Diagnostic Accuracy of Chest Radiograph, and When Concomitantly Studied Lung Ultrasound, in Critically Ill Patients With Respiratory Symptoms: A Systematic Review and Meta-Analysis

Objectives: Chest radiograph is considered the first-line diagnostic imaging modality for patients presenting with pulmonary symptoms in the ICU. In this meta-analysis, we aim to evaluate the diagnostic accuracy of chest radiograph, and when concomitantly studied lung ultrasound, in comparison with the gold-standard CT for adult critically ill patients with respiratory symptoms. Data Sources: PubMed, EMBASE, and Gray literature. Study Selection: Studies comparing chest radiograph, and if performed lung ultrasound, with CT for adult ICU patients with respiratory symptoms. Data Extraction: Quality was scored with Quality Assessment of Diagnostic Accuracy Studies-2, and study setting, test characteristics, and study design were extracted. Data Synthesis: In the meta-analysis, we included 10 full-text studies, including 543 patients, and found that chest radiograph has an overall sensitivity of 49% (95% CI, 40–58%) and specificity of 92% (86–95%). In seven studies, where also lung ultrasound was studied, lung ultrasound had an overall sensitivity of 95% (92–96%) and specificity of 94% (90–97%). Substantial heterogeneity was found. A planned subgroup analysis for individual pathologies was performed. The results of four abstract-only studies, included in the systematic review, were considered unlikely to significantly influence results of our meta-analysis. Study limitations were that most studies were of low power combined with methodological limitations. Conclusions: This meta-analysis demonstrates that chest radiograph has a low sensitivity and reasonable specificity compared with CT for detecting lung pathology in critically ill patients. The studies also investigating lung ultrasound, showed lung ultrasound to be clearly superior to chest radiograph in terms of sensitivity with similar specificity, thereby opting to be the first-line diagnostic tool in these patients. All authors take responsibility for the integrity of the data interpretation and analysis. All authors contributed substantially in the study design, data interpretation, and the writing of the article. Dr. van de Ven performed statistical analysis and data syntheses. All authors approved the final version of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (https://ift.tt/29S62lw). Supported, in part, by Departmental funds. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: p.tuinman@vumc.nl Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Revisited: A Systematic Review of Therapeutic Hypothermia for Adult Patients Following Traumatic Brain Injury

Objectives: Therapeutic hypothermia has been of topical interest for many years and with the publication of two international, multicenter randomized controlled trials, the evidence base now needs updating. The aim of this systematic review of randomized controlled trials is to assess the efficacy of therapeutic hypothermia in adult traumatic brain injury focusing on mortality, poor outcomes, and new pneumonia. Data Sources: The following databases were searched from January 1, 2011, to January 26, 2018: Cochrane Central Register of Controlled Trial, MEDLINE, PubMed, and EMBASE. Study Selection: Only foreign articles published in the English language were included. Only articles that were randomized controlled trials investigating adult traumatic brain injury sustained following an acute, closed head injury were included. Two authors independently assessed at each stage. Data Extraction: Quality was assessed using the Cochrane Collaboration’s tool for assessing the risk of bias. All extracted data were combined using the Mantel-Haenszel estimator for pooled risk ratio with 95% CIs. p value of less than 0.05 was considered statistically significant. All statistical analyses were conducted using RevMan 5 (Cochrane Collaboration, Version 5.3, Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014). Data Synthesis: Twenty-two studies with 2,346 patients are included. Randomized controlled trials with a low risk of bias show significantly more mortality in the therapeutic hypothermia group (risk ratio, 1.37; 95% CI, 1.04–1.79; p = 0.02), whereas randomized controlled trials with a high risk of bias show the opposite with a higher mortality in the control group (risk ratio, 0.70; 95% CI, 0.60–0.82; p

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Increasing the Number of Medical Emergency Calls Does Not Improve Hospital Mortality

Objectives: Medical emergency teams were established to rescue patients experiencing clinical deterioration thus preventing cardiac arrest and unexpected hospital mortality. Although hospitals are encouraged to increase emergency calling rates to improve in-hospital mortality, there are increasing concerns about the impact these calls have on the workload of the teams and the skill levels on the general wards. We set out to examine the relationship between emergency calling rates and adjusted in-hospital mortality. Design: Retrospective analysis of prospectively collected patient and emergency call data. Setting: Tertiary, metropolitan, and regional hospitals in the State of Victoria, Australia. Patients: Consecutive patients discharged from 1) St Vincent’s Hospital Melbourne from January 2008 to June 2016 and 2) 15 Victorian hospitals from July 2010 to June 2015. Measurements and Main Results: We studied 441,029 patients from St Vincent’s Hospital Melbourne. Median age was 61.0 years (interquartile range, 45–74 yr), 57.2% were men, and 0.70% died; monthly emergency calling rates varied between 9.21 and 30.69 (median 18.4) per 1,000 discharges. In-hospital mortality adjusted for age, gender, emergency status, same day admission, year of discharge, and Charlson Comorbidity Index was not reduced by higher calling rates in the month of discharge (odds ratio, 1.019; 95% CI, 1.008–1.031). We then examined 3,339,789 discharges from 15 Victorian hospitals with median age 61 years (interquartile range, 43–74 yr), 51.4% men, and hospital mortality 0.83% where yearly emergency calling rates varied from 18.46 to 33.40 (median, 25.75) per 1,000 discharges. Again, adjusted mortality was not reduced by higher calling rates in the year of discharge (odds ratio, 1.003; 95% CI, 1.001–1.006). Conclusions: With adjustment for patient factors, illness, and comorbidities, increased emergency calling rates were not associated with reduced in-hospital mortality. Efforts to increase calling rates do not seem warranted. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (https://ift.tt/29S62lw). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: john.santamaria@svha.org.au Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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The Development of a Machine Learning Inpatient Acute Kidney Injury Prediction Model

Objectives: To develop an acute kidney injury risk prediction model using electronic health record data for longitudinal use in hospitalized patients. Design: Observational cohort study. Setting: Tertiary, urban, academic medical center from November 2008 to January 2016. Patients: All adult inpatients without pre-existing renal failure at admission, defined as first serum creatinine greater than or equal to 3.0 mg/dL, International Classification of Diseases, 9th Edition, code for chronic kidney disease stage 4 or higher or having received renal replacement therapy within 48 hours of first serum creatinine measurement. Interventions: None. Measurements and Main Results: Demographics, vital signs, diagnostics, and interventions were used in a Gradient Boosting Machine algorithm to predict serum creatinine–based Kidney Disease Improving Global Outcomes stage 2 acute kidney injury, with 60% of the data used for derivation and 40% for validation. Area under the receiver operator characteristic curve (AUC) was calculated in the validation cohort, and subgroup analyses were conducted across admission serum creatinine, acute kidney injury severity, and hospital location. Among the 121,158 included patients, 17,482 (14.4%) developed any Kidney Disease Improving Global Outcomes acute kidney injury, with 4,251 (3.5%) developing stage 2. The AUC (95% CI) was 0.90 (0.90–0.90) for predicting stage 2 acute kidney injury within 24 hours and 0.87 (0.87–0.87) within 48 hours. The AUC was 0.96 (0.96–0.96) for receipt of renal replacement therapy (n = 821) in the next 48 hours. Accuracy was similar across hospital settings (ICU, wards, and emergency department) and admitting serum creatinine groupings. At a probability threshold of greater than or equal to 0.022, the algorithm had a sensitivity of 84% and a specificity of 85% for stage 2 acute kidney injury and predicted the development of stage 2 a median of 41 hours (interquartile range, 12–141 hr) prior to the development of stage 2 acute kidney injury. Conclusions: Readily available electronic health record data can be used to predict impending acute kidney injury prior to changes in serum creatinine with excellent accuracy across different patient locations and admission serum creatinine. Real-time use of this model would allow early interventions for those at high risk of acute kidney injury. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (https://ift.tt/29S62lw). Dr. Koyner has received research funding from Satellite Healthcare. Drs. Edelson and Churpek have a patent pending (ARCD. P0535US.P2) for risk stratification algorithms for hospitalized patients. Dr. Edelson has received research funding from Philips Healthcare and Early Sense and has ownership interests in Quant HC, which is developing products for risk stratification of hospitalized patients. Mr. Carey has disclosed that he does not have any potential conflicts of interest. For information regarding this article, E-mail: jkoyner@uchicago.edu Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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The Speaker Gender Gap at Critical Care Conferences

Objectives: To review women’s participation as faculty at five critical care conferences over 7 years. Design: Retrospective analysis of five scientific programs to identify the proportion of females and each speaker’s profession based on conference conveners, program documents, or internet research. Setting: Three international (European Society of Intensive Care Medicine, International Symposium on Intensive Care and Emergency Medicine, Society of Critical Care Medicine) and two national (Critical Care Canada Forum, U.K. Intensive Care Society State of the Art Meeting) annual critical care conferences held between 2010 and 2016. Subjects: Female faculty speakers. Interventions: None. Measurements and Main Results: Male speakers outnumbered female speakers at all five conferences, in all 7 years. Overall, women represented 5–31% of speakers, and female physicians represented 5–26% of speakers. Nursing and allied health professional faculty represented 0–25% of speakers; in general, more than 50% of allied health professionals were women. Over the 7 years, Society of Critical Care Medicine had the highest representation of female (27% overall) and nursing/allied health professional (16–25%) speakers; notably, male physicians substantially outnumbered female physicians in all years (62–70% vs 10–19%, respectively). Women’s representation on conference program committees ranged from 0% to 40%, with Society of Critical Care Medicine having the highest representation of women (26–40%). The female proportions of speakers, physician speakers, and program committee members increased significantly over time at the Society of Critical Care Medicine and U.K. Intensive Care Society State of the Art Meeting conferences (p

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Which safety standards should your ambulance remount meet?

