Burn patient decontamination outside of mass casualties.

OBJECTIVE: Decontamination protocols for victims of mass casualty events are well documented and emphasized to protect physicians, nurses and facilities. Decontamination practices outside of mass casualty events are unknown. This pilot study was undertaken to assess the current practices of burn patient decontamination outside of mass casualty events within level I and II trauma center emergency departments in the state of Michigan. METHODS: Using the Michigan Trauma Quality Improvement Project membership, a 10-question online survey was sent to trauma program managers at all level I and II trauma centers in Michigan. Survey questions focused on institutional decontamination protocols and consistency of use. RESULTS: Survey response was 50%. Of the responding facilities, 31% did not decontaminate burn patients. Of the centers who indicated that they did decontaminate burn patients, 31% did not follow a standardized protocol. Our survey revealed that 69% of facilities used a protocol for decontamination: 45% used the protocol consistently on all burns, and 55% at physician discretion. Products used most frequently to decontaminate burn patients included water (100%) followed by soap (44%). CONCLUSION: This pilot survey of level I and II trauma centers in the state of Michigan revealed variability in the use of burn patient decontamination protocols and consistency of use. Additional research is warranted to determine if our results are reflective of trauma centers nationally.

Changes in Therapeutic Intensity Level Following Airway Pressure Release Ventilation in Severe Traumatic Brain Injury.

PURPOSE: Airway pressure release ventilation (APRV) utilizes high levels of airway pressure coupled with brief expiratory release to facilitate open lung ventilation. The aim of our study was to evaluate the effects of APRV-induced elevated airway pressure mean in patients with severe traumatic brain injury. MATERIALS AND METHODS: This was a retrospective cohort study at a 424-bed Level I trauma center. Linear mixed effects models were developed to assess the difference in therapeutic intensity level (TIL), intracranial pressure (ICP), and cerebral perfusion pressure (CPP) over time following the application of APRV. RESULTS: The study included 21 epochs of APRV in 21 patients. In the 6-hour epoch following the application of APRV, the TIL was significantly increased ( P = .002) and the ICP significantly decreased ( P = .041) compared to that before 6 hours. There was no significant change in CPP ( P = .42) over time. The baseline static compliance and time interaction was not significant for TIL (χ2 = 0.2 [ df 1], P = .655), CPP (χ2 = 0 [ df 1], P = 1), or ICP (χ2 = 0.1 [ df 1], P = .752). CONCLUSIONS: Application of APRV in patients with severe traumatic brain injury was associated with significantly, but not clinically meaningful, increased TIL and decreased ICP. No significant change in CPP was observed. No difference was observed based on the baseline pulmonary static compliance.

Sedation and Analgesia in Transportation of Acutely and Critically Ill Patients.

Transportation of acutely or critically ill patients is a challenge for health care providers. Among the difficulties that providers face is the balance between adequate sedation and analgesia for the transportation event and maintaining acceptable respiratory and physiologic parameters of the patient. This article describes common challenges in providing sedation and analgesia during various phases of transport.

Ten Years of Equine-related Injuries: Severity and Implications for Emergency Physicians.

BACKGROUND: The size, speed, and unpredictable nature of horses present a significant risk for injury in all equine-related activities. OBJECTIVE: We sought to examine the mechanism, severity, frequency, body regions affected, surgical requirements, rehabilitation needs, safety equipment utilization, and outcomes of equine-related injured patients. METHODS: Records of inpatients who sustained an equine-related injury from 2002-2011 with International Classification of Diseases, Ninth Revision codes E828 and E906 were retrospectively reviewed for pertinent data. RESULTS: Ninety patients, 70% female, age (mean ± SD) 37.3 ± 19.4 years, length of stay 3.7 ± 4.5 days, Injury Severity Score 12.9 ± 8.4. Predominant mechanism of injury was fall from horse (46.7%). The chest (23%) was most frequently injured, followed by brain/head (21.5%). Thirty patients (33%) required 57 surgical procedures. Twenty percent of patients required occupational therapy and 33.3% required physical therapy while hospitalized. Only 3% required rehabilitation, with 90% discharged directly home. Safety equipment was not used in 91.9% of patients. One patient sustained a cord injury. Six patients expired, all from extensive head injuries. CONCLUSION: The majority of equine-related injuries occur while pursuing recreational activities and are due to falls. Our patients experienced more severe injuries to the trunk and head and required more surgical intervention for pelvic, facial, and brain injuries than previously reported. Failure to use safety equipment contributes to the risk of severe injury. Education and injury prevention is essential. The need for complex surgical intervention by multiple specialties supports transfer to Level I trauma centers.

