A Retrospective Nationwide Comparison of the iGel and King Laryngeal Tube Supraglottic Airways for Out-of-Hospital Cardiac Arrest Resuscitation.

INTRODUCTION: While various supraglottic airway devices are available for use during out-of-hospital cardiac arrest (OHCA) resuscitation, comparisons of patient outcomes by device are limited. In this study, we aimed to compare outcomes of OHCA patients who had airway management by emergency medical services (EMS) with the iGel or King-LT. METHODS: We used the 2018-2021 ESO Data Collaborative public use research datasets for this retrospective study. All patients with non-traumatic OHCA who had iGels or King-LTs inserted by EMS were included. Our primary outcome was survival to discharge to home, and secondary outcomes included first-pass success, return of spontaneous circulation (ROSC), and prehospital rearrest. We examined the association between airway device and each outcome using two-level mixed effects logistic regression with EMS agency as the random effect, adjusted for standard Utstein variables and failed intubation prior to supraglottic airway insertion. Average treatment effects were calculated through propensity score matching. RESULTS: A total of 286,192 OHCA patients were screened, resulting in 93,866 patients eligible for inclusion in this analysis. A total of 9,456 transported patients (59.8% iGel) had associated hospital disposition data. Use of the iGel was associated with greater survival to discharge to home (aOR:1.36 [1.06, 1.76]; ATE: 2.2%[+0.5, +3.8]; n = 7,576), first pass airway success (aOR:1.94 [1.79, 2.09]; n = 73,658), and ROSC (aOR:1.19 [1.13, 1.26]; n = 73,207) in comparison to airway management with the King-LT. iGel use was associated with lower odds of experiencing a rearrest (aOR:0.73 [0.67, 0.79]; n = 20,776). Among patients who received a supraglottic device as a primary airway, use of the iGel was not associated with significantly greater survival to discharge to home (aOR:1.26 [0.95, 1.68]). Among patients who received a supraglottic device as a rescue airway following failed intubation, use of the iGel was associated with greater odds of survival to discharge to home (aOR:2.16 [1.15, 4.04]). CONCLUSION: In this dataset, use of the iGel during adult OHCA resuscitation was associated overall with better outcomes compared to use of the King-LT. Subgroup analyses suggested that use of the iGel was associated with greater odds of achieving the primary outcome than the King-LT when used as a rescue device but not when used as the primary airway management device.

The Association of Combined Prehospital Hypotension and Hypoxia with Outcomes following Out-of-Hospital Cardiac Arrest Resuscitation.

BACKGROUND: Prehospital post-resuscitation hypotension and hypoxia have been associated with adverse outcomes in the context of out-of-hospital cardiac arrest (OHCA). We aimed to investigate the association between clinical outcomes and post-resuscitation hypoxia alone, hypotension alone, and combined hypoxia and hypotension. METHODS: We used the 2018-2021 ESO annual datasets to conduct this study. All EMS-treated non-traumatic OHCA patients who had a documented prehospital return of spontaneous circulation (ROSC) and two or more SpO2 readings and systolic blood pressures recorded were evaluated for inclusion. Patients who were less than 18 years of age, pregnant, had a do-not-resuscitate order or similar, achieved ROSC after bystander CPR only, or had an EMS-witnessed cardiac arrest were excluded. Multivariable logistic regression adjusted for standard Utstein factors and highest prehospital Glasgow Coma Scale (GCS) score was used to investigate the association between hypoxia, hypotension, and outcomes. RESULTS: We analyzed data for 17,943 patients, of whom 3,979 had hospital disposition data. Hypotension and hypoxia were not documented in 1,343 (33.8%) patients, 1,144 (28.8%) had only hypoxia documented, 507 (12.7%) had only hypotension documented, and 985 (24.8%) had both hypoxia and hypotension documented. In comparison to patients who did not have documented hypotension or hypoxia, patients who had documented hypoxia (aOR: 1.76 [1.38, 2.24]), documented hypotension (aOR: 3.00 [2.15, 4.18]), and documented hypoxia and hypotension combined (aOR: 4.87 [3.63, 6.53]) had significantly increased mortality. The relationship between mortality and vital sign abnormalities (hypoxia and hypotension > hypotension > hypoxia) was observed in every evaluated subgroup. CONCLUSIONS: In this large dataset, hypotension and hypoxia were independently associated with mortality both alone and in combination. Compared to patients without documented hypotension and hypoxia, patients with documented hypotension and hypoxia had nearly five-fold greater odds of mortality.

