States. Often, these patients require supermassive transfusion (SMT), which we define as receipt of >80 mL/kg blood products, double the proposed volume for standard pediatric massive transfusion (MT). Evaluating the blood volumes, injury patterns, clinical findings, and prehospital interventions predictive for SMT are critical to reducing pediatric mortality. We describe the pediatric casualties, injury patterns, and clinical findings that comprise SMT. METHODS: We retrospectively analyzed pediatric trauma data from the Department of Defense Trauma Registry from January 2007-2016. We stratified patients into two cohorts based on blood products received in the first 24 h after injury: 1) those who received 40-80 mL/kg (MT), or 2) those who received >80 mL/kg (SMT). We evaluated demographics, injury patterns, prehospital interventions, and clinical findings. RESULTS: Our original dataset included 3439 pediatric casualties. We identified 536 patients who met inclusion parameters (receipt of ≥40 mL/kg of blood products [whole blood, packed red blood cells, fresh frozen plasma, platelets, or cryoprecipitate]). The MT cohort included 271 patients (50.6%), and the SMT cohort comprised 265 patients (49.4%). Survival to discharge was significantly lower (78% for SMT, 86% for MT; p < 0.011) in the SMT cohort. Multivariable analysis of injury patterns revealed serious injuries (Abbreviated Injury Scale 3-6) to the extremities (OR 2.13, 95% CI 1.45-3.12) and abdomen (OR 1.65, 1.08-2.53) were associated with SMT. Wound dressings (41% versus 29%; p = 0.003), tourniquets (23% vs 12%; p = 0.001), and IO access (17% vs 10%; p = 0.013) were more common in the SMT group. Age-adjusted hypotension was significantly higher in the SMT group (41%, n = 100 vs 23%, n = 59; p < 0.001) with no statistical difference detected in tachycardia (87%, n = 223 vs 87%, n = 228; p = 0.932). CONCLUSIONS: Our research demonstrates that pediatric SMT patients are at increased risk of mortality. Our study highlights the seriousness of extremity injuries in pediatric trauma patients, identifying associations between severe injuries to the extremities and abdomen with the receipt of SMT. Prehospital interventions of wound dressing, tourniquets, and IO access were more frequent in the SMT cohort. Our research determined that hypotension was associated with SMT, but tachycardia was not a reliable predictor of SMT over MT.

2.
Trials ; 22(1): 784, 2021 Nov 08.
Artigo em Inglês | MEDLINE | ID: mdl-34749762

RESUMO

BACKGROUND: Targeted normoxia (SpO2 90-96% or PaO2 60-100 mmHg) may help to conserve oxygen and improve outcomes in critically ill patients by avoiding potentially harmful hyperoxia. However, the role of normoxia for critically ill trauma patients remains uncertain. The objective of this study is to describe the study protocol and statistical analysis plan for the Strategy to Avoid Excessive Oxygen for Critically Ill Trauma Patients (SAVE-O2) clinical trial. METHODS: Design, setting, and participants: Protocol for a multicenter cluster randomized, stepped wedge implementation trial evaluating the effectiveness of a multimodal intervention to target normoxia in critically ill trauma patients at eight level 1 trauma centers in the USA. Each hospital will contribute pre-implementation (control) and post-implementation (intervention) data. All sites will begin in the control phase with usual care. When sites reach their randomly assigned time to transition, there will be a one-month training period, which does not contribute to data collection. Following the 1-month training period, the site will remain in the intervention phase for the duration of the trial. MAIN OUTCOME MEASURES: The primary outcome will be supplemental oxygen-free days, defined as the number of days alive and not on supplemental oxygen. Secondary outcomes include in-hospital mortality to day 90, hospital-free days to day 90, ventilator-free days (VFD) to day 28, time to room air, Glasgow Outcome Score (GOS), and duration of time receiving supplemental oxygen. DISCUSSION: SAVE-O2 will determine if a multimodal intervention to improve compliance with targeted normoxia will safely reduce the need for concentrated oxygen for critically injured trauma patients. These data will inform military stakeholders regarding oxygen requirements for critically injured warfighters, while reducing logistical burden in prolonged combat casualty care. TRIAL REGISTRATION: ClinicalTrials.gov NCT04534959 . Registered September 1, 2020.


