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1.
West J Emerg Med ; 22(5): 1156-1166, 2021 Aug 30.
Artigo em Inglês | MEDLINE | ID: mdl-34546893

RESUMO

INTRODUCTION: Patients with pyogenic spinal Infection (PSI) are often not diagnosed at their initial presentation, and diagnostic delay is associated with increased morbidity and medical-legal risk. We derived a decision tool to estimate the risk of spinal infection and inform magnetic resonance imaging (MRI) decisions. METHODS: We conducted a two-part prospective observational cohort study that collected variables from spine pain patients over a six-year derivation phase. We fit a multivariable regression model with logistic coefficients rounded to the nearest integer and used them for variable weighting in the final risk score. This score, SIRCH (spine infection risk calculation heuristic), uses four clinical variables to predict PSI. We calculated the statistical performance, MRI utilization, and model fit in the derivation phase. In the second phase we used the same protocol but enrolled only confirmed cases of spinal infection to assess the sensitivity of our prediction tool. RESULTS: In the derivation phase, we evaluated 134 non-PSI and 40 PSI patients; median age in years was 55.5 (interquartile range [IQR] 38-70 and 51.5 (42-59), respectively. We identified four predictors for our risk score: historical risk factors; fever; progressive neurological deficit; and C-reactive protein (CRP) ≥ 50 milligrams per liter (mg/L). At a threshold SIRCH score of ≥ 3, the predictive model's sensitivity, specificity, and positive predictive value were, respectively, as follows: 100% (95% confidence interval [CI], 100-100%); 56% (95% CI, 48-64%), and 40% (95% CI, 36-46%). The area under the receiver operator curve was 0.877 (95% CI, 0.829-0.925). The SIRCH score at a threshold of ≥ 3 would prompt significantly fewer MRIs compared to using an elevated CRP (only 99/174 MRIs compared to 144/174 MRIs, P <0.001). In the second phase (49 patient disease-only cohort), the sensitivities of the SIRCH score and CRP use (laboratory standard cut-off 3.5 mg/L) were 92% (95% CI, 84-98%), and 98% (95% CI, 94-100%), respectively. CONCLUSION: The SIRCH score provides a sensitive estimate of spinal infection risk and prompts fewer MRIs than elevated CRP (cut-off 3.5 mg/L) or clinician suspicion.


Assuntos
Dor nas Costas/diagnóstico por imagem , Sistemas de Apoio a Decisões Clínicas , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Imageamento por Ressonância Magnética/métodos , Adulto , Idoso , Dor nas Costas/microbiologia , Proteína C-Reativa/análise , Diagnóstico Tardio , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Sensibilidade e Especificidade
2.
Med J (Ft Sam Houst Tex) ; (PB 8-21-04/05/06): 78-82, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34251670

RESUMO

BACKGROUND: Academic productivity is a requirement by the Accreditation Council for Graduate Medical Education (ACGME). In addition to the requirements by the ACGME, residency training programs are required to provide education on medical research with the end-goal of teaching physicians how to read, interpret, and apply medical evidence in the form of evidence-based medicine. An understanding of research design, evidencebased medicine, and critical appraisal of available literature is central to practicing medicine and applying new research to clinical practice. However, residency programs vary significantly in research curricula provided to residents. We describe an innovative integrated military-civilian emergency medicine research curriculum that provides foundational knowledge in research design and critical appraisal.


Assuntos
Medicina de Emergência , Internato e Residência , Médicos , Currículo , Educação de Pós-Graduação em Medicina , Medicina de Emergência/educação , Humanos
3.
Med J (Ft Sam Houst Tex) ; (PB 8-21-04/05/06): 93-97, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34251672

