Elizabeth Powell

Shorter times to packed red blood cell transfusion are associated with decreased risk of death in traumatically injured patients.

BACKGROUND Hemorrhage is a leading cause of death in traumatically injured patients. Currently, the importance of earlier administration of packed red blood cells (pRBC) to improve outcomes is limited. We evaluated the association of earlier pRBC administration and mortality when compared with later transfusion initiation. METHODS This single-center retrospective cohort study of trauma patients transported by a single helicopter service from the scene of injury to an urban academic trauma center included patients receiving at least one unit of pRBC within 24 hours of hospital arrival. The final cohort included patients transported to the trauma center between March 11, 2010, and October 30, 2013. The helicopter service carries two units of pRBC for protocol-driven prehospital transfusion. Logistic regression was used to model odds of death, and 95% confidence intervals were calculated. RESULTS The 94 patients meeting inclusion criteria had a mean (SD) age of 43 (19) years; 87 (93%) of 94 were white, 66 (70%) of 94 were male, and 88(94%) of 94 sustained blunt force injuries. Median Injury Severity Score was 29 (range, 2–75), and 31 (33%) of 94 died within 30 days. Most patients [82/94 (87%)] received their first pRBC transfusion during transport or within one hour of arrival at the emergency department (ED). For the 82 patients receiving a first pRBC transfusion within one hour of ED arrival, each 10-minute increase in time to transfusion increased the odds of death [OR, 1.27 (95% CI, 1.01–1.62; p = 0.044)], controlling for TRISS. At 30 days, 29/82 (35%) patients who received a pRBC transfusion within one hour of ED arrival, and 2 (16%) of 12 patients who received delayed transfusion were deceased (difference, 19%; 95% CI, −5% to 42%). CONCLUSION In this study, delays in time to pRBC administration of as short as 10 minutes were associated with increased odds of death for patients receiving ultra-early pRBC transfusion. Expedient prehospital and ED transfusion capabilities may improve outcomes after trauma. LEVEL OF EVIDENCE Therapeutic/care management study, level III.

A 20-Year-Old-Male with Hemorrhagic Shock

Hemorrhagic shock from trauma is a leading cause of morbidity and mortality and commonly encountered by HEMS agencies. Understanding of the management of patients in hemorrhagic shock transported from the scene and interfacility transfers is important for all critical care providers.

A 47-Year-Old Man With a Spinal Cord Injury After a Parachute Jump

A 47-year-old man was participating in a parachute demonstration when he became tangled with another member of the demonstration team and suffered a free fall of approximately 20 to 25 feet. On the initial jump, the patients parachute deployed without incident. Unfortunately, however, the chute opened immediately before landing and tangled with another team member. The patient sustained a direct fall, landing feet first on a grass field. Subsequently, he then fell backwards. Ground emergency medical services were on-site for the event and immediately assessed the patient. He was unable to ambulate and complained of left foot pain and back pain. He was wearing a helmet and denied loss of consciousness. The patient initially had a blood pressure of 147/ 87, heart rate of 83, and an oxygen saturation of 98% on room air. Once assessed, the patient had a cervical collar placed, and he was secured to a backboard. He received several doses of fentanyl for pain. He remained hemodynamically stable without additional complaints and was taken to the closest level III trauma center for further evaluation without incident. On arrival, the provider assessed his critical systems, and they were not altered. However, during the neurologic examination, he was noted to be able to dorsiflex and plantarflex without compromise of his strength in the right lower extremity but was unable to raise his right leg off the bed. On the left lower extremity, the patient had a deformity to the ankle, and he had no movement to the left lower extremity. The left foot had no palpable dorsalis pedis or posterior tibial pulse, and the toes were dusky. His bilateral upper extremities were

A 77-Year-Old Man With Large Vessel Acute Ischemic Stroke

Air Medical Journal 34:5 A 77-year-old man with a past medical history significant for hypertension, coronary artery disease on aspirin, congestive heart failure, a remote history of deep vein thrombosis formerly on warfarin (noncurrently), and an old right-sided ischemic stroke with residual tremor in his left lower extremity for which he takes levetiracitam presented to a rural emergency department after developing acute-onset left-sided hemiplegia. Local emergency medical services was called to the patient’s home after his family noted the deficits shortly after dinner. He was found sitting on the couch in the family living room after having shared an evening meal with the rest of his family. The paramedic noted complete left-sided hemiplegia, including left-sided facial droop and gaze deviation to the right, and marked dysarthria. During transport, the ground team reported stable vital signs and a blood glucose level of 158 mg/dL. Upon arrival to the emergency department, the patient was “last seen normal” 1 hour 15 minutes before. On examination, he was awake and alert but had 0/5 strength to his left upper and lower extremities, including significant left-sided facial droop. He had a rightward gaze deviation with dense left-sided neglect and significant dysarthria with aphasia. His National Institutes of Health Stroke Scale score was 18. He was rapidly taken for a noncontrasted head computed tomographic (CT) scan and a CT angiogram of the head and neck. The noncontrasted head CT scan showed a right-sided hyperdense area of ischemia noted to be a middle cerebral artery (MCA) sign (Fig. 1) suggestive of large proximal MCA thrombus with no evidence of acute hemorrhage. The CT angiogram showed a right-sided M1 distribution occlusion or cutoff (Fig. 2). Laboratory values were obtained, and an electrocardiogram showed new-onset atrial fibrillation. The regional stroke team was consulted using a telemedicine robot terminal with bidirectional cameras and speakers. The patient was deemed a candidate for thrombolytic therapy and was treated with an intravenous (IV) tissue plasminogen activator (tPA) bolus followed by a 1-hour infusion 1 hour 53 minutes from “last seen normal.” Rotor wing critical care transport was contacted to transport the patient to a neurointervention suite at the receiving facility. The patient spent a total of 1 hour 17 minutes in the emergency department before helicopter emergency medical services (HEMS) transport. On HEMS arrival, the patient was found to be hemo dynamically stable with a blood pressure of 143/66, a heart rate of 67, and an oxygen saturation of 96% on a 2-L nasal cannula. The patient was placed on the transport stretcher, transferred to the transport monitor, and tPA infusion was continued. The patient’s systolic blood pressure remained under 180 systolic, and no blood pressure management was required throughout the flight. The patient was taken directly to angiography, and care was transferred without incident. Upon arrival to the receiving facility, the patient had aspiration thrombectomy of the right M1 artery occlusion with reperfusion shown intraprocedure at 3 hours 58 minutes from the “last seen normal” time (Figs. 3 and 4). The patient initially had some improvement in his neurologic examination demonstrated by some movement in his left upper and lower extremity but went on to have a hospital course complicated by left-sided anterior cerebral artery ischemic stroke and a urinary tract infection. He was discharged to a skilled nursing facility on hospital day 13.