Airway and ventilation management strategies for hemorrhagic shock. To tube, or not to tube, that is the question!

Emergency Operable Traumatic Pulmonary Injury at a Level 1 Trauma Center: A Retrospective Descriptive Study

INTRODUCTION

Despite the use of body armor, emergency operable pulmonary trauma (EOPT) remains a major cause of battlefield morbidity and mortality. While EOPT during military conflicts has some features that distinguish it from EOPT in civilian settings, the 2 occurrences demonstrate overall parallel findings related to presentation, management, and outcome. The goals of the present study were to provide a descriptive analysis of the nature of EOPT and its management at a level 1 trauma center and to determine the associations between EOPT patient demographics and/or patient management and outcome in order to better understand battlefield EOPT.

MATERIALS AND METHODS

This is a retrospective, descriptive analysis of EOPT at a level 1 trauma center during a recent 9-year period (2012-2020). The Oregon Health & Science University Trauma Registry was searched, and 106 patients met inclusion criteria for the study. Patients with primary cardiac trauma were excluded. Individual electronic medical records were reviewed to obtain descriptive data, and associations were evaluated for statistical significance.

RESULTS

In-hospital mortality in this cohort was 17.0%. The most common pulmonary injury associated with EOPT was unilateral diaphragmatic laceration (62.3%), and the most common single operation performed for EOPT was a laparotomy (71.7%) often involving diaphragmatic repair. In the remaining instances of EOPT, a thoracotomy (11.3%), a thoracotomy and a laparotomy (10.4%), or another surgery (6.6%) occurred. The primary indication for EOPT surgery was uncontrolled hemorrhage, and one-third of patients received massive transfusion. One-lung ventilation (OLV) was infrequently employed (8.5%). When OLV was used, it was equally likely to involve a single-lumen endotracheal tube (SLETT) with mainstem bronchus insertion, a SLETT with a bronchial blocker, or a double-lumen endotracheal tube. Time from EOPT to operating room arrival was inversely related to in-hospital mortality. Also, both initial in-hospital endotracheal intubation and low injury severity score were strongly associated with survival in the population studied.

CONCLUSIONS

The most common indication for EOPT surgery was uncontrolled hemorrhage. The most frequent operation performed for this EOPT cohort was a laparotomy for diaphragmatic repair. A total of 91.5% of EOPT surgery was performed without OLV, an unexpected finding. When OLV occurred, it was equally likely to involve an SLETT with mainstem bronchus insertion, an SLETT with bronchial blocker, or a double-lumen endotracheal tube. The most common indication for OLV was surgical exposure. More extensive injury (expressed as an injury severity score), preadmission endotracheal intubation, and a shorter time from EOPT to operating room arrival were associated with increased odds ratios for mortality. A better understanding of the nature of EOPT at a civilian level 1 trauma center can serve to identify conditions that are associated with more favorable outcomes for EOPT under battlefield conditions and thereby assist in both management decisions and to help prognosticate and triage severely injured patients in that setting.

Predictors of Short-Term Trauma Laparotomy Outcomes in an Integrated Military-Civilian Health System: A 23-Year Retrospective Cohort Study

Background: Trauma laparotomy (TL) remains a cornerstone of trauma care. We aimed to investigate prehospital measures associated with in-hospital mortality among casualties subsequently undergoing TLs in civilian hospitals. Methods: This retrospective cohort study cross-referenced the prehospital and hospitalization data of casualties treated by Israel Defense Forces-Medical Corps teams who later underwent TLs in civilian hospitals between 1997 and 2020. Results: Overall, we identified 217 casualties treated by IDF-MC teams that subsequently underwent a TL, with a mortality rate of 15.2% (33/217). The main mechanism of injury was documented as penetrating for 121/217 (55.8%). The median heart rate and blood pressure were within the normal limit for the entire cohort, with a low blood pressure predicting mortality (65 vs. 127, p < 0.001). In a multivariate analysis, prehospital endotracheal intubation (ETI), emergency department Glasgow coma scores of 3-8, and the need for a thoracotomy or bowel-related procedures were significantly associated with mortality (OR 6.8, p < 0.001, OR = 48.5, p < 0.001, and OR = 4.61, p = 0.002, respectively). Conclusions: Prehospital interventions introduced throughout the study period did not lead to an improvement in survival. Survival was negatively influenced by prehospital ETI, reinforcing previous observations of the potential deleterious effects of definitive airways on hemorrhaging trauma casualties. While a low blood pressure was a predictor of mortality, the median systolic blood pressure for even the sickest patients (ISS > 16) was within normal limits, highlighting the challenges in triage and risk stratification for trauma casualties.