RESUMO

INTRODUCTION: Airway obstruction is the second leading cause of potentially preventable death on the battlefield. Endotracheal intubation is a critical skill needed by emergency military physicians to manage these patients. Our objective is to describe the development of the Defense Registry for Emergency Airway Management (DREAM) at Brooke Army Medical Center (BAMC), a level 1 trauma center over a 7-month period. METHODS: Emergency physicians (EP) performing endotracheal intubations in the BAMC emergency department (ED) completed standardized data collection forms with information about each event. Trained study team members extracted additional data from the medical records. We cross-referenced each intubation with patient tracking systems in the department and would fill in missing variables through interview with the intubating operator and/or medical records review. RESULTS: The study period comprised January through July 2020. During the study period emergency physicians (EP) performed a total of 74 intubations. Reasons for intubation were related to trauma for 47 patients (64%) and medical conditions for 26 patients (36%). The median age was 51 (interquartile range 30-72) and most were male 48 (65.7%). Difficult airway characteristics encountered included blood in the airway (26%), facial trauma (23%), and airway obstruction (1%). Most intubations utilized video laryngoscopy, and the most frequently used airway devices were Macintosh-shaped (45%) and hyperangulated-shaped (41%). Overall, firstpass success rate was 93% (69) with majority of intubations performed by second-year emergency residents (61%) followed by first-year residents (28%). CONCLUSIONS: Most DREAM intubations were related to traumatic injuries. The most frequently encountered difficult airway characteristics were blood in airway and facial trauma. Most intubations were conducted using video laryngoscopy with a high first-pass success rate similar to other published studies. Expansion of the registry to other military emergency departments would enable a data-driven solution for development of individual critical task lists.


Assuntos
Manuseio das Vias Aéreas , Laringoscópios , Serviço Hospitalar de Emergência , Humanos , Intubação Intratraqueal , Masculino , Pessoa de Meia-Idade , Sistema de Registros
4.
J Exp Anal Behav ; 116(1): 96-113, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34261190

RESUMO

Researchers used a conjugate preparation to evaluate how response force changed based on participants' preferences for visual stimuli. First, researchers used a verbal preference assessment to evaluate each participant's preference for viewing for five object categories of visual stimuli; this process identified high preference (HP) stimuli and low preference stimuli for most participants. Thereafter, researchers exposed each participant to the five stimulus categories in a randomized order while using a force dynamometer to measure their response force to increase visual clarity of each stimulus. Results indicate the majority of participants' HP stimuli corresponded to the stimulus category for which they exerted the highest mean force. These preliminary findings suggest conjugate preparations involving response force may provide another option for measuring the relative value of some stimulus events.

5.
Resuscitation ; 162: 403-411, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33684505

RESUMO

AIM: To determine the incidence of peri-intubation cardiac arrest through analysis of a multi-center Emergency Department (ED) airway registry and to report associated clinical characteristics. METHODS: This is a secondary analysis of prospectively collected data (National Emergency Airway Registry) comprising ED endotracheal intubations (ETIs) of subjects >14 years old from 2016 to 2018. We excluded those with cardiac arrest prior to intubation. The primary outcome was peri-intubation cardiac arrest. Multivariable logistic regression generated adjusted odds ratios (aOR) of variables associated with this outcome, controlling for clinical features, difficult airway characteristics, and ETI modality. RESULTS: Of 15,776 subjects who met selection criteria, 157 (1.0%, 95% CI 0.9-1.2%) experienced peri-intubation cardiac arrest. Pre-intubation systolic blood pressure <100 mm Hg (aOR 6.2, 95% CI 2.5-8.5), pre-intubation oxygen saturation <90% (aOR 3.1, 95% CI 2.0-4.8), and clinician-reported need for immediate intubation without time for full preparation (aOR 1.8, 95% CI, 1.2-2.7) were associated with higher likelihood of peri-intubation cardiac arrest. The association between pre-intubation shock and cardiac arrest persisted in additional modeling stratified by ETI indication, induction agent, and oxygenation status. CONCLUSIONS: Peri-intubation cardiac arrest for patients undergoing ETI in the ED is rare. Higher likelihood of arrest occurs in patients with pre-intubation shock or hypoxemia. Prospective trials are necessary to determine whether a protocol to optimize pre-intubation haemodynamics and oxygenation mitigates the risk of peri-intubation cardiac arrest.


