The Association of Calcium Derangements With 24-Hour Outcomes in the Deployed Combat Setting.

INTRODUCTION: Calcium derangements remain poorly characterized in the combat trauma population. We describe the incidence of emergency department (ED) calcium derangements, associated physiologic derangements, and 24-hour mortality from the deployed combat setting. MATERIALS AND METHODS: We analyzed adult casualties from 2007 to 2023 from the DoD Trauma Registry for U.S. military, U.S. contractor, and coalition casualties that had at least 1 ionized calcium value documented in the ED at a Role 2 or Role 3 military treatment facility. We constructed a series of multivariable logistic regression models to test for the association of hypocalcemia and hypercalcemia with physiological derangements, blood product consumption, and survival. Vital signs and other laboratory studies were based on the concurrent ED encounter. RESULTS: There were 941 casualties that met inclusion for this analysis with 26% (245) having at least 1 calcium derangement. Among those, 22% (211) had at least 1 episode of hypocalcemia and 5% (43) had at least 1 episode of hypercalcemia in the ED. The vast majority (97%, 917) received calcium at least once. Median composite injury severity scores were lower among those with no calcium derangement (8 versus 17, P < .001). Survival was higher during the total hospitalization (98% versus 93%) among those with calcium derangements but similar at 24 hours (99% versus 98%, P = .059). After adjusting for confounder, any hypocalcemic measurement was associated with an elevated international normalized ratio (odds ratio 1.94, 95% CI 1.19-3.16), acidosis (1.66, 1.17-2.37), tachycardia (2.11, 1.42-3.15), hypotension (1.92, 1.09-3.38), depressed Glasgow coma scale (3.20, 2.13-4.81), elevated shock index (2.19, 1.45-3.31), submassive transfusion (3.97, 2.60-6.05), massive transfusion (4.22, 2.66-6.70), supermassive transfusion (3.65, 2.07-6.43), and all hospital stay mortality (2.30, 1.00-5.29). Comparatively, any hypercalcemic measurement was associated with acidosis (2.96, 1.39-6.32), depressed Glasgow coma scale (4.28, 1.81-10.13), submassive transfusion (3.40, 1.37-8.43), massive transfusion (6.25, 2.63-14.83), and supermassive transfusion (13.00, 5.47-30.85). CONCLUSIONS: Both hypocalcemia and hypercalcemia in the ED were associated with physiological derangements and blood product use, with a greater extent observed in those with hypocalcemia compared to those with hypercalcemia. Prospective studies are underway to better explain and validate these findings.

The Impact of Progressive Simulation-Based Training on Tourniquet Application.

The Advanced Combat Medical Experience (ACME) is a progressive simulation-based training held for second-year medical students at the Uniformed Services University (USU). This study explored the impact of participating in ACME on students' tourniquet application skills. A panel of emergency medicine physician experts developed an assessment to evaluate the participants' performance. Trained raters then scored students' tourniquet application performance before and after participating in ACME. We conducted a Wilcoxon signed-rank test to detect any significant difference in the participants' pretest and posttest ratings as well as time it took them to apply the tourniquet. Our results indicated a significant difference in the pre- and posttest ratings of students as well as the time it took them to apply the tourniquet. This study confirms the effectiveness of progressive simulation-based education for teaching TCCC skills to military medical trainees.

Use of RIFLE criteria to predict the severity and prognosis of acute kidney injury in emergency department patients with rhabdomyolysis.

BACKGROUND: RIFLE criteria (Risk, Injury, Failure, Loss, End-stage) have not been evaluated in Emergency Department (ED) patients at risk of acute kidney injury (AKI). AKI occurs in rhabdomyolysis. STUDY OBJECTIVES: To use RIFLE criteria to stratify the severity of AKI and predict prognosis in ED patients with acute rhabdomyolysis. METHODS: This is a retrospective study of consecutive patients with rhabdomyolysis over a 44-month period. Data included ED admission anion gap, blood urea nitrogen (BUN), calcium, phosphate, potassium, urinalysis, toxicology screen, and hematocrit. Creatine kinase, creatinines, and hematocrits were followed serially. Hospital length of stay (LOS) and need for dialysis were also recorded. RESULTS: RIFLE categories were calculated for 135 patients. At admission, 60 (44%) had no AKI, 20 (15%) had Risk, 32 (24%) had Injury, and 23 (17%) had Failure. These categories were significantly associated with increasing magnitude of volume depletion, potassium, phosphate, BUN, and the anion gap. They predicted differences in LOS, dialysis, discharge creatinine, and the rate of normalization of the admission creatinine. Mortality was low (2%), as was morbidity. Only 8/132 surviving patients (6%) were discharged with a creatinine >2 mg/dL. CONCLUSIONS: The RIFLE categories correlated significantly with known markers of rhabdomyolysis and AKI. They also predicted LOS, dialysis, renal morbidity, and the timing of recovery. RIFLE criteria could be used to predict the outcome of ED patients and facilitate admission and discharge decisions.