Assuntos
Estado Terminal , Hiperóxia , Humanos , Hiperóxia/diagnóstico , Estudos Multicêntricos como Assunto , Oxigênio , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
3.
Prehosp Emerg Care ; : 1-10, 2021 Nov 03.
Artigo em Inglês | MEDLINE | ID: mdl-34731068

RESUMO

Background: Combat injury related wound infections are common. Untreated, these wound infections may progress to sepsis and septic shock leading to increased morbidity and mortality rates. Understanding infectious complications, patterns, progression, and correlated prehospital interventions is vital to understand the development of sepsis. We aim to analyze demographics, injury patterns, and interventions associated with sepsis in battlefield settings.Materials and Methods: This is a secondary analysis of previously published data from the Department of Defense Trauma Registry (DoDTR) from 2007 to 2020. We searched for casualties diagnosed with sepsis (excluding line-sepsis) throughout their initial hospitalization. Regression models were used to seek associations.Results: Our initial request yielded 28,950 encounters, of which 25,654 (88.6%) were adults that met inclusion, including 243 patients (0.9%) diagnosed with sepsis. Patients included US military (34%), non-North Atlantic Treaty Organization (NATO) military (33%) and humanitarian (30%) groups. Patients diagnosed with sepsis had a significantly lower survival rate than non-septic patients (78.1% vs. 95.7%, p < 0.001). There was no significant difference in administration of prehospital antibiotics between septic and the general populations (10.6% vs. 12.3%, p = 0.395). Prehospital intraosseous access (OR 1.56, 95% CI 1.27-1.91, p = 0.207) and packed red cell administration (1.63, 1.24-2.15, 0.029) were the interventions most associated with sepsis.Conclusions: Sepsis occurred infrequently in the DoDTR when evacuation from battlefield is not delayed, but despite increased intervention frequency, developing sepsis demonstrates a significant drop in survival rates. Future research would benefit from the development of risk mitigation measures.

4.
Med J (Ft Sam Houst Tex) ; PB 8-21-07/08/09(PB 8-21-07-08-09): 3-14, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34449854

RESUMO

INTRODUCTION: Studies assessing early trauma resuscitation have used long-term endpoints, such as 28- or 30-day mortality or Glasgow Outcomes Scores at 6-months. These endpoints are convenient but may not accurately reflect the effect of early resuscitation. We sought expert opinion and consensus on endpoints and definitions of variables needed to conduct a Department of Defense- (DoD) funded study to epidemiologically assess combat-relevant mortality and morbidity due to timeliness of resuscitation among critically injured civilians internationally. METHODS: We conducted an online modified Delphi process with an international panel of civilian and US military experts. In several iterative rounds, experts reviewed background information, appraised relevant scientific evidence, provided comments, and rendered a vote on each variable. A-priori, we set consensus at ≥80% concordant votes. RESULTS: Twenty panelists participated with a 100% response rate. Eight items were presented, with the following outputs for the epidemiologic study: Assess mortality within 7-days of injury; assess multi-organ failure using SOFA scores measured early (at day 3) and late (at day 7); assess traumatic brain injury mortality early (≤7-days) and late (28-days); hybrid (anatomic and physiologic) injury severity scoring is optimal; capture comorbidities per the US National Trauma Data Standard list with specific additions; assign resuscitative interventions to one of five standardized phases of trauma care; and, use a novel trauma death categorization system. CONCLUSIONS: A modified Delphi process yielded expert-ratified definitions and endpoints of variables necessary to conduct a combat-relevant epidemiologic study assessing outcomes due to early trauma resuscitation. Outputs may also benefit other groups conducting trauma resuscitation research.


Assuntos
Militares , Ressuscitação , Consenso , Humanos
5.
Med J (Ft Sam Houst Tex) ; (PB 8-21-07/08/09): 25-30, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34449857

RESUMO

BACKGROUND: Battlefield first responders (BFR) are the first non-medical personnel to render critical lifesaving interventions for combat casualties, especially for massive hemorrhage where rapid control will improve survival. Soldiers receive medical instruction during initial entry training (IET) and unit-dependent medical training, and by attending the Combat Lifesaver (CLS) course. We seek to describe the interventions performed by BFRs on casualties with only BFRs listed in their chain of care within the Prehospital Trauma Registry (PHTR). METHODS: This is a secondary analysis of a dataset from the PHTR from 2003-2019. We excluded encounters with a documented medical officer, medic, or unknown prehospital provider at any time in their chain of care during the Role 1 phase to isolate only casualties with BFR medical care. RESULTS: Of the 1,357 encounters in our initial dataset, we identified 29 casualties that met inclusion criteria. Pressure dressing was the most common intervention (n=12), followed by limb tourniquets (n=4), IV fluids (n=3), hemostatic gauze (n=2), and wound packing (n=2). Bag-valve-masks, chest seals, extremity splints, and nasopharyngeal airways (NPA) were also used (n=1 each). Notably absent were backboards, blizzard blankets, cervical collars, eye shields, pelvic splints, hypothermia kits, chest tubes, supraglottic airways (SGA), intraosseous (I/O) lines, and needle decompression (NDC). CONCLUSIONS: Despite limited training, BFRs employ vital medical skills in the prehospital setting. Our data show that BFRs largely perform medical interventions within the scope of their medical knowledge and training. Better datasets with efficacy and complication data are needed.


