John McManus

New hemostatic agents in the combat setting

BACKGROUND: Hemorrhage is a leading cause of potentially preventable death in both civilian and military trauma patients. Animal data have shown that hemostatic bandages reduce hemorrhage and improve survival. This article reports recent clinical observations regarding the efficacy and evolution of use of two new hemostatic bandages employed in the global war on terrorism.

No Deaths Associated with Patient Refusal of Transport After Naloxone-Reversed Opioid Overdose

Abstract Introduction. Naloxone is widely used in the treatment and reversal of opioid overdose. Most emergency medical services (EMS) systems administer naloxone by standing order, and titrate only to reverse respiratory depression without fully reversing sedation. Some EMS systems routinely administer sufficient naloxone to fully reverse the effects of opioid overdose. Frequently patients refuse further medical evaluation or intervention, including transport. Objectives. The purpose of this study was to evaluate the safety of this practice and determine whether increased mortality is associated with full reversal of opioids. As a component of a comprehensive quality assurance initiative, we assessed mortality during the 48 hours after patients received naloxone to reverse opioid overdose followed by patient-initiated refusal of transportation. Methods. The setting was a large urban fire-based EMS system. Investigators provided the Bexar County Medical Examiners Office (MEO) with a list of patients who were treated by the San Antonio Fire Department with naloxone, and not transported. Inclusion criteria were administration of naloxone and patient-initiated refusal. Patient dispositions also included aid only, referral to the MEO, or referral to law enforcement. The list was then compared with the MEO database. A chart review was completed on all patients treated and subsequently presented to the MEO within two days. A secondary time period of 30 days was also assessed. Results. The list identified 592 patients treated with naloxone and not transported to the emergency department. Five-hundred fifty-two patients received naloxone and refused transport or were not transported. The remaining 40 patients all presented to EMS in cardiac arrest, naloxone was administered during the course of resuscitation, and subsequent efforts were terminated in the field. None of the patients receiving naloxone with a subsequent patient-initiated refusal were examined at the MEO within the two-day end point. The 30-day assessment revealed that nine individuals were treated with naloxone and subsequently died, but the shortest time interval between date of service and date of death was four days. Conclusion. The primary outcome was that no patients who were treated with naloxone for opioid overdose and then refused care were examined by the MEO within a 48-hour time frame.

The accuracy of portable ultrasonography to diagnose fractures in an austere environment

Background. Previous literature has shown the ability of ultrasonography technology to accurately assess orthopedic pathology. Over the past two decades, the use of ultrasound in the prehospital setting has become an important tool for triage, diagnosis, and treatment, especially in austere and remote environments that lack appropriate radiography capability and logistical support. The purpose of our study was to assess the accuracy of ultrasound in the austere, combat environment for diagnosis of orthopedic fracture. Methods. We conducted a longitudinal, prospective, observational study on patients presenting with suspected closed fractures using a digital handheld ultrasound device. All patients presenting with suspected fracture underwent an ultrasound examination by a board-certified emergency medicine physician credentialed in emergency ultrasonography. Patients were then categorized into ultrasound-positive and ultrasound-negative groups. Results. A total of 44 subjects underwent ultrasound examination for suspected fractures. There were initially 12 (27%) positive and 32 (73%) negative scans. Of the initial 12 positive scans, ten had a true fracture verified by plain radiography. Ultrasonography yielded an overall sensitivity of 100% and a specificity of 94%. Only four patients with an initial negative ultrasound scan continued to have clinical symptoms for more than three days and were found to have no evidence of fracture by radiograph. Conclusions. Our data show that use of ultrasound by an experienced clinician in the austere environment can be performed accurately and can possibly prevent unnecessary evacuations for suspected fractures requiring radiographic verification. The purpose of our study was to assess the accuracy of ultrasound examination in the austere, combat environment for diagnosis of orthopedic fracture.