Prehospital and emergency department airway management of severe penetrating trauma in Sweden during the past decade

BACKGROUND

Prehospital tracheal intubation (TI) is associated with increased mortality in patients with penetrating trauma, and the utility of prehospital advanced airway management is debated. The increased incidence of deadly violence in Sweden warrants a comprehensive evaluation of current airway management for patients with penetrating trauma in the Swedish prehospital environment and on arrival in the emergency department (ED).

METHODS

This was an observational, multicenter study of all patients with penetrating trauma and injury severity scores (ISSs) ≥ 15 included in the Swedish national trauma register (SweTrau) between 2011 and 2019. We investigated the frequency and characteristics of prehospital and ED TI, including 30-day mortality and patient characteristics associated with TI.

RESULT

Of 816 included patients, 118 (14.5%) were intubated prehospitally, and 248 (30.4%) were intubated in the ED. Patients who were intubated prehospitally had a higher ISS, 33 (interquartile range [IQR] 25, 75), than those intubated in the ED, 25 (IQR 18, 34). Prehospital TI was associated with a higher associated mortality, OR 4.26 (CI 2.57, 7.27, p < 0.001) than TI in the ED, even when adjusted for ISS (OR 2.88 [CI 1.64, 5.14, p < 0.001]). Hemodynamic collapse (≤ 40 mmHg) and low GCS score (≤ 8) were the characteristics most associated with prehospital TI. Traumatic cardiac arrests (TCAs) occurred in 154 (18.9%) patients, of whom 77 (50%) were intubated prehospitally and 56 (36.4%) were intubated in the ED. A subgroup analysis excluding TCA showed that patients with prehospital TI did not have a higher mortality rate than those with ED TI, OR 2.07 (CI 0.93, 4.51, p = 0.068), with OR 1.39 (0.56, 3.26, p = 0.5) when adjusted for ISS.

CONCLUSION

Prehospital TI was associated with a higher mortality rate than those with ED TI, which was specifically related to TCA; intubation did not affect mortality in patients without cardiac arrest. Mortality was high when airway management was needed, regardless of cardiac arrest, thereby emphasizing the challenges posed when anesthesia is needed. Several interventions, including whole blood transfusions, the implementation of second-tier EMS units and measures to shorten scene times, have been initiated in Sweden to counteract these challenges.

Prehospital transportation of severe penetrating trauma victims in Sweden during the past decade: a police business?

INTRODUCTION

Sweden is facing a surge of gun violence that mandates optimized prehospital transport approaches, and a survey of current practice is fundamental for such optimization. Management of severe, penetrating trauma is time sensitive, and there may be a survival benefit in limiting prehospital interventions. An important aspect is unregulated transportation by police or private vehicles to the hospital, which may decrease time but may also be associated with adverse outcomes. It is not known whether transport of patients with penetrating trauma occurs outside the emergency medical services (EMS) in Sweden and whether it affects outcome.

METHOD

This was a retrospective, descriptive nationwide study of all patients with penetrating trauma and injury severity scores (ISSs) ≥ 15 registered in the Swedish national trauma registry (SweTrau) between June 13, 2011, and December 31, 2019. We hypothesized that transport by police and private vehicles occurred and that it affected mortality.