Females Engaged in Elite Training Previously Only Open to Males: Exploring the Variables of Successful Outcomes.

To date, there has been no analysis of the skills or attributes predicting success in female trainees who undergo traditionally male elite military training. This retrospective case control study characterized variables specific to females in the Special Operations Combat Medic course. 20/39 males and 15/38 females successfully completed the course. Several objective variables of interest including height and body weight, marital status, dependents, and physical fitness scores revealed trends but marital status and dependents were the only variables that achieved statistical significance. Exploration of subjective measures also highlighted potential trends in upper body strength and personal versus behavioral issues. These variables should be explored further for applicability to altering selection criteria or adjusting training conditions to mitigate sex disparities without altering standards of performance or creating an imbalance of resource investment for intended returns. The variables identified in this sample can be explored in other populations as females are integrated in other previously closed realms of military service.

Integrating Chemical Biological, Radiologic, and Nuclear (CBRN) Protocols Into TCCC Introduction of a Conceptual Model - TCCC + CBRN = (MARCHE)2.

The authors would like to introduce TCCC [Tactical Combat Casualty Care] + CBRN [chemical, biological, radiological, and nuclear] = (MARCHE)2 as a conceptual model to frame the response to CBRN events. This model is not intended to replace existing and well-established literature on CBRNE events but rather to serve as a response tool that is an adjunct to agent specific resources.

Toxicologic issues during cardiopulmonary resuscitation.

PURPOSE OF REVIEW: The following review intends to outline the unique aspects of providing cardiopulmonary resuscitation for the poisoned patient and highlights both current practice and new therapies that apply to toxicologic cases. RECENT FINDINGS: Although there are few prospective randomized studies to further evidence-based care of the poisoned patient, there have been several reports of novel uses of both established medications and new medications in toxicologic patients. These case reports highlight treatment possibilities and potential avenues for further research. SUMMARY: It is important for providers to recognize the limitations of standard advanced cardiac life support algorithms when caring for poisoned patients. Toxicologic causes of cardiopulmonary compromise should be considered along with administration of appropriate antidotes and adjunctive therapies.

Prevalence of cocaine use in ED patients with severe hypertension.

STUDY OBJECTIVE: We prospectively evaluated the prevalence of cocaine use in emergency department patients with elevated diastolic blood pressure greater than 120 mm Hg. DESIGN: Urine was collected on adult patients with diastolic blood pressure greater than 120 mm Hg. The Institutional Review Board granted a waiver of informed consent based on complete deidentification of the data to prevent selection bias. Spontaneously voided urine specimens were analyzed for the presence of the benzoylecgonine. RESULTS: Of 107 eligible patients with a diastolic blood pressure equal to or greater than 120 mm Hg, 99 were tested. Of the 99, 13 (13%) tested positive, and of which, 6 (46%) presented with a request for medication refill. Five patients (39%) had cardiovascular and/or pulmonary complaints. CONCLUSION: Emergency department patients with hypertension who have recently used cocaine may be difficult to differentiate from those who have not. Consideration should be given to the potential for cocaine use when making treatment decisions in patients with hypertension.

Cardiotoxicity associated with accidental bupropion ingestion in a child.

Bupropion, an atypical antidepressant commonly used for depression and smoking cessation, is well known to cause seizures in both therapeutic use and overdose, but cardiac effects have been reported as minimal, usually sinus tachycardia. We describe an ingestion of bupropion estimated to be greater than 2 g by a 3-year-old boy that resulted in seizures. The child was decontaminated with whole bowel irrigation (WBI), and he experienced aspiration of polyethylene glycol and electrolyte solution used for the WBI. The patient ultimately developed hypotension and bradycardia requiring cardiopulmonary resuscitation due to the effects of the bupropion combined with the complications of WBI. In contrast to previous literature, which showed few clinical effects aside from seizures from ingestion of bupropion by children, our case highlights the dangers of pediatric bupropion ingestion and highlights risks of WBI.

