Evaluation of Contingency Telemedical Support to Improve Casualty Care at a Simulated Military Intermediate Resuscitation Facility: The EM-ANGEL Study.

OBJECTIVE: We sought to determine whether Contingency Telemedical Support (CTS) improves the success rate and efficiency of primary care providers performing critical actions during simulated combat trauma resuscitation. Critical actions included advanced airway, chest decompression, extremity hemorrhage control, hypothermia prevention, antibiotics and analgesics, and hypotensive resuscitation, among others. BACKGROUND: Recent studies report improved survival associated with skilled triage and treatment in the out-of-hospital/preoperative phase of combat casualty care. Historically, ground combat units are assigned primary care physicians and physician assistants as medical staff, due to resource limitations. Although they are recognized as optimal resuscitators, demand for military trauma surgeons and emergency physicians exceeds supply and is unlikely to improve in the near term. METHODS: A prospective trial of telemedical mentoring during a casualty resuscitation encounter was studied using a high-fidelity patient simulator (HFPS). Subjects were randomized and formed into experimental (CTS) or control teams. CTS team leaders were equipped with a headset/microphone interface and telementored by a combat-experienced emergency physician or trauma surgeon. A standardized, scripted clinical scenario and HFPS were used with 14 critical actions. At completion, subjects were surveyed. Statistical approach included contingency table analysis, two-tailed t-test, and correlation coefficient. This study was reviewed and approved by our institutional review board (IRB). RESULTS: Eighteen CTS teams and 16 control teams were studied. By intention-to-treat ITT analysis, 89% of CTS teams versus 56% of controls completed all life-threatening inventions (LSIs) (p<.01); 78% versus 19% completed all critical actions (p<.01); and 89% versus 56% established advanced airways within 8 minutes (p<.06). Average time to completion in minutes (95% confidence interval [CI] 95) was 12 minutes (10?14) for CTS versus 18 (16?20) for controls, with 75% of control teams not completing all critical actions. CONCLUSION: In this model, real-time telementoring of simulated trauma resuscitation was feasible and improved accuracy and efficiency of non?emergency-trained resuscitators. Clinical validation and replicated study of these findings for guiding remote damage control resuscitation are warranted.

Vented versus unvented chest seals for treatment of pneumothorax and prevention of tension pneumothorax in a swine model.

BACKGROUND: Unvented chest seals (CSs) are currently recommended for the management of penetrating thoracic injuries in the battlefield. Since no supporting data exist, we compared the efficacy of a preferred unvented with that of a vented CS in a novel swine model of pneumothorax (PTx). METHODS: An open chest wound was created in the left thorax of spontaneously air-breathing anesthetized pigs (n = 8). A CS was applied over the injury, then tension PTx was induced by incremental air injections (0.2 L) into the pleural cavity via a cannula that was also used to measure intrapleural pressure (IP). Both CS were tested on each pig in series. Tidal volume (V(T)), respiratory rate, IP, heart rate, mean arterial pressure, cardiac output, central venous pressure, pulmonary arterial pressure, venous and peripheral oxygen saturations (SvO2, SpO2) were recorded. Tension PTx was defined as a mean IP equal to or greater than +1 mm Hg plus significant (20-30%) deviation in baseline levels of the previously mentioned parameters and confirmed by chest x-ray study. PaO2 and PaCo2 were also measured. RESULTS: PTx produced immediate breathing difficulty and significant rises in IP and pulmonary arterial pressure and falls in V(T), SpO2, and SvO2. Both CSs returned these parameters to near baseline within 5 minutes of application. After vented CS was applied, serial air injections up to 2 L resulted in no significant change in the previously mentioned parameters. After unvented CS application, progressive deterioration of all respiratory parameters and onset of tension PTx were observed in all subjects after approximately 1.4-L air injection. CONCLUSION: Both vented and unvented CSs provided immediate improvements in breathing and blood oxygenation in our model of penetrating thoracic trauma. However, in the presence of ongoing intrapleural air accumulation, the unvented CS led to tension PTx, hypoxemia, and possible respiratory arrest, while the vented CS prevented these outcomes.

Analysis of remote trauma transfers in South Central Texas with comparison with current US combat operations: results of the RemTORN-I study.

BACKGROUND: This study aimed to analyze demographic, epidemiologic, temporal, and outcome data from an integrated trauma registry of patients undergoing initial stabilization and transfer within a mature domestic trauma network; compare data with a companion subset from the Department of Defense Trauma Registry. Texas Trauma Service Area-P is composed of 25 counties, 15 rural Level IV trauma centers (no acute care surgery), and two Level I trauma centers. METHODS: This study has a retrospective cohort design. We hypothesize that Injury Severity Scores (ISSs), time intervals, and other clinical indicators would be complimentary to contemporary combat casualties. Inclusion criteria include age 18 years to 80 years, transferred from Level IV to Level I trauma center, or expired en route. RESULTS: A total of 543 subjects (84%) met the criteria and were analyzed. Averages and confidence intervals were as follows: age of 40 years (38-41 years), males at 81%, ISS of 10 (10-11), intensive care unit stay of 2 days (1-3 days), and hospital stay of 5 days (4-6 days). Mechanisms of injury were as follows: penetrating (15%), blunt weapon (19%), stabs (9%), burns (5%), and gunshots (5%). Eight percent received blood within the first 24 hours. Survival was at 98%. Time intervals (95% confidence interval) were as follows: prehospital at 1:43 (1:29-1:58), Level IV dwell time at 3:17 (3:06-3:28), interfacility transfer at 1:43 (1:36-1:49), and total at 6:39 (6:20-6:58). RemTORN cases were older, spent longer time en route to Level I, and had ISS similar to combat casualties. Rates of blood transfusion in the first 24 hours and survival were similar in order of magnitude. CONCLUSION: The RemTORN platform is operational. Demographic, epidemiologic, and temporal characteristics as observed will support clinical investigations of traumatic coagulopathy, shock, and potential interventions before Level I arrival. Results of such investigations will likely be applicable to the contemporary and future battlefield.