Quality improvement in the golden hour for premature infants: a scoping review.

BACKGROUND AND OBJECTIVE: Evidence-based research has shown that golden hour quality improvement (QI) measures can improve the quality of care and reduce serious complications of premature infants. Herein, we sought to review golden hour QI studies to evaluate the impact on the outcome of preterm infants. METHODS: A comprehensive literature search was conducted in PubMed, Embase, Cochrane Library, and SinoMed databases from inception to April 03, 2023. Only studies describing QI interventions in the golden hour of preterm infants were included. Outcomes were summarized and qualitative synthesis was performed. RESULTS: Ten studies were eligible for inclusion. All studies were from single centers, of which nine were conducted in the USA and one in Israel. Seven were pre-post comparative studies and three were observational studies. Most included studies were of medium quality (80%). The most common primary outcome was admission temperatures and glucose. Five studies (n = 2308) reported improvements in the admission temperature and three studies (n = 2052) reported improvements in hypoglycemia after QI. Four studies (n = 907) showed that the incidence of bronchopulmonary dysplasia (BPD) was lower in preterm infants after QI: 106/408 (26.0%) vs. 122/424(29.5%) [OR = 0.68, 95% CI 0.48-0.97, p = 0.04]. CONCLUSIONS: Our study showed that the golden hour QI bundle can improve the short-term and long-term outcomes for extremely preterm infants. There was considerable heterogeneity and deficiencies in the included studies, and the variation in impact on outcomes suggests the need to use standardized and validated measures. Future studies are needed to develop locally appropriate, high-quality, and replicable QI projects.

The golden hour in shock management: do a lot, do it quickly.

Cardiogenic shock can be defined as a state of inadequate organ perfusion linked primarily to cardiac pump dysfunction. The two predominant causes of this condition are acute myocardial infarction and acutely decompensated heart failure (ADHF). In recent years, a significant increase in cases of cardiogenic shock from ADHF has been described. Recent evidence has defined that the factors with the greatest impact on the prognosis in this context are the early clinical assessment, the definition of the aetiology, the timely application of pharmacological therapies, or individualized mechanical supports for the circulation. Haemodynamic monitoring can help in the phenotyping of cardiogenic shock and therefore guide therapeutic choices, especially if implemented with the aid of advanced monitoring tools such as the Swan-Ganz catheter. Finally, the presence of a dedicated shock team in the 'hub' centres is fundamental, which facilitates the choice of the best therapeutic strategy on a case-by-case basis.

Prehospital time and mortality in pediatric trauma.

PURPOSE: The "Golden Hour" of transportation to a hospital has long been accepted as a central principal of trauma care. However, this has not been studied in pediatric populations. We assessed for non-linearity of the relationship between prehospital time and mortality in pediatric trauma patients, redefining the threshold at which reducing this time led to more favorable outcomes. METHODS: We performed an analysis of the 2017-2018 American College of Surgeons Trauma Quality Improvement Program, including trauma patients age < 18 years. We examined the association between prehospital time and odds of in-hospital mortality using linear, polynomial, and restricted cubic spline (RCS) models, ultimately selecting the non-linear RCS model as the best fit. RESULTS: 60,670 patients were included in the study, of whom 1525 died and 3074 experienced complications. Prolonged prehospital time was associated with lower mortality and fewer complications. Both models demonstrated that mortality risk was lowest at 45-60 min, after which time was no longer associated with reduced probability of mortality. CONCLUSIONS: The demonstration of a non-linear relationship between pre-hospital time and patient mortality is a novel finding. We highlight the need to improve prehospital treatment and access to pediatric trauma centers while aiming for hospital transportation within 45 min.

Association between Time to Emergent Surgery and Outcomes in Trauma Patients: A 10-Year Multicenter Study.