With more safety data available, ambulance remounts may be the next to receive significant upgrades to minimum quality standards

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Comparison of the diagnostic values of vascular adhesion protein-1 and intestinal fatty acid-binding protein in the diagnosis of acute mesenteric ischemia

Abstract

Objectives

The aim of this study is to compare the diagnostic values of plasma levels of vascular adhesion protein-1 (VAP-1) and intestinal fatty acid-binding protein (I-FABP) for diagnosing acute mesenteric ischemia (AMI).

Methods

The study used a randomized, controlled experimental design. Forty-two female Sprague–Dawley rats were divided into three control groups and three ischemia groups. Plasma VAP-1 and I-FABP levels were measured, and the extent of ischemic damage was determined using a histopathological damage score in terminal ileum tissue samples.

Results

In the early phase of AMI (i.e. at the 30-min time point), VAP-1 levels did not differ between the control and ischemia groups (p > 0.05), but I-FABP levels were significantly higher in the ischaemia groups (p = 0.017). Although both VAP-1 and I-FABP levels increased in the ischaemia groups, only VAP-1 levels showed a significant increase compared to the control group at the 2-h time point (p = 0.011). Ischemic damages associated with AMI became the most prominent at the 6-h time point. During this phase, both VAP-1 and I-FABP levels were significantly higher in the ischemia groups than in the control groups (p = 0.007 and p = 0.002, respectively). Both VAP-1 and I-FABP levels showed a significant correlation with ischemic changes, but a higher correlation was observed for VAP-1 levels (r = 0.771).

Conclusions

Both I-FABP and VAP-1 levels were useful for diagnosing AMI, but VAP-1 levels correlated better with the extent of ischaemic damage.

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How to train for 3 common patient lifting scenarios

Prepare mentally and physically to avoid injury when lifting patients from awkward positions

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New policies needed for civilian air medevac transportation

Lawmakers should evaluate billing issues and insurance company procedure to guide healthcare policy and protect patients

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AT&T announces nationwide launch of FirstNet

“The launch of the network core comes a year into the FirstNet public-private partnership” FirstNet Senior Vice President Chris Sambar said

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Effect of Administration of Ramelteon, a Melatonin Receptor Agonist, on the Duration of Stay in the ICU: A Single-Center Randomized Placebo-Controlled Trial

Objectives: Occurrence of delirium in the ICU is associated with a longer stay in the ICU. To examine whether the use of ramelteon, a melatonin agonist, can prevent delirium and shorten the duration of ICU stay of critically ill patients. Design: A single-center, triple-blinded, randomized placebo-controlled trial. Setting: ICU of an academic hospital. Patients: Eligible patients were ICU patients who could take medicines orally or through a nasogastric tube during the first 48 hours of admission. Interventions: The intervention group received ramelteon (8 mg/d), and the control group received placebo (1 g/d of lactose powder) at 20:00 hours every day until discharge from the ICU. Measurements and Main Results: A total of 88 subjects were randomized to the ramelteon group (45 subjects) or the placebo group (43 subjects). As the primary endpoint, there was a trend toward decrease in the duration of ICU stay (4.56 d) in the ramelteon group compared with the placebo group (5.86 d) (p = 0.082 and p = 0.028 before and after adjustments). As the secondary endpoints, statistically significant decreases in the occurrence rate (24.4% vs 46.5%; p = 0.044) and duration (0.78 vs 1.40 d; p = 0.048) of delirium were observed in the ramelteon group. The nonintubated patients of the ramelteon group showed statistically significantly fewer awakenings per night and a higher proportion of nights without awakenings. Conclusions: Ramelteon tended to decrease the duration of ICU stay as well as decreased the occurrence rate and duration of delirium statistically significantly. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (https://ift.tt/29S62lw). Supported, in part, by the Clinical Research Program at Nagoya University. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: m0528332626@yahoo.co.jp Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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One-Year Outcomes in Patients With Acute Respiratory Distress Syndrome Enrolled in a Randomized Clinical Trial of Helmet Versus Facemask Noninvasive Ventilation

Objectives: Many survivors of acute respiratory distress syndrome have poor long-term outcomes possibly due to supportive care practices during “invasive” mechanical ventilation. Helmet noninvasive ventilation in acute respiratory distress syndrome may reduce intubation rates; however, it is unknown if avoiding intubation with helmet noninvasive ventilation alters the consequences of surviving acute respiratory distress syndrome. Design: Long-term follow-up data from a previously published randomized controlled trial. Patients: Adults patients with acute respiratory distress syndrome enrolled in a previously published clinical trial. Setting: Adult ICU. Intervention: None. Measurements and Main Results: The primary outcome was functional independence at 1 year after hospital discharge defined as independence in activities of daily living and ambulation. At 1 year, patients were surveyed to assess for functional independence, survival, and number of institution-free days, defined as days alive spent living at home. The presence of ICU-acquired weakness and functional independence was also assessed by a blinded therapist on hospital discharge. On hospital discharge, there was a greater prevalence of ICU-acquired weakness (79.5% vs 38.6%; p = 0.0002) and less functional independence (15.4% vs 50%; p = 0.001) in the facemask group. One-year follow-up data were collected for 81 of 83 patients (97.6%). One-year mortality was higher in the facemask group (69.2% vs 43.2%; p = 0.017). At 1 year, patients in the helmet group were more likely to be functionally independent (40.9% vs 15.4%; p = 0.015) and had more institution-free days (median, 268.5 [0–354] vs 0 [0–323]; p = 0.017). Conclusions: Poor functional recovery after invasive mechanical ventilation for acute respiratory distress syndrome is common. Helmet noninvasive ventilation may be the first intervention that mitigates the long-term complications that plague survivors of acute respiratory distress syndrome managed with noninvasive ventilation. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT01680783. Drs. Patel, Pohlman, Hall, and Kress participated in the conception of the trial. Drs. Patel, Esbrook, Pawlik, Hall, and Kress participated in study design. Drs. Patel, Pohlman, and Kress recruited patients and collected data. Drs. Wolfe, MacKenzie, Salem, Esbrook, Pawlik, Stulberg, Kemple, Teele, Zeleny, and Macleod collected data alone. Drs. Patel, Wolfe, MacKenzie, Pawlik, Hall, and Kress analyzed the data. All authors participated in the interpretation of the results. Dr. Patel drafted the article. All authors have seen and approved the final version of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (https://ift.tt/29S62lw). Supported, in part, by the Daniel J. Edelman grant, a gift of the Edelman family; NIH/National Heart, Lung and Blood Institute T32 HL007605 Research training in Respiratory Biology; Parker B. Francis Foundation. Drs. Patel’s, Stulberg’s, and Kemple’s institutions received funding from a Daniel Edelman grant. Dr. Patel’s institution received funding from a Parker B. Francis Foundation Career Development Award (salary support). Drs. Patel’s and Wolfe’s institutions received funding from the National Institutes of Health (NIH) T32 salary support, and they received support for article research from the NIH. Dr. Pohlman received funding from B. Braun (consultant). The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: jkress@medicine.bsd.uchicago.edu Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Dynamics of Endotoxin, Inflammatory Variables, and Organ Dysfunction After Treatment With Antibiotics in an Escherichia coli Porcine Intensive Care Sepsis Model

Objectives: To investigate the dynamics of antibiotic-induced endotoxin liberation and inflammatory response in vivo in a clinically relevant large animal intensive care sepsis model and whether the addition of an aminoglycoside to a β-lactam antibiotic affects these responses. Design: Prospective, placebo-controlled interventional experimental study. Setting: University research unit. Subjects: Thirty-six healthy pigs administered Escherichia coli as a 3-hour infusion. Interventions: After 2 hours, during E. coli infusion, the animals were exposed to cefuroxime alone, the combination of cefuroxime and tobramycin, or saline. Measurements and Main Results: Plasma endotoxin, interleukin-6, tumor necrosis factor-α, leucocytes, and organ dysfunction were recorded for 4 hours after antibiotic treatment, and differences to the values before treatment were calculated. In vitro experiments were performed to ascertain whether endotoxin is released during antibiotic-induced bacterial killing of this E. coli strain. Despite differences between the treatment arms in vitro, no differences in plasma endotoxin were observed in vivo. Antibiotic-treated animals demonstrated a higher interleukin-6 response (p

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Emergency Reporting releases ‘Ten Useful Apps for First Responders’ e-book

New e-book highlights ten mobile apps for firefighters and EMS personnel. BELLINGHAM, Wash. — Emergency Reporting (ER), a leader in cloud-based Fire and EMS records management, has released a free e-book titled “Ten Useful Apps for First Responders.” The e-book, available for download on the ER website, features an app on each page, including a summary, screenshots, a list of useful ...

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Removal of totally implanted venous access ports for suspected infection in the intensive care unit: a multicenter observational study

While no data support this practice, international guidelines recommend the removal of totally implanted venous access ports (TIVAPs) in patients with suspicion of TIVAP-related bloodstream infection admitted ...

