armyemdoc

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It's so often that those of us who work in EM and critical care see devastating injuries and wonder whether we're really making a difference...

SPC Jordan Kirkpatrick is a @usarmy Soldier who was riding his motorcycle on his day off when he had a high-speed collision. He had a bad TBI (IPH, SAH, DAI), pulmonary contusions, multiple rib fractures, skull fracture, facial fractures, femur fracture, multiple pelvic fractures, and a splenic laceration.

EMS found him hypotense with a GCS of 3. Shortly after EMS arrival, he arrested. EMS started CPR, an i-gel was placed, and his chest was decompressed with ROSC achieved. In the ED, they intubated him, placed chest tubes, and transfusions were started. He was emergently taken to the OR for a multi-surgeon case and received >30 units of blood. Shortly after surgery, he went into ARDS/TRALI refractory to all medical management. @uchealth LifeLine air lifted in very critical condition to @CUAnschutz where he was emergently cannulated for ECMO. He had a bolt and EVD placed, was deeply sedated, paralyzed, and cooled for his TBI. He spent several weeks on ECMO in our CTICU and then was decannulated and transferred to our STICU, where he spent several months receiving dozens of procedures. I was part of his critical team in the STICU for several weeks.

He's now almost fully recovered mentally and is making progress physically recovering. Next week, he will be discharged from in-patient rehab. He will rejoin his fellow Soldiers at Fort Carson and transition to the Soldier Recovery Unit. The video and photos are from him and his family documenting his journey.

It's patients like Jordan who remind you that what you do matters.

(Photos, video, and story shared with patient and family permission)

#emergency #emergencymedicine #criticalcare #icu #erlife #iculife #science #army #armymedicine #trauma #motivation #motivating

Severely elevated blood pressure—but no acute target-organ injury. Do we need to treat the number immediately? The short answer is: no.

BLUF: This newly published systematic review found no evidence of benefit from treating asymptomatic hypertension. One RCT demonstrated that time was just as effective as oral medication.

This systematic review included seven studies comparing acute blood-pressure treatment with observation in emergency and acute-care settings.

Key findings:

• In ED patients, major cardiovascular events were rare, and immediate medication did not consistently reduce adverse events, return visits, or hospital admission within seven days.

• One randomized trial found that two hours of rest lowered blood pressure similarly to oral antihypertensive medication.

• Among hospitalized patients, IV antihypertensive treatment was associated with excessive blood-pressure reduction and more myocardial injury—but these observational findings may reflect differences in the in-patient population compared to the ED.

Important limitations: Only one randomized trial was available, outcomes and treatment strategies varied substantially, and the rarity of adverse events limited statistical power. Larger RCTs are needed. In the meantime, the data supports a watch and wait methodology.

The term "hypertensive urgency" should really be removed from our vernacular. We should categorize this as either hypertensive emergency (acute problem) or uncontrolled hypertension (chronic problem).

doi.org/10.1186/s12873…

#emergency #emegencymedicine #science #data #hypertension

Who's coming to AMSUS this Thursday?!

#military #emergency #science #sanantonio #texas

Does prehospital whole blood improve survival in traumatic hemorrhagic shock?

BLUF: Current evidence does not demonstrate a short- or long-term survival advantage for prehospital whole blood over blood components. Therefore, based on current data the benefit is derived solely from the simplicity.

This systematic review and meta-analysis included six studies—three randomized trials and three observational cohorts—enrolling 4,040 adult trauma patients.

Key findings:

• 24-hour mortality: no significant difference
RR 1.00 (95% CI, 0.79–1.27)

• 28/30-day mortality: no significant difference
RR 1.09 (95% CI, 0.87–1.38)

• No significant differences were found in 6-hour mortality, in-hospital mortality, massive transfusion, or hospital length of stay.

• Whole blood was associated with 0.97 fewer RBC units during the first 24 hours after arrival. However, this secondary finding lost statistical significance during sensitivity analysis and was largely driven by observational studies at risk of bias.

• ARDS, stroke, and thromboembolic events were not significantly different, but the analyses were underpowered to establish safety for rare complications.

Important context:

The comparators varied across studies and included component therapy, RBC-based resuscitation, crystalloid-containing strategies, and whole blood initiated shortly after trauma-center arrival. This was not simply a comparison of whole blood versus no transfusion.

All studies were conducted in civilian trauma systems. The results may not apply to prolonged evacuation, austere environments, or military casualties.

doi.org/10.1016/j.inju…

#emergency #emergencymedicine #trauma #blood #science

Should vasopressin be started earlier in septic shock?

BLUF: Starting vasopressin at a lower norepinephrine-equivalent dose did not better outcomes.

The VASSPR trial included 3,959 patients across 13 US hospitals and compared two hospital-level strategies:

• Lower threshold: Start vasopressin when other vasopressors reached 0.1 µg/kg/min of norepinephrine equivalent.

• Higher threshold: Wait until other vasopressors reached 0.4 µg/kg/min.

The strategies created meaningful separation. Vasopressin was administered to 52.4% of patients under the lower-threshold strategy versus 32.9% under the higher-threshold strategy.

However, earlier vasopressin did not improve outcomes:

• 28-day mortality: 31.8% vs 33.0%
• No difference in 90-day mortality
• No difference in kidney replacement therapy–free days
• No difference in ICU-, hospital-, or vasopressor-free days

Cardiogenic shock occurred slightly more often with the lower-threshold strategy—7.4% versus 6.3%—but this was an exploratory finding, was not adjusted for multiple comparisons, and was not consistent across sensitivity analyses.

Important limitation: This pragmatic trial tested hospital-level strategies under real-world conditions. Clinician discretion, crossover, and imperfect adherence were allowed, so it was not a tightly controlled efficacy trial of two mandatory thresholds.

doi.org/10.1001/jama.2…

#emergency #emergencymedicine #icu #criticalcare #science