Background: Research on the impact of reduced time to emergent surgery in trauma patients has yielded inconsistent results. Therefore, this study investigated the relationship between waiting emergent surgery time (WEST) and outcomes in trauma patients. Methods: This retrospective, multicenter study used data from the Tzu Chi Hospital trauma database. The primary clinical outcomes were in-hospital mortality, intensive care unit (ICU) admission, and prolonged hospital length of stay (LOS) of ≥30 days. Results: A total of 15,164 patients were analyzed. The median WEST was 444 min, with an interquartile range (IQR) of 248-848 min for all patients. Patients who died in the hospital had a shorter median WEST than did those who survived (240 vs. 446 min, p < 0.001). Among the trauma patients with a WEST of <2 h, the median time was 79 min (IQR = 50-100 min). No significant difference in WEST was observed between the survival and mortality groups for patients with a WEST of <120 min (median WEST: 85 vs. 78 min, p < 0.001). Multivariable logistic regression analysis revealed that WEST was not associated with an increased risk of in-hospital mortality (adjusted odds ratio [aOR] = 1.05, 95% confidence interval [CI] = 0.17-6.35 for 30 min ≤ WEST < 60 min; aOR = 1.12, 95% CI = 0.22-5.70 for 60 min ≤ WEST < 90 min; and aOR = 0.60, 95% CI = 0.13-2.74 for WEST ≥ 90 min). Conclusions: Our findings do not support the "golden hour" concept because no association was identified between the time to definitive care and in-hospital mortality, ICU admission, and prolonged hospital stay of ≥30 days.

Prehospital Transport Time and Outcomes for Pediatric Trauma: A National Study.

INTRODUCTION: Historically, emergency medical services have aimed to deliver trauma patients to definitive care within the 60 min (min) "Golden Hour" to optimize survival. There is little evidence to support or refute this for pediatric trauma. The objective of this investigation was to describe national trends in prehospital transport time, in relation to the "Golden Hour," and pediatric trauma outcomes. METHODS: Retrospective cohort study of patients (<15 y old) receiving emergency medical services trauma transport between 2017 and 2019. Transport time (less than or greater than 60 min) was the exposure variable, and analyses were adjusted for injury severity score (ISS). Continuous variables with a normal distribution were compared by t-test was and skewed variables were compared by Mann-Whitney U-test. Categorical variables were compared by Chi-Square test. RESULTS: 54,489 patients met our criteria: 49,628 blunt and 4861 penetrating. Most patients (62.2%) had transport times less than 60 min: 30,389 (61.2%) blunt and 3479 (71.6%) penetrating. The overall mortality rate was 1.6%, 1.2% for blunt and 5.5% for penetrating. For blunt trauma, mortality was higher for transport times less than 60 min (1.5%). For penetrating trauma, mortality was lower for transport times less than 60 min (0.7%). Mean ISS was greater for blunt (7.9) compared to penetrating trauma (7.1), and greater for both trauma types with transport times less than 60 min. For both trauma types, mean length of stay was significantly longer for transport times greater than 60 min, when adjusting for ISS (P < 0.001). CONCLUSIONS: We did not find evidence that prehospital transport within the "Golden Hour" had a substantial association with survival, though it may be associated with length of stay. There are many factors contributing to trauma outcomes, so efforts should continue to expand access and pediatric readiness.

Pharmacological torpor prolongs rat survival in lethal normobaric hypoxia.

Resistance to hypoxia is one of the most prominent features of natural hibernation and is expected to be present in the pharmacological torpor (PT) that simulates hibernation. We studied resistance to lethal hypoxia (3.5% oxygen content) in rats under PT. To initiate PT, we used the previously developed pharmacological composition (PC) which, after a single intravenous injection, can induce a daily decrease in Tb by 7 °C-8 °C at the environmental temperature of 22 °C-23 °C. Half-survival (median) time of rats in lethal hypoxia was found to increase from 5 ± 0.8 min in anesthetized control rats to 150 ± 12 min in rats injected with PC, which is a 30-fold increase. Behavioral tests after PT and hypoxia, including the traveling distance, the number of rearing and grooming episodes, revealed that animal responses are significantly restored within a week. It is assumed that the discovered unprecedented resistance of artificially torpid rats to lethal hypoxia may open up broad prospects for the therapeutic use of PT for preconditioning to various damaging factors, treatment of diseases, and extend the so-called "golden hour" for lifesaving interventions.