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Prevent controlled substance diversion with a digital record of entry

Careful monitoring, witnessed documentation and a record of any actions will protect controlled substances in the ambulance from theft

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Subacute Combined Degeneration from Recreational Nitrous Oxide Inhalation

Publication date: Available online 27 March 2018
Source:The Journal of Emergency Medicine
Author(s): Michael U. Antonucci




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Neurosyphilis as a Cause of Transverse Myelitis in a Teenage Girl

Publication date: Available online 27 March 2018
Source:The Journal of Emergency Medicine
Author(s): Karen Kim Jo Yaphockun, Shannon Wai
BackgroundSyphilis is a sexually transmitted infection that was nearly eradicated in 2001 but is now making a resurgence. It has a wide range of clinical manifestations depending on disease stage. Neurosyphilis is an infrequently seen infectious disease with central nervous system involvement that can occur in either early- or late-stage syphilis. The diagnosis of neurosyphilis is challenging, primarily because Treponema pallidum, the infecting organism, cannot be cultured in vitro. This article describes a patient with neurosyphilis and reviews the epidemiology and clinical manifestations, diagnostics, and treatment of neurosyphilis.Case ReportIn compliance with the request of the Privacy Board of our institution, the numerical age of this patient has been omitted. A sexually active teenage girl who was treated for primary syphilis 2 years earlier presented to a tertiary children's hospital with paresthesia and weakness of her right leg, left arm, and neck. Magnetic resonance imaging revealed cervical intramedullary cord edema consistent with transverse myelitis. Serum studies showed positive syphilis enzyme immunoassay, T. pallidum particle agglutination assay, and fluorescent treponemal antibody absorption. A serum rapid plasma reagin test was negative. A lumbar puncture was performed with normal cell count and protein. A cerebrospinal fluid Venereal Disease Research Laboratory test was negative. She was diagnosed with neurosyphilis and treated with intravenous steroids and penicillin G, with near complete resolution of symptoms.Why should an Emergency Physician Be Aware of This?The Centers for Disease Control and prevention has noted a steady rise of the incidence of syphilis since 2002. Emergency physicians should be familiar with the spectrum of the clinical manifestations of syphilis, challenges in diagnostics, and appropriate treatment course.



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Abdominal Cutaneous Nerve Entrapment Syndrome: The Cause of Localized Abdominal Pain in a Young Pregnant Woman

Publication date: Available online 27 March 2018
Source:The Journal of Emergency Medicine
Author(s): Sody A. Naimer
BackgroundDespite the broad differential diagnosis in any patient referring with symptoms involving the chest or abdomen, a small number of conditions overshadow the rest by their probability. Chest and abdominal wall pain continues to constitute a common and expensive overlooked source of pain of unknown cause. In particular, cutaneous nerve entrapment syndrome is commonly encountered but not easily diagnosed unless its specific symptoms are sought and the precise physical examination undertaken.Case ReportA primigravida woman with unbearable abdominal pain was referred repeatedly seeking a solution for her suffering. Numerous laboratory and imaging studies were employed in order to elucidate the cause of her condition. After numerous visits and unnecessary delay, the diagnosis was finally made by a physician fully versed in the field of torso wall pain. The focused physical examination disclosed abdominal cutaneous nerve entrapment syndrome as the diagnosis, and anesthetic infiltration led to immediate alleviation of her pain.Why Should an Emergency Physician Be Aware of This?Cutaneous nerve entrapment is a common cause of abdominal pain that is reached on the basis of thorough history and physical examination alone. Knowledge dissemination of the various torso wall syndromes is imperative for prompt delivery of suitable care. All emergency physicians should be fully aware of this entity because the diagnosis is based solely on physical examination, and immediate relief can be provided in the framework of the first visit. Wider recognition of this syndrome will promise that such mishaps are not repeated in the future.



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CRITICAL CARE PARAMEDIC - Community Ambulance

Community Ambulance is a 911 provider in the Southern portion of Las Vegas, NV and provides non-emergent transport within Henderson, Las Vegas, and Unincorporated Clark County. We are looking for full-time Critical Care Paramedics who are looking to work for a private agency that provides excellent pay and benefits as well as work in one of the most interesting cities in the world. Contact us for additional ...

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EMS Instructor - Lane Community College

EMS Instructor Lane Community College • First applicant review date is March 29, 2018, closes April 6, 2018 • View Job and Apply: https://ift.tt/2Ib3tGB Faculty Schedule: This position is for nine (9) months (1.0 FTE) with the expectation of approximately one (1) month or equivalent work during the summer.(With an outstanding benefits package!) Looking for a new direction for your EMS skills and ...

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EMT - Basic - First Response Ambulance

Emergency Medical Technicians-Basic (EMT-B) respond to emergency calls to provide efficient and immediate care to the critically ill and injured, and to transport the patient to a medical facility. After receiving the call from the dispatcher, the EMT-B drives the ambulance to address or location given, using the most expeditious route, depending on traffic and weather conditions. The EMT-B must observe ...

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Editors’ Preface 2018 THOR Supplement

No abstract available

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Effect of hypobaria and hyperoxia during sepsis on survival and energy metabolism

BACKGROUND Injured warfighters air evacuated to tertiary medical care facilities are subjected to many stresses that may promote the development of sepsis. In this study we tested the hypothesis that exposure to “in-flight” hypobaria and/or hyperoxia within 24 hr after onset of intra-abdominal infection in rats accelerates the development and/or severity of sepsis and neurologic injury in survivors. METHODS Sprague-Dawley rats underwent cecal ligation/puncture (CLP) or sham procedures. Twenty-four hr later, rats were then placed in hypobaric chambers for 6 hrs and assigned to normobaric conditions and maintained at either 21% or 100% O2, or under hypobaric conditions (pressure equivalent to an altitude of 8,000 ft) but maintained under either 28% or 100% O2. Two days after CLP or sham blood samples were obtained for cytokine levels, and mitochondria were isolated from the brain and heart of a subset of animals for analysis of mitochondrial oxygen consumption. Animals were also evaluated for neuromotor impairment before and 15 days post-surgery. RESULTS Among the 70 rats studied 16.7% of CLP but none of the sham-treated rats died. All of the CLP but none of the sham rats had evidence of peritonitis at 2 days. Twenty percent (6/30) CLP rats undergoing hypobaria vs. 12.5% (3/24) of CLP rats exposed to normobaria died (p=0.715) while 12% (3/25) of CLP rats exposed to hyperoxia vs. 20.7% (6/29) of CLP rats exposed to normoxia died (p=0.48). The ratio of mitochondrial ATP-generating O2consumption to resting respiration was higher in the CLP plus hypobaria under 100% compared to shams. The only difference in H2O2 production was observed in mitochondria from CLP rats exposed to hyperoxia under normobaric conditions. Composite neurologic scores obtained 15 days post-injury were lower than those at baseline for shams. CONCLUSION We conclude that neither “in-flight” hyperoxia nor hypobaria exacerbate sepsis or neurologic injury. Address for reprints: Alan S. Cross, MD, Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, USA; email: across@som.umaryland.edu This study was presented at the 2017 annual meeting of the Military Health Sciences Research Symposium, August 27-30, 2017, in Kissimmee, Florida © 2018 Lippincott Williams & Wilkins, Inc.

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Pediatric Trauma Society 2017 Presidential Address The Hippocratic Paradox: A Surgeon’s Journey to Death Row and Back

No abstract available

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Laparoscopy in a Combat Theater of Operations

No abstract available

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NeuroSurgical Workload During U.S. Combat Operations: 2002-2016

Background Approximately 4.5% of surgical procedures performed at Role 2 (forward surgical) and Role 3 (theater) medical treatment facilities can be classified as neurosurgical. These procedures are foreign to the routine daily practice of the military general surgeon. The purpose of this study is to examine the neurosurgical workload in Iraq and Afghanistan in order to inform the future predeployment neurosurgical training needs of non-neurosurgical providers. Methods Retrospective analysis of the Department of Defense Trauma Registry (DoDTR) for all Role 2 and Role 3 medical facilities, from January 2002 to May 2016. The 103 neurosurgical ICD-9-CM procedure codes identified were grouped by anatomic location. Select groups were further subdivided. Data analysis used Stata Version 14 (College Station, Texas). Results A total of 7,509 neurosurgical procedures were identified. The majority (7,244, 96.5%) occurred at Role 3 theatre hospitals. Cranial procedures were the most common at both Role 2 (120, 45.3%) and Role 3 (4,483, 61.9%), with craniotomy/craniectomy the most frequent procedure. Spine procedures were performed almost exclusively at Role 3, with 61.1% being fusions/stabilizations, and 26.9% being spinal decompression alone. Neurosurgical caseload was variable over the 15 year study period, dropping to almost zero in 2016. Conclusions Neurosurgical procedures were performed primarily at larger Role 3 theatre hospitals where neurosurgeons were assigned if present in theater; however, over 100 cranial procedures were performed at forward Role 2s where neurosurgeons were not deployed. Considering that neurosurgeons are not everywhere available within the war zone, deploying general surgeons should have familiarity with trauma neurosurgery. Level of Evidence Level III, Epidemiologic study Correspondence: Caryn Turner, MPH, Joint Trauma System, San Antonio Military Medical Center, 3698 Chambers Pass, Bldg. 3611, Ft. Sam Houston, Texas 78234-7767. Phone: 888-422-2007, Ext. 313. Fax: 210-539-8215. Email: Caryn.A.Turner.ctr@mail.mil; Caryn.A.Turner@gmail.com Conflict of Interest: The authors declare no conflicts of interest. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army, Department of the Navy or the Department of Defense. Presentations: Quick Shot: 31st Annual Meeting of the Eastern Association for the Surgery of Trauma, January 9-13, 2018 in Lake Buena Vista, Florida. © 2018 Lippincott Williams & Wilkins, Inc.

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Geriatric traumatic brain injury – What we know and what we don’t

The issue of geriatric trauma is a significant and growing concern among trauma surgeons. The outcomes of geriatric patients with traumatic brain injury are worse than younger cohorts and the number of traumatic brain injury (TBI)-related hospitalizations and fatalities in elderly patients will continue to increase as the world’s population ages. Although guidelines for the treatment of TBI have been established, they do not address the challenges of managing TBI in older patients. Issues of anticoagulation reversal, confounding of clinical exam by premorbid conditions, and optimal timing and frequency of imaging remain poorly studied. Additionally, current guidelines for optimal management of blood pressure, intracranial monitoring, cerebral perfusion pressure and operative management fail to address the unique concerns in the geriatric patient. Prognostication of acceptable outcomes in older patients with TBI is more challenging compared to younger cohorts and require early palliative care approaches targeted to the geriatric patient. Geriatric-specific research is sorely needed in nearly all aspects of TBI care. Given the paucity of data available, this non-systematic review seeks to outline the unique considerations of the geriatric patient with TBI and highlight what is currently unknown about the best way to care for elderly patients with TBI. Corresponding Author Contact Information: Deborah M. Stein, MD, MPH, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Baltimore, MD, 21201, (410) 328-3495 Conflict of Interest Statements None of the authors has any conflict of interest to report Funding Statement This was not funded. © 2018 Lippincott Williams & Wilkins, Inc.

