Expeditionary Resuscitation Surgical Team: The US Army's Initiative to Provide Damage Control Resuscitation and Surgery to Forces in Austere Settings.

Improvements in surgical care on the battlefield have contributed to reduced morbidity and mortality in wounded Servicemembers. 1 Point-of-injury care and early surgical intervention, along with improved personal protective equipment, have produced the lowest casualty statistics in modern warfare, resulting in improved force strength, morale, and social acceptance of conflict. It is undeniable that point-of-care injury, followed by early resuscitation and damage control surgery, saves lives on the battlefield. The US Army's Expeditionary Resuscitation Surgical Team (ERST) is a highly mobile, interprofessional medical team that can perform damage control resuscitation and surgery in austere locations. Its configuration and capabilities vary; however, in general, a typical surgical element can perform one major surgery and one minor surgery without resupply. The critical care element can provide prolonged holding in garrison, but this diminishes in the austere setting with complex and acutely injured patients.

Does a non-invasive hemoglobin monitor correlate with a venous blood sample in the acutely ill?

Non-invasive hemoglobin measuring technology has potential for rapid, portable, and accurate way of providing identification of blood loss or anemia. Our objective is to determine if this technology is reliable in critically ill patients presenting to the Emergency Department. Prospective cross-sectional observational study was done at an urban level-one trauma center, 135 subjects were conveniently sampled, suspected of having active bleeding, sepsis, or other critically ill condition. Non-invasive measurements with Masimo (Irvine, CA, USA) Radical-7 and Rad-57 hemoglobin monitors were compared with the Beckman-Coulter LH-550 (Brea, CA, USA) clinical laboratory blood cell analyzer. The primary outcome was the relationship of the non-invasive device to the clinical laboratory results. Secondary evaluations included the effect of pulse rate, systolic BP, respiratory rate, temperature, capillary refill, skin color, nail condition, extremity movement. The Radical-7 was able to capture reading in 78% (88/113) of subjects, and the Rad-57 in 65% (71/110) of subjects. The correlation (R(2)) of the device Hb was 0.69 and 0.67 (p < 00.01) for the Radical-7 and Rad-57, respectively. The coefficient of variation for the Radical-7 was 18%, and for the Rad57 it was 13%. Univariate analysis shows none of the observed factors is associated with the difference values between the device Hb and laboratory Hb. Our results show that Radical-7 and Rad-57 devices do not report readings in 29% of patients and accuracy is significantly lower than reported by the manufacturer with over 50% of readings falling outside of ± 1 g/dL. We determined that none of the several potential factors examined are associated with the degree of device accuracy.

Intra-articular Morphine versus Lidocaine for Acute Knee Pain.

OBJECTIVE: The authors conducted an unfunded randomized controlled trial approved by the Brooke Army Medical Center (BAMC) Institutional Review Board (IRB) to determine the possible efficacy of intra-articular morphine for pain in acute knee injuries. METHODS: Patients presenting to the emergency department at San Antonio Military Medical Center (SAMMC) from May 2012 to August 2013 with knee pain due to an acute injury were consented and then enrolled based on a convenience sample. Patients were randomized to one of three intervention arms (morphine, lidocaine, or morphine and lidocaine) and were blinded to the intervention. The respective solution was injected into the knee joint using standard techniques. The patients self-reported their levels of knee pain via a standard 100mm visual analogue scale (VAS) at the time of injection and 30 minutes, 60 minutes, 90 minutes, 2 hours, 6 hours, and 24 hours postinjection. At 24 hours, the patients also reported the estimated amount of time they applied ice to the knee and the amount of oral analgesia consumed in the previous 24 hours. RESULTS: The primary outcome was relative pain reduction as measured by the VAS. Secondary outcomes were the total cumulative use of ice and analgesics during the first 24 hours. Although this was a small study, the results showed a possible trend toward better pain control at all time intervals with injections containing morphine compared with lidocaine-only injections. Ice and oral analgesia usage was equivalent between the three intervention arms. CONCLUSION: Further investigation with a larger sample is required to explore whether these results are statistically significant and the possible superiority of intra-articular morphine to lidocaine for acute knee pain.