Assuntos
Serviços Médicos de Emergência , Socorristas , Medicina Militar , Hemorragia/terapia , Humanos , Torniquetes
6.
Med J (Ft Sam Houst Tex) ; (PB 8-21-04/05/06): 72-77, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34251669

RESUMO

BACKGROUND: Personal protective equipment (PPE) is crucial to force protection and preservation. Innovation in PPE has shifted injury patterns, with protected body regions accounting for decreased proportions of battlefield trauma relative to unprotected regions. Little is known regarding the PPE in use by warfighters at the time of injury. METHODS: We queried the Prehospital Trauma Registry (PHTR) for all encounters from 2003-2019. This is a sub-analysis of casualties with documented PPE at the time of medical encounter. When possible, encounters were linked to the Department of Defense Trauma Registry (DODTR) for outcome data. Serious injuries are defined as an abbreviated injury scale of 3 or greater. RESULTS: Of 1,357 total casualty encounters in the PHTR, 83 were US military with documented PPE. We link 62 of this cohort to DODTR. The median composite Injury Severity Score (ISS) was 6 (Interquartile range (IQR) 4-21), and 11 casualties (18%) had an ISS >25. The most seriously injured body regions were the extremities (21%), head/neck (16%), thorax (16%), and abdomen (10%). PPE worn at time of injury included helmet (91%), eye protection (73%), front (75%) and rear plates (77%), left/right plates (65%), tactical vest (46%), groin protection (12%), neck protection (6%), pelvic shield (3%), and deltoid protection (3%). CONCLUSION: Our data set demonstrates that the extremities were the most commonly injured body region, followed by head/neck, and thorax. PPE designed for the extremities and neck are also among the least commonly worn protective equipment.


Assuntos
Militares , Equipamento de Proteção Individual , Campanha Afegã de 2001- , Humanos , Escala de Gravidade do Ferimento , Sistema de Registros
7.
Transfusion ; 61 Suppl 1: S2-S7, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34269463

RESUMO

BACKGROUND: Whole blood therapy-which contains the ideal balance of components, and particularly fresh whole blood-has been shown to be beneficial in adult trauma. It remains unclear whether there is potential benefit in the pediatric population. STUDY DESIGN AND METHODS: This is a secondary analysis of previously published data analyzing pediatric casualties undergoing massive transfusion in the Department of Defense Trauma Registry. Pediatric patients with traumatic injury who were transfused at least one blood product were included in the analysis. We compared children who received component therapy exclusively to those who received any amount of warm fresh whole blood. RESULTS: Of the 3439 pediatric casualties within our dataset, 1244 were transfused at least one blood product within the first 24 h. There were 848 patients without severe head injury. Within this cohort, 23 children received warm fresh whole blood overall, 20 of whom did not have severe head injury. In an adjusted analysis, the odds ratio (95% confidence interval [CI]) for survival for warm fresh whole blood recipients was 2.86 (0.40-20.45). After removing children with severe brain injury, there was an independent association with improved survival for warm fresh whole blood recipients with an odds ratio (95% CI) of 58.63 (2.70-1272.67). DISCUSSION: Our data suggest that warm fresh whole blood may be associated with improved survival in children without severe head injury. Larger prospective studies are needed to assess the efficacy and safety of whole blood in children with severe traumatic bleeding.


Assuntos
Transfusão de Sangue , Ferimentos e Lesões/terapia , Adolescente , Afeganistão/epidemiologia , Criança , Pré-Escolar , Feminino , Hemorragia/sangue , Hemorragia/epidemiologia , Hemorragia/terapia , Humanos , Lactente , Iraque/epidemiologia , Masculino , Análise de Sobrevida , Resultado do Tratamento , Ferimentos e Lesões/sangue , Ferimentos e Lesões/epidemiologia
8.
Clin Toxicol (Phila) ; : 1-10, 2021 Jul 30.
Artigo em Inglês | MEDLINE | ID: mdl-34328378

