Jonathan D. Auten

The safety of early fresh, whole blood transfusion among severely battle injured at US Marine Corps forward surgical care facilities in Afghanistan.

BACKGROUND In Afghanistan, care of the acutely injured trauma patient commonly occurred in facilities with limited blood banking capabilities. Apheresis platelets were often not available. Component therapy consisted of 1:1 packed red blood cells and fresh frozen plasma. Fresh, whole blood transfusion often augmented therapy in the severely injured patient. This study analyzed the safety of fresh, whole blood use in a resource-limited setting. METHODS A retrospective analysis was performed on a prospectively collected data set of US battle injuries presenting to three US Marine Corps (USMC) expeditionary surgical care facilities in Helmand Province, Afghanistan, between January 2010 and July 2012. Included in the review were patients with Injury Severity Scores (ISSs) of 15 or higher receiving blood transfusions. Univariate analyses were performed, followed by multivariable logistic regression to describe the relationship between the treatment group and posttreatment complications such as trauma-induced coagulopathy, infection, mortality, venous thromboembolism, and transfusion reaction. Propensity scores were calculated and included in multivariable models to adjust for potential bias in treatment selection. RESULTS A total of 61 patients were identified; all were male marines with a mean (SD) age of 23.5 (3.6) years. The group receiving fresh, whole blood was noted to have higher ISSs and lower blood pressure, pH, and base deficits on arrival. Traumatic coagulopathy was significantly less common in the group receiving fresh, whole blood (odds ratio, 0.01; 95% confidence interval, 0.00–0.18). Multivariable models found no other significant differences between the treatment groups. CONCLUSION The early use of fresh, whole blood in a resource-limited setting seems to confer a benefit in reducing traumatic coagulopathy. This study’s small sample size precludes further statement on the overall safety of fresh, whole blood use. LEVEL OF EVIDENCE Therapy study, level IV.

Pediatric Acute Flaccid Paralysis: Enterovirus D68–Associated Anterior Myelitis

BACKGROUNDnEnteroviral infections can cause acute flaccid paralysis secondary to anterior myelitis. Magnetic resonance imaging (MRI) is important in the diagnosis of this potentially devastating pediatric disease. Before the 2014 outbreak of Enterovirus D68 (EV-D68), the virus was considered a relatively benign disease.nnnCASE REPORTnAxa0fully immunized 8-year-old boy was brought to the emergency department complaining of a cough, headache, neck pain, and right arm pain and weakness. Deep tendon reflexes in the weak arm could not be elicited. MRI of the brain and cervical spine revealed anterior myelitis of the cervical spine. The patient was given intravenous antibiotics, acyclovir, and methylprednisolone with no initial improvement. He was then given intravenous immunoglobulin over 3xa0days with improvement in symptoms. Nasal swab polymerase chain reaction revealed EV-D68. Despite medical management, the child was left with long-term motor disability in the effected extremity. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Acute flaccid paralysis is a potential devastating complication of enteroviral infections. Extremity complaints in the clinical setting of central nervous system infection should raise concern for encephalomyelitis. MRI is extremely helpful in establishing this diagnosis. Prevalence of non-polio enteroviral paralytic events is increasing in the United States. Potential EV-D68 cases should be reported to local health departments. Emergency medicine providers should consider this complication in the child with acute, unexplained significant respiratory illness with new neurologic complaints.

A rare seizure: Tumor lysis syndrome after radiation therapy of a solid tumor

Tumor lysis syndrome (TLS) is an uncommon but life threatening condition seen in oncology patients. Due to its underlying pathophysiology, it is classically associated with hematologic malignancies following chemotherapeutic treatment. In this article, we present a case of TLS in the setting of two rare features: a solid tumor malignancy and the absence of recent chemotherapy. We briefly review risk factors and the diagnosis of this potentially fatal but treatable condition.

Acute, Proximal Aortic Dissection With Negative D-Dimer Assay and Normal Portable Chest Radiograph: A Case Report

Acute aortic dissection is one of the most devastating and time-sensitive diagnosis to consider in young adults with chest pain. Military medicine is represented by a larger proportion of 18- to 50-year-old individuals than is seen in the general medical population. Although uncommon in frequency, younger patients are more likely to suffer from proximal, aortic dissections. Chest radiographs and D-Dimer assays are used frequently as risk stratification tools, but have significant limitations in these more proximal dissections. Because of the frequency and lethality of nonspecific presentations, there exists a need for a sensitive screening tool. This case report presents a 43-year-old male with a concerning history and physical examination for aortic dissection, but a normal portable chest radiograph and a normal D-Dimer assay. It highlights the importance of clinical acumen in developing and maintaining a high clinical index of suspicion based on a Bayesian pretest probability model.