Immediate skin-to-skin contact is feasible for very preterm infants but thermal control remains a challenge.

AIM: Current care of very preterm infants in an incubator implies separation of the mother-infant dyad. The aim of this study was to determine whether skin-to-skin contact (SSC) between parent and very preterm infant from birth and during the first postnatal hour is feasible. METHODS: Infants born in 2014-16 in Stockholm at gestational age 28 + 0-33 + 6 weeks were randomised to care provided in SSC with a parent or on a resuscitaire and later in an incubator or bed during the first postnatal hour. Infant body temperature was measured on admission to the neonatal unit and at one postnatal hour. Data on respiratory support and breastfeeding were prospectively collected. RESULTS: We studied 55 infants at 32 + 0 ± 1.4 weeks (range 28 + 2-33 + 6), with birthweight 1760 g ± 449 g (range 885-2822). 60% were boys. Mean body temperature in the SSC group was 0.3°C lower 1 hour after birth, 36.3°C ± 0.52 (range 34.4-37.2) vs 36.6°C ± 0.42 (range 36.0-37.4, P = .03). No differences between groups were seen in respiratory support or breastfeeding. CONCLUSION: Stabilisation of very preterm infants can be performed while in SSC with a parent, but caution needs to be paid to maintain normothermia.

Relative Mortality Analysis Of The "Golden Hour": A Comprehensive Acuity Stratification Approach To Address Disagreement In Current Literature.

OBJECTIVE: This study sought to address the disagreement in literature regarding the "golden hour" in trauma by using the Relative Mortality Analysis to overcome previous studies' limitations in accounting for acuity when evaluating the impact of prehospital time on mortality. METHODS: The previous studies that failed to support the "golden hour" suffered from limitations in their efforts to account for the confounding effects of patient acuity on the relationship between prehospital time and mortality in their trauma populations. The Relative Mortality Analysis was designed to directly address these limitations using a novel acuity stratification approach, based on patients' probability of survival (PoS), a comprehensive triage metric calculated using Trauma and Injury Severity Score methodology. For this analysis, the population selection and analysis methods of these previous studies were compared to the Relative Mortality Analysis on how they capture the relationship between prehospital time and mortality in the University of Virginia (UVA) Trauma Center population. RESULTS: The methods of the previous studies that failed to support the "golden hour" also failed to do so when applied to the UVA Trauma Center population. However, when applied to the same population, the Relative Mortality Analysis identified a subgroup, 9.9% (with a PoS 23%-91%), of the 5,063 patient population with significantly lower mortality when transported to the hospital within 1 hour, supporting the "golden hour." CONCLUSION: These results suggest that previous studies failed to support the "golden hour" not due to a lack of patients significantly impacted by prehospital time within their trauma populations, but instead due to limitations in their efforts to account for patient acuity. As a result, these studies inappropriately rejected the "golden hour," leading to the current disagreement in literature regarding the relationship between prehospital time and trauma patient mortality. The Relative Mortality Analysis was shown to overcome the limitations of these studies and demonstrated that the "golden hour" was significant for patients who were not low acuity (PoS >91%) or severely high acuity (PoS <23%).

Extending surgeon response times in tier 2 traumas does not adversely affect patient outcomes.