RESUMO

CONTEXT: Hydrogen cyanide and methanethiol are two toxic gases that inhibit mitochondrial cytochrome c oxidase. Cyanide is generated in structural fires and methanethiol is released by decaying organic matter. Current treatments for cyanide exposure do not lend themselves to treatment in the field and no treatment exists for methanethiol poisoning. Sodium tetrathionate (tetrathionate), a product of thiosulfate oxidation, could potentially serve as a cyanide antidote, and, based on its chemical structure, we hypothesized it could react with methanethiol. RESULTS: We show that tetrathionate, unlike thiosulfate, reacts directly with cyanide in vitro under physiological conditions, and based on rabbit studies where we monitor cyanide poisoning in real-time, tetrathionate likely reacts directly with cyanide in vivo. We found that tetrathionate administered by intramuscular injection rescues >80% of juvenile, young adult, and old adult mice from exposure to inhaled hydrogen cyanide gas that is >80% lethal. Tetrathionate also rescued young adult rabbits from intravenously administered sodium cyanide. Tetrathionate was reasonably well-tolerated by mice and rats, yielding a therapeutic index of ∼5 in juvenile and young adult mice, and ∼3.3 in old adult mice; it was non-mutagenic in Chinese Hamster ovary cells and by the Ames bacterial test. We found by gas chromatography-mass spectrometry that both tetrathionate and thiosulfate react with methanethiol to generate dimethyldisulfide, but that tetrathionate was much more effective than thiosulfate at recovering intracellular ATP in COS-7 cells and rescuing mice from a lethal exposure to methanethiol gas. CONCLUSION: We conclude that tetrathionate has the potential to be an effective antidote against cyanide and methanethiol poisoning.

9.
Clin Toxicol (Phila) ; : 1-7, 2021 Jun 18.
Artigo em Inglês | MEDLINE | ID: mdl-34142637

RESUMO

BACKGROUND: Cyanide is a rapid acting, lethal, metabolic poison and remains a significant threat. Current FDA-approved antidotes are not amenable or efficient enough for a mass casualty incident. OBJECTIVE: The objective of this study is to evaluate short and long-term efficacy of intramuscular aqueous dimethyl trisulfide (DMTS) on survival and clinical outcomes in a swine model of cyanide exposure. METHODS: Anesthetized swine were instrumented and acclimated until breathing spontaneously. Potassium cyanide infusion was initiated and continued until 5 min after the onset of apnea. Subsequently, animals were treated with intramuscular DMTS (n = 11) or saline control (n = 10). Laboratory values and DMTS blood concentrations were assessed at various time points and physiological parameters were monitored continuously until the end of the experiment unless death occurred. A subset of animals treated with DMTS (n = 5) were survived for 7 days to evaluate muscle integrity by repeat biopsy and neurobehavioral outcomes. RESULTS: Physiological parameters and time to apnea were similar in both groups at baseline and at time of treatment. Survival in the DMTS-treated group was 90% and 30% in saline controls (p = 0.0034). DMTS-treated animals returned to breathing at 12.0 ± 10.4 min (mean ± SD) compared to 22.9 ± 7.0 min (mean ± SD) in the 3 surviving controls. Blood collected prior to euthanasia showed improved blood lactate concentrations in the DMTS treatment group; 5.47 ± 2.65 mmol/L vs. 9.39 ± 4.51 mmol/L (mean ± SD) in controls (p = 0.0310). Low concentrations of DMTS were detected in the blood, gradually increasing over time with no elimination phase observed. There was no mortality, histological evidence of muscle trauma, or observed adverse neurobehavioral outcomes, in DMTS-treated animals survived to 7 days. CONCLUSION: Intramuscular administration of aqueous DMTS improves survival following cyanide poisoning with no observed long-term effects on muscle integrity at the injection site or adverse neurobehavioral outcomes.

