Amid the ongoing U.S. opioid crisis, achieving safe and effective chronic pain management while reducing opioid-related morbidity and mortality is likely to require multi-level efforts across health ...systems, including the Military Health System (MHS), Department of Veterans Affairs (VA), and civilian sectors.
We conducted a series of qualitative panel discussions with national experts to identify core challenges and elicit recommendations toward improving the safety of opioid prescribing in the U.S.
We invited national experts to participate in qualitative panel discussions regarding challenges in opioid risk mitigation and how best to support providers in delivery of safe and effective opioid prescribing across MHS, VA, and civilian health systems.
Eighteen experts representing primary care, emergency medicine, psychology, pharmacy, and public health/policy participated.
Six qualitative panel discussions were conducted via teleconference with experts. Transcripts were coded using team-based qualitative content analysis to identify key challenges and recommendations in opioid risk mitigation.
Panelists provided insight into challenges across multiple levels of the U.S. health system, including the technical complexity of treating chronic pain, the fraught national climate around opioids, the need to integrate surveillance data across a fragmented U.S. health system, a lack of access to non-pharmacological options for chronic pain care, and difficulties in provider and patient communication. Participating experts identified recommendations for multi-level change efforts spanning policy, research, education, and the organization of healthcare delivery.
Reducing opioid risk while ensuring safe and effective pain management, according to participating experts, is likely to require multi-level efforts spanning military, veteran, and civilian health systems. Efforts to implement risk mitigation strategies at the patient level should be accompanied by efforts to increase education for patients and providers, increase access to non-pharmacological pain care, and support use of existing clinical decision support, including state-level prescription drug monitoring programs.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Toxic alcohol ingestion is a rare but serious condition that carries with it a high rate of morbidity and mortality.
This review highlights the pearls and pitfalls of toxic alcohol ingestion, ...including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.
Toxic alcohols include ethylene glycol, methanol, isopropyl alcohol, propylene glycol, and diethylene glycol. These substances can be found in several settings including hospitals, hardware stores, and the household, and ingestion can be accidental or intentional. Toxic alcohol ingestion presents with various degrees of inebriation, acidemia, and end-organ damage depending on the substance. Timely diagnosis is critical to prevent irreversible organ damage or death and is based primarily on clinical history and consideration of this entity. Laboratory evidence of toxic alcohol ingestion includes worsening osmolar gap or anion-gap acidemia and end organ injury. Treatment depends on the ingestion and severity of illness but includes alcohol dehydrogenase blockade with fomepizole or ethanol and special considerations for the initiation of hemodialysis.
An understanding of toxic alcohol ingestion can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
Background
The hemodynamic impact of induction agents is a critically important consideration in emergency intubations. We assessed the relationship between peri‐intubation hypotension and the use of ...ketamine versus etomidate as an induction agent for emergency department (ED) intubation.
Methods
We analyzed ED intubation data for patients aged >14 years from the National Emergency Airway Registry performed in 25 EDs during 2016 through 2018. We excluded patients with preintubation hypotension (systolic blood pressure <100 mm Hg) or cardiac arrest prior to intubation. The primary outcome was peri‐intubation hypotension. Secondary outcomes included interventions for hypotension (e.g., intravenous fluids or vasopressors). We report adjusted odds ratios (aOR) from multivariable logistic regression models controlling for patient demographics, difficult airway characteristics, and intubation modality.
Results
There were 738 encounters with ketamine and 6,068 with etomidate. Patients receiving ketamine were more likely to have difficult airway characteristics (effect size difference = 8.8%, 95% confidence interval CI = 5.3% to 12.4%) and to undergo intubation with video laryngoscopy (8.1%, 95% CI = 4.4% to 12.0%). Peri‐intubation hypotension incidence was 18.3% among patients receiving ketamine and 12.4% among patients receiving etomidate (effect size difference = 5.9%, 95% CI = 2.9% to 8.8%). Patients receiving ketamine were more likely to receive treatment for peri‐intubation hypotension (effect size difference = 6.5%, 95% CI = 3.9% to 9.3%). In logistic regression analyses, patients receiving ketamine remained at higher risk for peri‐intubation hypotension (aOR = 1.4, 95% CI = 1.2 to 1.7) and treatment for hypotension (aOR = 1.8, 95% CI = 1.4 to 2.0). There was no difference in the aOR of hypotension between patients receiving ketamine at doses ≤1.0 mg/kg versus >1.0 mg/kg or patients receiving etomidate at doses ≤0.3 mg/kg versus >0.3 mg/kg.
Conclusions
Pending additional data, our results suggest that clinicians should not necessarily prioritize ketamine over etomidate based on concern for hemodynamic compromise among ED patients undergoing intubation.
Although both succinylcholine and rocuronium are used to facilitate emergency department (ED) rapid sequence intubation, the difference in intubation success rate between them is unknown. We compare ...first-pass intubation success between ED rapid sequence intubation facilitated by succinylcholine versus rocuronium.
