ATTAC! Development of a Novel Advanced Trauma Team Application Course.

BACKGROUND: Although existing trauma nurse courses provide basic education, advanced courses with simulation experiences that enhance team leadership, communication, and workflows are lacking. OBJECTIVE: To design and implement the Advanced Trauma Team Application Course (ATTAC) to promote advanced skills for nurses and respiratory therapists with varied experience and skill levels. METHODS: Trauma nurses and respiratory therapists were selected to participate based on years of experience and the novice to expert nurse model. Two nurses from each level (excluding novice) participated, ensuring a diverse cohort to promote development and mentorship. The 11-module course was presented over 12 months. A five-question survey was employed at the end of each module to self-evaluate assessment skills, communication skills, and comfort for trauma patient care. Participants rated skills and comfort on a "0-10" scale, with 0 being "not at all" to 10 being "extensively." RESULTS: The pilot course was conducted from May 2019 to May 2020 at a Level II trauma center in the Northwest United States. Nurses reported ATTAC improved assessment skills, team communication, and comfort in caring for trauma patients (mean = 9.4; 95% CI [9.0, 9.8]; scale of 0-10). Participants indicated scenarios closely mimicked real-world situations; concept application commenced directly following each session. CONCLUSION: This novel approach to advanced trauma education promotes development of advanced skills that enable nurses to anticipate needs rather than being reactive, engage in critical thinking, and adapt to rapidly changing patient conditions.

Bringing Trauma Education to the Frontier: Overcoming Distance Barriers Utilizing a Virtual Platform.

BACKGROUND: The American College of Surgeons and state regulations mandate that trauma facilities offer trauma-specific continuing education throughout the region they serve. These requirements come with unique challenges when serving a rural and sparsely populated state. A novel approach to providing education was necessitated by the coronavirus disease 2019 pandemic, travel distance, and limited local specialists. OBJECTIVE: The purpose of this article is to describe the development of a virtual educational program used to improve access to quality trauma education and decrease barriers to obtaining continuing education hours inherent in the region. METHODS: This article describes the development and implementation of the Virtual Trauma Education program, which provided one free continuing education hour per month from October 2020 to October 2021. The program reached more than 2,000 viewers and established a method to provide continuous monthly educational offerings throughout the region. RESULTS: After the Virtual Trauma Education program implementation, monthly educational attendance increased from an average of 55 to 190. Viewership data indicate that trauma education across our region is far more robust, available, and accessible using a virtual platform. With more than 2,000 views from October 2020 to October 2021, Virtual Trauma Education offerings have spread far beyond regional borders, reaching 25 states and 169 communities. CONCLUSION: Virtual Trauma Education delivers easily accessible trauma education and is a program that has proven its sustainability.

Characterizing Utilization and Outcomes of Digoxin Immune Fab for Digoxin Toxicity.

BACKGROUND: Digoxin is a widely prescribed drug for congestive heart failure and atrial fibrillation. Digoxin has a narrow therapeutic index and toxicity can develop quite easily. Digoxin immune fab (DIF) is an effective treatment for toxicity, however there are limited studies characterizing its impact on clinical outcomes in real-world clinical practice. OBJECTIVES: The aim of this study was to identify factors and healthcare outcomes associated with digoxin immune fab (DIF) treatment in patients with confirmed/suspected digoxin toxicity. METHODS: An IRB-approved retrospective chart review of digoxin toxic patients (2011-2020) presenting at an academic healthcare system was conducted. Demographic and clinical data were collected. Patients were stratified by DIF treatment versus non-DIF treatment. DIF utilization patterns (appropriate, use when not indicated, or underutilized) were determined using pre-defined criteria. Severe digoxin toxicity was defined as having one or more of the following: mental status disturbances, antiarrhythmic therapy, acute renal impairment or dehydration, serum digoxin concentration (SDC) > 4 ng/mL, or serum K+ > 5 mEq/mL. Logistic multivariable regression analysis evaluated factors associated with DIF use. All statistical analyses were performed in R version 4.1. RESULTS: Data from 96 patients (non-DIF treated group = 49; DIF treated group = 47) were analyzed. DIF was used appropriately in 70 patients (73%), underutilized in 19 (20%), and administered to 7 (7%) patients when it was not indicated. Several clinical parameters differentiated the DIF from the non-DIF group (p < 0.05) including higher mean SDC (3.41 ± 1.63 vs 2.87 ± 1.17), higher mean potassium (5.33 ± 1.48 vs 4.55 ± 0.87), more toxicity severity (85% vs 49%), and more likely to require cardiac pacing (26% vs 4%). Digoxin toxicity resolved sooner in the DIF group (coefficient - 0.702, 95% CI - 1.137 to - 0.267) (p < 0.01) and they had shorter intensive care unit lengths of stay (12.4 ± 20.3 vs 24.4 ± 28.7 days; p = 0.018). The all-cause mortality rate in patients appropriately managed with DIF therapy versus those patients where DIF was underutilized was 11% and 21%, respectively. CONCLUSIONS: Based on our study population, DIF therapy appears to be beneficial in limiting duration of toxicity and intensive care unit lengths of stay in digoxin toxic patients. Although DIF was appropriately utilized in most cases, there was a relatively high proportion of cases in which DIF treatment was either underutilized or not indicated.

