David J. Dula

Rural interhospital helicopter transport of motor vehicle trauma victims: Causes for delays and recommendations

One hundred twenty-six consecutive ACS Category I motor vehicle trauma patients transported by helicopter from 25 hospitals to a regional trauma center in rural Pennsylvania during a 14-month period were reviewed retrospectively. The overall mortality was 13%. Average round-trip distance was 79 miles. Interventions by the medical flight team (emergency physician/nurse) included endotracheal intubation, tube thoracostomy, and/or central venous access in 42 patients (33%) prior to lift-off. Ground time at the referring facility, from landing to lift-off, when no interventions were required of the flight team, averaged 31.2 minutes (baseline). Ground time when major therapeutic interventions were required (principally airway management), however, averaged 57.4 minutes, an 84% increase over baseline (P less than .01). A major cause of the excessive ground times was the lack of standardized diagnostic workup and stabilization of patients prior to arrival of the flight team. Recommendations for standardized emergency department preparation of trauma victims requiring aeromedical evacuation are made.

Patient Outcome Using Medical Protocol to Limit “Lights and Siren” Transport

INTRODUCTIONnEmergency medical services vehicle collisions (EMVCs) associated with the use of warning lights and siren (L&S) are responsible for injuries and death to emergency medical services (EMS) personnel and patients. This study examines patient outcome when medical protocol directs L&S transport.nnnDESIGNnDuring four months, all EMS calls initiated as an emergency request for service and culminating in transport to an emergency department (ED) were included. Medical criteria determined emergent (L&S) versus non-emergent transport. Patients with worsened conditions, as reported by EMS providers, were reviewed.nnnSETTINGnCountywide suburban/rural EMS system.nnnRESULTSnNinety-two percent (1,495 of 1,625) of patients were transported nonemergently. Thirteen (1%) of these were reported to have worsened during transport, and none of them suffered any worsened outcome related to the non-L&S transport.nnnCONCLUSIONnThis medical protocol directing the use of warning L&S during patient transport results in infrequent L&S transport. In this study, no adverse outcomes were found related to non-L&S transports.

Use of prehospital fluids in hypotensive blunt trauma patients

Objective. To compare the outcomes of blunt trauma victims with systolic blood pressure ≤90 mm Hg who received prehospital fluids with the outcomes of those who did not receive prehospital fluids. Methods. This matched-pairs case-control study used records of blunt trauma patients with scene systolic blood pressure ≤90 mm Hg obtained from the Pennsylvania Trauma Systems Foundation. Patients who received >500 mL prehospital fluids (n = 75) were matched by Injury Severity Score (ISS) and systolic blood pressure on scene with those who did not receive any prehospital fluids (n = 75). Outcomes compared included change in systolic blood pressure, survival to discharge, and length of hospital stay. Results. Those who received fluids were more likely to have an increase in systolic blood pressure at arrival to the emergency department [odds ratio for fluid use = 2.41; 95% confidence interval (95% CI) = 1.02, 5.73; p = 0.046]. There was no significant difference in survival to discharge (odds ratio for fluid use = 1.02; 95% CI = 0.40, 2.60; p = 0.969). There was no significant difference in length of hospital stay: 5.4 days (SD = 2.8) for those with fluids; 5.2 days (SD = 2.8) for those with no fluids; difference = 0.2 days; 95% CI = −1.6, 1.8; p = 0.870. Conclusions. This study suggests that prehospital fluid resuscitation of blunt injured trauma patients with systolic blood pressure ≤90 increases systolic blood pressure but has no effect on survival or length of hospital stay.

Detectability of drug tablets and capsules by plain radiography

This study was undertaken to determine the detectability of drugs in tablet or capsule form by plain radiography. A total of 459 drugs in tablet or capsule form were radiographed in water with parameters commonly used in routine upper abdominal films. Detectability was judged subjectively by radiologists readings and objectively by the use of a densitometer. Of the total, 6.3% were as radiopaque as a ferrous sulfate control tablet, 29.6% were moderately radiopaque, but less than control values, and 64% were essentially nondetectable. Potential benefits of this information in the clinical setting are discussed.

A prospective study comparing i.m. ketorolac with i.m. meperidine in the treatment of acute biliary colic

Ketorolac is a nonsteroidal anti-inflammatory medication that is used widely for pain management. Its effects are mediated through the inhibition of prostaglandins, which makes it uniquely different from opioids in relieving pain. We conducted a randomized, prospective, double blind study of patients presenting to our Emergency Department (ED) with a diagnosis of acute biliary colic. Study patients were randomized into one of two treatment groups, meperidine 1.5 mg/kg with a maximum dose of 100 mg or ketorolac 60 mg given intramuscularly (i.m.). The patients rated their pain before and 30 min after medication on a scale of 1 to 10 using a Visual Analog Pain Scale. Overall pain relief was compared between the two groups using a two-sample t test. Thirty patients were enrolled in the study, 16 in the ketorolac group and 14 in the meperidine group. Patients ranged in age from 18 to 71 years and 6 (20%) were male. The average pain score at time 0 was 7.6 for the ketorolac group and 7.3 for the meperidine group. Pain relief at time 30 min was 3.8 in the ketorolac group and 3.9 in the meperidine group, which was not statistically different. The mean global pain score and need for an emergency cholecystectomy were similar in the two groups. Rescue medication for additional analgesia at 30 min was needed in 4 patients in the meperidine group and in 2 patients in the ketorolac group (28.6% versus 12.5%, respectively; NS). In this study of patients with acute biliary colic there was no significant difference in the pain relief achieved by using either ketorolac or meperidine.

