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Schauer SG, April MD, Arana AA, Long BJ, Maddry JK. Ketamine during resuscitation - Is it as hemodynamically perfect as we think? Am J Emerg Med 2023; 73:234.e3-234.e7. [PMID: 37690953 DOI: 10.1016/j.ajem.2023.08.040] [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: 05/16/2023] [Revised: 08/02/2023] [Accepted: 08/22/2023] [Indexed: 09/12/2023] Open
Abstract
INTRODUCTION Ketamine administration in patients experiencing or at risk for hypotension is common based upon the presumption of this agent's favorable hemodynamic profile. The Compensatory Reserve Measurement (CRM) is a novel algorithm that accurately tracks systemic adequacy for delivery of oxygen (DO2) to the tissues. We present a case series of trauma patients receiving ketamine with CRM measurements to offer insight into the DO2 during resuscitation. METHODS We captured vital signs along with analog arterial waveform data from trauma patients meeting major activation criteria using a prospective study design. Study team members tracked interventions and vital signs including systolic blood pressure (SBP), mean arterial pressure (MAP), and heart rate (HR) throughout their emergency department stay. RESULTS Our study included 8 patients who received ketamine for intubation or analgesia (20-300 mg) and had adequate data for analysis. Most were male (88%) with a median age of 28. The most common mechanisms of injury were motor vehicle collisions (MVCs) (38%) and gunshot wounds (38%). After ketamine administration SBP, MAP, and HR all increased while the CRM exhibited minimal change. CONCLUSIONS SBP, MAP, and HR generally appeared to increase while the CRM remained unchanged. Our findings suggest that while standard vital sign measurements appear to increase, ketamine may not improve delivery of oxygen to the tissues. This warrants further study to better understand the effects of ketamine on hemodynamics.
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Affiliation(s)
- Steven G Schauer
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA; Departments of Anesthesiology and Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA; Center for Combat and Battlefield (COMBAT) Research, University of Colorado School of Medicine, Aurora, Colorado, USA.
| | - Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA; 14th Field Hospital, Fort Stewart, GA, USA
| | | | - Brit J Long
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA; Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA; 59th Medical Wing, JBSA Lackland, TX, USA
| | - Joseph K Maddry
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA; Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA; 59th Medical Wing, JBSA Lackland, TX, USA
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Cohen N, Cohen DM, Barbi E, Shavit I. Analgesia and Sedation of Pediatric Patients with Major Trauma in Pre-Hospital and Emergency Department Settings-A Narrative Review. J Clin Med 2023; 12:5260. [PMID: 37629302 PMCID: PMC10455791 DOI: 10.3390/jcm12165260] [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: 06/20/2023] [Revised: 07/18/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
Children who sustain major injuries are at risk of receiving insufficient pain relief and sedation, which can have physical and psychological repercussions. Heightened emotional distress can increase the likelihood of developing symptoms of post-traumatic stress. Providing sufficient analgesia and sedation for children with major trauma presents specific challenges, given the potential for drug-related adverse events, particularly in non-intubated patients. The current literature suggests that a relatively low percentage of pediatric patients receive adequate analgesia in pre-hospital and emergency department settings following major trauma. There are only sparse data on the safety of the provision of analgesia and sedation in children with major trauma in the pre-hospital and ED settings. The few studies that examined sedation protocols in this context highlight the importance of physician training and competency in managing pediatric airways. There is a pressing need for prospective studies that focus upon pediatric major trauma in the pre-hospital and emergency department setting to evaluate the benefits and risks of administering analgesia and sedation to these patients. The aim of this narrative review was to offer an updated overview of analgesia and sedation management in children with major trauma in pre-hospital and ED settings.
