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Trauma accounts for nearly half of all deaths of pregnant women. Pregnant women have distinct physiologic and anatomic characteristics which complicate their management following major trauma. This paper comprises a narrative review of the most recent literature informing the management of pregnant trauma patients. The incidence of trauma during pregnancy is 6–8%. The focus of clinical assessment must be on the mother, starting with the primary survey. During airway management, clinicians should consider early intubation if necessary and utilize gastric tubes to minimize the risk of aspiration. Pregnant women experience progesterone-mediated hyperventilation, and normal PaCO2 levels may portend imminent respiratory failure. Clinicians should utilize left lateral tilt in hypotensive pregnant women to displace the uterus off the inferior vena cava. Ultrasonography is an attractive imaging modality for pregnant women which is specific for ruling in intraabdominal hemorrhage but not sufficiently sensitive to exclude this diagnosis. Clinicians should not hesitate to order computed tomography imaging in unstable patients if there is diagnostic ambiguity. Cardiotocographic monitoring simultaneously assesses uterine contractions and fetal heart rate and should last at least 4 h for pregnant women following even minor abdominal trauma if their fetus has achieved viable gestational age (approximately 24 weeks). In the event of cardiac arrest, peri-mortem cesarean section may improve outcomes for the mother and fetus alike. Unique specific complications include uterine rupture and placental abruption, which require emergent resuscitation and obstetrics consultation for definitive management. Emergency clinicians should maintain a low threshold for transfer to a tertiary care center given correlations between even isolated and relatively minor traumatic injuries with adverse fetal and maternal outcomes. Trauma is a common cause of morbidity and mortality in pregnant women. Emergency clinicians must understand the evaluation and management of pregnant trauma patients.

Trauma patients often present with injuries requiring resuscitation and further evaluation. Many providers advocate for whole body computed tomography (WBCT) for rapid and comprehensive diagnosis of life-threatening injuries. Evaluate the literature concerning mortality effect, emergency department (ED) length of stay, radiation, and incidental findings associated with WBCT. Physicians have historically relied upon history and physical examination to diagnose life-threatening injuries in trauma. Diagnostic imaging modalities including radiographs, ultrasound, and computed tomography have demonstrated utility in injury detection. Many centers routinely utilize WBCT based on the premise this test will improve mortality. However, WBCT may increase radiation and incidental findings when used without considering pre-test probability of actionable traumatic injuries. Studies supporting WBCT are predominantly retrospective and incorporate trauma scoring systems, which have significant design weaknesses. The recent REACT-2 trial randomized trauma patients with high index of suspicion for actionable injuries to WBCT versus selective imaging and found no mortality difference. Additional prospective trials evaluating WBCT in specific trauma subgroups (e.g. polytrauma) are needed to evaluate benefit. In the interim, the available data suggests clinicians should adopt a selective imaging strategy driven by history and physical examination. While observational data suggests an association between WBCT and a benefit in mortality and ED length of stay, randomized controlled data suggests no mortality benefit to this diagnostic tool. The literature would benefit from confirmatory studies of the use of WBCT in trauma sub-groups to clarify its impact on mortality for patients with specific injury patterns.

Military hospital healthcare providers treated children during the recent conflicts in Afghanistan and Iraq. Compared to adults, pediatric patients present unique challenges during trauma resuscitations and have notably been discussed in few research reports. We seek to describe ED interventions performed on pediatric trauma patients in Iraq and Afghanistan. We queried the Department of Defense Trauma Registry (DODTR) for all pediatric patients in Iraq and Afghanistan from January 2007 to January 2016. Subjects were grouped based on Centers for Disease Control age categories. We used descriptive statistics. During this period, there were 3388 pediatric encounters that arrived at the ED with signs of life or on-going interventions. Most subjects were male (77.2%), located in Afghanistan (67.9%), injured by explosive (43.2%), and admitted to an intensive care unit (57.8%). Most of those arriving to the ED alive or with on-going interventions survived to hospital discharge (91.6%). The most frequently encountered age group was 5–9years (33.3%) followed by 10–14years (31.5%). The most common interventions were vascular access (86.6%), fluid administration (85.0%), and external warming (44.6%). Intubation was the most frequent airway intervention (18.2%). Packed red blood cells were the most frequently administered blood product (33.8% of subjects). Pediatric subjects accounted for a notable portion of care delivered in theater emergency departments during the study period. Vascular access and fluid administration were the most frequently performed interventions. Pediatric-specific training is needed as a part of deployment medicine operations.

