A Letter to CMS from Paul Marik

Marik to CMS

EMCrit by Scott Weingart.

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A Letter to CMS from Paul Marik

Marik to CMS

EMCrit by Scott Weingart.

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CAMTS awarded prestigious ANSI accreditation

Commission on Accreditation of Medical Transport Systems ANDERSON, S.C. — CAMTS has received coveted accreditation as an American National Standards Institute (ANSI) Accredited Standards Developer. ANSI accreditation provides assurance that standards, goods, and services meet essential requirements throughout the global supply chain – engendering consumer trust and fostering competitiveness ...

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Every minute counts: Time to delivery of initial massive transfusion cooler and its impact on mortality.

BACKGROUND: ACS-TQIP Best Practices recommends initial massive transfusion (MT) cooler delivery within 15 minutes of protocol activation, with a goal of 10 minutes. The current study sought to examine the impact of timing of first cooler delivery on patient outcomes. METHODS: Patients predicted to receive MT at 12 level-1 trauma centers were randomized to two separate transfusion ratios as described in the PROPPR trial. ABC score or clinician gestalt prediction of MT was used to randomize patients and call for initial study cooler. In this planned sub-analysis, the time to MT protocol activation and time to delivery of the initial cooler were evaluated. The impact of these times on mortality and time to hemostasis were examined using both Wilcoxon rank sum and linear and logistic regression. RESULTS: Among 680 patients, the median time from patient arrival to MT protocol activation was 9 minutes with a median time from MT activation call to delivery of first cooler of 8 minutes. An increase in both time to MT activation and time to arrival of first cooler were associated with prolonged time to achieving hemostasis (coef 1.09, p=0.001 and coef. 1.16, p

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Paying it forward: Four-year analysis of the Eastern Association for the Surgery of Trauma (EAST) Mentoring Program.

Background: Mentorship programs in surgery are utilized to overcome barriers to clinical and academic productivity, research success, and work-life balance. We sought to determine if the Eastern Association for the Surgery of Trauma (EAST) Mentoring Program has met its goals of fostering academic and personal growth in young acute care surgeons. Methods: We conducted a systematic program evaluation of EAST Mentoring Program's first four years. Demographic information was collected from EAST records, mentorship program applications, and mentee-mentor career development plans. We reviewed the career development plans for thematic commonalities and results of a structured, online questionnaire distributed since program inception. A mixed methods approach was used to better understand the program goals from both mentee and mentor perspectives, as well as attitudes and barriers regarding the perceived success of this career development program. Results: During 2012-2015, 65 mentoring dyads were paired and 60 completed the program. Of 184 surveys distributed, 108 were returned (57% response rate). Respondents were evenly distributed between mentees and mentors (53 vs. 55, p=0.768). In participant surveys, mentoring relationships were viewed to focus on research (45%), 'sticky situations' [e.g., communication, work-life balance] (27%), education (18%), or administrative issues (10%). Mentees were more focused on research and education vs. mentors (74% vs. 50%, p=0.040). Mentees felt that goals were 'always' or 'usually' met vs. mentors (89% vs. 77% p= 0.096). Two barriers to successful mentorship included time and communication, with most pairs communicating by email. Most respondents (91%) planned to continue the relationship beyond the EAST Mentoring Program and recommended the experience to colleagues. Conclusions: Mentee satisfaction with the EAST Mentoring Program was high. Mentoring is a beneficial tool to promote success amongst EAST's young members, but differences exist between mentee and mentor perceptions. Revising communication expectations and time commitment to improve career development may help our young acute care surgeons. LEVEL OF EVIDENCE: V STUDY TYPE: Epidemiological (C) 2017 Lippincott Williams & Wilkins, Inc.

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Combination therapy of levetiracetam and gabapentin against nonconvulsive seizures induced by penetrating traumatic brain injury.

Background: Post-traumatic seizures are a medical problem affecting patients with traumatic brain injury. Yet effective treatment is lacking owing to the limitations of anti-epileptic drugs (AEDs) applicable to these patients. Method: In this study, we evaluated the dose-response efficacy of levetiracetam (12.5-100.0mg/kg) and gabapentin (1.25-25.0mg/kg) administered either individually or in pairs at fixed-dose ratios as a combination in mitigating post-traumatic nonconvulsive seizures induced by severe penetrating ballistic-like brain injury (PBBI) in rats. Seizures were detected by continuous EEG monitoring for 72h post-injury. Animals were treated twice per day for 3 days by intravenous injections. Results: Both levetiracetam (25-100mg/kg) and gabapentin (6.25-25mg/kg) significantly reduced PBBI-induced seizure frequency by 44-73% and 61-69%, and seizure duration by 45-64% and 70-78%, respectively. However the two drugs manifested different dose-response profiles. Levetiracetam attenuated seizure activity in a dose-dependent fashion, whereas the beneficial effects of gabapentin plateaued across the 3 highest doses tested. Combined administration of levetiracetam and gabapentin mirrored the more classic dose-response profile of levetiracetam monotherapy. However, no additional benefit was derived from the addition of gabapentin. Furthermore, isobolicgraphic analysis of the combination dose-response profile of levetiracetam and gabapentin failed to reach the expected level of additivity, suggesting an unlikelihood of favorable interactions between these two drugs against spontaneously occurring post-traumatic seizure activities at the particular set of dose ratios tested. Discussion: This study was the first attempt to apply isobolographic approach to studying AED combination therapy in the context of spontaneously occurring post-traumatic seizures. Despite the failure to achieve additivity from levetiracetam and gabapentin combination, it is important to recognize the objectivity of the isobolographic approach in the evaluation of AED combination therapy in the context of seizures directly associated with brain injuries. (C) 2017 Lippincott Williams & Wilkins, Inc.

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Platelet and coagulation function before and after burn and smoke inhalation injury in sheep.

Background: Smoke inhalation and burn injury remain a major source of morbidity and mortality. There is known dysregulation of hemostasis in burn patients, but either hyper- or hypocoagulation states are reported. Sheep are an established animal model for studying burn pathology and provide robust data on hemostatic function at baseline and after injury. Methods: Following an IACUC-approved protocol, 15 sheep were anesthetized and subjected to a 40% full thickness burn with smoke inhalation. Blood was sampled at baseline, 1 day post injury (early effects) and days 2, 3 and 4 (late effects) after injury. Assays at each time point assessed: hemostatic function by thromboelastography; platelet counts and function by flow cytometry and aggregometry; coagulation protein levels; and free hemoglobin. Data was analyzed by the Wilcoxon paired test (non-parametric) with significance set at

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A Retrievable RESCUE Stent Graft and Radiofrequency Positioning for Rapid Control of Noncompressible Hemorrhage.

Background: Non-compressible hemorrhage of the torso remains a challenging surgical dilemma. Stent graft repair requires endovascular expertise, imaging, and inventory that are not available within the critical window of massive hemorrhage. We developed a retrievable stent graft for rapid hemorrhage. We further investigated a radiofrequency (RF) positioning approach as a possible alternative to the logistics of fluoroscopy. Methods: A retrievable stent graft was constructed with a novel "petal and stem" design from nitinol and covered with a sleeve of electrospun polyurethane. The stent graft was tested using an in vitro model of simulated hemorrhage. Next the stent graft was examined in vivo using a porcine model of noncompressible hemorrhage. The stent was examined for hemorrhage control in a porcine model of either aortic or caval injury. An RF reader was assembled from an Arduino processor while RF tags were affixed to the ends of the stent graft. Detection accuracy of a handheld RF wand for an RF tag was quantified both in vitro and through tissue. Results: The retrievable RESCUEstent graft was deployed within minutes and rapidly controlled traumatic hemorrhage angiographically in both aortic injury (n=3) and caval injury (n=2). Stent grafts were easily recaptured in both models in under 15 seconds. The LED light of a handheld RF detector illuminated when positioned directly over an RF tag. The RF detection approach revealed positioning accuracy to within 1 cm of the intended target, despite tissue interference. Conclusions: This study demonstrates the rapid deployment and retrieval of a RESCUE stent graft as well as the ability to tamponade injuries of the aorta and cava. In addition, this study demonstrate the feasibility of radiofrequency tags to guide stent placement through tissue. More rigorous models are needed to define the effectiveness of this approach in the setting of vascular injury and shock. (C) 2017 Lippincott Williams & Wilkins, Inc.

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Acute Procedural Interventions Following Pediatric Blunt Abdominal Trauma: A Prospective Multicenter Evaluation.

Background: Pediatric intraabdominal injuries (IAI) from blunt abdominal trauma (BAT) rarely require emergent intervention. For those children undergoing procedural intervention, our aim was to understand the timing and indications for operation and angiographic embolization. Methods: We prospectively enrolled children

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Leukocyte Filtration Lesion Impairs Functional Coagulation in Banked Whole Blood.

Background: Whole blood (WB) transfusion is a promising alternative to component therapy in hemostatic resuscitation. Use of banked WB requires filtration of white blood cells (leukoreduction) and an established shelf life during which WB retains coagulant capacities. The goal of this study was to define the time course of coagulation stability in leukoreduced compared to unfiltered WB under standard refrigeration conditions. Methods: Twelve WB units were donated by healthy volunteers after routine screening. Five units underwent standard leukocyte filtration and five did not. Two units were aliquoted into filtered and unfiltered samples, with platelets added to each sample on Day 14. Units were stored at 4[degrees]C and sampled on days 0, 1, 2, 3, 4, 5, 6, 7, 10, 14, 21, 28, and 35 for immediate thromboelastogram (TEG) analysis, and centrifuged and stored at -80[degrees]C for later Calibrated Automated Thrombogram (CAT) and coagulation factor assays. Results: K-dependent factors and fibrinogen were low normal, decreased slightly over 35 days, and were similar between unfiltered and filtered units. Labile factors were better preserved in filtered units, although unfiltered units did not show impaired coagulation over 35 days. Filtered blood had delayed clot initiation on days 0, 1, and 2 as measured by TEG R (p

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Incompatible Type A Plasma Transfusion in Patients Requiring Massive Transfusion Protocol: Outcomes of an EAST Multicenter Study.

With a relative shortage of type AB plasma, many centers have converted to type A plasma for resuscitation of patients whose blood type is unknown. The goal of this study is to determine outcomes for trauma patients who received incompatible plasma transfusions as part of a massive transfusion protocol (MTP). Methods: As part of an EAST multi-institutional trial, registry and blood bank data were collected from 8 trauma centers for trauma patients (age >= 15 years) receiving emergency release plasma transfusions as part of MTPs from January 2012 - August 2016. Incompatible type A plasma was defined as transfusion to patient blood type B or AB. Results: Of the 1536 patients identified, 92% received compatible plasma transfusions and 8% received incompatible type A plasma. Patient characteristics were similar except for greater penetrating injuries (48% vs. 36%, p=.01) in the incompatible group. In the incompatible group, patients were transfused more plasma units at 4 hours (median 9 vs. 5, p<.001 and overall for stay vs. p=".03)." no hemolytic transfusion reactions were reported. two trali events reported in the compatible group. between incompatible groups there was difference rates of ards thromboembolic sepsis or acute renal failure mortality at hours days discharge similar groups. multivariate regression demonstrated that iss older age more rbc independently associated with death predictors morbidity. not an independent determinant conclusion: type a plasma to blood b ab appears relatedly transfusions as part mtp. level evidence: iii study type: therapeutic lippincott williams wilkins inc.>

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Inefficacy of standard vital signs for predicting mortality and the need for prehospital life-saving interventions in blunt trauma patients transported via helicopter: A repeated call for new measures.