BACKGROUND: The presence of a trauma surgeon during patient resuscitations is required at most American College of Surgeons-verified trauma centers despite little evidence showing improved patient outcomes in the less-than-critically injured (Tier 2) trauma patients. This study was designed to identify the impact of extending required surgeon response times on outcomes in tier 2 trauma patients. METHODS: An American College of Surgeons-verified level 2 trauma center extended the maximum allowed surgeon response time for tier 2 activations from 60 min to 120 min on November 1, 2011. Surgeon response time and patient outcomes of the retrospective control group (January 1, 2008-October 31, 2011) were then compared with the prospective test group (November 1, 2011-December 31, 2014). Primary outcomes included mortality and hospital length of stay (HLOS). Secondary outcomes were emergency department length of stay, and time from ED arrival to CT scan. A subset analysis of all patients evaluated by a surgeon within 60 min of arrival versus those evaluated by a surgeon after 60 min was also performed. RESULTS: The control and test groups were composed of 757 and 792 patients, and their mean injury severity score was 9.0 and 6.0, respectively. Emergency department length of stay showed a statistically significant increase of 12 min, whereas HLOS was unchanged throughout the study. Mortality was not significantly different between the groups. Subset analysis revealed a median surgeon arrival time of 15 min in the <60-min group and 85 min in the >60-min group, whereas the injury severity score, HLOS, and mortality were not significantly different between these subsets. No correlation existed between these outcomes and surgeon arrival time. CONCLUSIONS: Doubling required surgeon response time in tier 2 trauma patients does not produce negative outcomes in this patient group. Mandatory surgeon response times in similar patient groups can be re-evaluated to allow for greater flexibility of a limited surgeon workforce while still providing safe care.

Golden hour management practices for infants <32 weeks gestational age in Canada.

OBJECTIVES: To determine 'Golden Hour' resuscitation and stabilization practices for infants <32 weeks gestational age in Canadian neonatal intensive care units (NICUs). METHODS: A survey was distributed to investigators of the Evidence-based Practice for Improving Quality study within the Canadian Neonatal Network in June 2014. The questionnaire was designed to obtain information on antenatal counselling, resuscitation environment, resuscitation and management practices, including respiratory and nutritional practices in the first hour of life. Responses to these categories were stratified into gestational age groupings: 230/7-236/7, 240/7-256/7, 260/7-276/7 and 280/7-316/7 weeks. Findings were summarized using descriptive statistics. RESULTS: Investigators from 14 of the 23 (61%) NICUs responded. Antenatal counselling was provided to >75% of expectant parents by Staff Neonatologists and Neonatal Fellows. Most NICUs (78%) provided resuscitation in a room adjacent to the high-risk delivery room or the NICU, while few (36%) resuscitated in the delivery room only. Twelve (86%) NICUs practiced delayed cord clamping while two practiced milking of the cord (14%) and 100% used thermal wrap for infants <28 weeks' gestation. All, with the exception of three NICUs used fraction of inspired oxygen ≤0.3 for initial resuscitation and 12/14 (86%) centres applied continuous positive airway pressure for spontaneously breathing infants <256/7 weeks' gestation. CONCLUSIONS: Participating Canadian NICUs reported that they generally follow Neonatal Resuscitation Program recommendations for stabilization of preterm infants; however, considerable variation exists in the application of evidence-based interventions. Our findings can be used to inform quality improvement initiatives to improve clinical outcomes for this vulnerable population.

The evaluation and management of heat injuries in an intensive care unit.

In this summer season (May-June 2014) most of the days temperature was more than 40°C. Our hospital is surrounded by huge slums area. The population which is low in socioeconomic status used to work in such high temperature for more than 8 h daily. Hence, they are very prone to develop heat injuries in the form of heat edema, heat tetany, heat syncope, heat cramps, miliaria rubra, heat exhaustion, and heatstroke. Again it is compulsory to upgrade our knowledge on this life threatening condition.

Road accidents on Indian National highways, ambulance reachability and transportation of injured to trauma facility: Survey-based introspection of golden hour.

