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1.
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.

2.
South Med J ; 114(9): 597-602, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34480194

RESUMO

OBJECTIVES: Coronavirus disease 2019 (COVID-19) threatens vulnerable patient populations, resulting in immense pressures at the local, regional, national, and international levels to contain the virus. Laboratory-based studies demonstrate that masks may offer benefit in reducing the spread of droplet-based illnesses, but few data are available to assess mask effects via executive order on a population basis. We assess the effects of a county-wide mask order on per-population mortality, intensive care unit (ICU) utilization, and ventilator utilization in Bexar County, Texas. METHODS: We used publicly reported county-level data to perform a mixed-methods before-and-after analysis along with other sources of public data for analyses of covariance. We used a least-squares regression analysis to adjust for confounders. A Texas state-level mask order was issued on July 3, 2020, followed by a Bexar County-level order on July 15, 2020. We defined the control period as June 2 to July 2 and the postmask order period as July 8, 2020-August 12, 2020, with a 5-day gap to account for the median incubation period for cases; longer periods of 7 and 10 days were used for hospitalization and ICU admission/death, respectively. Data are reported on a per-100,000 population basis using respective US Census Bureau-reported populations. RESULTS: From June 2, 2020 through August 12, 2020, there were 40,771 reported cases of COVID-19 within Bexar County, with 470 total deaths. The average number of new cases per day within the county was 565.4 (95% confidence interval [CI] 394.6-736.2). The average number of positive hospitalized patients was 754.1 (95% CI 657.2-851.0), in the ICU was 273.1 (95% CI 238.2-308.0), and on a ventilator was 170.5 (95% CI 146.4-194.6). The average deaths per day was 6.5 (95% CI 4.4-8.6). All of the measured outcomes were higher on average in the postmask period as were covariables included in the adjusted model. When adjusting for traffic activity, total statewide caseload, public health complaints, and mean temperature, the daily caseload, hospital bed occupancy, ICU bed occupancy, ventilator occupancy, and daily mortality remained higher in the postmask period. CONCLUSIONS: There was no reduction in per-population daily mortality, hospital bed, ICU bed, or ventilator occupancy of COVID-19-positive patients attributable to the implementation of a mask-wearing mandate.


Assuntos
COVID-19/mortalidade , COVID-19/prevenção & controle , Controle de Doenças Transmissíveis/legislação & jurisprudência , Recursos em Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Controle de Doenças Transmissíveis/métodos , Implementação de Plano de Saúde , Política de Saúde , Humanos , Governo Local , Máscaras , SARS-CoV-2 , Texas/epidemiologia
3.
J Emerg Med ; 2021 Sep 09.
Artigo em Inglês | MEDLINE | ID: mdl-34511297

RESUMO

BACKGROUND: Sternoclavicular dislocation (SCD) is a rare injury but can result in hemodynamic and neurovascular complications. Emergency clinicians play an integral role in the evaluation and management of these injuries. OBJECTIVE: This article provides a narrative review of the diagnosis and management of SCD for the emergency clinician. DISCUSSION: SCD is an infrequent injury and may be misdiagnosed in the emergency department (ED). SCDs may be anterior or posterior. Although anterior SCD is more common, posterior SCD is more dangerous with a risk of pneumothorax or injury to the subclavian artery or vein, esophagus, trachea, or brachial plexus. Most patients present with shoulder and clavicular pain and decreased active range of motion. Clinicians should assess the sternoclavicular joint in patients with shoulder symptoms and consider SCD in traumatic shoulder injuries. Plain radiographs might not identify SCD, and computed tomography is recommended for both the diagnosis of SCD and evaluation of complications. Anterior SCD can be managed in the ED with analgesia, sedation, and closed reduction. If patients with posterior SCDs display airway, hemodynamic, or vascular compromise, emergent reduction is recommended with cardiothoracic consultation. Any complicated anterior SCD, including those with fracture, and all posterior SCDs require emergent orthopedic consultation, with considerations for cardiothoracic or vascular surgery notification. CONCLUSIONS: SCD is an uncommon orthopedic injury but may result in patient morbidity or mortality. Knowledge of SCDs can optimize emergency clinician evaluation and management of this condition.

