Ketamine Use in Operation Enduring Freedom

ABSTRACT Introduction Ketamine is a dissociative anesthetic increasingly used in the prehospital and battlefield environment. As an analgesic, it has been shown to have comparable effects to opioids. In 2012, the Defense Health Board advised the Joint Trauma System to update the Tactical Combat Casualty Care Guidelines to include ketamine as an acceptable first line agent for pain control on the battlefield. The goal of this study was to investigate trends in the use of ketamine during Operation Enduring Freedom (OEF) and Operation Freedom’s Sentinel (OFS) during the years 2011-2016. Materials and Methods A retrospective review of Department of Defense Trauma Registry (DoDTR) data was performed for all patients receiving ketamine during OEF/OFS in 2011-2016. Prevalence of ketamine use, absolute use, mechanism of injury, demographics, injury severity score, provider type, and co-administration rates of various medications and blood products were evaluated. Results Total number of administrations during the study period was 866. Ketamine administration during OEF/OFS increased during the years 2011-2013 (28 patient administrations in 2011, 264 administrations in 2012, and 389 administrations in 2013). A decline in absolute use was noted from 2014 to 2016 (98 administrations in 2014, 41 administrations in 2015, and 46 administrations in 2016). The frequency of battlefield ketamine use increased from 0.4% to 11.3% for combat injuries sustained in OEF/OFS from 2011 to 2016. Explosives (51%) and penetrating trauma (39%) were the most common pattern of injury in which ketamine was administered. Ketamine was co-administered with fentanyl (34.4%), morphine (26.2%), midazolam (23.1%), tranexamic acid (12.3%), plasma (10.3%), and packed red blood cells (18.5%). Conclusions This study demonstrates increasing use of ketamine by the U.S. Military on the battlefield and effectiveness of clinical practice guidelines in influencing practice patterns.

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The Triage of Injured Patients: Mechanism of Injury, Regardless of Injury Severity, Determines Hospital Destination

The American Surgeon ◽

10.1177/000313481608200422 ◽

2016 ◽

Vol 82 (4) ◽

pp. 356-361 ◽

Cited By ~ 7

Author(s):

Kristan Staudenmayer ◽

N. Ewen Wang ◽

Thomas G. Weiser ◽

Paul Maggio ◽

Robert C. Mackersie ◽

...

Keyword(s):

Injury Severity ◽

Hospital Admissions ◽

Motor Vehicle ◽

Health Planning ◽

Trauma System ◽

Penetrating Trauma ◽

Emergency Department Visits ◽

Three Dimensions ◽

Mechanism Of Injury ◽

Injured Patients

The target rate for trauma undertriage is <5 per cent, but rates are as high as 30 to 40 per cent in many trauma systems. Wehypothesized that high undertriage rates were duetothe tendencyto undertriage injured elderly patients and a growing elderly population. We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database over a 5-year period. All hospital admissions and emergency department visits associated with injury were longitudinally linked. The primary outcome was triage pattern. Triage patterns were stratified across three dimensions: age, mechanism of injury, and access to care. A total of 60,182 severely injured patients were included in the analysis. Fall-related injuries were frequently undertriaged compared with injuries from motor vehicle collisions (MVCs) and penetrating trauma (52% vs 12% and 10%, respectively). This pattern was true for all age groups. Conversely, MVCs and penetrating traumas were associated with high rates of overtriage (>70% for both). In conclusion, in contrast to our hypothesis, we found that triage is largely determined by mechanism of injury regardless of injury severity. High rates of undertriage are largely due to the undertriage of fall-related injuries, which occurs in both younger and older adults. Patients injured after MVCs and penetrating trauma victims are brought to trauma centers regardless of injury severity, resulting in high rates of overtriage. These findings suggest an opportunity to improve trauma system performance.

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The Pennsylvania Trauma Outcomes Study Risk-Adjusted Mortality Model: Results of a Statewide Benchmarking Program

The American Surgeon ◽

10.1177/000313481708300516 ◽

2017 ◽

Vol 83 (5) ◽

pp. 445-452 ◽

Cited By ~ 5

Author(s):

Douglas J. Wiebe ◽

Daniel N. Holena ◽

M. Kit Delgado ◽

Nathan Mcwilliams ◽

Juliet Altenburg ◽

...

