Pain Control and Point-of-Care Ultrasound: An Approach to Rib Fractures for the Austere Provider.

Rib fractures are common injuries that cause significant discomfort and can lead to severe pulmonary complications. Rib injury most often results from high-velocity traumatic mechanisms, while rarely representing underlying metastatic disease or secondary injury due to pulmonary illness. Because most rib fractures are caused by obvious trauma, algorithms are focused on treatment rather than investigating the exact mechanism of rib fractures. Chest radiographs are often the initial imaging performed but have proven to be unreliable in identification of rib fracture. Computed tomography (CT) is a diagnostic option as it is more sensitive and specific than simple radiographs. However, both modalities are generally unavailable to Special Operations Forces (SOF) medical personnel working in austere locations. These medical providers could potentially diagnose and treat rib fractures in any environment using a standardized approach that includes clarity of mechanism, pain relief, and point-of-care ultrasound (POCUS). This case demonstrates an approach to the diagnosis and treatment of a rib fracture in a 47-year-old male who presented to a military treatment facility with unlocalized flank and back pain, but the methods employed have applicability to the austere provider working far from the resources of a medical center.

Mild Grisel Syndrome: Expanding the Differential for Posttonsillectomy Adenoidectomy Symptoms.

Background: Tonsillectomy with or without adenoidectomy is the second most common pediatric surgical procedure in the United States with up to 97% performed as an outpatient.1,2 While it is largely a safe procedure, several complications have been described and are encountered in the emergency department and primary care setting. Presentation: A 29-month child presented to the emergency department with neck stiffness 10 days after tonsillectomy and adenoidectomy. A computed tomography scan of the neck limited by motion artifact was unrevealing, but a consult to the pediatric otolaryngologist generated concern for Grisel syndrome, the atraumatic rotary subluxation of the atlantoaxial joint. While surgical intervention can be required, the patient had an uncomplicated clinical course and the anomalous neck posture resolved with time and antiinflammatories alone. Conclusions: Keeping a broad differential for posttonsillectomy and adenoidectomy patient concerns is important for the clinician. Serious, life-threatening complications can arise from Grisel syndrome while good functional outcomes can be achieved with timely and appropriate treatment.

Casualty Evacuation (CASEVAC) Platform Review and Case Series of US Military Enroute Critical Care Team With Contract Personnel Recovery Services in an Austere Environment.

In a rapidly changing operational environment, in which there has been an emphasis on prolonged field care and limited evacuation platforms, military providers must practice to the full scope of their training to maximize outcomes. In addition to pushing military providers further into combat zones, the Department of Defense has relied on contracted personnel to help treat and evacuate servicemembers. This article is a retrospective review on the interoperability of the expeditionary resuscitative surgical team (ERST) and a contracted personnel recovery (CPR) team in a far-forward austere environment and will discuss actual patient transport case reviews that used multiple evacuation platforms across thousands of miles of terrain. To effectively incorporate CPR personnel into a military transport team model, we recommend including cross-training on equipment and formularies, familiarization with CPR evacuation platforms, and mass casualty (MASCAL) exercises that incorporate the different platforms available.

Extubation Failure in a Burn Intensive Care Unit: Examination of Contributing Factors.

Extubation failure is associated with negative outcomes making the identification of risk factors for failure paramount. Burn patients experience a high incidence of respiratory failure requiring mechanical ventilation. There is no consensus on the acceptable rate of extubation failure and many conventional indices do not accurately predict extubation outcomes in burn patients. The purpose of this study was to examine the rate of extubation failure in the burned population and to examine the impact of factors on extubation outcomes. Burn patients from a single center over 9 years were examined and included if they were intubated prior to arrival or within 48 hours of admission and underwent a planned extubation. From this cohort, a matched case-control analysis based on age, TBSA, and sex was performed of patients who succeeded after extubation, defined as not requiring reintubation within 72 hours, to those who failed. Characteristics and clinical parameters were compared to determine whether any factors could predict extubation failure. There was a 12.3% incidence of extubation failure. In the matched case-control analysis, the presence of inhalation injury was associated with extubation success. Higher heart rate and lower serum pH were associated with extubation failure. ANCOVA analysis demonstrated that a sodium trending higher before extubation was associated with more successes, possibly indicative of a lower volume status. Classic extubation criteria do not accurately predict extubation outcomes in burn patients; analysis of other parameters may be able to provide better predictions. A constellation of these parameters needs to be studied prospectively.

2-(1,2,3,4-Tetra-hydro-phenanthren-1-yl-idene)malononitrile.

In the title complex, C(17)H(12)N(2), the non-aromatic six-membered ring adopts an envelope conformation. The dihedral angle between the eight-membered plane containing the malononitrile group and the aromatic system is 25.88 (4)°. The distance from the central C atom of the malononitrile group to the centroid of the n-glide-related distal aromatic ring is 3.66 Å, suggesting π-π inter-actions.