Objective: The aim of this study was to investigate the efficacy of traditional vital signs for predicting mortality and the need for prehospital life-saving interventions (LSIs) in blunt trauma patients requiring helicopter transport to a Level I trauma center. Our hypothesis was that standard vital signs are not sufficient for identifying or determining treatment for those patients most at risk. Methods: This study involved prehospital trauma patients suffering from blunt trauma (motor vehicle/cycle collision) and transported from the point of injury via helicopter. Means and standard deviations for vital signs and Glasgow coma scale scores (GCS) were obtained for non-LSI versus LSI and survivor versus non-survivor patient groups and then compared using Wilcoxon statistical tests. Variables with statistically significant differences between patient groups were then used to develop multivariate logistic regression models for predicting mortality and/or the need for prehospital LSIs. Receiver-operating characteristic (ROC) curves were also obtained in order to compare these models. Results: A final cohort of 195 patients was included in the analysis. 30 (15%) patients received a total of 39 prehospital LSIs. Of these, 12 (40%) died. In total, 33 (17%) patients died. Of these, 21 (74%) did not receive prehospital LSIs. Model variables were field heart rate, lowest systolic blood pressure, shock index, pulse pressure, and GCS components. Using vital signs alone, ROC curves demonstrated poor prediction of LSI needs, mortality, and non-survivors who did not receive LSIs (area under the curve [AUC], AUCs: 0.72, 0.65, and 0.61). When using both vital signs and GCS, ROC curves still demonstrated poor prediction of non-survivors overall and non-survivors who did not receive LSIs (AUCs: 0.67, 0.74). Conclusion: The major implication of this study was that traditional vital signs cannot identify or determine treatment for many prehospital blunt trauma patients who are at great risk. This study reiterated the need for new measures in order to improve blunt trauma triage and prehospital care. Level of Evidence: Level IV Therapeutic/Care Management. Funding: U.S. Army Combat Casualty Care Research Program (C) 2017 Lippincott Williams & Wilkins, Inc.

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Aeromedical evacuation-relevant hypobaria worsens axonal and neurologic injury in rats following underbody blast-induced hyperacceleration.

BACKGROUND: Occupants of military vehicles targeted by explosive devices often suffer from traumatic brain injury (TBI) and are typically transported by the aeromedical evacuation (AE) system to a military medical center within a few days. This study tested the hypothesis that exposure of rats to AE-relevant hypobaria worsens cerebral axonal injury and neurologic impairment caused by underbody blasts. METHODS: Anesthetized adult male rats were secured within cylinders attached to a metal plate, simulating the hull of an armored vehicle. An explosive located under the plate was detonated, resulting in a peak vertical acceleration force on the plate and occupant rats of 100G. Rats remained under normobaria or were exposed to hypobaria equal to 8,000 ft in an altitude chamber for 6 h, starting at 6 h to 6 d after blast. At 7 d, rats were tested for vestibulomotor function using the balance beam walking task and euthanized by perfusion. The brains were then analyzed for axonal fiber injury. RESULTS: The number of internal capsule silver-stained axonal fibers was greater in animals exposed to 100G blast than in shams. Animals exposed to hypobaria starting at 6 h to 6 d after blast exhibited more silver-stained fibers than those not exposed to hypobaria. Rats exposed to 100% oxygen (O2) during hypobaria at 24 h post-blast displayed greater silver staining and more balance beam foot-faults, in comparison with rats exposed to hypobaria under 21% O2. CONCLUSIONS: Exposure of rats to blast-induced acceleration of 100G increases cerebral axonal injury, which is significantly exacerbated by exposure to hypobaria as early as 6 h and as late as 6 d post-blast. Rats exposed to underbody blasts and then to hypobaria under 100% O2 exhibit increased axonal damage and impaired motor function compared to those subjected to blast and hypobaria under 21% O2. These findings raise concern about the effects of AE-related hypobaria on TBI victims, the timing of AE following TBI, and whether these effects can be mitigated by supplemental oxygen. (C) 2017 Lippincott Williams & Wilkins, Inc.

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Acute and sub-acute microRNA dysregulation is associated with cytokine responses in the rodent model of penetrating ballistic-like brain injury.

Background: MicroRNAs (miRNAs) are small stable RNAs that regulate translational degradation or repression of genes involved in brain trauma-mediated inflammation. More recently, miRNAs have emerged as potential novel TBI biomarkers. The aim of this study was to determine if a select set of miRNAs (miR-21, Let-7i, miR-124a, miR-146a, miR-107) that were previously associated with TBI models and clinical studies would be dysregulated and correlated to inflammatory cytokine abundance in the rat penetrating ballistic-like brain injury (PBBI) model. Methods: Adult male Sprague-Dawley rats received a unilateral frontal 10% PBBI, which produces a temporary cavity. Sham animals received a craniotomy only. Ipsilateral brain tissue and serum were collected 4h-7d post-injury. Quantitation of miR-21, Let-7i, miR-124a, miR-146a, or miR-107 levels was conducted using Taqman PCR assays normalized to the endogenous reference, U6 snRNA. Brain tissue derived from matching cohorts was used to determine 1L-1beta and IL6 levels by ELISA. Results: Brain tissue Let-7i and miR-21 increased at 4h and 1d, while miR-124a and miR-107 were enhanced only 1d post-injury. MiR-146a displayed a bi-phasic response and increased 1d and 7d, whereas elevation of miR-21 was sustained 1-7d after PBBI. Pathway analysis indicated that miRNAs were linked to inflammatory proteins, IL-6 and IL-1beta. Confirmation by ELISA indicated that both cytokines were increased and peaked at 1d, but fell at 3-7d after PBBI indicating an inverse relationship with miRNA abundance. Serum Let-7i, alone, was differentially abundant 7d after PBBI. Conclusions: Brain tissue derived miRNAs linked to increased cytokine levels demonstrates a plausible therapeutic target of TBI induced-inflammation. Suppression of serum derived Let-7i may have utility as a biomarker of subacute injury progression or therapeutic responses. (C) 2017 Lippincott Williams & Wilkins, Inc.

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Differential inflammatory networks distinguish responses to bone marrow-derived vs. adipose-derived mesenchymal stem cell therapies in vascularized composite allotransplantation.

Background: Vascularized composite allotransplantation (VCA) is aimed at enabling injured individuals to return to their previous lifestyles. Unfortunately, VCA induces an immune/inflammatory response, which mandates lifelong, systemic immunosuppression, with attendant detrimental effects. Mesenchymal stem cells (MSC) - both adipose-derived (AD-MSC) and bone marrow-derived (BM-MSC) - can reprogram inflammation and have been suggested as an alternative to immunosuppression, but their mechanism of action is as yet not fully elucidated. We sought to gain insights into these mechanisms using a systems biology approach. Methods: PKH26 (red) dye-labeled AD-MSC or BM-MSC were administered intravenously to Lewis rat recipients of mismatched Brown Norway hindlimb transplants. Short course tacrolimus (FK-506) monotherapy was withdrawn at POD 21. Sera were collected at 4, 6, 18 weeks, assayed for 29 inflammatory/immune mediators, and the resultant data were analyzed using Dynamic Network Analysis (DyNA), Dynamic Bayesian Network (DyBN) inference, and Principal Component Analysis (PCA). Results: DyNA network complexity decreased with time in AD-MSC rats, but increased in BM-MSC rats. DyBN and PCA suggested mostly different central nodes and principal characteristics, respectively, in AD-MSC vs. BM-MSC rats. Conclusions: AD-MSC and BM-MSC are associated with both overlapping and distinct dynamic networks and principal characteristics of inflammatory/immune mediators in VCA grafts with short course tacrolimus induction therapy. The decreasing inflammatory complexity of dynamic networks in the presence of AD-MSC supports the previously suggested role for regulatory T cells induced by AD-MSC. The finding of some overlapping and some distinct central nodes and principal characteristics suggests the role of key mediators in the response to VCA in general, as well as potentially differential roles for other mediators ascribed to the actions of the different MSC populations. Thus, combined in vivo/in silico strategies may yield novel means of optimizing MSC therapy for VCA. (C) 2017 Lippincott Williams & Wilkins, Inc.

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Field and en route REBOA: A feasible military reality?.

BACKGROUND: Severe non-compressible torso hemorrhage (NCTH) remains a leading cause of potentially preventable death in modern military conflicts. Resuscitative endovascular occlusion of the aorta (REBOA) has demonstrated potential as an effective adjunct to the treatment of NCTH in the civilian early hospital and even pre-hospital settings - but the application of this technology for military pre-hospital use has not been well described. We aimed to assess the feasibility of both field and en route pre-hospital REBOA in the military exercise setting simulating a modern armed conflict. METHODS: Two adult male Sus Scrofa underwent simulated junctional combat injury in the context of a planned military training exercise. Both underwent zone I REBOA in conjunction with standard tactical combat casualty care (TCCC) interventions - one during point of injury care and the other during en route flight care. Animals were sequentially evacuated to two separate Forward Surgical Teams (FSTs) by rotary wing platform where the balloon position was confirmed by chest X-Ray. Animals then underwent different damage control thoracic and abdominal procedures before euthanasia. RESULTS: The first swine underwent immediate successful REBOA at the point of injury 7:30 minutes after the injury. It required 6 minutes total from initiation of procedure to effective aortic occlusion. Total occlusion time was 60 minutes. In the second animal, the REBOA placement procedure was initiated immediately after take-off (17:40 minutes after the injury). Although the movements and vibration of flight were not significant impediments, we only succeeded to put a 6-Fr sheath into a femoral artery during the 14 minutes flight due to lighting and visualization challenges. After the sheath had been upsized in the FST, the REBOA catheter was primarily placed in zone I followed by its replacement to zone III. Both animals survived to study completion and the termination of training. No complications were observed in either animal. CONCLUSION: Our study demonstrates the potential feasibility of REBOA for use during tactical field and en route (flight) care of combat casualties. Further study is needed to determine the optimal training and utilization protocols required to facilitate the effective incorporation of REBOA into military pre-hospital care capabilities. (C) 2017 Lippincott Williams & Wilkins, Inc.

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KAOLIN-BASED HEMOSTATIC DRESSING IMPROVES HEMORRHAGE CONTROL FROM A PENETRATING IVC INJURY IN COAGULOPATHIC SWINE.