RESULT

A total of 657 patients were included. EMS transported 612 patients (93.2%), police 10 patients (1.5%), and private vehicles 27 patients (4.1%). Gunshot wounds (GSWs) were more common in police transport, 80% (n = 8), compared with private vehicles, 59% (n = 16), and EMS, 32% (n = 198). The Glasgow coma scale score (GCS) in the emergency department (ED) was lower for patients transported by police, 11.5 (interquartile range [IQR] 3, 15), in relation to EMS, 15 (IQR 14, 15) and private vehicles 15 (IQR 12.5, 15). The 30-day mortality for EMS was 30% (n = 184), 50% (n = 5) for police transport, and 22% (n = 6) for private vehicles. Transport by private vehicle, odds ratio (OR) 0.65, (confidence interval [CI] 0.24, 1.55, p = 0.4) and police OR 2.28 (CI 0.63, 8.3, p = 0.2) were not associated with increased mortality in relation to EMS.

CONCLUSION

Non-EMS transports did occur, however with a low incidence and did not affect mortality. GSWs were more common in police transport, and victims had lower GCS scorescores when arriving at the ED, which warrants further investigations of the operational management of shooting victims in Sweden.

The forgotten cohort-lessons learned from prehospital trauma death: a retrospective cohort study

BACKGROUND

Trauma related deaths remain a relevant public health problem, in particular in the younger male population. A significant number of these deaths occur prehospitally without transfer to a hospital. These patients, sometimes termed "the forgotten cohort", are usually not included in clinical registries, resulting in a lack of information about prehospitally trauma deaths. The aim of the present study was to compare patients who died prehospital with those who sustained life-threatening injuries in order to analyze and potentially improve prehospital strategies.

METHODS

This cohort study included all primary operations carried out by Switzerland's largest helicopter emergency medical service (HEMS) between January 1, 2011, and December 31, 2021. We included all adult trauma patients with life-threatening or fatal conditions. The outcome of this study is the vital status of the patient at the end of mission, i.e. fatal or life-threatening. Injury, rescue characteristics, and interventions of the forgotten trauma cohort, defined as patients with a fatal injury (NACA score of VII), were compared with life-threatening injuries (NACA score V and VI).

RESULTS

Of 110,331 HEMS missions, 5534 primary operations were finally analyzed, including 5191 (93.8%) life-threatening and 343 (6.2%) fatal injuries. More than two-thirds of patients (n = 3772, 68.2%) had a traumatic brain injury without a significant difference between the two groups (p > 0.05). Thoracic trauma (44.6% vs. 28.7%, p < 0.001) and abdominal trauma (22.2% vs. 16.1%, p = 0.004) were more frequent in fatal missions whereas pelvic trauma was similar between the two groups (13.4% vs. 12.9%, p = 0.788). Pneumothorax decompression rate (17.2% vs. 3.7%, p < 0.001) was higher in the forgotten cohort group and measures for bleeding control (15.2% vs. 42.7%, p < 0.001) and pelvic belt application (2.9% vs. 13.1% p < 0.001) were more common in the life-threating injury group.

CONCLUSION

Chest decompression rates and measures for early hemorrhage control are areas for potential improvement in prehospital care.

Permissive hypoventilation equally effective to maintain oxygenation as positive pressure ventilation after porcine class III hemorrhage and whole blood resuscitation

BACKGROUND

Prehospital anesthesia may lead to circulatory collapse after severe hemorrhage. It is possible that permissive hypoventilation, refraining from tracheal intubation and accepting spontaneous ventilation, decreases this risk, but it is not known if oxygen delivery can be maintained. We investigated the feasibility of permissive hypoventilation after class III hemorrhage and whole blood resuscitation in three prehospital phases: 15 min on-scene, 30 min whole blood resuscitation, and 45 min after.