Assuntos
Parada Cardíaca , Intubação Intratraqueal , Adolescente , Serviço Hospitalar de Emergência , Parada Cardíaca/epidemiologia , Parada Cardíaca/terapia , Humanos , Intubação Intratraqueal/efeitos adversos , Estudos Prospectivos , Sistema de Registros
6.
Behav Anal Pract ; 14(1): 110-119, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33732581

RESUMO

Previous research has evaluated the effects of various commonly used mastery criteria on skill maintenance by directly manipulating the accuracy requirement, as well as the sessions across which these accuracy levels must be demonstrated. The current study extends this literature by including a rate dimension within the mastery criterion with a unique population. We implemented a fluency-oriented treatment package to increase intraverbal skills related to state sex laws using a multiple-baseline design across 3 target sets for 2 individuals adjudicated for illegal sexual behavior. Within this intervention package, we included 2 distinct components of a single mastery criterion: (a) accuracy (i.e., 100% accuracy across 3 consecutive sessions) and (b) speed. We evaluated how each of these measurable dimensions of behavior maintained across time. Results indicate this mastery criterion produced over 80% accuracy during maintenance probes for 10 weeks across all sets for both students. However, this mastery criterion produced idiosyncratic maintenance of rates across students and sets. These results suggest that each of these dimensions of behavior does not necessarily covary and should be conceptualized as distinct clinical targets by applied behavior clinicians.

7.
Mil Med ; 2021 Jan 25.
Artigo em Inglês | MEDLINE | ID: mdl-33492388

RESUMO

INTRODUCTION: Opioids carry high risk of dependence, and patients can rapidly build tolerance after repetitive dosing. Low-dose ketamine is an analgesic agent alternative that provides more hemodynamic stability. We sought to describe the effects of prolonged ketamine use in non-burn patients. MATERIALS AND METHODS: We queried the electronic health system at the Brooke Army Medical Center for patient encounters with ketamine infusions lasting >72 hours. We abstracted data describing demographics, vital signs, ketamine infusion dose and duration, and discharge diagnoses potentially relevant to ketamine side effects. RESULTS: We identified 194 subjects who met the study inclusion criteria. The median age was 39 years, most were male (67.0%), and most were primarily admitted for a non-trauma reason (59.2%). The mean ketamine drip strength was 43.9 mg/h (95% CI, 36.7-51.1; range 0.1-341.6) and the mean drip length was 130.8 hours (95% CI, 120.3-141.2; range 71-493). Most subjects underwent mechanical ventilation (56.1%) at some point during the infusion and most survived to hospital discharge (83.5%). On a per-day basis, the average heart rate was 93 beats per minute, systolic blood pressure was 128 mmHg, diastolic blood pressure was 71 mmHg, oxygen saturation was 96%, and respiratory rate was 22 respirations per minute. CONCLUSIONS: We demonstrate that continuous ketamine infusions provide a useful adjunct for analgesia and/or sedation. Further development of this adjunct modality may serve as an alternative agent to opioids.

8.
Behav Modif ; 45(5): 797-821, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-32249591

RESUMO

Several studies have used interdependent group contingencies to decrease disruptive behavior and increase appropriate behavior for groups of adolescents. In addition, one study demonstrated that rules plus feedback about rule violations, without additional group contingencies, decreased problem behavior and increased appropriate behavior for adolescents in three classrooms within a residential juvenile facility. Given the rapid behavior change observed in the aforementioned study, it is possible behavior changes were produced by reactivity to obtrusive observation from program implementers. To address this question, we used two A-B designs in conjunction with the conservative dual-criterion (CDC) method to evaluate the extent to which obtrusive observation alone and rules, without systematic consequences, decreased problem behaviors in two classrooms within a residential juvenile facility. Results from visual and CDC analyses indicate that (a) obtrusive observation did not affect problem behavior in either classroom and (b) rules decreased problem behavior in both classrooms and increased appropriate behavior in one classroom. In addition, a measure of social validity indicated that the procedures and outcomes were acceptable to the classroom teacher.

