Prehospital Analgesia for Pediatric Trauma Patients in Iraq and Afghanistan

Schauer, Steven G; Araña, Allyson A.; Naylor, Jason F; Hill, Guyon J.; April, Michael D.

doi:10.1080/10903127.2018.1428839

Cited by 20 publications

(16 citation statements)

References 22 publications

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“…7 These characteristics have led to increased use of ketamine, particularly for patients with hypotension, including widespread use of the medication by military health care personnel in combat environments. 8 Neither drug is perfect; however, an association does exist between etomidate use and transient adrenal suppression. This association has prompted some users to preferentially reach for alternative agents in patients in whom there is concern for sepsis.…”

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confidence: 99%

“…It indirectly releases catecholamines and has a favorable safety profile with preservation of cardiopulmonary function in reported overdoses ranging up to 100‐fold above the therapeutic dose 7 . These characteristics have led to increased use of ketamine, particularly for patients with hypotension, including widespread use of the medication by military health care personnel in combat environments 8 …”

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confidence: 99%

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Ketamine Versus Etomidate and Peri‐intubation Hypotension: A National Emergency Airway Registry Study

April

Araña

Schauer

et al. 2020

Academic Emergency Medicine

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Background: The hemodynamic impact of induction agents is a critically important consideration in emergency intubations. We assessed the relationship between peri-intubation hypotension and the use of ketamine versus etomidate as an induction agent for emergency department (ED) intubation. Methods: We analyzed ED intubation data for patients aged >14 years from the National Emergency Airway Registry performed in 25 EDs during 2016 through 2018. We excluded patients with preintubation hypotension (systolic blood pressure <100 mm Hg) or cardiac arrest prior to intubation. The primary outcome was periintubation hypotension. Secondary outcomes included interventions for hypotension (e.g., intravenous fluids or vasopressors). We report adjusted odds ratios (aOR) from multivariable logistic regression models controlling for patient demographics, difficult airway characteristics, and intubation modality. Results: There were 738 encounters with ketamine and 6,068 with etomidate. Patients receiving ketamine were more likely to have difficult airway characteristics (effect size difference = 8.8%, 95% confidence interval [CI] = 5.3% to 12.4%) and to undergo intubation with video laryngoscopy (8.1%, 95% CI = 4.4% to 12.0%). Periintubation hypotension incidence was 18.3% among patients receiving ketamine and 12.4% among patients receiving etomidate (effect size difference = 5.9%, 95% CI = 2.9% to 8.8%). Patients receiving ketamine were more likely to receive treatment for peri-intubation hypotension (effect size difference = 6.5%, 95% CI = 3.9% to 9.3%). In logistic regression analyses, patients receiving ketamine remained at higher risk for peri-intubation hypotension (aOR = 1.4, 95% CI = 1.2 to 1.7) and treatment for hypotension (aOR = 1.8, 95% CI = 1.4 to 2.0). There was no difference in the aOR of hypotension between patients receiving ketamine at doses ≤1.0 mg/kg versus >1.0 mg/kg or patients receiving etomidate at doses ≤0.3 mg/kg versus >0.3 mg/kg. Conclusions: Pending additional data, our results suggest that clinicians should not necessarily prioritize ketamine over etomidate based on concern for hemodynamic compromise among ED patients undergoing intubation.

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confidence: 99%

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confidence: 99%

Ketamine Versus Etomidate and Peri‐intubation Hypotension: A National Emergency Airway Registry Study

April

Araña

Schauer

et al. 2020

Academic Emergency Medicine

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“…Increasing severity of injury may require increased dose, repeat dose, or alternative mechanisms of analgesia for sufficient pain control. One study suggests that Injury Severity Score > 15 required additional doses of analgesia [25]. Furthermore, increased severity of injuries may lead to an increased likelihood of hemodynamic instability following analgesic administration.…”

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confidence: 99%

Evaluation of Safety and Efficacy of Prehospital Paramedic Administration of Sub-Dissociative Dose of Ketamine in the Treatment of Trauma-Related Pain in Adult Civilian Population

