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Maddry JK, Araña AA, Mora AG, Schauer SG, Reeves LK, Cutright JE, Paciocco JA, Perez CA, Davis WT, Ng PC. Management of Combat Casualties during Aeromedical Evacuation from a Role 2 to a Role 3 Medical Facility. Mil Med 2024; 189:e1003-e1008. [PMID: 37966379 DOI: 10.1093/milmed/usad404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/23/2023] [Accepted: 10/12/2023] [Indexed: 11/16/2023] Open
Abstract
INTRODUCTION Emergent clinical care and patient movements through the military evacuation system improves survival. Patient management differs when transporting from the point-of-injury (POI) to the first medical treatment facility (MTF) versus transporting from the Role 2 to the Role 3 MTF secondary to care rendered within the MTF, including surgery and advanced resuscitation. The objective of this study was to describe care provided to patients during theater inter-facility transports and compare with pre-hospital transports (POI to first MTF). MATERIALS AND METHODS We performed a retrospective chart review of patients with the Role 2 to the Role 3 transports in Afghanistan and Iraq from 2007 to 2016. Data collected included procedures and events at the MTF and during transport. We compared the intra-theater transport data (Role 2 to Role 3) to data from a previous study evaluating pre-hospiital transports (POI to first MTF). RESULTS We reviewed the records of 869 Role 2 to Role 3 transport patients. Role 2 to Role 3 transports were longer in duration compared to POI transports (39 minutes vs. 23 minutes) and were more likely to be staffed by advanced personnel (nurses, physician assistants, and physicians) (57% vs. 3%). The sample primarily consisted of military-aged males (mean age 27 years) who suffered from explosive or blunt force injuries. Procedures performed during each phase of care reflected the capabilities of the teams and locations. Pain and cardiac events were more common in POI evacuations compared to the Role 2 to Role 3 transports, but documentation of respiratory events, hemodynamic events, neurologic events, and equipment failure was more common during the Role 2 to Role 3 transports. Survival rates were slightly higher among the Role 2 to Role 3 cohort (98% vs. 95%, difference 3% [95% confidence interval of the difference 1-5%]). CONCLUSIONS Inter-facility transports (Role 2 to Role 3) are longer in duration, transport more complex patients, and are staffed by more advanced level provider types compared to transports from POI.
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Affiliation(s)
- Joseph K Maddry
- United States Air Force En route Care Research/59th Medical Wing/Science & Technology, JBSA Lackland Air Force Base, TX 78236, USA
- Department of Emergency Medicine, Brooke Army Medical Center, JBSA Ft. Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD 20814, USA
- US Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX 78234, USA
| | - Allyson A Araña
- United States Air Force En route Care Research/59th Medical Wing/Science & Technology, JBSA Lackland Air Force Base, TX 78236, USA
| | - Alejandra G Mora
- United States Air Force En route Care Research/59th Medical Wing/Science & Technology, JBSA Lackland Air Force Base, TX 78236, USA
| | - Steven G Schauer
- Department of Emergency Medicine, Brooke Army Medical Center, JBSA Ft. Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD 20814, USA
- US Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX 78234, USA
| | - Lauren K Reeves
- United States Air Force En route Care Research/59th Medical Wing/Science & Technology, JBSA Lackland Air Force Base, TX 78236, USA
| | - Julie E Cutright
- United States Air Force En route Care Research/59th Medical Wing/Science & Technology, JBSA Lackland Air Force Base, TX 78236, USA
| | - Joni A Paciocco
- United States Air Force En route Care Research/59th Medical Wing/Science & Technology, JBSA Lackland Air Force Base, TX 78236, USA
| | - Crystal A Perez
- United States Air Force En route Care Research/59th Medical Wing/Science & Technology, JBSA Lackland Air Force Base, TX 78236, USA
| | - William T Davis
- United States Air Force En route Care Research/59th Medical Wing/Science & Technology, JBSA Lackland Air Force Base, TX 78236, USA
- Department of Emergency Medicine, Brooke Army Medical Center, JBSA Ft. Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD 20814, USA
| | - Patrick C Ng
- United States Air Force En route Care Research/59th Medical Wing/Science & Technology, JBSA Lackland Air Force Base, TX 78236, USA
- Department of Emergency Medicine, Brooke Army Medical Center, JBSA Ft. Sam Houston, TX 78234, USA
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Dünser MW, Noitz M, Tschoellitsch T, Bruckner M, Brunner M, Eichler B, Erblich R, Kalb S, Knöll M, Szasz J, Behringer W, Meier J. Emergency critical care: closing the gap between onset of critical illness and intensive care unit admission. Wien Klin Wochenschr 2024:10.1007/s00508-024-02374-w. [PMID: 38755419 DOI: 10.1007/s00508-024-02374-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 04/20/2024] [Indexed: 05/18/2024]
Abstract
Critical illness is an exquisitely time-sensitive condition and follows a disease continuum, which always starts before admission to the intensive care unit (ICU), in the majority of cases even before hospital admission. Reflecting the common practice in many healthcare systems that critical care is mainly provided in the confined areas of an ICU, any delay in ICU admission of critically ill patients is associated with increased morbidity and mortality. However, if appropriate critical care interventions are provided before ICU admission, this association is not observed. Emergency critical care refers to critical care provided outside of the ICU. It encompasses the delivery of critical care interventions to and monitoring of patients at the place and time closest to the onset of critical illness as well as during transfer to the ICU. Thus, emergency critical care covers the most time-sensitive phase of critical illness and constitutes one missing link in the chain of survival of the critically ill patient. Emergency critical care is delivered whenever and wherever critical illness occurs such as in the pre-hospital setting, before and during inter-hospital transfers of critically ill patients, in the emergency department, in the operating theatres, and on hospital wards. By closing the management gap between onset of critical illness and ICU admission, emergency critical care improves patient safety and can avoid early deaths, reverse mild-to-moderate critical illness, avoid ICU admission, attenuate the severity of organ dysfunction, shorten ICU length of stay, and reduce short- and long-term mortality of critically ill patients. Future research is needed to identify effective models to implement emergency critical care systems in different healthcare systems.