Background: Retrohepatic Vena Cava (RIVC) Injuries are often lethal due to challenges in obtaining hemorrhage control. We hypothesized that packing with a new kaolin-based hemostatic dressing (Z-Medica, Control + (R)) would improve hemorrhage control from a penetrating RIVC injury compared to packing with standard laparotomy sponges alone. Methods: Twelve male Yorkshire pigs received a 25% exchange transfusion of blood for refrigerated normal saline to induce a hypothermic coagulopathy. A laparotomy was performed and a standardized 1.5cm injury to the RIVC was created which was followed by temporary abdominal closure and a period of uncontrolled hemorrhage. When the mean arterial pressure reached 70% of baseline, demonstrating hemorrhagic shock, the abdomen was re-entered and the injury was treated with perihepatic packing using standard laparotomy sponges (L; n=6) or a new kaolin-based hemostatic dressing (K; n=6). Animals were then resuscitated for 6 hours with crystalloid solution. The two groups were compared using the Wilcoxon rank sum test and Fisher exact test. A p0.05). In the laparotomy sponge group, 5 of 6 pigs survived the entire study period while all 6 pigs treated with kaolin-based D2 hemostatic dressings survived. Importantly, there was significantly less blood loss after packing with the new hemostatic kaolin-based dressing compared to packing with laparotomy sponge (651mL+/-180 vs 1073mL+/-342; p

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The Effect of REBOA, Partial Aortic Occlusion and Aggressive Blood Transfusion on Traumatic Brain Injury in a Swine Polytrauma Model.

Objectives: Despite clinical reports of poor outcomes, the degree to which REBOA exacerbates traumatic brain injury (TBI) is not known. We hypothesized that combined effects of increased proximal mean arterial pressure (pMAP), carotid blood flow (Qcarotid), and intracranial pressure (ICP) from REBOA would lead to TBI progression compared to partial aortic occlusion (PAO) or no intervention. Methods: 21 swine underwent a standardized TBI via computer Controlled cortical impact followed by 25% total blood volume rapid hemorrhage. After 30 minutes of hypotension, animals were randomized to 60 minutes of continued hypotension (Control), REBOA, or PAO. REBOA and PAO animals were then weaned from occlusion. All animals were resuscitated with shed blood via a rapid blood infuser. Physiologic parameters were recorded continuously and brain computed tomography obtained at specified intervals. Results: There were no differences in baseline physiology or during the initial 30 minutes of hypotension. During the 60-minute intervention period, REBOA resulted in higher maximal pMAP (REBOA 105.3+/-8.8; PAO 92.7+/-9.2; Control 48.9+/-7.7, p=0.02) and higher Qcarotid (REBOA 673.1+/-57.9; PAO 464.2+/-53.0; Control 170.3+/-29.4, p

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Optimization of brain metabolism using metabolic-targeted therapeutic hypothermia can reduce mortality from traumatic brain injury.

Background: Therapeutic hypothermia is widely used to treat traumatic brain injuries (TBIs). However, determining the best hypothermia therapy strategy remains a challenge. We hypothesized that reducing the metabolic rate, rather than reaching a fixed body temperature, would be an appropriate target as optimizing metabolic conditions especially the brain metabolic environment may enhance neurologic protection. A pilot single-blind randomized controlled trial was designed to test this hypothesis, and a nested metabolomics study was conducted to explore the mechanics thereof. Methods: Severe TBI patients (Glasgow Coma Scale, 3-8) were randomly divided into the metabolic-targeted hypothermia treatment (MTHT) group: 50-60% rest metabolic ratio as the hypothermia therapy target, and the body temperature-targeted hypothermia treatment (BTHT) control group: hypothermia therapy target of 32-35[degrees]C body temperature. Brain and circulatory metabolic pool blood samples were collected at baseline and on days 1, 3, and 7 during the hypothermia treatment, which were selected randomly from a subgroup of MTHT and BTHT groups. The primary outcome was mortality. Using 1HNMR technology, we tracked and located the disturbances of metabolic networks. Results: 88 severe TBI patients were recruited and analyzed from December 2013 to December 2014, 44 each were assigned in the MTHT and BTHT groups (median age, 42 years; 69.32% males; mean Glasgow Coma Scale 6.17+/-1.02). The mortality was significantly lower in the MTHT than the BTHT group (15.91% vs. 34.09%, p=0.049). From these, 8 cases of MTHT and 6 cases from BTHT group were enrolled for metabolomics analysis, which showed a significant difference between the brain and circulatory metabolic patterns in MTHT group on day 7 based on the model parameters and scores plots. Finally, metabolites representing potential neuroprotective monitoring parameters for hypothermia treatment were identified through 1HNMR metabolomics. Conclusions: MTHT can significantly reduce the mortality of severe TBI patients. Metabolomics research showed that this strategy could effectively improve brain metabolism, suggesting that reducing the metabolic rate to 50-60% should be set as the hypothermia therapy target. Study Type: Randomized Controlled Trial Level of Evidence: I (C) 2017 Lippincott Williams & Wilkins, Inc.

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Platelet transfusions reduce fibrinolysis but do not restore platelet function during trauma hemorrhage.

Introduction: Platelets play a critical role in hemostasis with aberrant function implicated in trauma-induced coagulopathy. However, the impact of massive transfusion protocols on platelet function during trauma hemorrhage is unknown. The aim of this study was to characterize the effects of platelet transfusion on platelet aggregation and fibrinolytic markers during hemostatic resuscitation. Methods: Trauma patients enrolled into the prospective Activation of Coagulation and Inflammation in Trauma (ACIT) study between January 2008 and November 2015 who received at least four units of packed red blood cells (PRBCs) were included. Blood was drawn in the emergency department within 2 hours of injury and at intervals after every 4 units of PRBCs transfused. Platelet aggregation was assessed in whole blood with multiple electrode aggregometry. Plasma proteins were quantified by enzyme-linked immunosorbent assay. Results: Of 161 patients who received 4 or more PRBCs as part of their initial resuscitation, 44 received 8-11 units and 28 received 12 units or more. At each time point during bleeding, platelet aggregation was similar in patients who had received a platelet transfusion compared to those who had only received other blood products (p>0.05 for all time points). Platelet transfusion during the 4PRBC intervals was associated with a decrease in maximum lysis on rotational thromboelastometry (start of interval 6% [2-12] vs end of interval 2% [0-5], p=0.001), an increase in plasminogen activator inhibitor-1 (PAI-1; start of interval: 35.9 +/- 14.9 vs end of interval: 66.7 +/- 22.0, p=0.007) and a decrease in tissue plasminogen activator (start of interval: 26.2 +/- 10.5 vs end of interval: 19.0 +/- 5.1, p=0.04). No statistically significant changes in these parameters occurred in intervals which did not contain platelets. Conclusion: Current hemostatic resuscitation strategies do not appear to restore platelet aggregation during active hemorrhage. However, stored platelets may attenuate fibrinolysis by providing an additional source of PAI-1. Further investigation into the effects of early platelet transfusion on platelet function, haemostatic and clinical outcomes during bleeding are warranted. Level of Evidence: Prospective observational study, level III (C) 2017 Lippincott Williams & Wilkins, Inc.

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Multicenter retrospective study of non-compressible torso hemorrhage: anatomic locations of bleeding and comparison of endovascular versus open approach.

Objective: Rational development of technology for rapid control of non-compressible torso hemorrhage (NCTH) requires detailed understanding of what is bleeding. Our objectives were to describe the anatomic location of truncal bleeding in patients presenting with NCTH and compare endovascular (ENDO) versus open (OPEN) management. Methods: Retrospective study of adult trauma patients with NCTH admitted to 4 urban level 1 trauma centers in the Houston and San Antonio metropolitan areas in 2008-2012. Inclusion criteria: named axial torso vessel disruption, AIS chest or abdomen >=3 with shock (base excess

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The impact of patient weight on burn resuscitation.

Introduction: Optimal fluid resuscitation of burn patients with burns greater than 20% total body surface area (TBSA) is critical to prevent burn shock during the initial 24 to 48 hours post burn. Currently, most resuscitation formulas incorporate the patient's weight when estimating 24-hour fluid requirements. The objective of this study was to determine the impact of weight on fluid resuscitation requirements and outcomes during the initial 24 hours after admission. Methods: We performed a retrospective review of patients admitted to our burn intensive care unit from December 2007 to April 2013, resuscitated with a computerized decision support system. We classified patients into body mass index (BMI) categories of underweight (BMI:30.0). We also calculated the percent difference from ideal body weight (IBW) and compared 24-hour fluid volumes received. Results: Patients with missing weight and/or height values were excluded from the study, resulting in a final cohort of 161 patients for analysis. Mean TBSA was 42+/-20% with a full thickness burn of 18+/-23%. Mean age, weight, and height were 47+/-19 years, 83+/-19 kg, and 68+/-4 in, respectively. IBW for this cohort was 68+/-11 kg with a BMI of 28+/-6. Univariate analysis showed significant differences in 24-hour resuscitation volumes (ml/kg) between normal and obese patients (p

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Surgical management of pancreatic necrosis: A practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Pancreatic or peripancreatic tissue necrosis confers substantial morbidity and mortality. New modalities have created a wide variation in approaches and timing of interventions for necrotizing pancreatitis. As acute care surgery evolves, its practitioners are increasingly being called upon to manage these complex patients. METHODS: A systematic review of the MEDLINE database using PubMed was performed. English language articles regarding pancreatic necrosis from 1980 to 2014 were included. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included operative timing, the use of adjuvant therapy and the type of operative repair. GRADE methodology was applied to question development, outcome prioritization, evidence quality assessments, and recommendation creation. RESULTS: 88 studies were included and underwent full review. Increasing the time to surgical intervention had an improved outcome in each of the time periods evaluated (72 hours, 12-14, 30 days) with a significant improvement in outcomes if surgery was delayed 30 days. The use of percutaneous and endoscopic procedures were shown to postpone surgery and potentially be definitive. The use of minimally invasive surgery for debridement and drainage has been shown to be safe and associated with reduce morbidity and mortality. CONCLUSION: Acute Care Surgeons are uniquely trained to care for those with pancreatic necrosis due their training in critical care and complex surgery with ongoing shock. In adult patients with pancreatic necrosis, we recommend that pancreatic necrosectomy be delayed until at least day 12. During the first 30 days of symptoms with infected necrotic collections, we conditionally recommend surgical debridement only if the patients fail to improve after radiologic or endoscopic drainage. Finally, even with documented infected necrosis, we recommend that patients undergo a step-up approach to surgical intervention as the preferred surgical approach. Level of Evidence: Systematic review/guideline, level III (C) 2017 Lippincott Williams & Wilkins, Inc.