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Affiliation(s)
- Neta Cohen
- Pediatric Emergency Medicine Department, Dana Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, 6 Weizman St, Tel Aviv 6423906, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Daniel M. Cohen
- Nationwide Children’s Hospital, The Ohio State University, Columbus, OH 43210, USA;
| | - Egidio Barbi
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS Burlo Garofolo, 34137 Trieste, Italy;
- Clinical Department of Medical Surgical and Health Science, University of Trieste, 34127 Trieste, Italy
| | - Itai Shavit
- Division of Pediatrics, Hadassah Medical Center, Jerusalem 9112001, Israel;
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem 9112102, Israel
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Frawley J, Goyal A, Gappy R, Sandoval S, Chen NW, Crowe R, Swor R. A Comparison of Prehospital Pediatric Analgesic Use of Ketamine and Opioids. PREHOSP EMERG CARE 2023; 27:915-919. [PMID: 36857195 DOI: 10.1080/10903127.2023.2183295] [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: 11/22/2022] [Revised: 02/15/2023] [Accepted: 02/15/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVE/INTRODUCTION Ketamine is an opioid-alternative used for analgesia in the prehospital setting. There are knowledge gaps regarding its use during emergency medical services (EMS) encounters for pediatric patients. Our objective was to compare pain reduction, adverse events, and prehospital deaths between ketamine and opioids when used for analgesia administered by any route among pediatric patients. METHODS This was a retrospective review of 9-1-1 EMS records of injured pediatric patients (≤17 years of age) who received ketamine or opioids for analgesia using the ESO Data Collaborative (calendar years 2019-2020). We excluded interfacility transfers, patients receiving both medications, those with EMS clinician impressions indicating behavioral disorders, and those who received medication to facilitate advanced airway placement. EMS narrative review was performed to confirm ketamine use was for analgesia and to identify any unplanned airway placements. We assessed pain score reduction (0-10 ordinal scale) and clinician-documented patient response (improved, unchanged, worsened, unknown). Adverse events were defined as change in vital signs (GCS, SBP, RR, SpO2), bag valve mask ventilation alone, or death. Descriptive statistics were calculated to compare outcomes between groups. RESULTS Overall, 9,223 patients were included, 190 (2.1%) received ketamine and 9,033 (97.9%) received opioids. Mean age in years was 12.8 [SD 4.0] for ketamine and 12.7 [SD 4.0] for opioids. Patients in both groups experienced pain reduction, and more patients receiving ketamine had EMS clinician reported improvement (93.2% vs. 87.9%, p = 0.03). Ketamine was associated with a greater average reduction in pain score than opioids (mean difference: -4.4 [SD 3.5], and -3.1 [SD 2.8], p < 0.001). Adverse events were rare with few patients receiving ventilatory support following the use of ketamine or opioids, (0, [SD 0.0%] vs. 6 [SD 0.1%], p = 1). There were no unplanned airway placements or prehospital deaths identified. CONCLUSION We identified similar high rates of pain reduction and rare adverse events among pediatric patients who received ketamine or opioids. A greater pain reduction was noted among patients administered ketamine. Intubation as a result of medication administration did not occur and need for ventilatory assistance was rare.
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Affiliation(s)
- John Frawley
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, Michigan
| | - Ashima Goyal
- Division of Pediatric Emergency Medicine, Beaumont Hospital, Royal Oak, Michigan
| | - Revelle Gappy
- Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
| | - Sariely Sandoval
- Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
| | - Nai-Wei Chen
- Division of Bioinformatics, Beaumont Research Institute, Royal Oak, Michigan
| | | | - Robert Swor
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, Michigan
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Goyal A, Frawley J, Gappy R, Sandoval S, Chen NW, Crowe R, Swor R. Prehospital Ketamine Use in Pediatrics. PREHOSP EMERG CARE 2022; 27:360-365. [PMID: 35771721 DOI: 10.1080/10903127.2022.2096161] [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: 10/17/2022]
Abstract
