Lateral chest thrusts for choking

An interesting animal study examined the techniques recommended in basic choking management algorithms for foreign body airway obstruction (chest and abdominal thrusts). In terms of the pressures generated, lateral chest thrusts were the most effective, although they are not recommended in current guidelines.

The technique described (on intubated pigs) was:

The animals were placed on the floor and on their side. The lower (dependent) side of the chest was braced by the ground and thrust was applied to the upper part of the upper side by two hands side by side with the higher one just below the axilla.

Interestingly – and I didn’t know this (although perhaps should have!) – the Australian Resuscitation Council (ARC) recommended lateral chest thrusts instead of abdominal thrusts for over 20 years.

While we should always exercise extreme caution in extrapolating animal studies to humans, this makes me want to consider lateral thrusts in the first aid (ie. no equipment) situation if other measures are failing.

Lateral versus anterior thoracic thrusts in the generation of airway pressure in anaesthetised pigs
Resuscitation. 2013 Apr;84(4):515-9
Abstract

Updated Difficult Airway Guidelines

The American Society of Anesthesiologists has published an update to its Practice Guidelines for Management of the Difficult Airway. You can get the full PDF for free. I’m linking to it for interest, but do not expect to find anything groundbreaking for the management of critical patients.

Practice Guidelines for Management of the Difficult Airway: An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway
Anesthesiology 2013;118:251-70

New Sepsis Guidelines

The latest update of the Surviving Sepsis Campaign Guidelines has been released.

There’s too much interesting stuff to easily summarise, but luckily the full text article is available at the link below.
Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012
Crit Care Med 2013 Feb;41(2):580-637 FREE FULL TEXT

New STEMI guidelines

Primary percutaneous coronary intervention or fibrinolysis for STEMI? What if you don’t have PCI at your hospital?

The new 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction is out and you can get the summary here.

Here’s what they say about initial reperfusion therapy:

Onset of Myocardial Infarction: Recommendations
Regional Systems of STEMI Care, Reperfusion Therapy, and Time-to-Treatment Goals

Class I

1. All communities should create and maintain a regional system of STEMI care that includes assessment and continuous quality improvement of emergency medical services and hospital-based activities. Performance can be facilitated by participating in programs such as Mission: Lifeline and the Door-to-Balloon Alliance.(Level of Evidence: B)

2. Performance of a 12-lead electrocardiogram (ECG) by emergency medical services personnel at the site of first medical contact (FMC) is recommended in patients with symptoms consistent with STEMI.(Level of Evidence: B)

3. Reperfusion therapy should be administered to all eligible patients with STEMI with symptom onset within the prior 12 hours. (Level of Evidence: A)

4. Primary PCI is the recommended method of reper- fusion when it can be performed in a timely fashion by experienced operators. (Level of Evidence: A)

5. Emergency medical services transport directly to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI, with an ideal FMC-to-device time system goal of 90 minutes or less.(Level of Evidence: B)

6. Immediate transfer to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI who initially arrive at or are transported to a non–PCI-capable hospital, with an FMC-to-device time system goal of 120 minutes or less.(Level of Evidence: B)

7. In the absence of contraindications, fibrinolytic therapy should be administered to patients with STEMI at non–PCI-capable hospitals when the anticipated FMC-to-device time at a PCI-capable hospital exceeds 120 minutes because of unavoidable delays.(Level of Evidence: B)

8. When fibrinolytic therapy is indicated or chosen as the primary reperfusion strategy, it should be administered within 30 minutes of hospital arrival.(Level of Evidence: B)

Class IIa

1. Reperfusion therapy is reasonable for patients with STEMI and symptom onset within the prior 12 to 24 hours who have clinical and/or ECG evidence of ongoing ischemia. Primary PCI is the preferred strategy in this population. (Level of Evidence: B)

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
Circulation. 2012 Dec 17. [Epub ahead of print]

Perimortem Caesarean Delivery: Late is Better than Not

“To date, approximately one-third of the women who die during pregnancy remain undelivered at the time of death”

Guidelines recommend cardiac arrest in pregnant women beyond 20 weeks gestation should be treated with perimortem caesarean delivery (PMCD) commenced within 4 minutes of arrest and completed within 5. These time intervals come from two papers, neither of which is current or used robust review methodology.