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How to treat sudden cardiac arrest, opioid overdose

An unconscious patient, with absent or ineffective breathing, may be in sudden cardiac arrest or have overdosed on an opioid; here's how to assess and treat the patient

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Emergency Physicians Are Able to Detect Right Ventricular Dilation with Good Agreement Compared to Cardiology

Abstract

Objective

Focused cardiac ultrasound (FOCUS) is a useful tool in evaluating patients presenting to the emergency department (ED) with acute dyspnea. Prior work has shown that right ventricular (RV) dilation is associated with repeat hospitalizations and shorter life expectancy. Traditionally, RV assessment has been evaluated by cardiologist-interpreted comprehensive echocardiography. The primary goal of this study was to determine the interrater reliability between emergency physicians (EPs) and a cardiologist for determining RV dilation on FOCUS performed on ED patients with acute dyspnea.

Methods

Prospective, observational study at two urban academic EDs; patients were enrolled if they had acute dyspnea and a computed tomographic pulmonary angiogram without acute disease. All patients had an EP-performed FOCUS to assess for RV dilation. RV dilation was defined as an RV to left ventricular ratio greater than 1. FOCUS interpretations were compared to a blinded cardiologist FOCUS interpretation using agreement and kappa statistics.

Results

Of 84 FOCUS examinations performed on 83 patients, 17% had RV dilation. Agreement and kappa, for EP-performed FOCUS for RV dilation were 89% (95% confidence interval [CI] 80-95%) and 0.68 (95% CI 0.48-0.88), respectively.

Conclusions

EP sonographers are able to detect RV dilation with good agreement when compared to cardiology. These results support the wider use of EP-performed FOCUS to evaluate for RV dilation in dyspneic ED patients.

This article is protected by copyright. All rights reserved.

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Application period open to join National EMS Advisory Council

NHTSA's Office of EMS WASHINGTON — Applications are now being accepted to join the 25-member National EMS Advisory Council. Every two years, the Secretary of Transportation appoints members to the council, which is authorized to advise and consult with the Department of Transportation and the Federal Interagency Committee on EMS on matters related to EMS. Each NEMSAC member represents a specific ...

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Paramedics teach high school students hands-only CPR

Gov. Jerry Brown signed legislation requiring California high schools to teach hands-only CPR training by 2018-2019

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Does n-terminal pro-brain type natriuretic peptide predict cardiac complications after hip fracture surgery?

Clinical Orthopedics and Related Research

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US Senate panel votes in favor of Gottlieb to run FDA

Reuters Health News

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Practicality of exchanging transparent 3D CT for radiography for pelvic fractures

Clinical Imaging

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South Korea fines Novartis $49M over kickbacks, suspends insurance payment

Reuters Health News

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Role of acute negative pressure wound therapy over primarily closed surgical incisions in acetabular fracture ORIF: A prospective randomized trial

Injury

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Alcohol use and risk of intracerebral hemorrhage

Neurology®

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Effect of an automated tracking registry on the rate of tracking failure in incidental pulmonary nodules

Journal of the American College of Radiology

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Comparing mortality between fibrinolysis and primary percutaneous coronary intervention in patients with acute myocardial infarction: A systematic review and meta-analysis of 27 randomized-controlled trials including 11429 patients

Coronary Artery Disease

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A comparison of treatment setting for elderly patients with hip fracture, is the geriatric ward superior to conventional orthopedic hospitalization?

Injury

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Acute myocardial infarction and antiphospholipid antibody syndrome: A systematic review

Coronary Artery Disease

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Improved survival of patients with extensive burns: Trends in patient characteristics and mortality among burn patients in a tertiary care burn facility, 2004-2013

Journal of Burn Care & Research

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Extracorporeal membrane oxygenation (ECMO) as a treatment strategy for severe acute respiratory distress syndrome (ARDS) in the low tidal volume era: A systematic review

Journal of Critical Care

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Roche Q1 sales boosted by 2 new cancer medicines

AP

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Treatment of type B pelvic fracture using anterior subcutaneous internal fixator with triple pedicle screws: A new surgical technique

Archives of Orthopaedic and Trauma Surgery

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The effects of trauma on perinatal depression: Examining trajectories of depression from pregnancy through 24 months postpartum in an at-risk population

Journal of Affective Disorders

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Serum albumin, a good indicator of persistent organ failure in acute pancreatitis

BMC Gastroenterology

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Estimation of the severity of breathlessness in the emergency department: A dyspnea score

BMC Emergency Medicine

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Accuracy of circulating histones in predicting persistent organ failure and mortality in patients with acute pancreatitis

British Journal of Surgery

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Association of femoral head and acetabular fractures on computerized tomography: Correlation with the Judet-Letournel classification

Emergency Radiology

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An unbalanced inflammatory cytokine response is not associated with mortality following sepsis: a prospective cohort study

Critical Care Medicine

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10 worst reasons for joining EMS

A few weeks ago, with nothing to do until the lights came back on after a storm-related power outage, I made a list of all the EMS positions I’ve had since becoming a paramedic in 1995. OK, maybe that wasn’t the most constructive pastime with tornadoes in the area, but let me show you how that mindless exercise turned out to be worthwhile. Not counting writing, speaking and consulting, which ...

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Automated chest compression devices: 10 things you need to know to save lives

Knowing how and when to use these devices could save lives

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A novel approach to study medical decision-making in the clinical setting: The “own-point-of-view” perspective

Abstract

Background

Making diagnostic and therapeutic decisions is a critical activity among physicians. It relies on the ability of physicians to use cognitive processes and specific knowledge in the context of a clinical reasoning. This ability is a core competency in physicians, especially in the field of emergency medicine where the rate of diagnostic errors is high. Studies that explore medical decision-making in an authentic setting are increasing significantly. They are based on the use of qualitative methods which are applied at two separate times: 1) a video recording of the subject's actual activity in an authentic setting and 2) an interview with the subject, supported by the video recording. Traditionally, activity is recorded from an “external perspective”, i.e. a camera is positioned in the room in which the consultation takes place. This approach has many limits, both technical and with respect to the validity of the data collected.

Objectives

The article aims at 1) describing how decision-making is currently being studied, especially from a qualitative standpoint, and the reasons why new methods are needed, and 2) reporting how we used an original, innovative approach to study decision-making in the field of emergency medicine and findings from these studies to guide further the use of this method. The method consists in recording the subject's activity from his own-point-of-view, by fixing a microcamera on his temple or the branch of his glasses. An interview is then held on the basis of this recording, so that the subject being interviewed can relive the situation, in order to facilitate the explanation of his reasoning with respect to his decisions and actions.

Results and conclusions

We describe how this method has been used successfully in investigating medical decision-making in emergency medicine. We provide details on how to use it optimally, taking into account the constraints associated with the practice of emergency medicine, and the benefits in the study of clinical reasoning. The ‘own-point-of-view’ video technique is a promising method to study clinical decision-making in emergency medicine. It is a powerful tool to stimulate recall and help physicians make their reasoning explicit, thanks to a greater psychological immersion.

This article is protected by copyright. All rights reserved.

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Koenig and Schultz's Disaster Medicine: Comprehensive Principles and Practices, 2nd Edition

Abstract

Disaster medicine has emerged as a critical discipline within emergency medicine in recent years. Mass casualty incidents and large{\hyphen}scale environmental events have shed light on the need for more formalized disaster medicine curricula and structured response plans. Koenig and Schultz’ Disaster Medicine: Comprehensive Principles and Practices, 2^ndedition lives up to its title yet again and delivers in{\hyphen}depth, evidence{\hyphen}based recommendations for healthcare providers, educators, and administrators working in disaster management.

This article is protected by copyright. All rights reserved.

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iSimulate Launches REALITi at IMSH 2017

iSimulate was interviewed about their recently launched REALITi: a cost effective mobile video recording simulation to go along with their realistic healthcare simulation patient vital sign monitors. You can find out more about REALITi at their official website.

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iSimulate Launches REALITi at IMSH 2017

iSimulate was interviewed about their recently launched REALITi: a cost effective mobile video recording simulation to go along with their realistic healthcare simulation patient vital sign monitors. You can find out more about REALITi at their official website.

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iSimulate Launches REALITi at IMSH 2017

iSimulate was interviewed about their recently launched REALITi: a cost effective mobile video recording simulation to go along with their realistic healthcare simulation patient vital sign monitors. You can find out more about REALITi at their official website.

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iSimulate exhibits REALITi patient simulator ahead of May 4 launch

ORLANDO, Fla. — REALITi, the latest training tool by iSimulate, was most recently exhibited at IMSH 2017 ahead of its May 4 launch. iSimulate founder Anthony Lewis held guided demonstration's of REALITi and conducted a video interview discussing the new platform. Click the image to watch a video demonstration of REALITi hosted by iSimulate founder Anthony Lewis. REALITi is a new, all-inclusive ...

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BLACKHAWK! launches new fall apparel line at 2017 National Rifle Association Annual Meetings and Exhibits

OVERLAND PARK, Kan. BLACKHAWK!'s commitment to quality, reliability and durability are reflected in every item it produces. That includes BLACKHAWK!'s new fall apparel line for 2017, which launches at the NRA Show on April 27 to 30. The line features eight new clothing styles, including shirts, pants and jackets--- everything needed to feel comfortable and confident while performing at the highest ...

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iSimulate Launches REALITi at IMSH 2017

iSimulate was interviewed about their recently launched REALITi: a cost effective mobile video recording simulation to go along with their realistic healthcare simulation patient vital sign monitors. You can find out more about REALITi at their official website.

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Firefighter-paramedic invents device to protect stethoscope

The StethoSafe is a patent pending case that protects the head of a stethoscope

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Firemedic invents device that saves EMS agencies money and improves patient care

The StethoSafe is a patent pending case that greatly extends the life of a stethoscope by quickly and easily protecting the head of a stethoscope.

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2 EMS providers injured after ambulance strikes tree

Firefighters extricated a paramedic who was trapped in the ambulance

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Woman with Cri-du-chat syndrome made honorary paramedic for the day

By EMS1 Staff KISSIMMEE, Fla. — A battalion chief's daughter was made an honorary paramedic Monday. Osceola News-Gazette reported that Holly Thomason, daughter of Battalion Chief Cleve Thomason, recently expressed her desire to become a paramedic. Thomason served the Kissimmee Fire Department for 31 years before retiring five years ago. Holly was born with Cri-du-chat syndrome, which causes ...