Radial pulse character relationships to systolic blood pressure and trauma outcomes

Background. Patient measurements that do not require monitoring equipment may be the only way to evaluate casualties in austere conditions to determine treatment andtransport priority. Objective. To test the hypothesis that palpable pulse characteristics in the radial artery would estimate systolic blood pressure (SBP) andpredict outcome in trauma patients. Methods. Data were analyzed from the medical records of 342 trauma patients ranging from 18 to 50 years of age. Prehospital data were collected by helicopter emergency medical personnel at the scene of the injury. Based on radial pulse character, patients were divided into normal (n = 313) andweak (n = 29) groups. Those whose medical records did not describe pulse characters were not considered. Differences in SBP, mortality, andmedical interventions between the radial-pulse-character groups were evaluated. Results. The SBP taken at the scene was a mean of 26 mm Hg lower in those patients with weak radial pulse characters (102 mm Hg versus 128 mm Hg). Similarly, the lowest mean SBPs recorded in the field between the normal- andweak-pulse-character groups were 112 mm Hg and99 mm Hg, respectively. Patient mortality increased with weak pulse character such that the mortality rats were 3% for the normal-pulse-character group and29% for the weak-pulse-character-group (odds ratio = 15.2). Conclusions. These preliminary data suggest that a weak radial pulse may be an acceptable method for initial rapid evaluation of trauma patients. This simple andrapid method of pulse evaluation should be considered for the triage of trauma patients in field conditions with limited instrumentation. Key words: pulse character; radial artery; systolic blood pressure; trauma; mortality.

A case Series Describing Thermal Injury Resulting From Zeolite Use for Hemorrhage Control in Combat Operations

Four cases are presented to illustrate cutaneous burns sustained with the use of zeolite in the treatment of major hemorrhage secondary to combat wounds. Zeolite, a microporous crystalline aluminosilicate granular hemostatic agent, can cause secondary thermal injuries through an exothermic reaction that is likely related to the absorption of free fluid at the hemorrhage site. Understanding of this process may help both military andcivilian EMS personnel avoid or minimize secondary thermal injury while still benefiting from zeolites hemostatic capabilities.

Pain management in current combat operations

Pain management in the U.S. Military, particularly in combat, shares many of the same principles found in civilian heath care organizations andinstitutions. Pain is one of the most common reasons for which soldiers seek medical attention in the combat environment, which mirrors the civilian experience. However, the combat environment exacerbates the typical challenges found in treating acute pain andhas the additional obstacles of a lack of supplies andequipment, delayed or prolonged evacuation times anddistances, devastating injuries, provider inexperience, anddangerous tactical situations. These factors contribute to the difficulty in controlling a soldiers pain in combat. Furthermore, civilian health care providers have also learned the importance of practicing pain management principles in austere andtactical environments because of recent natural andman-made domestic disasters. Pain management research, education, andtreatment strategies have been created to try to achieve adequate battlefield analgesia, andthese lessons learned may aid civilian health care providers if the circumstances arise. This article presents a brief history andcurrent overview of pain management for combat casualties on todays battlefield. Recent natural disasters andincreased threats for terrorist acts have proven the need for civilian health care providers to be properly trained in pain management principles in an austere or tactical environment

Use of ultrasonography to avoid an unnecessary procedure in the prehospital combat environment: a case report.

The role of ultrasonography in the prehospital combat setting has become a useful tool for triage, diagnosis, andtreatment. Recent literature has demonstrated that ultrasonography has a greater sensitivity andspecificity than clinical examination andplain radiography for pneumothorax detection in trauma patients, particularly small pneumothoraces. This becomes especially critical in austere andremote environments. Although many pneumothoraces are initially considered non–life-threatening, austere andcombat environments possess additional risks of limited supplies, multiple casualties, andprolonged evacuation times that may potentially increase the morbidity of these injuries. This case report discusses the role of ultrasonography in pneumothorax detection in the prehospital combat environment.