Utilization of Bedside Urogenital Ultrasound in an Austere Combat Setting: Enterovesicular Fistula Case Report

The role of bedside ultrasound by physicians with advanced ultrasound training, such as emergency medicine providers, has been clearly established in the austere setting of combat medicine. This highly mobile, noninvasive, and versatile imaging modality has a role in evaluating battle- and nonbattle-related presentations. This case report describes a U.S. Marine reporting to an austere medical facility with the chief complaint of abdominal pain. An ultrasound of the patients urinary tract revealed abnormalities that suggested right bladder wall thickening and an echo dense layer of sediment as the potential source of his discomfort. These findings supported patient transfer to a higher echelon of care. Further diagnostic testing revealed Crohns disease with an associated enterovesicular fistula.

The non-visualized appendix and secondary signs on ultrasound for pediatric appendicitis in the community hospital setting

BackgroundSecondary signs of appendicitis on ultrasound may aid with diagnosis in the setting of a non-visualized appendix (NVA). This role has not been shown in the community hospital setting.Materials and methodsAll right lower quadrant ultrasounds performed in children for clinical suspicion of appendicitis over a 5-year period in a single community hospital were evaluated. Secondary signs of inflammation including free fluid, ileus, fat stranding, abscess, and lymphadenopathy were documented. Patients were followed for 1xa0year for the primary outcome of appendicitis. These data were analyzed to determine the utility of secondary signs in the diagnosis of acute appendicitis when an NVA is reported.ResultsSix hundred and seventeen ultrasounds were reviewed; 470 of these had an NVA. Of NVAs, 47 (10%) of patients were diagnosed with appendicitis. Sensitivity and specificity of having at least one secondary were 38.3% and 80%, respectively. The positive and negative predictive values of having at least one secondary sign were 17.3% and 92%, respectively.ConclusionThese data suggest that the absence of secondary signs has a strong negative predictive value for appendicitis in the community hospital setting; however, the full utility of secondary signs may be limited in this setting.

Fatal and Non-Fatal Electrocution Injuries at U.S. Marine Corps Forward Medical Facilities During Operation Enduring Freedom and Operation Iraqi Freedom

INTRODUCTIONnDeath from electrocution is rare and generally an accidental occurrence. In contrast to civilian patterns of electrocution injury, the military work environment suffers from a greater percentage of fatal high-voltage electrocutions. This study compared U.S. and international electrocution case fatality rates to rates among deployed military personnel presenting for care at expeditionary medical care facilities. We also sought to identify potential risk factors for fatal electrocution injury among deployed military personnel.nnnMATERIALS AND METHODSnA retrospective analysis was performed on electrocution injuries presenting to U.S. Marine Corps forward deployed medical facilities in Iraq and Afghanistan between January 2004 and December 2012. Descriptive statistics were used to describe the study population and compare fatal and nonfatal electrocutions. Fatality rates were reported in cases per 1,000,000 people per year.nnnRESULTSnA total of 38 patients were identified; all were males with a mean (SD) age of 25.3 (5.3) years. Most electrocutions occurred on base (68%), whereas a smaller number (21%) occurred while conducting operations outside of the base. A majority of fatal cases (80%) occurred while outside of base on foot or vehicle mounted patrol. The rate of fatal electrocutions among U.S. Marine Corps personnel during this period was 37 per 1,000,000 people per year, 7-fold higher than the international electrocution fatality rate of 5.4 per 1,000,000 people per year and nearly three-fold above the U.S. utility and construction workers fatality rate of 14 per 1,000,000 people per year.nnnCONCLUSIONSnElectrocution injuries occurring during foot or vehicle mounted patrols seem to account for findings of higher case fatality rates among deployed military personnel than those found in international or high risk civilian occupational settings. Basic life support training for medical and nonmedical military personnel is critical to optimizing care delivered at the scene of these injuries.

Temporal artery and axillary thermometry comparison with rectal thermometry in children presenting to the ED

Background Accurate temperature readings, often obtained rectally, are an important part of the initial evaluation of pediatric patients in the Emergency Department. Temporal artery thermometry (TAT) is one way to noninvasively measure temperature. We sought to compare the accuracy of axillary and temporal artery temperatures compared to rectal. Methods This prospective study included children age 0–36 months presenting to the Emergency Department of a large military treatment facility. Rectal, axillary, and temporal artery temperatures were obtained. Test characteristics (sensitivity, specificity, NPV, PPV) were reported. The effect of cutoff values 99.9 °F, 100.4 °F, and 102.2 °F on test characteristics were also evaluated. Results The sensitivities of axillary and temporal artery thermometry to detect rectal fever is 11.5% and 61.5% respectively. Cutoff values did not significantly alter test characteristics. In this study, temporal artery thermometry was 0.2 °C lower than rectal temperature, axillary measurement was 0.9 °C below the reference standard. Mean temperature difference in the febrile group between TAT and rectal thermometry was >0.5 °C compared with a mean temperature difference 0.05 °C in afebrile patients. Conclusion The findings of our study do not support using axillary thermometry to screen pediatric patients for fever in the emergency department. TAT cannot be recommended as a rectal thermometry replacement where height and duration of fever are used in pediatric disease prediction models. TAT may have a role in screening for fever in the appropriate pediatric patient population like primary orthopedic or trauma presentations where the balance between device precision, data capture and patient comfort may favor use of TAT.