Implementation of a workshop for mass casualty incident triage training using an immersive virtual reality simulation.

Objective: We offered a workshop at the 2023 annual meeting of the Society for Academic Emergency Medicine to teach the Sort-Assess-Lifesaving Interventions-Treatment/Transport (SALT) triage protocol for responding to mass casualty incidents (MCIs) using an immersive virtual reality (VR) simulator. Here, we report workshop outcomes. Methods: After a 1-h didactic on the basics of triage protocols, workshop participants rotated through three skill stations at which learners learned how to use the VR headset and controllers, practiced applying SALT triage skills through a tabletop exercise, and then finally used our VR simulator for training responses to MCIs. During their encounter with VR, participants applied their new knowledge to triaging and treating the victims of an explosion in a virtual subway station. After a brief orientation, participants entered the scene to treat and triage virtual patients who had various life-threatening (e.g., acute arterial bleed, penetrating injury, pneumothorax, amputations) and non-life-threatening injuries (lacerations, sprains, hysteria, confusion). The simulator generated a performance report for each workshop attendee to be used for debriefing by a skilled facilitator. Results: Participants were mostly trainees (residents), all of whom properly initiated their encounter with global sort commands (walk and wave) to identify the most critically injured. On average, participants correctly treated 92% of 18 injuries, with all bleeding injuries being properly controlled (tourniquets or wound packing). On average, participants correctly tagged 87.7% of 11 patients, but only took the pulse of 67% of the 11 patients. Learners had difficulty with cases involving embedded shrapnel and properly tagging patients who were stable after treatments. Conclusions: Our VR simulator provided a practical, portable, reproducible training and assessment system for preparing future emergency medical systems (EMS) medical directors to teach their EMS professionals the triage and lifesaving intervention treatment skills needed to save lives.

State Requirements for Medical Directors in the United States.

BACKGROUND: The requirements for emergency medical services (EMS) medical directors are commonly defined by state rules and regulations without national standardization. The extent of variability in the requirements to be an EMS medical director in the US is unclear. The objective of this study is to describe the state requirements to function as an EMS medical director in the US. METHODS: This was an evaluation of the rules and statutes governing the current requirements to function as an agency-level EMS medical director and defined tasks in the US. Regulations and governmental statutes were reviewed from 50 states and the District of Columbia using publicly available governmental websites focusing on the specific qualifications required to work as an EMS medical director and perform the associated tasks. Data were tabulated, and descriptive statistics were calculated. RESULTS: Data were available and extracted for all 50 states and the District of Columbia. Being a licensed physician is the minimum requirement in 50 states (50/51, 98%). One state, Montana, allows for medical direction by a licensed physician or physician assistant. Board certification in emergency medicine is required by 8% (4/51). No state requires EMS subspecialty certification. The majority of states require that EMS medical directors participate in EMS oversight (76%), EMS clinician training (71%), protocol development (67%), and quality improvement and assurance (65%). CONCLUSIONS: Requirements for EMS medical direction across the US are not standardized. Many states require a medical license, but emergency medicine board certification is not a common requirement. Future work will need to focus on required competencies for EMS medical direction to set clear standards and educational requirements in the US.

A Different Type of Tension Headache: A Case Report of Traumatic Tension Pneumocephalus.

Tension pneumocephalus is a rare neurosurgical emergency requiring cranial decompression to prevent permanent neurological injury, herniation, and death. In this report, we present a trauma patient struck by a knife in the forehead who presented with agitation and vomiting. Imaging ultimately revealed a minimally displaced frontal sinus fracture through both the anterior and posterior walls of the sinus. This disruption, acting as a ball-valve for air entry into the cranium, resulted in extensive pneumocephalus and eventual tension physiology. The patient required immediate neurosurgical decompression. This case illustrates both the importance in recognition of this uncommon pathology as well as the need for rapid reassessment with clinical changes in trauma patients. Topics: Tension pneumocephalus, facial fracture, head trauma.

Prehospital Stroke Assessment for Large Vessel Occlusions: A Systematic Review.