STUDY DESIGN AND METHODS

19 crossbred swine, mean weight 58.5 kg, were anesthetized with ketamine/midazolam and hemorrhaged to a mean (SD) 1298 (220) mL (33%) and randomized to permissive hypoventilation (n = 9) or positive pressure ventilation with FiO2 21% (n = 10).

RESULTS

In permissive hypoventilation versus positive pressure ventilation, indexed oxygen delivery (DO2 I) decreased to mean (SD) 4.73 (1.06) versus 3.70 (1.13) mL min-1  kg-1 after hemorrhage and increased to 8.62 (2.09) versus 6.70 (1.56) mL min-1  kg-1 at completion of resuscitation. DO2 I, indexed oxygen consumption (VO2 I), and arterial saturation (SaO2 ) did not differ. Permissive hypoventilation increased the respiratory rate and increased pCO2 . Positive pressure ventilation did not deteriorate circulation. Cardiac index (CI), systolic arterial pressure (SAP), hemoglobin (Hb), and heart rate did not differ.

DISCUSSION

Permissive hypoventilation and positive pressure ventilation were equally effective to maintain oxygen delivery in all phases. A respiratory rate of 40 was feasible, showing no signs of respiratory fatigue for 90 min, indicating that whole blood resuscitation may be prioritized in select patients with severe hemorrhage and spontaneous breathing.

Is prehospital intubation of severely injured children in accordance with guidelines?

BACKGROUND

The current German S3 guideline for polytrauma lists five criteria for prehospital intubation: apnea, severe traumatic brain injury (GCS ≤8), severe chest trauma with respiratory failure, hypoxia, and persistent hemodynamic instability. These guideline criteria, used in adults in daily practice, have not been previously studied in a collection of severely injured children. The aim of this study was to assess the extent to which the criteria are implemented in clinical practice using a multivariate risk analysis of severely injured children.

METHODS

Data of 289,698 patients from the TraumaRegister DGU® were analyzed. Children meeting the following criteria were included: Maximum Abbreviated Injury Scale 3+, primary admission, German-speaking countries, years 2008-2017, and declaration of intubation. Since children show age-dependent deviating physiology, four age groups were defined (years old: 0-2; 3-6; 7-11; 12-15). An adult collective served as a control group (age: 20-50). After a descriptive analysis in the first step, factors leading to prehospital intubation in severely injured children were analyzed with a multivariate regression analysis.

RESULTS

A total of 4489 children met the inclusion criteria. In this cohort, young children up to 2 years old had the significantly highest injury severity (Injury Severity Score: 21; p ≤ 0.001). Falls from both high (> 3 m) and low heights (< 3 m) were more common in children than in adults. The same finding applied to the occurrence of severe traumatic brain injury. When at least one intubation criterion was formally present, the group up to 6 years old was least likely to actually be intubated (61.4%; p ≤ 0.001). Multivariate regression analysis showed that Glasgow Coma Scale score ≤ 8 in particular had the greatest influence on intubation (odds ratio: 26.9; p ≤ 0.001).

CONCLUSIONS

The data presented here show for the first time that the existing criteria in the guideline for prehospital intubation are applied in clinical practice (approximately 70% of cases), compared to adults, in the vast majority of injured children. Although severely injured children still represent a minority of all injured patients, future guidelines should focus more on them and address them in a specialized manner.

Continuum of Care: A Multiagency Approach to Seamless Warmed Prehospital Whole Blood Resuscitation of a Patient with Noncompressible Truncal Hemorrhage

BACKGROUND

Prehospital transfusion capabilities vary widely in the United States. Here we describe a case of prehospital resuscitation using warmed, whole blood in a patient with penetrating torso trauma and associated hemorrhagic shock.