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Affiliation(s)
- Martin W Dünser
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria.
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4020, Linz, Austria.
| | - Matthias Noitz
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Thomas Tschoellitsch
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Markus Bruckner
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Markus Brunner
- Ambulance and Disaster Relief Services, Oberösterreichisches Rotes Kreuz, 4020, Linz, Austria
| | - Bernhard Eichler
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Romana Erblich
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Stephan Kalb
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Marius Knöll
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | | | - Wilhelm Behringer
- Department of Emergency Medicine, Vienna General Hospital, 1090, Vienna, Austria
| | - Jens Meier
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
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Pinto-Villalba RS, Leon-Rojas JE. Reported adverse events during out-of-hospital mechanical ventilation and ventilatory support in emergency medical services and critical care transport crews: a systematic review. Front Med (Lausanne) 2023; 10:1229053. [PMID: 37877027 PMCID: PMC10590890 DOI: 10.3389/fmed.2023.1229053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 09/20/2023] [Indexed: 10/26/2023] Open
Abstract
Background Emergency medical services (EMS) and critical care transport crews constantly face critically-ill patients who need ventilatory support in scenarios where correct interventions can be the difference between life and death; furthermore, challenges like limited staff working on the patient and restricted spaces are often present. Due to these, mechanical ventilation (MV) can be a support by liberating staff from managing the airway and allowing them to focus on other areas; however, these patients face many complications that personnel must be aware of. Aims To establish the main complications related to out-of-hospital MV and ventilatory support through a systematic review. Methodology PubMed, BVS and Scopus were searched from inception to July 2021, following the PRISMA guidelines; search strategy and protocol were registered in PROSPERO. Two authors carried out an independent analysis of the articles; any disagreement was solved by mutual consensus, and data was extracted on a pre-determined spreadsheet. Only original articles were included, and risk of bias was assessed with quality assessment tools from the National Institutes of Health. Results The literature search yielded a total of 2,260 articles, of which 26 were included in the systematic review, with a total of 9,418 patients with out-of-hospital MV; 56.1% were male, and the age ranged from 18 to 82 years. In general terms of aetiology, 12.2% of ventilatory problems were traumatic in origin, and 64.8% were non-traumatic, with slight changes between out-of-hospital settings. Mechanical ventilation was performed 49.2% of the time in prehospital settings and 50.8% of the time in interfacility transport settings (IFTS). Invasive mechanical ventilation was used 98.8% of the time in IFTS while non-invasive ventilation was used 96.7% of the time in prehospital settings. Reporting of adverse events occurred in 9.1% of cases, of which 94.4% were critical events, mainly pneumothorax in 33.1% of cases and hypotension in 27.6% of cases, with important considerations between type of out-of-hospital setting and ventilatory mode; total mortality was 8.4%. Conclusion Reported adverse events of out-of-hospital mechanical ventilation vary between settings and ventilatory modes; this knowledge could aid EMS providers in promptly recognizing and resolving such clinical situations, depending on the type of scenario being faced.