To address this, an up-to-date fairly comprehensive review was undertaken of published cases of maternal cardiac arrests occurring prior to delivery. The primary outcome measures were maternal and neonatal survival to hospital discharge and the relationship between PMCD and this outcome.

The Arrests

94 cases were included in the final analysis.Most pregnancies were singleton (90.4%, n = 85) with an average gestational age at the time of the arrest of 33 ± 7 weeks (median 35, range 10–42).

The most common causes of arrest were trauma, maternal cardiac problems, severe pre-eclampsia and amniotic fluid embolism, together comprising about 70% of arrests; two thirds occurred in hospital.

The Outcomes

Overall, return of spontaneous circulation (ROSC) was achieved more often than not (60.6%) and overall survival to hospital discharge was 54.3%

Only 57 cases (75%) reported the time from arrest to delivery; the average time was 16.6 ± 12.5 min (median 10, range 1–60), with only 4 cases making it under the advocated 4-min time limit.

Timing of PMCD and Maternal Survival

In cases undergoing PMCD the average time elapsing from arrest to PMCD was significantly different between surviving (27/57) and non-surviving (30/57) mothers [10.0 ± 7.2 min (median 9, range 1–37) and 22.6 ± 13.3 min (median 20, range 4–60) respectively (p < 0.001, 95%CI 6.9–18.2)].

Timing of PMCD and Neonatal Survival

Mean times to PMCD were 14±11min (median=10, range=1–47) and 22 ± 13 min (median = 20, range = 4–60) in neonatal survivors and non-survivors respectively (p=0.016)

In cases with PMCD which reported outcome, the overall neonatal survival rate was 63.6% (42/66).

“The 4-min time frame advocated for PMCD usually remains unmet yet neonatal survival is still likely if delivery occurs within 10 or even 15 min of arrest”

Both maternal & neonatal mortality were higher with prehospital arrest location.

Summary

The study may be limited by recall bias, under-reporting and publication bias, but provides a more comprehensive evidence base on which to base resuscitation recommendations. The authors provide a useful warning against becoming fixated with the recommended four minute window, which may lead teams to fail to attempt a potentially life-saving intervention:

“Fixation on specific time frames for PMCD may not be ideal. It may be more important to focus on event recognition and good overall performance…. It may be wise to advocate a short time frame for performance of PMCD in order to achieve better outcomes; however, blanket endorsement of an unrealistic time frame may well create a defeatist attitude when that time frame cannot be met.”

Maternal cardiac arrest and perimortem caesarean delivery: Evidence or expert-based?
Resuscitation. 2012 Oct;83(10):1191-200
Click for abstract

A whole bunch of trauma guidelines

The Eastern Association for the Surgery of Trauma has published a number of helpful evidence-based guidelines for trauma management, and many of them are included in this month’s Journal of Trauma and Acute Care Surgery

Here are brief snippets from some of them. All the guidelines can be viewed or downloaded in full for free here.

 

Nonoperative management of blunt hepatic injury

• Nonoperative management of blunt hepatic injuries currently is the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury or patient age.

• Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention.

• Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt hepatic injuries.

 

Selective nonoperative management of blunt splenic injury

• Nonoperative management of blunt splenic injuries is now the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury, patient age, or the presence of associated injuries.

• Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention.

• Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt splenic injuries.

 

Screening for blunt cardiac injury

• Electrocardiogram (ECG) alone is not sufficient to rule out BCI.

• BCI can be ruled out only if both ECG result and troponin I level are normal, a significant change from the previous guideline.

• Patients with new ECG changes and/or elevated troponin I should be admitted for monitoring.

• Echocardiogram is not beneficial as a screening tool for BCI and should be reserved for patients with hypotension and/or arrhythmias.

• The presence of a sternal fracture alone does not predict BCI.

• Cardiac computed tomography or magnetic resonance imaging can be used to differentiate acute myocardial infarction from BCI in trauma patients.

 

Evaluation and management of penetrating lower extremity arterial trauma

• Expedited triage of patients is possible with physical examination and/or the measurement of ankle-brachial indices.

• Computed tomographic angiography has become the diagnostic study of choice when imaging is required.

• Tourniquets and intravascular shunts have emerged as adjuncts in the treatment of penetrating lower extremity arterial trauma.

 

Prophylactic antibiotic use in penetrating abdominal trauma

• There is evidence to support a Level I recommendation that prophylactic antibiotics should only be administered for 24 hours in the presence of a hollow viscus injury.