Introduction: Information regarding prehospital ketamine use in the pediatric population is limited as existing literature focuses primarily on critical care and air transport. Our objective was to describe patient characteristics among pediatric EMS patients who received ketamine. Secondarily, we assessed effectiveness, deviation from recommended dosing, and adverse outcomes of pediatric EMS patients who received ketamine.Methods: We conducted a retrospective data review of records from the ESO Data Collaborative for all 9-1-1 transports of pediatric patients (≤ 18 years of age) who received ketamine from 2019-2020. We categorized EMS primary impressions as a proxy for medication indication. We defined effectiveness as paramedic-identified clinical improvement, and pain relief as decrease in pain score ≥2 points between initial and final recording. Descriptive statistics were used to summarize clinical characteristics. Non-parametric Wilcoxon signed-rank test was used to assess change in pain score.Results: Out of 422,968 ground-ambulance pediatric patients, 1,291 received ketamine. They were predominately male (842, 65.2%), teenagers (median age 16, IQR: 13-17), Caucasian (810, 62.7%), and from urban areas (1,041, 80.6%). The most common EMS impressions were related to injuries (810, 62.7%) and behavior disorders (281, 21.8%). Only 980/1,291 (75.9%) had weights and identifiable routes recorded. Most patients (960, 74.4%) received single doses of ketamine, with EMS clinicians reporting improvement in 855 (89.1%) of 960 patients. Among non-behavioral emergency patients, 727/1,010 (72.0%) had pain scores recorded. Pain scores decreased significantly from a median of 8 (IQR: 4-10) to 2 (IQR: 0-6) (p < 0.001) with 59% (429) of 727 patients reporting pain score reductions of 2 or more points. Desaturation (<90% SpO2) events were noted to be minimal (1.8%). A small number (28, 2.2%) received positive pressure ventilation without advanced airway placement. No prehospital deaths were documented.Conclusion: In this large review of pediatric prehospital ketamine use, ketamine was primarily used for analgesia, but was frequently used for other indications. Most patients were observed to improve after ketamine use, with most injured patients reporting decreases in pain scores. We observed few significant adverse events related to ketamine use in this population.
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Affiliation(s)
- Ashima Goyal
- Division of Pediatric Emergency Medicine, Beaumont Hospital
| | - John Frawley
- Department of Emergency Medicine, Beaumont Hospital
| | - Revelle Gappy
- Oakland University William Beaumont School of Medicine
| | | | - Nai-Wei Chen
- Division of Informatics and Biostatistics, Beaumont Research Institute
| | | | - Robert Swor
- Department of Emergency Medicine, Beaumont Hospital
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Pain Management in Pediatric Trauma. CURRENT TRAUMA REPORTS 2021. [DOI: 10.1007/s40719-021-00216-y] [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]
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An Analysis of Intracranial Hemorrhage in Wartime Pediatric Casualties. World Neurosurg 2021; 154:e729-e733. [PMID: 34343690 DOI: 10.1016/j.wneu.2021.07.128] [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: 06/30/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Children make up a significant cohort of patients treated at combat support hospitals. Where traumatic head injury, including intracranial hemorrhage (ICH), is well studied in military adults, such research is lacking regarding pediatric patients. We seek to describe the incidence and outcomes of ICH within this population. METHODS This is a secondary analysis of a previously published dataset from the Department of Defense Trauma Registry for all pediatric casualties in Iraq and Afghanistan from January 2007 to January 2016. Within our dataset, we searched for casualties with an ICH. RESULTS Of the 3439 pediatric encounters in our dataset, we identified 495 (14%) casualties that had at least 1 type of ICH. Most were between 5 and 12 years of age, male (74%), and injured by an explosive (42%). Of the casualties with ICHs, 82 had epidural (16.6%), 237 had subdural (47.9%), 153 had subarachnoid (30.9%), 157 had parenchymal bleeds (31.7%), and 239 had ICHs not otherwise specified (48.3%). In the hospital setting, the epidural group was more frequently treated with skull decompression (41%) and craniotomy with skull elevation (28%). The subdural group was more frequently treated with a craniectomy (17%) and the parenchymal group had more frequent intracranial pressure monitoring (18%). In our dataset, 22 received ketamine prehospital (4.4%) and most were discharged alive from the hospital (79%). CONCLUSIONS Within our dataset, we identified 495 cases of ICH in pediatric patients. Most survived to hospital discharge despite less than half undergoing a decompression procedure.