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Affiliation(s)
- Ricardo Sabastian Pinto-Villalba
- Carrera de Atención Prehospitalaria y en Emergencias, Universidad Central del Ecuador, Quito, Ecuador
- Facultad de Medicina, Carrera de Atención Prehospitalaria y en Emergencias, Universidad UTE, Quito, Ecuador
- Medignosis, Medical Research Department, Quito, Ecuador
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Maddry JK, Mora AG, Perez CA, Arana AA, Medellin KL, Paciocco JA, Ng PC, Davis WT, Hunninghake JC, Bebarta VS. Improved Adherence to Best Practice Ventilation Management After Implementation of Clinical Practice Guideline (CPG) for United States Military Critical Care Air Transport Teams (CCATTs). Mil Med 2023; 188:e125-e132. [PMID: 34865107 DOI: 10.1093/milmed/usab474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/22/2021] [Accepted: 10/29/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Critical Care Air Transport Teams (CCATTs) play a vital role in the transport and care of critically ill and injured patients in the combat theater to include mechanically ventilated patients. Previous research has demonstrated improved morbidity and mortality when lung protective ventilation strategies are used. Our previous study of CCATT trauma patients demonstrated frequent non-adherence to the Acute Respiratory Distress Syndrome Network (ARDSNet) protocol and a corresponding association with increased mortality. The goals of our study were to examine CCATT adherence with ARDSNet guidelines in non-trauma patients, compare the findings to our previous publication of CCATT trauma patients, and evaluate adherence before and after the publication of the CCATT Ventilator Management Clinical Practice Guideline (CPG). METHODS We performed a retrospective chart review of ventilated non-trauma patients who were evacuated out of theater by Critical Care Air Transport Teams (CCATT) between January 2007 and April 2015. Data abstractors collected flight information, oxygenation status, ventilator settings, procedures, and in-flight assessments. We calculated descriptive statistics to determine the frequency of compliance with the ARDSNet protocol before and after the CCATT Ventilator CPG publication and the association between ARDSNet protocol adherence and in-flight events. RESULTS We reviewed the charts of 124 mechanically ventilated patients transported out of theater via CCATT on volume control settings. Seventy percent (n = 87/124) of records were determined to be Non-Adherent to ARDSNet recommendations predominately due to excessive tidal volume settings and/or high FiO2 settings relative to the patient's positive end-expiratory pressure setting. The Non-Adherent group had a higher proportion of in-flight respiratory events. Compared to our previous study of ventilation guideline adherence in the trauma population, the Non-Trauma population had a higher rate of non-adherence to tidal volume and ARDSNet table recommendations (75.6% vs. 61.5%). After the CPG was rolled out, adherence improved from 24% to 41% (P = 0.0496). CONCLUSIONS CCATTs had low adherence with the ARDSNet guidelines in non-trauma patients transported out of the combat theater, but implementation of a Ventilator Management CPG was associated with improved adherence.
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Affiliation(s)
- Joseph K Maddry
- Air Force 59th MDW/ST-En Route Care Research Center, JBSA Ft Sam Houston, TX 78234, USA
- Department of Emergency Medicine, Brooke Army Military Medical Center, JBSA Ft Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD 20814, USA
| | - Alejandra G Mora
- Air Force 59th MDW/ST-En Route Care Research Center, JBSA Ft Sam Houston, TX 78234, USA
| | - Crystal A Perez
- Air Force 59th MDW/ST-En Route Care Research Center, JBSA Ft Sam Houston, TX 78234, USA
| | - Allyson A Arana
- Air Force 59th MDW/ST-En Route Care Research Center, JBSA Ft Sam Houston, TX 78234, USA
| | - Kimberly L Medellin
- Air Force 59th MDW/ST-En Route Care Research Center, JBSA Ft Sam Houston, TX 78234, USA
| | - Joni A Paciocco
- Air Force 59th MDW/ST-En Route Care Research Center, JBSA Ft Sam Houston, TX 78234, USA
| | - Patrick C Ng
- Air Force 59th MDW/ST-En Route Care Research Center, JBSA Ft Sam Houston, TX 78234, USA
- Department of Emergency Medicine, Brooke Army Military Medical Center, JBSA Ft Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD 20814, USA
| | - William T Davis
- Air Force 59th MDW/ST-En Route Care Research Center, JBSA Ft Sam Houston, TX 78234, USA
- Department of Emergency Medicine, Brooke Army Military Medical Center, JBSA Ft Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD 20814, USA
| | - John C Hunninghake
- Critical Care Medicine, Brooke Army Military Medical Center, JBSA Ft Sam Houston, TX 78234, USA
| | - Vikhyat S Bebarta
- Center for COMBAT Research, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
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Abstract
OBJECTIVES To assess recent advances in interfacility critical care transport. DATA SOURCES PubMed English language publications plus chapters and professional organization publications. STUDY SELECTION Manuscripts including practice manuals and standard (1990-2021) focused on interfacility transport of critically ill patients. DATA EXTRACTION Review of society guidelines, legislative requirements, objective measures of outcomes, and transport practice standards occurred in work groups assessing definitions and foundations of interfacility transport, transport team composition, and transport specific considerations. Qualitative analysis was performed to characterize current science regarding interfacility transport. DATA SYNTHESIS The Task Force conducted an integrative review of 496 manuscripts combined with 120 from the authors' collections including nonpeer reviewed publications. After title and abstract screening, 40 underwent full-text review, of which 21 remained for qualitative synthesis. CONCLUSIONS Since 2004, there have been numerous advances in critical care interfacility transport. Clinical deterioration may be mitigated by appropriate patient selection, pretransport optimization, and transport by a well-resourced team and vehicle. There remains a dearth of high-quality controlled studies, but notable advances in monitoring, en route management, transport modality (air vs ground), as well as team composition and training serve as foundations for future inquiry. Guidance from professional organizations remains uncoupled from enforceable regulations, impeding standardization of transport program quality assessment and verification.