Background: The transportation system plays a crucial role in the context of socioeconomic development, whereas the highway infrastructure acts as a base for the transportation system. In recent years, a rich impetus has been given to the development of road infrastructure by Indian governance. There is a need to introspect how well the prevailing highway infrastructure is equipped with emergency rescue management during road accidents. Lack of ambulance service and trauma facilities along the highways results in a steady loss of lives and injuries and increases people's exposure to risks. Objective: This study aims to determine the response time of ambulance reachability to the accident spot on Indian national highways associated with heavy commercial transportation. Also, determining the time to transport the injured to the nearest trauma facility is another factor included as an objective in this investigation. Methods: The study adopted survey-based research, whereby the variables in the questionnaire were designed to record and assess the time for an ambulance to reach the accident spot and, from there, to transport the injured to the trauma management facility on Indian highways. Two hundred twenty-five participants who were either victims/relatives of victims or those involved in the rescue of the injured have participated in the survey. The dates of the accident events were 2017 and 2022. Results: The survey resulted in the identification of two categories of highway accidents. The first category of accidents happened on the highways near city limits/dense settlements, and the second category occurred on the core highways. The percentage of accidents caused on the highways either adjacent to or passing through the city limits/dense settlements was reported to be higher than the accidents on the core highways. Ninety percent of the participants reported successful contact with the ambulance call/service centre, but only ~75% success rate exists for ambulances to reach the accident scene. On the core highways, the time taken for the ambulance to arrive at the accident scene is 25-35 minutes. The results from the survey ascertained that the patients were prioritised for treatment in the nearest hospitals (irrespective of having a trauma facility) at a distance of ~12-20 km, for which the time taken is ~15-25 minutes. Importantly, from the interviews, it is understood that in many cases, these hospitals have further referred to specialty hospitals located in nearby cities or trauma centres with greater facilities. Occasions exist where the injured were taken directly to hospitals 30-40 km from the accident spot, for which the time was more than 40 minutes. Conclusions: The results provide evidence that in either of the accident cases on the highways that are adjacent to/passing through the city limits or on the core highways, the total time for emergency care accessibility is nearly 60 minutes or greater; this implies that in the majority of cases, there is very meagre time left to provide emergency medical care to the needy and injured on the Indian highways to abide by the concept of golden hour. Plausible reforms backed by technology for enabling highways into 'emergency rescuable highways' are highly needed to guarantee a safer and more sustainable transportation system in India.

Acute Stroke in the Emergency Department: Profiles of Patients and Obstacles to Acute Intervention.

AIMS: To build a demographic profile of patients presenting to the emergency department (ED) with stroke, determine the proportion who successfully undergo thrombolysis and active interventions, and study their outcomes up to discharge or death in the hospital. METHODS AND MATERIALS: A sample size of 215 was calculated and patients were recruited consecutively on presentation to the ED after obtaining consent. Data was collected and they were followed up till the outcome. Data was tabulated and analyzed both as a whole and after further categorization into infarction, hemorrhagic stroke, and cerebral venous thrombosis (CVT). Mean and standard deviation were used for continuous variables and chi-square for categorical variables. RESULTS: A total of 216 patients were recruited, 156 (72%) male and 60 (28%) female. There were 135 (63%) ischemic strokes, 67 (31%) hemorrhagic, and 14 (6%) CVT. The mean age was 56.57 years (SD 14.22 years). A total of 12 patients (5.5%) presented within the 'golden hour' and 28 ischemic strokes presented within the thrombolysis window, of which nine were thrombolyzed. In total, 39 patients were intubated in the ED, of which 10 (7.41%) had ischemic strokes, 27 (40.3%) had hemorrhagic strokes and two (14.29%) had CVTs. There were 192 patients admitted to in-patient care, while 24 (11%) were discharged against medical advice. A further 14 patients were intubated during admission. Nine patients (13.43%) with hemorrhagic strokes underwent surgical decompression, five (7.46%) had an external ventricular drain (EVD) placed, six (8.96%) underwent aneurysm clipping, and two (2.99%) underwent aneurysm coiling. One case of CVT underwent surgical decompression. CONCLUSIONS: Stroke is a highly heterogeneous clinical entity with nuanced differences between the different subtypes. There appear to be significant obstacles regarding the early presentation of strokes to hospitals and the initiation of thrombolysis in the case of acute interventions.