Preparation for mass casualty incidents.

Mass casualty incidents are events where the number of injured patients exceeds the resources of the health care institution to the degree that care may not be available or may be limited for a portion of the casualties. Mass casualty incidents are increasing in frequency throughout the United States. Managing mass casualty incidents has not traditionally been part of the nursing curriculum; however, our changing world requires us to become educated and prepared to respond to these scenarios. This article focuses on intentional explosive disasters and the nursing and institutional response to these incidents. This information is of value to nursing professionals and other health care providers.

Resurgence of methamphetamine related burns and injuries: a follow-up study.

PURPOSE: Legislation enacted to curb methamphetamine production has only temporarily succeeded. Experiencing a recent increase in burns as a result of the new one-pot method, we compared methamphetamine related burn patients who utilized the previous anhydrous ammonia method of production to current patients who largely used the new one-pot method of production. BASIC PROCEDURES: Patients who were burned as a result of methamphetamine production were retrospectively reviewed. Comparisons were made including demographics, length of stay, injury severity score, hospital charges, total body surface area burned, inhalation injury, intubation, ventilator days, toxicology, fluid volumes, surgeries and complications. MAIN FINDINGS: Eighteen current study patients (88.9% male) were compared to twenty-nine (86.2% male) previous study patients. The groups were similar in age, pattern of burn injury and intubation. Total body surface area burned, injury severity score, inhalation injuries, and ventilator days were not significantly increased in the current study. Longer length of stay and greater hospital charges were incurred by the current group. Burn surgeries per patient were significantly increased in the current group. PRINCIPAL CONCLUSIONS: A new one-pot method has emerged despite legislative attempts to curtail methamphetamine production, and burns have also increased. The reason for more extensive burn surgeries in the current METH related burn patients remains enigmatic. Severity of injury and cost to society remain high.

Percutaneous tracheostomy: a new approach to the emergency airway.

BACKGROUND: Endotracheal intubation is the preferred method of airway control. Current surgical standard of care for the emergent airway when endotracheal intubation cannot be performed is cricothyroidotomy. Percutaneous tracheostomy (PT) is a widely accepted technique for elective long-term airway management in the critical care setting. We describe our experience with successful placement of PT for emergency airway control. METHODS: After institutional review board approval was obtained, patients were identified retrospectively from January 2003 to present that had emergency PT performed as identified by the DRG International Classification of Diseases--9th Rev. procedure code (31.1). Data included demographics, body mass index, admitting service, size of tracheostomy tube, reason for urgent airway access, duration PT was required, unit, time and hospital day performed, and complications. RESULTS: Eighteen patients underwent emergency PT; 61% were male, and age range was 21 years to 86 years. Indications for PT included respiratory failure associated with anaphylaxis, supraglottic edema, cardiac arrest, and blood or edema blocking the airway preventing intubation. PT was performed in various departments throughout the hospital. Admitting services included critical care intensivist (44.4%), trauma surgery (27.7%), cardiology (11.1%), medicine (11.1%), and neurology (5.5%). Most of the tracheostomy tube sizes were no. 8 (61.1%), followed by no. 7 (22.2%), no. 6 (5.5%), and no. 9 (5.5%). All PTs were successfully placed, and there were no complications. Ten of our patients had no airway in place at the time of procedure. Six patients had emergency esophageal-tracheal airways in place. Two patients had a cricothyroidotomy that was not functioning adequately. Nine patients had body mass indexes ranging from 30 kg/m² to 112 kg/m². CONCLUSION: PT provided a safe, effective emergency airway in adult patients who presented with a variety of indications, in varying locations throughout the hospital. PT performed by appropriately trained personnel may be a potential adjunct for emergent airway control in diverse settings.

Imaging utilization during explosive multiple casualty incidents.

BACKGROUND: Emergency radiology is a vital tool in the evaluation of victims of explosive multiple casualty incidents (MCIs). Prior reports estimate that approximately 50% of explosive MCI patients required imaging, including 7% to 22% who required computed tomography (CT) studies. This report describes the contemporary utilization of emergency radiology during the evaluation of explosive MCI victims in a modern US military trauma hospital in Iraq. We hypothesized that a much higher number of patients received imaging than has been reported previously in the literature. METHODS: We performed a retrospective chart review of records from 3 MCIs managed at the US Air Force Theater Hospital, Balad AB, Iraq between February and April 2008. All three incidents were the result of improvised explosive devices. RESULTS: Overall, 50 patients had a mean Injury Severity Score of 19 and a mortality of 8%. Ninety-two percent received imaging during their emergency department evaluation, including 90% who received CT, 70% who received X-rays, and 38% who received extended focused abdominal sonography for trauma ultrasound examinations. Overall, patients had a mean of 3.5 CTs and 1.9 X-rays during their initial assessment. Of the CTs, 93% were part of a trauma pan-scan, and 49% of the CT results were clinically significant. CONCLUSION: These results are significantly different from previous reports and indicate that victims of explosive MCIs will require more imaging, especially CT, than previously anticipated. These data will allow improved integration of radiology staffing and resource allocation into disaster management plans designed to prepare for future explosive MCIs.