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Video: Self-flying drones could serve as emergency responders

“Swarm drones” can navigate themselves and coordinate with each other, making them potentially useful for high-level rescue missions and more

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Does Your SOP Need Updating?

Your standard operating procedure doesn't have to change. It just needs updating. Incorporate DeconTect decontamination products to modernize your decon systems. Brought to you by First Line Technology.

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Blunt traumatic injury during pregnancy: a descriptive analysis from a level 1 trauma center

Abstract

Purpose

The precise incidence of trauma in pregnancy is not well-known, but trauma is estimated to complicate nearly 1 in 12 pregnancies and it is the leading non-obstetrical cause of maternal death.

Methods

A retrospective study of all pregnant women presented to national level 1 trauma center from July 2013 to June 2015 was conducted. Descriptive and inferential statistics applied for data analysis.

Results

Across the study period, a total of 95 pregnant women were presented to the trauma center. The average incidence rate of traumatic injuries was 250 per 1000 women of childbearing age presented to the Hamad Trauma Center. The mean age of patients was 30.4 ± SD 5.6 years, with age ranging from 20 to 42 years. The mean gestational age at the time of injury was 24.7 ± 8.7 weeks which ranged from 5 to 37 weeks. The majority (47.7%) was in the third trimester of the pregnancy. In addition, the large majority of injuries was due to MVCs (74.7%) followed by falls (15.8%).

Conclusions

Trauma during pregnancy is not an uncommon event particularly in the traffic-related crashes. As it is a complex condition for trauma surgeons and obstetrician, an appropriate management protocol and multidisciplinary team are needed to improve the outcome and save lives of both the mother and fetus.

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Does Your SOP Need Updating?

Your standard operating procedure doesn't have to change. It just needs updating. Incorporate DeconTect decontamination products to modernize your decon systems. Brought to you by First Line Technology.

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Nucleated red blood cells as predictors of mortality in patients with acute respiratory distress syndrome (ARDS): an observational study

Nucleated red blood cells (NRBCs) in critically ill patients are associated with increased mortality and poor outcome. The aim of the present study was to evaluate the predictive value of NRBCs in patients wit...

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Hyperchloraemia in sepsis

Chloride represents—quantitatively—the most prevalent, negatively charged, strong plasma electrolyte. Control of chloride concentration is a probable major mechanism for regulating the body’s acid–base balance...

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In-hospital and day-120 survival of critically ill solid cancer patients after discharge of the intensive care units: results of a retrospective multicenter study—A Groupe de recherche respiratoire en réanimation en Onco–Hématologie (Grrr-OH) study

To assess outcomes at hospital discharge and day-120 after intensive care unit (ICU) discharge among patients with solid cancer admitted to ICU and to identify characteristics associated with in-hospital and d...

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Does Your SOP Need Updating?

Your standard operating procedure doesn't have to change. It just needs updating. Incorporate DeconTect decontamination products to modernize your decon systems. Brought to you by First Line Technology.

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Does Your SOP Need Updating?

Your standard operating procedure doesn't have to change. It just needs updating. Incorporate DeconTect decontamination products to modernize your decon systems. Brought to you byFirst Line Technology.

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Pre-hospital extra-corporeal cardiopulmonary resuscitation

Survival from out-of-hospital cardiac arrest (OHCA) has remained low despite advances in resuscitation science. Hospital-based extra-corporeal cardiopulmonary resuscitation (ECPR) is a novel use of an establis...

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Trauma facilities in Denmark - a nationwide cross-sectional benchmark study of facilities and trauma care organisation

Trauma is a leading cause of death among adults aged

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The impact of direct oral anticoagulants in traumatic brain injury patients greater than 60-years-old

Traumatic brain injury (TBI) is the leading cause of death among trauma patients. Patients under antithrombotic therapy (ATT) carry an increased risk for intracranial haematoma (ICH) formation. There is a pauc...

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Emergency Tracheal Intubation in an Ankylosing Spondylitis Patient in a Sitting Position Using an Airway Scope Combined with Face-to-Face and Digital Intubation

Publication date: Available online 26 March 2018
Source:The Journal of Emergency Medicine
Author(s): Pei-Shing Hsieh, Hon-Ping Ma, Chung-Shun Wong, Jiann Ruey Ong
BackgroundEmergency intubation in a patient with advanced ankylosing spondylitis (AS) who presents with severe thoracic kyphosis deformity, rigid cervical flexion deformity of the neck, and an inability to achieve the supine position is particularly challenging to emergency physicians.Case ReportThis study reports on an AS patient presenting with these difficult airway characteristics and acute respiratory failure who was successfully intubated using video laryngoscope-assisted inverse intubation (II) and blind digital intubation (BDI). By using Pentax AirwayScope-assisted inverse intubation, the tracheal tube tip was passed through the glottic opening, but an unexpected resistance occurred during tube advancement, which was overcome by subsequent BDI. By using laryngoscope-assisted II complemented by the BDI technique, the patient was successfully intubated without complications.Why Should an Emergency Physician Be Aware of This?Our case demonstrated that these two emergency airway management techniques are valuable backup methods and complement each other when applied to certain unstable airways, especially when the traditional patient position is not easily accomplished. Unexpected difficulty is not rare during airway management; emergency physicians should always be well prepared both mentally and practically.



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Be prepared for any mass casualty incident with AmbuBus

Quickly and easily retrofit buses and other vehicles of opportunity into mass casualty transport and evacuation vehicles. The AmbuBus Kit from First Line Technology is an effective and efficient solution for all of your mass casualty transport needs.

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Be prepared for any mass casualty incident with AmbuBus

Quickly and easily retrofit buses and other vehicles of opportunity into mass casualty transport and evacuation vehicles. The AmbuBus Kit from First Line Technology is an effective and efficient solution for all of your mass casualty transport needs.

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Be prepared for any mass casualty incident with AmbuBus

Quickly and easily retrofit buses and other vehicles of opportunity into mass casualty transport and evacuation vehicles. The AmbuBus Kit from First Line Technology is an effective and efficient solution for all of your mass casualty transport needs.

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Be prepared for any mass casualty incident with AmbuBus

Quickly and easily retrofit buses and other vehicles of opportunity into mass casualty transport and evacuation vehicles. The AmbuBus Kit from First Line Technology is an effective and efficient solution for all of your mass casualty transport needs.

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Firemedic - City of Seminole

**FIREMEDIC (Firefighter/Paramedic):** The City of Seminole Fire Rescue Department is seeking qualified candidates for the position of Firefighter/Paramedic working 24/48 hour shift work. The starting salary is $45,500.00/year and a competitive benefits package is provided. At time of oral interview, applicant must possess valid Florida Paramedic certification or be actively enrolled in a Florida Paramedic ...

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Watch: Paramedic to release movie to inspire future EMTs

By EMS1 Staff BATON ROUGE, La. — A paramedic and filmmaker is set to release a movie he hopes will inspire younger generations to join the EMS industry. Baton Rouge Proud reported that paramedic David Jarreau’s new film, “Unit 68,” tells the story of a young boy who finds a mysterious ambulance and meets his future self inside. Jarreau said his goal with the movie is to inspire ...

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Moving beyond the 'standard' 12-lead ECG

There's more to a diagnostic ECG than just 12-leads, and there's more to a 12-lead than just ST-Elevation

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Rick Santorum: Students should learn CPR, not seek gun laws

Santorum's comments prompted outrage on social media a day after hundreds of thousands of teenagers and their supporters rallied across the U.S.

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PulmCrit- APROCCHSS vs. ADRENAL: Are we asking the right question?

ADRENAL and APROCCHSS were both designed with mortality as a primary endpoint.  They reached opposite conclusions:  steroid had no effect on mortality in ADRENAL, whereas it improved mortality in APROCCHSS.  Why?

EMCrit Project by Josh Farkas.

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PulmCrit- APROCCHSS vs. ADRENAL: Are we asking the right question?

ADRENAL and APROCCHSS were both designed with mortality as a primary endpoint.  They reached opposite conclusions:  steroid had no effect on mortality in ADRENAL, whereas it improved mortality in APROCCHSS.  Why?

EMCrit Project by Josh Farkas.