Ultra-forward surgical support for special operations forces. Conception, development and certification of the French Special Operations Surgical Team (SOST) airborne capability.

When special operations forces (SOF) are in action, a surgical team (SOST) is usually ground deployed as close as possible to the combat area, to try and provide surgical support within the golden hour. The French SOST is composed of 6 people: 2 surgeons, 1 scrub nurse, 1 anaesthetist, 1 anesthetic nurse and 1 SOF paramedic. It can be deployed in 45 min under a tent or in a building. However, some tactical situations prevent the ground deployment. A solution is to deploy the SOST in a tactical unprepared aircraft hold, to make it possible to offer DCS, to treat non-compressible exsanguinating trauma, without any ground logistical footprint. This article describes the stages of the design, development and certification process of the airborne SOST capability. The authors report the modifications and adaptations of the equipment and the surgical paradigms which make it possible to solve the constraints linked to the aeronautical and combat environment. Study type/level of evidence Care management Level of Evidence IV.

Delivery room glucose to reduce the risk of admission hypoglycemia in preterm infants: a systematic literature review.

AIMS: In order to mitigate early hypoglycemia in preterm infants, some clinicians have recently explored interventions such as delivery room commencement of dextrose infusions or delivery room administration of buccal dextrose gel. This review aimed to systematically investigate the literature regarding the provision of delivery room (prior to admission) parenteral glucose as a method to reduce the risk of initial hypoglycemia (measured at the time of NICU admission blood testing) in preterm infants. MATERIALS AND METHODS: Using PRISMA guidelines a literature search (May 2022) was conducted using PubMed, Embase, Scopus, Cochrane Library, OpenGrey, and Prospero databases. The clinicaltrials.gov database was searched for possible completed/ongoing clinical trials. Studies that included moderate preterm (≤33+6 weeks) or younger birth gestations or very low birth weight (or smaller) infants, and that administered parenteral glucose in the delivery room were included. The literature was appraised via data extraction, narrative synthesis, and critical review of the study data. RESULTS: A total of five studies (published 2014-2022) were eligible for inclusion (three before-after "quasi-experimental" studies, one retrospective cohort study, and one case-control study). Most included studies used intravenous dextrose as the intervention. Individual study effects (odds ratios) favored the intervention in all included studies. It was felt that the low number of studies, the variability in study design, and the nonadjustment for confounding co-interventions (co-exposures) precluded a meta-analysis. Quality assessment of the studies revealed a spectrum of bias from low to high risk, however, most studies had moderate to high risk of bias, and their direction of bias favored the intervention. CONCLUSIONS: This extensive search and systematic appraisal of the literature indicates that there exists few studies (these are low grade and at moderate to high risk of bias) for the interventions of either intravenous or buccal dextrose given in the delivery room. It is not clear if these interventions impact on rates of early (NICU admission) hypoglycemia in these preterm infants. Obtaining intravenous access in the delivery room is not guaranteed and can be difficult in these small infants. Future research should consider various routes for commencing delivery room glucose in these preterm infants and should take the form of randomized controlled trials.

Association of Time to Definitive Hemostasis With Mortality in Patients With Solid Organ Injuries.