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Combat Trauma-Related Acute Respiratory Distress Syndrome: A Scoping Review. Crit Care Explor 2022; 4:e0759. [DOI: 10.1097/cce.0000000000000759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Roginski MA, Burney CP, Husson EG, Harper KR, Atchinson PRA, Munson JC. Influence of Critical Care Transport Ventilator Management on Intensive Care Unit Care. Air Med J 2022; 41:96-102. [PMID: 35248352 DOI: 10.1016/j.amj.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/16/2021] [Accepted: 10/13/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE High tidal volume ventilation is associated with ventilator-induced lung injury. Early introduction of lung protective ventilation improves patient outcomes. This study describes ventilator management during critical care transport and the association between transport ventilator settings and ventilator settings in the intensive care unit (ICU). METHODS This was a retrospective review of mechanically ventilated adult patients transported to an academic medical center via a critical care transport program between January 2018 and April 2019. Ventilator settings during transport were compared with the initial and 6- and 12-hour postadmission ventilator settings. RESULTS Three hundred eighty patients were identified; 114 (30%) received tidal volumes > 8 mL/kg predicted body weight at the time of transfer. The transport handoff tidal volume strongly correlated with the ICU tidal volume (Pearson r = 0.7). Patients receiving high tidal volumes during transport were more likely to receive high tidal volumes initially upon transfer (relative risk [RR] = 4.6; 95% confidence interval [CI], 3.3-6.5) and at 6 and 12 hours after admission (RR = 2.6; 95% CI, 1.8-3.8 and RR = 2.7; 95% CI, 1.7-4.3, respectively). CONCLUSION Exposure to high tidal volumes during transport is associated with high tidal volume ventilation in the ICU, even up to 12 hours after admission. This study identifies opportunities for improving patient care through the application of lung protective ventilation strategies during transport.
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Affiliation(s)
- Matthew A Roginski
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Medicine, Section of Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - Charles P Burney
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | | | - Patricia Ruth A Atchinson
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Medicine, Section of Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jeffrey C Munson
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
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Strauss R, Menchetti I, Perrier L, Blondal E, Peng H, Sullivan-Kwantes W, Tien H, Nathens A, Beckett A, Callum J, da Luz LT. Evaluating the Tactical Combat Casualty Care principles in civilian and military settings: systematic review, knowledge gap analysis and recommendations for future research. Trauma Surg Acute Care Open 2021; 6:e000773. [PMID: 34746434 PMCID: PMC8527149 DOI: 10.1136/tsaco-2021-000773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/27/2021] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES The Tactical Combat Casualty Care (TCCC) guidelines detail resuscitation practices in prehospital and austere environments. We sought to review the content and quality of the current TCCC and civilian prehospital literature and characterize knowledge gaps to offer recommendations for future research. METHODS MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials were searched for studies assessing intervention techniques and devices used in civilian and military prehospital settings that could be applied to TCCC guidelines. Screening and data extraction were performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Quality appraisal was conducted using appropriate tools. RESULTS Ninety-two percent (n=57) of studies were observational. Most randomized trials had low risk of bias, whereas observational studies had higher risk of bias. Interventions of massive hemorrhage control (n=17) were wound dressings and tourniquets, suggesting effective hemodynamic control. Airway management interventions (n=7) had high success rates with improved outcomes. Interventions of respiratory management (n=12) reported low success with needle decompression. Studies assessing circulation (n=18) had higher quality of evidence and suggested improved outcomes with component hemostatic therapy. Hypothermia prevention interventions (n=2) were generally effective. Other studies identified assessed the use of extended focused assessment with sonography in trauma (n=3) and mixed interventions (n=2). CONCLUSIONS The evidence was largely non-randomized with heterogeneous populations, interventions, and outcomes, precluding robust conclusions in most subjects addressed in the review. Knowledge gaps identified included the use of blood products and concentrate of clotting factors in the prehospital setting. LEVEL OF EVIDENCE Systematic review, level III.