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What Faces Reveal: A Novel Method to Identify Patients at Risk of Deterioration Using Facial Expressions

Objectives: To identify facial expressions occurring in patients at risk of deterioration in hospital wards. Design: Prospective observational feasibility study. Setting: General ward patients in a London Community Hospital, United Kingdom. Patients: Thirty-four patients at risk of clinical deterioration. Interventions: A 5-minute video (25 frames/s; 7,500 images) was recorded, encrypted, and subsequently analyzed for action units by a trained facial action coding system psychologist blinded to outcome. Measurements and Main Results: Action units of the upper face, head position, eyes position, lips and jaw position, and lower face were analyzed in conjunction with clinical measures collected within the National Early Warning Score. The most frequently detected action units were action unit 43 (73%) for upper face, action unit 51 (11.7%) for head position, action unit 62 (5.8%) for eyes position, action unit 25 (44.1%) for lips and jaw, and action unit 15 (67.6%) for lower face. The presence of certain combined face displays was increased in patients requiring admission to intensive care, namely, action units 43 + 15 + 25 (face display 1, p

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Intra-Abdominal Hypertension Is More Common Than Previously Thought: A Prospective Study in a Mixed Medical-Surgical ICU

Objectives: To determine the prevalence of intra-abdominal hypertension in mixed medical-surgical critically ill patients using modern definitions and measurement techniques. Secondarily to determine variables associated with intra-abdominal hypertension and ICU mortality. Design: A prospective observational study. Setting: Single institution trauma, medical and surgical ICU in Canada. Patients: Consecutive adult patients admitted to the ICU (n = 285). Intervention: Intra-abdominal pressure measurements twice a day during admission to the ICU. Measurements and Main Results: In 285 patients who met inclusion criteria, 30% were diagnosed with intra-abdominal hypertension at admission and a further 15% developed intra-abdominal hypertension during admission. The prevalence of abdominal compartment syndrome was 3%. Obesity, sepsis, mechanical ventilation, and 24-hour fluid balance (> 3 L) were all independent predictors for intra-abdominal hypertension. Intra-abdominal hypertension occurred in 28% of nonventilated patients. Admission type (medical vs surgical vs trauma) was not a significant predictor of intra-abdominal hypertension. Overall ICU mortality was 20% and was significantly higher for patients with intra-abdominal hypertension (30%) compared with patients without intra-abdominal hypertension (11%). Intra-abdominal hypertension of any grade was an independent predictor of mortality (odds ratio, 3.33; 95% CI, 1.46–7.57). Conclusions: Intra-abdominal hypertension is common in both surgical and nonsurgical patients in the intensive care setting and was found to be independently associated with mortality. Despite prior reports to the contrary, intra-abdominal hypertension develops in nonventilated patients and in patients who do not have intra-abdominal hypertension at admission. Intra-abdominal pressure monitoring is inexpensive, provides valuable clinical information, and there may be a role for its routine measurement in the ICU. Future work should evaluate the impact of early interventions for patients with intra-abdominal hypertension. This work was performed at the London Health Sciences Centre and Western University. Trial Registration: ClinicalTrials.gov NCT02514135. Drs. Murphy, Parry, Leslie, Vogt, and Ball participated in study design and served as content experts in the field. Data collection was performed by Drs. Murphy and Sela, and analysis was performed by Dr. Murphy. Dr. Vogt also reviewed and repeated the data analysis. All authors contributed to and reviewed the final article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (https://ift.tt/29S62lw). Supported, in part, by resident research grant from the Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada. Presented, in part, at the 2016 American Association for the Surgery of Trauma Conference, Hawaii, HI, September 14, 2016. Dr. Murphy received funding from Western University. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: patrick.murphy@londonhospitals.ca Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Woman recalls trying to save life of stranger hit by truck

Former corrections officer Faith Appelgren and a trauma nurse performed CPR on the victim in the middle of the road while responders were stuck in traffic

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How web-based ePCR provides a long-term solution for Miramar Fire-Rescue

Electronic health records and other reporting tools from ESO Solutions helped streamline documentation at a pioneering Florida agency

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Could resuscitative endovascular balloon occlusion of the aorta improve survival among severely injured patients with post-intubation hypotension?

Abstract

Current literature shows the association of post-intubation hypotension and increased odds of mortality in critically ill non-trauma and trauma populations. However, there is a lack of research on potential interventions that can prevent or ameliorate the consequences of endotracheal intubation and thus improve the prognosis of trauma patients with post-intubation hypotension. This review paper hypothesizes that the deployment of REBOA among trauma patients with PIH, by its physiologic effects, will reduce the odds of mortality in this population. The objective of this paper is to review the current literature on REBOA and post-intubation hypotension, and, furthermore, to provide a rational hypothesis on the potential role of REBOA in severely injured patients with post-intubation hypotension.

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Using ultrasound for firefighter health and wellness programs

Consider incorporating this diagnostic tool into firefighter physicals to support early diagnosis and intervention that can save lives

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Review of 14 drowning publications based on the Utstein style for drowning

The Utstein style for drowning (USFD) was published in 2003 with the aim of improving drowning research. To support a revision of the USFD, the current study aimed to generate an inventory of the use of the US...

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Some Vt. rural cell service, including 911, could end

It will be challenge to find a replacement, state officials said, but they are working on it

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Decision-making for complex scapula and ipsilateral clavicle fractures: a review

Abstract

Introduction

Complex scapula with ipsilateral clavicle fracures remains a challange and treatment recommendations are still missing.  This review provides an overview of the evolution of the definition, classification and treatment strategies for complex scapula and ipsilateral clavicle fractures. As with other rare conditions, consensus has not been reached on the most suitable management strategies to treat these patients. The aim of this review is twofold: to compile and summarize the currently available literature on this topic, and to recommend treatment approaches.

Materials and methods

Included in the review are the following topics: biomechanics of scapula and ipsilateral clavicle fractures, preoperative radiological evaluation, surgical treatment of the clavicle only, surgical treatment of both the clavicle and scapula, and nonsurgical treatment options.

Results

A decision-making algorithm is proposed for different treatment strategies based on pre-operative parameters, and an example of a case treated our institution is presented to illustrate use of the algorithm.

Discussion

The role of instability in complex scapula with ipsilateral clavicle fractures remains unclear. The question of stability is preoperatively less relevant than the question of whether the dislocated fragments lead to compromised shoulder function.

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EMS From a Distance: Language and prose on the offensive

Long before I recorded my first blood pressure as an EMT, I was a hockey writer for a now-defunct monthly magazine. Our 1973 Stanley Cup Playoffs issue included my predictions about which players would disappoint. Non-clairvoyants like me who write such nonsense guess wrong a lot, like when I said New York Rangers’ goaltender Ed Giacomin would be the “goat” of his team’s opening ...

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Causes of Emergency Department Overcrowding and Blockage of Access to Critical Services in Beijing: A 2-Year Study

Publication date: Available online 21 March 2018
Source:The Journal of Emergency Medicine
Author(s): Zhen Wang, Xiaying Xiong, Shuang Wang, Junguo Yan, Martin Springer, R.P. Dellinger
BackgroundEmergency department (ED) overcrowding is a serious issue worldwide.ObjectivesThis study was done to evaluate the degree of overcrowding in local “teaching hospitals” in Beijing, and to ascertain the apparent root causes for the pervasive degree of overcrowding in these EDs.MethodsThis is a multicenter cross-sectional study. The studied population included all ED patients from 18 metropolitan teaching hospital EDs in Beijing for calendar years 2013 and 2014. Patient characteristics, and the primary reasons that these patients sought care in these EDs, are described.ResultsThe total numbers of annual emergency visits were 1,554,387 and 1,615,571 in 2013 and 2014, respectively. High acuity cases accounted for 4.6% and 5.5% of the total annual emergency visits in 2013 and 2014, respectively. The percentage of patients placed into “Observation” beds, which were created to accommodate patients deemed to have problems too complex to be treated in an inpatient bed, or to accommodate patients simply needing chronic care, was 11.9% and 13.1% in 2013 and 2014, respectively. The ED-boarded patients accounted for 2.71% and 2.6% of the total annual emergency visits in 2013 and 2014, respectively. The average waiting time to admit the ED-boarded patients was 37.1 h and 36.2 h in 2013 and 2014, respectively. Respiratory symptoms were the most common presenting complaints, and an upper respiratory infection was the most common ED diagnosis. Patients who had pneumonia or various manifestations of end-stage diseases, such as advanced dementia or multiple organ dysfunction, were the most common characteristics of patients who had stays in “Observation” units.ConclusionsOne principal reason for ED crowding in Beijing lies in the large numbers of patients who persist in the expectation of receiving ongoing care in the ED for minor illnesses. However, as is true in many nations, one of the other most important root causes of ED crowding is “access block,” the inability to promptly move patients deemed by emergency physicians to need inpatient care to an inpatient bed for that care. However, in our system, another challenge, not widely described as a contributor to crowding in other nations, is that doctors assigned to inpatient services have been empowered to refuse to admit patients perceived to have overly “complex” needs. Further, patients with multisystem illnesses or end-stage status, who need ongoing chronic care to manage activities of daily living, have begun to populate Beijing EDs in increasing numbers. This is an issue with various root causes.



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Medic Mindset Podcast: A flight medic's passion for free medical education

In this episode of Medic Mindset, Ginger Locke interviews Tyler Christifulli. Christifulli is a flight medic, an EMS educator and an EMS podcast creator. He and Ginger share a passion for podcasting and free online access medical education (FOAMed). In this episode, they discuss: The three signs that indicate cardiac arrest is imminent. What five medications Christifulli would want on his ambulance/helicopter ...

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The alcohol-intoxicated trauma patient: impact on imaging and radiation exposure

Abstract

Introduction

The purpose of this study was to investigate the effects of alcohol intoxication in trauma patients in regard to its impact on application of computed tomography (CT) and associated radiation exposure.

Methods

We conducted a retrospective study from a continuous patient cohort. Inclusion criteria: admission to the emergency room of an urban Level 1 trauma center with trauma team activation during a 12-month period (Jan 1st–Dec 31st 2012). Patients with incomplete data, age ≤ 12 years and with neurological diseases were excluded. Demographics, mechanisms, severity and patterns of injury (Abbreviated Injury Scale, Injury Severity Score, Glasgow Coma Scale), blood alcohol concentration (BAC, in permille, ‰), imaging studies (head/whole body CT), radiation exposure, and hospital length of stay, surgical procedures and mortality were evaluated with SPSS statistics (Version 25, IBM Inc., Armonk, New York).

Results

A positive BAC (mean 1.80 ± 0.767) was reported in 19.2% (n = 41/214) of the cohort. Alcohol intoxication was associated with higher utilization of head CT (65.9 vs. 46.8%, p = 0.017) and radiation exposure (231.75 vs. 151.25 mAS, p = 0.045; dose-length product, 583.03 vs. 391.04, p = 0.006). In general, the presence of alcohol was associated with over-triage (p = 0.001), despite minor injury severity (ISS < 9) and a comparable rate of head injuries (p = 0.275). Head injury (AIS ≥ 3) and positive BAC (OR 2.34, 95% CI 1.096–5.001) were identified as strongest independent predictors for head CT.