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Powered stretchers 'back-saver' for paramedics lifting obese patients

Ambulances are equipped with power-assisted stretchers that lower and lift; the stretchers can handle up to 700 pounds

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Motocross-associated head and spine injuries in adult patients evaluated in an emergency department

The American Journal of Emergency Medicine

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California lawmakers consider dumping health insurers

AP

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Meningitis outbreak in Nigeria has killed 813 people: Minister

Reuters Health News

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Incidence of diabetic ketoacidosis among patients with type 2 diabetes mellitus treated with SGLT2 inhibitors and other antihyperglycemic agents

Diabetes Research and Clinical Practice

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Scientists develop fluid-filled artificial womb to help premature babies

Reuters Health News

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A cohort study of immediate implant exchange during acute infection in the setting of breast reconstruction

Journal of Plastic, Reconstructive & Aesthetic Surgery

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Benefits of statin therapy in patients with acute myocardial infarction with serum low-density lipoprotein cholesterol ? 50 mg/dl

The American Journal of Cardiology

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Fireworks type, injury pattern, and permanent impairment following severe fireworks-related injuries

The American Journal of Emergency Medicine

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The underutilisation of dual antiplatelet therapy in acute coronary syndrome

International Journal of Cardiology

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Survey: Nearly 60 percent of seniors use cell phones while driving

UC San Diego Health System News

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Association of time from arrest to percutaneous coronary intervention with survival outcomes after out-of-hospital cardiac arrest

Resuscitation

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Medication burden in patients with acute coronary syndromes

The American Journal of Managed Care

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Effectiveness of nutritional supplementation on sarcopenia and recovery in hip fracture patients: A multi-centre randomized trial

Maturitas

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Development of reliable and validated tools to evaluate technical resuscitation skills in a pediatric simulation setting: resuscitation and emergency simulation checklist for assessment in pediatrics

The Journal of Pediatrics

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Accuracy of current diagnostic criteria for acute bacterial infection in older adults in the emergency department

Journal of the American Geriatrics Society

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Senior general surgery residents can be trained to perform focused assessment with sonography for trauma patients accurately

Surgery Today

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Endoscopic variceal ligation combined with argon plasma coagulation versus ligation alone for the secondary prophylaxis of variceal bleeding: A systematic review and meta-analysis

European Journal of Gastroenterology & Hepatology

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Frequent attenders of the emergency department: patients perspectives and impact of a multidisciplinary case management intervention in reducing attendance

Academic Emergency Medicine

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The impact of carperitide usage on the cost of hospitalization and outcome in patients with acute heart failure: High value care vs. low value care campaign in Japan

International Journal of Cardiology

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In-hospital airway management training for non-anesthesiologist EMS physicians: A descriptive quality control study

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

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Serum Neutrophil Gelatinase-Associated Lipocalin: A Diagnostic Marker in Pediatric Sepsis.

Objectives: Sepsis is a life-threatening condition that arises when the response of the body to infection injures its own tissues and organs. The early prediction of sepsis by current clinical and laboratory methods remains inadequate. Serum neutrophil gelatinase-associated lipocalin level is increased in sepsis irrespective of renal dysfunction. Therefore, we aimed to correlate the serum neutrophil gelatinase-associated lipocalin value determined at admission with clinical progression and severity of disease in critically ill children and to declare its role as a potential diagnostic and prognostic marker for sepsis in critically ill children in the emergency department. Design: A prospective cohort study. Setting: The study carried out at the PICU of Menoufia University Hospital. Patients: We serially enrolled 120 critically ill children admitted to the PICU at 2 fixed days per week in addition to 40 healthy children served as controls. Interventions: Clinical examination was performed including calculation of the Pediatric Risk of Mortality and Pediatric Index of Mortality 2. Serum neutrophil gelatinase-associated lipocalin measurement was performed for patients at admission and for the controls. Patients were followed up for 30 days. The discriminatory power of neutrophil gelatinase- associated lipocalin was determined using the receiver-operating characteristic and other predictive likelihood values. Measurements and Main Results: Serum neutrophil gelatinase-associated lipocalin level was significantly higher among the total patient cohort and those with sepsis than among the controls (p

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Increased Mortality and Length of Stay Associated With Medical Emergency Team Review in Hospitalized Pediatric Patients: A Retrospective Cohort Study.

Objective: Rapid response systems using medical emergency teams reduce hospital wide cardiorespiratory arrest and mortality. While rapid response systems improve hospital-wide outcomes, children receiving medical emergency team review may still be at increased risk for morbidity and mortality. The study purpose was to compare the length of stay and mortality rate in children receiving a medical emergency team review with those of other hospitalized children. Design: Retrospective cohort study. Setting: Tertiary Pediatric Hospital, Children's Hospital of Eastern Ontario, Ottawa, Canada. Patients: Cohort of 42,308 pediatric admissions to the general inpatient ward. Interventions: Data over 7 years were obtained from a prospectively maintained rapid response systems database. Measurements and Main Results: From the cohort, 995 (2.35%) of the admissions had one and 276 (0.65%) had multiple medical emergency team activations. When compared with patients without, children having one or multiple medical emergency team reviews had 13.34 (95% CI, 5.33-33.2) and 50.10 (95% CI, 19.86-126.39) times the odds of death, respectively. Patients experiencing a medical emergency team review stayed in hospital 1.59 times (95% CI, 1.39-1.82) longer, whereas those with multiple medical emergency team reviews stayed 2.44 times (95% CI, 1.85-3.20) longer. The associations remained significant after controlling for important confounders and excluding elective admissions from the analyses. Most repeat medical emergency team reviews occurred within a day of the initial review or involved patients with multiple comorbidities. Conclusions: Our study suggests that pediatric patients reviewed by the medical emergency team are at significantly higher risk of mortality and longer length of stay than general ward inpatients. As well, patients with multiple medical emergency team reviews were at particularly high risk compared with patients with one medical emergency team review. Patients who experience medical emergency team reviews should be recognized as a high-risk group, and future studies should consider how to decrease morbidity and mortality. Based on our findings, we suggest that these patients be followed for 24-48 hours after any medical emergency team activation. (C)2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Evaluation of a Pediatric Early Warning Score Across Different Subspecialty Patients.

Objective: To evaluate the ability of a Pediatric Early Warning Score to predict deterioration in different subspecialty patient populations. Design: Single center, retrospective cohort study. Patients were classified into five groups: 1) cardiac; 2) hematology/oncology/bone marrow transplant; 3) surgical; 4) neurologic; and 5) general medical. The relationship between the Pediatric Early Warning Score and unplanned ICU transfer requiring initiation of specific ICU therapies (intubation, high-flow nasal cannula, noninvasive ventilation, inotropes, or aggressive fluid hydration within 12 hr of transfer) was evaluated. Setting: Tertiary care, free-standing, academic children's hospital. Patients: All hospitalized acute care patients admitted over a 6-month time period (September 2012 to March 2013). Interventions: None. Measurements and Main Results: During the study time period, 33,800 patient-days and 136 deteriorations were evaluated. Area under the curve ranged from 0.88 (surgical) to 0.94 (cardiac). Sensitivities for a Pediatric Early Warning Score greater than or equal to 3 ranged from 75% (surgical) to 94% (cardiology) and number needed to evaluate to find one deterioration was 11.5 (neurologic) to 43 patients (surgical). Sensitivities for a Pediatric Early Warning Score greater than or equal to 4 ranged from 54% (general medical) to 79% (hematology/oncology/bone marrow transplant) and number needed to evaluate of 5.5 (neurologic) to 12 patients (general medical). Sensitivities for a Pediatric Early Warning Score of greater than or equal to 5 ranged from 25% (surgical) to 58% (hematology/oncology/bone marrow transplant) and number needed to evaluate of 3.5 (cardiac, hematology/oncology/bone marrow transplant, neurologic) to eight patients (surgical). Conclusions: An elevated Pediatric Early Warning Score is associated with ICU transfer and receipt of ICU-specific interventions in patients across different pediatric subspecialty patient populations. (C)2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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NAEMT names 'EMS Advocate of the Year' award winners

National Association of Emergency Medical Technicians CLINTON, Miss. — The National Association of Emergency Medical Technicians (NAEMT) will present the 2017 EMS Advocate of the Year Awards on April 25 during EMS On The Hill Day. EMS Advocate of the Year Awards recognize professionals whose volunteer efforts advance EMS through educating and engaging elected government leaders, the EMS community ...

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Seawater drowning-associated pneumonia: a 10-year descriptive cohort in intensive care unit

Pneumonia is one of the major complications of drowning, but the optimal empirical antibiotic treatment is not clearly defined. Multidrug-resistant (MDR) bacteria and fungi have been identified in a recent se...

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In-hospital airway management training for non-anesthesiologist EMS physicians: a descriptive quality control study

Pre-hospital airway management is a major challenge for emergency medical service (EMS) personnel. Despite convincing evidence that the rescuer’s qualifications determine efficacy of tracheal intubation, in-ho...

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Treatment-limiting decisions in patients with severe traumatic brain injury in a Norwegian regional trauma center

Treatment-limiting decisions (TLD) for severe traumatic brain injury (sTBI) have been sparsely studied. This study determine prevalence, main reason for, categories and timing of TLDs in a Norwegian regional t...

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AMR teams up with IAFC, ACEP to train 1M people in bystander CPR

The organizations will come together for the World CPR Challenge, which trains bystanders to recognize the signs of sudden cardiac arrest

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Officials: Software glitch to blame for 911 outage

Technical teams are working to ensure that the backup system kicks in automatically during any future malfunction

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NAEMT announces recipients of 'EMS Advocate of the Year' award

National Association of Emergency Medical Technicians CLINTON, Miss. — The National Association of Emergency Medical Technicians (NAEMT) will present the 2017 EMS Advocate of the Year Awards on April 25 during EMS On The Hill Day. EMS Advocate of the Year Awards recognize professionals whose volunteer efforts advance EMS through educating and engaging elected government leaders, the EMS community ...

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AMR's NASCAR Safety Team appoints medical director

American Medical Response GREENWOOD VILLAGE, Colo. — American Medical Response (AMR) announced today the appointment of Angela Fiege, M.D., as the NASCAR/AMR Safety Team medical director. As a physician medical consultant to NASCAR for the past two years, she has been instrumental in enhancing on-track care and advocating for the health and safety of drivers and crew members. She will build ...

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NAEMSP members gather to talk medical care access, quality

National Association of EMS Physicians WASHINGTON — Members of the National Association of EMS Physicians (NAEMSP) gather in Washington, D.C. this week to advocate for the Protecting Patient Access to Emergency Medications Act (H.R. 304), and other issues affecting access to and quality of out-of-hospital emergency medical care, such as EMS payment reform. NAEMSP is an organization of physicians ...