We analyzed prospectively collected data from the National Emergency Airway Registry, a multicenter registry collecting data on all intubations performed in 22 EDs. We included intubations of patients older than 14 years who received succinylcholine or rocuronium during 2016. We compared the first-pass intubation success between patients receiving succinylcholine and those receiving rocuronium. We also compared the incidence of adverse events (cardiac arrest, dental trauma, direct airway injury, dysrhythmias, epistaxis, esophageal intubation, hypotension, hypoxia, iatrogenic bleeding, laryngoscope failure, laryngospasm, lip laceration, main-stem bronchus intubation, malignant hyperthermia, medication error, pharyngeal laceration, pneumothorax, endotracheal tube cuff failure, and vomiting). We conducted subgroup analyses stratified by paralytic weight-based dose.
There were 2,275 rapid sequence intubations facilitated by succinylcholine and 1,800 by rocuronium. Patients receiving succinylcholine were younger and more likely to undergo intubation with video laryngoscopy and by more experienced providers. First-pass intubation success rate was 87.0% with succinylcholine versus 87.5% with rocuronium (adjusted odds ratio 0.9; 95% confidence interval 0.6 to 1.3). The incidence of any adverse event was also comparable between these agents: 14.7% for succinylcholine versus 14.8% for rocuronium (adjusted odds ratio 1.1; 95% confidence interval 0.9 to 1.3). We observed similar results when they were stratified by paralytic weight-based dose.
In this large observational series, we did not detect an association between paralytic choice and first-pass rapid sequence intubation success or peri-intubation adverse events.
During the past 17 years of conflict the deployed US military health care system has found new and innovative ways to reduce combat mortality down to the lowest case fatality rate in US history. ...There is currently a data dearth of emergency department (ED) care delivered in this setting. We seek to describe ED interventions in this setting.
We used a series of ED procedure codes to identify subjects within the Department of Defense Trauma Registry from January 2007 to August 2016.
During this time, 28,222 met inclusion criteria. The median age of causalities in this dataset was 25 years and most (96.9%) were male, US military (41.3%), and part of Operation Enduring Freedom (66.9%). The majority survived to hospital discharge (95.5%). Most subjects sustained injuries by explosives (55.3%) and gunshot wound (GSW). The majority of subjects had an injury severity score that was considered minor (74.1%), while the preponderance of critically injured casualties sustained injuries by explosive (0.7%). Based on AIS, the most frequently seriously injured body region was the extremities (23.9%). The bulk of administered blood products were packed red blood cells (PRBC, 26.4%). Endotracheal intubation was the most commonly performed critical procedure (11.9%). X-ray (79.9%) was the most frequently performed imaging study.
US military personnel comprised the largest proportion of combat casualties and most were injured by explosive. Within this dataset, ED providers most frequently performed endotracheal intubation, administered blood products, and obtained diagnostic imaging studies.
ABSTRACT
Introduction
Uncontrolled hemorrhage remains the leading cause of preventable death in the prehospital, combat setting. Treatment guidelines emphasize immediate hemorrhage control and early ...resuscitation with whole blood or blood products. Current methods for the delivery of blood products are often insufficient to provide trauma resuscitation. The novel LifeFlow device is a hand-powered device that can rapidly infuse fluids, including blood products. However, successful use of this device in the hands of the intended end user has not been demonstrated.
Materials and Methods
We conducted a pilot study to assess how quickly and effectively medics could set up the LifeFlow device and infuse mock blood products into a casualty. They were provided with a brief block of instruction (<10 min) and the opportunity to handle the device. The time to set up the device and proportion of successful completion were recorded. Participants were surveyed regarding the use of the device including post-study interview.
Results
Forty medics, who were recruited and eligible to participate, completed the study procedures. All medics were able to successfully set up the device and perform the infusion. We had two instances of fluid leakage owing to malfunctions with the simulation arm, not the LifeFlow device. The mean time to device setup was 112 s (95% confidence interval CI, 101-124). The mean time for infusion of 500 mL of fluid was 94 s (95% CI, 83-105). The mean time for all procedures was 197 s (95% CI, 178-213). On product feedback, they generally found it easier to use, easy to manipulate, possessing a useful grip, easily set up, and requiring minimal training.
Conclusions
The medics were able to reliably assemble and use the LifeFlow rapid infusion device. However, there were concerns about the packaging and the single indication for the device.
Prehospital and Emergency Management Williams, Jasmine M; Ingle, Chelsea L; Schauer, Steven G ...
The Surgical clinics of North America
103, Številka:
3
Journal Article
Recenzirano
Burn care in the prehospital and emergency settings requires rapid assessment of airway, breathing, and circulation. Intubation (if indicated) and fluid resuscitation are most important in emergency ...burn care. Total body surface area burned and depth of burn are important early assessments that help guide resuscitation and disposition. Burn care in the emergency department further includes carbon monoxide and cyanide toxicity evaluation and management.