Conclusion

Alcohol intoxication is a common finding in trauma patients, and the rate of moderate and serious head injuries seems to be comparable to a more severely injured control group. Furthermore, head CT utilization in intoxicated patients is associated with significant radiation exposure, despite poor image quality, due to motion artifacts (27%). Future strategies are required to exclude head injuries safely, while reducing the rate of head CT and associated radiation exposure in intoxicated patients.

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Potentially modifiable respiratory variables contributing to outcome in ICU patients without ARDS: a secondary analysis of PRoVENT

The majority of critically ill patients do not suffer from acute respiratory distress syndrome (ARDS). To improve the treatment of these patients, we aimed to identify potentially modifiable factors associated...

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Wife saves her firefighter husband's life with CPR

Jessica Pichette said she thought her husband, Capt. Luke Pichette, was having a stroke when he began making strange noises before bed

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How Children’s Hospital of Omaha achieved interoperability between EMS and hospital patient data

Struggling with a documentation system that left providers with incomplete data, one EMS leader found a solution that works for both her team and her hospital

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Determinants of Lactic Acidosis in Acute Cyanide Poisonings

Objectives: To investigate the magnitude of lactic acidosis in response to cyanide poisoning compared with the secondary response caused by cardiovascular shock. Design: Retrospective case-control observational study. Setting: University Hospital of Assistance Publique – Hôpitaux de Paris. Subjects: Patients admitted for suspicion of cyanide poisoning or drug overdose. Medical charts provided by Assistance Publique - Hôpitaux de Paris of patients between January 1988 and December 2015. Intervention: None. Measurements and Main Results: Twelve cyanide poisoned patients were matched to 48 controls by age, sex, systolic blood pressure, catecholamine administration, and outcome at discharge from ICU. Extracted data included age, sex, vital signs, symptoms, biochemical parameters, toxicological analysis, treatment, and outcome. Non-parametric tests were used. Multivariable analysis was used to adjust for confounders causing hyperlactacidemia. The median blood lactate concentration was significantly greater in the cyanide group (15.6 mmol/L) compared to the control group (4.1 mmol/L; p = 0.0003). Similarly, blood lactate concentration greater than or equal to 8 mmol/l was observed in 83% of the cyanide cases versus 27% of the matched controls. Multivariate analysis conferred hyperlactacidemia as the lone factor which significantly predicted cyanide poisoning at an odds of 73.0 (5.7-936.1). Moreover, blood cyanide level significantly correlated with the increase of blood lactate (p = 0.0033). Conclusions: This study supports the hypothesis lactic acidosis primarily results from the direct toxicity of cyanide. Dr. Baud was expert consultant at Merck-Serono, the Pharmaceutical Company who developed hydroxocobalamin, his consultancy ended in late 2013. Dr. Baud did not receive any payment for writing the article. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail address: baud.frederic@wanadoo.fr Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Extensive Myocardial Calcification in Critically Ill Patients

Objectives: To describe an unusual complication on extracorporeal membrane oxygenation. Data Sources: Clinical observation. Study Selection: Case report. Data Extraction: Relevant clinical information. Data Synthesis: We report the cases of three young patients who developed extensive myocardial calcifications on prolonged extracorporeal membrane oxygenation support for severe acute respiratory distress syndrome with septic cardiomyopathy, postresuscitation cardiogenic shock, and septic shock complicating severe acute respiratory distress syndrome, respectively. Extensive myocardial calcifications were confirmed by echocardiography, CT, and cardiac biopsy. The combination of multiple factors, for example, prolonged hemodynamic failure, profound acidosis, high vasopressor doses, and renal failure, may lead to this unusual and severe complication. Conclusions: Intensivists should be aware of this rare but rapid complication on extracorporeal membrane oxygenation support that may directly impact outcome. The precise role of extracorporeal membrane oxygenation support in the timing and frequency of new-onset diffuse myocardial calcification deserves further investigation. Dr. Fouret received funding from Office National d’Indemnisation des Accidents médicaux. Dr. Luyt’s institution received funding from Bayer Healthcare, and he received funding from Bayer Healthcare and MSD. The remaining authors have disclosed that they do not have any potential conflicts of interest. Address requests for reprints to: Matthieu Schmidt, MD, PhD, Service de Réanimation Médicale, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, 47, bd de l’Hôpital, Paris, France. E-mail: matthieu.schmidt@aphp.fr Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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EMS on the Hill: The importance of political advocacy

By Allison G. S. Knox, EMT-B, faculty member at American Military University Emergency medical services are a critically important part of public safety, but its voice is not as loud as that of other healthcare entities, such as insurance providers, pharmaceutical companies and hospital networks. There needs to be considerably more support for EMS – both from those working in the profession as ...

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Should pre-hospital resuscitative thoracotomy be reserved only for penetrating chest trauma?

Abstract

Purpose

The indications for pre-hospital resuscitative thoracotomy (PHRT) remain undefined. The aim of this paper is to explore the variation in practice for PHRT in the UK, and review the published literature.

Methods

MEDLINE and PUBMED search engines were used to identify all relevant articles and 22 UK Air Ambulance Services were sent an electronic questionnaire to assess their PHRT practice.

Results

Four European publications report PHRT survival rates of 9.7, 18.3, 10.3 and 3.0% in 31, 71, 39 and 33 patients, respectively. All patients sustained penetrating chest injury. Six case reports also detail survivors of PHRT, again all had sustained penetrating thoracic injury. One Japanese paper presents 34 cases of PHRT following blunt trauma, of which 26.4% survived to the intensive therapy unit but none survived to discharge. A UK population reports a single survivor of PHRT following blunt trauma but the case details remain unpublished. Ten (45%) air ambulance services responded, each service reported different indications for PHRT. All perform PHRT for penetrating chest trauma, however, length of allowed pre-procedure down time varied, ranging from 10 to 20 min. Seventy percent perform PHRT for blunt traumatic cardiac arrest, a procedure which is likely to require aggressive concurrent circulatory support, despite this only 5/10 services carry pre-hospital blood products.

Conclusions

Current indications for PHRT vary amongst different geographical locations, across the UK, and worldwide. Survivors are likely to have sustained penetrating chest injury with short down time. There is only one published survivor of PHRT following blunt trauma, despite this, PHRT is still being performed in the UK for this indication.

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Can We Finally Dispense With Ketamine's Many Myths?

Publication date: Available online 21 March 2018
Source:The Journal of Emergency Medicine
Author(s): Joshua Hurwitz




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ER program aims to catch patients bouncing from one to another

Dr. Scott Weiner’s PreManage ED project aims to coordinate better care for “high risk and complex patients” who regularly visit several ERs

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An Exploratory Study of Sevoflurane as an Alternative for Difficult Sedation in Critically Ill Children

Objectives: To analyze the effectiveness of inhaled sevoflurane in critically ill children with challenging sedation. Design: Prospective case series. Setting: Two PICUs of university hospitals in Spain. Interventions: Prospective observational study and exploratory investigation conducted in two PICUs in Madrid, Spain, over a 6-year period. Children treated with inhaled sevoflurane due to difficult sedation were included. Sevoflurane was administered via the anesthetic conserving device (AnaConDa) connected to a Servo-I ventilator (Maquet, Solna, Sweden). A morphine infusion was added to sevoflurane for analgesia. Demographic and clinical data, oral and IV sedatives, Sedation and Analgesic Clinical scores, and Bispectral Index Score monitoring were registered. Measurements and Main Results: Twenty-three patients with a median age of 6 months old were included. Fifty percentage of the patients had critical heart diseases. Sedative and analgesic drugs used before starting sevoflurane were mainly midazolam (63%) and fentanyl (53%). Six patients (32%) also received muscle relaxants. Sevoflurane was administered for a median of 5 days (interquartile range, 5.5–8.5 d). Median end-tidal sevoflurane concentration was 0.8% (interquartile range, 0.7–0.85%), achieved with an infusion rate of 7.5 mL/hr (5.7–8.6 mL/hr). After 48 hours of treatment, some sedative drugs could be removed in 18 patients (78%). Median Bispectral Index Score value prior to sevoflurane administration was 61 (interquartile range, 49–62), falling to 42 (interquartile range, 41–47; p

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PulmCrit Wee- Secondary endpoints: Can we separate the wheat from the chaff?

This post will attempt to create a rough framework for analyzing secondary endpoints.  This is primarily intended as a springboard for debate, rather than a final answer to this thorny issue (one which has remained unresolved for decades).

EMCrit Project by Josh Farkas.

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PulmCrit Wee- Secondary endpoints: Can we separate the wheat from the chaff?

This post will attempt to create a rough framework for analyzing secondary endpoints.  This is primarily intended as a springboard for debate, rather than a final answer to this thorny issue (one which has remained unresolved for decades).

EMCrit Project by Josh Farkas.

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Paramedic - Falck Rocky Mountain

Falck Rocky Mountain is proud to be the exclusive emergency ambulance provider for the City of Aurora, Colorado. Following a competitive bid process, Falck was recommended unanimously as the provider of choice by a committee of local hospital representatives, fire department subject matter experts, and City of Aurora management and finance staff. With our innovative public/private partnership with Aurora ...

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Paramedic Part Time - Dodge Center Ambulance

General Duties: The City of Dodge Center is accepting applications for the position of part-time Paramedic with Dodge Center Ambulance. This position is responsible for emergency response, treatment and transport of the sick and injured and will assist with the day to day operations of the ambulance service to include cleaning, stocking, training and education, mentoring, and public outreach.