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Affiliation(s)
- Rachel Strauss
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Isabella Menchetti
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laure Perrier
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Erik Blondal
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Henry Peng
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Wendy Sullivan-Kwantes
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Homer Tien
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Avery Nathens
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andrew Beckett
- Department of Surgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Jeannie Callum
- Laboratory Medicine and Molecular Diagnostics, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Luis Teodoro da Luz
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Ponsin P, Swiech A, Poyat C, Alves F, Jacques AE, Franchin M, Raynaud L, Boutonnet M. Strategic air medical evacuation of critically ill patients involving an intensive care physician: A retrospective analysis of 16 years of mission data. Injury 2021; 52:1176-1182. [PMID: 33082029 DOI: 10.1016/j.injury.2020.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/18/2020] [Accepted: 10/01/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Strategic medical evacuation (MEDEVAC) allows airborne repatriation of soldiers injured or sick on missions to their national territory. The aim of this study was to describe the epidemiology of strategic MEDEVAC performed by intensive care physicians (ICP) and to analyze the role of the ICP in the management of critical care situations in flight. METHODS All soldiers who had high or medium dependency conditions and who benefited from a strategic MEDEVAC with an ICP on board between 1 January 2001 and 30 November 2017 were included in this epidemiological retrospective study. RESULTS A total of 452 soldiers were repatriated; the causes of repatriation were either trauma (n = 245; 54%) or medical pathologies (n = 207; 46%). Two hundred and seventy-six (61%) evacuations were performed within 48 h. The median annual number of strategic MEDEVAC with an ICP was 26 [20-32]. One hundred and fifty-five (34%) patients were mechanically ventilated and 103 (23%) received catecholamines. The median SAPS II score was 13 [8-24]. One hundred and seventy-eight adverse events were identified, of which 123 (69%) related to a worsening of the patient's clinical condition and 30 (20%) related to a technical problem. Forty-seven (20%) patients who initially appeared stable worsened during the flight. No deaths occurred on board, however, and no flights had to be diverted due to an uncontrolled care situation. CONCLUSION The results suggested that the presence of an ICP ensured a continued high-level care for patients with serious trauma and medical injuries, due to the medical and aeronautical expertise that resulted from the theoretical and practical training of the personnel on board. Based on these results, lessons regarding future MEDEVAC flights could be learned in order to continue to improve patient outcome.
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Affiliation(s)
- Pauline Ponsin
- Burn Treatment Center, Percy Military Teaching Hospital, Clamart, France.
| | - Astrée Swiech
- Department of Anesthesiology and Intensive care, Percy Military Teaching Hospital, Clamart, France
| | - Chrystelle Poyat
- Department of Anesthesiology and Intensive care, Percy Military Teaching Hospital, Clamart, France.
| | - François Alves
- Department of Anesthesiology and Intensive Care, Sud Francilien Teaching Hospital, Corbeil-Essonnes, France
| | | | - Marylin Franchin
- 2ème Centre Medical des Armées, 12ème Antenne Médicale, French Army Medical Service, Villacoublay, France.
| | - Laurent Raynaud
- Department of Anesthesiology and Intensive care, Bégin Military Teaching Hospital, Saint-Mandé, France.
| | - Mathieu Boutonnet
- Department of Anesthesiology and Intensive care, Percy Military Teaching Hospital, Clamart, France
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Maddry JK, Araña AA, Reeves LK, Mora AG, Gutierrez XE, Perez CA, Ng PC, Griffiths SA, Bebarta VS. Patients With Traumatic Brain Injury Transported by Critical Care Air Transport Teams: The Influence of Altitude and Oxygenation during Transport. Mil Med 2021; 185:e1646-e1653. [PMID: 32515785 DOI: 10.1093/milmed/usaa124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Traumatic brain injuries (TBIs) are life-threatening, and air transport of patients with TBI requires additional considerations. To mitigate the risks of complications associated with altitude, some patients fly with a cabin altitude restriction (CAR) to limit the altitude at which an aircraft's cabin is maintained. The goal of this study was to examine the effects of CARs on patients with TBI transported out of theater via Critical Care Air Transport Teams. MATERIALS AND METHODS We conducted a retrospective chart review of patients with moderate-to-severe TBI evacuated out of combat theater to Landstuhl Regional Medical Center via Critical Care Air Transport Teams. We collected demographics, flight and injury information, procedures, oxygenation, and outcomes (discharge disposition and hospital/ICU/ventilator days). We categorized patients as having a CAR if they had a documented CAR or maximum cabin altitude of 5,000 feet or lower in their Critical Care Air Transport Teams record. We calculated descriptive statistics and constructed regression models to evaluate the association between CAR and clinical outcomes. RESULTS We reviewed the charts of 435 patients, 31% of which had a documented CAR. Nineteen percent of the sample had a PaO2 lower than 80 mm Hg, and 3% of patients experienced a SpO2 lower than 93% while in flight. When comparing preflight and in-flight events, we found that the percentage of patients who had a SpO2 of 93% or lower increased for the No CAR group, whereas the CAR group did not experience a significant change. However, flying without a CAR was not associated with discharge disposition, mortality, or hospital/ICU/ventilator days. Further, having a CAR was not associated with these outcomes after adjusting for additional flights, injury severity, injury type, or preflight head surgery. CONCLUSIONS Patients with TBI who flew with a CAR did not differ in clinical outcomes from those without a CAR.