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Wu Y, Zhao Y, Lin G, Sharma M, Wang Y, Chen L, Wu L. Measures and Effects of Pain Management for Wound Dressing Change in Outpatient Children in Western China. J Pain Res 2021; 14:399-406. [PMID: 33603454 PMCID: PMC7886234 DOI: 10.2147/jpr.s281876] [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: 11/12/2020] [Accepted: 01/28/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose The present study investigated the pain management of wound dressing change in outpatient children in western China, and the results may provide a reference to improve the pain management of wound dressing change. Methods A cross-sectional survey was performed to investigate the pain management of wound dressing change in outpatient children in western China. A total of 47 hospitals were selected via convenience sampling, and the pain management organization systems, concrete measures and barriers to adequate pain management of these hospitals were investigated. Results More than 70% of these hospitals had established pain management systems, analgesic drug management norms and wound care teams. Nurses were the primary providers for wound dressing change in 48.94% of the hospitals. The assessment, documentation or health education of the pain was not standard in 46.81% of the hospitals. Drug and non-drug analgesia measures were used in most hospitals, however, children did not receive adequate analgesia in 70% of the hospitals. Ibuprofen (30.49%) and lidocaine (29.27%) were commonly used analgesic drugs, and distraction (43.01%) was commonly used as a non-drug analgesia measure. The top three barriers to adequate pain management were medical staff lacking analgesic knowledge (82.98%), family members refusing to use analgesics (61.70%) and low compliance of children (55.32%). Conclusion The concrete measures for the management of wound dressing pain in children are not standardized, and the analgesic effect is poor. In order to improve the pain management of children, Standardized procedures for pain management (pain assessment, analgesia measures, pain documentation and health education) should be strictly followed during wound dressing change, and the identified barriers should be addressed.
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Affiliation(s)
- Yujie Wu
- Department of Nursing, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People's Republic of China
| | - Yong Zhao
- School of Public Health and Management, Chongqing Medical University, Chongqing, People's Republic of China
| | - Guangyan Lin
- Department of Outpatient Surgery, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Manoj Sharma
- Environmental & Occupational Health, University of Nevada, Las Vegas, NV, USA
| | - Yan Wang
- Department of Nursing, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People's Republic of China
| | - Liping Chen
- Department of Nursing, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People's Republic of China
| | - Liping Wu
- Department of Nursing, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People's Republic of China
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High crystalloid volumes negate benefit of hemostatic resuscitation in pediatric wartime trauma casualties. J Trauma Acute Care Surg 2021; 89:S185-S191. [PMID: 31972756 DOI: 10.1097/ta.0000000000002590] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recent data for adult trauma patients suggest improved survival when using hemostatic resuscitation, which includes limiting crystalloids and using closer to 1:1 ratios for both fresh frozen plasma (FFP) and platelets (PLTs) relative to packed red blood cells (PRBCs). Pediatric studies have shown similar but mixed results and often lack measuring crystalloids. We seek to evaluate in-hospital survival based on crystalloid administration and different blood product ratios in pediatric casualties during the recent conflicts. METHODS We queried the Department of Defense Trauma Registry for all pediatric encounters in Iraq and Afghanistan from January 2007 to January 2016 and included those with at least 40 mL/kg of total blood products administered provided that they received at least 1 U of PRBC. We grouped children as younger (0-7 years) and older (8-17 years). We grouped low versus high ratios for FFP/PRBC (≤1:2 vs. >1:2) and PLT/PRBC (≤1:6 vs. >1.6). We used a threshold of 40 mL/kg to for high versus low crystalloid resuscitation. RESULTS During this time, there were 3,439 encounters in the registry with 521 (15.1%) that met the inclusion criteria. The median age of casualties that met the inclusion was 10 years (interquartile range, 5-13), most were male (73.5%), with a moderate median injury severity score (17; interquartile range, 13-25). We performed regression modeling with adjustments for mechanism of injury, composite injury severity score, and total blood product volume (mL/kg based), grouping children based on high versus low fluid resuscitation. In the low-volume crystalloid group, we found that higher (>1:2) FFP/PRBC was associated with improved survival (odds ratio [OR], 3.42). However, in the high fluid crystalloid resuscitation group, we found that that higher ratios for PLT/PRBC (>1:6) overall (OR, 0.46) and the FFP/PRBC (>1:2) in younger children (OR, 0.28) was associated with worse survival. The remaining associations were not statistically significant. CONCLUSION We found an association with survival in massively transfused pediatric trauma patients who received both a high FFP/PRBC ratio and low crystalloid administration. The benefit of this high ratio is negated, in patients receiving high crystalloid volumes, particularly among smaller children. Future studies on hemostatic resuscitation evaluating blood product ratios should also account for crystalloid and colloid administration. LEVEL OF EVIDENCE Retrospective, comparative, level III.