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Paramedic Chief Digital: Guide to emerging technologies

This issue features articles on the challenges of and lessons learned from several important innovations

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The diagnostic accuracy of evoked potential monitoring techniques during intracranial aneurysm surgery for predicting postoperative ischaemic damage: A systematic review and meta-analysis

World Neurosurgery

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Deal charge pushes drugmaker Eli Lilly to 1Q loss

AP

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The current utilization and perceptions of prescription drug monitoring programs among emergency medicine providers in Florida

International Journal of Emergency Medicine

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Elton John recovering from 'potentially deadly' bacterial infection

Reuters Health News

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Quality of life and mediating role of patient scar assessment in burn patients

Burns

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Optimal secondary prevention medication use in acute myocardial infarction patients with nonobstructive coronary artery disease is modified by management strategy: Insights from the TRIUMPH Registry

Clinical Cardiology

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Outcomes of acute kidney injury in a department of internal medicine in Abidjan (Cote d'Ivoire)

Nephrology

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Cerebrolysin for functional recovery in patients with acute ischemic stroke: A meta-analysis of randomized controlled trials

Drug Design, Development and Therapy

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Outcome of extremely low birth weight infants with a history of neonatal acute kidney injury

Pediatric Nephrology

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Effects of home-based supportive care on improvements in physical function and depressive symptoms in stroke patients: A meta-analysis

Archives of Physical Medicine and Rehabilitation

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An analysis of ideal and actual time to surgery after traumatic spinal cord injury in Canada

Spinal Cord

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Electro-acupuncture for post-stroke spasticity: A systematic review and meta-analysis

Archives of Physical Medicine and Rehabilitation

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Swiss drugs giant Novartis posts 15% drop in profit

AP

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Burns to the genitalia, perineum, and buttocks increase the risk of death among U.S. service members sustaining combat-related burns in Iraq and Afghanistan

Burns

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Delayed presentation of acute cholecystitis: Comparative outcomes of same-admission versus delayed laparoscopic cholecystectomy

Journal of Gastrointestinal Surgery

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Piperacillin-tazobactam versus cefepime incidence of acute kidney injury in combination with vancomycin and tobramycin in pediatric cystic fibrosis patients

Pediatric Pulmonology

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Longitudinal recovery of local neuronal activity and consciousness level in acquired brain injury

Human Brain Mapping

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Resuscitative endovascular balloon occlusion of the aorta or resuscitative thoracotomy with aortic clamping for noncompressible torso hemorrhage: A retrospective nationwide study

The Journal of Trauma and Acute Care Surgery

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Femoral nerve block in a representative sample of elderly people with hip fracture: A randomised controlled trial

Injury

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Heart rate recovery improvement in patients following acute myocardial infarction: Exercise training, β-blocker therapy or both

Clinical Physiology and Functional Imaging

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10 ways to develop confident EMS volunteers

Volunteer agency leaders are often discouraged by what seems like a lack of interest in continuing education or participation in monthly drills. Yet, ask any EMT if they want to provide the best possible care for their patients and the answer is a resounding “Yes! Absolutely!” How do you, as an EMS leader, fix that disconnect" Find out exactly what kind of training your EMTs feel is meaningful ...

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Safer VL intubation: Use video laryngoscope channel blade

Safer intubations tip #1 from Williamson County EMS.

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Remember 2 Things: Stroke center designations

Steve Whitehead, host of Remember 2 Things, discusses two types of stroke center designations to keep in mind if a patient you're transporting is having a stroke.

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Safer VL intubation: Use video laryngoscope channel blade

Safer intubations tip #1 from Williamson County EMS.

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Remember 2 Things: Stroke center designations

Steve Whitehead, host of Remember 2 Things, discusses two types of stroke center designations to keep in mind if a patient you're transporting is having a stroke.

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Safer VL intubation: Use video laryngoscope channel blade

Safer intubations tip #1 from Williamson County EMS.

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Remember 2 Things: Stroke center designations

Steve Whitehead, host of Remember 2 Things, discusses two types of stroke center designations to keep in mind if a patient you're transporting is having a stroke.

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Safer VL intubation: Use video laryngoscope channel blade

Safer intubations tip #1 from Williamson County EMS.

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Remember 2 Things: Stroke center designations

Steve Whitehead, host of Remember 2 Things, discusses two types of stroke center designations to keep in mind if a patient you're transporting is having a stroke.

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Inhaled Treprostinil Drug Delivery During Mechanical Ventilation and Spontaneous Breathing Using Two Different Nebulizers.

Objectives: To determine the feasibility of delivering inhaled treprostinil during mechanical ventilation and spontaneous unassisted ventilation using the Tyvaso Inhalation System and the vibrating mesh nebulizer. We sought to compare differences in fine particle fraction, and absolute inhaled treprostinil mass delivered to neonatal, pediatric, and adult models affixed with a face mask, conventional, and high-frequency ventilation between Tyvaso Inhalation System and with different nebulizer locations between Tyvaso Inhalation System and vibrating mesh nebulizer. Design: Fine particle fraction was first determined via impaction with both the Tyvaso Inhalation System and vibrating mesh nebulizer. Next, a test lung configured with neonatal, pediatric, and adult mechanics and a filter to capture medication was attached to a realistic face model during spontaneous breathing or an endotracheal tube during conventional ventilation and high-frequency oscillator ventilator. Inhaled treprostinil was then nebulized with both the Tyvaso Inhalation System and vibrating mesh nebulizer, and the filter was analyzed via high-performance liquid chromatography. Testing was done in triplicate. Independent two-sample t tests were used to compare mean fine particle fraction and inhaled mass between devices. Analysis of variance with Tukey post hoc tests were used to compare within device differences. Setting: Academic children's hospital aerosol research laboratory. Measurements and Main Results: Fine particle fraction was not different between the Tyvaso Inhalation System and vibrating mesh nebulizer (0.78 +/- 0.04 vs 0.77 +/- 0.08, respectively; p = 0.79). The vibrating mesh nebulizer delivered the same or greater inhaled treprostinil than the Tyvaso Inhalation System in every simulated model and condition. When using the vibrating mesh nebulizer, delivery was highest when using high-frequency oscillator ventilator in the neonatal and pediatric models, and with the nebulizer in the distal position in the adult model. Conclusions: The vibrating mesh nebulizer is a suitable alternative to the Tyvaso Inhalation System for inhaled treprostinil delivery. Fine particle fraction is similar between devices, and vibrating mesh nebulizer delivery meets or exceeds delivery of the Tyvaso Inhalation System. Delivery for infants and children during high-frequency oscillator ventilator with the vibrating mesh nebulizer may result in higher than expected dosages. (C)2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Ketamine ……. then Rocuronium, DSI & The Timing Principle

More on rocketamine...

EMCrit by Scott Weingart.

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Priority Ambulance raises funding to support continued growth

KNOXVILLE, Tenn. — Priority Ambulance, LLC announced today that it has raised funding through Monroe Capital LLC to support the company’s future growth. “Priority Ambulance has grown aggressively since we began the company in 2014,” said Priority Ambulance CEO Bryan Gibson. “With this additional available financing, we will continue to seek out companies to add to our growing ...

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Ketamine ……. then Rocuronium, DSI & The Timing Principle

More on rocketamine...

EMCrit by Scott Weingart.

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Paramedics revive 9-year-old boy hit by line drive

Crews revived the boy using a defibrillator, CPR, a breathing tube, and medication

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Cut-offs of isokinetic strength ratio and hamstring strain prediction in professional soccer players

Scandinavian Journal of Medicine & Science in Sports

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NY health care providers to push for supervised drug sites

AP

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Canada recommends against testing everyone for hepatitis C

Reuters Health News

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The effect of pre-existing malnutrition on pediatric burn mortality in a sub-Saharan African burn unit

Burns

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Vaccination gaps lead to dangerous measles outbreaks in Europe: ECDC

Reuters Health News

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Delirium and mortality in critically ill children: epidemiology and outcomes of pediatric delirium

Critical Care Medicine

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Long-term survival of out-of-hospital cardiac arrest patients with malignancy

The American Journal of Emergency Medicine

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Correlation of carotid blood flow and corrected carotid flow time with invasive cardiac output measurements

Critical Ultrasound Journal

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Child-Turcotte-Pugh class is best at stratifying risk in variceal hemorrhage: Analysis of a US multicenter prospective study

Journal of Clinical Gastroenterology

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Public–private implementation of integrated emergency response services: Case study of GVK Emergency Management and Research Institute in Karnataka, India

Surgery

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Percutaneous transluminal coronary angioplasty for acute myocardial infarction: The impact on sexual function in men

International Journal of Impotence Research: The Journal of Sexual Medicine

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Computed tomography angiographic assessment of acute chest pain

Journal of Thoracic Imaging

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Early-onset ventilator-associated pneumonia in patients with severe traumatic brain injury: incidence, risk factors, and consequences in cerebral oxygenation and outcome

Neurocritical Care

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Pre-post evaluation of effects of a Titanium Dioxide coating on environmental contamination of an Intensive Care Unit: the TITANIC study

Journal of Hospital Infection

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Effect of baseline characteristics on the outcome of stent retriever based thrombectomy in acute basilar artery occlusions--A single center experience and pooled-data analysis

World Neurosurgery

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An evaluation of two different methods of coccygectomy in patients with traumatic coccydynia

Journal of Pain Research

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Intracranial pressure monitoring in severe traumatic brain injuries: A closer look at level I trauma centers in the United States

Injury

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Hypothermia in trauma victims at first arrival of ambulance personnel: An observational study with assessment of risk factors

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

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Effects of a simple home-based exercise program on fall prevention in older adults: A 12-month primary care setting, randomized controlled trial

Geriatrics and Gerontology International

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Timi risk index as a predictor of 30-day outcomes in patients with acute pulmonary embolism

Heart, Lung, and Circulation

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A Method to Account for Variation in Congenital Heart Surgery Length of Stay.

Objectives: We sought to develop a risk-adjustment methodology for length of stay in congenital heart surgery, as none exist. Design: Prospective cohort analysis combined with previously obtained retrospective cohort analysis of a Department of Cardiovascular Surgery clinical database. Patients: Patients discharged from Boston Children's Hospital between October 1, 2006, and May 31, 2014, that underwent a congenital heart surgery procedure(s) linked to one of 103 surgical procedure types. Measurements and Main Results: Six thousand two hundred nine discharges during the reporting period at Boston Children's Hospital comprised the cohort. Seven Surgical Length Categories were developed to group surgical procedure types. A multivariable model for outcome length of stay was built using a derivation cohort consisting of a 75% random sample, starting with Surgical Length Categories and considering additional a priori factors. Postoperative factors were then added to improve predictive performance. The remaining 25% of the cohort was used to validate the multivariable models. The coefficient of determination (R2) was used to estimate the variability in length of stay explained by each factor. The Surgical Length Categories yielded an R2 of 42%. Model performance increased when the a priori factors preoperative status, noncardiac abnormality, genetic anomaly, preoperative catheterization during episode of care, weight less than 3 kg, and preoperative vasoactive support medication were introduced to the model (R2 = 60.8%). Model performance further improved when postoperative ventilation greater than 7 days, operating room time, postoperative catheterization during episode of care, postoperative reintubation, number of postoperative vasoactive support medications, postoperative ICU infection, and greater than or equal to one secondary surgical procedure were added (R2 = 76.7%). The validation cohort yielded an R2 of 76.5%. Conclusions: We developed a statistically valid procedure-based categorical variable and multivariable model for length of stay of congenital heart surgeries. The Surgical Length Categories and important a priori and postoperative factors may be used to pursue a predictive tool for length of stay to inform scheduling and bed management practices. (C)2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Crestline Remounted Ambulances: Reduce, ReUse & Remount

Remounting is an excellent, environmentally responsible and economical solution. Our product is designed with remount-ability in mind. Having the option to remount the box onto a new chassis not only saves money but extends the life of each unit. A typical ambulance will be on the road anywhere from 5 – 7 years. Having the option to remount the box extends its life. Crestline’s remount center has seen significant growth in this area over the past 5 years.