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Affiliation(s)
- Joseph K Maddry
- United States Air Force En route Care Research Center/59th MDW/ST, San Antonio, TX.,Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX
| | - Allyson A Araña
- United States Air Force En route Care Research Center/59th MDW/ST, San Antonio, TX
| | - Lauren K Reeves
- United States Air Force En route Care Research Center/59th MDW/ST, San Antonio, TX
| | - Alejandra G Mora
- United States Air Force En route Care Research Center/59th MDW/ST, San Antonio, TX
| | - Xandria E Gutierrez
- United States Air Force En route Care Research Center/59th MDW/ST, San Antonio, TX
| | - Crystal A Perez
- United States Air Force En route Care Research Center/59th MDW/ST, San Antonio, TX
| | - Patrick C Ng
- United States Air Force En route Care Research Center/59th MDW/ST, San Antonio, TX.,Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX
| | - Sean A Griffiths
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX
| | - Vikhyat S Bebarta
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
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11
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Maddry JK, Mora AG, Perez CA, Reeves LK, Paciocco JA, Clemons MA, Sheean A, Kester NM, Bebarta VS. Characterization of Long-range Aeromedical Transport and Its Relationship to the Development of Traumatic Extremity Compartment Syndrome: A 7-year, Retrospective Study. Mil Med 2021; 187:e224-e231. [PMID: 33433584 DOI: 10.1093/milmed/usaa462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/23/2020] [Accepted: 01/08/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Military aeromedical transport evacuates critically injured patients are for definitive care, including patients with or at risk for developing traumatic compartment syndrome of the extremities (tCSoE). Compartment pressure changes of the extremities have not been determined to be associated with factors inherent to aeromedical transport in animal models, but the influence of aeromedical evacuation (AE) transport on the timing of tCSoE development has not been studied in humans. Using a registry-based methodology, this study sought to characterize the temporal features of lower extremity compartment syndrome relative to the timing of transcontinental AE. With this approach, this study aims to inform practice in guidelines relating to the timing and possible effects of long-distance AE and the development of lower extremity compartment syndrome. Using patient care records, we sought to characterize the temporal features of tCSoE diagnosis relative to long-range aeromedical transport. In doing so, we aim to inform practice in guidelines relating to the timing and risks of long-range AE and postulate whether there is an ideal time to transport patients who are at risk for or with tCSoE. METHODS We performed a retrospective record review of patients with a diagnosis of tCSoE who were evacuated out of theater from January 2007 to May 2014 via aeromedical transport. Data abstractors collected flight information, laboratory values, vital signs, procedures, in-flight assessments, and outcomes. We used the duration of time from injury to arrival at Landstuhl Regional Medical Center (LRMC) to represent time to transport. We compared groups based on time of tCSoE (inclusive of upper and lower extremity) diagnosis relative to injury day and time of transport (preflight versus postflight). We used descriptive statistics and multivariable regression models to determine the associations between time to transport, time to tCSoE diagnosis, and outcomes. RESULTS Within our study window, 238 patients had documentation of tCSoE. We found that 47% of patients with tCSoE were diagnosed preflight and 53% were diagnosed postflight. Over 90% in both groups developed tCSoE within 48 hours of injury; the time to diagnosis was similar for casualties diagnosed pre- and postflight (P = .65). There was no association between time to arrival at LRMC and day of tCSoE diagnosis (risk ratio, 1.06; 95% CI, 0.96-1.16). CONCLUSION The timing of tCSoE diagnosis is not associated with the timing of transport; therefore, AE likely does not influence the development of tCSoE.