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Lauby RS, Johnson SA, Borgman MA, Bynum J, Hill GJ, Schauer SG. Analysis of Prehospital Administration of Blood Products to Pediatric Casualties in Iraq and Afghanistan. PREHOSP EMERG CARE 2020; 25:615-619. [PMID: 32870733 DOI: 10.1080/10903127.2020.1817216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Hemorrhage is one of the leading causes of preventable death in both military and civilian trauma. Implementation of items such as tourniquets and hemostatic dressings are helpful in controlling hemorrhage and increasing the survival rate of casualties when such injuries occur. Prehospital blood transfusions are used to treat patients with severe injuries where the standard methods of hemorrhage control are not an effective form of treatment. There is limited research and no widely accepted protocol on pediatric prehospital blood transfusions. METHODS We queried the Department of Defense Trauma Registry (DODTR) for all pediatric subjects admitted to U.S. and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. This is a secondary analysis of casualties that received blood products prehospital. RESULTS From January 2007 through January 2016 there were 3439 pediatric casualties within the registry. Within this group, 22 casualties that received one or more blood product prehospital were identified. Children in the 10-14 years age (40%) group made up the largest proportion, 86% were male, almost all were injured by explosive (63%) or firearm (27%), and 77% survived to hospital discharge. The most frequently administered blood product was packed red cells (n = 17). Of the 22, 15 underwent massive transfusion within the first 24 hours of admission. CONCLUSIONS Prehospital administration of blood products occurred infrequently within this pediatric dataset, but those that received blood were critically injured with most receiving a massive transfusion. Given the frequency with which medical personnel are carrying blood products in the prehospital, combat setting, guidelines specific to pediatric administration would be beneficial.
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Jabourian A, Dong F, Mackey K, Vaezazizi R, Pennington TW, Neeki M. Evaluation of Safety and Efficacy of Prehospital Paramedic Administration of Sub-Dissociative Dose of Ketamine in the Treatment of Trauma-Related Pain in Adult Civilian Population. Cureus 2020; 12:e9567. [PMID: 32782893 PMCID: PMC7411289 DOI: 10.7759/cureus.9567] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Opiates are addicting and have a high potential for dependency. In the past decades, opiates remained the first-line pharmaceutical option of prehospital treatment for acute traumatic pain in the civilian population. Ketamine is an N-methyl-d-aspartate (NMDA) receptor antagonist that has analgesic properties and may serve as an alternative agent for the treatment of acute traumatic pain in prehospital settings. This study aims to assess the safety and efficacy of ketamine administration by paramedics in civilian prehospital settings for the treatment of acute traumatic pain. This was a prospective observational study in San Bernardino, Riverside and Stanislaus counties. Patients were included if they were > 15 years of age with complaints of traumatic or burn-related pain. Patients were excluded if they received opiates up to six hours prior to or concurrently with ketamine administration. The dose administered was 0.3 mg/kg intravenously over five minutes with a maximum dose of 30 mg. The option to administer a second dose was available to paramedics if the patient continued to have pain after 15 minutes following the first administration. Paired-T tests were conducted to assess the change in the primary outcome (pain score) and secondary outcomes (e.g. systolic blood pressure, pulse, and respiratory rate). P-value<0.05 was considered to be statistically significant. A total of 368 patients were included in the final analysis. The average age was 52.9 ± 23.1 years, and the average weight was 80.4 ± 22.2 kg. There was a statistically significant reduction in the pain score (9.13 ± 1.28 vs 3.7 ± 3.4, delta=5.43 ± 3.38, p<0.0001). Additionally, there was a statistically significant change in systolic blood pressure (143.42 ± 27.01 vs 145.65 ± 26.26, delta=2.22 ± 21.1, p=0.044), pulse (88.06 ± 18 vs 84.64 ± 15.92, delta= -3.42 ± 12.12, p<0.0001), and respiratory rate (19.04 ± 3.59 vs 17.74 ± 3.06, delta=-1.3 ± 2.96, p<0.0001). The current study suggested that paramedics are capable of safely identifying the appropriate patients for the administration of sub-dissociative doses of ketamine in the prehospital setting. Furthermore, the current study suggested that ketamine may be an effective analgesic in a select group of adult trauma patients.
