Steven G. Schauer

Low-dose ketamine vs morphine for acute pain in the ED: a randomized controlled trial☆ , ☆☆

OBJECTIVES To compare the maximum change in numeric rating scale (NRS) pain scores, in patients receiving low-dose ketamine (LDK) or morphine (MOR) for acute pain in the emergency department. METHODS We performed an institutional review board-approved, randomized, prospective, double-blinded trial at a tertiary, level 1 trauma center. A convenience sample of patients aged 18 to 59 years with acute abdominal, flank, low back, or extremity pain were enrolled. Subjects were consented and randomized to intravenous LDK (0.3mg/kg) or intravenous MOR (0.1mg/kg). Our primary outcome was the maximum change in NRS scores. A sample size of 20 subjects per group was calculated based on an 80% power to detect a 2-point change in NRS scores between treatment groups with estimated SDs of 2 and an α of .05, using a repeated-measures linear model. RESULTS Forty-five subjects were enrolled (MOR 21, LDK 24). Demographic variables and baseline NRS scores (7.1 vs 7.1) were similar. Ketamine was not superior to MOR in the maximum change of NRS pain scores, MOR=5 (confidence interval, 6.6-3.5) and LDK=4.9 (confidence interval, 5.8-4). The time to achieve maximum reduction in NRS pain scores was at 5 minutes for LDK and 100 minutes for MOR. Vital signs, adverse events, provider, and nurse satisfaction scores were similar between groups. CONCLUSION Low-dose ketamine did not produce a greater reduction in NRS pain scores compared with MOR for acute pain in the emergency department. However, LDK induced a significant analgesic effect within 5 minutes and provided a moderate reduction in pain for 2 hours.

Gabapentin Overdose in a Military Beneficiary

We report the case of a 59-year-old military beneficiary that presented to the emergency department after ingesting approximately 90 g of gabapentin immediate-release capsules during a deliberate self-harm attempt. Her serum gabapentin level was 72.8 mcg/mL approximately 3 hours after ingestion. Her renal function panel, complete blood count, and liver function panel were normal. Her urine drug screen, aspirin, ethanol, and acetaminophen level were negative. Her electrocardiogram was normal, including a normal QTc interval. Her only symptoms were nausea and mild sedation. She was admitted for observation with no sequelae noted. She was transferred to a psychiatric facility at that time for further evaluation and treatment. We report a case of gabapentin overdose that presented to the emergency department. Given the large volume ingestion with minimal morbidity, it appears that gabapentin has a wide therapeutic margin and may be safe in overdose.

A Comparison of the Incidence of Cricothyrotomy in the Deployed Setting to the Emergency Department at a Level 1 Military Trauma Center: A Descriptive Analysis

Airway management is a critical skill of emergency medicine physicians and prehospital providers. Airway compromise is the cause of 1.8% of battlefield deaths. Cricothyrotomy is a critical, lifesaving procedure. In this study, we conducted a retrospective descriptive analysis comparing the incidence of cricothyrotomies in the deployed setting versus the incidence in a military level 1 trauma center emergency department (ED) setting in San Antonio, Texas. The deployed/in-theater procedures were performed from September 2007 to July 2009. The ED procedures were performed from April 2010 to February 2012. Over these study periods, 28 cricothyrotomies were performed in the deployed setting against a backdrop of 11,492 trauma admissions compared to 4 cricothyrotomies performed during 2,741 trauma admissions in the ED setting. The per admission incidence of deployed cricothyrotomies was 0.24% versus an incidence of 0.15% in the ED (p=0.46). We conclude that this rare, lifesaving procedure is performed more often in the deployed setting than the ED, but this difference was not statistically significant.

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.

Multicenter, Prospective Study of Prehospital Administration of Analgesia in the U.S. Combat Theater of Afghanistan

Abstract Background: Published data on prehospital medical care in combat is limited, likely due to the chaotic and unpredictable nature of care under fire and difficulty in documentation There is limited data on how often analgesic agents are administered, which drug are being used, and whether there is an association with injury patterns. Methods: This study was a prospective, multicenter, observational study to determine which analgesic agents are being used prehospital and whether there is an association with injury patterns. Data was collected and recorded as casualties were brought into combat surgical hospitals in Afghanistan from October 2012 to April 2014. Onsite, trained investigators collected the data as part of a IRB approved protocol. Outcome data to 30 days was obtained from the DoD Trauma Registry (DODTR) within the Joint Trauma System. Results: During the study period 532 patient encounters available for inclusion with 378 receiving an analgesic agent (total of 541 administrations). The average age was 27 (range 21–31), 99% male, 40% were US or coalition forces. Parenteral medications used were ketamine, fentanyl, morphine, hydromorphone and ketorolac. Penetrating injuries were more likely to receive analgesic agent (89% vs 79%, p=0.0057). Blunt trauma was less likely to receive ketamine (p=0.008). Fentanyl was used more for patients with an Injury Severity Score (ISS) >15 (p=0.016). Conclusion: Patients with penetrating trauma are more likely to receive analgesic agents in the combat prehospital setting. The most common analgesic used was ketamine. Patient ISS was not associated with administration of analgesia. Patients receiving analgesia were more likely to still be hospitalized at 30 days. The prospective nature of this study supports feasibility for future, larger, more comprehensive projects.