• There are no data to support continuing prophylactic antibiotics longer than 24 hours in damage control laparotomy.

 

Screening for thoracolumbar spinal injuries in blunt trauma

• Multidetector computed tomographic scans have become the screening modality of choice and the criterion standard in screening for TLS injuries.

• Patients without altered mentation or significant mechanism may be excluded by clinical examination without imaging.

• Patients with gross neurologic deficits or concerning clinical examination findings with negative imaging should receive a magnetic resonance imaging expediently, and the spine service should be consulted

 

Emergency tracheal intubation immediately following traumatic injury

• The decision to intubate a patient following traumatic injury is based on multiple factors, including the need for oxygenation and ventilation, the extent and mechanism of injury, predicted operative need, or progression of disease.

• Rapid sequence intubation with direct laryngoscopy continues to be the recommended method for ETI, although the use of airway adjuncts such as blind insertion supraglottic devices and video laryngoscopy may be useful in facilitating successful ETI and may be preferred in certain patient populations.

• There is no pharmacologic induction agent of choice for ETI; however, succinylcholine is the neuromuscular blockade agent recommended for rapid sequence intubation.

 

Presumptive antibiotic use in tube thoracostomy for traumatic hemopneumothorax

• Routine presumptive antibiotic use to reduce the incidence of empyema and pneumonia in TT for traumatic hemopneumothorax is controversial; however, there is insufficient published evidence to support any recommendation either for or against this practice.

 

Evaluation and management of geriatric trauma

• Effective evidence-based care of aging patients necessitates aggressive triage, correction of coagulopathy, and limitation of care when clinical evidence points toward an overwhelming likelihood of poor long-term prognosis

 

Management of pulmonary contusion and flail chest

• Patients with PC-FC should not be excessively fluid restricted but should be resuscitated to maintain signs of adequate tissue perfusion.

• Obligatory mechanical ventilation in the absence of respiratory failure should be avoided.

• The use of optimal analgesia and aggressive chest physiotherapy should be applied to minimize the likelihood of respiratory failure.

• Epidural catheter is the preferred mode of analgesia delivery in severe flail chest injury.

• Paravertebral analgesia may be equivalent to epidural analgesia and may be appropriate in certain situations when epidural is contraindicated.

• A trial of mask continuous positive airway pressure should be considered in alert patients with marginal respiratory status.

• Patients requiring mechanical ventilation should be supported in a manner based on institutional and physician preference and separated from the ventilator at the earliest possible time.

• Positive end-expiratory pressure or continuous positive airway pressure should be provided.

• High-frequency oscillatory ventilation should be considered for patients failing conventional ventilatory modes. Independent lung ventilation may also be considered in severe unilateral pulmonary contusion when shunt cannot be otherwise corrected.

• Surgical fixation of flail chest may be considered in cases of severe flail chest failing to wean from the ventilator or when thoracotomy is required for other reasons.

• Self-activating multidisciplinary protocols for the treatment of chest wall injuries may improve outcome and should be considered where feasible.

• Steroids should not be used in the therapy of pulmonary contusion.

• Diuretics may be used in the setting of hydrostatic fluid overload in hemodynamically stable patients or in the setting of known concurrent congestive heart failure.

 

Evaluation and management of small-bowel obstruction

• Level I evidence now exists to recommend the use of computed tomographic scan, especially multidetector computed tomography with multiplanar reconstructions, in the evaluation of patients with SBO because it can provide incremental clinically relevant information over plains films that may lead to changes in management.

• Patients with evidence of generalized peritonitis, other evidence of clinical deterioration, such as fever, leukocytosis, tachycardia, metabolic acidosis, and continuous pain, or patients with evidence of ischemia on imaging should undergo timely exploration.

• The remainder of patients can safely undergo initial nonoperative management for both partial and complete SBO.

• Water-soluble contrast studies should be considered in patients who do not clinically resolve after 48 to 72 hours for both diagnostic and potential therapeutic purposes.

• Laparoscopic treatment of SBO has been demonstrated to be a viable alternative to laparotomy in selected cases.

 

2012 Eastern Association for the Surgery of Trauma (EAST) Practice Management Guidelines Supplement
J Trauma Acute Care Surg. 2012 Nov;73(5 Suppl 4)

Upper GI bleeding guideline update

The UK’s National Institute for Health and Clinical Excellence has issued updated guidance on the management of acute upper gastrointestinal bleeding.

