Jason F. Naylor

Emergency department imaging of pediatric trauma patients during combat operations in Iraq and Afghanistan

BackgroundMilitary hospitals in Iraq and Afghanistan treated children with traumatic injuries during the recent conflicts. Diagnostic imaging is an integral component of trauma management; however, few published data exist on its use in the wartime pediatric population.ObjectiveThe authors describe the emergency department (ED) utilization of radiology resources for pediatric trauma patients in Iraq and Afghanistan.Materials and methodsWe queried the Department of Defense Trauma Registry (DODTR) for all pediatric patients admitted to military fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. We retrieved ED data on ultrasound (US), radiographic and computed tomography (CT) studies.ResultsDuring the study period, there were 3,439 pediatric encounters, which represented 8.0% of all military hospital trauma admissions. ED providers obtained a total of 12,376 imaging studies on 2,920 (84.9%) children. Of the 12,376 imaging studies, 1,341 (10.8%) were US, 4,868 (39.3%) were radiographic and 6,167 (49.8%) were CT exams. Most children undergoing radiographic evaluation were boys (77.8%) and located in Afghanistan (70.4%), and they sustained penetrating injuries (68.0%). Children who underwent imaging had higher composite injury severity scores in comparison to those who did not undergo imaging (10 versus 9).ConclusionMilitary health care providers frequently utilized radiographic studies in the evaluation of pediatric trauma casualties in Iraq and Afghanistan. Deployed military hospitals that treat children would benefit from dedicated pediatric-specific imaging training and protocols.

Trends in Prehospital Analgesia Administration by US Forces From 2007 Through 2016

Abstract Background: Tactical Combat Casualty Care (TCCC) guidelines regarding prehospital analgesia agents have evolved. The guidelines stopped recommending intramuscular (IM) morphine in 1996, recommending only intravenous (IV) routes. In 2006, the guidelines recommended oral transmucosal fentanyl citrate (OTFC), and in 2012 it added ketamine via all routes. It remains unclear to what extent prehospital analgesia administered on the battlefield adheres to these guidelines. We seek to describe trends in analgesia administration patterns on the battlefield during 2007–2016. Methods: This is a secondary analysis of a Department of Defense Trauma Registry data set from January 2007 to August 2016. Within that group, we searched for subjects who received IM morphine, IV morphine, OTFC, parenteral fentanyl, or ketamine (all routes). Results: Our predefined ED search codes captured 28,222 subjects during the study period. Of these, 594 (2.1%) received IM morphine; 3,765 (13.3%) received IV morphine; 589 (2.1%) received OTFC; and 1,510 (5.4%) subjects received ketamine. Annual rates of administration of IM morphine were relatively stable during the study period, while those for OTFC and ketamine generally trended upward starting in 2012. In particular, the proportion of subjects receiving ketamine rose from 3.9% (nu2009=u2009995/25,618) during the study period preceding its addition to the TCCC guidelines (2007 to 2012) to 19.8% thereafter (2013–2016, nu2009=u2009515/2,604, pu2009<u20090.001). Conclusions: During the study period, rates of prehospital administration of IM morphine remained relatively stable while those for OTFC and ketamine both rose. These findings suggest that TCCC guidelines recommending the use of these agents had a material impact on prehospital analgesia patterns.

An analysis of casualties presenting to military emergency departments in Iraq and Afghanistan

Background: 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. Methods: We used a series of ED procedure codes to identify subjects within the Department of Defense Trauma Registry from January 2007 to August 2016. Results: 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. Conclusions: 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.

Emergency department resuscitation of pediatric trauma patients in Iraq and Afghanistan

Background Military hospital healthcare providers treated children during the recent conflicts in Afghanistan and Iraq. Compared to adults, pediatric patients present unique challenges during trauma resuscitations and have notably been discussed in few research reports. We seek to describe ED interventions performed on pediatric trauma patients in Iraq and Afghanistan. Methods We queried the Department of Defense Trauma Registry (DODTR) for all pediatric patients in Iraq and Afghanistan from January 2007 to January 2016. Subjects were grouped based on Centers for Disease Control age categories. We used descriptive statistics. Results During this period, there were 3388 pediatric encounters that arrived at the ED with signs of life or on‐going interventions. Most subjects were male (77.2%), located in Afghanistan (67.9%), injured by explosive (43.2%), and admitted to an intensive care unit (57.8%). Most of those arriving to the ED alive or with on‐going interventions survived to hospital discharge (91.6%). The most frequently encountered age group was 5–9 years (33.3%) followed by 10–14 years (31.5%). The most common interventions were vascular access (86.6%), fluid administration (85.0%), and external warming (44.6%). Intubation was the most frequent airway intervention (18.2%). Packed red blood cells were the most frequently administered blood product (33.8% of subjects). Conclusions Pediatric subjects accounted for a notable portion of care delivered in theater emergency departments during the study period. Vascular access and fluid administration were the most frequently performed interventions. Pediatric‐specific training is needed as a part of deployment medicine operations.