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Mercury Medical announces new agreement with Henry Schein Medical to expand the EMS market distribution of airway management product lines

CLEARWATER, Fla. — Doug Smith, Mercury’s VP of Sales & Marketing, is pleased to announce that Mercury Medical has signed an agreement with Henry Schein Medical, the U.S. medical division of Henry Schein, Inc., to represent the company’s Airway Management Devices in the United States’ Emergency Medical Services (EMS) market. Effective January 1, 2018, the EMS business of Henry ...

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EMCrit RACC Podcast 220 – Beat the Stress Fool with Mike Lauria — Just In Time Performance-Enhancing Psychological Skills

Beat The Stress Fool!

EMCrit Project by Scott Weingart.

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EMCrit RACC Podcast 220 – Beat the Stress Fool with Mike Lauria — Just In Time Performance-Enhancing Psychological Skills

Beat The Stress Fool!

EMCrit Project by Scott Weingart.

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How to avoid the most common active shooter training mistakes

Great active shooter incident training takes a concerted effort to make exercises real, relevant, interesting and captivating for all participants

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How to avoid the most common active shooter training mistakes

Active shooter training exercises are becoming more commonplace across the country; which is a good thing. However, without proper planning, many of these well-meaning exercises leave the responders no better off than before or possibly even worse. A strong, multi-discipline exercise design team, a solid exercise plan and buy in from the responding disciplines are critical ingredients for success. Use ...

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EMS Pioneers: A Minnesota medic marks 40 years in EMS

When the Woodbury, Minn., fire department needed volunteers in 1978, John Dillon was ready to serve. “I grew up in the Johnny-and-Roy era,” says Dillon, then a 17-year-old EMT. “‘Emergency!’” was my introduction to EMS. I drank the Kool-Aid about saving lives and couldn’t wait to get started.” There was just one problem: John was still in high school ...

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TRAUMA SURGEON PERFORMANCE OF APPENDECTOMY IN 5-10 YEAR-OLD CHILDREN IS SAFE AND DECREASES LENGTH OF HOSPITAL STAY

Background Even in metropolitan areas, on-call pediatric surgeons may not always be immediately available for surgical care of appendicitis, potentially leading to delays in care. In 2012, the in-house trauma group at a suburban Level 1 trauma center (none with formal pediatric fellowship training) assumed surgical care of 5-10 year-old children with appendicitis, who had previously been cared for by pediatric surgeons. We propose to compare the outcomes of the trauma and pediatric surgery groups. Methods Retrospective chart review of 5-10 year-olds undergoing emergency appendectomy at a suburban Level 1 trauma center between January, 2007 and December, 2016 was performed. Patients were classified as having surgery performed by the trauma surgery group or the pediatric surgery group. Patient characteristics, clinical course, and outcomes were compared. Results A total of 220 patients were identified for study, 138 in the trauma group and 82 in the pediatric surgery group. Patients cared for by the trauma group were more likely to be female (47% vs. 32%; p=0.03), were less likely to be diagnosed without imaging (2% vs. 26%; p

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Direct to Operating Room Trauma Resuscitation Decreases Mortality Among Severely Injured Children

Background Expediting evaluation and intervention for severely injured patients has remained a mainstay of advanced trauma care. One technique, direct to operating room (DOR) resuscitation, for selective adult patients has demonstrated decreased mortality. We sought to investigate the application of this protocol in children. Methods All DOR pediatric patients from 2009–2016 at a pediatric Level I Trauma Center were identified. DOR criteria included penetrating injury, chest injuries, amputations, significant blood loss, cardiopulmonary resuscitation, and surgeon discretion. Demographics, injury patterns, interventions, and outcomes were analyzed. Observed mortality was compared to expected mortality, calculated using Trauma Injury Severity Score (TRISS) methodology, with two-tailed t-tests and a p-value 15, 33% had GCS≤8, and 9% were hypotensive. The most commonly injured body regions were external (66%), head (34%), chest (30%), and abdomen (27%). Sixty-seven patients (82%) required emergent procedural intervention, most commonly wound exploration/repair (35%), central venous access (22%), tube thoracostomy (19%) and laparotomy (18%). Predictors of intervention were ISS>15 (odds ratio=14, p=0.013) and GCS

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Pre-hospital Low Titer Cold Stored Whole Blood: Philosophy for Ubiquitous Utilization of O Positive Product for Emergency Use in Hemorrhage due to Injury

The mortality from hemorrhage in trauma patients remains high. Early balanced resuscitation improves survival. These truths, balanced with the availability of local resources and our goals for positive regional impact, were the foundation for the development of our pre-hospital whole blood initiative—using low titer cold stored O RhD positive whole blood (LTO+WB). The main concern with use of RhD positive blood is the potential development of isoimmunization in RhD negative patients. We used our retrospective massive transfusion protocol (MTP) data to analyze the anticipated risk of this change in practice. In 30 months, out of 124 total MTP patients, only one female of childbearing age that received an MTP was RhD negative. With the risk of isoimmunization very low and the benefit of increased resources for the early administration of balanced resuscitation high, we determined that utilization of LTO+WB would be safe and best serve our community. Disclosure: No conflicts of interest to disclose. This manuscript has not been previously presented or published. © 2018 Lippincott Williams & Wilkins, Inc.

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PD-1/PD-L1 pathway participates in gastric surgery-induced imbalance of Th17/Treg cells in mice

Background The T-helper 17 (Th17)/regulatory T (Treg) balance is essential for immune homeostasis. But the effects of gastric surgery on this balance remain unclear. The aim of present study is to identify the influence of gastric surgery on Th17/Treg balance and the role of programmed death 1 (PD-1)/programmed cell death-ligand 1 (PD-L1) pathway in this process. Methods Mice were divided into Control, Sham and Surgery group randomly. Animals in Surgery group accepted partial gastrectomy. Mice in Sham group only received laparotomy without partial gastrectomy. Then we detected the percentages of Treg and Th17 cells, the expression of fork-head/winged helix transcription factor (Foxp3) and retinoic acid-related orphan receptor γt (RORγt) in splenocytes, as well as plasma levels of transforming growth factor (TGF)-β1 and interleukin (IL)-17 on days 1, 3, 5, 7 after surgery. We also analyzed the expression of programmed death 1 (PD-1) and programmed cell death-ligand 1 (PD-L1). The roles of PD-1/PD-L1 on the Th17/Treg balance were evaluated by the induction of Th17 or Treg cells in the presence or absence of PD-1 antibody and recombinant PD-L1 immunoglobulin (Ig) in vitro. Results The percentage of Treg cells increased, accompanied with elevated expression of Foxp3 and TGF-β1 (p

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Effects of Platelet Sparing Leukocyte Reduction and Agitation Methods on In Vitro Measures of Hemostatic Function in Cold-Stored Whole Blood

Background Agitation of platelet units stored at room temperature is performed routinely to maintain platelet function and leukoreduction of blood products is standard of care in many countries to reduce immune consequences of transfusion. The effect of agitation and leukoreduction on whole blood stored at 4° C requires investigation as reductions in hemostatic capacity of whole blood may reduce its efficacy in treating trauma-induced coagulopathy and platelet dysfunction. We hypothesize that agitation of whole blood will not affect hemostatic function and that leukoreduction will reduce hemostatic function of whole blood. Methods In this in vitro randomized- controlled study, 21 units of leukoreduced and 20 non-leukoreduced whole blood units were each randomly assigned into 4 agitation groups. Hemostatic parameters were measured using viscoelastic assays (ROTEM-EXTEM and TEG-Platelet Mapping), impedance aggregometry (agonists-adenosine phosphate, arachidonic acid, thrombin receptor activating peptide, and collagen), and a thrombin generation assay from these whole blood units pre- and post-filtration and on day 0, 5, 10 and 15 days of storage at 4°C. Results Leukoreduction compared to non-leukoreduction reduced platelet concentration on day 0. Viscoelastic measures and thrombin generation parameters revealed significant reduction in hemostatic function between the leukoreduced units and the non-leukoreduced units at a few time points. Leukoreduced units consistently demonstrated reduced platelet aggregation compared to the non-leukoreduced units. Agitation methods did not significantly affect any of the hemostatic parameters examined. Conclusions Leukoreduction of whole blood with a platelet-sparing filter caused a moderate but significant reduction in some measures of whole blood hemostatic function most evident early in storage. The benefits of leukoreduction should be weighed against the potential reduced hemostatic function of leukoreduced units. Agitation of whole blood is not required to maintain hemostatic function. Level of Evidence Level 1 Study Type in vitro randomized- controlled trial Corresponding Author: Kenneth E. Remy, MD, MHSc, Washington University School of Medicine, Department of Pediatrics, Division of Pediatric Critical Care, 660 S. Euclid Ave. St. Louis, MO 63110, kremy@wustl.edu, (314) 286-2830 This manuscript is for the THOR supplement. Conflicts of Interest and Source of Funding: All authors have no conflicts of interest to declare. © 2018 Lippincott Williams & Wilkins, Inc.

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MINIMALLY INVASIVE APPROACH TO INCARCERATED OR STRANGULATED GROIN HERNIAS: A 2018 EAST MASTER CLASS VIDEO PRESENTATION

Groin hernia repair is one of the most common general surgical procedures performed worldwide. Though only a small percentage will become incarcerated or strangulated this is an indication for repair. Minimally invasive surgery is becoming standard of care for most procedures and we believe this to be a safe and feasible approach for incarcerated or strangulated groin hernias. We present a description of our recommend approach with technical details and accompanying video clips to highlight these techniques. Presented in Master Class Surgical Video Session at the 2018 Eastern Association for the Surgery of Trauma Annual Scientific Assembly, Lake Buena Vista, Florida Conflicts of Interest: The authors have no conflicts of interest to declare and received no financial or material support related to this manuscript. Corresponding Author Contact information: Andrea Pakula MD, MPH, FACS, Trauma and Acute Care Surgery Service, Kern Medical, 1700 Mt. Vernon Ave., Bakersfield, CA 93306, (909)224-9848, Apakula333@aol.com © 2018 Lippincott Williams & Wilkins, Inc.