Trauma to -the Cervical Spine

Ninety-one patients with cervical injuries treated at the Geisinger Medical Center Emergency Department were reviewed. Most injuries were bony injuries with no evidence of cord injury. Of the 43 cases with cord injury, 56% had partial cord injuries and 44% had complete cord injuries. Clinical presentations of these patients were reviewed. A basic outline of management is discussed.

The ‘Ring Sign’: Is it a reliable indicator for cerebral spinal fluid?

STUDY OBJECTIVEnTo study the development of a ring sign when blood is mixed with various fluids.nnnMETHODSnOne drop of blood and one drop of either spinal fluid, saline, tap water, or rhinorrhea fluid were placed simultaneously on filter paper, and the specimens were examined after ten minutes for the development of a ring. A variety of filter paper agents were used, including standard laboratory filter paper, paper towels, coffee filters, and bed linens.nnnRESULTSnAll fluids, when mixed with blood, gave rise to a ring sign; blood alone did not. The type of filter paper did not affect the development of a ring.nnnCONCLUSIONnIn this experimental setting, the ring or halo sign is reliable for detecting cerebrospinal fluids but is not exclusive for cerebrospinal fluid.

Rapid flow rates for the resuscitation of hypovolemic shock

Nine dogs were hemorrhaged to approximately 40% of their blood volume and then were resuscitated with a crystalloid solution (Normosol) at various flow rates. Three study groups with three dogs in each group were resuscitated at 15 mL/min/kg (Group 1), 6 mL/min/kg (Group 2), and 4 mL/min/kg (Group 3). Central venous pressure (CVP), pulmonary artery wedge pressure (PAWP), mean arterial pressure, and cardiac output (CO) were monitored during the hemorrhage and the resuscitation from shock. During the infusion of fluids, Group 1 animals demonstrated an elevation of the PAWP of 31 mm Hg and elevation of CVP to 23.2 mm Hg; CO rose to 8.4 L/min. In Group 2 animals CO rose to 6.1 L/min; CVP was 10.5 mm Hg; and PAWP was 25 mm Hg. Group 3 animals had a rise in CO to 5 L/min; CVP and PAWP rose to 4.5 mm Hg and 6.8 mm Hg, respectively. In this experimental shock study, infusion of crystalloids at 6 mL/min/kg appeared to result in an improved physiologic response, although no statistical difference was demonstrated. Further studies are necessary to demonstrate the optimum flow rate for resuscitation of hypovolemic shock using crystalloids.

A 10-year experience in the use of air medical transport for medical scene calls☆☆☆

OBJECTIVEnThe objective of this retrospective descriptive study was to evaluate the use of air medical services in response to medical scene calls for transport to tertiary care in the rural setting.nnnMETHODSnThis study is a retrospective descriptive review of all medical scene calls during a 10-year study period. The cases were analyzed for demographics, transport time, medical indication, procedures, role of ground EMS services, effects on community hospitals, and patient outcomes. A case-by-case review by emergency medicine (EM) physicians was conducted to determine necessity of air medical transport.nnnRESULTSnA total of 8106 medical flights were conducted during the study period. Of these, 103 were scene calls for which 85 charts were available for review. The breakdown of medical scene calls is cardiac (29%), poisoning (17%), co poisoning (11%), neurologic (11%), and other (32%). Ground EMS was involved in 80% of the cases; ground advanced life support (ALS) was present in 58%. In 86% of the flights reviewed, an EM resident was aboard the helicopter. Of the 85 patients whose charts were available, 41 required admission to the ICU, five required hyperbaric oxygen (HBO) treatment, and 14 died before admission.nnnCONCLUSIONnEvacuation of the rural patient with a medical emergency accounts for an extremely small percentage of an air medical services use. ALS services, including emergency procedures at the scene and rapid transport to a tertiary care, were provided. Seventy-one percent of the flights reviewed required transport to a tertiary care facility, indicating that air medical transport was appropriate. Physician guidelines to ensure effective and cost-efficient use of these services should be developed. Responding for victims in cardiopulmonary arrest appears to provide little benefit with respect to outcome.

Vascular injury following disc surgery

The case of a patient who suffered a vascular injury following lumbar disk surgery is presented. She presented to the emergency department for evaluation of hypotension and congestive heart failure, which occurred acutely several days after her surgery. At angiography, a large A:V fistula was demonstrated between the aorta and vena cava. The diagnosis and pathophysiology of this complication of lumbar disc surgery is discussed.