The Association of Prehospital End-Tidal Carbon Dioxide with Survival Following Out-of-Hospital Cardiac Arrest.

OBJECTIVE: End tidal carbon dioxide (ETCO2) is often used to assess ventilation and perfusion during cardiac arrest resuscitation. However, few data exist evaluating the relationship between ETCO2 values and mortality in the context of contemporary resuscitation practices. We aimed to explore the association between ETCO2 and mortality following out-of-hospital cardiac arrest (OHCA). METHODS: We used the 2018-2021 ESO annual datasets to query all non-traumatic OHCA patients with attempted resuscitation. Patients with documented DNR/POLST, EMS-witnessed arrest, ROSC after bystander CPR only, or < 2 documented ETCO2 values were excluded. The lowest and highest ETCO2 values recorded during the total prehospital interval, in addition to the pre- and post-ROSC intervals for resuscitated patients, were calculated. Multivariable logistic regression models adjusted for age, sex, initial rhythm, witnessed status, bystander CPR, etiology, OHCA location, sodium bicarbonate administration, number of milligrams of epinephrine administered, and response interval were used to evaluate the association between measures of ETCO2 and mortality. RESULTS: Hospital outcome data were available for 14,122 patients, and 2,209 (15.6%) were classified as surviving to discharge. Compared to patients with maximum prehospital ETCO2 values of 30-40 mmHg, odds of mortality were increased for patients with maximum prehospital ETCO2 values of <20 mmHg (aOR: 3.5 [2.1, 5,9]), 20-29 mmHg (aOR: 1.5 [1.1, 2.1]), and >50 mmHg (aOR: 1.5 [1.2, 1.8]). After 20 minutes of ETCO2 monitoring, <12% of patients had ETCO2 values <10 mmHg. This cutpoint was 96.7% specific and 6.9% sensitive for mortality. CONCLUSION: In this dataset, both high and low ETCO2 values were associated with increased mortality. Contemporary resuscitation practices may make low ETCO2 values uncommon, and field termination decision algorithms should not use ETCO2 values in isolation.

Biofilm Formation on Central Venous Catheters: A Pilot Study.

INTRODUCTION: Central line-associated bloodstream infection is a complication with serious consequences and biofilm development is thought to play a role. This study evaluated the impact of sterilization technique on central venous catheter (CVC) biofilm formation. MATERIALS AND METHODS: This pilot study was conducted in the surgical intensive care unit of a tertiary care facility. All CVCs were inserted with chlorhexidine preparation (CHG). CHG-only CVCs were compared to the use of CHG with chlorhexidine gluconate-impregnated sponge (CHGIS). After removal, a punch biopsy of the CVC was taken at the noted skin level. Scanning electron microscopy identified the stage of biofilm. Confocal laser scanning microscopy with SYPRO stain confirmed the presence of glycocalyx and a volumetric analysis was completed. RESULTS: Twenty four CVCs were collected. Indications for line placement were similar, with 42% placed for sepsis in the CHGIS group and 33% in the CHG group. There were no positive line cultures or bacteremia and 2/12 CHGIS patients had candidemia. CHGIS lines were in place for a mean of 91 h, compared to 60 h with CHG alone (P = 0.19). The interior of CVCs had lower stage biofilms than the exterior and lacked stage 4 biofilms. Stage 4 biofilms were present externally on 50% of CVCs (8/12 CHG and 4/12 CHGIS). Stage 3 biofilms were present on 7/12 CHG and 6/12 CHGIS interior samples. Volume analysis found an increase in biofilm and glycocalyx in CHGIS compared to CHG samples. CONCLUSIONS: This study identified biofilms on both surfaces of CVCs. No significant difference in biofilm formation was found based on a sterilization technique.

Falls in the Bathroom: A Mechanism of Injury for All Ages.