Further Evaluation of Factors That May Predict Biphasic Reactions in Emergency Department Anaphylaxis Patients.

BACKGROUND: Anaphylaxis is a systemic allergic reaction that is commonly treated in the emergency department (ED). The risk of a biphasic reaction is the rationale for observation. OBJECTIVE: To derive a prediction rule to stratify ED anaphylaxis patients at risk of a biphasic reaction. METHODS: We conducted an observational study of a cohort of patients presenting to an academic ED with signs and symptoms of anaphylaxis. We collected clinical data on biphasic reactions meeting National Institutes of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network diagnostic criteria. Logistic regression analyses were conducted to identify predictors of biphasic reactions, and odds ratios (ORs) with 95% CIs are reported. The predictive ability of the model features is summarized using the area under a receiver operating characteristics curve, or AUC. Internally validated AUCs were obtained using bootstrap resampling. RESULTS: We identified 872 anaphylaxis-related visits. Thirty-six (4.1%) visits resulted in biphasic reactions. Multivariable analysis showed that prior anaphylaxis (OR, 2.74; 95% CI, 1.33-5.63), unknown inciting trigger (OR, 2.40; 95% CI, 1.14-4.99), and first epinephrine administration more than 60 minutes after symptom onset (OR, 2.29; 95% CI, 1.09-4.79) were statistically significantly associated with biphasic reactions. The AUC of this model was 0.70 (95% CI, 0.61-0.79), with an internally validated AUC of 0.67 (95% CI, 0.59-0.76). The P value from the goodness-of-fit test was .91. CONCLUSIONS: Our study demonstrated a 4.1% rate of biphasic reactions and found that prior anaphylaxis, unknown inciting trigger, and delayed epinephrine use were risk factors for biphasic reactions.

Statistical analysis of the photodegradation of imazethapyr on the surface of extracted soybean (Glycine max) and corn (Zea mays) epicuticular waxes.

The photodegradation rate of the herbicide imazethapyr on epicuticular waxes of soybean and corn plants was investigated. Plant age, relative humidity, temperature, and number of light banks were varied during plant growth, analyzed statistically, and examined to determine if these factors had an effect on the photodegradation of imazethapyr. Through ultraviolet/visible (UV-Vis) and fluorescence spectroscopy, epicuticular wax characteristics of soybean and corn plants were explored, were used to confirm observations determined statistically, and explain correlations between the rate constants and the composition of the epicuticular waxes. Plant age, the interaction between plant age and light, and the quadratic dependence on temperature were all determined to have a significant impact on the photodegradation rate of imazethapyr on the epicuticular waxes of soybean plants. As for the photodegradation rate on the epicuticular waxes of corn plants, the number of light banks used during growing and temperature were significant factors.

Analysis of the Photodegradation of the Imidazolinone Herbicides Imazamox, Imazapic, Imazaquin, and Imazamethabenz-methyl in Aqueous Solution.

The photodegradation of the imidazolinone herbicides imazamox, imazapic, imazaquin, and imazamethabenz-methyl has been investigated in phosphate-buffered solutions and buffered solutions containing natural organic matter (NOM). The hydrolysis of imazamethabenz-methyl, the only imidazolinone herbicide susceptible to hydrolysis, was also examined. The rate of hydrolysis of imazamethabenz-methyl increased with increasing pH, with the para isomer degrading more rapidly than the meta isomer. All photodegradation rate constants increased with pH and plateaued after pH 5.2. All imidzaolinones degraded more quickly under 253.7 nm lamps as compared to degradation under 310 nm lamps. Imazamox and imazapic degraded more rapidly than imazaquin at all pH values and had higher quantum yields. In addition, imazamox and imazapic quantum yields increased as a function of pH, whereas imazaquin quantum yields showed no trend as a function of pH. Photodegradation reaction rate constants decreased as the concentration of NOM was increased in the solutions due to the effect of light screening. Formulas for the proposed photoproducts for imazamox, imazapic, and imazaquin in pH 7 phosphate buffers were identified, and structures for the photoproducts are proposed.