4.
J Spec Oper Med ; 21(3): 66-70, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34529808

RESUMO

BACKGROUND: United States Africa Command (US AFRICOM) is one of six US Defense Department's geographic combatant commands and is responsible to the Secretary of Defense for military relations with African nations, the African Union, and African regional security organizations. A full-spectrum combatant command, US AFRICOM is responsible for all US Department of Defense operations, exercises, and security cooperation on the African continent, its island nations, and surrounding waters. We seek to characterize blood product administration within AFRICOM using the in-transit visibility tracking tool known as TRAC2ES (TRANSCOM Regulating and Command & Control Evacuation System). METHODS: We performed a retrospective review of TRAC2ES medical evacuations from the AFRICOM theater of operations conducted between 1 January 2008 and 31 December 2018. RESULTS: During this time, there were 963 cases recorded in TRAC2ES originating within AFRICOM, of which 10 (1%) cases received blood products. All patients were males. One was a Department of State employee, one was a military working dog, and the remainder were military personnel. Of the ten humans, seven were the result of trauma, most by way of gunshot wound, and three were due to medical causes. Among human subjects receiving blood products for traumatic injuries, a total of 5 units of type O negative whole blood, 29 units of packed red blood cells (pRBCs), and 9 units of fresh frozen plasma (FFP) were transfused. No subjects underwent massive transfusion of blood products, and only one subject received pRBCs and FFP in 1:1 fashion. All subjects survived until evacuation. CONCLUSIONS: Within the TRAC2ES database, blood product administration within AFRICOM was infrequent, with some cases highlighting lack of access to adequate blood products. Furthermore, the limitations within this database highlight the need for systems designed to capture medical care performance improvement, as this database is not designed to support such analyses. A mandate for performance improvement within AFRICOM that is similar to that of the US Central Command would be beneficial if major improvements are to occur.


Assuntos
Militares , Ferimentos e Lesões , Ferimentos por Arma de Fogo , Animais , Transfusão de Sangue , Cães , Humanos , Masculino , Plasma , Estudos Retrospectivos , Estados Unidos , Ferimentos por Arma de Fogo/terapia
5.
Med J (Ft Sam Houst Tex) ; PB 8-21-04/05/06(PB 8-21-04-05-06): 32-37, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34251662

RESUMO

BACKGROUND: Failed airway management is the second leading cause of preventable death on the battlefield. The prehospital trauma registry (PHTR) after action-review (AAR) allows for unique perspectives and an enhanced analysis of interventions performed. We analyzed AAR comments related to airway interventions performed in deployed settings to examine and identify trends in challenges related to airway management in combat. DESIGN AND METHODS: We analyzed all AAR comments included for airway interventions reported in the Joint Trauma System PHTR. We applied unstructured qualitative methods to analyze themes within these reports and generated descriptive statistics to summarize findings related to airway management. RESULTS: Out of 705 total casualty encounters in the PHTR system between January 2013 and September 2014, 117 (16.6%) had a documented airway intervention. From this sample, 17 (14.5%) had accompanying AAR comments for review. Most patients were identified as host nation casualties (94%, n =16), male (88%, n = 15), and prioritized as urgent evacuation (100%, n = 17). Twenty-five airway interventions were described in the AAR comments, the most being endotracheal intubation (52%, n = 13), followed by ventilation management (28%, n = 7), and cricothyroidotomy (12%, n = 3). Comments indicated difficulties with surgical procedures and suboptimal anatomy identification. CONCLUSIONS: AAR comments focused primarily on cricothyroidotomy, endotracheal intubation, and ventilation management, citing needs for improvement in technique and anatomy identification. Future efforts should focus on training methods for these interventions and increased emphasis on AAR completion.


Assuntos
Serviços Médicos de Emergência , Afeganistão , Manuseio das Vias Aéreas , Humanos , Intubação Intratraqueal , Masculino , Sistema de Registros
6.
Med J (Ft Sam Houst Tex) ; (PB 8-21-04/05/06): 38-43, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34251663