BACKGROUND: When ground-level falls occur in the bathroom, there is particular potential for morbidity and mortality given the high density of hard surfaces. Risk factors are not clearly defined by the existing literature. The objective of this study was to define the epidemiology, injury patterns, and outcomes after falls in the bathroom. MATERIALS AND METHODS: All patients presenting to LAC+USC Medical Center (01/2008-05/2015) after a fall in the bathroom (ICD-9 code E884.6) were included. Demographics, injury data, investigations, procedures, and outcomes were collected. RESULTS: Fifty-seven patients were included, with mean age 45 y (range 0-92). All ages were affected, with ages 41-60 y at highest risk. Common comorbidities included cardiovascular disease (n = 23, 40%), neuromuscular disorders (n = 13, 23%), and diabetes (n = 9, 16%). Ten patients (18%) were intoxicated. Home medications included antihypertensives (n = 18, 32%), antipsychotics (n = 9, 16%), and anticoagulants (n = 8, 14%). Common investigations included X-rays (n = 41, 72%) and CT scans of the head (n = 20, 35%). The most frequent injuries were contusion/laceration (n = 45, 79%), fracture (n = 12, 21%), and traumatic brain injury (n = 7, 12%). Most patients did not require hospital admission (n = 46, 81%), although 4 (7%) needed intensive care unit care and operative intervention (ORIF [n = 2, 4%] or craniectomy [n = 2, 4%]). Mortality was low (n = 1, 2%). Most patients were discharged home (n = 40, 70%). CONCLUSIONS: All ages, especially 41-60 y, are susceptible to falls in the bathroom. Despite the potential for serious injury, most do not require hospital admission. Risk factors include drugs/alcohol, cardiovascular disease, neuromuscular disorders, and diabetes. Efforts to minimize fall risk should be directed toward these individuals.

Old Age With a Traumatic Mechanism of Injury Should Be a Trauma Team Activation Criterion.

BACKGROUND: Age is not a standard trauma team activation (TTA) criteria recommended by the Committee on Trauma. However, there is concern that vital signs in elderly patients are often unreliable. In addition, elderly patients are at risk after moderate trauma. At our institution, age ≥ 70 years with traumatic mechanisms of injury has been a TTA criterion for more than 15 years. OBJECTIVE: Our aim was to determine whether age ≥70 years as a TTA criterion appropriately identifies patients in need of additional resources without significantly impacting overtriage rates. METHODS: We conducted a retrospective trauma registry study of TTAs for age ≥ 70 years from January 2012-December 2016. Demographics, injury data, Injury Severity Score (ISS), procedures, emergency department (ED) disposition, and hospital data were collected. Primary outcome was mortality, secondary outcomes were intensive care unit (ICU) and hospital lengths of stay. Patients were stratified into meeting standard criteria (TTA-S) or activated based on age alone (TTA-A). TTA patients with ISS > 15, ED intubation, ICU admission, immediate operating room or catheter-based intervention, and mortalities were appropriately triaged. RESULTS: During the study, there were 5436 total TTAs. Seven hundred and thirty-nine TTAs in patients aged ≥ 70 years, of which 198 (26.8%) were TTA-S and 541 (73.2%) were TTA-A. In the TTA-A group, 49 (9%) patients died, 149 (27.5%) had ISS > 15, 65 (12%) underwent immediate intervention, 72 (13%) had ED intubations, and 306 (56.6%) required admission to the ICU. The overtriage rate in the TTA-A group was 39.6%. CONCLUSIONS: Elderly patients with severe trauma patients often do not meet the standard TTA criteria, resulting in potentially dangerous undertriage. Addition of age (≥70 years) criterion for TTA reduces undertriage and does not result in excessive overtriage.

Beta-blockers and Traumatic Brain Injury: A Systematic Review, Meta-analysis, and Eastern Association for the Surgery of Trauma Guideline.

OBJECTIVE: To determine if beta-(ß)-blockers improve outcomes after acute traumatic brain injury (TBI). BACKGROUND: There have been no new inpatient pharmacologic therapies to improve TBI outcomes in a half-century. Treatment of TBI patients with ß-blockers offers a potentially beneficial approach. METHODS: Using MEDLINE, EMBASE, and CENTRAL databases, eligible articles for our systematic review and meta-analysis (PROSPERO CRD42016048547) included adult (age ≥ 16 years) blunt trauma patients admitted with TBI. The exposure of interest was ß-blocker administration initiated during the hospitalization. Outcomes were mortality, functional measures, quality of life, cardiopulmonary morbidity (e.g., hypotension, bradycardia, bronchospasm, and/or congestive heart failure). Data were analyzed using a random-effects model, and represented by pooled odds ratio (OR) with 95% confidence intervals (CI) and statistical heterogeneity (I). RESULTS: Data were extracted from 9 included studies encompassing 2005 unique TBI patients with ß-blocker treatment and 6240 unique controls. Exposure to ß-blockers after TBI was associated with a reduction of in-hospital mortality (pooled OR 0.39, 95% CI: 0.27-0.56; I = 65%, P < 0.00001). None of the included studies examined functional outcome or quality of life measures, and cardiopulmonary adverse events were rarely reported. No clear evidence of reporting bias was identified. CONCLUSIONS: In adults with acute TBI, observational studies reveal a significant mortality advantage with ß-blockers; however, quality of evidence is very low. We conditionally recommend the use of in-hospital ß-blockers. However, we recommend further high-quality trials to answer questions about the mechanisms of action, effectiveness on subgroups, dose-response, length of therapy, functional outcome, and quality of life after ß-blocker use for TBI.

