Evidence-Based Guidelines for Prehospital Pain Management: Recommendations.

This project sought to develop evidence-based guidelines for the administration of analgesics for moderate to severe pain by Emergency Medical Services (EMS) clinicians based on a separate, previously published, systematic review of the comparative effectiveness of analgesics in the prehospital setting prepared by the University of Connecticut Evidence-Based Practice Center for the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel (TEP) was assembled consisting of subject matter experts in prehospital and emergency care, and the development of evidence-based guidelines and patient care guidelines. A series of nine "patient/population-intervention-comparison-outcome" (PICO) questions were developed based on the Key Questions identified in the AHRQ systematic review, and an additional PICO question was developed to specifically address analgesia in pediatric patients. The panel made a strong recommendation for the use of intranasal fentanyl over intravenous (IV) opioids for pediatric patients without intravenous access given the supporting evidence, its effectiveness, ease of administration, and acceptance by patients and providers. The panel made a conditional recommendation for the use of IV non-steroidal anti-inflammatory drugs (NSAIDs) over IV acetaminophen (APAP). The panel made conditional recommendations for the use of either IV ketamine or IV opioids; for either IV NSAIDs or IV opioids; for either IV fentanyl or IV morphine; and for either IV ketamine or IV NSAIDs. A conditional recommendation was made for IV APAP over IV opioids. The panel made a conditional recommendation against the use of weight-based IV ketamine in combination with weight-based IV opioids versus weight-based IV opioids alone. The panel considered the use of oral analgesics and a conditional recommendation was made for either oral APAP or oral NSAIDs when the oral route of administration was preferred. Given the lack of a supporting evidence base, the panel was unable to make recommendations for the use of nitrous oxide versus IV opioids, or for IV ketamine in combination with IV opioids versus IV ketamine alone. Taken together, the recommendations emphasize that EMS medical directors and EMS clinicians have a variety of effective options for the management of moderate to severe pain in addition to opioids when designing patient care guidelines and caring for patients suffering from acute pain.

Initial Evaluation and Management of the Injured Patient.

This update is a conversation with our trauma medical director about the initial evaluation and management of the injured patient. After a brief historical perspective, we discuss the immediate treatment of life-threatening injuries at local hospitals within the context of definitive care at a level 1 trauma center. Our journey is colored by recent cases we have treated at our institution with the hope that we save more Missourian lives.

In-flight ultrasound identification of pneumothorax.

Ultrasound is a standard adjunct to the initial evaluation of injured patients in the emergency department. We sought to evaluate the ability of prehospital, in-flight thoracic ultrasound to identify pneumothorax. Non-physician aeromedical providers were trained to perform and interpret thoracic ultrasound. All adult trauma patients and adult medical patients requiring endotracheal intubation underwent both in-flight and emergency department ultrasound evaluations. Findings were documented independently and reviewed to ensure quality and accuracy. Results were compared to chest X-ray and computed tomography (CT). One hundred forty-nine patients (136 trauma/13 medical) met inclusion criteria. Mean age was 44.4 (18-94) years; 69 % were male. Mean injury severity score was 17.68 (1-75), and mean chest injury score was 2.93 (0-6) in the injured group. Twenty pneumothoraces and one mainstem intubation were identified. Sixteen pneumothoraces were correctly identified in the field. A mainstem intubation was misinterpreted. When compared to chest CT (n = 116), prehospital ultrasound had a sensitivity of 68 % (95 % confidence interval (CI) 46-85 %), a specificity of 96 % (95 % CI 90-98 %), and an overall accuracy of 91 % (95 % CI 85-95 %). In comparison, emergency department (ED) ultrasound had a sensitivity of 84 % (95 % CI 62-94 %), specificity of 98 % (95 % CI 93-99 %), and an accuracy of 96 % (95 % CI 90-98 %). The unique characteristics of the aeromedical environment render the auditory element of a reliable physical exam impractical. Thoracic ultrasonography should be utilized to augment the diagnostic capabilities of prehospital aeromedical providers.

Less Is More: Low-dose Prothrombin Complex Concentrate Effective in Acute Care Surgery Patients.