BACKGROUND AND OBJECTIVE: Stroke is the leading cause of disability in the United States and new evidence shows interventional procedures provide better outcomes for large vessel occlusions (LVO). We performed a systematic review of the literature on prehospital stroke scales used to identify LVOs comparing the scales with analysis of the sensitivity, specificity, and predictive values. The goal was to determine if emergency medical services (EMS) are able to accurately identify LVO in the field. METHODS: In this systematic review, multiple databases were searched for articles that addressed our goal. The identified studies were evaluated for their statistical performance of various stroke scales. In addition, we assessed biases that may explain the varying results reported. RESULTS: Eight studies encompassing 6787 patients were included in our systematic review. Of the 8 studies, 6 were retrospective studies, 1 was a prospective cohort, and 1 was a prospective observational study. Sensitivities of the studies ranged from 49% to 91% while specificity of the studies varied from 40% to 94%. CONCLUSION: At this time, further evaluations must be done in the prehospital setting to determine the ease of use and true sensitivity and specificity of these scales in identifying LVOs.

Iron, inflammation and atherosclerosis risk in men vs. perimenopausal women.

OBJECTIVE: Age at first atherosclerotic event is typically older for women vs. men; monthly iron loss has been postulated to contribute to this advantage. We investigated the relationship between an MRI-based arterial wall biomarker and the serum inflammatory biomarker high-sensitivity C-reactive protein (hsCRP) in perimenopausal women vs. men. METHODS AND RESULTS: Women without evident atherosclerotic disease were prospectively enrolled and observed over 24 months of menopause transition, indicated by hormone levels and reduction in median number of menstrual cycles from 4 [3-6] per year to 0 [0-1] per year (P < 0.01). Higher hsCRP predicted shorter carotid artery wall T2* in women entering the menopause transition (r = -0.3139, P = 0.0014); this relationship weakened after 24 months of perimenopause in women (r = -0.1718, P = 0.0859) and was not significant in a cohort of men matched for age and cardiovascular risk category (r = -0.0310, P = 0.8362). Serum ferritin increased from baseline to 24-month follow-up during women's menopause transition (37 [20-79] to 67 [36-97] ng/mL, P < 0.01), but still remained lower compared to men (111 [45-220] ng/mL, P < 0.01). Circulating ferritin levels correlated with arterial wall T2* values in women at baseline (r = -0.3163, P = 0.0013) but not in women after 24 months (r = -0.0730, P = 0.4684) of menopause transition nor in men (r = 0.0862, P = 0.5644). CONCLUSIONS: An arterial wall iron-based imaging biomarker reflects degree of systemic inflammation in younger women, whereas this relationship is lost as women transition through menopause to become more similar to men. Iron homeostasis and inflammation in the arterial wall microenvironment warrants further investigation as a potential early target for interventions that mitigate atherosclerosis risk.

Iron and noncontrast magnetic resonance T2* as a marker of intraplaque iron in human atherosclerosis.

OBJECTIVE: Iron has been implicated in atherogenesis and plaque destabilization, whereas less is known about iron-related proteins in this disease. We compared ex vivo quantities with in vivo vessel wall T2*, which is a noncontrast magnetic resonance relaxation time that quantitatively shortens with increased tissue iron content. We also tested the hypothesis that patients with carotid atherosclerosis have abnormal T2* times vs controls that would help support a role for iron in human atherosclerosis. METHODS: Forty-six patients undergoing carotid endarterectomy and 14 subjects without carotid disease were prospectively enrolled to undergo carotid magnetic resonance imaging. Ex vivo measurements were performed on explanted plaque and 17 mammary artery samples. RESULTS: Plaques vs normal arteries had higher levels of ferritin (median, 7.3 [interquartile range (IQR), 4-13.8] vs 1.0 [IQR, 0.6-1.3] ng/mg; P < .001) and oxidized low-density lipoprotein (median, 0.17 [IQR, 0.12-0.30] vs 0.01 [IQR, 0.003-0.03] ng/mg; P < .001) as well as hepcidin (median, 8.7 [IQR, 4.6-12.4] vs 2.6 [IQR, 1.3-7.0] ng/mL; P = .03); serum hepcidin levels did not distinguish atherosclerosis patients from controls (median, 40.6 [IQR, 18.8-88.6] vs 33.9 [IQR, 17.6-55.2]; P = .42). Shorter in vivo T2* paralleled larger plaque volume (ρ = -.44; P = .01), and diseased arteries had shorter T2* values compared with controls (median, 17.7 ± 4.3 vs 23.0 ± 2.4 ms; P < .001). CONCLUSIONS: Diseased arteries have greater levels of iron-related proteins ex vivo and shorter T2* times in vivo. Further studies should help define the role of T2* as a biomarker of iron and atherosclerosis.

