- Email: [email protected]
347
Research Forum Abstracts this may be one explanation for the higher mortality of L2TC for patients taken URGENTLY or DELAYED to OR.
347
United States Air Force Critical Care Air Transport Teams in Operation Iraqi Freedom: A Prospective Study
Mason PE, Eadie JS, Holder AD/Wilford Hall Medical Center and The San Antonio Uniformed Services Health Education Consortium, Lackland AFB, TX
Background: In the mid-1990’s the United States Air Force created Critical Care Air Transport Teams (CCATT) to support the new military doctrine of forward resuscitation and early evacuation of battlefield casualties. Operation Iraqi Freedom (OIF) represents the first large scale test of the CCATT concept. The feature of the CCATT that distinguishes it from civilian aeromedical teams is the ability to transport multiple unstable patients, many of whom have only received temporizing care, over long distances. The teams consist of a physician, a critical care nurse, and a respiratory therapist. Study Objective: The purpose of this study is to provide a characterization of the missions flown by CCATT’S stationed at a forward location in support of OIF. Methods: This is a prospective study of all patients transported by three emergency physician led teams flying from a major air base in Iraq to Landstuhl Regional Medical Center, Germany. Standardized forms were used to collect data over a six month period. Results: Seventy-two consecutive patients were enrolled. One patient was removed from the aircraft prior to takeoff and was excluded from analysis. The 71 study patients were transported on 34 flights, 27 of which were non-stop from Iraq to Germany. The mean flight time was 5hr 10min [Range 4hr 40min - 7hr 0min] for non-stop flights and 9hr 10min [Range 7hr 41min - 11hr 30min] for those including an intermediate stop. The maximum number of patients carried on one mission was five and the maximum number of mechanically ventilated patients on a mission was three. Battle injuries accounted for 42 patients [59%], medical conditions for 24 [34%] and non-battle injuries for 5 [7%]. In medical patients the most common diagnoses were chest pain or myocardial infarction in 12 [50%] patients, intracranial hemorrhage in 3 [13%] and pneumonia in 3 [13%]. Thirty-five [83%] patients wounded in battle had more than one diagnosis. The most common of these were lower extremity soft tissue wounds in 23 [55%] patients, lower extremity fractures in 20 [48%] and vascular injuries in 14 [33%]. For patients wounded in battle, the mean time from injury until takeoff was 28hr 30min [Range 8hr 20min - 68hr 20min]. Between the times of injury and takeoff, 93% of these patients had at least one surgical procedure and 88% had at least one inter-facility transfer by helicopter. Forty of the 71 [56%] patients were mechanically ventilated, 41 [58%] had central venous catheters and 46 [65%] had arterial pressure catheters. Intracranial pressure monitors were present in 7 [10%] patients. Vasoactive agents were needed in fourteen [20%] patients, and 4 [6%] patients received blood products. The most common in-flight complication was hypotension which occurred in 15 [21%] of patients. Conclusions: United States Air Force CCATT’S rapidly evacuate patients who are injured or become critically ill while serving in Iraq. These patients are commonly mechanically ventilated, frequently require vasopressors and often need continuous invasive monitoring. One-third of them have medical diagnoses. The breadth of the emergency physician skill set is uniquely suited to performing this mission.
348
Intact Automotive Glass Associated with Absence of Cervical Spine Injury
DeFlorio P/Wilford Hall Medical Center, Lackland AFB, TX
Study Objectives: Evaluation of the motor-vehicle collision (MVC) victim’s cervical spine is of critical importance. Despite the implementation of validated clinical decision-making rules (such as the NEXUS criteria), many MVC victims continue to undergo unnecessary c-spine evaluations, which involve significant cost, discomfort, and radiation exposure. We assessed the ability of a single field test to exclude c-spine injury. We hypothesized that if the forces involved in an MVC are not sufficient to damage any of the automobile’s windows– or greenhouse–then these forces would not cause significant c-spine injury, prospectively defined as an Abbreviated Injury Score of 2 or greater.