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Cuenca CM, Borgman MA, April MD, Fisher AD, Schauer SG. Validation of the age-adjusted shock index for pediatric casualties in Iraq and Afghanistan. Mil Med Res 2020; 7:33. [PMID: 32616047 PMCID: PMC7331217 DOI: 10.1186/s40779-020-00262-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 06/24/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Pediatric casualties account for a notable proportion of encounters in the deployed setting based on the humanitarian medical care mission. Previously published data demonstrates that an age-adjust shock index may be a useful tool in predicting massive transfusion and death in children. We seek to determine if those previous findings are applicable to the deployed, combat trauma setting. METHODS We queried the Department of Defense Trauma Registry (DODTR) for all pediatric subjects admitted to US and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. This is a secondary analysis of casualties seeking to validate previously published data using the shock index, pediatric age-adjusted. We then used previously published thresholds to determine patients outcome for validation by age grouping, 1-3 years (1.2), 4-6 years (1.2), 7-12 years (1.0), 13-17 years (0.9). RESULTS From January 2007 through January 2016 there were 3439 pediatric casualties of which 3145 had a documented heart rate and systolic pressure. Of those 502 (16.0%) underwent massive transfusion and 226 (7.2%) died prior to hospital discharge. Receiver operating characteristic (ROC) thresholds were inconsistent across age groups ranging from 1.0 to 1.9 with generally limited area under the curve (AUC) values for both massive transfusion and death prediction characteristics. Using the previously defined thresholds for validation, we report sensitivity and specificity for the massive transfusion by age-group: 1-3 (0.73, 0.35), 4-6 (0.63, 0.60), 7-12 (0.80, 0.57), 13-17 (0.77, 0.62). For death, 1-3 (0.75, 0.34), 4-6 (0.66-0.59), 7-12 (0.64, 0.52), 13-17 (0.70, 0.57). However, negative predictive values (NPV) were generally high with all greater than 0.87. CONCLUSIONS Within the combat setting, the age-adjusted pediatric shock index had moderate sensitivity and relatively poor specificity for predicting massive transfusion and death. Better scoring systems are needed to predict resource needs prior to arrival, that perhaps include other physiologic metrics. We were unable to validate the previously published findings within the combat trauma population.
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Affiliation(s)
- Camaren M Cuenca
- US Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, San Antonio, TX, 78234-7767, USA
| | - Matthew A Borgman
- Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA.,Uniformed Services University of the Heath Sciences, Bethesda, MD, USA
| | - Michael D April
- Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA
| | - Andrew D Fisher
- Texas Army National Guard, Austin, TX, USA.,Department of Surgery, UNM School of Medicine, Albuquerque, NM, USA
| | - Steven G Schauer
- US Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, San Antonio, TX, 78234-7767, USA. .,Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA. .,Uniformed Services University of the Heath Sciences, Bethesda, MD, USA. .,59th Medical Wing, JBSA Lackland, San Antonio, TX, USA.
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April MD, Becker TE, Fisher AD, Naylor JF, Schauer SG. Vital sign thresholds predictive of death in the combat setting. Am J Emerg Med 2020; 44:423-427. [PMID: 32466872 DOI: 10.1016/j.ajem.2020.05.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 05/03/2020] [Accepted: 05/04/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Identifying patients at imminent risk of death is a paramount priority in combat casualty care. This study measures the vital sign values predictive of mortality among combat casualties in Iraq and Afghanistan. METHODS We used data from the Department of Defense Trauma Registry from January 2007 to August 2016. We used the highest documented heart rate and the lowest documented systolic pressure in the emergency department for each casualty. We constructed receiver operator curves (ROCs) to assess the accuracy of these variables for predicting survival to hospital discharge. RESULTS There were 38,769 encounters of which our dataset included 15,540 (40.1%). The median age of these patients was 25 years and 97.5% were male. The most common mechanisms of injury were explosives (n = 9481, 61.0%) followed by gunshot wounds (n = 2393, 15.3%). The survival rate to hospital discharge was 97.5%. The median heart rate was 94 beats per minute (bpm) with area under the ROC of 0.631 with an optimal threshold to predict mortality of 110 bpm (sensitivity 52.2%, specificity 79.2%). The median systolic blood pressure was 128 mmHg with area under the ROC of 0.790 with an optimal threshold to predict mortality of 112 mmHg (sensitivity 68.5%, specificity 81.5%). CONCLUSIONS Casualties with a systolic blood pressure <112 mmHg, are at high risk of mortality, a value significantly higher than the traditional 90 mmHg threshold. Our dataset highlights the need for better methods to guide resuscitation as vital sign measurements have limited accuracy in predicting mortality.