The initial resuscitation section recommends haemostatic blood product resuscitation for unstable patients in line with massive transfusion practice in trauma.

A risk assessment is recommended using the Blatchford score pre-endoscopy at first assessment, and the full Rockall score after endoscopy.

Consider early discharge for patients with a pre-endoscopy Blatchford score of 0.

In non-varicesal haemorrhage, acid-suppression drugs (proton pump inhibitors or H2-receptor antagonists) before endoscopy are not recommended.

Terlipressin should be given to patients with suspected variceal bleeding at presentation and continued until definitive haemostasis has been achieved, or after 5 days, unless there is another indication for its use.

Prophylactic antibiotic therapy should be offered at presentation to patients with suspected or confirmed variceal bleeding.

National Institute for Health and Clinical Excellence: CG141 Acute upper GI bleeding: NICE guideline
http://guidance.nice.org.uk/CG141/NICEGuidance/pdf/English

Nonshockable arrest survival improves with uninterrupted compressions

A study of nonshockable out of hospital cardiac arrest survival showed significant improvement in short- and long-term survival and neurological outcome after implementation of a protocol consistent with CPR guidelines that prioritised chest compressions. These improvements were especially evident among arrests attributable to a cardiac cause, although there was no evidence of harm among arrests attributable to a noncardiac cause.

This was not a randomised trial so unrecognised factors may have contributed to the improved outcome in addition to the change in CPR protocol. However, it is interesting as it provides up to date survival rates from a large population sample: Non shockable out of hospital cardiac arrests achieve return of spontaneous circulation in 34%, 6.8% are discharged from hospital (5.1% with a favourable neurological outcome), and 4.9% survived one year.

The breakdown between PEA and asystole is of course telling, and unsurprising, with 12.8% versus 1.1% being discharged with a favourable neurological outcome, respectively. I would imagine then that some of the PEA patients had beating hearts with hypotension extreme enough to cause pulselessness (pseudo-electromechanical dissociation) – clinically a ‘cardiac arrest’ but really nothing of the sort, and the reason we use cardiac ultrasound to prognosticate.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) claims millions of lives worldwide each year. OHCA survival from shockable arrhythmias (ventricular fibrillation/ tachycardia) improved in several communities after implementation of American Heart Association resuscitation guidelines that eliminated “stacked” shocks and emphasized chest compressions. “Nonshockable” rhythms are now the predominant presentation of OHCA; the benefit of such treatments on nonshockable rhythms is uncertain.

METHODS AND RESULTS: We studied 3960 patients with nontraumatic OHCA from nonshockable initial rhythms treated by prehospital providers in King County, Washington, over a 10-year period. Outcomes during a 5-year intervention period after adoption of new resuscitation guidelines were compared with the previous 5-year historical control period. The primary outcome was 1-year survival. Patient demographics and resuscitation characteristics were similar between the control (n=1774) and intervention (n=2186) groups, among whom 471 of 1774 patients (27%) versus 742 of 2186 patients (34%), respectively, achieved return of spontaneous circulation; 82 (4.6%) versus 149 (6.8%) were discharged from hospital, 60 (3.4%) versus 112 (5.1%) with favorable neurological outcome; 73 (4.1%) versus 135 (6.2%) survived 1 month; and 48 (2.7%) versus 106 patients (4.9%) survived 1 year (all P≤0.005). After adjustment for potential confounders, the intervention period was associated with an improved odds of 1.50 (95% confidence interval, 1.29-1.74) for return of spontaneous circulation, 1.53 (95% confidence interval, 1.14-2.05) for hospital survival, 1.56 (95% confidence interval, 1.11-2.18) for favorable neurological status, 1.54 (95% confidence interval, 1.14-2.10) for 1-month survival, and 1.85 (95% confidence interval, 1.29-2.66) for 1-year survival.

CONCLUSION: Outcomes from OHCA resulting from nonshockable rhythms, although poor by comparison with shockable rhythm presentations, improved significantly after implementation of resuscitation guideline changes, suggesting their potential to benefit all presentations of OHCA.