9.
Mil Med ; 2020 Dec 08.
Artigo em Inglês | MEDLINE | ID: mdl-33289834

RESUMO

BACKGROUND: Airway obstruction is the second leading cause of preventable death on the battlefield. Video laryngoscopy has improved airway management in the emergency setting for several decades, and technology continues to improve. Current technology in the supply chain is cost-prohibitive to incorporate at Role 1 facilities, which is where many intubations occur by novice intubators. The i-view is a novel video laryngoscopy device that is handheld, inexpensive, and disposable. The aim of this study was to determine if the i-view is suitable based on performance assessments by physician assistant trainees and survey feedback. MATERIALS AND METHODS: We prospectively enrolled physician assistant students at the Interservice Physician Assistant Program at Joint Base San Antonio-Fort Sam Houston. We provided them structured training on how to use the device, and then, a board-certified emergency medicine physician or certified registered nurse anesthetist assessed their intubations performed on a SynDaver mannequin model. We surveyed the participants afterward. RESULTS: We enrolled 60 Interservice Physician Assistant Program students. Most participants were male (75%) with a median age of 32 years. Service affiliations included Army (50%), Navy (23%), Air Force (18%), and Coast Guard (8%). Most (70%) had previous deployment experience. All the participants successfully cannulated the mannequins and 98% achieved first-attempt success. Most participants (78%) reported a grade 1 view. On postprocedure survey, 91% strongly agreed with using this device in the deployed setting and 89% strongly agreed with finding it easy to use. CONCLUSIONS: All physician assistant trainees successfully and rapidly performed endotracheal intubation using the disposable i-view video laryngoscope. Study participants rated the device as easy to use and desirable for deployment. Further research is necessary to validate this novel device in the clinical setting before recommending dissemination to the deployed military medical force sets, kits, and outfits.

10.
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.

11.
CJEM ; 22(6): 836-843, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32538336

RESUMO

OBJECTIVES: The aim of this study was to describe the sensitivity of various C-reactive protein (CRP) cut-off values to identify patients requiring magnetic resonance imaging evaluation for pyogenic spinal infection among emergency department (ED) adults presenting with neck or back pain. METHODS: We prospectively enrolled a convenience series of adults presenting to a community ED with neck or back pain in whom ED providers had concern for pyogenic spinal infection in a derivation cohort from 2004 to 2010 and a validation cohort from 2010 to 2018. The validation cohort included only patients with pyogenic spinal infection. We analysed diagnostic test characteristics of various CRP cut-off values. RESULTS: We enrolled 232 patients and analysed 201 patients. The median age was 55 years, 43.8% were male, 4.0% had history of intravenous drug use, and 20.9% had recent spinal surgery. In the derivation cohort, 38 (23.9%) of 159 patients had pyogenic spinal infection. Derivation sensitivity and specificity of CRP cut-off values were > 3.5 mg/L (100%, 24.8%), > 10 mg/L (100%, 41.3%), > 30 mg/L (100%, 61.2%), and > 50 mg/L (89.5%, 69.4%). Validation sensitivities of CRP cut-off values were > 3.5 mg/L (97.6%), > 10 mg/L (97.6%), > 30 mg/L (90.4%), and > 50 mg/L (85.7%). CONCLUSIONS: CRP cut-offs beyond the upper limit of normal had high sensitivity for pyogenic spinal infection in this adult ED population. Elevated CRP cut-off values of 10 mg/L and 30 mg/L require validation in other settings.


Assuntos
Proteína C-Reativa , Infecções , Dor nas Costas , Proteína C-Reativa/análise , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sensibilidade e Especificidade
12.
Acad Emerg Med ; 27(11): 1106-1115, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32592205

RESUMO

BACKGROUND: The hemodynamic impact of induction agents is a critically important consideration in emergency intubations. We assessed the relationship between peri-intubation hypotension and the use of ketamine versus etomidate as an induction agent for emergency department (ED) intubation. METHODS: We analyzed ED intubation data for patients aged >14 years from the National Emergency Airway Registry performed in 25 EDs during 2016 through 2018. We excluded patients with preintubation hypotension (systolic blood pressure <100 mm Hg) or cardiac arrest prior to intubation. The primary outcome was peri-intubation hypotension. Secondary outcomes included interventions for hypotension (e.g., intravenous fluids or vasopressors). We report adjusted odds ratios (aOR) from multivariable logistic regression models controlling for patient demographics, difficult airway characteristics, and intubation modality. RESULTS: There were 738 encounters with ketamine and 6,068 with etomidate. Patients receiving ketamine were more likely to have difficult airway characteristics (effect size difference = 8.8%, 95% confidence interval [CI] = 5.3% to 12.4%) and to undergo intubation with video laryngoscopy (8.1%, 95% CI = 4.4% to 12.0%). Peri-intubation hypotension incidence was 18.3% among patients receiving ketamine and 12.4% among patients receiving etomidate (effect size difference = 5.9%, 95% CI = 2.9% to 8.8%). Patients receiving ketamine were more likely to receive treatment for peri-intubation hypotension (effect size difference = 6.5%, 95% CI = 3.9% to 9.3%). In logistic regression analyses, patients receiving ketamine remained at higher risk for peri-intubation hypotension (aOR = 1.4, 95% CI = 1.2 to 1.7) and treatment for hypotension (aOR = 1.8, 95% CI = 1.4 to 2.0). There was no difference in the aOR of hypotension between patients receiving ketamine at doses ≤1.0 mg/kg versus >1.0 mg/kg or patients receiving etomidate at doses ≤0.3 mg/kg versus >0.3 mg/kg. CONCLUSIONS: Pending additional data, our results suggest that clinicians should not necessarily prioritize ketamine over etomidate based on concern for hemodynamic compromise among ED patients undergoing intubation.