Keyword(s):

Quality Improvement ◽

Injury Severity ◽

Trauma System ◽

Area Under The Curve ◽

Penetrating Trauma ◽

Quality Improvement Program ◽

Trauma Centers ◽

Improvement Program ◽

Trauma Outcomes ◽

Expected Mortality

Trauma centers need objective feedback on performance to inform quality improvement efforts. The Trauma Quality Improvement Program recently published recommended methodology for case mix adjustment and benchmarking performance. We tested the feasibility of applying this methodology to develop risk-adjusted mortality models for a statewide trauma system. We performed a retrospective cohort study of patients ≥16 years old at Pennsylvania trauma centers from 2011 to 2013 (n = 100,278). Our main outcome measure was observed-to-expected mortality ratios (overall and within blunt, penetrating, multisystem, isolated head, and geriatric subgroups). Patient demographic variables, physiology, mechanism of injury, transfer status, injury severity, and pre-existing conditions were included as predictor variables. The statistical model had excellent discrimination (area under the curve = 0.94). Funnel plots of observed-to-expected identified five centers with lower than expected mortality and two centers with higher than expected mortality. No centers were outliers for management of penetrating trauma, but five centers had lower and three had higher than expected mortality for blunt trauma. It is feasible to use Trauma Quality Improvement Program methodology to develop risk-adjusted models for statewide trauma systems. Even with smaller numbers of trauma centers that are available in national datasets, it is possible to identify high and low outliers in performance.

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Structured and Systematic Team and Procedure Training in Severe Trauma: Going from ‘Zero to Hero’ for a Time-Critical, Low-Volume Emergency Procedure Over Three Time Periods

World Journal of Surgery ◽

10.1007/s00268-021-05980-1 ◽

2021 ◽

Vol 45 (5) ◽

pp. 1340-1348

Author(s):

Maryam Meshkinfamfard ◽

Jon Kristian Narvestad ◽

Johannes Wiik Larsen ◽

Arezo Kanani ◽

Jørgen Vennesland ◽

...

Keyword(s):

Injury Severity ◽

Trauma System ◽

Severe Trauma ◽

Emergency Procedure ◽

Emergency Thoracotomy ◽

Severity Scores ◽

Time Periods ◽

Low Volume ◽

Time Critical ◽

Over Time

Abstract Background Resuscitative emergency thoracotomy is a potential life-saving procedure but is rarely performed outside of busy trauma centers. Yet the intervention cannot be deferred nor centralized for critically injured patients presenting in extremis. Low-volume experience may be mitigated by structured training. The aim of this study was to describe concurrent development of training and simulation in a trauma system and associated effect on one time-critical emergency procedure on patient outcome. Methods An observational cohort study split into 3 arbitrary time-phases of trauma system development referred to as ‘early’, ‘developing’ and ‘mature’ time-periods. Core characteristics of the system is described for each phase and concurrent outcomes for all consecutive emergency thoracotomies described with focus on patient characteristics and outcome analyzed for trends in time. Results Over the study period, a total of 36 emergency thoracotomies were performed, of which 5 survived (13.9%). The “early” phase had no survivors (0/10), with 2 of 13 (15%) and 3 of 13 (23%) surviving in the development and mature phase, respectively. A decline in ‘elderly’ (>55 years) patients who had emergency thoracotomy occurred with each time period (from 50%, 31% to 7.7%, respectively). The gender distribution and the injury severity scores on admission remained unchanged, while the rate of patients with signs on life (SOL) increased over time. Conclusion The improvement over time in survival for one time-critical emergency procedure may be attributed to structured implementation of team and procedure training. The findings may be transferred to other low-volume regions for improved trauma care.

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186 Acute Kidney Injury in Skeletal Trauma Admissions to Intensive Care: An Under-Estimated Complication

British Journal of Surgery ◽

10.1093/bjs/znab134.537 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

O Brown ◽

T Crisp ◽

M Flatman ◽

C Hing

Keyword(s):

Acute Kidney Injury ◽

Intensive Care ◽

Injury Severity ◽

Penetrating Trauma ◽

Kidney Injury ◽

Long Bone ◽

Trauma Patients ◽

Skeletal Trauma ◽

Body Regions ◽

Intensive Care Stay

Abstract Introduction Acute kidney injury (AKI) is associated with prolonged admission and 3.5 times increased mortality for trauma patients requiring intensive care (ICU) treatment. Blunt trauma confers greater risk of AKI than penetrating trauma, potentially related to long bone fracture. The relationship between skeletal trauma and AKI in ICU has not previously been investigated. Method Retrospective data was analysed from 202 consecutive adult patients admitted to ICU with skeletal trauma from 01/06/2018 to 01/06/2019. AKI was defined by creatinine rise >1.5 times baseline. Results AKI was found in 70/202 (34.65%) patients aged 16-99 years, 138 males and 64 females. Mean limb Abbreviated Injury Scale (AIS) was significantly higher in AKI (AIS= 2.57 (SD 0.53) versus non-AKI AIS=2.38 (SD 0.61), p = 0.027). Other body regions and total Injury Severity Score (ISS) were non-significant. AKI was associated with a significantly worse Glasgow Outcome Score (AKI 3.28 (SD 1.52) versus 4.02 (SD 1.08) p < 0.001), increased intensive care stay (AKI 7.03 (SD 8.30) days versus non-AKI 3.8 (SD 4.1) days p < 0.001) and increased 30-day mortality (AKI 18/70 (25.71%) versus non-AKI 10/132 (7.58%) p < 0.001) Conclusions Skeletal trauma patients have a high incidence of AKI, which was significantly correlated with severity of skeletal limb trauma but not overall ISS.