Emergency front of neck access (eFONA) is an emergent procedure performed in “cannot intubate, cannot ventilate” scenarios to establish a patent airway that was otherwise compromised. We sought to describe the recent literature on eFONA. We conducted a scoping review using the PRISMA-ScR Checklist to provide comprehensive summary of the most relevant eFONA literature over topics such as civilian and military incidence and outcome, available techniques, the use of ultrasound in performing eFONA, training data, complications and contraindications, and emerging data on the procedure. Additionally, knowledge gaps were identified that would benefit from further study. We used PubMed and Google Scholar to identify eFONA literature from 2001 to 2024. We identified 89 English studies for this analysis –retrospective studies (n = 35) were most frequent followed by, comparative studies (n = 17), and randomized controlled trials (n = 14). Of the studies analyzed, 86 were original research studies. The papers used came from journals and registries worldwide to provide an accurate representation of in many emergency settings. Our findings suggest that eFONA remains a rare procedure, but when performed by clinicians with sufficient practice, it can be a successful airway management strategy. Areas that would benefit from more research include identifying the types of eFONA used in the prehospital and emergency settings, including additional exploration of surgical and needle techniques along with skills attainment and sustainment.

Airway management is a key intervention during the resuscitation of critically ill trauma patients. Emergency surgical airway (ESA) placement is taught as a backup option when endotracheal intubation (ETI) fails. We sought to (1) describe the incidence of the emergency department (ED) ESA, (2) compare ESA versus ETI-only recipients, and (3) determine which factors were associated with receipt of an ESA. We searched within the Trauma Quality Improvement Program datasets from 2017 to 2022 for all emergency department surgical airway placement and/or endotracheal intubations recipients. We compared ESA versus ETI-only recipients. From 2017 to 2022, there were 6,477,759 within the datasets, of which 238,128 met inclusion for this analysis. Within that, there were 236,292 ETIs, 2264 ESAs, with 428 (<1 %) having documentation of both. Of the ESAs performed, there were 82 documented in children <15 years of age with the youngest being 1 year of age. The ETI-only group had a lower proportion serious injuries to the head/neck (52 % versus 59 %), face (2 % versus 8 %), and skin (3 % versus 6 %). However, the ETI-only group had a higher proportion of serious injuries to the abdomen (15 % versus 9 %) and the extremities (19 % versus 12 %). Survival at 24-h was higher in the ETI-only group (83 % versus 76 %) as well as survival to discharge (70 % versus 67 %). In the subanaysis of children <15 years (n = 82), 34 % occurred in the 1–4 years age group, 35 % in the 5–9 years age group, and 30 % in the 10–14 years age group. In our multivariable logistic regression analysis, serious injuries to the head/neck (odds ratio [OR] 1.37, 95 % CI 1.23–1.54), face (OR 3.41, 2.83–4.11), thorax (OR 1.19, 1.06–1.33), and skin (OR 1.53, 1.15–2.05) were all associated with receipt of cricothyrotomy. Firearm (OR 3.62, 3.18–4.12), stabbing (2.85, 2.09–3.89), and other (OR 2.85, 2.09–3.89) were associated with receipt of ESA when using collision as the reference variable. ESA placement is a rarely performed procedure but frequently used as a primary airway intervention in this dataset. Penetrating mechanisms, and injuries to face were most associated with ESA placement. Our findings reinforce the need to maintain this critical airway skill for trauma management. •Emergency surgical airway (ESA) access is often used as a primary airway intervention.•ESA access is documented in children as young as 1 with similar survival to adults.•Serious injuries to the face, firearms, and stabbings are associated with receipt of ESA.

Peri-intubation complications are important sequelae of airway management in the emergency department (ED). Our objective was to quantify the increased risk of complications with multiple attempts at emergency airway intubation in the ED. This is a secondary analysis of a prospectively collected multicenter registry (National Emergency Airway Registry) consisting of attempted ED intubations among subjects aged >14 years. The primary exposure variable was the number of intubation attempts. The primary outcome measure was the occurrence of peri-intubation major complications within 15 min of intubation including hypotension, hypoxemia, vomiting, dysrhythmias, cardiac arrest, esophageal intubation, and failed airway with cricothyrotomy. We constructed multivariable logistic regression models to determine the associations between complications and the number of intubation attempts while controlling for measured pre-exposure variables. There were 19,071 intubations in the NEAR database, of which 15,079 met inclusion for this analysis. Of these, 13,459 were successfully intubated on the first attempt, 1,268 on the second attempt, 269 on the third attempt, 61 on the fourth attempt, and 22 on the fifth or more attempt. A complication occurred in 2,137 encounters (14 %). Major complications accompanied 1,968 encounters (13 %) whereas minor complications affected 315 encounters (2 %). The most common major complication was hypoxia. In our multivariable logistic regression model, odds ratios with 95 % confidence intervals for the occurrence of major complications for multiple attempts compared to first-pass success were 4.4 (3.6–5.3), 7.4 (5.0–10.7), 13.9 (5.6–34.3), and 9.3 (2.1–41.7) for attempts 2–5+ (reference attempt 1), respectively. We found an independent association between the number of intubation attempts among ED patients undergoing emergency airway intubation and the risk of complications.