CASE REPORT

A 68-year-old man sustained a single gunshot wound to the left chest and was found to have a shock index of 1.5 at the time of emergency medical services (EMS) arrival. Rapid peripheral intravenous and central venous access enabled the infusion of warmed low-titer O-positive whole blood. The EMS crew intentionally resuscitated the patient before managing the airway by means of rapid sequence intubation. An air medical services helicopter crew assumed patient care from the ground EMS crew and continued the warmed, whole blood transfusion during the flight to a regional Level I trauma center. The patient went directly to the operating room from the helipad, underwent definitive operative management, and was ultimately discharged home on hospital day nine.

CONCLUSION

Early recognition of hemorrhagic shock, implementation of prehospital transfusion protocols that emphasize transfusion of warmed blood without interruption, and an organized, regional approach to trauma care are critical for improving patient survival.

Remote Damage Control Resuscitation: A Case Report of Hemorrhagic Shock Secondary to Multiple Gunshot Wounds

Hypovolemic shock is the leading cause of preventable death on the battlefield. Remote damage control resuscitation has evolved dramatically in the past decade by introducing novel treatments and approaches to bleeding in the prehospital setting. This report presents a case of a casualty who sustained multiple gunshot wounds to the chest and gluteal regions and suffered from hemorrhagic shock with an Injury Severity Score of 34. The casualty was treated at the point of injury and during evacuation according to the IDF's remote damage control resuscitation algorithm utilizing the range of blood products available in the IDF. Prompt identification of the mechanism of injury, clinical and tactical decision-making, and immediate advanced medical care through several prehospital medical evacuation platforms culminated in this casualty's survival. This case emphasizes the importance of medical advancements in prehospital field care and guideline-directed treatment to improve casualty survival.

Prehospital Trauma Airway Management: An NAEMSP Position Statement and Resource Document

Definitive management of trauma is not possible in the out-of-hospital environment. Rapid treatment and transport of trauma casualties to a trauma center are vital to improve survival and outcomes. Prioritization and management of airway, oxygenation, ventilation, protection from gross aspiration, and physiologic optimization must be balanced against timely patient delivery to definitive care. The optimal prehospital airway management strategy for trauma has not been clearly defined; the best choice should be patient-specific. NAEMSP recommends:The approach to airway management and the choice of airway interventions in a trauma patient requires an iterative, individualized assessment that considers patient, clinician, and environmental factors.Optimal trauma airway management should focus on meeting the goals of adequate oxygenation and ventilation rather than on specific interventions. Emergency medical services (EMS) clinicians should perform frequent reassessments to determine if there is a need to escalate from basic to advanced airway interventions.Management of immediately life-threatening injuries should take priority over advanced airway insertion.Drug-assisted airway management should be considered within a comprehensive algorithm incorporating failed airway options and balanced management of pain, agitation, and delirium.EMS medical directors must be highly engaged in assuring clinician competence in trauma airway assessment, management, and interventions.

Pre-hospital emergency anaesthesia in trauma patients treated by anaesthesiologist and nurse anaesthetist staffed critical care teams

Background

Pre‐hospital tracheal intubation in trauma patients has recently been questioned. However, not only the trauma and patient characteristics but also airway provider competence differ between systems making simplified statements difficult.

Method

The study is a subgroup analysis of trauma patients included in the PHAST study. PHAST was a prospective, observational, multicentre study on pre‐hospital advanced airway management by anaesthesiologist and nurse anaesthetist manned pre‐hospital critical care teams in the Nordic countries May 2015‐November 2016. Endpoints include intubation success rate, complication rate (airway‐related complication according to Utstein Airway Template by Sollid et al), scene time (time from arrival of the critical care team to departure of the patient) and pre‐hospital mortality.

Result

The critical care teams intubated 385 trauma patients, of which 65 were in shock (SBP <90 mm Hg), during the study. Of the trauma patients, 93% suffered from blunt trauma, the mean GCS was 6 and 75% were intubated by an experienced provider who had performed >2500 tracheal intubations. The pre‐hospital tracheal intubation overall success rate was 98.6% and the complication rate was 13.6%, with no difference between patients with or without shock. The mean scene time was significantly shorter in trauma patients with shock (21.4 min) compared to without shock (21.4 vs 25.1 min). Following pre‐hospital tracheal intubation, 97% of trauma patients without shock and 91% of the patients in shock with measurable blood pressure were alive upon arrival to the ED.