10.
Crit Care Explor ; 3(5): e0418, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-34036272

RESUMO

OBJECTIVES: Hyperoxia is common among critically ill patients and may increase morbidity and mortality. However, limited evidence exists for critically injured patients. The objective of this study was to determine the association between hyperoxia and in-hospital mortality in adult trauma patients requiring ICU admission. DESIGN SETTING AND PARTICIPANTS: This multicenter, retrospective cohort study was conducted at two level I trauma centers and one level II trauma center in CO between October 2015 and June 2018. All adult trauma patients requiring ICU admission within 24 hours of emergency department arrival were eligible. The primary exposure was oxygenation during the first 7 days of hospitalization. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcome was in-hospital mortality. Secondary outcomes were hospital-free days and ventilator-free days. We included 3,464 critically injured patients with a mean age of 52.6 years. Sixty-five percent were male, and 66% had blunt trauma mechanism of injury. The primary outcome of in-hospital mortality occurred in 264 patients (7.6%). Of 226,057 patient-hours, 46% were spent in hyperoxia (oxygen saturation > 96%) and 52% in normoxia (oxygen saturation 90-96%). During periods of hyperoxia, the adjusted risk for mortality was higher with greater oxygen administration. At oxygen saturation of 100%, the adjusted risk scores for mortality (95% CI) at Fio2 of 100%, 80%, 60%, and 50% were 6.4 (3.5-11.8), 5.4 (3.4-8.6), 2.7 (1.7-4.1), and 1.5 (1.1-2.2), respectively. At oxygen saturation of 98%, the adjusted risk scores for mortality (95% CI) at Fio2 of 100%, 80%, 60%, and 50% were 7.7 (4.3-13.5), 6.3 (4.1-9.7), 3.2 (2.2-4.8), and 1.9 (1.4-2.7), respectively. CONCLUSIONS: During hyperoxia, higher oxygen administration was independently associated with a greater risk of mortality among critically injured patients. Level of evidence: Cohort study, level III.

11.
J Trauma Acute Care Surg ; 91(2S Suppl 2): S169-S175, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-33797494

RESUMO

BACKGROUND: Avoidance of hypoxia and hyperoxia may reduce morbidity and mortality in critically ill civilian and military trauma patients. The objective of this study was to determine if a multimodal quality improvement intervention increases adherence to a consensus-based, targeted normoxia strategy. We hypothesized that this intervention would safely improve compliance with targeted normoxia. METHODS: This is a pre/postquasiexperimental pilot study to improve adherence to normoxia, defined as a pulse oximetry (SpO2) of 90% to 96% or an arterial partial pressure oxygen (PaO2) of 60 to 100 mm Hg. We used a multimodal informatics and educational intervention guiding clinicians to safely titrate supplemental oxygen to normoxia based on SpO2 monitoring in critically ill trauma patients admitted to the surgical-trauma or neurosurgical intensive care unit within 24 hours of emergency department arrival. The primary outcome was effectiveness in delivering targeted normoxia (i.e., an increase in the probability of being in the targeted normoxia range and/or a reduction in the probability of being on a higher fraction-inspired oxygen concentration [FiO2]). RESULTS: Analysis included 371 preintervention subjects and 201 postintervention subjects. Preintervention and postintervention subjects were of similar age, race/ethnicity, and sex and had similar comorbidities and Acute Physiologic and Chronic Health Evaluation II scores. Overall, the adjusted probability of being hyperoxic while on supplemental oxygen was reduced during the postintervention period (adjusted odds ratio, 0.74; 95% confidence interval, 0.57-0.97). There was a higher probability of being on room air (FiO2, 0.21) in the postintervention period (adjusted odds ratio, 1.38; 95% confidence interval, 0.83-2.30). In addition, there was a decreased amount of patient time spent on higher levels of FiO2 (FiO2, >40%) without a concomitant increase in hypoxia. CONCLUSION: A multimodal intervention targeting normoxia in critically ill trauma patients increased normoxia and lowered the use of supplemental oxygen. A large clinical trial is needed to validate the impact of this protocol on patient-centered clinical outcomes. LEVEL OF EVIDENCE: Therapeutic/care management, level II.


Assuntos
Estado Terminal , Oxigênio/sangue , Ferimentos e Lesões/terapia , Estado Terminal/mortalidade , Sistemas de Apoio a Decisões Clínicas , Feminino , Fidelidade a Diretrizes , Humanos , Hiperóxia/prevenção & controle , Hipóxia/prevenção & controle , Masculino , Pessoa de Meia-Idade , Oximetria , Avaliação de Resultados da Assistência ao Paciente , Projetos Piloto , Melhoria de Qualidade , Respiração Artificial , Ferimentos e Lesões/sangue , Ferimentos e Lesões/mortalidade
12.
J Med Toxicol ; 17(3): 257-264, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33821433