Management of acute asthma in the emergency department.

Asthma is primarily a clinical diagnosis that is made from a combination of historical features and clinical examination findings. The mainstay of asthma treatment includes short-acting beta agonist therapy (albuterol) and steroids. Handheld inhalers are sufficient for most inhaled therapy; all patients on inhalers should be provided with a spacer. The severity of asthma exacerbations is determined by 3 features: (1) clinical presentation, (2) peak expiratory flow rates, and (3) vital signs. Additional testing, such as chest x-ray and blood gas measurements, is reserved for select patients. Spirometry aids in the diagnosis of asthma and measurement of severity, but it is not always required, nor should it be solely relied upon to make disposition decisions. Inhaled ipratropium decreases hospitalization rates, and it should be routinely used. Levalbuterol provides little to no advantage over less-expensive racemic albuterol. Noninvasive positive pressure ventilation may be utilized in patients with moderate to severe exacerbations. Ketamine may be considered in severe exacerbations, but it should not be used routinely. Magnesium sulfate may be beneficial in severe asthma exacerbations, but routine use for mild to moderate exacerbations is not indicated.

Torsion of undescended testis in a 14-month-old child refusing to bear weight.

In this report, we discuss a case of a 14-month-old male presenting in the emergency department with refusal to bear weight on his left leg. Plain radiographic studies revealed no evidence of effusion, fracture, or dislocation. Laboratory studies were significant for an elevated white blood cell count, erythrocyte sedimentation rate, and C-reactive protein. Further studies included unremarkable ultrasound of the left hip and normal magnetic resonance imaging (MRI) of both hips. An incidental finding on MRI was a left inguinal mass concerning an incarcerated hernia. Ultrasound of this mass demonstrated a left undescended testis within the inguinal canal and possible incarcerated paratesticular inguinal hernia. The final pathologic diagnosis of a torsed gangrenous left testicle within the inguinal canal was confirmed during surgery.

Delayed traumatic spinal epidural hematoma with spontaneous resolution of symptoms.

Post-traumatic spinal epidural hematomas are uncommon, usually requiring emergent neurosurgical evacuation. We present a symptomatic delayed post-traumatic epidural hematoma of the T-spine that resolved within hours of administration of high dose steroids. A 22-year-old man presented 10 days after sustaining blunt trauma during a motor vehicle crash. He developed signs of acute cord compression with loss of sensation and motor function in bilateral lower extremities with priapism. Magnetic resonance imaging demonstrated a spinal epidural hematoma with 50% canal stenosis at the T4 level. His symptoms improved 1 h after the administration of high dose steroids. All symptoms resolved completely while the patient was in the Emergency Department and he was treated conservatively by Neurosurgery with no further sequelae. Thoracic spinal epidural hematoma is an uncommon condition that may present in delayed fashion after trauma with significant neurologic compromise. If neurologic symptoms improve with initial steroid therapy, patients with this condition may be treated conservatively with steroids and observation.

Intubating laryngeal mask airway versus laryngoscopy and endotracheal intubation in the nuclear, biological, and chemical environment.

OBJECTIVE: Intubation is a difficult skill under normal circumstances and more so with a limited visual field such as wearing a protective mask in a chemical or biological incident. This study sought to determine whether successful intubation using the intubating laryngeal mask airway (ILMA) under protective mask conditions was equivalent to standard endotracheal intubation. METHODS: A pilot study was conducted using emergency medicine personnel. Participant's attempted intubation of a manikin while wearing a standard U.S. Army M-40 protective mask. Two attempts were performed with each method. RESULTS: One hundred percent of the ILMA placements were successful with only 78% success with endotracheal intubation (p = 0.1). Time to successful intubation and ventilation was significantly less for the ILMA versus endotracheal intubation (p = 0.005). CONCLUSION: This study suggests that under simulated chemical and biological conditions using an M-40 protective mask, intubation is accomplished faster and with more success with the ILMA.