Quantification of aortic stiffness using MR elastography and its comparison to MRI-based pulse wave velocity.

PURPOSE: To determine the correlation in abdominal aortic stiffness obtained using magnetic resonance elastography (MRE) (µ(MRE)) and MRI-based pulse wave velocity (PWV) shear stiffness (µ(PWV)) estimates in normal volunteers of varying age, and also to determine the correlation between µ(MRE) and µ(PWV). MATERIALS AND METHODS: In vivo aortic MRE and MRI were performed on 21 healthy volunteers with ages ranging from 18 to 65 years to obtain wave and velocity data along the long axis of the abdominal aorta. The MRE wave images were analyzed to obtain mean stiffness and the phase contrast images were analyzed to obtain PWV measurements and indirectly estimate stiffness values from the Moens-Korteweg equation. RESULTS: Both µ(MRE) and µ(PWV) measurements increased with age, demonstrating linear correlations with R(2) values of 0.81 and 0.67, respectively. Significant difference (P ≤ 0.001) in mean µ(MRE) and µ(PWV) between young and old healthy volunteers was also observed. Furthermore, a poor linear correlation of R(2) value of 0.43 was determined between µ(MRE) and µ(PWV) in the initial pool of volunteers. CONCLUSION: The results of this study indicate linear correlations between µ(MRE) and µ(PWV) with normal aging of the abdominal aorta. Significant differences in mean µ(MRE) and µ(PWV) between young and old healthy volunteers were observed.

Iron and atherosclerosis: nailing down a novel target with magnetic resonance.

Iron is an essential mineral in many proteins and enzymes in human physiology, with limited means of iron elimination to maintain iron balance. Iron accrual incurs various pathological mechanisms linked to cardiovascular disease. In atherosclerosis, iron catalyzes the creation of reactive oxygen free radicals that contribute to lipid modification, which is essential to atheroma formation. Inflammation further fuels iron-related pathologic processes associated with plaque progression. Given iron's role in atherosclerosis development, in vivo detection techniques sensitive iron are needed for translational studies targeting iron for earlier diagnosis and treatment. Magnetic resonance imaging is uniquely able to quantify iron in human tissues noninvasively and without ionizing radiation, offering appealing for longitudinal and interventional studies. Particularly intriguing is iron's complementary biology vs. calcium, which is readily detectable by computed tomography. This review summarizes the role of iron in atherosclerosis with considerable implications for novel diagnostic and therapeutic approaches.

Improved in vivo human carotid artery wall T2 estimation.

T(2) quantification has been shown to noninvasively and accurately estimate tissue iron content in the liver and heart; applying this to thin-walled carotid arteries introduces a new challenge to the estimation process. With most imaging voxels in a vessel being along its boundaries, errors in parameter estimation may result from partial volume mixing and misregistration due to motion in addition to noise and other common error sources. To minimize these errors, we propose a novel technique to reliably estimate T(2) in thin regions of vessel wall. The technique weights data points to reduce the influence of expected error sources. It uses neighborhoods of data to increase the number of points for fitting and to assess lack of fit for automated outlier detection and deletion. The performance of this method was observed in simulations, phantom and in vivo patient studies and compared to results obtained using a pixelwise linear least squares estimation of T(2). The new proposed method showed a closer match to the expected results, and a 4.2-fold decrease in interobserver variability for in vivo studies. This increased confidence in estimation should improve the ability to reliably quantify iron noninvasively in the arterial wall.