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Affiliation(s)
- Joseph K Maddry
- Air Force 59th MDW/ST - En Route Care Research Center, JBSA Ft Sam Houston, TX 78234, USA.,Department of Emergency Medicine, Brooke Army Medical Center, Ft Sam Houston, TX 78234, USA
| | - Alejandra G Mora
- Air Force 59th MDW/ST - En Route Care Research Center, JBSA Ft Sam Houston, TX 78234, USA
| | - Crystal A Perez
- Air Force 59th MDW/ST - En Route Care Research Center, JBSA Ft Sam Houston, TX 78234, USA
| | - Lauren K Reeves
- Air Force 59th MDW/ST - En Route Care Research Center, JBSA Ft Sam Houston, TX 78234, USA
| | - Joni A Paciocco
- Department of Emergency Medicine, University of Texas Health Science Center San Antonio, San Antonio, TX 78229, USA
| | - Melissa A Clemons
- Air Force 59th MDW/ST - En Route Care Research Center, JBSA Ft Sam Houston, TX 78234, USA
| | - Andrew Sheean
- Department of Orthopedic Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX 78234, USA
| | - Nurani M Kester
- Department of Emergency Medicine, University of Texas Health Science Center San Antonio, San Antonio, TX 78229, USA
| | - Vikhyat S Bebarta
- Center for COMBAT Research, University of Colorado School of Medicine, Aurora, CO 80045, USA.,Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
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12
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Maddry JK, Ball EM, Cox DB, Flarity KM, Bebarta VS. En Route Resuscitation - Utilization of CCATT to Transport and Stabilize Critically Injured and Unstable Casualties. Mil Med 2020; 184:e172-e176. [PMID: 30535030 DOI: 10.1093/milmed/usy371] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/08/2018] [Accepted: 11/15/2018] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The U.S. Air Force utilizes specialized Critical Care Air Transport Teams (CCATT) for transporting "stabilized" patients. Given the drawdown of military forces from various areas of operation, recent CCATT operations have increasingly involved the evacuation of unstable and incompletely resuscitated patients from far forward, austere locations. This brief report describes unique cases representative of the evolving CCATT mission and provides future direction for changes in doctrine and educational requirements in preparation for en route combat casualty care. METHODS AND MATERIALS This case series describes three patients who required significant resuscitation during CCATT transport from austere locations between April and November 2017. Approval for this project was received from the US Air Force 59th Medical Wing Institutional Review Board as non-research. RESULTS Case 1: CCATT was dispatched to transport patient 1 who was reported to have a head injury after a fall. Upon evaluation of the patient onboard the aircraft, it was discovered that the patient was in cardiac arrest. Cardiopulmonary resuscitation was performed during tactical takeoff with frequent combat maneuvers. The patient developed a palpable pulse after three rounds of CPR, three doses of epinephrine, and one unit of packed red blood cells. Point of care laboratory analysis demonstrated a profoundly elevated lactate level. Cyanide poisoning was a concern but there was no antidote available in the available equipment set. After delivery to a medical facility, blood samples were positive for cyanide. Over the next 2 weeks, the patient improved and was discharged home, neurologically intact. Case 2: Patient 2 sustained complex blast injuries and bilateral lower extremity amputations. He required early transport for continuous renal replacement therapy (CRRT). The patient received 200 units of blood products in the 24 hours prior to transport and developed renal failure, pulmonary edema, and elevated ICP. During the 7 hour flight, Patient 2 received frequent adjustments of vasopressor medications, multiple Dakins solution soaks and flushes, and 1 unit of fresh frozen plasma. He remained alive 2 months later. Case 3: The team was notified to collect an urgent patient with a blast lung injury and bilateral lower extremity amputations. The ground team encountered difficulty ventilating the patient. Patient 3 arrived in the back of a pickup truck accompanied by medics and being bag valve mask ventilated with a pulse oximetry reading of 65%. He was secured to the floor of the aircraft which departed within 5 minutes of arrival. An ultrasound of the lungs showed no pneumothorax. By the end of the flight, the patient's oxygen saturation had risen to 95% and he was delivered to the emergency department in stable condition. He later passed away in the operating room due to severe blast lung and cardiac contusion. CONCLUSION This brief report demonstrates the need of CCATT in the transport of unstable patients from forward deployed locations. The Air Force has adapted and is continuing to adapt CCATT training, equipment, onboard diagnostics and therapies, and team members' clinical skills to meet en route care combat casualty needs.