A team approach to effectively discharge trauma patients.

BACKGROUND: Trauma patients represent a high-volume and high-acuity population. This makes discharge planning difficult. Discharged by noon is a metric shown to correlate with hospital throughput. Improvements in efficiency will be needed to improve resource utilization and increase discharge by noon rate. This study aimed to evaluate the impact of a standardized discharge team on length of stay and discharge by noon. MATERIALS AND METHODS: A university level I trauma center implemented a discharge team composed of a trauma attending and an advanced practice provider. This team is tasked with evaluating patients on the discharge list daily. This allowed patients ready for discharge to be evaluated and discharged before noon. A retrospective review was performed to analyze discharge by noon rates before and after implementation of the discharge team. RESULTS: A total of 3053 patients were discharged before the implementation of the discharge team and 3801 after. Discharges by noon increased from 25.5% to 51.2% in the post. For patients with an injury severity score >15, this same improvement was seen, 22.5% to 51.9%. Similar improvements were seen when controlling for final discharge disposition and primary payer status. CONCLUSIONS: By establishing a separate discharge team, large improvements can be seen in the discharge by noon rate. These improvements were maintained when controlling for injury severity score, final discharge disposition, and insurance status. Significant savings are possible in both charges to the patient and direct costs to the facility. The utilization of a discharge team should be considered at similar facilities.

Investigation and Validation of the TEG6s During Rotary Wing Aeromedical Flight.

INTRODUCTION: In order to improve rural and austere trauma care, hospital-based testing performed at the point of injury may shorten the time lapsed from injury to intervention. This study aimed to evaluate the use of the TEG6s® device in a rotary wing aircraft. Prior attempts suffered from limitation related to lack of vibration mitigation. METHODS: This was an investigator initiated, industry supported study. Haemonetics® provided a TEG6s® analyzer. The device underwent a standard validation. It was secured in place on the aircraft utilizing shipping foam for vibration mitigation. Donors provided 2 tubes of sample blood in one sitting. Paired studies were performed on the aircraft during level flight and in the hospital, using the Global Hemostasis with Lysis Cartridge. Both normal and presumed pathologic samples were tested in separate phases. Paired T-tests were performed. RESULTS: For normal donors, mean R (minutes) for laboratory compared to the aircraft was 6.2 vs. 7.2 (p = 0.025). Mean CRT MA (mm) was 59.3 and 55.9 ± 7.3 (p < 0.001) for lab and aircraft (p < 0.001). Among normal donors, R was within normal range for 17/18 laboratory and 18/18 aircraft tests (p > 0.99).During the testing of pathologic samples mean R time was 14.8 for lab samples and 12.6 minutes for aircraft (p = 0.02). Aircraft samples were classified as abnormal in 78% of samples, this was not significantly different than lab samples (p = 0.5). CONCLUSIONS: The use of the TEG6s® for inflight viscoelastic testing appears promising. While statistically significant differences are seen in some results, these values are not considered clinically significant. Classifying samples as normal or abnormal demonstrated a higher correlation. Future studies should focus on longer flight times to evaluate for LY30, takeoff and landing effects. Overall, this study suggests that TEG6s® can be utilized in a prehospital environment, and further study is warranted. LEVEL OF EVIDENCE: Level II, Diagnostic Tests or Criteria.

Chest X-Ray Remains a Vital Component Prior to Tube Thoracostomy.