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Crestline Remounted Ambulances: Reduce, ReUse & Remount

Remounting is an excellent, environmentally responsible and economical solution. Our product is designed with remount-ability in mind. Having the option to remount the box onto a new chassis not only saves money but extends the life of each unit. A typical ambulance will be on the road anywhere from 5 – 7 years. Having the option to remount the box extends its life. Crestline’s remount center has seen significant growth in this area over the past 5 years.

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Crestline Remounted Ambulances: Reduce, ReUse & Remount

Remounting is an excellent, environmentally responsible and economical solution. Our product is designed with remount-ability in mind. Having the option to remount the box onto a new chassis not only saves money but extends the life of each unit. A typical ambulance will be on the road anywhere from 5 – 7 years. Having the option to remount the box extends its life. Crestline’s remount center has seen significant growth in this area over the past 5 years.

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Crestline Remounted Ambulances: Reduce, ReUse & Remount

Remounting is an excellent, environmentally responsible and economical solution. Our product is designed with remount-ability in mind. Having the option to remount the box onto a new chassis not only saves money but extends the life of each unit. A typical ambulance will be on the road anywhere from 5 – 7 years. Having the option to remount the box extends its life. Crestline’s remount center has seen significant growth in this area over the past 5 years.

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H&H Medical releases new DualSeal Occlusive Chest Dressing

H&H Medical's newest product adds to their line of hydrogel chest dressings with a portable two-pack. WILLIAMSBURG, Va. — H&H Medical Corporation, a leader in emergency pre-hospital trauma products, announces the launch of its newest addition to its line of products, the DualSeal™ occlusive chest dressing pack. Having emergency trauma products when disaster strikes is crucial ...

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Binder Lift offers trade-in for other lifting related products crediting up to 100% of original purchase price

Binder Lift's Trade-In program allows departments to put 100% of the original purchase price of their products towards a Binder Lift product, and donates used gear to Medical Teams International. CODY, Wy. — Binder Lift is pleased to announce the launch of their new Trade-In Program. “This is something that we have been working on for a long time,” states Rick Binder, Director ...

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EMT and Paramedic full time positions - A-1 Ambulance Inc.

EMT and Paramedics will be responsible for caring for and transporting both ALS and BLS patients along with out of town transfers. The EMT and Paramedic will work together with the medical director to provide top notch care that is in his/her scope of practice and adhere to the protocols already in place.

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10 tips to maximize learning in lab scenarios

Patient care scenarios provide an opportunity for learners to apply classroom material and isolated skill practice in realistic situations. The NREMT now requires paramedic students to demonstrate competency in scenarios that cover a variety of topic areas over the course of the program, and the new NREMT Psychomotor Competency Exam includes a patient care scenario [1]. Scenarios can also be used to ...

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Woman thanks AMR paramedic for saving her life

By EMS1 Staff PORTLAND, Ore. — A woman took a moment to thank a paramedic for saving her life. KGW.com reported that Roya Quirk thought she hurt her ankle while working out. It was swollen and continued to get worse. She collapsed days after the incident. "When we arrived, we quickly realized that she was critically sick and the importance of getting her to the right place at the right time ...

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Hypothermia in trauma victims at first arrival of ambulance personnel: an observational study with assessment of risk factors

Hypothermia is common in trauma victims and is associated with increased mortality, however its causes are little known. The objective of this study was to identify the risk factors associated with hypothermia...

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Student-run organization to provide EMS to campus, community

Associated Press BURLINGTON, Vt. — Construction is underway at the University of Vermont on a new $1.4 million headquarters for UVM Rescue, a student-run organization that provides ambulance services to the campus and community. The new facility within a complex of university buildings on Burlington's East Avenue will include a heated garage for two ambulances, crew quarters and a common room ...

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Crews narrowly avoid injury when DWI suspect barrels into ambulance

The driver slammed into the passenger side of the rig; none of the responders working 10 feet away were hurt

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Texas ambulance flips in two-vehicle crash

A paramedic and student were taken to the hospital with minor injuries

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PulmCrit- Rocketamine vs. keturonium for rapid sequence intubation

Background:  Devil in the details Airway management is a detail-oriented sport.  Minor nuances of patient positioning can be essential.  Or gentle laryngeal manipulation.  Apneic oxygenation can improve first-pass success.  Placing the pulse oximeter on the same arm as the blood pressure cuff can cause real headache.  Failure to recognize and remove dentures is an enormous […]

EMCrit by Josh Farkas.

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PulmCrit- Rocketamine vs. keturonium for rapid sequence intubation

Background:  Devil in the details Airway management is a detail-oriented sport.  Minor nuances of patient positioning can be essential.  Or gentle laryngeal manipulation.  Apneic oxygenation can improve first-pass success.  Placing the pulse oximeter on the same arm as the blood pressure cuff can cause real headache.  Failure to recognize and remove dentures is an enormous […]

EMCrit by Josh Farkas.

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Prognostication in critically ill patients with severe traumatic brain injury: The TBI-Prognosis multicentre feasibility study

BMJ Open

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$3M award in suit against drug company over man's suicide

AP

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The association of patient and trauma characteristics with the health-related quality of life in a Dutch trauma population

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

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Researchers to look for CTE evidence in Hernandez's brain

AP

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Home or hospital for people with dementia and one or more other multimorbidities: What is the potential to reduce avoidable emergency admissions? The HOMEWARD Project Protocol

BMJ Open

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Lipid biomarkers for risk assessment in acute coronary syndromes

Current Cardiology Reports

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The role of cognitive functioning in the relationship between childhood trauma and a mixed phenotype of affective-anxious-psychotic symptoms in psychotic disorders

Schizophrenia Research

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The effect of 50% compared to 100% inspired oxygen fraction on brain oxygenation and post cardiac arrest mitochondrial function in experimental cardiac arrest

Resuscitation

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An update on cardiopulmonary resuscitation in children

Current Anesthesiology Reports

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Is there inequity in hospital care among patients with acute coronary syndrome who are proficient and not proficient in English language?: Analysis of the SNAPSHOT ACS study

Journal of Cardiovascular Nursing

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The comparison of point-of-care ultrasonography and radiography in the diagnosis of tibia and fibula fractures

Injury

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Serial procalcitonin predicts mortality in severe sepsis patients: Results from the Multicenter Procalcitonin MOnitoring SEpsis (MOSES) study

Critical Care Medicine

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Lawmakers revisiting requiring those on Medicaid to work

AP

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Randomized clinical trial of propofol versus alfentanil for moderate procedural sedation in the emergency department

The American Journal of Emergency Medicine

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Behavioral emergency response team: Implementation improves patient safety, staff safety, and staff collaboration

Worldviews on Evidence-Based Nursing

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More complications in uncemented compared to cemented hemiarthroplasty for displaced femoral neck fractures: A randomized controlled trial of 201 patients, with one-year follow-up

BMC Musculoskeletal Disorders

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Significance of NT-pro-BNP in acute exacerbation of COPD patients without underlying left ventricular dysfunction

International Journal of COPD

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Impact of respiratory viruses in hospital-acquired pneumonia in the intensive care unit: A single-center retrospective study

Journal of Clinical Virology

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Outcomes of hemiarthroplasty and total hip arthroplasty for femoral neck fracture: A Medicare cohort study

Journal of Orthopaedic Trauma

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Early whole brain radiotherapy in primary CNS lymphoma: Negative impact on quality of life in the randomized G-PCNSL-SG1 trial

Journal of Cancer Research & Clinical Oncology

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EMT/Paramedic - Permian Basin Ambulance

EMT and Paramedics are responsible for providing basic/advanced life support care(s) for the sick, injured, traumatic and non-emergent patient. The EMT/Paramedic will work within their scope of practice and agency’s protocols as directed by agency’s medical director. Primary responsibilities This is a general overview of responsibilities. Assess nature of patient's illness and or mechanism ...

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Wash. firefighters, paramedics to get ballistic vests, helmets

Two sets will be kept with each medic unit and three sets will be kept with each fire unit

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ECTES-Abstracts 2017

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4 ways to demonstrate fiscal stability for EMS grant funding

Nearly all grant applications have a section requiring the explanation of your EMS organization’s sustainability. Funders want to know that when their funding of a one year or multiple-year project ends your organization will be able to continue to support the project. Sustainability is proof that a grant was a wise investment for a funder. The sustainability plan is often the most difficult piece ...

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Innovation Zone - MedixSafe

MedixSafe safes offer multiple layers of authentication for positive control over your narcotics and other vital equipment.

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Innovation Zone - MedixSafe

MedixSafe safes offer multiple layers of authentication for positive control over your narcotics and other vital equipment.

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Innovation Zone - MedixSafe

MedixSafe safes offer multiple layers of authentication for positive control over your narcotics and other vital equipment.

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Innovation Zone - MedixSafe

MedixSafe safes offer multiple layers of authentication for positive control over your narcotics and other vital equipment.

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Differentiating Delirium From Sedative/Hypnotic-Related Iatrogenic Withdrawal Syndrome Lack of Specificity in Pediatric Critical Care Assessment Tools.

Objectives: To identify available assessment tools for sedative/hypnotic iatrogenic withdrawal syndrome and delirium in PICU patients, the evidence supporting their use, and describe areas of overlap between the components of these tools and the symptoms of anticholinergic burden in children. Data Sources: Studies were identified using PubMed and EMBASE from the earliest available date until July 3, 2016, using a combination of MeSH terms "delirium," "substance withdrawal syndrome," and key words "opioids," "benzodiazepines," "critical illness," "ICU," and "intensive care." Review article references were also searched. Study Selection: Human studies reporting assessment of delirium or iatrogenic withdrawal syndrome in children 0-18 years undergoing critical care. Non-English language, exclusively adult, and neonatal intensive care studies were excluded. Data Extraction: References cataloged by study type, population, and screening process. Data Synthesis: Iatrogenic withdrawal syndrome and delirium are both prevalent in the PICU population. Commonly used scales for delirium and iatrogenic withdrawal syndrome assess signs and symptoms in the motor, behavior, and state domains, and exhibit considerable overlap. In addition, signs and symptoms of an anticholinergic toxidrome (a risk associated with some common PICU medications) overlap with components of these scales, specifically in motor, cardiovascular, and psychiatric domains. Conclusions: Although important studies have demonstrated apparent high prevalence of iatrogenic withdrawal syndrome and delirium in the PICU population, the overlap in these scoring systems presents potential difficulty in distinguishing syndromes, both clinically and for research purposes. (C)2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Biomarkers for Early Acute Kidney Injury Diagnosis and Severity Prediction: A Pilot Multicenter Canadian Study of Children Admitted to the ICU.