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Affiliation(s)
- Joseph K Maddry
- 59th Medical Wing/US Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX
| | - Eric M Ball
- 959th Medical Wing, 3551 Roger Brook Dr., Fort Sam Houston, TX
| | - Daniel B Cox
- University of Alabama at Birmingham, Birmingham, AL
| | - Kathleen M Flarity
- HQ Air Mobility Command, Command Surgeon's Office, Scott AFB, IL.,University of Colorado Health, Aurora, CO
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13
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Schauer SG, April MD, Naylor JF, Mould-Millman NK, Bebarta VS, Becker TE, Maddry JK, Ginde AA. Incidence of Hyperoxia in Combat Wounded in Iraq and Afghanistan: A Potential Opportunity for Oxygen Conservation. Mil Med 2019; 184:661-667. [PMID: 31141134 DOI: 10.1093/milmed/usz125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 04/01/2019] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Oxygen supplementation is frequently used in critically injured trauma casualties in the combat setting. Oxygen supplies in the deployed setting are limited so excessive use of oxygen may unnecessarily consume this limited resource. We describe the incidence of supraphysiologic oxygenation (hyperoxia) within casualties in the Department of Defense Trauma Registry (DoDTR). METHODS This is a subanalysis of previously published data from the DoDTR - we isolated casualties with a documented arterial blood gas (ABG) and categorized hyperoxia as an arterial oxygen >100 mmHg and extreme hyperoxia > 300 mmHg (a subset of hyperoxia). We defined serious injuries as those with an Abbreviated Injury Score (AIS) of 3 or greater. We defined a probable moderate traumatic brain injury of those with an AIS of 3 or greater for the head region and at least one Glasgow Coma Scale at 8 or less. RESULTS Our initial search yielded 28,222 casualties, of which 10,969 had at least one ABG available. Within the 10,969, the proportion of casualties experiencing hyperoxia in this population was 20.6% (2,269) with a subset of 4.1% (452) meeting criteria for extreme hyperoxia. Among those with hyperoxia, the median age was 25 years (IQR 21-30), most were male (96.8%), most frequently US forces (41.4%), injured in Afghanistan (68.3%), injured by explosive (61.1%), with moderate injury scores (median 17, IQR 10-26), and most (93.8%) survived to hospital discharge. A total of 17.8% (1,954) of the casualties underwent endotracheal intubation: 27.5% (538 of 1,954) prior to emergency department (ED) arrival and 72.5% (1,416 of 1,954) within the ED. Among those intubated in the prehospital setting, upon ED arrival 35.1% (189) were hyperoxic, and a subset of 5.6% (30) that were extremely hyperoxic. Among those intubated in the ED, 35.4% (502) were hyperoxic, 7.9% (112) were extremely hyperoxic. Within the 1,277 with a probable TBI, 44.2% (565) experienced hyperoxia and 9.5% (122) met criteria for extreme hyperoxia. CONCLUSIONS In our dataset, more than 1 in 5 casualties overall had documented hyperoxia on ABG measurement, 1 in 3 intubated casualties, and almost 1 in 2 TBI casualties. With limited oxygen supplies in theater and logistical challenges with oxygen resupply, efforts to avoid unnecessary oxygen supplementation may have material impact on preserving this scarce resource and avoid potential detrimental clinical effects from supraphysiologic oxygen concentrations.
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Affiliation(s)
- Steven G Schauer
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX.,Brooke Army Medical Center, JBSA Fort Sam Houston, TX.,59th Medical Wing, JBSA Lackland, TX.,Uniformed Services University of the Heatlh Sciences, Bethesda, Maryland
| | | | - Jason F Naylor
- Madigan Army Medical Center, Joint Base Lewis McChord, WA
| | | | - Vikhyat S Bebarta
- 59th Medical Wing, JBSA Lackland, TX.,Madigan Army Medical Center, Joint Base Lewis McChord, WA
| | | | - Joseph K Maddry
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX.,Brooke Army Medical Center, JBSA Fort Sam Houston, TX.,59th Medical Wing, JBSA Lackland, TX.,Uniformed Services University of the Heatlh Sciences, Bethesda, Maryland
| | - Adit A Ginde
- University of Colorado School of Medicine, Aurora, CO
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14
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Resuscitation and Evacuation from Low Earth Orbit: A Systematic Review. Prehosp Disaster Med 2019; 34:521-531. [PMID: 31462335 DOI: 10.1017/s1049023x19004734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Provision of critical care and resuscitation was not practical during early missions into space. Given likely advancements in commercial spaceflight and increased human presence in low Earth orbit (LEO) in the coming decades, development of these capabilities should be considered as the likelihood of emergent medical evacuation increases. METHODS PubMed, Web of Science, Google Scholar, National Aeronautics and Space Administration (NASA) Technical Server, and Defense Technical Information Center were searched from inception to December 2018. Articles specifically addressing critical care and resuscitation during emergency medical evacuation from LEO were selected. Evidence was graded using Oxford Centre for Evidence-Based Medicine guidelines. RESULTS The search resulted in 109 articles included in the review with a total of 2,177 subjects. There were two Level I systematic reviews, 33 Level II prospective studies with 647 subjects, seven Level III retrospective studies with 1,455 subjects, and two Level IV case series with four subjects. There were two Level V case reports and 63 pertinent review articles. DISCUSSION The development of a medical evacuation capability is an important consideration for future missions. This review revealed potential hurdles in the design of a dedicated LEO evacuation spacecraft. The ability to provide critical care and resuscitation during transport is likely to be limited by mass, volume, cost, and re-entry forces. Stabilization and treatment of the patient should be performed prior to departure, if possible, and emphasis should be on a rapid and safe return to Earth for definitive care.
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