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A Descriptive Analysis of Traction Splint Utilization and IV Analgesia by Emergency Medical Services

Prehospital and Disaster Medicine ◽

10.1017/s1049023x17006859 ◽

2017 ◽

Vol 32 (6) ◽

pp. 631-635 ◽

Cited By ~ 2

Author(s):

Joshua Nackenson ◽

Amado A. Baez ◽

Jonathan P. Meizoso

Keyword(s):

Emergency Medical Services ◽

Blunt Trauma ◽

Injury Severity ◽

Femur Fracture ◽

Descriptive Analysis ◽

Penetrating Trauma ◽

Physical Exam ◽

Medical Services ◽

Prehospital Treatment ◽

Emergency Medical

AbstractStudy ObjectivesTraction splinting has been the prehospital treatment of midshaft femur fracture as early as the battlefield of the First World War (1914-1918). This study is the assessment of these injuries and the utilization of a traction splint (TS) in blunt and penetrating trauma, as well as intravenous (IV) analgesia utilization by Emergency Medical Services (EMS) in Miami, Florida (USA).MethodsThis is a retrospective study of patients who sustained a midshaft femur fracture in the absence of multiple other severe injuries or severe physiologic derangement, as defined by an injury severity score (ISS) <20 and a triage revised trauma score (T-RTS)≥10, who presented to an urban, Level 1 trauma center between September 2008 and September 2013. The EMS patient care reports were assessed for physical exam findings and treatment modality. Data were analyzed descriptively and statistical differences were assessed using odds ratios and Z-score with significance set at P≤.05.ResultsThere were 170 patients studied in the cohort. The most common physical exam finding was a deformity +/- shortening and rotation in 136 patients (80.0%), followed by gunshot wound (GSW) in 22 patients (13.0%), pain or tenderness in four patients (2.4%), and no findings consistent with femur fracture in three patients (1.7%). The population was dichotomized between trauma type: blunt versus penetrating. Of 134 blunt trauma patients, 50 (37.0%) were immobilized in traction, and of the 36 penetrating trauma victims, one (2.7%) was immobilized in traction. Statistically significant differences were found in the application of a TS in blunt trauma when compared to penetrating trauma (OR=20.83; 95% CI, 2.77-156.8; P <.001). Intravenous analgesia was administered to treat pain in only 35 (22.0%) of the patients who had obtainable IV access. Of these patients, victims of blunt trauma were more likely to receive IV analgesia (OR=6.23; 95% CI, 1.42-27.41; P=.0067).ConclusionAlthough signs of femur fracture are recognized in the majority of cases of midshaft femur fracture, only 30% of patients were immobilized using a TS. Statistically significant differences were found in the utilization of a TS and IV analgesia administration in the setting of blunt trauma when compared to penetrating trauma.NackensonJ, BaezAA, MeizosoJP. A descriptive analysis of traction splint utilization and IV analgesia by Emergency Medical Services.Prehosp Disaster Med. 2017;32(6):631–635.

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Trauma

Paediatric Surgery ◽

10.1093/med/9780198798699.003.0010 ◽

2020 ◽

pp. 433-448

Keyword(s):

Injury Severity ◽

Splenic Injury ◽

Damage Control ◽

Penetrating Trauma ◽

Damage Control Surgery ◽

Organ Injury ◽

Blast Injuries ◽

Compression Injury ◽

Specific Organ ◽

Thoracic And Abdominal

This chapter covers trauma and the mechanisms of injury (blunt, penetrating, and burns or scalds), grading of injury severity, and initial management. The incidence, clinical features, and management of thoracic and abdominal trauma, including specific organ injury, and blast injuries are all described. The concepts of damage control resuscitation (DCR) and damage control surgery (DCS); organ injury scaling (OIS), blunt and penetrating trauma, compression injury to the chest; pneumothorax; liver injury; splenic injury: and intestinal injury are detailed. The role of contrast-enhanced ultrasound (CEUS) and endoscopic retrograde cholangiopancreatography (ERCP) is emphasized in liver and splenic injury. Blast injuries affecting children are also reviewed.