Contrast-enhanced magnetic resonance imaging (MRI) is the preferred imaging modality for diagnosing pyogenic spinal infection (PSI), but it is not always available. Our objective was to describe pyogenic spinal infection imaging characteristics in patients presenting to a community emergency department (ED) and estimate the computed tomography (CT) sensitivity for these infections. We examined the MRI reports from a cohort of 88 PSI patients whom we enrolled in a prospective cohort study and report the prevalence of each PSI type (spinal epidural abscess/infection, vertebral osteomyelitis/discitis, septic facet, and paravertebral abscess/infection) according to contemporary nomenclature. In a 14 patient subcohort who underwent both CT and MRI studies, we report the sensitivity for each PSI from a post hoc blinded overread of the CT imaging by a single neuroradiologist. Of the 88 PSI patients, the median age was 55 years, and 31% were female. The PSI prevalence included: spinal epidural abscess/infection (SEA) in 61(69%), vertebral osteomyelitis/discitis (VO/D) in 54 (61%), septic facet (SF) in 15 (17%), and paravertebral abscess/infection (PVA) in 53 (60%). Of the SEAs, 82% (50/61) were associated with other spinal infections, while 18% (11/61) were isolated SEAs. The overall CT sensitivity in a masked overread was 79% (11/14) for any PSI, 83% (10/12) for any infection outside the spinal canal, and only 18% (2/11) for SEA. Patients found to have vertebral osteomyelitis/discitis, septic facet, and paravertebral infections frequently had a SEA coinfection. CT interpretation by a neuroradiologist had moderate sensitivity for infections outside the spinal canal but had low sensitivity for SEA. •PSIs comprise four distinct neuroradiological entities.•PSI rarely confines itself to one spinal anatomical compartment.•PSIs frequently coinfect the epidural space.•If MRI is unavailable, CT imaging may identify some PSIs but not epidural infections.

Endotracheal intubation (ETI) is a high-risk procedure frequently performed in the emergency department (ED), particularly in trauma patients, where it presents unique challenges. These include anatomically difficult airways, adverse effects of medications used for rapid sequence intubation (RSI), and the need to manage hemodynamically unstable patients. This study characterizes the incidence of ED ETI over a six-year period, with 24-h survival as the primary outcome and secondary outcomes including all-cause ED mortality, factors associated with ED ETI, and subgroup analyses in pediatric patients. We conducted a retrospective cohort study using data from the American College of Surgeons Trauma Quality Improvement Program (TQIP), focusing on trauma patients who underwent ETI in the ED. Descriptive statistics, inferential analyses, and multivariable logistic regression were used to assess associated factors. From 2017 to 2023, 7,620,399 trauma encounters met inclusion criteria, of which 279,627 (3.7 %) underwent ED ETI. The primary outcome of 24-h survival was significantly lower in patients who underwent ED ETI compared to those who did not (69.8 % vs. 97.5 %; difference 27.6 %, 95 % confidence interval [CI] 26.5–27.8). Among intubated patients, the secondary outcome of all-cause mortality in ED was 10.2 %. Factors independently associated with ED ETI included male sex (odds ratio [OR] 1.40, CI 1.38–1.42), firearm injury (1.52, 1.48–1.55), stabbing (1.34, 1.31–1.38), head/neck injury (2.40, 2.37–2.42), face (1.57, 1.51–1.63), thorax (1.61, 1.59–1.63), abdomen (1.66, 1.63–1.69), extremities (1.23, 1.22–1.25), skin (1.84, 1.78–1.91), elevated shock index (1.73, 1.71–1.75), depressed Glasgow Coma Scale (GCS) (0.69, 0.69–0.69), need for respiratory assistance on arrival (5.70, 5.61–5.79), and EMS arrival (2.14, 2.09–2.19). In the pediatric subgroup (<18 years, a secondary outcome analysis), 815,531 encounters met inclusion, with 18,417 (2.3 %) undergoing ED ETI. Similar factors were associated with ED ETI, including male sex (1.05, 1.01–1.09), collision (1.08, 1.01–1.09), firearm injury (2.29, 2.11–2.48), head/neck injury (3.55, 3.41–3.71), face (1.26, 1.08–1.47), thorax (1.91, 1.85–2.00), abdomen (1.64, 1.55–1.76), extremities (1.26, 1.19–1.32), skin (1.79, 1.55–2.06), elevated SI (1.19, 1.15–1.23), depressed GCS (0.69, 0.69–0.70), respiratory assistance on arrival (6.51, 6.14–6.91), and EMS arrival (1.90, 1.77–2.04). In this large, national trauma cohort, approximately 3.7 % of patients underwent ED ETI. These primary outcome of 24-h survival was significantly lower in patients requiring intubation, and secondary analyses demonstrated high all-cause ED mortality, distinct predictors of ETI and similar associations in pediatric patients. The findings underscore the critical importance of optimizing emergency airway management in trauma care.