Case Report: Soldier With Latrodectism After Black Widow Spider Bite During a Field Training Exercise.

Latrodectism from black widow spider (BWS) bites is rare in the United States. Latrodectism is a severe systemic manifestation of the envenomation that includes severe abdominal pain mimicking acute surgical abdomen and, in rare cases, could lead to acute myocarditis and rhabdomyolysis. The BWS typically inhabits dark, low-lying areas such as woodpiles, tree stumps, outdoor storage, outdoor furniture, outdoor toilets, and rock piles and is most active during warm weather months. Military service members often participate in field training exercises during warm weather in wooded areas littered with woodpiles and tree stumps; therefore, they are at an increased risk for bites by arachnids. We report the case of a 26-year-old active duty male soldier evacuated from field training with latrodectism and possible envenomation-induced myocarditis after a suspected BWS bite.

Immersive Virtual Reality for Pain Control and Anxiolysis During IV Blood Draws in Adults: A Randomized Controlled Trial.

OBJECTIVE: To evaluate immersive virtual reality's (IVR) effectiveness as a distraction in reducing perceived pain and anxiety among adults undergoing intravenous (IV) blood draw. METHODS: In this randomized controlled trial, we recruited adult patients 18-50 years of age scheduled for routine blood draws at the phlebotomy lab and randomized them into experimental and control groups. The experimental group underwent IV blood draw with IVR, and the control group underwent IV blood draw with standard practice. Before the procedure, subjects rated their anxiety level and the pain they "expected" to experience during blood draw. Immediately afterward, the subjects rated their actual "perceived" pain level. We measured the "expected" and the "perceived" pain and anxiety scores using a 100 mm visual analog scale. The primary outcome was the difference in "perceived" pain scores (0-100) between the two cohorts. Secondary outcomes were differences between the anxiety scores and the "expected" and "perceived" pain between the two cohorts, as well as degree of satisfaction with IVR during the blood draw and willingness to use IVR in future procedures. RESULTS: Fifty-nine subjects completed the study, 31 in the experimental group and 28 in the control group. For the primary outcome, the control group reported a perceived median pain score of 6.5 vs. the experimental group of 5; P = .55. For the secondary outcomes, the median anxiety scores were 22 (6.25-45.75) and 24 (2.00-35.00) for the control and the experimental groups, respectively, P = .44. The control group reported an expected median pain score of 20 vs. a perceived score of 6.5; P = .25, and the experimental group reported an expected median pain score of 22 vs. a perceived score of 5; P < .01. Median Likert scores were 5 (1-5) for satisfaction and preference for future use during painful procedures. CONCLUSIONS: The results of our study demonstrated that there was no significantly lower perceived pain or anxiety when using IVR compared to standard practice in adults undergoing IV blood draw.

Femoral Pulse Ultrasound Assessment Accuracy by Emergency Medicine Trainees on a Porcine Model.

of care ultrasound (POCUS) is increasingly used in emergency medicine (EM), including EM physician residents and EM physician assistant (EMPA) residents. Scant literature assesses accuracy and duration of POCUS pulse assessment by this group during cardiac resuscitation given recommendations for minimal pauses in chest compressions. Evaluation is needed for accuracy and duration of pulse interpretation in EM trainees utilizing POCUS. METHODS: We conducted a double-blind observational study of EM clinician trainee POCUS assessment of pulses using porcine models. Volunteers were blinded to the cardiac status of 5 porcine models randomized as deceased or living and performed femoral artery evaluation using color power Doppler POCUS. The primary outcome was accuracy of pulse assessment. Secondary outcomes included time to verbalization and differences based on reported duration of EM training, experience with ultrasound, and cardiac arrest resuscitation experience. RESULTS: 17 EM and EMPA trainees completed 85 total POCUS pulse assessments with 98.82% accuracy (n=84). Mean verbalization time was 6.95 seconds, and most verbalized interpretations were within 10-seconds (82.4%, n=70). This was grossly consistent between living and deceased models. Subgroup analysis found no significant differences of accuracy or verbalization time based on reported demographics. CONCLUSION: EM clinician trainees demonstrate a high degree of accuracy and low average time for verbalized interpretation of femoral artery pulse assessment, most within recommended time guidelines. Further study is needed to correlate these findings in human patients.

US Army Combat Medic Performance With Portable Ultrasound to Detect Sonographic Findings of Pneumothorax in a Cadaveric Model.

