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IntroductionEmergency resuscitative thoracotomy (ERT) is a resource-intensive procedure that can deplete a combat surgical team’s supply and divert attention from casualties with more survivable injuries. An understanding of survival after ERT in the combat trauma population will inform surgical decision-making.MethodsWe requested all encounters from 2007 to 2023 from the Department of Defense Trauma Registry (DoDTR). We analysed any documented thoracotomy in the emergency department and excluded any case for which it was not possible to distinguish ERT from operating room thoracotomy. The primary outcome was 24-hour mortality.ResultsThere were 48 301 casualties within the original dataset. Of those, 154 (0.3%) received ERT, with 114 non-survivors and 40 survivors at 24 hours. There were 26 (17%) survivors at 30 days. The majority were performed in role 3. The US military made up the largest proportion among the non-survivors and survivors. Explosives predominated in both groups (61% and 65%). Median Composite Injury Severity Scores were lower among the non-survivors (19 vs 33). Non-survivors had a lower proportion of serious head injuries (13% vs 40%) and thorax injuries (32% vs 58%). Median RBC consumption was lower among non-survivors (10 units vs 19 units), as was plasma (6 vs 16) and platelets (0 vs 3). The most frequent interventions and surgical procedures were exploratory thoracotomy (n=140), chest thoracostomy (n=137), open cardiac massage (n=131) and closed cardiac massage (n=121).ConclusionERT in this group of combat casualties resulted in 26% survival at 24 hours. Although this proportion is higher than that reported in civilian data, more rigorous prospective studies would need to be conducted or improvement in the DoDTR data capture methods would need to be implemented to determine the utility of ERT in combat populations.

IntroductionThe US military has frequently used a ‘walking blood bank’, formally known as an ‘emergency donor panel’ (EDP) to obtain warm fresh whole blood (WFWB) which is then immediately transfused into the casualty. We describe the frequency of EDP activation by the US military.MethodsWe analysed data from 2007 to 2015 within the Department of Defense Trauma Registry for US, Coalition and US contractor casualties that received at least 1 unit of blood product within the first 24 hours and described the frequency of WFWB use.ResultsThere were 3474 casualties that met inclusion, of which, 290 casualties (8%) required activation of the EDP. The highest proportion of EDP events was in 2014, whereas the highest number of EDP events was in 2011. Median injury severity scores were higher in the recipients, compared with non-EDP recipients (29 vs 20), as were proportions with serious injuries to the abdomen (43% vs 19%) and extremities (77% vs 65%). The median number of units of all blood products, except for packed red blood cells, was higher for WFWB recipients. Of the WFWB recipients, the median was 5 units (IQR 2–10) with a maximum documented 144 units. There were four documented cases of EDP recipients receiving >100 units of WFWB with only one surviving to hospital discharge. During the study period, there were a total of 3102 (3%) units of WFWB transfused among a total of 104 288 total units.ConclusionsWe found nearly 1 in 11 casualties who received blood required activation of the EDP. Blood from the EDP accounted for 3% of all units transfused. These findings will enable future mission planning and medical training, especially for units with smaller, limited blood supplies. The lessons learned here can also enable mass casualty planning in civilian settings.

While the previous study was US-based, a study based in Madrid found a temporal trend with increased police reporting of intimate partner violence that centered around the weekends and the Christmas holiday [4]. [...]with any large retrospective study, there is both inclusion bias and data extraction bias. [...]as this is a retrospective observational study, we can only identify patterns and associations, and thus we cannot draw firm conclusions regarding causation.

Early recognition and management of hemorrhage, damage control resuscitation, and blood product administration have optimized management of severe trauma. Recent data suggest hypocalcemia exacerbates the ensuing effects of coagulopathy in trauma. This narrative review of available literature describes the physiology and role of calcium in trauma resuscitation. Authors did not perform a systematic review or meta-analysis. Calcium is a divalent cation found in various physiologic forms, specifically the bound, inactive state and the unbound, physiologically active state. While calcium plays several important physiologic roles in multiple organ systems, the negative hemodynamic effects of hypocalcemia are crucial to address in trauma patients. The negative ramifications of hypocalcemia are intrinsically linked to components of the lethal triad of acidosis, coagulopathy, and hypothermia. Hypocalcemia has direct and indirect effects on each portion of the lethal triad, supporting calcium's potential position as a fourth component in this proposed lethal diamond. Trauma patients often present hypocalcemic in the setting of severe hemorrhage secondary to trauma, which can be worsened by necessary transfusion and resuscitation. The critical consequences of hypocalcemia in the trauma patient have been repeatedly demonstrated with the associated morbidity and mortality. It remains poorly defined when to administer calcium, though current data suggest that earlier administration may be advantageous. Calcium is a key component of trauma resuscitation and the coagulation cascade. Recent data portray the intricate physiologic reverberations of hypocalcemia in the traumatically injured patient; however, future research is needed to further guide the management of these patients.

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.

Blast injury is a unique condition that carries a high rate of morbidity and mortality, often with mixed penetrating and blunt injuries. This review highlights the pearls and pitfalls of blast injuries, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. Explosions may impact multiple organ systems through several mechanisms. Patients with suspected blast injury and multisystem trauma require a systematic evaluation and resuscitation, as well as investigation for injuries specific to blast injuries. Blast injuries most commonly affect air-filled organs but can also result in severe cardiac and brain injury. Understanding blast injury patterns and presentations is essential to avoid misdiagnosis and balance treatment of competing interests of patients with polytrauma. Management of blast victims can also be further complicated by burns, crush injury, resource limitation, and wound infection. Given the significant morbidity and mortality associated with blast injury, identification of various injury patterns and appropriate management are essential. An understanding of blast injuries can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

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.

Ketamine administration in patients experiencing or at risk for hypotension is common based upon the presumption of this agent's favorable hemodynamic profile. The Compensatory Reserve Measurement (CRM) is a novel algorithm that accurately tracks systemic adequacy for delivery of oxygen (DO2) to the tissues. We present a case series of trauma patients receiving ketamine with CRM measurements to offer insight into the DO2 during resuscitation. We captured vital signs along with analog arterial waveform data from trauma patients meeting major activation criteria using a prospective study design. Study team members tracked interventions and vital signs including systolic blood pressure (SBP), mean arterial pressure (MAP), and heart rate (HR) throughout their emergency department stay. Our study included 8 patients who received ketamine for intubation or analgesia (20-300 mg) and had adequate data for analysis. Most were male (88%) with a median age of 28. The most common mechanisms of injury were motor vehicle collisions (MVCs) (38%) and gunshot wounds (38%). After ketamine administration SBP, MAP, and HR all increased while the CRM exhibited minimal change. SBP, MAP, and HR generally appeared to increase while the CRM remained unchanged. Our findings suggest that while standard vital sign measurements appear to increase, ketamine may not improve delivery of oxygen to the tissues. This warrants further study to better understand the effects of ketamine on hemodynamics.

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.