RESUMO

INTRODUCTION: Cyanide is a deadly poison, particularly with oral exposure where larger doses can occur before symptoms develop. Prior studies and multiple governmentagencies highlight oral cyanide as an agent with the potential for use in a terrorist attack. Currently, there are no FDA approved antidotes specific to oralcyanide. An oral countermeasure that can neutralize and prevent absorption of cyanide from the GI tract after oral exposure is needed. Our objective was toevaluate the efficacy of oral sodium thiosulfate on survival and clinical outcomes in a large, swine model of severe cyanide toxicity. METHODS: Swine (45-55kg) were instrumented, sedated, and stabilized. Potassium cyanide (8 mg/kg KCN) in saline was delivered as a one-time bolus via an orogastric tube. Three minutes after cyanide, animals randomized to the treatment group received sodium thiosulfate (510 mg/kg, 3.25 M solution) via orogastric tube. Our primary outcome was survival at 60 minutes after exposure. We compared survival between groups by log-rank, Mantel-Cox analysis and trended labs and vital signs. RESULTS: At baseline and time of treatment all animals had similar weights, vital signs, and laboratory values. Survival at 60 min was 100% in treated animals compared to 0% in the control group (p=0.0027). Animals in the control group became apneic and subsequently died by 35.0 min (20.2,48.5) after cyanide exposure. Mean arterial pressure was significantly higher in the treatment group compared to controls (p=0.008). Blood lactate (p=0.02) and oxygen saturation (p=0.02) were also significantly different between treatment and control groups at study end. CONCLUSION: Oral administration of sodium thiosulfate improved survival, blood pressure, respirations, and blood lactate concentrations in a large animal model of acute oral cyanide toxicity.


Assuntos
Antídotos/uso terapêutico , Cianetos/toxicidade , Tiossulfatos/uso terapêutico , Administração Oral , Animais , Humanos , Modelos Animais , Suínos , Tiossulfatos/administração & dosagem , Resultado do Tratamento
13.
Prehosp Emerg Care ; : 1-15, 2021 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-33760684

RESUMO

Background: Most potentially preventable deaths occur in the prehospital setting before reaching a military treatment facility with surgical capabilities. Thus, optimizing the care we deliver in the prehospital combat setting represents a ripe target for reducing mortality. We sought to analyze prehospital data within the Department of Defense Trauma Registry (DODTR). Materials and methods: We requested all encounters with any prehospital activity (e.g., interventions, transportation, vital signs) documented within the DODTR from January 2007 to March 2020 along with all hospital-based data that was available. We excluded from our search casualties that had no prehospital activity documented. Results: There were 28,950 encounters that met inclusion criteria. Of these, 25,897 (89.5%) were adults and 3053 were children (10.5%). There was a steady decline in the number of casualties encountered with the most notable decline occurring in 2014. U.S. military casualties comprised the largest proportion (n = 10,182) of subjects followed by host nation civilians (n = 9637). The median age was 24 years (interquartile range/IQR 21-29). Most were battle injuries (78.6%) and part of Operation ENDURING FREEDOM (61.8%) and Operation IRAQI FREEDOM (24.4%). Most sustained injuries from explosives (52.1%) followed by firearms (28.1%), with serious injury to the extremities (24.9%) occurring most frequently. The median injury severity score was 9 (IQR 4-16) with most surviving to discharge (95.0%). A minority had a documented medic or combat lifesaver (27.9%) in their chain of care, nor did they pass through an aid station (3.0%). Air evacuation predominated (77.9%). Conclusions: Within our dataset, the deployed U.S. military medical system provided prehospital medical care to at least 28,950 combat casualties consisting mostly of U.S. military personnel and host nation civilian care. There was a rapid decline in combat casualty volumes since 2014, however, on a per-encounter basis there was no apparent drop in procedural volume.

14.
Mil Med ; 2021 Jan 12.
Artigo em Inglês | MEDLINE | ID: mdl-33433584

RESUMO

BACKGROUND: Military aeromedical transport evacuates critically injured patients are for definitive care, including patients with or at risk for developing traumatic compartment syndrome of the extremities (tCSoE). Compartment pressure changes of the extremities have not been determined to be associated with factors inherent to aeromedical transport in animal models, but the influence of aeromedical evacuation (AE) transport on the timing of tCSoE development has not been studied in humans. Using a registry-based methodology, this study sought to characterize the temporal features of lower extremity compartment syndrome relative to the timing of transcontinental AE. With this approach, this study aims to inform practice in guidelines relating to the timing and possible effects of long-distance AE and the development of lower extremity compartment syndrome. Using patient care records, we sought to characterize the temporal features of tCSoE diagnosis relative to long-range aeromedical transport. In doing so, we aim to inform practice in guidelines relating to the timing and risks of long-range AE and postulate whether there is an ideal time to transport patients who are at risk for or with tCSoE. METHODS: We performed a retrospective record review of patients with a diagnosis of tCSoE who were evacuated out of theater from January 2007 to May 2014 via aeromedical transport. Data abstractors collected flight information, laboratory values, vital signs, procedures, in-flight assessments, and outcomes. We used the duration of time from injury to arrival at Landstuhl Regional Medical Center (LRMC) to represent time to transport. We compared groups based on time of tCSoE (inclusive of upper and lower extremity) diagnosis relative to injury day and time of transport (preflight versus postflight). We used descriptive statistics and multivariable regression models to determine the associations between time to transport, time to tCSoE diagnosis, and outcomes. RESULTS: Within our study window, 238 patients had documentation of tCSoE. We found that 47% of patients with tCSoE were diagnosed preflight and 53% were diagnosed postflight. Over 90% in both groups developed tCSoE within 48 hours of injury; the time to diagnosis was similar for casualties diagnosed pre- and postflight (P = .65). There was no association between time to arrival at LRMC and day of tCSoE diagnosis (risk ratio, 1.06; 95% CI, 0.96-1.16). CONCLUSION: The timing of tCSoE diagnosis is not associated with the timing of transport; therefore, AE likely does not influence the development of tCSoE.