INTRODUCTION: The identification and treatment of traumatic pneumothorax (PTX) has long been a focus of bedside imaging in the trauma patient. While the emergence of bedside ultrasound (BUS) provides an opportunity for earlier detection, the need for tube thoracostomy (TT) based on bedside imaging, including BUS and supine AP chest X-ray (CXR) is less established in the medical literature. METHODS: Retrospective data from 2017 to 2020 were collected of all adult trauma activations at a level 1 rural trauma facility. Every adult patient included in this study received a CXR and BUS (eFast) upon arrival. The need for TT was determined by the emergency medicine attending or the trauma surgery attending evaluating the patient. McNemar's chi-squared test and conditional logistic regression analysis were performed comparing BUS, CXR, and the combination of BUS and CXR findings for the need for TT. Subgroup analyses were performed comparing BUS, CXR, and the combination of BUS and CXR for the detection of PTX compared to CT scan. RESULTS: Of the 12,244 patients who underwent trauma activation during this timeframe, 602 were included in the study. 74.9% were males with an age range of 36-63 years. Of the 602 patients, 210 received TT. Positive PTX was recorded with BUS in 128 (21%) patients with 16 false negatives (FNs) and 98 false positives (FPs), 100 (17%) PTX were identified with CXR with 114 FNs and 4 FPs, and 72 (11.9%) were noted on both CXR and BUS with 140 FNs and 2 FPs. The odds ratio of TT placement was 22 times with positive BUS alone (P < .0001, 95% CI: 10.9-43.47), 47 times with positive CXR alone (P < .0001, 95% CI: 16.99-127.5), and 70 times with both positive CXR and BUS (P < .0001, 95% CI: 17.08-288.4). CONCLUSION: A positive finding of PTX on BUS combined with CXR is more indicative of the need for TT in the trauma patient when compared with BUS or CXR alone.

A retrospective, multi-agency 'target trial emulation' for the comparison of post-resuscitation epinephrine to norepinephrine.

INTRODUCTION: Epinephrine and norepinephrine are the two most commonly used prehospital vasopressors in the United States. Prior studies have suggested that use of a post-ROSC epinephrine infusion may be associated with increased rearrest and mortality in comparison to use of norepinephrine. We used target trial emulation methodology to compare the rates of rearrest and mortality between the groups of OHCA patients receiving these vasopressors in the prehospital setting. METHODS: Adult (18-80 years of age) non-traumatic OHCA patients in the 2018-2022 ESO Data Collaborative datasets with a documented post-ROSC norepinephrine or epinephrine infusion were included in this study. Logistic regression modeling was used to evaluate the association between vasopressor agent and outcome using two sets of covariables. The first set of covariables included standard Utstein factors, the dispatch to ROSC interval, the ROSC to vasopressor interval, and the follow-up interval. The second set added prehospital systolic blood pressure and SpO2 values. Kaplan-Meier time-to-event analysis was also conducted and the vasopressor groups were compared using a multivariable Cox regression model. RESULTS: Overall, 1,893 patients treated by 309 EMS agencies were eligible for analysis. 1,010 (53.4%) received an epinephrine infusion and 883 (46.7%) received a norepinephrine infusion as their initial vasopressor. Adjusted analyses did not discover an association between vasopressor agent and rearrest (aOR: 0.93 [0.72, 1.21]) or mortality (aOR: 1.00 [0.59, 1.69]). CONCLUSIONS: In this multi-agency target trial emulation, the use of a post-resuscitation epinephrine infusion was not associated with increased odds of rearrest in comparison to the use of a norepinephrine infusion.

Prevalence of Burn Pit Associated Symptoms Among US Veterans Who Utilize Non-Veteran's Affairs Private Healthcare.

OBJECTIVE: Do the 3.5 million US veterans, who primarily utilize private healthcare, have similar burn pit exposure and disease compared to the VA Burn Pit registry? METHODS: This is an online volunteer survey of Gulf War and Post-9/11 veterans. RESULTS: Burn pit exposure had significantly higher odds of extremity numbness, aching pain and burning, asthma, chronic obstructive pulmonary disease, interstitial lung disease, constrictive bronchiolitis, pleuritis, and pulmonary fibrosis. Chi-square did not reveal a difference in burn pit exposure and cancer diagnoses. CONCLUSIONS: These data demonstrate increased risk of neurological symptoms associated with burn pit exposure, which are not covered in the 2022 federal Promise to Address Comprehensive Toxics Act. Additional data will allow for the continued review and consideration for future medical benefits.

Reverse shock index multiplied by the motor component of the Glasgow Coma Scale predicts mortality and need for intervention in pediatric trauma patients.