RESUMO

INTRODUCTION: Retrobulbar hemorrhage (RBH) occurs in only 0.45% of ocular trauma, but failure to provide timely lateral canthotomy and cantholysis (LCC) risks permanent visual deficits. With ocular trauma rates as high as 8.5-10% amongst modern combat injuries, and more than 2,000 severe eye injuries documented over a 10 year span, this concern increases.12-15 However, given infrequent RBH occurrence in the non-combat environment, emergency medicine residents trained in stateside settings may not receive adequate LCC exposure prior to military deployment. Simulators should be evaluated for procedural confidence compared to expensive and cumbersome traditional live tissue training (LTT) options. We seek to compare procedural confidence and usability of emergency medicine military residents performing LCC on a novel simulator to those using LTT. METHODS: This study randomized 32 emergency physician and physician assistant residents to perform LCC on a simulator or LTT model. All received a standardized brief on RBH recognition and LCC, then completed an 11-question survey using a 100-mm visual numerical rating scale about their ability to correctly identify RBH and perform LCC. The survey was repeated after LCC completion. All volunteers additionally completed a 10-question survey utilizing a 5-point Likert scale on the usability of the model to which they were randomized. RESULTS: No significant difference in reported confidence changes between groups was found; however, significant increases were found across all reported confidence measures between pre- and post-trainer use in the overall sample population. LCC simulator users reported significantly higher usability in 7 of 10 ratings. CONCLUSION: The lack of a statistically significant difference between groups in procedural confidence suggests artificial LCC simulators may offer an attractive alternative to logistically-complicated porcine models. Further research is needed to evaluate non-inferiority and procedural performance.


Assuntos
Medicina de Emergência , Traumatismos Oculares , Medicina Militar , Hemorragia Retrobulbar , Animais , Pálpebras , Humanos , Suínos
7.
Med J (Ft Sam Houst Tex) ; (PB 8-21-04/05/06): 57-61, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34251666

RESUMO

of care ultrasound (POCUS) is increasingly used in emergency medicine (EM), including EM physician residents and EM physician assistant (EMPA) residents. Scant literature assesses accuracy and duration of POCUS pulse assessment by this group during cardiac resuscitation given recommendations for minimal pauses in chest compressions. Evaluation is needed for accuracy and duration of pulse interpretation in EM trainees utilizing POCUS. METHODS: We conducted a double-blind observational study of EM clinician trainee POCUS assessment of pulses using porcine models. Volunteers were blinded to the cardiac status of 5 porcine models randomized as deceased or living and performed femoral artery evaluation using color power Doppler POCUS. The primary outcome was accuracy of pulse assessment. Secondary outcomes included time to verbalization and differences based on reported duration of EM training, experience with ultrasound, and cardiac arrest resuscitation experience. RESULTS: 17 EM and EMPA trainees completed 85 total POCUS pulse assessments with 98.82% accuracy (n=84). Mean verbalization time was 6.95 seconds, and most verbalized interpretations were within 10-seconds (82.4%, n=70). This was grossly consistent between living and deceased models. Subgroup analysis found no significant differences of accuracy or verbalization time based on reported demographics. CONCLUSION: EM clinician trainees demonstrate a high degree of accuracy and low average time for verbalized interpretation of femoral artery pulse assessment, most within recommended time guidelines. Further study is needed to correlate these findings in human patients.


Assuntos
Medicina de Emergência , Animais , Frequência Cardíaca , Humanos , Suínos , Ultrassonografia
8.
J Spec Oper Med ; 21(2): 49-53, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34105121

RESUMO

BACKGROUND: After-action reviews (AARs) in the Prehospital Trauma Registry (PHTR) enable performance improvements and provide commanders feedback on care delivered at Role 1. No published data exist exploring overall trends of end-user performance-improvement feedback. METHODS: We performed an expert panel review of AARs within the PHTR in Afghanistan from January 2013 to September 2014. When possible, we categorized our findings and selected relevant medical provider comments. RESULTS: Of 737 registered patient encounters found, 592 (80%) had AAR documentation. Most AAR patients were male (98%, n = 578), injured by explosion (48%, n = 283), and categorized for urgent evacuation (64%, n = 377). Nearly two thirds of AARs stated areas needing improvement (64%, n = 376), while the remainder left the improvement section blank (23%, n = 139) or specified no improvements (13%, n = 76). The most frequently cited areas for improvement were medical knowledge (23%, n = 136), evacuation coordination (19%, n = 115), and first responder training (16%, n = 95). CONCLUSIONS: Our expert panel reviewed AARs within the PHTR and found substantial numbers of AARs without improvements recommended, which limits quality improvement capabilities. Our analysis supports previous calls for better documentation of medical care in the prehospital combat setting.