Optimal dosing of prothrombin complex concentrate (PCC) has yet to be defined and varies widely due to concerns of efficacy and thrombosis. We hypothesized a dose of 15 IU/kg actual body weight of a three-factor PCC would effectively correct coagulopathy in acute care surgery patients. Retrospective review of 41 acute care surgery patients who received 15 IU/kg (± 10%) actual body weight PCC for correction of coagulopathy. Demographics, laboratory results, PCC dose, blood and plasma transfusions, and thrombotic complications were analyzed. We performed subset analyses of trauma patients and those taking warfarin. Mean age was 69 years (18-94 years). Thirty (73%) trauma patients, 8 (20%) emergency surgery patients, 2 (5%) burns, and 1 (2%) nontrauma neurosurgical patient were included. Mean PCC dose was 1305.4 IU (14.2 IU/kg actual body weight). Mean change in INR was 2.52 to 1.42 (p 0.00004). Successful correction (INR <1.5) was seen in 78 per cent. Treatment failures had a higher initial INR (4.3 vs 2.03, p 0.01). Mean plasma transfusion was 1.46 units. Mean blood transfusion was 1.61 units. Patients taking prehospital warfarin (n = 29, 71%) had higher initial INR (2.78 vs 1.92, p 0.05) and received more units of plasma (1.93 vs 0.33, p 0.01) than those not taking warfarin. No statistical differences were seen between trauma and nontrauma patients. One thrombotic event occurred. Administration of low-dose PCC, 15 IU/kg actual body weight, effectively corrects coagulopathy in acute care surgery patients regardless of warfarin use, diagnosis or plasma transfusion.

A randomized crash injury prevention trial of transitioning high-risk elders from driving.

UNLABELLED: Supplemental digital content is available in the text. BACKGROUND: Older adults with medical conditions that impair function are at risk for experiencing a motor vehicle crash. This randomized controlled trial tested an intervention to reduce crash-related risk among older patients. METHODS: A 2-to-1 allocation ratio resulted in comparisons between 26 intervention and 13 attention control (n = 39) group members who were recruited from inpatient and outpatient settings. The intervention consisted of two sessions of facilitated planning in which participants' health, transportation alternatives, attitudes/emotions regarding a change in mobility, and actions to ensure continued safe mobility were discussed. Moreover, all participants received supportive telephone calls during the 6-month intervention period. RESULTS: Results showed that when compared with the control group, the intervention group had significantly better subjective health, had fewer high-risk driving behaviors, and drove less distance on excursions from home at follow-up. Yet, simple repeated-measures analyses were not significant. CONCLUSION: Results suggest that facilitated planning may help ease the transition to driving retirement among some high-risk older patients. Larger samples and longer study duration are needed to confirm these effects and to measure direct crash and injury outcomes. A significant proportion of high-risk patients do not plan for driving retirement and remain a crash risk. LEVEL OF EVIDENCE: Therapeutic/care management study, level III.

Provider X-ray exposure in the trauma bay: results of a radiation field analysis.

Radiation exposure during trauma care has increased in recent years. Radiation risk to providers during the care of injured patients is not well defined. We aimed to gather environmental exposure data from dosimeters placed at fixed points in the trauma bay to act as surrogates for personnel radiation exposure during trauma team activations. Forty-four (44) radiation dosimeters were placed throughout a single trauma bay in a university level 1 trauma center. We analyzed shallow (SDE) and deep dose equivalents (DDE) over 6 months. We measured distance from the radiation source for each dosimeter. Four controls were included. We recorded patient injury and X-ray data for each patient. During the study period, 417 patients were evaluated in the trauma bay under study. Mean ISS was 14.3 (range 0-75). A total of 2,107 plain X-rays were taken, with a mean of 5.1 X-rays per patient (range 0-32). Extremity films were most often performed, followed by chest and shoulder films. No measurable dose was identified with the dosimeter controls. The majority (27, 68 %) of dosimeters registered the lowest doses (<1 mSv DDE). Five dosimeters revealed doses between 1 and 2 mSv DDE. Four dosimeters registered over 2 mSv DDE, with a mean DDE of 3 mSv. Distances of less than 5 ft from the radiation source had the highest DDE dose. Maximum annual occupational DDE dose is conventionally 50 mSv. None of the dosimeters registered DDE doses over 4.31 mSv during the study period, supporting low radiation risk to providers in the trauma bay.

Trauma transfers and definitive imaging: patient benefit but at what cost?