15.
Am J Emerg Med ; 41: 104-109, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33421674

RESUMO

INTRODUCTION: Early recognition and management of hemorrhage, damage control resuscitation, and blood product administration have optimized management of severe trauma. Recent data suggest hypocalcemia exacerbates the ensuing effects of coagulopathy in trauma. OBJECTIVE: This narrative review of available literature describes the physiology and role of calcium in trauma resuscitation. Authors did not perform a systematic review or meta-analysis. DISCUSSION: Calcium is a divalent cation found in various physiologic forms, specifically the bound, inactive state and the unbound, physiologically active state. While calcium plays several important physiologic roles in multiple organ systems, the negative hemodynamic effects of hypocalcemia are crucial to address in trauma patients. The negative ramifications of hypocalcemia are intrinsically linked to components of the lethal triad of acidosis, coagulopathy, and hypothermia. Hypocalcemia has direct and indirect effects on each portion of the lethal triad, supporting calcium's potential position as a fourth component in this proposed lethal diamond. Trauma patients often present hypocalcemic in the setting of severe hemorrhage secondary to trauma, which can be worsened by necessary transfusion and resuscitation. The critical consequences of hypocalcemia in the trauma patient have been repeatedly demonstrated with the associated morbidity and mortality. It remains poorly defined when to administer calcium, though current data suggest that earlier administration may be advantageous. CONCLUSIONS: Calcium is a key component of trauma resuscitation and the coagulation cascade. Recent data portray the intricate physiologic reverberations of hypocalcemia in the traumatically injured patient; however, future research is needed to further guide the management of these patients.


Assuntos
Hipocalcemia/etiologia , Ressuscitação , Ferimentos e Lesões/complicações , Ferimentos e Lesões/terapia , Cálcio/fisiologia , Humanos , Ferimentos e Lesões/mortalidade
16.
Mil Med ; 186(3-4): e359-e365, 2021 02 26.
Artigo em Inglês | MEDLINE | ID: mdl-33399866

RESUMO

INTRODUCTION: Within the Military Health System, the process of transporting patients from an initial point of injury and throughout the entire continuum of care is called "en route care." A Committee on En Route Combat Casualty Care was established in 2016 as part of the DoD Joint Trauma System to create practice guidelines, recommend training standards, and identify research priorities within the military en route care system. MATERIALS AND METHODS: Following an analysis of currently funded research, future capabilities, and findings from a comprehensive scoping study, members of a sub-working group for research identified the top research priorities that were needed to better guide evidence-based decisions for practice and policy, as well as the future state of en route care. RESULTS: Based on the input from the entire committee, 10 en route care research topics were rank-ordered in the following manner: (1) medical documentation, (2) clinical decision support, (3) patient monitoring, (4) transport physiology, (5) transfer of care, (6) maintaining normothermia, (7) transport timing following damage control resuscitation or surgery, (8) intelligent tasking, (9) commander's risk assessment, and (10) unmanned transport. Specific research questions and technological development needs were further developed by committee members in an effort to guide future research and development initiatives that can directly support operational en route care needs. The research priorities reflect three common themes, which include efforts to enhance or increase care provider capability and capacity; understand the impact of transportation on patient physiology; and increase the ability to coordinate, communicate, and facilitate patient movement. Technology needs for en route care must support interoperability of medical information, equipment, and supplies across the global military health system in addition to adjusting to a dynamic transport environment with the smallest possible weight, space, and power requirements. CONCLUSIONS: To ensure an evidence-based approach to future military conflicts and other medical challenges, focused research and technological development to address these 10 en route care research gaps are urgently needed.


