Opioids carry high risk of dependence, and patients can rapidly build tolerance after repetitive dosing. Low-dose ketamine is an analgesic agent alternative that provides more hemodynamic stability. ...We sought to describe the effects of prolonged ketamine use in non-burn patients.
We queried the electronic health system at the Brooke Army Medical Center for patient encounters with ketamine infusions lasting >72 hours. We abstracted data describing demographics, vital signs, ketamine infusion dose and duration, and discharge diagnoses potentially relevant to ketamine side effects.
We identified 194 subjects who met the study inclusion criteria. The median age was 39 years, most were male (67.0%), and most were primarily admitted for a non-trauma reason (59.2%). The mean ketamine drip strength was 43.9 mg/h (95% CI, 36.7-51.1; range 0.1-341.6) and the mean drip length was 130.8 hours (95% CI, 120.3-141.2; range 71-493). Most subjects underwent mechanical ventilation (56.1%) at some point during the infusion and most survived to hospital discharge (83.5%). On a per-day basis, the average heart rate was 93 beats per minute, systolic blood pressure was 128 mmHg, diastolic blood pressure was 71 mmHg, oxygen saturation was 96%, and respiratory rate was 22 respirations per minute.
We demonstrate that continuous ketamine infusions provide a useful adjunct for analgesia and/or sedation. Further development of this adjunct modality may serve as an alternative agent to opioids.
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.
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.
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.
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.
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.
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).
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.
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.
Heat stress followed by an accompanying hemorrhagic challenge may influence hemostasis. We tested the hypothesis that hemostatic responses would be increased by passive heat stress, as well as ...exercise-induced heat stress, each with accompanying central hypovolemia to simulate a hemorrhagic insult. In aim 1, subjects were exposed to passive heating or normothermic time control, each followed by progressive lower-body negative pressure (LBNP) to presyncope. In aim 2 subjects exercised in hyperthermic environmental conditions, with and without accompanying dehydration, each also followed by progressive LBNP to presyncope. At baseline, pre-LBNP, and post-LBNP (<1, 30, and 60 min), hemostatic activity of venous blood was evaluated by plasma markers of hemostasis and thrombelastography. For aim 1, both hyperthermic and normothermic LBNP (H-LBNP and N-LBNP, respectively) resulted in higher levels of factor V, factor VIII, and von Willebrand factor antigen compared with the time control trial (all P < 0.05), but these responses were temperature independent. Hyperthermia increased fibrinolysis clot lysis 30 min after the maximal amplitude reflecting clot strength (LY
) to 5.1% post-LBNP compared with 1.5% (time control) and 2.7% in N-LBNP ( P = 0.05 for main effect). Hyperthermia also potentiated increased platelet counts post-LBNP as follows: 274 K/µl for H-LBNP, 246 K/µl for N-LBNP, and 196 K/µl for time control ( P < 0.05 for the interaction). For aim 2, hydration status associated with exercise in the heat did not affect the hemostatic activity, but fibrinolysis (LY
) was increased to 6-10% when subjects were dehydrated compared with an increase to 2-4% when hydrated ( P = 0.05 for treatment). Central hypovolemia via LBNP is a primary driver of hemostasis compared with hyperthermia and dehydration effects. However, hyperthermia does induce significant thrombocytosis and by itself causes an increase in clot lysis. Dehydration associated with exercise-induced heat stress increases clot lysis but does not affect exercise-activated or subsequent hypovolemia-activated hemostasis in hyperthermic humans. Clinical implications of these findings are that quickly restoring a hemorrhaging hypovolemic trauma patient with cold noncoagulant fluids (crystalloids) can have serious deleterious effects on the body's innate ability to form essential clots, and several factors can increase clot lysis, which should therefore be closely monitored.
ABSTRACT
Background
Evidence from military populations showed that resuscitation using whole blood (WB), as opposed to component therapies, may provide additional survival benefits to traumatically ...injured patients. However, there is a paucity of data available for the use of WB in uninjured patients requiring transfusion. We sought to describe the use of WB in non-trauma patients at Brooke Army Medical Center (BAMC).
Materials and Methods
Between January and December 2019, the BAMC ClinComp electronic medical record system was reviewed for all patients admitted to the hospital who received at least one unit of WB during this time period. Patients were sorted based on their primary admission diagnosis. Patients with a primary trauma-based admission were excluded.
Results
One hundred patients were identified who received at least one unit of WB with a primary non-trauma admission diagnosis. Patients, on average, received 1,064 mL (750–2,458 mL) of WB but received higher volumes of component therapy. Obstetric/gynecologic (OBGYN) indications represented the largest percentage of non-trauma patients who received WB (23%), followed by hematologic/oncologic indications (16%).
Conclusion
In this retrospective study, WB was most commonly used for OBGYN-associated bleeding. As WB becomes more widespread across the USA for use in traumatically injured patients, it is likely that WB will be more commonly used for non-trauma patients. More outcome data are required to safely expand the indications for WB use beyond trauma.
In adults with traumatic brain injuries (TBI), hypotension and hypertension at presentation are associated with mortality. The effect of age-adjusted blood pressure in children with TBI has been ...insufficiently studied. We sought to determine if age-adjusted hypertension in children with severe TBI is associated with mortality.
