Michael J Leicht

Hospital-based rotorcraft aeromedical emergency care services and trauma mortality: A multicenter study

A group of 1,273 blunt trauma patients who were treated and transported from the site of injury by seven different hospital-based rotorcraft aeromedical emergency care services were studied using a methodology based on injury severity designed to predict the mortality of such patients. The methodology predicted that 241 patients should have died; 191 patients did die. This 21% reduction in expected mortality was highly significant ( P P

Non-traumatic headache in the emergency department

Four hundred eighty-five patients between the ages of 15 and 89 made 631 visits to a medical center emergency department with a chief complaint of headache or head pain during a 12-month period from May 1977 to April 1978, accounting for 1.6% of all patient visits. One hundred ninety-three (40%) had subsequent follow-up data available for review. Muscle contraction-tension headache and migraine headache were the most common diagnoses, accounting for 54.5% of all patients. The female/male distribution was 3:2 for the entire group. Five percent of the overall group had serious neurological conditions. Analysis of the emergency department evaluations, results of follow-up, and reviews of other recent series are reported. Based on current literature, recommendations for the detailed laboratory evaluation of the suspicious headache are described.

Physician-staffed helicopter scene response from a rural trauma center

One hundred ten consecutive trauma patients transported directly from the scene of injury by a hospital-based helicopter emergency medical service were reviewed. These patients were injured in the rural areas of central and northeastern Pennsylvania and were transported to a level I trauma center. The medical flight team consisted of an emergency physician and a registered nurse. The average round-trip flight distance was 44 miles. The overall mortality was 21.8%. Eighty-eight percent of the injuries were motor vehicle related. Only two patients received advanced life support prior to arrival of the helicopter. Forty-five percent of patients required major intervention by the medical flight team at the scene. The average scene time was 33.6 minutes for transported patients. Sixteen patients required extrication after the arrival of the flight crew and had significantly prolonged scene times averaging 61.8 minutes (P less than .001). Patient entrapment was the most important contributing factor in on-scene ground time.

Cricoarytenoid arthritis: A cause of laryngeal obstruction

Cricoarytenoid arthritis, principally as a result of long-standing rheumatoid arthritis, is a disorder that may present to the emergency physician with a number of symptoms and signs referable to the larynx. The presentation of this disorder as acute laryngeal obstruction and collapse is uncommon. It is important to recognize early cricoarytenoid joint involvement and not mistakenly diagnose mild cases as asthma or psychoneurosis. The use of steroids in mild cases has been beneficial at times, but progressive airway obstruction and fatalities have occurred during their administration.

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.

Lidocaine toxicity following subcutaneous administration

A case of a 2-year-old girl who survived grand mal seizures secondary to toxicity from massive subcutaneous administration of lidocaine is presented. She was treated with intravenous diazepam and was intubated. After 24 hours of observation she was discharged, and there have been no sequelae or recurrence of seizure activity during ten months follow up. Central nervous system, cardiac, and hematologic effects of lidocaine toxicity are discussed. Drug interactions that may potentiate lidocaine toxicity are listed.

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.

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

OBJECTIVE The 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. METHODS This 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. RESULTS A 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. CONCLUSION Evacuation 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.

Degloving injury of the mandible

A young boy fell off his bicycle, striking his face on the pavement. On arrival in the emergency department, his only apparent injuries were facial abrasions; however, further examination of his oral cavity revealed that the soft tissues overlying the mandible had been stripped from the bone. Oral Surgery was consulted and the patient was taken to the operating room, where debridement and primary closure of the wound was performed under general anesthesia. Soft tissue injuries that result from a shearing or stripping force are termed degloving injuries, which are described best in relation to injuries of the hand, although other body parts can be involved. We report the case of a degloving injury of the mandible, an injury that has not been reported previously.

Air medical tracheal intubation: Establishing a threshold for this QA indicator

Endotracheal intubation is a critical skill necessary in a number of situations encountered by air medical personnel. The purpose of this study was to establish a threshold for the quality assurance indicator of successful tracheal intubation in a physician-staffed air medical system. The records of all patients transported by a physician-staffed air medical system over a 36-month period were reviewed. One hundred and forty-three patients had endotracheal intubation attempted. Blind nasotracheal intubation attempts were successful in 71% of those in whom it was attempted, while the overall intubation success rate was 92%. Based on this study and the existing literature, a threshold of 90% is recommended for the quality assurance indicator of successful tracheal intubation in physician-staffed air medical systems.