Assuntos
Militares , Humanos , Monitorização Fisiológica , Pesquisa , Ressuscitação
17.
J Chromatogr A ; 1638: 461856, 2021 Feb 08.
Artigo em Inglês | MEDLINE | ID: mdl-33485031

RESUMO

Plant parasites and soilborne pathogens directly reduce the overall yield of crops, vegetables, and fruits, negatively impacting the market demand for these products and their net profitability. While preplant soil fumigation helps maintain the consistent production quality of high-value cash crops, most soil fumigants are toxic to off-target species, including humans. Dimethyl disulfide (DMDS) has recently been introduced as a relatively low toxicity soil fumigant. Although DMDS exhibits low toxicity compared to other soil fumigants, it is volatile and exposure can cause eye, nasal, and upper respiratory tract irritation, skin irritation, nausea, dizziness, headache, and fatigue. While there is one analysis method available for DMDS from biological matrices, it has significant disadvantages. Hence, in this study, a dynamic headspace gas chromatography-mass spectroscopy (DHS-GC-MS) method was developed for the analysis of DMDS in swine whole blood. This method is highly sensitive and requires only three steps: 1) acid denaturation, 2) addition of internal standard, and 3) DHS-GC-MS analysis. The method produced a wide linear range from 0.1 - 200 µM with an excellent limit of detection of 30 nM. Intra- and interassay accuracy (100±14% and 100±11%, respectively) and precision (<5% and <6% relative standard deviation, respectively) were also excellent. The method worked well to quantify the DMDS levels in the blood of dimethyl trisulfide (DMTS)-treated swine (i.e., DMDS is a byproduct of DMTS treatment) with no interfering substances at or around the retention time of DMDS (i.e., 2.7 min). This simple, rapid, and extremely sensitive method can be used for the quantification of DMDS levels in blood to verify exposure to DMDS or to monitor levels of DMDS following DMTS treatment (e.g., for cyanide poisoning).


Assuntos
Dissulfetos/sangue , Cromatografia Gasosa-Espectrometria de Massas , Poluentes do Solo/sangue , Suínos , Animais , Fumigação , Praguicidas/sangue , Sulfetos/sangue
18.
Mil Med ; 186(3-4): e319-e326, 2021 02 26.
Artigo em Inglês | MEDLINE | ID: mdl-33175959

RESUMO

INTRODUCTION: Hydrazines are highly toxic inorganic liquids that are used as propellants in military and aviation industries, such as the U.S. Air Force F-16 Emergency Power Unit and SpaceX SuperDraco Rockets. The most commonly used derivatives include hydrazine, monomethylhydrazine, and 1,1-dimethylhydrazine (unsymmetrical dimethylhydrazine). Industrial workers in close contact with hydrazines during routine maintenance tasks can be exposed to levels well above the National Institute for Occupational Safety and Health relative exposure limits. MATERIALS AND METHODS: A systematic review was performed using PubMed, Web of Science, Google Scholar, National Aeronautics and Space Administration Technical Server, and Defense Technical Information Center, and data related to hydrazine exposures were searched from inception to April 2020. Publications or reports addressing hydrazine toxicity, pathophysiology, and treatment of hydrazine fuel exposure were selected. RESULTS: Acute toxic exposures to hydrazine and its derivatives are rare. There are few case reports of acute toxic exposure in humans, and data are largely based on animal studies. The initial search identified 741 articles, manuscripts, and government reports. After screening for eligibility, 51 were included in this review. Eight articles reported acute exposures to hydrazine propellant in humans, and an additional 14 articles reported relevant animal data. CONCLUSIONS: Exposure to small amounts of hydrazine and its derivatives can cause significant soft tissue injury, pulmonary injury, seizures, coma, and death. Neurologic presentations can vary based on exposure compound and dose. Decontamination is critical as treatment is mainly supportive. High-dose intravenous pyridoxine has been suggested as treatment for hydrazine-related neurologic toxicity, but this recommendation is based on limited human data. Despite recent research efforts to generate less toxic alternatives to hydrazine fuel, it will likely continue to have a role in military and aviation industries. Aerospace and military physicians should be aware of the toxicity associated with hydrazine exposure and be prepared to treat hydrazine toxicity in at-risk populations.


Assuntos
Militares , Animais , Aviação , Humanos , Hidrazinas/toxicidade , Estados Unidos
19.
Prehosp Emerg Care ; 25(5): 656-663, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32940577

RESUMO

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.


Assuntos
Serviços Médicos de Emergência , Transferência da Responsabilidade pelo Paciente , Documentação , Humanos , Pacientes Internados , Registros Médicos , Centros de Traumatologia
20.
Pediatr Emerg Care ; 37(1): e21-e24, 2021 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-30893227

RESUMO

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.

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