BACKGROUND: Timely identification of high-risk pediatric trauma patients and appropriate resource mobilization may lead to improved outcomes. We hypothesized that reverse shock index times the motor component of the Glasgow Coma Scale (rSIM) would perform equivalently to reverse shock index times the total Glasgow Coma Scale (rSIG) in the prediction of mortality and the need for intervention following pediatric trauma. METHODS: The 2017-2020 National Trauma Data Bank datasets were used. We included all patients <16 years of age that had a documented prehospital and trauma bay systolic blood pressure, heart rate, and total GCS. We excluded all patients who arrived at the trauma center without vital signs and interfacility transport patients. Receiver operating characteristic (ROC) curves were used to model the performance of each metric as a classifier with respect to our primary and secondary outcomes, and the area under the ROC curve (AUC) was used for comparison. Our primary outcome was mortality prior to hospital discharge. Secondary outcomes included blood product administration or hemorrhage control intervention (surgery or angiography) < 4 hours following hospital arrival and ICU admission. RESULTS: After application of exclusion criteria, 77,996 patients were included in our analysis. rSIM and rSIG performed equivalently as predictors of mortality in the 1-2 (p = 0.05) and 3-5 (p = 0.28) year categories, but rSIM was statistically outperformed by rSIG in the 6-12 (AUC: 0.96 vs. 0.95, p = 0.04) and 13-16 (AUC: 0.96 vs. 0.95, p < 0.01) year-old age categories. rSIM and rSIG also performed similarly with respect to prediction of secondary outcomes. CONCLUSION: rSIG and rSIM are both outstanding predictors of mortality following pediatric trauma. Statistically significant differences in favor of rSIG were noted in some age groups. Because of the simplicity of calculation, rSIM may be a useful tool for pediatric trauma triage. LEVEL OF EVIDENCE: III, Diagnostic Tests or Criteria.

The association of clinical, treatment, and demographic characteristics with rearrest in a national dataset.

INTRODUCTION: Following initial resuscitation from out-of-hospital cardiac arrest, rearrest frequently occurs and has been associated with adverse outcomes. We aimed to identify clinical, treatment, and demographic characteristics associated with prehospital rearrest at the encounter and agency levels. METHODS: Adult non-traumatic cardiac arrest patients who achieved ROSC following EMS resuscitation in the 2018-2021 ESO annual datasets were included in this study. Patients were excluded if they had a documented DNR/POLST or achieved ROSC after bystander CPR only. Rearrest was defined as post-ROSC CPR initiation, administration of ≥ 1 milligram of adrenaline, defibrillation, or a documented non-perfusing rhythm on arrival at the receiving hospital. Multivariable logistic regression modeling was used to evaluate the association between rearrest and case characteristics. Linear regression modeling was used to evaluate the association between agency-level factors (ROSC rate, scene time, and scene termination rate), and rearrest rate. RESULTS: Among the 53,027 cases included, 16,116 (30.4%) experienced rearrest. Factors including longer response intervals, longer 'low-flow' intervals, unwitnessed OHCA, and a lack of bystander CPR were associated with rearrest. Among agencies that treated ≥ 30 patients with outcome data, the agency-level rate of rearrest was inversely associated with agency-level rate of survival to discharge to home (R2 = -0.393, p < 0.001). CONCLUSIONS: This multiagency retrospective study found that factors associated with increased ischaemic burden following OHCA were associated with rearrest. Agency-level rearrest frequency was inversely associated with agency-level survival to home. Interventions that decrease the burden of ischemia sustained by OHCA patients may decrease the rate of rearrest and increase survival.

Prehospital Tourniquet Use Should be a Trauma Team Activation Criterion.

PURPOSE: Prehospital tourniquet application is not a standard trauma team activation (TTA) criterion recommended by the ACS COT. Tourniquet use has seen a resurgence recently with associated risks and benefits of more liberal usage. Our institution added tourniquet application as TTA criterion in January 2019. This study aimed to evaluate the effect this would have on patient care and overtriage. METHODS: A prospective analysis was conducted for all TTA associated with tourniquets placed during 2019. An overtriage analysis was conducted utilizing a modified Cribari method as described in Resources for the Optimal Care of the Injured Patient, comparing patients that met standard TTA criteria (TTA-S), to those who met criteria due to tourniquet placement (TTA-T). RESULTS: During the study, there were 46 TTA with tourniquets. Mean prehospital tourniquet time was 80 minutes. Median ISS was 10, 8 (17%) had an ISS >15. Urgent operative intervention was needed in 74%, with 23% and 21% requiring orthopedic and vascular procedures, respectively. Tourniquets were correctly placed in 80% and clinically appropriate in 57%. Of these subjects, 25 (54%) were TTA-S and 21 TTA-T. Overtriage analysis was performed. Overtriage for TTA-T was 33.3%. Overtriage among TTA-S was 4%. CONCLUSION: Patients with prehospital tourniquets are frequently severely injured. The immediate presence of a trauma surgeon can have significant impacts in these cases. This is particularly important in a rural environment with long tourniquet times. Prehospital tourniquet application as a TTA criteria does not result in excessive overtriage.