Assuntos
Analgésicos , Serviço Hospitalar de Emergência , Etomidato , Hipotensão , Ketamina , Adolescente , Adulto , Idoso , Analgésicos/efeitos adversos , Etomidato/efeitos adversos , Humanos , Hipotensão/induzido quimicamente , Hipotensão/epidemiologia , Intubação Intratraqueal/efeitos adversos , Ketamina/efeitos adversos , Pessoa de Meia-Idade , Sistema de Registros , Adulto Jovem
13.
Afr J Emerg Med ; 10(1): 13-16, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32161706

RESUMO

Introduction: With personnel scattered throughout a continent 3 times larger than the United States, a lack of mature medical facilities necessitates a significant transportation network for medical evacuation in US Africa Command (AFRICOM). We describe medical evacuations analyzed from the US Air Force Transportation Command Regulating and Command & Control Evacuation System (TRAC2ES). Methods: We performed a retrospective review of all TRAC2ES medical records for medical evacuations from the AFRICOM theater of operations conducted between January 1, 2008 and December 31, 2018. We abstracted free text data entry in TRAC2ES for diagnostic and therapeutic interventions performed prior to the patient movement request. Results: During this time, there were 963 cases recorded in TRAC2ES originating within AFRICOM. 961 records were complete for analysis. Most patients were male (82%) and military personnel (92%). Most transports originated in Djibouti (72%), and Germany (93%) was the most common destination. Medical evacuations were largely routine (66%), and routine evacuations were proportionally highest amongst US military personnel compared to all other groups. A small portion of patients were evacuated for battle injuries (4%), compared to non-battle injury (33%) and disease (63%). Within disease, the largest proportion of patient complaints centered on gastrointestinal symptoms (13%), behavioral health (11%) and chest pain (8%). Prior to evacuation, only 55% of patients were document as receiving any medication. Pain control was documented in 21% of cases, most commonly being NSAIDs (7%). Discussion: Extremely low numbers of battle injuries highlight the unique nature of AFRICOM operations compared to areas with more intense combat operations. Limitations of the dataset highlight the need for a data collection mandate within AFRICOM as within other areas for optimization and performance improvement.

14.
Am J Emerg Med ; 38(3): 491-496, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31128933

RESUMO

OBJECTIVE: To identify clinical characteristics associated with pyogenic spinal infection among adults presenting to a community emergency department (ED) with neck or back pain. A secondary objective was to describe the frequency of these characteristics among patients with spinal epidural abscess (SEA). METHODS: We conducted a prospective cohort study in a community ED enrolling adults with neck or back pain in whom the ED provider had clinical concern for pyogenic spinal infection. Study phase 1 (Jan 2004-Mar 2010) included patients with and without pyogenic spinal infection. Phase 2 (Apr 2010-Aug 2018) included only patients with pyogenic spinal infection. We performed univariate and multivariate analyses for association of clinical characteristics with pyogenic spinal infection. RESULTS: We enrolled 232 and analyzed 223 patients, 89 of whom had pyogenic spinal infection. The median age was 55 years and 102 patients (45.7%) were male. The clinical characteristics associated with pyogenic spinal infection on multivariate analysis of study phase 1 included recent soft tissue infection or bacteremia (OR 13.5, 95% CI 3.6 to 50.7), male sex (OR 5.0, 95% CI 2.5 to 10.0), and fever in the ED or prior to arrival (OR 2.8, 95% CI 1.3 to 6.0). Among patients with SEA (n = 61), 49 (80.3%) had at least one historical risk factor, 12 (19.7%) had fever in the ED, and 8 (13.1%) had a history of intravenous drug use. CONCLUSION: Male sex, fever, and recent soft tissue infection or bacteremia were associated with pyogenic spinal infection in this prospective ED cohort.