Objective: Acute kidney injury occurs early in PICU admission and increases risks for poor outcomes. We evaluated the feasibility of a multicenter acute kidney injury biomarker urine collection protocol and measured diagnostic characteristics of urine neutrophil gelatinase-associated lipocalin, interleukin-18, and liver fatty acid binding protein to predict acute kidney injury and prolonged acute kidney injury. Design: Prospective observational pilot cohort study. Setting: Four Canadian tertiary healthcare PICUs. Patients: Eighty-one children 1 month to 18 years old. Exclusion criteria were as follows: cardiac surgery, baseline severe kidney disease, and inadequate urine or serum for PICU days 1-3. Interventions: PICUs performed standardized urine collection protocol to obtain early PICU admission urine samples, with deferred consent. Measurements and Main Results: Study barriers and facilitators were recorded. Acute kidney injury was defined based on Kidney Disease: Improving Global Outcomes serum creatinine criteria (acute kidney injuryserum creatinine) and by serum creatinine and urine output criteria (acute kidney injuryserum creatinine+urine output) Prolonged acute kidney injury was defined as acute kidney injury duration of 48 hours or more. PICU days 1-3 neutrophil gelatinase-associated lipocalin, interleukin-18, and liver fatty acid binding protein were evaluated for acute kidney injury prediction (area under the curve). Biomarkers on the first day of acute kidney injury attainment (day 1 acute kidney injury) were evaluated for predicting prolonged acute kidney injury. Eighty-two to 95% of subjects had urine collected from PICU days 1-3. Acute kidney injuryserum creatinine developed in 16 subjects (20%); acute kidney injuryserum creatinine+urine outputdeveloped in 38 (47%). On PICU day 1, interleukin-18 predicted acute kidney injuryserum creatinine with area under the curve=0.82, but neutrophil gelatinase-associated lipocalin and liver fatty acid binding protein predicted acute kidney injuryserum creatinine with area under the curve of less than or equal to 0.69; on PICU day 2, area under the curve was higher (not shown). Interleukin-18 and liver fatty acid binding protein on day 1 acute kidney injury predicted prolonged acute kidney injuryserum creatinine (area under the curve=0.74 and 0.83, respectively). When acute kidney injuryserum creatinine+urine output was used to define acute kidney injury, biomarker area under the curves were globally lower. Conclusions: Protocol urine collection to procure early admission samples is feasible. Individual biomarker acute kidney injury prediction performance is highly variable and modest. Larger studies should evaluate utility and cost effectiveness of using early acute kidney injury biomarkers. (C)2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Paramedic - Remote Medical International

The Role: We are actively seeking a highly qualified paramedic with experience in remote, industrial or clinic settings. This position will take place in an industrial setting, where you will utilize your expertise to mitigate and treat illnesses and injuries while activating the local emergency response system when appropriate. We are looking for candidates with a commitment to a proactive approach ...

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Armor Express launches next-generation protective solutions for the global Fire and EMS markets

Company to showcase its comprehensive offerings for first responders at the 2017 Fire Department Instructor’s Conference

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Wife collapses in yard, husband performs CPR for 12 minutes

His wife was taken to a hospital, where her treatment included the installation of a pacemaker to defibrillate her heart if it arrests again

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Man claims 911 didn't answer call during allergic reaction emergency

Walter Clark couldn't get a hold of his wife, so he decided to call 911; he was shocked when no one answered

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Dispatchers dealing with accidental calls from Apple watches

Officials sent a warning to Apple Watch users about the spike in "wrist-dials"

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Class offers direct path from high school to EMT job

By Lynn Horsley The Kansas City Star KANSAS CITY, Mo. — Like many Kansas City public high school students, Amauri Steele didn’t have a clear career path in mind. So as a senior this year, he signed up for Manual Tech’s new emergency medical technician licensing class that had him on an ambulance ride-along this month. And it was quite a ride. Suddenly, he was watching the crew stick ...

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Characteristics of hospital emergency room visits for mental and substance use disorders

Psychiatric Services

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Multidisciplinary team approach to traumatic spinal cord injuries: A single institutions quality improvement project

European Journal of Trauma and Emergency Surgery

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U.S. hospital stocks fall on reports of health-bill progress

Reuters Health News

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Radiographic outcomes of single versus dual plate fixation of acute mid-shaft clavicle fractures

Archives of Orthopaedic and Trauma Surgery

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Two-horse race: Auris, Otonomy seek FDA nod for inner-ear therapies

Reuters Health News

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Intoxication-Related AmED (Alcohol Mixed with Energy Drink) Expectancies Scale: Initial Development and Validation

Alcoholism: Clinical and Experimental Research

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Can high-flow nasal cannula reduce the rate of endotracheal intubation in adult patients with acute respiratory failure compared with conventional oxygen therapy and noninvasive positive pressure ventilation?: a systematic review and meta-analysis

Chest

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Urinary biomarkers are associated with severity and mechanism of injury

Shock

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Effects of Testosterone and Evoked Resistance Exercise after Spinal Cord Injury (TEREX-SCI): Study protocol for a randomized controlled trial

BMJ Open

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What happened in the 1951 case of Henrietta Lacks, and could it happen again today?

AP

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Impact of metformin use on lactate kinetics in patients with severe sepsis and septic shock

Shock

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Occurrence, predictors, and prognosis of alcohol withdrawal syndrome and delirium tremens following traumatic injury

Critical Care Medicine

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A comparison of remote and bedside assessment of the national institute of health stroke scale in acute stroke patients

European Neurology

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Muscle oxygenation as an early predictor of shock severity in trauma patients

Shock

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Statin use and other factors associated with mortality after major lower extremity amputation

Journal of Vascular Surgery

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Intensive care nurses experiences of infants and partners presence on the postoperative ward after an emergency caesarean section; An interview study

Intensive and Critical Care Nursing

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Coinfection and mortality in pneumonia-related acute respiratory distress syndrome patients with bronchoalveolar lavage: a prospective observational study

Shock

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The Behavior Rating Inventory of Executive Function (BRIEF) to identify pediatric acute lymphoblastic leukemia (ALL) survivors at risk for neurocognitive impairment

Journal of Pediatric Hematology/Oncology

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Randomized comparison of packed red blood cell-to-fresh frozen plasma transfusion ratio of 4: 1 vs 1: 1 during acute massive burn excision

Journal of Burn Care & Research

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Arizona hospital discharge and emergency department database: Implications for occupational health surveillance

Journal of Occupational and Environmental Medicine

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The protective association of endogenous immunoglobulins against sepsis mortality is restricted to patients with moderate organ failure

Pre-evaluation of endogenous immunoglobulin levels is a potential strategy to improve the results of intravenous immunoglobulins in sepsis, but more work has to be done to identify those patients who could ben...

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Loop Ileostomy Vs. Total Colectomy As Surgical Treatment For Clostridium Difficile Associated Disease: An Eastern Association for the Surgery of Trauma Multicenter Trial.

Objectives: The mortality of patients with Clostridum Dificile Associated Disease (CDAD) requiring surgery continues to be very high. Loop ileostomy (LI) was introduced as an alternative procedure to total colectomy (TC) for CDAD by a single center study. To date, no reproducible results have been published. The objective of this study is to compare these two procedures in a multicentric approach to help the surgeon decide what procedure is best suited for the patient in need. Methods: This was a retrospective multicenter study conducted under the sponsorship of the Eastern Association for the Surgery of Trauma (EAST). Demographics, medical history, clinical presentation, APACHE score, and outcomes were collected. We used the Research Electronic Data Capture (REDCap) tool to store the data. Mann-Whitney (continuous data) and Fisher's Exact (categorical data) were utilized to compare TC with LI. Logistic regression was performed to determine predictors of mortality. A propensity score analysis was done to control for potential confounders and determine adjusted mortality rates by procedure type. Results: We collected data from 10 centers of patients that presented with CDAD requiring surgery between July 1of 2010 to July 30 of 2014. Two patients died during the surgical procedure leaving 98 individuals in the study. The overall mortality was 32% and 75% suffered postoperative complications. Median age was 64.5 years, 59% were male. Concerning preoperative patient conditions 54% were on pressors, 47% had renal failure, and 36% suffered respiratory failure. When comparing TC and LI, there was no statistical difference regarding these conditions. Univariate pre-procedure predictors of mortality were age, lactate, timing of operation, vasopressor use, and acute renal failure. There was no statistical difference between the APACHE score of patients undergoing either procedure (TC=22 vs LI= 16). Adjusted mortality (controlled for pre-procedure confounders) was significantly lower in the LI group (17.2% vs. 39.7%, p=0.002). Conclusions: This is the first multicenter study comparing TC with LI for the treatment of CDAD. In this study LI carried less mortality than TC. In patients without contraindications, LI should be considered for the surgical treatment of CDAD. Level of evidence: prognostic retrospective multi-centric level III (C) 2017 Lippincott Williams & Wilkins, Inc.

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Combat Surgical Workload in OIF/OEF: The Definitive Analysis.

Background: Relatively few publications exist on surgical workload in the deployed military setting. This study analyses U.S. Military combat surgical workload in Iraq and Afghanistan to gain a more thorough understanding of surgical training gaps and personnel requirements. Methods: A retrospective analysis of the Department of Defense Trauma Registry (DoDTR) was performed for all Role 2 (R2) and Role 3 (R3) Military Treatment Facilities (MTFs), from January 2001 to May 2016. ICD-9-CM procedure codes were grouped into 19 categories based on functional surgical skill sets. The 189,167 surgical procedures identified were stratified by Role of care, month and year. Percentiles were calculated for the number of procedures for each skill set. A literature search was performed for publications documenting combat surgical workload during the same period. Results: A total of 23,548 surgical procedures were performed at R2 facilities while 165,619 surgical procedures were performed at R3 facilities. The most common surgical procedures performed overall were soft tissue (37.5%), orthopedic (13.84%), abdominal (13.01%), and vascular (6.53%). The least common surgical procedures performed overall were cardiac (0.23%), Peripheral Nervous System (0.53%), and spine (0.34%). Mean surgical workload at any point in time clearly underrepresented those units in highly kinetic areas, at times by an order of magnitude or more. The published literature always demonstrated workloads well in excess of the 50th percentile for the relevant time period. Conclusions: The published literature on combat surgical workload represents the high end of the spectrum of deployed surgical experience. These trends in surgical workload provide vital information that can be used to determine the manpower needs of future conflicts in ever-changing operational tempo environments. Our findings provide surgical types and surgical workload requirements that will be useful in surgical training and placement of medical assets in future conflicts. Level of Evidence: Level III, Epidemiologic study (C) 2017 Lippincott Williams & Wilkins, Inc.

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