Many patients undergo computed tomography (CT) scan before transfer to definitive care. Despite this, studies are often repeated on arrival to the trauma center. We evaluated a policy to provide formal in-house interpretation of images performed at outside hospitals. A 3-month retrospective analysis was performed. Two groups were compared. Patients in the in-house interpretation (IHI) group underwent in-house interpretation of outside images. Those images not meeting criteria were placed in the comparison group without in-house radiologic interpretation. Demographics, CT scan data, billing and productivity loss, and extrapolated cancer risk reduction were analyzed. There were no significant differences in demographic or injury data. Fewer total CT scans were performed in the IHI group (223 vs. 320, P = 0.04). The IHI group underwent fewer repeated CT scans (25 vs. 62, P = 0.02; odds ratio [OR], 0.53). Fewer patients were exposed to repeat CT scans (17 vs. 32; OR, 0.48). Total hospital billings decreased by $188,285 ($4,592/patient) in the IHI group. Uncaptured work relative value units totaled 152.19 (3.71/patient) in the IHI group. Radiation exposure decreased by 8 per cent. Use of outside hospital imaging as the definitive evaluation of injured patients is safe and results in an overall decrease in radiation exposure and healthcare cost.

Experience with prothrombin complex for the emergent reversal of anticoagulation in rural geriatric trauma patients.

BACKGROUND: Therapeutic anticoagulation in the geriatric trauma population is increasingly common. Fresh frozen plasma, while the criterion standard for correction, has limited availability and associated transfusion risks. We examined our use of prothrombin complex concentrate for immediate reversal of therapeutically anticoagulated geriatric trauma patients. METHODS: This was a 1-year, retrospective review of 25 geriatric trauma patients who received either fresh frozen plasma alone or prothrombin complex concentrate and met the inclusion criteria of age >55 years, current warfarin use, and an admission international normalized ratio of >1.5. Fifteen patients received prothrombin complex concentrate and 10 patients received fresh frozen plasma alone. We examined demographics, laboratory values, and blood product use. RESULTS: The mean ages were similar (77 vs 80 years). Patients had similar mean Injury Severity Score (19.1 vs 19.2). Survivor duration of hospital stay (7.7 vs 9.5; P = .37) and duration of stay in the intensive care unit (4.4 vs 7.1; P = .25) trended positively in the prothrombin complex concentrate group. The prothrombin complex concentrate group received fewer units of fresh frozen plasma (1.6 [range, 0-6] vs 2.7 [range, 2-4]; P = .05), with a greater decrease in international normalized ratio (51% vs 43%; P = .05). Six patients (40%) in the prothrombin complex concentrate group avoided fresh frozen plasma transfusion altogether. CONCLUSION: Prothrombin complex may be used safely and effectively to reverse emergently anticoagulation in geriatric trauma patients.

Impact of acute care surgery to departmental productivity.

BACKGROUND: The face of trauma surgery is rapidly evolving with a paradigm shift toward acute care surgery (ACS). The formal development of ACS has been viewed by some general surgeons as a threat to their practice. We sought to evaluate the impact of a new division of ACS to both departmental productivity and provider satisfaction at a University Level I Trauma Center. METHODS: Two-year retrospective analysis of annual work relative value unit (wRVU) productivity, operative volume, and FTEs before and after establishment of an ACS division at a University Level I trauma center. Provider satisfaction was measured using a 10-point scale. Analysis completed using Microsoft Excel with a p value less than 0.05 significant. RESULTS: The change to an ACS model resulted in a 94% increase in total wRVU production (78% evaluation and management, 122% operative; p<0.05) for ACS, whereas general surgery wRVU production increased 8% (-15% evaluation and management, 14% operative; p<0.05). Operative productivity was substantial after transition to ACS, with 129% and 44% increases (p<0.05) in operative and elective case load, respectively. Decline in overall general surgery operative volume was attributed to reduction in emergent cases. Establishment of the ACS model necessitated one additional FTE. Job satisfaction substantially improved with the ACS model while allowing general surgery a more focused practice. CONCLUSIONS: The ACS practice model significantly enhances provider productivity and job satisfaction when compared with trauma alone. Fears of a productivity impact to the nontrauma general surgeon were not realized.

Acute esophageal necrosis with pneumomediastinum: a case report.

A case of acute esophageal necrosis with pneumomediastinum is presented with a review of the literature. To our knowledge, this is the only such case reported in the literature. The diagnosis, clinical course, management and potential causes of this rare condition are examined.