S104 Annals of Emergency Medicine
Methods: Using a nested retrospective cohort format, we studied data from the National Highway Traffic Safety Administration’s National Automotive Sampling System’s Crashworthiness Data System from 1993-2003. Before beginning, we chose to examine only belted front seat occupants, aged 16-60 years, who did not have an airbag deploy, and who were in cars with raised windows. We then compared the incidence of c-spine injuries in subjects with intact and non-intact greenhouses. Results: We examined a total of 95,365 front seat occupants, with 646 excluded due to unknown air bag status. Of that total, 23,246 met enrollment criteria and were studied. Of those, 12,231 had non-intact greenhouses, and 215 of these occupants had significant c-spine injuries. Of the remaining 11,015 occupants in MVC’s with intact greenhouses, only 21 were injured. Sensitivity was 0.91 (95% CI 0.87-0.94), specificity was 0.48 (95% CI 0.47-0.48), and negative predictive value (NPV) was 99.8% (95% CI 99.7-99.9). Conclusion: While not perfect, using an intact greenhouse to predict the absence of significant c-spine injury may prove useful; this study’s NPV equals that of the NEXUS criteria. Prospective validation is needed before clinical application is appropriate.
349
Delta GCS: A New Predictor of Outcome in Blunt Trauma?
Flagel B, Irvine C, Sherifali S/St. John Hospital and Medical Center, Detroit, MI
Study Objectives: The Glasgow Coma Scale (GCS) has been an integral tool in the quantitative evaluation of neurological status of head trauma patients since the 1970’s. While emergency department-based prediction models using numerous physiologic and or anatomic variables exist, none have examined the usefulness of a simple and easily calculated variable: the change in the Glasgow Coma Scale score from scene to emergency department (ED). We sought to evaluate the predictive potential of delta GCS (defined as ED GCS score minus scene GCS score) for mortality and severity of injury in adult blunt trauma patients with scene GCS 10-15. Methods: The National Trauma Data Bank (NTDB), version 5.0, was queried using Microsoft Access 2003 for patients with these inclusion criteria: age ⬎ or ⫽18 years, scene GCS 10-15, “legitimate” (not intubated or sedated) ED GCS score, and blunt trauma mechanism. Variables extracted from the database included: scene GCS score, ED GCS score, age, injury severity score (ISS), and discharge status (“dead” or “alive). Data was analyzed using Microsoft Excel 2003. Results: There were 74,848 patients extracted from the NTDB meeting inclusion criteria. The average scene GCS score was 14.5, and the average ED GCS score was 14.6. Delta GCS ranged from ⫺12 to ⫹5. Of the patients meeting inclusion criteria, 25.7% of the patients had a change in their GCS (scene to ED). For delta GCS 0 to ⫺3, a substantial correlation with mortality was found with rate of 1.5% for delta GCS ⫽ 0, 3.8% for delta GCS ⫽ ⫺1, 6.3% for delta GCS ⫽ ⫺2, and 10.8% for delta GCS ⫽ ⫺3 (r2 ⫽0.9713). The mortality rate for delta GCS ⫺3 to ⫺12 also increased linearly but did not have as high a correlation rate (r2 ⫽ 0.7558). The correlation of delta GCS with ISS was also significant for delta GCS ⫽ 0, ISS ⫽ 9.2, delta GCS ⫽ ⫺1, ISS⫽12.6, for delta GCS ⫽ ⫺2, ISS⫽15.0, for delta GCS ⫽ ⫺3, ISS⫽16.6 (r2⫽0.9766). Conclusion: In adult blunt trauma patients with a scene GCS score between 10 and 15, there is a linear relationship in patients with delta GCS score of 0 to ⫺3 with a substantially increased mortality rate from 1.5% to 10.8%. There is also a linear relationship in patients with delta GCS score of 0 to ⫺3 with a substantially increased injury severity score from 9.2 to 16.9. The delta GCS score may be a simple and useful predictor for injury severity and mortality in adult blunt trauma patients with initial GCS of 10-15.