Assuntos
Serviços Médicos de Emergência , Medicina Militar , Ferimentos e Lesões , Afeganistão , Documentação , Feminino , Humanos , Masculino , Sistema de Registros , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/terapia
9.
Mil Med ; 2021 Apr 07.
Artigo em Inglês | MEDLINE | ID: mdl-33825888

RESUMO

INTRODUCTION: American military personnel in U.S. Africa Command (AFRICOM) operate in a continent triple the size of the USA without mature medical facilities, requiring a substantial transportation network for medical evacuation. We describe medical transportation based on ophthalmic complaints analyzed from the U.S. Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES) database from 2008 to 2018. METHODS: We conducted a retrospective review of all TRAC2ES records for medical evacuations for ophthalmic complaints from the AFRICOM theater of operations conducted between January 1, 2008 and December 31, 2018. We analyzed free-text data in TRAC2ES for ophthalmic diagnostic and therapeutic interventions performed before established patient movement requests. An expert panel analyzed evacuations for their indications and interventions. RESULTS: Nine hundred and sixty-one total records originating within AFRICOM were identified in TRAC2ES. Forty-three cases (4%) had ophthalmic complaints. The majority of transports were routine (72%) and originated in Djibouti (83%), and all were transported to Landstuhl Regional Medical Center. The majority of patients were evacuated without a definitive diagnosis (60%). Leading ophthalmic diagnoses were chalazion (14%), corneal abrasion/ulcer (14%), and posterior vitreous detachment (12%). More than one-quarter of patients were transported without recorded evaluation and approximately half (51%) did not receive any intervention before evacuation. Consultation with an ophthalmologist occurred in only 16 (37%) cases. By majority, the expert panel deemed 12 evacuations (28%) potentially unnecessary. CONCLUSION: Evacuations were primarily routine often for disease etiology and further diagnostic evaluation. These findings support opportunities for telemedicine consultation to avoid potentially unnecessary transportation. Increased ophthalmic care and enhanced data collection on transports would support process improvement, optimize ophthalmic care by ensuring proper disposition of patients thus limiting unnecessary evacuations, and ultimately strengthen the entire fighting force.

10.
Mil Med ; 2021 Mar 20.
Artigo em Inglês | MEDLINE | ID: mdl-33742649

RESUMO

Cellulitis and abscess are common skin infections in military populations. Although complications of necrotizing soft tissue infections (NSTIs) such as Fournier Gangrene (FG) are rare, they are associated with significant morbidity and mortality. Laboratory and radiological studies may aid in the evaluation of NSTI; however, focus should remain on physical examination and prompt surgical consultation, as these infections can spread rapidly with significant increases in mortality with delayed management. We present the case of a 37-year-old male soldier with reported history of two distant left inguinal hernia repairs, complaining of increasing buttock pain despite outpatient antibiotic therapy for perineal cellulitis from his primary clinician. Despite normal vital signs and low risk from established NSTI calculator scores, examination revealed crepitus and severe tenderness extending from the buttock through the perineum and scrotum characteristic of FG. Preoperative computed tomography found additional spread of subcutaneous air from these areas into the lower abdomen, likely facilitated by the previously repaired left inguinal hernia. Surgical management necessitated debridement, multiple washouts, and ileostomy. Follow-up evaluations revealed previously undiagnosed Crohn's disease with fistula-in-ano as the inciting factor.

11.
Cureus ; 13(2): e13256, 2021 Feb 10.
Artigo em Inglês | MEDLINE | ID: mdl-33728197

RESUMO

Osgood-Schlatter disease (OSD) proposes that bony microtrauma of the patellar tendon insertion on the tibial tuberosity may be due to inappropriate stress with adolescent activity, and is a common pathology among pediatric patients. Lack of activity restrictions may further contribute to significant bony damage due to continued quadriceps contraction, which in some cases results in a tibial tuberosity avulsion fracture. Evaluation in the ED should include distal neurovascular status, as compartment syndrome has also been documented. Radiographs are generally definitive for diagnosis; however, bedside ultrasound and CT may help further define injury severity and delineate conservative rather than operative management. We highlight the case of a 13-year-old male with a recently diagnosed history of OSD who presented to the ED for severe knee pain after landing forcefully onto the ipsilateral foot and was found to have a large avulsion fracture of the tibial tuberosity. We also provide a brief review of the literature.