This was a retrospective analysis of the Department of Defense Trauma Registry (DoDTR) between 2001 and 2013. We included for analysis patients <18 years with severe TBI defined as Abbreviated Injury Severity (AIS) scores of the head ≥3. We defined hypertension as moderate for systolic blood pressures (SBP) between the 95
and 99
percentile for age and gender and severe if greater than the 99th percentile. Hypotension was defined as SBP <90 mmHg for children >10 years or < 70mmHg + (2 × age) for children ≤10 years. We performed multivariable logistic regression and Cox regression to determine if BP categories were associated with mortality.
Of 4,990 children included in the DoDTR, 740 met criteria for analysis. Fifty patients (6.8%) were hypotensive upon arrival to the ED, 385 (52.0%) were normotensive, 115 (15.5%) had moderate hypertension, and 190 (25.7%) had severe hypertension. When compared to normotensive patients, moderate and severe hypertension patients had similar Injury Severity Scores, similar AIS head scores, and similar frequencies of neurosurgical procedures. Multivariable logistic regression demonstrated that hypotension (odd ratio OR 2.85, 95 confidence interval CI 1.26-6.47) and severe hypertension (OR 2.58, 95 CI 1.32-5.03) were associated with increased 24-hour mortality. Neither hypotension (Hazard ratio (HR) 1.52, 95 CI 0.74-3.11) nor severe hypertension (HR 1.65, 95 CI 0.65-2.30) was associated with time to mortality.
Pediatric age-adjusted hypertension is frequent after severe TBI. Severe hypertension is strongly associated with 24-hour mortality. Pediatric age-adjusted blood pressure needs to be further evaluated as a critical marker of early mortality.
In adults, early traumatic coagulopathy and shock are both common and independently associated with mortality. There are little data regarding both the incidence and association of early coagulopathy ...and shock on outcomes in pediatric patients with traumatic injuries. Our objective was to determine whether coagulopathy and shock on admission are independently associated with mortality in children with traumatic injuries.
A retrospective review of the Joint Theater Trauma Registry from U.S. combat support hospitals in Iraq and Afghanistan from 2002 to 2009 was performed. Coagulopathy was defined as an international normalized ratio of ≥1.5 and shock as a base deficit of ≥6. Laboratory values were measured on admission. Primary outcome was inhospital mortality. Univariate analyses were performed on all admission variables followed by reverse stepwise multivariate logistic regression to determine independent associations.
Combat support hospitals in Iraq and Afghanistan.
Patients <18 yrs of age with Injury Severity Score, international normalized ratio, base deficit, and inhospital mortality were included. Of 1998 in the cohort, 744 (37%) had a complete set of data for analysis.
None.
The incidence of early coagulopathy and shock were 27% and 38.3% and associated with mortality of 22% and 16.8%, respectively. After multivariate logistic regression, early coagulopathy had an odds ratio of 2.2 (95% confidence interval 1.1-4.5) and early shock had an odds ratio of 3.0 (95% confidence interval 1.2-7.5) for mortality. Patients with coagulopathy and shock had an odds ratio of 3.8 (95% confidence interval 2.0-7.4) for mortality.
In children with traumatic injuries treated at combat support hospitals, coagulopathy and shock on admission are common and independently associated with a high incidence of inhospital mortality. Future studies are needed to determine whether more rapid and accurate methods of measuring coagulopathy and shock as well as if early goal-directed treatment of these states can improve outcomes in children.
•When comparing ABLS-Sim to ABLS Live, the ABLS-Sim group demonstrated a higher written post test score (p<0.01).•This simulation model was easily integrated into traditional ABLS curriculum and was ...replicable throughout the hospital.•This active learning experience enriched psychomotor, critical thinking, and cognitive skills progression of participants.•The success of this model was supported by increased objective performance and subjective self-responded confidence levels.
The Advanced Burn Life Support (ABLS) program is a burn-education curriculum nearly 30 years in the making, focusing on the unique challenges of the first 24h of care after burn injury. Our team applied high fidelity human patient simulation (HFHPS) to the established ABLS curriculum. Our hypothesis was that HFHPS would be a feasible, easily replicable, and valuable adjunct to the current curriculum that would enhance learner experience.
This prospective, evidenced-based practice project was conducted in a single simulation center employing the American Burn Association’s ABLS curriculum using HFHPS. Participants managed 7 separate simulated polytrauma and burn scenarios with resultant clinical complications. After training, participants completed written and practical examinations as well as satisfaction surveys.
From 2012 to 2013, 71 students participated in this training. Simulation (ABLS-Sim) participants demonstrated a 2.5% increase in written post-test scores compared to traditional ABLS Provider Course (ABLS Live) (p=0.0016). There was no difference in the practical examination when comparing ABLS-Sim versus ABLS Live. Subjectively, 60 (85%) participants completed surveys. The Educational Practice Questionnaire showed best practices rating of 4.5±0.7; with importance of learning rated at 4.4±0.8. The Simulation Design Scale rating for design was 4.6±0.6 with an importance rating of 4.4±0.8. Overall Satisfaction and Self-Confidence with Learning were 4.4±0.7 and 4.5±0.7, respectfully.
Integrating HFHPS with the current ABLS curriculum led to higher written exam scores, high levels of confidence, satisfaction, and active learning, and presented an evidenced-based model for education that is easily employable for other facilities nationwide.
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