Traumatic injury with subsequent hemorrhage is one of the leading causes of mortality among military personnel and civilians alike. Posttraumatic hemorrhage accounts for 40% to 50% of deaths in ...severe trauma patients occurring secondary to direct vessel injury or the development of trauma-induced coagulopathy (TIC). Hyperfibrinolysis plays a major role in TIC and its presence increases a patient's risk of mortality. Early therapeutic intervention with intravenous (IV) tranexamic acid (TXA) prevents development of hyperfibrinolysis and subsequent TIC leading to decreased mortality. However, obtaining IV access in an austere environment can be challenging. In this study, we evaluated the efficacy of intramuscular (IM) versus IV TXA at preventing hyperfibrinolysis in a hemorrhaged swine.
Yorkshire cross swine were randomized on the day of study to receive IM or IV TXA or no treatment. Swine were sedated, intubated, and determined to be hemodynamically stable before experimentation. Controlled hemorrhaged was induced by the removal of 30% total blood volume. After hemorrhage, swine were treated with 1,000 mg of IM or IV TXA. Control animals received no treatment. Thirty minutes post-TXA treatment, fibrinolysis was induced with a 50-mg bolus of tissue plasminogen activator. Blood samples were collected to evaluate blood TXA concentrations, blood gases, blood chemistry, and fibrinolysis.
Blood TXA concentrations were significantly different between administration routes at the early time points but were equivalent by 20 minutes after injection, remaining consistently elevated for up to 3 hours postadministration. Induction of fibrinolysis resulted in 87.18 ± 4.63% lysis in control animals, compared with swine treated with IM TXA, 1.96 ± 2.66% and 1.5 ± 0.42% lysis in the IV TXA group.
In the large swine model of hemorrhage with hyperfibrinolysis, IM TXA is bioequivalent and equally efficacious in preventing hyperfibrinolysis as IV TXA administration.
ABSTRACT
Introduction
Understanding usage patterns of current paper-based documentation can inform the development of electronic documentation forms for en route care. The primary objective was to ...analyze the frequency of use of each field within the 3899 L Patient Movement Record documented by en route Critical Care Air Transport Teams. Secondary objectives were to identify rarely utilized form fields and to analyze the proportion of verifiable major events documented within the 3899 L form.
Materials and methods
We performed a retrospective review of 3899 L patient movement records for patients transported via Critical Care Air Transport Teams from January 2019 to December 2019. Scanned 3899 L forms were manually transcribed into a Microsoft Access database for evaluation and analysis. Proportions were calculated for completed fields. Major vital sign event frequency was compared for checkbox fields versus the vital sign flow sheet for each patient. We performed descriptive analyses for the proportion of charts with completed documentation in each evaluated field and the proportion of flow sheet events documented in major event fields.
Results
We analyzed 130 records. Fourteen of 18 (77.8%) demographic fields had a 75% or greater completion ratio. Sections with the largest proportion of rarely or never utilized fields (<1.5% completed) were procedures (77.8% of fields) and major events (63.9% of fields). Major event checkboxes had low sensitivity for documented events in the flow sheet: Change in heart rate greater than 20% (1 of 28 patients); increase in the fraction of inspired oxygen requirement of greater than 10% (6 of 23 patients); decrease in mean arterial pressure of greater than 20% (1 in 12 patients); and temperature less than 35.6°C (1 in 13 patients).
Conclusions
Many of the current 3899 L fields are highly utilized, but some 3899 L sections contain high proportions of rarely utilized fields. Major event checkboxes did not consistently capture events documented within the in-flight vital sign flow sheet.
Introduction
Video laryngoscope (VL) technology improves first‐pass success. The novel i‐view VL device is inexpensive and disposable. We sought to determine the first‐pass intubation success with ...the i‐view VL device versus the standard reusable VL systems in routine use at each site.
Methods
We performed a prospective, pragmatic study at two major emergency departments (EDs) when VL was used. We rotated i‐view versus reusable VL as the preferred device of the month based on an a priori schedule. An investigator‐initiated interim analysis was performed. Our primary outcome was a first‐pass success with a non‐inferiority margin of 10% based on the per‐protocol analysis.
Results
There were 93 intubations using the reusable VL devices and 81 intubations using the i‐view. Our study was stopped early due to futility in reaching our predetermined non‐inferiority margin. Operator and patient characteristics were similar between the two groups. The first‐pass success rate for the i‐view group was 69.1% compared to 84.3% for the reusable VL group. A non‐inferiority analysis indicated that the difference (−15.1%) and corresponding 90% confidence limits (−25.3% to −5.0%) did not fall within the predetermined 10% non‐inferiority margin.
Conclusions
The i‐view device failed to meet our predetermined non‐inferiority margin when compared to the reusable VL systems with the study stopping early due to futility. Significant crossover occurred at the discretion of the intubating operator during the i‐view month.
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