Introduction The Golden Hour is a term used in the trauma setting to refer to the first 60 minutes after injury. Traditionally, definitive care within this period was believed to dramatically increase a patient's survival. Though the period of 60 minutes is unlikely to represent a point of distinct inflection in survival, the effect of time to definitive care on survival remains incompletely understood. This study aims to measure the association of time to definitive hemostasis with mortality in patients with solid organ injuries as well as the effect of survival bias and a form of selection bias known as indication by severity on the relationship between time to treatment and survival. Methodology This is a retrospective cohort study using data obtained from the American College of Surgeons National Trauma Data Bank (NTDB) from the years 2017 through 2019 selecting patients treated for blunt liver, spleen, or kidney injury who required angioembolization or surgical hemostasis within six hours. A Cox proportional hazards regression was used to analyze time to death. The association of probability of death with time was examined with a multivariate logistic regression initially treating the relationship as linear and subsequently transforming time to hemostasis with restricted cubic splines to model a non-linear association with the outcome. To model survival and indication by severity bias, we created a computer-generated data set and used LOESS regressions to display curves of the simulated data. Results The multivariate Cox proportional hazards analysis shows a coefficient of negative 0.004 for minutes to hemostasis with an adjusted hazard ratio of 0.9959 showing the adjusted hazard of death slightly diminishes with each increasing minute to hemostasis. The likelihood ratio chi-square difference between the model with time to hemostasis included as a linear term versus the model with the restricted cubic spline transformation is 97.46 (p<0.0001) showing the model with restricted cubic splines is a better fit for the data. The computer-generated data simulating treatment of solid organ injury with no programmed bias displays an almost linear association of mortality with increased treatment delay. When indications by severity bias and survival bias are introduced, the risk of death decreases with time to hemostasis as in the real-world data. Conclusion Decreasing mortality with increasing delay to hemostasis in trauma patients with solid organ injury is likely due to confounding due to indication by severity and survival bias. After taking these biases into account, the association of delayed hemostasis with better survival is not likely due to the benefit of delay but rather the delay sorts patients by severity of injury with those more likely to die being treated first. These biases are extremely difficult to eliminate which limits the ability to measure the true effect of delay with retrospective data. The findings may however be of value as a predictive model to anticipate the acuity of a patient after an interval of unavoidable delay such as with a long transfer time.

Improving delivery room and admission efficiency and outcomes for infants < 32 weeks: ELGAN+ (Extremely Low Gestational Age Neonate).

OBJECTIVE: To evaluate the implementation of a systematic approach to improve the resuscitation, stabilization, and admission of infants < 32 weeks gestation and also to ascertain its effect on organization, efficiency, and clinical outcomes during hospitalization. METHODS: Retrospective study involving a multidisciplinary team with checklists, role assignment, equipment organization, step by step protocol, and real time documentation for the care of infants < 32 weeks gestation in the delivery room to the neonatal intensive care unit. Pre-data collection (cases) period was from Aug, 2015 to July, 2017, and post-data collection(controls) period was from Aug, 2017 to Aug, 2019. RESULTS: 337 infants were included (179 cases; 158 controls). Increase surfactant use in the resuscitation room (41% vs. 27%, p = 0.007) and reduction in median time to administer surfactant (34 minutes (range, 6-120) vs. 74 minutes (range, 7-120), p = 0.001) observed in control-group. There was a significant reduction in incidence of bronchopulmonary dysplasia (27% vs. 39%), intraventricular hemorrhage (11% vs. 17%), severe retinopathy of prematurity (3% vs. 9%), and necrotizing enterocolitis (4% vs. 6%), however these results were not statistically significant after controlling for severity of illness. CONCLUSIONS: A systematic approach to the care of infants < 32 weeks gestation significantly improved mortality rates and reduced rates of comorbidities.

Casualty evacuation in arctic and extreme cold environments: A paradigm shift for traumatic hypothermia management in tactical combat casualty care.

In Arctic or extreme cold environments of Alaska, trauma care is complicated by large expanses of geography and lack of forward-positioned resources. This paper presents four hypothetical vignettes highlighting austere cold medical priorities: (1) traumatic hypothermia management as part of Tactical Combat Casualty Care (TCCC) is clinically and tactically important and hypothermia needs to be reprioritized in the MARCH algorithm to MhARCH; (2) at present it is unknown which TCCC recommended medical equipment/supplies will function as designed in the extreme cold; (3) ensuring advanced resuscitative care measures are available serves as a temporal bridge until casualties can receive damage control resuscitation (DCR); and (4) current systems for managing traumatic hypothermia in TCCC and casualty evacuation (CASEVAC) are insufficient. In conclusion, numerous assessments recognise the DoD's current solutions for employing medical forces in Arctic operations are not optimally postured to save lives. There should be a joint standard for fielding an arctic supplement to current medical equipment sets. A new way of thinking in terms of an "ecosystem" approach of immediate casualty protection and movement in CASEVAC doctrine is needed to optimise these "Golden Minutes."