Association of prehospital intubation with decreased survival among pediatric trauma patients in Iraq and Afghanistan

Introduction: Airway compromise is the second leading cause of preventable death on the battlefield among US military casualties. Airway management is an important component of pediatric trauma care. Yet, intubation is a challenging skill with which many prehospital providers have limited pediatric experience. We compare mortality among pediatric trauma patients undergoing intubation in the prehospital setting versus a fixed‐facility emergency department. Methods: We queried the Department of Defense Trauma Registry (DODTR) for all pediatric encounters in Iraq and Afghanistan from January 2007 to January 2016. We compared outcomes of pediatric subjects undergoing intubation in the prehospital setting versus the emergency department (ED) setting. Results: During this period, there were 3439 pediatric encounters (8.0% of DODTR encounters during this time). Of those, 802 (23.3%) underwent intubation (prehospital = 211, ED = 591). Compared to patients undergoing ED intubation, patients undergoing prehospital intubation had higher median composite injury severity scores (17 versus 16) and lower survival rates (66.8% versus 79.9%, p < 0.001). On univariable logistic regression analysis, prehospital intubation increased mortality odds (OR 1.97, 95% CI 1.39–2.79). After adjusting for confounders, the association between prehospital intubation and death remained significant (OR 2.03, 95% CI 1.35–3.06). Conclusions: Pediatric trauma subjects intubated in the prehospital setting had worse outcomes than those intubated in the ED. This finding persisted after controlling for measurable confounders.

A Survey of Wilderness Medicine Analgesia Practice Patterns

INTRODUCTIONnIn 2014, the Wilderness Medical Society (WMS) published guidelines for the treatment of acute pain in remote settings. We surveyed wilderness medicine providers on self-reported analgesia prescribing practices.nnnMETHODSnWe conducted a prospective, anonymous survey. Respondents were recruited from the WMS annual symposium in 2016. All willing attendees were included.nnnRESULTSnDuring the symposium, we collected a total of 124 surveys (68% response rate). Respondent age was 42±12 (24-79) years (mean±SD with range), 58% were male, and 69% reported physician-level training. All respondents had medical training of varying levels. Of the physicians reporting a specialty, emergency medicine (59%, n=51), family medicine (13%, n=11), and internal medicine (8%, n=7) were reported most frequently. Eighty-one (65%) respondents indicated they prefer a standardized pain assessment tool, with the 10-point numerical rating scale being the most common (54%, n=67). Most participants reported preferring oral acetaminophen (81%, n=101) or nonsteroidal anti-inflammatory drugs (NSAID) (91%, n=113). Of those preferring NSAID, most reported administering acetaminophen as an adjunct (82%, n=101). Ibuprofen was the most frequently cited NSAID (71%, n=88). Of respondents who preferred opioids, the most frequently preferred opioid was oxycodone (26%, n=32); a lower proportion of respondents reported preferring oral transmucosal fentanyl citrate (9%, n=11). Twenty-five (20%, n=25) respondents preferred ketamine.nnnCONCLUSIONSnWilderness medicine practitioners prefer analgesic agents recommended by the WMS for the treatment of acute pain. Respondents most frequently preferred acetaminophen and NSAIDs.

Prehospital Application of Hemostatic Agents in Iraq and Afghanistan

Abstract Introduction: Hemorrhage is the leading cause of death on the battlefield. Development of chitosan- and kaolin-based hemostatic agents has improved hemorrhage control options. Sparse data exists on the use of these agents in the prehospital, combat setting. We describe recent use of these agents and compare patients receiving hemostatic to the baseline population. Methods: We used a series of emergency department (ED) procedure codes to identify patients within the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. We only included patients for whom the DODTR specified the hemostatic agent utilized (chitosan or kaolin). We defined a serious injury by body region as an Abbreviated Injury Score (AIS) of 3 or greater. Results: Our predefined search codes captured 28,222 patients. Of those, 258 (0.9%) patients had documented hemostatic use: 58 chitosan, 201 kaolin, and one subject received both. Patients undergoing hemostatic agent application were more likely to be injured by gunshot wound or explosive. Patients with hemostatic application had higher median composite Injury Severity Scores (10 vs. 9, p < 0.001), and higher AIS for the abdomen, extremity and superficial body regions with higher rates of blood product utilization. Proportions of patients suffering traumatic amputations and undergoing tourniquet application were higher in the hemostatic agent group than the baseline population (11.6% vs. 6.7%, p = 0.002 and 43.4% vs. 13.8%, p < 0.001, respectively). Conclusions: Hemostatic agents were infrequently utilized to manage traumatic hemorrhage during the recent conflicts in Afghanistan and Iraq. Hemostatic agent use was more frequent in casualties with gunshot wounds, traumatic amputations, concomitant tourniquet application, and greater blood product administration.”