350
Metallic Foreign Body Removal with Ultrasound Guidance
Manson W, Ryan JG, Ladner H, Gupta S/New York Hospital Queens, Flushing, NY
Study Objectives: We compared the cosmetic outcome of metallic foreign body removal by emergency medicine residents using ultrasound guidance and conventional radiography. Methods: This blinded, randomized in-vitro study performed at an academic emergency department in New York City evaluated the ability of emergency medicine residents to remove metallic pins imbedded in pig feet. Each participant was given a brief lecture covering the use of ultrasonography in locating and
Volume , . : October
347
United States Air Force Critical Care Air Transport Teams in Operation Iraqi Freedom: A Prospective Study
Mason PE, Eadie JS, Holder AD/Wilford Hall Medical Center and The San Antonio Uniformed Services Health Education Consortium, Lackland AFB, TX
Background: In the mid-1990’s the United States Air Force created Critical Care Air Transport Teams (CCATT) to support the new military doctrine of forward resuscitation and early evacuation of battlefield casualties. Operation Iraqi Freedom (OIF) represents the first large scale test of the CCATT concept. The feature of the CCATT that distinguishes it from civilian aeromedical teams is the ability to transport multiple unstable patients, many of whom have only received temporizing care, over long distances. The teams consist of a physician, a critical care nurse, and a respiratory therapist. Study Objective: The purpose of this study is to provide a characterization of the missions flown by CCATT’S stationed at a forward location in support of OIF. Methods: This is a prospective study of all patients transported by three emergency physician led teams flying from a major air base in Iraq to Landstuhl Regional Medical Center, Germany. Standardized forms were used to collect data over a six month period. Results: Seventy-two consecutive patients were enrolled. One patient was removed from the aircraft prior to takeoff and was excluded from analysis. The 71 study patients were transported on 34 flights, 27 of which were non-stop from Iraq to Germany. The mean flight time was 5hr 10min [Range 4hr 40min - 7hr 0min] for non-stop flights and 9hr 10min [Range 7hr 41min - 11hr 30min] for those including an intermediate stop. The maximum number of patients carried on one mission was five and the maximum number of mechanically ventilated patients on a mission was three. Battle injuries accounted for 42 patients [59%], medical conditions for 24 [34%] and non-battle injuries for 5 [7%]. In medical patients the most common diagnoses were chest pain or myocardial infarction in 12 [50%] patients, intracranial hemorrhage in 3 [13%] and pneumonia in 3 [13%]. Thirty-five [83%] patients wounded in battle had more than one diagnosis. The most common of these were lower extremity soft tissue wounds in 23 [55%] patients, lower extremity fractures in 20 [48%] and vascular injuries in 14 [33%]. For patients wounded in battle, the mean time from injury until takeoff was 28hr 30min [Range 8hr 20min - 68hr 20min]. Between the times of injury and takeoff, 93% of these patients had at least one surgical procedure and 88% had at least one inter-facility transfer by helicopter. Forty of the 71 [56%] patients were mechanically ventilated, 41 [58%] had central venous catheters and 46 [65%] had arterial pressure catheters. Intracranial pressure monitors were present in 7 [10%] patients. Vasoactive agents were needed in fourteen [20%] patients, and 4 [6%] patients received blood products. The most common in-flight complication was hypotension which occurred in 15 [21%] of patients. Conclusions: United States Air Force CCATT’S rapidly evacuate patients who are injured or become critically ill while serving in Iraq. These patients are commonly mechanically ventilated, frequently require vasopressors and often need continuous invasive monitoring. One-third of them have medical diagnoses. The breadth of the emergency physician skill set is uniquely suited to performing this mission.
348
Intact Automotive Glass Associated with Absence of Cervical Spine Injury
DeFlorio P/Wilford Hall Medical Center, Lackland AFB, TX
Study Objectives: Evaluation of the motor-vehicle collision (MVC) victim’s cervical spine is of critical importance. Despite the implementation of validated clinical decision-making rules (such as the NEXUS criteria), many MVC victims continue to undergo unnecessary c-spine evaluations, which involve significant cost, discomfort, and radiation exposure. We assessed the ability of a single field test to exclude c-spine injury. We hypothesized that if the forces involved in an MVC are not sufficient to damage any of the automobile’s windows– or greenhouse–then these forces would not cause significant c-spine injury, prospectively defined as an Abbreviated Injury Score of 2 or greater.