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Affiliation(s)
- Michael D April
- 2nd Stryker Brigade Combat Team, 4th Infantry Division, Fort Carson, CO, USA; Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | - Tyson E Becker
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA
| | - Andrew D Fisher
- Texas Medical Command, Texas Army National Guard, Austin, TX, USA; Texas A&M College of Medicine, Temple, TX, USA; Prehospital Research in Military and Expeditionary Environments, San Antonio, TX, USA
| | - Jason F Naylor
- Madigan Army Medical Center, JBLM Fort Lewis, Washington, USA
| | - Steven G Schauer
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA; US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA; 59(th) Medical Wing, JBSA Lackland, TX, USA
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Bebarta VS, Mora AG, Bebarta EK, Reeves LK, Maddry JK, Schauer SG, Lairet JR. Prehospital Use of Ketamine in the Combat Setting: A Sub-Analysis of Patients With Head Injuries Evaluated in the Prospective Life Saving Intervention Study. Mil Med 2020; 185:136-142. [DOI: 10.1093/milmed/usz302] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
Ketamine is used as an analgesic for combat injuries. Ketamine may worsen brain injury, but new studies suggest neuroprotection. Our objective was to report the outcomes of combat casualties with traumatic brain injury (TBI) who received prehospital ketamine.
Methods
This was a post hoc, sub-analysis of a larger prospective, multicenter study (the Life Saving Intervention study [LSI]) evaluating prehospital interventions performed in Afghanistan. A DoD Trauma Registry query provided disposition at discharge and outcomes to be linked with the LSI data.
Results
For this study, we enrolled casualties that were suspected to have TBI (n = 160). Most were 26-year-old males (98%) with explosion-related injuries (66%), a median injury severity score of 12, and 5% mortality. Fifty-seven percent (n = 91) received an analgesic, 29% (n = 46) ketamine, 28% (n = 45) other analgesic (OA), and 43% (n = 69) no analgesic (NA). The ketamine group had more pelvic injuries (P = 0.0302) and tourniquets (P = 0.0041) compared to OA. In comparison to NA, the ketamine group was more severely injured and more likely to require LSI procedures, yet, had similar vital signs at admission and disposition at discharge.
Conclusions
We found that combat casualties with suspected TBI that received prehospital ketamine had similar outcomes to those that received OAs or NAs despite injury differences.