A novel animal model to study delayed resuscitation following traumatic hemorrhage.

A focus of combat casualty care research is to develop treatments for when full resuscitation after hemorrhage is delayed. However, few animal models exist to investigate such treatments. Given the kidney's susceptibility to ischemia, we determined how delayed resuscitation affects renal function in a model of traumatic shock. Rats were randomized into three groups: resuscitation after 1 h (ETH-1) or 2 h (ETH-2) of extremity trauma and hemorrhagic shock, and sham control. ETH was induced in anesthetized rats with muscle injury and fibula fracture, followed by pressure-controlled hemorrhage [mean arterial pressure (MAP) = 55 mmHg] for 1 or 2 h. Rats were then resuscitated with whole blood until MAP stabilized between 90 and 100 mmHg for 30 min. MAP, glomerular filtration rate (GFR), creatinine, blood gases, and fractional excretion of sodium (nFENa+) were measured for 3 days. Compared with control, ETH-1 and ETH-2 exhibited decreases in GFR and nFENa+, and increases in circulating lactate, creatinine, and blood urea nitrogen (BUN) before and within 30 min after resuscitation. The increases in creatinine, BUN, and potassium were greater in ETH-2 than in ETH-1, whereas lactate levels were similar between ETH-1 and ETH-2 before and after resuscitation. All measurements were normalized in ETH-1 within 2 days after resuscitation, with 22% mortality. However, ETH-2 exhibited a prolonged impairment of GFR, increased nFENa+, and a 66% mortality. Resuscitation 1 h after injury therefore preserves renal function, whereas further delay of resuscitation irreversibly impairs renal function and increases mortality. This animal model can be used to explore treatments for prolonged prehospital care following traumatic hemorrhage.NEW & NOTEWORTHY A focus of combat casualty care research is to develop treatment where full resuscitation after hemorrhage is delayed. However, animal models of combat-related hemorrhagic shock in which to determine physiological outcomes of such delays and explore potential treatment for golden hour extension are lacking. In this study, we filled this knowledge gap by establishing a traumatic shock model with reproducible development of AKI and shock-related complications determined by the time of resuscitation.

Influence of Spatial and Temporal Distance of the Hospital on Survival of Patients with Dangerous Injuries Sustained in Traffic Accidents.

Background: Effective care of any trauma is a priority in all health care systems. If a patient gets adequate treatment within "golden hour" from the injury the prognosis is better, but not as the only factor. The objective was focused on the influence of time and spacial distance of the hospital from the accident as determinant factors of survival, all in the aim Public Health System of Montenegro reorganisation for better accessibility for traumatized persons from 2011-2020. Methods: Among 334 subjects, three groups were defined according to the type of injury: bleeding, ashpyxiations, and cranio-cerebral injuries. In every group lethal and non-lethal subjects were analyzed. Results: Cut-off values are given by ROC curves following proximity and transportation time to hospital specific for injury sustained, as well as for nearest hospital, showed significant differences for proximity of any hospital for bleeding and asphyxiation injuries, and for proximity of any hospital and transportation time to the hospital specific for the sustained cranio-cerebral injury. Conclusion: Most of the seriously injured patients with bleeding or asphyxiation could be taken care of in any hospital while for cranio-cerebral injuries the specific hospital is crucial. How it is very often about, different organ systems are usualy injured in single patient, so the forming of easily available trauma centers net is the best solution for Montenegro, which is necessary for better survival rates.