Assuntos
Dor nas Costas/etiologia , Cervicalgia/etiologia , Doenças da Medula Espinal/diagnóstico , Adulto , Idoso , Bacteriemia/complicações , Serviço Hospitalar de Emergência/estatística & dados numéricos , Abscesso Epidural/epidemiologia , Abscesso Epidural/microbiologia , Feminino , Febre/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Fatores Sexuais , Infecções dos Tecidos Moles/complicações , Doenças da Medula Espinal/epidemiologia , Doenças da Medula Espinal/etiologia , Doenças da Medula Espinal/microbiologia
15.
Mil Med ; 185(1-2): e138-e145, 2020 02 13.
Artigo em Inglês | MEDLINE | ID: mdl-31334769

RESUMO

INTRODUCTION: Traumatic brain injury (TBI) is a leading cause of death and disability worldwide and is associated with mortality rates as high as 30%. Patients with TBI are at high risk for secondary injury and need to be transported to definitive care expeditiously. However, the physiologic effects of aeromedical evacuation are not well understood and may compound these risks. Combat TBI patients may benefit from delayed aeromedical evacuation. The goal of this study was to evaluate the impact of transport timing out of theater via Critical Care Air Transport Teams (CCATT) to a higher level facility on the clinical outcomes of combat casualties with TBI. MATERIALS AND METHODS: We performed a retrospective review of patients with TBI who were evacuated out of theater by CCATT from January 2007 to May 2014. Data abstractors collected flight information, vital signs, procedures, in-flight assessments, and outcomes. Time to transport was defined as the time from injury to CCATT evacuation out of combat theater. We calculated descriptive statistics and constructed regression models to determine the association between time to transport and clinical outcomes. This study was approved by the U.S. Air Force 59th Medical Wing Institutional Review Board. RESULTS: We analyzed the records of 438 patients evacuated out of theater via CCATT and categorized them into three groups: patients who were transported in one day or less (n = 165), two days (n = 163), and three or more days (n = 110). We used logistic regression models to compare outcomes among patients who were evacuated in two days or three or more days to those who were transported within one day while adjusting for demographics, injury severity, and injury type. Patients who were evacuated in two days or three or more days had 50% lower odds of being discharged on a ventilator and were twice as likely to return to duty or be discharged home than those who were evacuated within one day. Additionally, patients transported in three or more days were 70% less likely to be ventilated at discharge with a GCS of 8 or lower and had 30% lower odds of mortality than those transported within one day. CONCLUSIONS: In patients with moderate to severe TBI, a delay in aeromedical evacuation out of the combat theater was associated with improved mortality rates and a higher likelihood of discharge to home and return to duty dispositions. This study is correlational in nature and focused on CCATT transports from Role III to Role IV facilities; as such, care must be taken in interpreting our findings and future studies are needed to establish a causal link between delayed evacuation and improved discharge disposition. Our study suggests that delaying aeromedical evacuation of TBI patients when feasible may confer benefit.


Assuntos
Lesões Encefálicas Traumáticas , Militares , Campanha Afegã de 2001- , Resgate Aéreo , Lesões Encefálicas Traumáticas/terapia , Humanos , Guerra do Iraque 2003-2011 , Estudos Retrospectivos
18.
Am J Emerg Med ; 37(8): 1554-1561, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31060863