Injury patterns related to ultralight aircraft crashes.

PURPOSE: Flying ultralight aircraft is a popular and growing form of recreation. However, there is considerable risk involved in this activity. This study was undertaken to catalogue the injury patterns, surgical procedures, and complications of patients involved in ultralight crashes in southwest Michigan. BASIC PROCEDURES: The trauma registry at Bronson Methodist Hospital was used to retrospectively identify all ultralight crashes between 1983 and 2006. All patients who survived to the hospital were included in the study. MAIN FINDINGS: Seventeen patients were identified, all males with a mean age of 48.5 years. Mean injury severity score was 23, with all patients sustaining multiple injuries. Mortality was 17%. Lower extremity fractures were most common, followed by head/neck/facial injuries. Orthopedic extremity procedures were most commonly performed. PRINCIPAL CONCLUSIONS: Ultralight crashes result in complex high-energy injury patterns. These patients are likely to require the resources of designated trauma centers. Increased oversight may help prevent ultralight-related injuries.

Surgical response to multiple casualty incidents following single explosive events.

BACKGROUND: Modern publications on response to single explosive events are from non-US hospitals, predate current resuscitation guidelines and lack detail on surgical and intensive care unit (ICU) requirements. The objective of this study is to provide a contemporary account of surge response to multiple casualty incidences following explosive events managed at a US trauma hospital in Iraq. METHODS: Observational study and retrospective chart review of 72-hour transfusion, operating room, and ICU resource utilization from 3 multiple casualty incidences managed at the US Air Force Theater Hospital, Balad AB, Iraq between February and April 2008. RESULTS: Fifty patients were treated with a mean injury severity score of 19. Forty-eight percent (n = 24) of casualties required blood transfusion with 4 patients receiving 43% (N = 74 units) of the packed red blood cells (pRBC). An average of 3.5 and 3.8 units of pRBC and plasma, respectively, was transfused per casualty (pRBC:plasma ratio of 1:1.1). Seventy-six percent (n = 38) of patients required immediate operation upon initial presentation. A total of 191 procedures were performed in parallel during 75 operations (3.8 procedures per casualty). Fifty percent (n = 25) of patients required ICU admission with nearly the same number (n = 24) requiring mechanical ventilator support beyond that required for operation. All cause, in-hospital mortality was 8% (n = 4). CONCLUSIONS: Results from this study provide a contemporary assessment of transfusion, surgical, and intensive care resource requirements after a single explosive event. Data from this experience may translate into useful guidelines for emergency planners worldwide.

Methamphetamine production is hazardous to your health.

BACKGROUND: To describe the thermal injuries related to methamphetamine (METH) production, characterize patients' courses, and compare patients with matched controls and to the previously published series. METHODS: Trauma registry data from January 2001 to November 2005 was retrospectively reviewed. METH patients were compared with other burn patients of similar age and total body surface area burn size for toxicology, injury extent, therapies, hospital course, outcomes, and hospital charges. The METH group was compared with the other published series of METH-related burn patients. RESULTS: Twenty-nine patients (86.2% male) had METH-related burns. METH and control groups were similar in age, gender, predicted resuscitation fluid volume, and total body surface area. Mortality, mean length of stay, surgical procedures, and mean hospital charges did not differ significantly between the groups. Endotracheal intubation was required more frequently in METH patients (55.2% vs. 24.1%, p = 0.020). METH patients mean resuscitation volume was greater than controls (9,638 mL vs. 6,633 mL, p = 0.011), but neither group exceeded the volume predicted by the Parkland formula. More METH patients had inhalation injury (41.4% vs. 13.8%, p = 0.019). A METH patient was more likely to have a complication than his matched control (p = 0.049), and pneumonia was more frequent in the METH group (p = 0.005). Private insurance was less common in METH patients (10.3% vs. 58.6%, p < 0.001). CONCLUSIONS: METH patients suffer more frequent inhalation injuries, need greater initial fluid resuscitation volume, require endotracheal intubation more frequently, and are more likely to have complications than matched controls. This does not translate to greater mortality, longer length of stay, more surgical procedures, or significantly greater hospital charges. Few METH patients hold private insurance.