Substance use in rural trauma patients admitted for motor vehicle injuries before and during the COVID-19 pandemic.

BACKGROUND: Urban trauma centers reported increased substance use among individuals injured in motor vehicle collisions (MVC) after the start of the COVID-19 pandemic. Little is known about individuals admitted to rural trauma centers during this time. This study's purpose was to describe substance use trends before and during the pandemic among individuals injured in MVC and treated at a rural Level-1 trauma center in West Virginia. METHODS: A cross-sectional analysis was performed using patients' medical records. The study population included individuals ≥ 18 years of age who received treatment for a motor vehicle-related injury between September 1, 2018, and September 30, 2021, and were tested for drugs and alcohol upon admittance. The pre-COVID-19 period was defined as September 1, 2018-March 15, 2020. The COVID-19 period was March 16, 2020-September 30, 2021. The primary dependent variable was the patients' drug test results. The primary independent variable was the time period. The data were analyzed using Chi-square tests, logistic regression, and proportional odds models. RESULTS: During this time, 1465 patients received treatment. On average, patients were 45 years ± 20 of age and male (57%). During COVID-19, 17% of patients tested positive for alcohol and 58% tested positive for non-alcohol drugs. After adjusting for patients' sex and age, the number of drugs that patients tested positive for was 31% higher during COVID-19 (aOR 1.31; 95% CI 1.08, 1.58). The proportion of patients testing positive for cannabinoids (p = 0.05), opioids (p = 0.001), and stimulants (p = 0.010) increased from pre-COVID-19 to COVID-19 periods. CONCLUSIONS: Drug and alcohol use increased among trauma patients admitted to a rural trauma center during COVID-19. Significant increases were seen in the number of drugs and for cannabinoids, opioids, and stimulants.

Opioid-related polysubstance use and its effect on mortality and health resource utilization among trauma patients.

BACKGROUND: Pre-injury opioid use is common, but the effects of opioid-related polysubstance use on mortality and health resources utilization (HRU) have not been investigated yet. The objective of this study was to investigate the effects of opioid-related polysubstance use on mortality and HRU among patients in trauma centres in the US. METHODS: We conducted a retrospective cross-sectional study using the US National Trauma Databank from the year 2017 to 2019. Patients (≥ 18 years of age) who tested positive for opioids were included. Patients were analysed based on the number of substances used (i.e., opioids only, two substances (opioids + 1 substance), and three or more than three substances (opioids + ≥ 2 substances)), and polysubstance by type (i.e., opioids only, opioids and alcohol, opioids and stimulants, opioids and benzodiazepine, and other combinations). Multivariate logistic regression was used to determine the association between polysubstance use, mortality and HRU (i.e., need for hospital admission, ICU, and mechanical ventilation). RESULTS: Both polysubstance by number and type analyses showed that opioid-related polysubstance use was not significantly associated with mortality compared to opioids only. The odds of hospital admission were higher among the opioids and benzodiazepines group (OR 1.15, 95% CI 1.06-1.24, p < 0.01). The need for ICU was magnified using benzodiazepines and stimulants with opioids (OR 1.44, 95% CI 1.27-1.63, p < 0.01) when compared to the opioids only group. CONCLUSION: Opioid-related pre-injury polysubstance use was associated with higher HRU in trauma patients. The evidence can be used by policymakers and practitioners to improve patient outcomes in trauma centers.

Cost Effective Virtual Intensive Care Unit Expanding Capabilities in Critical Access Hospitals.