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Affiliation(s)
- Vikhyat S Bebarta
- 59th MDW/Chief Scientist Office, USAF En Route Care Research Center, JBSA-Lackland, TX; U.S. Army Institute of Surgical Research, Fort Sam Houston, TX, 1100 Wilford Hall Loop, JBSA-Lackland, TX 78236
- Department of Emergency Medicine, University of Colorado School of Medicine, 12401 E. 17th Avenue, Aurora, CO 80045
| | - Alejandra G Mora
- 59th MDW/Chief Scientist Office, USAF En Route Care Research Center, JBSA-Lackland, TX; U.S. Army Institute of Surgical Research, Fort Sam Houston, TX, 1100 Wilford Hall Loop, JBSA-Lackland, TX 78236
| | - Emma K Bebarta
- Cherry Creek High School, 9300 E Union Ave, Greenwood Village, CO 80111
| | - Lauren K Reeves
- Department of Emergency Medicine, University of Colorado School of Medicine, 12401 E. 17th Avenue, Aurora, CO 80045
| | - Joseph K Maddry
- 59th MDW/Chief Scientist Office, USAF En Route Care Research Center, JBSA-Lackland, TX; U.S. Army Institute of Surgical Research, Fort Sam Houston, TX, 1100 Wilford Hall Loop, JBSA-Lackland, TX 78236
| | - Steve G Schauer
- 59th MDW/Chief Scientist Office, USAF En Route Care Research Center, JBSA-Lackland, TX; U.S. Army Institute of Surgical Research, Fort Sam Houston, TX, 1100 Wilford Hall Loop, JBSA-Lackland, TX 78236
- US Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, Texas Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, Texas
| | - Julio R Lairet
- Department of Emergency Medicine, Emory University School of Medicine, 531 Asbury Circle, Annex Building Suite N340, Atlanta, GA 30322
- Headquarters Georgia Air National Guard, 1000 Halsey Avenue Bldg. 447, Marietta, GA 30060
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Pediatric Trauma Patient Intensive Care Resource Utilization in U.S. Military Operations in Iraq and Afghanistan. Crit Care Explor 2019; 1:e0062. [PMID: 32166243 PMCID: PMC7063925 DOI: 10.1097/cce.0000000000000062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Children represent a unique patient population treated by military personnel during wartime, as seen in the recent conflicts in Iraq and Afghanistan. We sought to describe ICU resource utilization by U.S. military personnel treating pediatric trauma patients in Iraq and Afghanistan.
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Naylor JF, Borgman MA, April MD, Hill GJ, Schauer SG. Normobaric hyperoxia in wartime pediatric trauma casualties. Am J Emerg Med 2019; 38:709-714. [PMID: 31182364 DOI: 10.1016/j.ajem.2019.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/01/2019] [Accepted: 06/02/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Mounting evidence suggests hyperoxia therapy may be harmful. We describe injury characteristics and survival outcomes for pediatric trauma casualties in Iraq and Afghanistan, stratified by partial pressure of arterial oxygen (PaO2). Secondarily, we performed subgroup analyses for severe traumatic brain injury (TBI) and massive transfusion of blood products (MT). METHODS We utilized Department of Defense Trauma Registry data. We included subjects <18 years. We excluded subjects without an arterial blood gas (ABG). We stratified subjects as hyperoxemia (PaO2 100-300 mmHg) and extreme hyperoxemia (PaO2 >300 mmHg). RESULTS January 2007-January 2016, 3439 pediatric encounters were in the database. Of those, 1323 had an ABG, with 291 (22%) demonstrating hyperoxemia and 43 (3.3%) extreme hyperoxemia. The median age was 8, most were male (76%) in Afghanistan (69%), and injured by explosive (42%). There were no significant differences in survival between subjects with no hyperoxemia, hyperoxemia, and extreme hyperoxemia (92% vs 87% vs 86%; p = 0.078). Also, there were no significant differences in survival between groups among TBI and MT subjects, and there were no increased odds of survival between groups on multivariable regression analyses. CONCLUSIONS Hyperoxemia was common among hospitalized, wartime pediatric trauma casualties in Iraq and Afghanistan that underwent ABG analysis. Survival to hospital discharge rates were not significantly different between subjects with hyperoxemia and subjects without hyperoxemia.
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Affiliation(s)
- Jason F Naylor
- Madigan Army Medical Center, Joint Base Lewis-McChord, Washington 98431, United States of America.
| | - Matthew A Borgman
- Brooke Army Medical Center, Joint Base San Antonio - Fort Sam Houston, TX 78243, United States of America
| | - Michael D April
- Brooke Army Medical Center, Joint Base San Antonio - Fort Sam Houston, TX 78243, United States of America
| | - Guyon J Hill
- Madigan Army Medical Center, Joint Base Lewis-McChord, Washington 98431, United States of America
| | - Steven G Schauer
- Brooke Army Medical Center, Joint Base San Antonio - Fort Sam Houston, TX 78243, United States of America; US Army Institute of Surgical Research, Joint Base San Antonio - Fort Sam Houston, TX 78243, United States of America; 59(th) Medical Wing, Joint Base San Antonio - Lackland, TX 78236, United States of America
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