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Systemic Hyperfibrinolysis after Trauma: A Pilot study of Targeted Proteomic Analysis of Superposed Mechanisms in Patient Plasma

Background Viscoelastic measurements of hemostasis indicate that 20% of seriously injured patients exhibit systemic hyperfibrinolysis, with increased early mortality. These patients have normal clot formation with rapid clot lysis. Targeted proteomics was applied to quantify plasma proteins from hyperfibrinolytic (HF) patients to elucidate potential pathophysiology. Methods Blood samples were collected in the field or at Emergency Department arrival and thrombelastography (TEG) was used to characterize in vitro clot formation under native and tissue plasminogen activator (tPA)-stimulated conditions. Ten samples were taken from injured patients exhibiting normal lysis time at 30 min (Ly30), “eufibrinolytic” (EF), 10 from HF patients, defined as tPA-stimulated TEG Ly30 >50%, and 10 from healthy controls. Trauma patient samples were analyzed by targeted proteomics and ELISA assays for specific coagulation proteins. Results HF patients exhibited increased plasminogen activation. Thirty-three proteins from the HF patients were significantly decreased compared to healthy controls and EF patients; 17 were coagulation proteins with anti-protease consumption (p0.1 and fold change of concentrations of 0.75-1.3). Conclusion HF patients had significant decreases in specific proteins and support mechanisms known in trauma-induced hyperfibrinolysis and also unexpected decreases in coagulation factors, factors II, X, and XIII, without changes in clot formation (SP, R times or angle). Decreased clot stability in HF patients was corroborated with tPA-stimulated TEGs. Level of Evidence III prognostic. Correspondence: Anirban Banerjee, PhD, Department of Surgery, School of Medicine, UCD, 12700 E 19th Ave. Mail Stop C320, Aurora, CO 80045, E-mail anirban.banerjee@ucdenver.edu The authors have no conflict of interest with the submitted work. This work was supported by grants P50 GM049222, NIGMS, NIH, T32 GM008315, NIGMS, NIH, and UM1-HL120877, NHLBI, NIH and the Department of Surgery and the Colorado Clinical and Translational Sciences Institute, School of Medicine, University of Colorado Denver, and Bonfils Blood Center. Both AB and CCS wrote the manuscript and contributed equally so that they should be co-first authors, Anirban Banerjee PhD; Christopher C Silliman MD, PhD. © 2018 Lippincott Williams & Wilkins, Inc.

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Adenosine, Lidocaine and Mg2+ (ALM) resuscitation fluid protects against experimental traumatic brain injury

Background Currently no drug therapy prevents secondary injury progression after TBI. Our aim was to investigate the effects of small-volume intravenous adenosine, lidocaine and Mg2+ (ALM) resuscitation fluid after moderate-TBI in a rat fluid-percussion injury model. Methods Anesthetized, mechanically-ventilated male Sprague–Dawley rats (449±5g) were randomly assigned to one of four groups: 1) Sham (craniotomy without TBI), 2) No-Treatment, 3) Saline-controls or 4) ALM therapy (all n=16). A subdural probe was implanted in n=8 animals per group to measure cerebral blood flow. Fifteen minutes after moderate-TBI was induced with lateral FPI (2.57 atm), a single 3% NaCl±ALM bolus (0.7 ml/kg) was injected IV, and after 60 min (Phase 1), 0.9% NaCl±ALM stabilization ‘drip’ (0.5 ml/kg/hour) was administered for 3 hours (Phase 2). Results Mortality (without subdural brain probe) was 25% (saline-controls), and 0% (ALM). Sixty-minutes after bolus, ALM significantly increased cardiac function, cortical blood flow (CBF) (~3-fold) and blunted systemic inflammation compared to saline-controls. Three hours after infusion 'drip', ALM improved left-ventricular function, supported higher CBF, decreased pro-inflammatory cytokines systemically (IL-1β, TNF-α, RANTES), increased anti-inflammatory cytokines in brain tissue (IL-10, IL-4), lowered brain injury markers (NSE, Syndecan-1, HMGB-1), reduced coagulopathy, increased platelet aggregation, and maintained baseline fibrinogen levels. Saline-controls were pro-inflammatory (brain, heart, lung and blood) and hypocoagulable with neurogenic right heart enlargement. Survival-time significantly correlated with plasma NSE (p=0.001) and CBF at 180 min (p=0.009), and CBF correlated with brain anti-inflammatory cytokines (p=0.001-0.034). Conclusion After moderate-TBI, ALM resuscitation fluid increased survival and protected against early secondary injury by reducing coagulopathy, inflammation and platelet dysfunction. Level of Evidence Level 1 Randomized animal study Funding Statement: This work was supported by USSOCOM, IACUC protocol A2118, USAMRMC proposal SO13004 under Award No. W81XWH-15-1-0002. The opinions, interpretations, conclusions are those of the authors and are not necessarily endorsed by the US Department of Defense. Author Disclosure Statement: GPD is the inventor of the ALM concept for cardiac surgery, trauma and sepsis, and has no competing financial interests. HLL has no competing financial interests. To whom correspondence should be addressed: Email: geoffrey.dobson@jcu.edu.au Fax: +61 747 816 279 Phone: +61 407 550 235 © 2018 Lippincott Williams & Wilkins, Inc.

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The evolution of pediatric transfusion practice during combat operations 2001-2013

Background Hemostatic resuscitation principles have significantly changed adult trauma resuscitation over the past decade. Practice patterns in pediatric resuscitation likely have changed as well; however, this evolution has not been quantified. We evaluated pediatric resuscitation practices over time within a combat trauma system. Methods The Department of Defense Trauma Registry (DoDTR) was queried from 2001–2013 for pediatric patients (

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Vitamin D Binding Protein (DBP) Deficiency in Mice Decreases Systemic and Select Tissue Levels of Inflammatory Cytokines in a Murine Model of Acute Muscle Injury

Background Severe acute muscle injury results in massive cell damage, causing the release of actin into extracellular fluids where it complexes with the vitamin D binding protein (DBP). We hypothesized that a systemic Vitamin D deficiency would result in a less pro-inflammatory phenotype. Methods C57BL/6 wild-type and DBP deficient (DBP−/−) mice received intramuscular injections of either 50% glycerol or phosphate-buffered saline into thigh muscles. Muscle injury was assessed by histology. Cytokine levels were measured in plasma, muscle, kidney and lung. Results All animals survived the procedure but glycerol injection in both strains of mice showed lysis of skeletal myocytes, and inflammatory cell infiltrate. The muscle inflammatory cell infiltrate in DBP deficient mice had remarkably few neutrophils as compared to wild-type mice. The neutrophil chemoattractant CXCL1 was significantly reduced in muscle tissue from DBP−/− mice. However, there were no other significant differences in muscle cytokine levels. In contrast, plasma obtained 48 hours after glycerol injection revealed that DBP deficient mice had significantly lower levels of systemic cytokines IL-6, CCL2, CXCL1 and G-CSF. Lung tissue from DBP−/− mice showed significantly decreased amounts of CCL2 and CXCL1 as compared to glycerol-treated wild-type mice. Several chemokines in kidney homogenates following glycerol-induced injury were significantly reduced in DBP−/− mice: CCL2, CCL5, CXCL1 and CXCL2. Conclusion Acute muscle injury triggered a systemic pro-inflammatory response as noted by elevated plasma cytokine levels. However, mice with a systemic DBP deficiency demonstrated a change in their cytokine profile 48 hours after muscle injury to a less pro-inflammatory phenotype. Study Type Prognostic/Epidemiologic Level of Evidence Level III Correspondence: Randeep S. Jawa, MD, Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY 11794-8191, tel: 631-444-8329, fax: 631-444-6176, randeep.jawa@stonybrookmedicine.edu Conflicts of Interest: None Funding: Stony Brook Department of Surgery competitive grant program (RSJ), and National Institutes of Health (RRK), Stony Brook University School of Medicine Office of Scientific Affairs Presentation: This work was presented in part at the 75th annual meeting of the American Association for the Surgery of Trauma in Waikoloa, HI in September, 2016. This work was presented with significant additional data at the 76th annual meeting of the American Association for the Surgery of Trauma in Baltimore, MD in September, 2017. © 2018 Lippincott Williams & Wilkins, Inc.

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Preperitoneal Pelvic Packing

No abstract available

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Organ donation in trauma victims: a systematic review and meta-analysis

Background Although trauma patients represent a large pool of potential organ donors (PODs), the donor conversion rates (DCRs) in this population are unclear. Our primary objective was to synthesize published evidence on DCRs in trauma patients. As a secondary objective, we investigated factors that affect organ donation (OD) in the trauma population. Methods We searched four electronic databases (PubMed, Embase, Web of Science, Cochrane Library) and grey literature for articles on OD in trauma patients (PROSPERO 2017: CRD42017070388). Articles were excluded if it was not possible to calculate the DCR (actual organ donors divided by PODs). We pooled DCRs and performed subgroups analysis by trauma subpopulation, patient age, and study publication date. Results We identified 27 articles with a total of 123,142 participants. Cohorts ranged in size from 28 to 120,512 patients (median 132), with most studies performed in the United States. Conversion rates among individual studies ranged from 14.0% to 75.2% (median 49.3%). All 27 studies were included in the meta-analysis. We found a pooled DCR of 48.1% using the random effects model. There was a high level of heterogeneity between studies (I2 = 97.4%). Upon subgroup analysis, we found DCRs were higher in head trauma patients compared with traumatic cardiac arrest patients (45.3% vs. 20.9%, p

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