Prehospital Interventions Performed on Pediatric Trauma Patients in Iraq and Afghanistan

Abstract Background: United States (US) and coalition military medical units deployed to combat zones frequently encounter pediatric trauma patients. Pediatric patients may present unique challenges due to their anatomical and physiological characteristics and most military prehospital providers lack pediatric-specific training. A minimal amount of data exists to illuminate the prehospital care of pediatric patients in this environment. We describe the prehospital care of pediatric trauma patients in Iraq and Afghanistan. Methods: 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. Subjects were grouped by age: <1, 1–4, 5–9, 10–14, and 15–17 years. We focused our analysis on interventions related to trauma resuscitation. Results: Of 42,790 encounters in the DODTR during the study period, 3,439 (8.0%) were aged <18 years. Most subjects were in the 5–9 age group (33.1%), male (77.1%), located in Afghanistan (67.8%), injured by explosives (43.1%). Most subjects survived to hospital discharge (90.2%). The most frequently performed interventions were tourniquet placement (6.6%), intubation (6.1%), supplemental oxygen (11.7%), IV access (24.8%), IV fluids (13.3%), IO access (5.1%), and hypothermia prevention (44.5%). The most frequently administered medications were antibiotics (6.2%) and opioids (15.0%). Most procedural and medication interventions occurred in subjects injured by explosives (43.1%) and gunshot wounds (22.1%). Conclusions: Pediatric subjects comprised over 1 in 13 casualties treated in the joint theaters with the majority injured by explosives. Vascular access and hypothermia prevention interventions were the most frequently performed procedures.

Prehospital Analgesia for Pediatric Trauma Patients in Iraq and Afghanistan

Abstract Background: Previous studies have evaluated prehospital analgesia during combat operations in Iraq and Afghanistan, but were limited to the adult population. However, a significant portion of the casualties of those conflicts were children. We describe the prehospital analgesia administered to wartime pediatric trauma patients. Methods: We queried the Department of Defense Trauma Registry (DODTR) for all pediatric patients (<18 years of age) admitted to United States and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. We divided pediatric patients into 2 groups: those that had documentation of receipt of analgesic drugs in the prehospital setting (n = 618) and those who had not received analgesia before reaching a fixed-facility (n = 2,821). For characterization of drug administration, we grouped patients into those receiving acetaminophen, NSAID, fentanyl, ketamine, morphine, or other analgesics (e.g., hydromorphone, tramadol, etc.). Results: During the study period, there were 3,439 pediatric encounters with documentation of 703 instances of analgesia administrations to 618 patients (17.9% of total pediatric encounters). Of the subjects receiving analgesic agents, 46.2% (n = 325) received morphine, 30.4% (n = 214) received fentanyl, 17.4% (n = 122) received ketamine, 1.8% (n = 13) received acetaminophen, and 2.8% (n = 20) received a non-steroidal anti-inflammatory drug. The remaining 9 administrations consisted of methoxyflourane (1), nalbuphine (2), hydromorphone (3), and tramadol (3). An injury severity score (ISS) >15 increased the odds of receiving an analgesic agent (OR 1.26, 95% CI 1.02–1.56). Additionally, there was an association between analgesia administration and the following prehospital interventions: wound dressing, tourniquet, intravenous (IV) line placement, intraosseous line placement, IV fluids, intubation, and external warming. Conclusions: Overall, a low proportion of pediatric trauma subjects within this population received analgesia in the prehospital environment. The most common analgesic medication administered was morphine. Those receiving analgesic agents had more severe injuries and higher rates of concomitant interventions. These results highlight the potential need for Tactical Combat Casualty Care guidelines specifically providing recommendations for analgesia administration among pediatric patients.

Prehospital Resuscitation Performed on Hypotensive Trauma Patients in Afghanistan: The Prehospital Trauma Registry Experience

INTRODUCTIONnHemorrhage is the leading cause of potentially preventable death on the battlefield. Hypotension in the setting of trauma portends a higher rate of mortality. We describe the interventions for trauma-related hypotension performed in the prehospital combat setting in accordance with Tactical Combat Casualty Care (TCCC) guidelines.nnnMATERIALS AND METHODSnWe searched the Prehospital Trauma Registry for casualties from January 2013 to September 2014. Within that group, we searched for all casualties with documented hypotension by either measured systolic blood pressure ≤90 mmHg or a weak or absent radial pulse documented by the prehospital provider. We used descriptive statistics to analyze the interventions performed in our study sample.nnnRESULTSnOf the 705 casualties available for query, 134 (19.0%) casualties with documented hypotension met inclusion criteria. Most casualties with hypotension had an alert mental status (70.1%), had a medical officer in their chain of care (59.0%), were Afghan (64.2%), and evacuated on an urgent status (78.4%). Explosives were the most frequent mechanism of injury (50.7%). There were 42 fluid administrations documented on 33 (24.6%) casualties. The most common fluid administered was normal saline (52.4%) followed by hetastarch solution (33.3%). There was one documented use of a fluid warmer in this cohort. One subject received four units of packed red blood cells. No other casualties had documented blood product administration. There were no documented administrations of PlasmaLyte. There were four casualties that received lactated Ringers.nnnCONCLUSIONnMost casualties with documented hypotension after trauma in the Prehospital Trauma Registry did not receive prehospital blood or fluid intervention. Of the interventions performed, most did not match with contemporary TCCC guidelines.