Non-battle Emergency Department Utilization of the First Modular Army Field Hospital Prototype in Support of Operation INHERENT RESOLVE.

INTRODUCTION: The 2010-2011 withdrawal from Iraq included the closure of all fixed-facility military medical resources. Operation INHERENT RESOLVE, the United States-led counter-terrorism mission in Iraq and Syria, subsequently commenced in 2014. With increasing combat operations, the 28th Combat Support Hospital deployed to Iraq to support that mission as a limited footprint unit prototyped after the new modular Army Field Hospital. We describe the non-battle utilization of the emergency medical treatment section. METHODS: We prospectively collected data for this project as part of a performance improvement initiative to track healthcare utilization to guide emergency medical treatment section staffing. The project took place at a combat support hospital near Baghdad, Iraq from July 2016 through January 2017. RESULTS: During this time, the emergency department (ED) averaged 3.5 visits per day totaling 675 non-battle encounters. Most (84.6%) were U.S. military personnel with a median age of 32 (IQR 26-38). The most common procedure performed was point-of-care ultrasound (n = 33). Most patients (96.9%) underwent discharge from the ED. Of the 21 subjects admitted, 6 were for surgical intervention and the remaining for medical or observational indications. The most common chief complaints were musculoskeletal (31.1%, n = 210), respiratory (15.3%, n = 103), and dermatologic (12.0%, n = 81). CONCLUSIONS: Non-battle injuries and illnesses were the predominant reason for ED utilization. Most subjects were discharged back to duty with relatively low-resource utilization. Few visits required procedural interventions.

An Unusual Presentation of Murine Typhus and Mononucleosis.

A 20-year-old female presented to the emergency department complaining of fever, cough, and dyspnea after a recent camping trip. The patient remained ill appearing, persistently tachycardic and dyspneic despite nebulizer treatments, and fluids in the emergency department. She was admitted for observation and gradually improved over the next 4 d. Inpatient laboratory studies indicated acute Epstein-Barr virus infection and she was discharged with a presumptive diagnosis of infectious mononucleosis. However, further testing showed a simultaneous rickettsial infection producing murine typhus. The patient ultimately recovered uneventfully once proper treatment was initiated. This patient's presentation represents a unique description of simultaneous infectious mononucleosis and murine typhus which underscores the importance of maintaining a broad differential diagnosis in the approach to febrile illnesses.

An Emergency Department Presentation of Secondary Syphilis.

In the United States, the rate of primary and secondary syphilis has increased by 18% in 2016, the highest rate since 1993. These patients can often present to the emergency department (ED) in various stages. Although syphilis is well described in the literature, there is a paucity of ED reports of atypical cases. A 22-yr-old male presented to the ED complaining of neck pain. The patient was found to have right-sided tender cervical lymphadenopathy causing neck pain. A thorough physical exam revealed diffuse lymphadenopathy. Without an obvious infectious etiology, the patient underwent a broad workup, which revealed a reactive rapid plasma reagin (RPR) assay with a titer of 1:64. The patient had no history of the classic painless penile ulcer. The ED presentation of secondary syphilis can be very insidious, and physicians should be aware of its various presentations.

QuikClot® Combat Gauze® Use by Ground Forces in Afghanistan The Prehospital Trauma Registry Experience.

BACKGROUND: QuikClot® Combat Gauze® (QCCG) was fielded in 2008 to replace previous generations of hemostatic products. To the best of our knowledge, despite nearly a decade of use, there are no published data on use among US combatant forces. We describe the use of QCCG by ground forces in Afghanistan and compare patients who received QCCG compared with the remaining population in the database who did not receive QCCG. METHODS: Data were obtained from the Prehospital Trauma Registry (PHTR). Joint Trauma System personnel linked patients to the Department of Defense Trauma Registry (DODTR) for outcome data, when available, upon reaching a fixed facility. RESULTS: Of the 705 patients within the entire PHTR, 118 (16.7%) had documented use of QCCG. Most patients (69.5%) were Afghan; all were male. Lower extremities accounted for the most common site of application (39.7%). Hemorrhage control occurred in 88.3% of encounters with hemorrhage control status documented. Patients receiving QCCG generally had higher rates of concomitant interventions. Of the 705 patients, 190 were linkable to the DODTR for outcome data; 25 of the 28 (89.3%) in the QCCG group were discharged alive compared with 153 of the 162 (94.4%) in the non-QCCG group (ρ = .300). CONCLUSION: QCCG appears to have common use on the battlefield as a concomitant intervention for obtaining hemorrhage control. Patients receiving QCCG had higher rates of gunshot wounds compared with the baseline population and were generally sicker. Hemorrhage control success was like that reported in other military and civilian settings.