13.
South Med J ; 114(1): 23-27, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33398356

RESUMO

OBJECTIVES: The concept of "historical alternans" (HA), a teaching folklore term referring to different descriptions of patient histories to trainees versus attending clinicians, can cause disjointed care and be a source of frustration for the trainee. Increased focus on the proper evaluation and treatment of pain in the emergency department (ED) setting prompts an evaluation of the HA concept as it relates to pain. METHODS: We conducted a prospective observational pilot study comparing pain descriptions given to attending and trainee clinicians in the ED using a five-question pain description survey. Trainees included emergency medicine physician residents, emergency medicine physician assistant residents, off-service residents, and students. Trainees completed the first survey and attending clinicians repeated survey questions after at least a 10-minute washout. Surveys include descriptions of pain as part of patients' primary concern, severity indicated by a verbal numerical rating score (VNRS), and pain location, quality, and duration. RESULTS: During a 10-day period, surveys were completed for 97 patient encounters. Most trainee clinicians were emergency medicine physician residents (53%), followed by emergency medicine physician assistants (32%), students (13%), and off-service residents (2%). Pain complaints centered on the abdomen (18.5%), chest (12%), and knee (6%). Differences in pain description were found in the majority of cases (55%), with most having one categorical difference. The majority of categorical differences were VNRS (38%), although the difference in scores was not statistically significant (P = 0.20). Medical students had the highest variance in VNRS difference compared with attending clinicians. There was no significant difference in described duration (P = 0.99) or quality of pain (P = 0.99) between trainee and attending clinicians. CONCLUSIONS: Most patient encounters had at least one difference in categorical pain descriptors between trainee and attending clinicians. Although differences in severity of pain were present, they were not significant. HA does occur in the ED setting, but the magnitude of difference may be minimal.


Assuntos
Medicina de Emergência/educação , Manejo da Dor/métodos , Manejo da Dor/psicologia , Adulto , Medicina de Emergência/tendências , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Militares/educação , Militares/psicologia , Militares/estatística & dados numéricos , Medição da Dor/métodos , Medição da Dor/psicologia , Estudos Prospectivos , Texas , Fatores de Tempo
14.
Mil Med ; 186(5-6): e464-e468, 2021 05 03.
Artigo em Inglês | MEDLINE | ID: mdl-33135736

RESUMO

INTRODUCTION: Whole blood (WB) is the optimal resuscitation fluid in hemorrhagic shock. Military research focuses on mortality benefits of WB acquired through walking blood banks (WBBs). Few military-based studies on donation effects exist, almost exclusively performed on small special operation forces. No Department of Defense regulations for postdonation precautions in nonaviation crew members exist. Further study is warranted regarding safety and limitations in postdonation populations. MATERIALS AND METHODS: A feasibility (n = 25) prospective interventional study examined the safety of exertion (defined as a 1.6-km treadmill run at volunteers' minimum passing pace for the Army Physical Fitness Test) following 1 unit of WB donation. Subjects served as their own controls, performing baseline testing 7 days before donation, with repeat testing 1 h following donation conducted by Armed Services Blood Program personnel. Adverse events, pre- and postexertion vital signs (VS) were evaluated. RESULTS: There were no adverse events throughout testing. Only resting heart rate (68 vs. 73 beats · min-1, p < 0.01) and postexertion heart rate were significantly different among pre- and postdonation VS. Additional significant findings were time to attain postexertion normocardia (116 vs. 147 seconds, p < 0.01). A small but statistically significant change in Borg perceived exertional scores was noted (10.3 vs. 10.8, p < 0.05). CONCLUSIONS: This feasibility study demonstrates the first safety test of regular military populations performing exertion immediately following the standardized WB donation. VS changes may translate into a small but significant increase in perceived postdonation exertion. Future studies should expand duration and intensity of exertion to match combat conditions.


