Added: Garland Chiang - Date: 30.04.2022 06:12 - Views: 47706 - Clicks: 8272
Airway compromise is the second leading cause of potentially survivable death on the battlefield. The purpose of this study was to better understand wartime prehospital airway patients. The Role 2 Database R2D was retrospectively reviewed for adult patients injured in Afghanistan between February and September Of primary interest were prehospital airway interventions and mortality. Prehospital combat mortality index CMI-PH , hemodynamic interventions, injury mechanism, and demographic data were also included in various statistical analyses.
A total of 12, trauma patients were recorded in the R2D of whom 7. Airway intervention was more common in patients who ultimately died Compared with U. In the R2D, airway intervention was associated with increased odds of mortality, although this was not statistically ificant. Other patients had higher odds of undergoing an airway intervention than U. Airway compromise is the second leading cause of potentially survivable death on the battlefield after hemorrhage. The military divides its casualty care into four roles, which patients move through as their needs, stability, and logistics of movement dictate.
Role 2 has limited hospital capabilities and can be augmented by the presence of a surgical team but is often still near the original point of injury. Role 4 is a traditional fixed facility hospital, well out of the combat theater.
Because of the nature of emergency stabilizing care while potentially under fire at Roles 1 and 2, it has been difficult to identify the frequency of airway procedures performed in this space. We ly attempted to assess this using the Prehospital Trauma Registry database, but it was limited by the of patients available and completeness of data. Recent studies using this newly available dataset have examined patient types and injuries treated at Role 2 facilities, 19 evacuation modalities between Role 1 and Role 2, 20 the en-route treatment and transport between Role 2 and Role 3, 21 factors determining length of stay at Role 2, 22 and the characteristics of casualties based on if and where they died.
Examinations of airway intervention patterns in the military prehospital space could improve research, training, and treatment algorithms. As yet, no study has done a comprehensive analysis of airway management performed before arrival at Role 2 facilities using the R2D, which contains much higher patient s than the ly used Prehospital Trauma Registry.
Therefore, the goal of this study was to characterize airway management patients in the prehospital setting under combat conditions in Afghanistan. Our primary hypothesis was that a relationship between airway intervention and mortality could be found, but without a priori commitment as to whether airway intervention should predispose to harm or protection. Given the conflicting literature on the role and benefit of civilian prehospital airway intervention, we sought to examine the R2D prehospital data for evidence of a direct relationship between airway intervention and mortality.
Data from the R2D were collected and entered by Role 2 facility members following casualty events. Role 2 personnel received basic training on the database once deployed and entered data on a voluntary basis; the data represent a convenience sample of patients cared for by Role 2 teams. When available, source documentation was used to validate and complete the Role 2 data by JTS; however, only a small percentage was linked at the time of analysis roughly 6.
Approval was obtained from the U. Army Institute of Surgical Research institutional regulatory department; the study was determined to be exempt. The R2D includes prehospital data: mechanism and type of injury, mode and time of transport, prehospital interventions, and vital s.
Role 2-related data elements include patient status, time, admission vital s, and some laboratory . Diagnoses, interventions, blood administrations, and some complications are also included. Patient affiliation identified a casualty as U. In place of injury severity scores ISS or abbreviated injury scores AIS , which were not available in this dataset, Combat Mortality Index CMI Prehospital PH , a measure developed by Le and colleagues, was used to adjust for injury severity among battlefield casualties; preliminary efforts and comparisons demonstrate that CMI is a better predictor of mortality than the existing revised trauma score, field triage score, and shock index score.
The two patients who underwent a prehospital tracheotomy were statistically combined with the patients who underwent CRIC. If a casualty received hemostatic dressings eg, QuikClot, Combat Gauze , tourniquet, or fluid resuscitation crystalloid, whole blood, or blood product , they were globally regarded as having received hemodynamic intervention; for the purposes of this airway investigation, attention paid to hemostasis and hemodynamic resuscitation efforts as equivalent and dichotomous subsequent analysis following logistic regression model development demonstrated negligible impact of separating bandage interventions and fluid resuscitation into separate variables.
To evaluate the primary hypothesis of a relationship between airway intervention and mortality, airway interventions were regarded as equivalent to maximize power, and mortality was dichotomized as those who survived to Role 2 discharge vs.
Clinically valid covariates were identified using the following model selection process to identify the best fit logistic regression model: First, we constructed a full model, where the outcome variable was mortality and the exposure variable was airway intervention dichotomous , including all covariates CMI-PH, hemodynamic intervention, mechanism of injury, class of injury, type of injury, age, gender, patient affiliation; time of transport was not included due to patients missing data, These covariates were then included in a reduced model.