S104 Annals of Emergency Medicine
Methods: Using a nested retrospective cohort format, we studied data from the National Highway Traffic Safety Administration’s National Automotive Sampling System’s Crashworthiness Data System from 1993-2003. Before beginning, we chose to examine only belted front seat occupants, aged 16-60 years, who did not have an airbag deploy, and who were in cars with raised windows. We then compared the incidence of c-spine injuries in subjects with intact and non-intact greenhouses. Results: We examined a total of 95,365 front seat occupants, with 646 excluded due to unknown air bag status. Of that total, 23,246 met enrollment criteria and were studied. Of those, 12,231 had non-intact greenhouses, and 215 of these occupants had significant c-spine injuries. Of the remaining 11,015 occupants in MVC’s with intact greenhouses, only 21 were injured. Sensitivity was 0.91 (95% CI 0.87-0.94), specificity was 0.48 (95% CI 0.47-0.48), and negative predictive value (NPV) was 99.8% (95% CI 99.7-99.9). Conclusion: While not perfect, using an intact greenhouse to predict the absence of significant c-spine injury may prove useful; this study’s NPV equals that of the NEXUS criteria. Prospective validation is needed before clinical application is appropriate.
349
Delta GCS: A New Predictor of Outcome in Blunt Trauma?
Flagel B, Irvine C, Sherifali S/St. John Hospital and Medical Center, Detroit, MI
Study Objectives: The Glasgow Coma Scale (GCS) has been an integral tool in the quantitative evaluation of neurological status of head trauma patients since the 1970’s. While emergency department-based prediction models using numerous physiologic and or anatomic variables exist, none have examined the usefulness of a simple and easily calculated variable: the change in the Glasgow Coma Scale score from scene to emergency department (ED). We sought to evaluate the predictive potential of delta GCS (defined as ED GCS score minus scene GCS score) for mortality and severity of injury in adult blunt trauma patients with scene GCS 10-15. Methods: The National Trauma Data Bank (NTDB), version 5.0, was queried using Microsoft Access 2003 for patients with these inclusion criteria: age ⬎ or ⫽18 years, scene GCS 10-15, “legitimate” (not intubated or sedated) ED GCS score, and blunt trauma mechanism. Variables extracted from the database included: scene GCS score, ED GCS score, age, injury severity score (ISS), and discharge status (“dead” or “alive). Data was analyzed using Microsoft Excel 2003. Results: There were 74,848 patients extracted from the NTDB meeting inclusion criteria. The average scene GCS score was 14.5, and the average ED GCS score was 14.6. Delta GCS ranged from ⫺12 to ⫹5. Of the patients meeting inclusion criteria, 25.7% of the patients had a change in their GCS (scene to ED). For delta GCS 0 to ⫺3, a substantial correlation with mortality was found with rate of 1.5% for delta GCS ⫽ 0, 3.8% for delta GCS ⫽ ⫺1, 6.3% for delta GCS ⫽ ⫺2, and 10.8% for delta GCS ⫽ ⫺3 (r2 ⫽0.9713). The mortality rate for delta GCS ⫺3 to ⫺12 also increased linearly but did not have as high a correlation rate (r2 ⫽ 0.7558). The correlation of delta GCS with ISS was also significant for delta GCS ⫽ 0, ISS ⫽ 9.2, delta GCS ⫽ ⫺1, ISS⫽12.6, for delta GCS ⫽ ⫺2, ISS⫽15.0, for delta GCS ⫽ ⫺3, ISS⫽16.6 (r2⫽0.9766). Conclusion: In adult blunt trauma patients with a scene GCS score between 10 and 15, there is a linear relationship in patients with delta GCS score of 0 to ⫺3 with a substantially increased mortality rate from 1.5% to 10.8%. There is also a linear relationship in patients with delta GCS score of 0 to ⫺3 with a substantially increased injury severity score from 9.2 to 16.9. The delta GCS score may be a simple and useful predictor for injury severity and mortality in adult blunt trauma patients with initial GCS of 10-15.
350
Metallic Foreign Body Removal with Ultrasound Guidance
Manson W, Ryan JG, Ladner H, Gupta S/New York Hospital Queens, Flushing, NY
Study Objectives: We compared the cosmetic outcome of metallic foreign body removal by emergency medicine residents using ultrasound guidance and conventional radiography. Methods: This blinded, randomized in-vitro study performed at an academic emergency department in New York City evaluated the ability of emergency medicine residents to remove metallic pins imbedded in pig feet. Each participant was given a brief lecture covering the use of ultrasonography in locating and
Volume , . : October