Assuntos
Militares , Doadores de Sangue , Estudos de Viabilidade , Humanos , Aptidão Física , Estudos Prospectivos
15.
Mil Med ; 2020 Nov 21.
Artigo em Inglês | MEDLINE | ID: mdl-33219660

RESUMO

INTRODUCTION: With more than 370,000 military and civilian personnel stationed across Pacific Command (PACOM), medical evacuation in this largest command presents unique challenges. The authors describe medical evacuations analyzed from the U.S. Air Force Transportation Command Regulating and Command & Control Evacuation System (TRAC2ES) in PACOM. MATERIALS AND METHODS: We performed a retrospective review of all TRAC2ES medical records for medical evacuations of adult patients from the PACOM theater of operations conducted between January 1, 2008 and December 31, 2018. We abstracted free text data entry in TRAC2ES to characterize the diagnoses requiring patient movement. Data are presented using descriptive statistics. RESULTS: During this 11-year period, 3,328 PACOM TRAC2ES encounters met inclusion criteria. Of these evacuations, 65.8% were male and were comprised mostly of active duty military (1,600, 48.1%) and U.S. civilians (1,706, 51.3%). Most transports originated in Japan (1,210 transports, 36.4%) or Guam (924 transports, 27.8%) with Hawaii (1,278 transports, 38.4%) as the most frequent destination. The majority of evacuations were routine (72.5%) with only 4.9% urgent evacuations. Medical conditions (2,905 transports, 87%) accounted for the largest proportion of transports, surpassing injuries (442 transports, 13%). The most common reasons for medical transports were behavioral health (671 transports, 20.2%) and cardiovascular disease (505 transports, 15.1%). CONCLUSIONS: The majority of medical evacuations in PACOM were because of medical illness with routine precedence category, mirroring the largely noncombat operations occurring across this large area.

16.
Mil Med ; 2020 Nov 26.
Artigo em Inglês | MEDLINE | ID: mdl-33242098

RESUMO

INTRODUCTION: The Prehospital Trauma Registry (PHTR) captures after-action reviews (AARs) as part of a continuous performance improvement cycle and to provide commanders real-time feedback of Role 1 care. We have previously described overall challenges noted within the AARs. We now performed a focused assessment of challenges with regard to hemodynamic monitoring to improve casualty monitoring systems. MATERIALS AND METHODS: We performed a review of AARs within the PHTR in Afghanistan from January 2013 to September 2014 as previously described. In this analysis, we focus on AARs specific to challenges with hemodynamic monitoring of combat casualties. RESULTS: Of the 705 PHTR casualties, 592 had available AAR data; 86 of those described challenges with hemodynamic monitoring. Most were identified as male (97%) and having sustained battle injuries (93%), typically from an explosion (48%). Most were urgent evacuation status (85%) and had a medical officer in their chain of care (65%). The most common vital sign mentioned in AAR comments was blood pressure (62%), and nearly one-quarter of comments stated that arterial palpation was used in place of blood pressure cuff measurements. CONCLUSIONS: Our qualitative methods study highlights the challenges with obtaining vital signs-both training and equipment. We also highlight the challenges regarding ongoing monitoring to prevent hemodynamic collapse in severely injured casualties. The U.S. military needs to develop better methods for casualty monitoring for the subset of casualties that are critically injured.

17.
Am J Emerg Med ; 38(10): 2203-2208, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-33071079

RESUMO

BACKGROUND: Clostridioides difficile infection (CDI), characterized primarily by diffuse diarrhea in the setting of recent healthcare and antibiotic exposure, maintains significantly high rates of diagnosis in the U.S., even in the emergency department (ED). Recent updates in the literature concerning CDI should be considered for effective clinical practice in the ED setting. OBJECTIVE: This narrative review provides an evidence-based summary of current data for the ED-based evaluation and management of CDI. DISCUSSION: Substantial literature on the risk factors, diagnostic criteria, and treatment regimens have recently published concerning CDI. These studies include evaluation of risks associated with specific antibiotic classes, demonstrating that even single doses of antibiotics pose significant risk of CDI. Disproportional increases in elderly CDI rates show particular vulnerability in this population. Updated literature reveals presenting symptoms with wide ranges in rates of diarrhea, abdominal pain, fever, and nausea with vomiting. In some patients diarrhea may be altogether absent, clouding clinical suspicion. Classification primarily centers on a non-severe/severe division from the IDSA. Treatment has largely shifted away from metronidazole as a first-line antibiotic, instead focusing on oral vancomycin and fidaxomicin, even for an initial episode of CDI in an uncomplicated patient. Attention to hand hygiene and adherence to contact precautions are key to infection prevention. CONCLUSIONS: CDI cause significant illness throughout the U.S. Successful CDI diagnosis and management in the ED require current knowledge of risk, presentation, diagnosis, and proper antibiotic treatment.