CHAMP Symposium on Androgens, Anabolic Steroids, and Related Substances: What We Know and What We Need to Know.

The Consortium of Health and Military Performance hosted a symposium in April 2015 entitled "Androgens, Anabolic Steroids, and Related Substances: What We Know and What We Need to Know" in response to concerns from the field regarding Anabolic Androgenic Steroids use by U.S. service members. The symposium was attended by military and civilian subject-matter experts in sports medicine and anabolic steroids and was held at the United Service Organizations (Naval Support Activity Bethesda) in Bethesda, Maryland. The expert panel was charged to define the way ahead in terms of androgen use, education, research, relevant policies and guidelines, and other concerns with particular relevancy to Special Operations Forces. The conference concluded with the following recommendations on these several key issues (1) connecting with users, (2) education and intervention, (3) knowledge and research gaps, and (4) establishing an information clearinghouse and clinical repository.

Term incomplete breech delivery in an ambulance: a case report.

Breech deliveries are the most common form of fetal malpresentations and are associated with significant risk for morbidity and mortality to mother and infant. There is an increased chance that emergency physicians may encounter breech deliveries as more women with known breech presentations are given the option for a trial of labor in lieu of mandatory caesarean section. Emergency physicians should be prepared for the complications that are associated with breech delivery and recognize the different maneuvers required to successfully deliver a breech infant.

Androgens and Androgen Derivatives: Science, Myths, and Theories: Explored From a Special Operations Perspective.

Androgen use outside of legitimate medical therapy is a perceived concern that is drawing attention across military and specifically Special Operations Forces (SOF) communities. For leadership and the medical community to properly address the issue and relate to those individuals who are using or considering use, it will be crucial to understand the scope of the problem. Limited data suggest that the prevalence of androgen use may be increasing, and inferences made from the scientific literature suggest that SOF may be a population of concern. While risks of androgen use are well known, there are little data specific to military performance that can be applied to a rigorous risk:benefit analysis, allowing myths and poorly supported theories to perpetuate within the community. Further efforts to define the potential benefits balanced against the short- and long-term risks should be undertaken. Providers within the SOF community should arm themselves with information to engage androgen users and leadership in meaningful discussion regarding androgen use.

MEDCAN-GRO: Medical Capacity for African Nations - Growing Regional Operability A Case Study in Special Operations Forces Capacity Building.

Medical Capacity for African Nations-Growing Regional Operability (MEDCAN-GRO) is a framework for addressing healthcare engagements that are intended to provide sustainable capacity building with partner nations. MEDCAN-GRO provides SOF units with a model that can be scaled to partner nation needs and aligned with the goals of the TSOC in an effort to enhance partner nation security.

Needle thoracostomy: implications of computed tomography chest wall thickness.

OBJECTIVES: To determine the length of catheter required to perform a needle thoracostomy, as determined by chest wall thickness, to treat the majority of patients presenting to the emergency department (ED) with a potential tension pneumothorax. METHODS: A convenience sample of 111 computed tomography (CT) scans of the chest in trauma and medical resuscitation patients at a military Level 1 trauma center in San Antonio, Texas, was pooled, and the chest wall thickness was measured at the second intercostal space, midclavicular line, to the nearest 0.1 cm. RESULTS: The mean chest wall thickness in the patients studied averaged 4.24 cm (95% confidence interval [CI] = 3.97 to 4.52). Nearly one fourth (25) of the study patients had a chest wall thicker than 5 cm. Women, on average, have thicker chest walls than men (4.90 for women; 4.16 for men; p = 0.022). CONCLUSIONS: In this study, a catheter length of 5 cm would reliably penetrate the pleural space of only 75% of patients. A longer catheter should be considered, especially in women.

Breast disorders: a review for emergency physicians.

Breast complaints are a common reason for women to seek medical attention. While true emergencies involving the breast are rare, the fact that one out of every eight women will develop breast cancer increases the sense of urgency for patients presenting with concerns related to the breast. This article reviews the evaluation and treatment of true breast emergencies as well as less urgent but more common concerns relating to the breast such as trauma, infection, pain, discharge, postoperative problems, complications of breast cancer, and use of medications by lactating women.