Conclusion

Pre‐hospital tracheal intubation success and complication rates in trauma patients were comparable with in‐hospital rates in a system with very experienced airway providers. Whether the short scene times contributed to a low pre‐hospital mortality needs further investigation in future studies.

[Cardiac arrest under special circumstances]

These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).

Rapid Sequence Induction Strategies Among Critically Injured U.S. Military During the Afghanistan and Iraq Conflicts

INTRODUCTION

Rapid sequence intubation of patients experiencing traumatic hemorrhage represents a precarious phase of care, which can be marked by hemodynamic instability and pulseless arrest. Military combat trauma guidelines recommend reduced induction dose and early blood product resuscitation. Few studies have evaluated the role of induction dose and preintubation transfusion on hemodynamic outcomes. We compared rates of postintubation systolic blood pressure (SBP) of < 70 mm Hg, > 30% drop in SBP, pulseless arrest, and mortality at 24 hours and 30 days among patients who did and did not receive blood products before intubation and then examined if induction agent and dose influenced the same outcomes.

MATERIALS AND METHODS

A retrospective analysis was performed of battle-injured personnel presenting to surgical care facilities in Iraq and Afghanistan between 2004 and 2018. Those who received blood transfusions, underwent intubation, and had an Injury Severity Score of  ≥15 were included. Intubation for primary head, facial, or neck injury, burns, operative room intubations, or those with cardiopulmonary resuscitation in progress were excluded. Multivariable logistic regression was performed with unadjusted and adjusted odds ratios for the five study outcomes among patients who did and did not receive preintubation blood products. The same analysis was performed for patients who received full or excessive versus partial induction agent dose.

RESULTS

A total of 153 patients had a mean age of 24.9 (SD 4.5), Injury Severity Score 29.7 (SD 11.2), heart rate 122.8 (SD 24), SBP 108.2 (SD 26.6). Eighty-one (53%) patients received preintubation blood products and had similar characteristics to those who did not receive transfusions. Adjusted multivariate analysis found odds ratios as follows: 30% SBP decrease 9.4 (95% CI 2.3-38.0), SBP < 70 13.0 (95% CI 3.3-51.6), pulseless arrest 18.5 (95% CI 1.2-279.3), 24-hour mortality 3.8 (95% CI 0.7-21.5), and 30-day mortality 1.3 (0.4-4.7). In analysis of induction agent choice and comparison of induction agent dose, no statistically significant benefit was seen.

CONCLUSION

Within the context of this historical cohort, the early use of blood products conferred a statistically significant benefit in reducing postintubation hypotension and pulseless arrest among combat trauma victims exposed to traumatic hemorrhage. Induction agent choice and dose did not significantly influence the hemodynamic or mortality outcomes.

European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances

These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).

Assessment of Nonroutine Events During Intubation After Pediatric Trauma

BACKGROUND

Intubation in the early postinjury phase can be a high-risk procedure associated with an increased risk of mortality when delayed. Nonroutine events (NREs) are workflow disruptions that can be latent safety threats in high-risk settings and may contribute to adverse outcomes.

MATERIALS AND METHODS

We reviewed videos of intubations of injured children (age<17 y old) in the emergency department occurring between 2014 and 2018 to identify NREs occurring between the decision to intubate and successful intubation ("critical window").