Impact of changes in resuscitation practice on survival and neurological outcome after out-of-hospital cardiac arrest resulting from nonshockable arrhythmia
Circulation. 2012 Apr 10;125(14):1787-94

Laryngospasm after Ketamine

A case is reported in Prehospital Emergency Care¹ in which an agitated patient (due to mania and alcohol intoxication) received 5 mg/kg (500 mg) of ketamine intramuscularly by an EMS crew which dissociated him within a few minutes. He subsequently developed episodes of laryngospasm in the emergency department which were unrelieved by head tilt, chin lift and simple airway adjuncts but responded to bag-mask ventilation (BMV). The patient was intubated because the laryngospasm recurred, although it had again responded to BMV.

The authors make the point that because of the response of laryngospasm to simple manoeuvres, and because in the prehospital environment a patient will not be left without an EMS provider present, ‘restricting ketamine to EMS units capable of rapid-sequence intubation therefore seems unnecessary.‘

This is one for EMS directors to consider seriously. Personally, I think practicing prehospital care without access to ketamine is like having a hand tied behind my back. Ketamine opens up a world of possibilities in controlling combative patients, optimising scene safety, providing sedation for painful procedures including extrication, and enabling severe pain to be controlled definitively.

I’ve been using ketamine regularly for prehospital analgesia and emergency department procedural sedation in both adults and kids for more than a decade. I’ve seen significant laryngospasm 5 times (twice in kids). On one of those occasions, a 3 year old child desaturated to around 50% twice during two episodes of laryngospasm. We weren’t slow to pick it up – that was just her showing us how quickly kids can desaturate which continued while we went through a stepwise approach until BMV resolved it. It was however an eye opener for the registrar (senior resident) assisting me, who became extremely respectful of ketamine after that. Our ED sedation policy (that I wrote) required that suxamethonium was ready and available and that an appropriate dose had been calculated before anyone got ketamine. Paralysis may extremely rarely be required, but when it’s needed you need to be ready.

Laryngospasm is rare but most regular prescribers of ketamine will have seen it; the literature says it occurs in about 1-2% of sedations, although anecdotally I think it’s a bit less frequent. Importantly for those weighing the risks of allowing non-RSI competent prescribers, the requirement for intubation is exceptionally rare (2 of 11,589 reported cases in one review). Anyone interested should read this excellent review of ketamine-related adverse effects provided by Chris Nickson at Life in The Fast Lane. Chris reminds us of the Larson manouevre, which is digital pressure in the notch behind and below the ear, described by Larson² as follows:

The technique involves placing the middle finger of each hand in what I term the laryngospasm notch. This notch is behind the lobule of the pinna of each ear. It is bounded anteriorly by the ascending ramus of the mandible adjacent to the condyle, posteriorly by the mastoid process of the temporal bone, and cephalad by the base of the skull. The therapist presses very firmly inward toward the base of the skull with both fingers, while at the same time lifting the mandible at a right angle to the plane of the body (i.e., forward displacement of the mandible or “jaw thrust”). Properly performed, it will convert laryngospasm within one or two breaths to laryngeal stridor and in another few breaths to unobstructed respirations.

I use this point most often to provide painful stimuli when assessing GCS in a patient, particular those I think may be feigning unconsciousness (I’ve done this for a number of years since learning how painful it can be when I was shown it by a jujitsu instructor). Dr Larson says he was taught the technique by Dr Guadagni, so perhaps we should be calling it the ‘Guadagni manouevre’. The lack of published evidence has led to some appropriate skepticism³, but as it can be combined with a jaw thrust it needn’t delay more aggressive interventions should they become necessary, it may work, and it’s likely to be harmless.

I presented the following suggested algorithm for management of laryngospasm during ketamine procedural sedation at a regional emergency medicine ‘Fellows Forum’ meeting in November 2007 in the UK. Since many paediatric procedural sedations were done using intramuscular (im) ketamine, it gives guidance based on whether or not vascular access has been obtained:

Some things I considered were:

• Neuromuscular blockade (NMB) isn’t always necessary – laryngospasm may be managed with other sedatives such as propofol. However, titrating further sedatives in a desaturating child in my view is inferior to definitive airway management and laryngeal relaxation with suxamethonium and a tube.
• Laryngospasm may be managed with much smaller doses of suxamethonium than are required for intubation – as little as 0.1 mg/kg may be effective. However, I think once we go down the NMB route we’re committed to intubation and therefore we should use a dose guaranteed to be effective in achieving intubating conditions.
• In the child without vascular access, I considered intraosseous and intralingual sux. However, intramuscular suxamethonium is likely to have a relaxant effect on the laryngeal muscles within 30-45 seconds, which has to be compared with time taken to insert and confirm intraosseous needle placement. I do not think the traditionally recommended intralingual injection has any role to play in modern airway management.
• At the time I wrote this most paediatric resuscitation bays in my area in the United Kingdom had breathing circuits capable of delivering PEEP – usually the Ayr’s T-Piece (specifically the Mapleson F system), which is why PEEP was included early in in the algorithm prior to BMV.