Assuntos
Clostridioides difficile/efeitos dos fármacos , Infecções por Clostridium/tratamento farmacológico , Antibacterianos/uso terapêutico , Clostridioides difficile/patogenicidade , Infecções por Clostridium/diagnóstico , Gerenciamento Clínico , Serviço Hospitalar de Emergência/organização & administração , Humanos
19.
J Spec Oper Med ; 20(3): 141-156, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32969020

RESUMO

This Role 1, prolonged field care (PFC) clinical practice guideline (CPG) is intended to be used after Tactical Combat Casualty Care (TCCC) Guidelines, when evacuation to higher level of care is not immediately possible. A provider must first and foremost be an expert in TCCC, the Department of Defense standard of care for first responders. The intent of this PFC CPG is to provide evidence and experience-based solutions to those who manage airways in an austere environment. An emphasis is placed on utilizing the tools and adjuncts most familiar to a Role 1 provider. The PFC capability of airway is addressed to reflect the reality of managing an airway in a Role 1 resource-constrained environment. A separate Joint Trauma System CPG will address mechanical ventilation. This PFC CPG also introduces an acronym to assist providers and their teams in preparing for advanced procedures, to include airway management.


Assuntos
Manuseio das Vias Aéreas , Serviços Médicos de Emergência , Socorristas , Humanos , Medicina Militar
20.
Mil Med ; 185(7-8): e977-e981, 2020 08 14.
Artigo em Inglês | MEDLINE | ID: mdl-32484224

RESUMO

INTRODUCTION: Consistent procedural volume is important for emergency physicians (EPs) to maintain opportunities for critical lifesaving skills. While non-EP literature demonstrates improved patient outcomes with higher volumes, few studies examine the optimal number of repetitions needed to maintain procedural competency in EP populations. The largely young, healthy active duty population that constitutes the majority of patients in military treatment facilities (MTFs) decreases the likelihood to utilize emergent procedures. Despite this likelihood, EPs are expected to maintain proficiency and readiness to perform critical procedures in deployed settings. MATERIALS AND METHODS: A retrospective analysis of de-identified data obtained through the Military Health System Mart was performed for procedural codes involving surgical airway, central venous access, and intubation. Data were sought for 2014-2016 calendar years from seven Army hospitals under the Southwest Region Medical Command. Procedural numbers were obtained for both overall volume and those performed per 1,000 encounters. Additionally, we analyzed for volume differences with the highest volume MTF (Brooke Army Medical Center [BAMC]) removed from the data set. RESULTS: A total of 1,450 procedures were performed among the MTFs analyzed, including 973 intubations, 473 central venous catheter placements, and 4 surgical airways. MTFs averaged 69.5 intubations and 38.8 venous catheters placed each year, but decreased to 28.1 intubations and 13.0 venous catheters placed annually when BAMC was removed from the data set (a 59.6 and 61.6% decrease, respectively). Monthly averages of 40.5 intubations and 19.7 central venous catheterizations per month among all included MTFs decreased to 14.0 and 6.5 when BAMC was removed. All surgical airways were performed at BAMC. Procedural frequency per 1,000 encounters was highest at BAMC, although ordinal differences were noted in the remaining six MTFs compared with overall procedural volumes. CONCLUSIONS: This retrospective analysis demonstrates a significant variation in procedural volumes across MTFs, illustrating disproportionate opportunities for procedural skill maintenance among Army EPs. Low procedural volume threatens the maintenance of critical EP skills. These numbers could also suggest low skills for other providers (such as physician assistants), further illustrating decreased skill readiness throughout the force. Further research is needed to examine procedural volumes per individual EP, as well as those performed by other providers to evaluate for overall procedural readiness across the military force.


Assuntos
Militares , Hospitais Militares , Humanos , Serviços de Saúde Militar , Assistentes Médicos , Estudos Retrospectivos , Estados Unidos
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