BACKGROUND: Ultrasound, due to recent advances in portability and versatility, has become a valuable clinical adjunct in austere, resource-limited settings and is well demonstrated to be an accurate/efficient means to detect pneumothorax. The purpose of this study was to evaluate the impact of hands-on ultrasound training on ultrasound-naive US Army combat medics' ability to detect sonographic findings of pneumothorax with portable ultrasound in a cadaver model. METHODS: Ultrasound-naive US Army combat medics assigned to conventional military units were recruited from a single US Army installation and randomized to receive either didactic training only, or "blended" (didactic and hands-on) training on ultrasound detection of pneumothorax. Blinded participants were asked to perform a thoracic ultrasound exam on ventilated human cadaver models. Primary outcome measured was sensitivity and specificity of detecting sonographic findings of pneumothorax between cohorts. RESULTS: Forty-three participants examined a total of 258 hemithoraces. The didactic-only cohort (n = 24) detected sonographic findings of pneumothorax with a sensitivity of 68% and specificity of 57%. The blended cohort (n = 19) detected sonographic findings of pneumothorax with an overall sensitivity of 91% and specificity of 80%. Detection sensitivities were similar between B-mode versus M-mode use. CONCLUSION: US Army combat medics can use portable U/S to detect sonographic findings of pneumothorax in a human cadaver model with high sensitivity after a brief, blended (didactic and hands-on) training intervention.

The US military experience with THAM.

BACKGROUND: Acidosis, a part of the lethal trauma triad, occurs frequently after major combat trauma. Tris-hydroxymethyl aminomethane (THAM) has been used to effectively treat acidosis in injured casualties. No research has been conducted assessing the safety of THAM in the military combat setting. We sought to describe the US military experience with THAM administration to battlefield injury subjects. METHODS: We conducted a retrospective descriptive cohort study reviewing the trauma data from the Department of Defense Trauma Registry. US military personnel with an injury severity score greater than 15, between September 2001 and December 2014, were analyzed. Our primary outcome was the 30-day all-cause mortality among cohort treated with THAM versus those who were not. Differences between the cohort were examined using a student t-test (continuous variables), Wilcoxon Rank Sum test (ordinal variables), and chi-squared test (nominal variables). RESULTS: 4558 subjects met the inclusion criteria. 69 received THAM and 4489 did not. Casualties receiving THAM had higher mean ISS scores (33 vs. 27, p < 0.001), and required significantly higher amounts of packed red blood cells (RBCs, 37 vs. 10, p < 0.001). THAM cohort had longer ventilator and intensive care unit (ICU) days with an overall lower survival to hospital discharge. On univariable analysis, THAM was associated with lower odds of survival (OR 0.18, 95% CI 0.11-0.31) but on multivariable analysis, when controlling for confounders, THAM use was not associated with a worse odds of survival (OR 0.83, 95% CI 0.21-3.24). CONCLUSIONS: Within our combat trauma population, we were unable to detect worse 30 day mortality associated with THAM administration. Prospective investigations are needed to validate its use in critically injured combat casualties.

A Comparison of the Laryngeal Handshake Method Versus the Traditional Index Finger Palpation Method in Identifying the Cricothyroid Membrane, When Performed by Combat Medic Trainees.

BACKGROUND: The laryngeal handshake method (LHM) may be a reliable standardized method to quickly and accurately identify the cricothyroid membrane (CTM) when performing an emergency surgical airway (ESA). However, there is currently minimal available literature evaluating the method. Furthermore, no previous CTM localization studies have focused on success rates of military prehospital providers. This study was conducted with the goal of answering the question: Which method is superior, the LHM or the traditional method (TM), for identifying anatomical landmarks in a timely manner when performed by US Army combat medic trainees? METHODS: This prospective randomized crossover study was conducted at Ft Sam Houston, TX, in September 2018. Two Army medic trainees with similar body habitus volunteered as subjects, and the upper and lower borders and midline of their CTMs were identified by ultrasound (US). The participants were also recruited from the medic trainee population. After receiving initial training on the LHM and refresher training on the TM, participants were asked to localize the CTMs of each subject with one method per subject. Success was defined as a marking within the borders and 5mm of midline within 2 minutes. RESULTS: Thirty-two combat medic trainees participated; 78% (n = 25) successfully localized the CTM using the TM versus 41% (n = 13) using the LHM (p = .002). CONCLUSION: Findings of this study support that at present the TM is a superior method for successful localization of the CTM when performed by Army combat medic trainees.