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Trauma and burns

Oxford Desk Reference: Critical Care ◽

10.1093/med/9780198723561.003.0029 ◽

2019 ◽

pp. 523-543

Author(s):

Carl Waldmann ◽

Andrew Rhodes ◽

Neil Soni ◽

Jonathan Handy

Keyword(s):

Multiple Trauma ◽

Injury Severity ◽

Fluid Management ◽

Specific Treatment ◽

Penetrating Trauma ◽

Pelvic Trauma ◽

Intensive Care Unit Care ◽

Need For Treatment ◽

Tertiary Survey ◽

Rapid Transfer

This chapter discusses trauma and burns and includes discussion on initial management of major trauma (ABCDE), head injury (both primary and secondary, but also clinical management, general intensive care unit care, and specific treatment of raised intracranial pressure), spinal trauma, chest trauma, pelvic trauma, the fluid management of burns and the general management of burns, and penetrating trauma. The concepts of permissive hypotension, ongoing resuscitation, and injury severity scores are discussed, together with the importance of the tertiary survey. The need for treatment in a centre that can deal with all aspects of multiple trauma and the rapid transfer to such a centre is emphasized. Burns treatment includes the effect of inhalational injury to the airway. The need for treatment in a centre that can deal with all aspects of multiple trauma and the rapid transfer to such a centre is emphasized.

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Is Outcome after Blunt Splenic Injury in Adults Better in High-Volume Trauma Centers?

The American Surgeon ◽

10.1177/000313480507101108 ◽

2005 ◽

Vol 71 (11) ◽

pp. 942-949 ◽

Cited By ~ 3

Author(s):

Brian G. Harbrecht ◽

Mazen S. Zenati ◽

Louis H. Alarcon ◽

Juan B. Ochoa ◽

Juan C. Puyana ◽

...

Keyword(s):

Emergency Department ◽

Trauma Center ◽

Injury Severity ◽

Trauma System ◽

High Volume ◽

Trauma Centers ◽

Case Volume ◽

Center Volume ◽

Low Volume ◽

Outcome Differences

An association between outcome and case volume has been demonstrated for selected complex operations. The relationship between trauma center volume and patient outcome has also been examined, but no clear consensus has been established. The American College of Surgeons (ACS) has published recommendations on optimal trauma center volume for level 1 designation. We examined whether this volume criteria was associated with outcome differences for the treatment of adult blunt splenic injuries. Using a state trauma database, ACS criteria were used to stratify trauma centers into high-volume centers (>240 patients with Injury Severity Score >15 per year) or low-volume centers, and outcome was evaluated. There were 1,829 patients treated at high-volume centers and 1,040 patients treated at low-volume centers. There was no difference in age, gender, emergency department pulse, emergency department systolic blood pressure, or overall mortality between high- and low-volume centers. Patients at low-volume centers were more likely to be treated operatively, but the overall success rate of nonoperative management between high-and low-volume centers was similar. These data suggest that ACS criteria for trauma centers level designation are not associated with differences in outcome in the treatment of adult blunt splenic injuries in this regional trauma system.

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High-Performance Trauma Centers in a Single-State Trauma System

The American Surgeon ◽

10.1177/0003134820934415 ◽

2020 ◽

Vol 86 (7) ◽

pp. 766-772

Author(s):

Justin S. Hatchimonji ◽

Elinore J. Kaufman ◽

Andrew J. Young ◽

Brian P. Smith ◽

Ruiying Xiong ◽

...

Keyword(s):

Mortality Risk ◽

High Performance ◽

Injury Severity ◽

Trauma System ◽

Trauma Centers ◽

High Performing ◽

Patient Level ◽

High Performer ◽

Chi Squared ◽

Expected Mortality

Background Trauma centers with low observed:expected (O:E) mortality ratios are considered high performers; however, it is unknown whether improvements in this ratio are due to a small number of unexpected survivors with high mortality risk (big saves) or a larger number of unexpected survivors with moderate mortality risk (marginal gains). We hypothesized that the highest-performing centers achieve that status via larger numbers of unexpected survivors with moderate mortality risk. Methods We calculated O:E ratios for trauma centers in Pennsylvania for 2016 using a risk-adjusted mortality model. We identified high and low performers as centers whose 95% CIs did not cross 1. We visualized differences between these centers by plotting patient-level observed and expected mortality; we then examined differences in a subset of patients with a predicted mortality of ≥10% using the chi-squared test. Results One high performer and 1 low performer were identified. The high performer managed a population with more blunt injuries (97.2% vs 93.6%, P < .001) and a higher median Injury Severity Score (14 vs 11, P < .001). There was no difference in survival between these centers in patients with an expected mortality of <10% (98.0% vs 96.7%, P = .11) or ≥70% (23.5% vs 10.8%, P = .22), but there was a difference in the subset with an expected mortality of ≥10% (77.5% vs 43.1%, P < .001). Conclusions Though patients with very low predicted mortality do equally well in high-performing and low-performing centers, the fact that performance seems determined by outcomes of patients with moderate predicted mortality favors a “marginal gains” theory.

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