Single Rescuer Ventilation Using a Bag Valve Mask with Removable External Handle: A Randomized Crossover Trial

Introduction Ventilation with a bag valve mask (BVM) is a challenging but critical skill for airway management in the prehospital setting. Hypothesis Tidal volumes received during single rescuer ventilation with a modified BVM with supplemental external handle will be higher than those delivered using a standard BVM among health care volunteers in a manikin model. METHODS This study was a randomized crossover trial of adult health care providers performing ventilation on a manikin. Investigators randomized participants to perform single rescuer ventilation, first using either a BVM modified by addition of a supplemental external handle or a standard unmodified BVM (Spur II BVM device; Ambu; Ballerup, Denmark). Participants performed mask placement and delivery of 10 breaths per minute for three minutes, as guided by a metronome. After a three-minute rest period, they performed ventilation using the alternative device. The primary outcome measure was mean received tidal volume as measured by the manikin (IngMar RespiTrainer model; IngMar Medical; Pittsburgh, Pennsylvania USA). Secondary outcomes included subject device preference. RESULTS Of 70 recruited participants, all completed the study. The difference in mean received tidal volume between ventilations performed using the modified BVM with external handle versus standard BVM was 20 ml (95% CI, -16 to 56 ml; P=.28). There were no significant differences in mean received tidal volume based on the order of study arm allocation. The proportion of participants preferring the modified BVM over the standard BVM was 47.1% (95% CI, 35.7 to 58.6%). CONCLUSIONS The modified BVM with added external handle did not result in greater mean received tidal volume compared to standard BVM during single rescuer ventilation in a manikin model. Reed P , Zobrist B , Casmaer M , Schauer SG , Kester N , April MD . Single rescuer ventilation using a bag valve mask with removable external handle: a randomized crossover trial. Prehosp Disaster Med. 2017;32(6):625-630.

Superior Mesenteric Artery Syndrome in a Young Military Basic Trainee

We report the case of a 19-year-old military trainee that presented to the emergency department with a 3-week history of diffuse abdominal pain, 1 to 2 hours postprandially. The timing, onset, quality, and location of her pain was concerning for intestinal angina. Her serum chemistry, hematology, and liver function tests were normal. The radiologists interpretation of the computed tomography angiogram of the abdomen was an abnormally narrow takeoff angle of the superior mesenteric artery (SMA) from the aorta near the third portion of the duodenum. She was diagnosed with SMA syndrome and received additional evaluation and treatment by her gastroenterologist and surgeon. SMA syndrome is rare and can cause bowel obstruction, perforation, gastric wall pneumatosis, and portal venous gas formation. Computed tomography angiography can be used to promptly diagnose this syndrome in the emergency department.

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% (n = 995/25,618) during the study period preceding its addition to the TCCC guidelines (2007 to 2012) to 19.8% thereafter (2013–2016, n = 515/2,604, p < 0.001). 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.

A randomized, cross-over, pilot study comparing the standard cricothyrotomy to a novel trochar-based cricothyrotomy device

[1] Eich C, Timmermann A, Russo SG, et al. A controlled rapid-sequence induction technique for infants may reduce unsafe actions and stress. Acta Anaesthesiol Scand 2009 Oct;53(9):1167–72. https://doi.org/10.1111/j.1399-6576.2009.02060.x [Epub 2009 Jul 22]. [2] Reid C, Chan L, Tweeddale M. The who, where, and what of rapid sequence intubation: prospective observational study of emergency RSI outside the operating theatre. Emerg Med J 2004;21:296–301. https://doi.org/10.1136/emj.2003.007344. [3] Weingart Scott. Podcast 92 – EMCrit Intubation Checklist. EMCrit Blog. Published on. [Available at] https://emcrit.org/emcrit/emcrit-intubation-checklist/; February 5, 2013, Accessed date: 24 August 2017. [4] Akre C, Suris JC, Belot A, Couret M, Dang TT, Duquesne A, et al. Building a transitional care checklist in rheumatology: a Delphi-like survey. Joint Bone Spine 2017 Sep 28 [pii: S1297-319X(17)30162–8]. [5] Desnoyer A, Blanc AL, Pourcher V, Besson M, Fonzo-Christe C, Desmeules J, et al. PIMCheck: development of an international prescription-screening checklist designed by aDelphimethod for internal medicine patients. BMJ Open 2017 Jul 31;7(7):e016070. [6] Thomassen Oyvind, Brattebø Guttorm, Søfteland Eirik, Lossius Hans, Heltne JonKenneth. The effect of a simple checklist on frequent pre-induction deficiencies. Acta Anaesthesiol Scand 2010;54:1179–84. https://doi.org/10.1111/j.1399-6576. 2010.02302.x. [7] Gawande A. The checklist manifesto: How to get things right. New York, NY: Metropolitan Books-Henry Holt & Co; 2009. https://doi.org/10.1007/s12663-009-0074-z. [8] Bowie Paul, Skinner Joe, deWet Carl. Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes. BMC Health Serv Res 2013;13:50. [9] Braithwaite J, Westbrook MT, Mallock NA, Travaglia JF, Iedema RA. Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. Qual Saf Health Care 2006 Dec;15(6):393–9. [10] http://www.businessdictionary.com/definition/gap-analysis. htmlBusinessdictionary.com. [Accessed on August 24th 2017].

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.