Jabourian¹,

Dong²,

Mackey³

et al. 2020

Cureus

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Opiates are addicting and have a high potential for dependency. In the past decades, opiates remained the first-line pharmaceutical option of prehospital treatment for acute traumatic pain in the civilian population. Ketamine is an N-methyl-d-aspartate (NMDA) receptor antagonist that has analgesic properties and may serve as an alternative agent for the treatment of acute traumatic pain in prehospital settings. This study aims to assess the safety and efficacy of ketamine administration by paramedics in civilian prehospital settings for the treatment of acute traumatic pain. This was a prospective observational study in San Bernardino, Riverside and Stanislaus counties. Patients were included if they were > 15 years of age with complaints of traumatic or burn-related pain. Patients were excluded if they received opiates up to six hours prior to or concurrently with ketamine administration. The dose administered was 0.3 mg/kg intravenously over five minutes with a maximum dose of 30 mg. The option to administer a second dose was available to paramedics if the patient continued to have pain after 15 minutes following the first administration. Paired-T tests were conducted to assess the change in the primary outcome (pain score) and secondary outcomes (e.g. systolic blood pressure, pulse, and respiratory rate). P-value<0.05 was considered to be statistically significant. A total of 368 patients were included in the final analysis. The average age was 52.9 ± 23.1 years, and the average weight was 80.4 ± 22.2 kg. There was a statistically significant reduction in the pain score (9.

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“…We queried the Department of Defense Trauma Registry (DODTR) for all pediatric (age < 18 years) encounters from January 2007 and January 2016. The DODTR, formerly known as the Joint Theater Trauma Registry, is the data repository for department of defense trauma‐related injuries 3, 15–19 . The DODTR includes documentation regarding demographics, injury‐producing incidents, diagnoses, treatments, and outcomes of injuries sustained by US/non‐US military and US/non‐US civilian personnel in wartime and peacetime from the point of injury to final disposition.…”

Section: Methodsmentioning

confidence: 99%

“…The DODTR, formerly known as the Joint Theater Trauma Registry, is the data repository for department of defense traumarelated injuries. 3,[15][16][17][18][19] The DODTR includes documentation regarding demographics, injury-producing incidents, diagnoses, treatments, and outcomes of injuries sustained by US/non-US military and US/non-US civilian personnel in wartime and peacetime from the point of injury to final disposition. The DODTR comprises all patients admitted to a fixed-facility or forward surgical team (FST) with an injury diagnosis using the International Classification of Disease 9th Edition (ICD-9) between 800 and 959.9, near-drowning/drowning with associated injury (ICD-9994.1) or inhalational injury (ICD-9987.9) and trauma occurring within 72 h from presentation.…”

Section: Department Of Defense Trauma Registry Descriptionmentioning

confidence: 99%

An analysis of outcomes for pediatric trauma warm fresh whole blood recipients in Iraq and Afghanistan

et al. 2021

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Background Whole blood therapy—which contains the ideal balance of components, and particularly fresh whole blood—has been shown to be beneficial in adult trauma. It remains unclear whether there is potential benefit in the pediatric population. Study Design and Methods This is a secondary analysis of previously published data analyzing pediatric casualties undergoing massive transfusion in the Department of Defense Trauma Registry. Pediatric patients with traumatic injury who were transfused at least one blood product were included in the analysis. We compared children who received component therapy exclusively to those who received any amount of warm fresh whole blood. Results Of the 3439 pediatric casualties within our dataset, 1244 were transfused at least one blood product within the first 24 h. There were 848 patients without severe head injury. Within this cohort, 23 children received warm fresh whole blood overall, 20 of whom did not have severe head injury. In an adjusted analysis, the odds ratio (95% confidence interval [CI]) for survival for warm fresh whole blood recipients was 2.86 (0.40–20.45). After removing children with severe brain injury, there was an independent association with improved survival for warm fresh whole blood recipients with an odds ratio (95% CI) of 58.63 (2.70–1272.67). Discussion Our data suggest that warm fresh whole blood may be associated with improved survival in children without severe head injury. Larger prospective studies are needed to assess the efficacy and safety of whole blood in children with severe traumatic bleeding.

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Prehospital Analgesia for Pediatric Trauma Patients in Iraq and Afghanistan

Cited by 20 publications

References 22 publications

Ketamine Versus Etomidate and Peri‐intubation Hypotension: A National Emergency Airway Registry Study

Ketamine Versus Etomidate and Peri‐intubation Hypotension: A National Emergency Airway Registry Study

Evaluation of Safety and Efficacy of Prehospital Paramedic Administration of Sub-Dissociative Dose of Ketamine in the Treatment of Trauma-Related Pain in Adult Civilian Population

An analysis of outcomes for pediatric trauma warm fresh whole blood recipients in Iraq and Afghanistan

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