Finally, every possible combination of the ly nonificant variables ie, patient affiliation, mechanism, age, and gender was added to the reduced model, but inclusion of nonificant variables did not generate a compelling change in reduced model effect estimates and no combination of those variables was found to be statistically ificant Supplemental Table SI. A sensitivity analysis was then performed by including elapsed transport time to evaluate the robustness of effect estimates in this subset; no model variable odds ratio changed ificantly.
Observing ificant discrepancy among airway intervention proportions between patient affiliation groups, an exploratory analysis was performed against the possibility of systematic differences in injury severity ing for the difference; groups were paired and stratified by CMI-PH, with pooled estimates of the odds ratio generated by Cochran-Mantel-Haenszel testing.
Analysis was performed using SAS 9. Patient Demographics in Casualties That Did vs. Did Not Undergo an Airway Procedure. Of those, 7. Patient affiliation included Military, Military, and A higher proportion of airway patients died Multivariable logistic regression model effect estimate odds ratios representing statistical associations with mortality. Type of injury Penetrating, Blunt, Burn. A similar relationship was found when comparing U. Cochran-Mantel-Haenszel pooled odds ratio demonstrating odds of non-U. Additional interventions and vital s in casualties that did vs did not undergo an airway procedure.
Most patients were categorized as battle injury The most common mechanisms of injury were explosion The most common injury types were penetrating Among those with available data, time of transport was faster for patients with airway intervention vs. Also more common in airway patients were needle decompression 3.
Airway patients received higher proportions of analgesia Among patients who received airway intervention, they were generally male While median admission temperature Airway intervention on the battlefield remains a daunting task in the management of combat casualties. While approaches are variable and meet with inconsistent success, casualties have been identified whose deaths may have been prevented had the airways been managed. Our primary hypothesis supposed a relationship between receiving airway intervention and mortality. In that regard, having ed for several potentially confounding factors, in the R2D we did not identify any statistical association between airway intervention and mortality in our model; while it is axiomatic that certain patients will die rapidly without emergency airway management, we also found evidence that airway management may not be consistently applied.
Although not statistically ificant, the possibility of airway intervention associated with increased odds of mortality is concerning, and findings of excess mortality associated with prehospital airway management in trauma patients have been ly published. The potential harms associated with positive-pressure ventilation in a patient already suffering from hemorrhagic shock have also been discussed. Time of transport was faster for patients with airway interventions, which further analysis suggested to be largely a reflection of their overall more severe clinical status.
The median transport time in our dataset was much longer than that reported by Kotwal et al. If evacuation will not solve the problem of airway management in the military context, military prehospital caregivers must receive optimal equipment and training in how to perform airway interventions and also have understanding of when to simply observe a patent airway in the prolonged field care setting.
It has been suggested that at times the correct answer is to do nothing with airway in hemorrhage, rather than inflict iatrogenic harms by positive pressure ventilation or unnecessary care delay. Of interest are the systematic differences in the application of airway interventions between affiliation groups having equivalent CMI-PH. This may be attributable to language barrier; a prior retrospective civilian study found that primarily Spanish-speaking trauma patients were intubated in excess of otherwise similar English-speaking patients.
Our observed proportion of 7. This is a retrospective study examining inconsistently entered data. Role 2 data throughout the time period in question were entered on a voluntary basis by local healthcare personnel. While there was training on the data entry system, ificant variation was found in the thoroughness of documentation. Given the deidentified nature of the dataset, it was not feasible to assess the relevance of this category beyond confidence that the airway had been managed.
With regard to the differences observed between national groups in terms of odds of receiving airway manipulation, specifics are not available regarding their injury patterns and whether those patterns were systematically different in a way which would compel point-of-injury caregivers toward consistently different decisions in airway management whether that be contrasts in body armor, differences in transportation or mission parameters, or as a function initial care given by nation-specific medical personnel at point of injury.
And though the large majority of airway patients for whom we have details of their transportation were evacuated by U. Ultimately, however, there is evidence of systematic differences, and the possible causes merit further exploration. However, this dataset is presently the best statistical window into wartime point-of-injury, prehospital interventions that exist. Airway management is a challenging aspect of trauma resuscitation, as the patient can rapidly die if an airway is required but not established, while excess harm can result through complications of a procedure that was not indicated.
In our analysis of the R2D focusing on patients who underwent airway procedures, we find no clear statistical association between airway intervention and mortality when adjusting for other ificant confounding factors in a multivariable logistic regression model.Skip the casualties
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