RESULTS

Among 34 children requiring intubation, the indications included GCS≤8 (n = 20, 58.8%), cardiac arrest (n = 6, 17.6%), airway protection (n = 5, 14.7%), and respiratory failure (n = 3, 8.8%). The median duration of the "critical window" was 7.5 min (range 1.4-27.5 min), with a median of six NREs per case in this period (range 2-30). Most NREs (n = 159, 61.9%) delayed workflow, with 31 (12.1%) of these delays each lasting more than one minute. Eighty-seven NREs (33.9%) had a potential for harm but did not lead to direct patient harm. The most common NREs directly related to the intubation process were poor positioning for intubation (n = 23, 8.9%) and difficulty passing the endotracheal tube (n = 5, 1.9%), with most being attributed to the anesthesiologist performing the intubation (n = 51, range 0-7).

CONCLUSIONS

Workflow disruptions related to nonroutine events were frequent during pediatric trauma intubation and were often associated with delays and potential for patient harm. Interventions for improving the efficiency and timeliness of the critical window should focus on adherence to intubation protocol and improving communication and teamwork related to tasks in this phase.

Challenges in anaesthesia and pain management for burn injuries

Burn-injured patients provide unique challenges to those providing anaesthesia and pain management. This review aims to update both the regular burn anaesthetist and the anaesthetist only occasionally involved with burn patients in emergency settings. It addresses some aspects of care that are perhaps contentious in terms of airway management, fluid resuscitation, transfusion practices and pharmacology. Recognition of pain management failures and the lack of mechanism-specific analgesics are discussed along with the opioid crisis as it relates to burns and nonpharmacological methods in the management of distressed patients.

Analysis of Casualties That Underwent Airway Management Before Reaching Role 2 Facilities in the Afghanistan Conflict 2008-2014

INTRODUCTION

Airway compromise is the second leading cause of potentially survivable death on the battlefield. The purpose of this study was to better understand wartime prehospital airway patients.

MATERIALS AND METHODS

The Role 2 Database (R2D) was retrospectively reviewed for adult patients injured in Afghanistan between February 2008 and September 2014. Of primary interest were prehospital airway interventions and mortality. Prehospital combat mortality index (CMI-PH), hemodynamic interventions, injury mechanism, and demographic data were also included in various statistical analyses.

RESULTS

A total of 12,780 trauma patients were recorded in the R2D of whom 890 (7.0%) received prehospital airway intervention. Airway intervention was more common in patients who ultimately died (25.3% vs. 5.6%); however, no statistical association was found in a multivariable logistic regression model (OR 1.28, 95% CI 0.98-1.68). Compared with U.S. military personnel, other military patients were more likely to receive airway intervention after adjusting for CMI-PH (OR 1.33, 95% CI 1.07-1.64).

CONCLUSIONS

In the R2D, airway intervention was associated with increased odds of mortality, although this was not statistically significant. Other patients had higher odds of undergoing an airway intervention than U.S. military. Awareness of these findings will facilitate training and equipment for future management of prehospital/prolonged field care airway interventions.

Thoracic trauma in military settings: a review of current practices and recommendations

PURPOSE OF REVIEW

To examine current literature on thoracic trauma related to military combat and to explore its relevance to the civilian population.

RECENT FINDINGS

Damage control resuscitation (DCR) has improved the management of hemorrhaging trauma patients. Permissive hypotension below 110 mmHg and antifibrinolytic use during DCR is widely accepted, whereas the use of freeze-dried plasma and whole blood is gaining popularity. The Modified Physiologic Triaging Tool can be used for primary triage and it may have applications in civilian trauma systems. Although Tactical Combat Casualty Care protocol recommends the Cric-Key device for surgical cricothyroidotomies, other devices may offer comparable performance. Recommendations for regional anesthesia after blunt trauma are not well defined. Increasing amounts of evidence favor the use of extracorporeal membrane oxygenation for refractory hypoxemia and resuscitative endovascular balloon occlusion of the aorta (REBOA) for severe hemorrhage. REBOA outcomes are potentially improved by partial occlusion and small 7 Fr catheters.

SUMMARY

The Global War on Terror has provided opportunities to better understand and treat thoracic trauma in military settings. Trauma registries and other data sources have contributed to significant advancements in the management of thoracic trauma in military and civilian populations.