RESUMO

INTRODUCTION: Patients with acute myocardial infarction (AMI) may suffer several complications after the acute event, including dysrhythmias and heart failure (HF). These complications place patients at risk for morbidity and mortality. OBJECTIVE: This narrative review evaluates literature and guideline recommendations relevant to the acute emergency department (ED) management of AMI complicated by dysrhythmia or HF, with a focus on evidence-based considerations for ED interventions. DISCUSSION: Limited evidence exists for ED management of dysrhythmias in AMI due to relatively low prevalence and frequent exclusion of patients with active cardiac ischemia from clinical studies. Management decisions for bradycardia in the setting of AMI are determined by location of infarction, timing of the dysrhythmia, rhythm assessment, and hemodynamic status of the patient. Atrial fibrillation is common in the setting of AMI, and caution is warranted in acute rate control for rapid ventricular rate given the possibility of compensation for decreased ventricular function. Regular wide complex tachycardia in the setting of AMI should be managed as ventricular tachycardia with electrocardioversion in the majority of cases. Management directed towards HF from left ventricular dysfunction in AMI consists of noninvasive positive pressure ventilation, nitroglycerin therapy, and early cardiac catheterization. Norepinephrine is the first line vasopressor for patients with cardiogenic shock and hypoperfusion on clinical examination. Early involvement of a multi-disciplinary team is recommended when caring for patients in cardiogenic shock. CONCLUSIONS: This review discusses considerations of ED management of dysrhythmias and HF associated with AMI.


Assuntos
Fibrilação Atrial/terapia , Bradicardia/tratamento farmacológico , Bloqueio Cardíaco/terapia , Insuficiência Cardíaca/terapia , Infarto do Miocárdio/complicações , Taquicardia Ventricular/terapia , Fibrilação Atrial/etiologia , Bradicardia/etiologia , Medicina de Emergência , Bloqueio Cardíaco/etiologia , Bloqueio Cardíaco/mortalidade , Insuficiência Cardíaca/etiologia , Humanos , Guias de Prática Clínica como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Choque Cardiogênico/complicações , Taquicardia Ventricular/etiologia
19.
Am J Emerg Med ; 37(6): 1175-1183, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30987913

RESUMO

INTRODUCTION: Despite the declining incidence of coronary heart disease (CHD) in the United States, acute myocardial infarction (AMI) remains an important clinical entity, with many patients requiring emergency department (ED) management for mechanical, inflammatory, and embolic complications. OBJECTIVE: This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of post myocardial infarction mechanical, inflammatory, and embolic complications. DISCUSSION: While 30-day mortality rate after AMI has decreased in the past two decades, it remains significantly elevated at 7.8%, owing to a wide variety of subacute complications evolving over weeks. Mechanical complications such as ventricular free wall rupture, ventricular septal rupture, mitral valve regurgitation, and formation of left ventricular aneurysms carry significant morbidity. Additional complications include ischemic stroke, heart failure, renal failure, and cardiac dysrhythmias. This review provides several guiding principles for management of these complications. Understanding these complications and an approach to the management of various complications is essential to optimizing patient care. CONCLUSIONS: Mechanical, inflammatory, and embolic complications of AMI can result in significant morbidity and mortality. Physicians must rapidly diagnose these conditions while evaluating for other diseases. In addition to understanding the natural progression of disease and performing a focused physical examination, an electrocardiogram and bedside echocardiogram provide quick, noninvasive determinations of the underlying pathophysiology. Management varies by presentation and etiology, but close consultation with cardiology and cardiac surgery is recommended.


Assuntos
Aneurisma Cardíaco/etiologia , Ruptura Cardíaca Pós-Infarto/etiologia , Insuficiência da Valva Mitral/etiologia , Infarto do Miocárdio/complicações , Pericardite/etiologia , Ecocardiografia , Eletrocardiografia , Medicina de Emergência , Aneurisma Cardíaco/diagnóstico , Aneurisma Cardíaco/terapia , Ruptura Cardíaca Pós-Infarto/diagnóstico , Ruptura Cardíaca Pós-Infarto/terapia , Humanos , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/terapia , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Narração , Pericardite/diagnóstico , Pericardite/terapia , Exame Físico , Sistemas Automatizados de Assistência Junto ao Leito , Fatores de Risco
20.
Clin Pract Cases Emerg Med ; 3(1): 33-35, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30775660

RESUMO

Transfusion-related acute lung injury (TRALI) is a complication of blood product transfusion characterized by respiratory distress with bilateral lung infiltrates and non-cardiogenic pulmonary edema developing within six hours of transfusion. TRALI is believed to result from an immunological response to transfused blood products. TRALI is a clinical diagnosis that requires the exclusion of other etiologies of pulmonary edema and acute lung injury. Here we report a case of a female who presented to the emergency department in acute respiratory distress two days after receiving a transfusion of packed red blood cells for post-operative anemia following a hysterectomy.

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