ABSTRACT An advanced life support emergency medical services (EMS) unit was dispatched with law enforcement to a report of a male patient with a possible overdose and psychiatric emergency. Police restrained the patient and cleared EMS into the scene. The patient was identified as having excited delirium, and ketamine was administered intramuscularly. Sedation was achieved and the patient was transported to the closest hospital. While in the emergency department, the patient developed laryngospasm and hypoxia. The airway obstruction was overcome with bag–valve–mask ventilation. Several minutes later, a second episode of laryngospasm occurred, which again responded to positive-pressure ventilation. At this point the airway was secured with an endotracheal tube. The patient was uneventfully extubated several hours later. This is the first report of laryngospam and hypoxia associated with prehospital administration of intramuscular ketamine to a patient with excited delirium.

1. Laryngospasm and Hypoxia After Intramuscular Administration of Ketamine to a Patient in Excited Delirium
Prehosp Emerg Care. 2012 Jul;16(3):412-4

2. Laryngospasm-The best treatment
Anesthesiology 1998; 89:1293-4

3. Management of Laryngospasm
http://www.respond2articles.com/ANA/forums/thread/1096.aspx

Prehospital burn management in a combat zone.

A military study revealed troops suffering from severe burns tended to receive either no prehospital fluid or too much fluid¹.

The authors point out some practical realities and an attempted solution:

For a medic potentially treating multiple casualties at once in a hostile environment, the calculation of the modified Brooke or Parkland formula may be unrealistic prior to beginning fluid resuscitation in the prehospital setting.

The USAISR’s Rule of 10 is a simplified formula to guide the initial fluid resuscitation of a burn victim. The burn size is estimated to the nearest 10% TBSA. For patients weighing 40 to 80 kg, the burn size is then multiplied by 10 to give the initial fluid rate in milliliters per hour. The rate is increased by 100 mL/hour for every 10 kg above 80 kg in terms of the patient’s weight. For the majority of adult burn patients, the Rule of 10 approximates the initial fluid rate within accepted ABA guidelines.

A previous study on the rule of 10 showed it provided an estimate that fell between the modified Brooke and Parkland estimates 87.8% of the time, less than the modified Brooke <12% of the time, and hardly ever (>1%) exceeded the Parkland estimate².

OBJECTIVE: The purpose of this article is to provide a descriptive study of the management of burns in the prehospital setting of a combat zone.

METHODS: A retrospective chart review was performed of U.S. casualties with >20% total-body-surface-area thermal burns, transported from the site of injury to Ibn Sina Combat Support Hospital (CSH) between January 1, 2006, and August 30, 2009.

RESULTS: Ibn Sina CSH received 225 burn casualties between January 2006 and August 2009. Of these, 48 met the inclusion criteria. The mean Injury Severity Score was 31.7 (range 4 to 75). Prehospital vascular access was obtained in 24 casualties (50%), and 20 of the casualties received fluid resuscitation. Out of the 48 casualties enrolled, 28 (58.3%) did not receive prehospital fluid resuscitation. Of the casualties who received fluid resuscitation, nearly all received volumes in excess of the guidelines established by the American Burn Association and those recommended by the Committee for Tactical Combat Casualty Care. With regard to pain management in the prehospital setting, 13 casualties (27.1%) received pain medication.

CONCLUSIONS: With regard to the prehospital fluid resuscitation of primary thermal injury in the combat zone, two extremes were noted. The first group did not receive any fluid resuscitation; the second group was resuscitated with fluid volumes higher than those expected if established guidelines were utilized. Pain management was not uniformly provided to major burn casualties, even in several with vascular access. These observations support improved education of prehospital personnel serving in a combat zone.

1. Prehospital burn management in a combat zone
Prehosp Emerg Care, 2012 vol. 16 (2) pp. 273-276

2. Simple derivation of the initial fluid rate for the resuscitation of severely burned adult combat casualties: in silico validation of the rule of 10
J Trauma. 2010 Jul;69 Suppl 1:S49-54

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