BACKGROUND: Tele-consults provide access to specialized care for a specific question and single point in time. eICU models utilize remote monitoring and ordering but have significant financial burden. We developed a virtual intensive care unit (VICU) for daily input of an intensivist working with local physicians. The purpose was to expand the acute care ability of the critical access hospital (CAH). The study evaluates the impact on the CAH and system. METHODS: The CAH developed an ICU team, led by a hospitalist, who staffed the intensive care unit (ICU). The CAH ICU team rounds daily via a secure video link to provide care in consultation with intensivists based at a university, tertiary care center (TC). A retrospective analysis was conducted 6 months before and after implementation (4/2018-3/2019). Fisher's exact test was used to compare pre- and post-intervention with significance at P < .04. RESULTS: After VICU implementation, there were 265 initial daily and 35 follow-up consults. Monthly transfers to a higher level of care decreased from 63 to 57 (P = .03). Transfers to TC increased from 49.6 to 62.0% (P = .001). Critical access hospital average monthly census and average monthly inpatient days increased (69 to 130 (P < .0001) and 158 to 319 (P < .0001), respectively). Critical access hospital physicians report increased comfort to admit ICU and non-ICU patients due to the program. The total startup cost was $5180. CAH hired 11 providers. There were no unanticipated deaths. DISCUSSION: VICU implementation resulted in new CAH jobs. The CAH experienced increased inpatient census and revenues (ICU and non-ICU) while decreasing patients transferred out of the system.

A retrospective comparison of the King Laryngeal Tube and iGel supraglottic airway devices: A study for the CARES surveillance group.

OBJECTIVE: Supraglottic airway devices are increasingly used during the resuscitation of out-of-hospital cardiac arrest (OHCA) patients in the United States and worldwide. In this study, we aimed to compare the neurologic outcomes of OHCA patients managed with the King Laryngeal Tube (King LT) to the neurologic outcomes of patients managed with the iGel. METHODS: We used the Cardiac Arrest Registry to Enhance Survival (CARES) public use research dataset for our analysis. Non-traumatic OHCA cases with attempted EMS resuscitation enrolled from 2013-2021 were included. We used two-level mixed effects multivariable logistic regression analyses with treating EMS agency as the random effect to determine the association between supraglottic airway device and outcome. The primary outcome was survival with a Cerebral Performance Category (CPC) score of 1 or 2 at discharge. Secondary outcomes included survival to hospital admission and survival to hospital discharge. Age, sex, calendar year of OHCA, initial ECG rhythm, witnessed status (unwitnessed, bystander witnessed, 9-1-1 responder witnessed), bystander CPR, response interval, and OHCA location (private/home, public, institutional) were used as covariables. RESULTS: In comparison to use of the King LT, use of the iGel was associated with greater neurologically favorable survival (aOR: 1.45 [1.33, 1.58]). In addition, use of the iGel was associated with greater survival to hospital admission (1.07 [1.02, 1.12]) and survival to hospital discharge (1.35 [1.26, 1.46]). CONCLUSIONS: This study adds to the body of literature suggesting that use of the iGel during OHCA resuscitation is associated with better outcomes than use of the King LT.

Stay and play or load and go? The association of on-scene advanced life support interventions with return of spontaneous circulation following traumatic cardiac arrest.

INTRODUCTION: Traumatic out-of-hospital cardiac arrest (tOHCA) has a mortality rate over 95%. Many current protocols dictate rapid intra-arrest transport of these patients. We hypothesized that on-scene advanced life support (ALS) would increase the odds of arriving at the emergency department with ROSC (ROSC at ED) in comparison to performance of no ALS or ALS en route. METHODS: We utilized the 2018-2021 ESO Research Collaborative public use datasets for this study, which contain patient care records from ~2000 EMS agencies across the US. All OHCA patients with an etiology of "trauma" or "exsanguination" were screened (n=15,691). The time of advanced airway management, vascular access, and chest decompression was determined for each patient. Logistic regression modeling was used to evaluate the association of ALS intervention timing with ROSC at ED. RESULTS: 4942 patients met inclusion criteria. 14.6% of patients had ROSC at ED. In comparison to no vascular access, on-scene (aOR: 2.14 [1.31, 3.49]) but not en route vascular access was associated with increased odds of having ROSC at ED arrival. In comparison to no chest decompression, neither en route nor on-scene chest decompression were associated with ROSC at ED arrival. Similarly, in comparison to no advanced airway management, neither en route nor on-scene advanced airway management were associated with ROSC at ED arrival. The odds of ROSC at ED decreased by 3% (aOR: 0.97 [0.94, 0.99]) for every 1-minute increase in time to vascular access and decreased by 5% (aOR: 0.95 [0.94, 0.99]) for every 1-minute increase in time to epinephrine. CONCLUSION: On-scene ALS interventions were associated with increased ROSC at ED in our study. These data suggest that initiating ALS prior to rapid transport to definitive care in the setting of tOHCA may increase the number of patients with a palpable pulse at ED arrival.