This is Africa: an introduction to medical operations on the African continent.

This article regarding Special Operations Forces (SOF) medical operations in Africa is an introduction to a follow-on series of articles that will address in more detail pertinent medical topics which pertain to operations on the African continent. Medical operations in Africa require dynamic and systematic approaches that consider the myriad challenges, yet offer flexible solutions applied as situations and environments dictate. We believe this series of articles will be of high interest to readers and provide key information that will be germane to future SOF operations.

Bites, stings, and rigors: clinical considerations in African operations.

The natural health threats in Africa pose daunting clinical challenges for any provider, as evidenced by the current Ebola epidemic in West Africa, but the threat is multiplied for the Special Operations provider on the continent who faces these challenges with limited resources and the tyranny of distance. The majority of operationally significant health risks can be mitigated by strict adherence to a comprehensive force health protection plan. The simplest, yet most effective, technique for preventing mosquito-borne diseases is the prevention of mosquito bites with repellent, bed nets, and appropriate clothing in addition to chemoprophylaxis. Some of the more likely or lethal infectious diseases encountered on the continent include malaria, Chikungunya, dengue, human immunodeficiency virus, and Ebola. Venomous snakes pose a particular challenge since the treatment can be as deadly as the injury. Providers supporting African operations should educate themselves on the clinical characteristics of possible envenomations in their area while promoting snake avoidance as the primary mitigation measure. To succeed in Africa, the Special Operations provider must consider how to meet these challenges in an environment where there may not be reliable evacuation, hospitalization, or logistics channels.

Toxic bradycardias in the critically ill poisoned patient.

Cardiovascular drugs are a common cause of poisoning, and toxic bradycardias can be refractory to standard ACLS protocols. It is important to consider appropriate antidotes and adjunctive therapies in the care of the poisoned patient in order to maximize outcomes. While rigorous studies are lacking in regards to treatment of toxic bradycardias, there are small studies and case reports to help guide clinicians' choices in caring for the poisoned patient. Antidotes, pressor support, and extracorporeal therapy are some of the treatment options for the care of these patients. It is important to make informed therapeutic decisions with an understanding of the available evidence, and consultation with a toxicologist and/or regional Poison Control Center should be considered early in the course of treatment.

Renal complications in oncologic patients.

Acute renal failure (ARF) can be one of the many complications associated with malignancy and, unfortunately, often harbors a worse prognosis for the afflicted patient. Insult to the kidneys can occur for a variety of reasons in the oncologic patient. This article focuses on several of these etiologies, such as tumor lysis syndrome (TLS) and thrombotic microangiopathy (TMA), which are unique threats faced by the oncologic patient.

Eschmann introducer through laryngeal mask airway: a cadaveric trial of an alternate means of rescue intubation.

STUDY OBJECTIVE: Laryngeal mask airways (LMAs) are often used as airway rescue devices where laryngoscopy is difficult. The LMA does not protect the airway and is preferably replaced with a cuffed endotracheal tube. There are reports of cases where an Eschmann tracheal tube introducer (ETTI) was successfully used to bridge between a standard LMA and an endotracheal tube. This project was designed to determine whether an Eschmann stylet can reliably be passed through an LMA into the trachea as a means of rescue intubation. METHODS: Nineteen emergency medicine residents and attending physicians, who were participants in a cadaveric airway course, placed and inflated a size 4 LMA (The Laryngeal Mask Company Ltd., San Diego, CA) on each of six unembalmed human cadavers in the usual fashion. They then attempted to pass a lubricated, 15 Fr, reusable, coude-tipped ETTI (Portex, Smiths Medical, Keene, NH)) through the airspace/handle of the inflated LMA. The LMA was then deflated and removed while the ETTI was held in place. Investigators then determined the location of the ETTI by laryngoscopy. RESULTS: Of 114 attempts at the rescue procedure, 59 resulted in placement of the bougie into the trachea, yielding an overall success rate of 52% (95% CI 48%-56%). There were no significant differences in performance based on level of training of residents or years of experience of attending physicians. CONCLUSIONS: While not a primary difficult airway option, the use of a ETTI as a bridge device between LMA and endotracheal tube was successful about 50% of the time.